Nordanest (Prilocaine + Epinephrine): Uses, Dosage & Side Effects
An injectable amide-type local anesthetic with an epinephrine vasoconstrictor, used to produce profound, long-lasting numbness for dental and minor surgical procedures
Nordanest is a prescription-only injectable local anesthetic that combines prilocaine hydrochloride 40 mg/ml (4%) with a low dose of epinephrine (adrenaline) 5 micrograms/ml, equivalent to a 1:200,000 dilution. Prilocaine is an amide-type local anesthetic closely related to lidocaine, while epinephrine serves as a vasoconstrictor that prolongs anesthesia and reduces bleeding at the injection site. Nordanest is used primarily in dentistry and oral surgery for procedures such as tooth extractions, fillings, endodontic treatment, and periodontal surgery. Prilocaine is included on the World Health Organization (WHO) Model List of Essential Medicines and has been in clinical use since 1965.
Quick Facts: Nordanest
Key Takeaways
- Nordanest is an injectable combination of prilocaine 40 mg/ml (an amide local anesthetic) and epinephrine 5 mcg/ml (a vasoconstrictor), primarily used to produce profound local anesthesia during dental and minor oral surgical procedures.
- The addition of epinephrine at 1:200,000 prolongs anesthesia (pulpal anesthesia typically 60–90 minutes, soft-tissue numbness 3–5 hours), reduces bleeding at the injection site, and lowers the risk of systemic prilocaine toxicity.
- Nordanest is contraindicated in patients with known hypersensitivity to amide-type local anesthetics, severe cardiac conduction disorders, congenital or idiopathic methemoglobinemia, and in infants younger than 6 months because of the risk of methemoglobinemia.
- Caution is required in patients treated with non-selective beta-blockers, tricyclic antidepressants, MAO inhibitors, or phenothiazines because of potential cardiovascular interactions with epinephrine, and in patients with severe liver or kidney disease.
- Only qualified dental and medical professionals should administer Nordanest. The maximum recommended dose of prilocaine in healthy adults is 600 mg (approximately 8.8 mg/kg body weight for prilocaine, or 6 mg/kg without vasoconstrictor according to some references); always follow local dosing guidelines.
What Is Nordanest and What Is It Used For?
Nordanest is a prescription-only injectable medication that combines two active substances: prilocaine hydrochloride 40 mg per milliliter (a 4% solution) and epinephrine (also known as adrenaline) 5 micrograms per milliliter, corresponding to a 1:200,000 dilution. Prilocaine is a synthetic amide-type local anesthetic, first synthesized in 1953 and introduced into clinical practice in 1965 by Swedish researchers at AstraZeneca. It is structurally related to lidocaine but has unique metabolic and pharmacologic properties that make it particularly suitable for certain anesthetic applications.
The mechanism by which Nordanest produces anesthesia involves the reversible blockade of voltage-gated sodium channels in nerve cell membranes. When applied to peripheral nerves, prilocaine binds to the intracellular portion of these channels and prevents the rapid influx of sodium ions that normally generates an action potential. As a result, pain signals cannot be transmitted from the site of injury to the brain, producing temporary numbness of the targeted tissue. The blockade is dose-dependent and fully reversible: as the drug is cleared from the tissue and metabolized, normal sensation returns.
The addition of epinephrine serves three important clinical purposes. First, epinephrine is a potent vasoconstrictor: by stimulating alpha-adrenergic receptors on local blood vessels, it causes them to narrow, which slows the rate at which prilocaine is washed away from the injection site. This dramatically prolongs the duration of anesthesia compared to plain prilocaine. Second, by reducing blood flow, epinephrine reduces peak plasma concentrations of prilocaine, thereby decreasing the risk of systemic toxicity. Third, local vasoconstriction reduces bleeding at the surgical site, improving visibility during dental and oral surgical procedures and making the clinician's work easier and safer.
Prilocaine with epinephrine is indicated for infiltration and regional nerve block anesthesia in dentistry. Typical clinical applications include:
- Restorative dentistry: Fillings (composite, amalgam), inlays, onlays, and crown preparations, particularly when prolonged anesthesia is required.
- Tooth extractions: Simple and surgical extractions of teeth, including wisdom teeth (third molars), when moderate-duration anesthesia is desired.
- Endodontic treatment (root canal therapy): Treatment of the dental pulp and root canals, where deep and sustained anesthesia of the tooth is required.
- Periodontal procedures: Scaling and root planing, gingivectomy, flap surgery, and other treatments for gum disease.
- Oral surgery: Apicectomy (surgical treatment of root tip infections), minor implant-related procedures, cyst removal, and soft-tissue biopsies.
- Mandibular (inferior alveolar) nerve block: Producing anesthesia of the lower jaw, tongue, and lip on one side, often used for procedures on the mandibular teeth.
- Maxillary infiltration: Localized anesthesia of upper teeth and surrounding gum tissue by injection into the buccal or palatal mucosa.
Compared to plain prilocaine formulations (typically 30 mg/ml with felypressin as the vasoconstrictor), the epinephrine-containing version provides a longer duration of action and a more pronounced vasoconstrictive effect, which is particularly valuable during procedures in highly vascular tissues such as the gingiva. Compared to lidocaine with epinephrine, prilocaine with epinephrine has a similar onset but may offer slightly shorter duration in some applications; prilocaine is also less cardiotoxic, which makes it a preferred option in certain patients with cardiovascular concerns, although the methemoglobinemia risk must be weighed.
Worldwide, prilocaine (including the combination with epinephrine) is available under numerous brand names including Nordanest, Citanest Dental Octapressin (Denmark, Norway, UK), Xylonest (Germany, Austria), and Citanest Forte (older formulation). It is included on the WHO Model List of Essential Medicines as part of the broader category of local anesthetics used for dental and surgical anesthesia. Prilocaine is also a component of the topical local anesthetic cream EMLA (eutectic mixture of local anesthetics) combined with lidocaine, used for skin anesthesia before needle procedures.
Local anesthetics like prilocaine relax blood vessels to some degree, which can paradoxically shorten their duration of action by increasing systemic absorption. Adding a small dose of a vasoconstrictor such as epinephrine counteracts this effect and keeps the anesthetic localized at the target site. In dental cartridges, epinephrine is most commonly included at 1:100,000 (10 mcg/ml) or 1:200,000 (5 mcg/ml). The lower 1:200,000 concentration used in Nordanest provides an excellent balance between prolonged anesthesia and minimal cardiovascular effects, making it well suited for adults without significant cardiovascular disease.
What Should You Know Before Receiving Nordanest?
Contraindications
Nordanest must not be administered to patients with certain medical conditions or known allergies. Understanding these absolute contraindications is essential for patient safety. Before any procedure involving Nordanest, the dental or medical professional should carry out a careful medical history review.
- Known hypersensitivity: Nordanest must not be used in patients with a known allergy or hypersensitivity to prilocaine, epinephrine, other amide-type local anesthetics (lidocaine, mepivacaine, bupivacaine, ropivacaine, articaine), or to any of the excipients, including sodium metabisulfite (the preservative added to stabilize epinephrine).
- Severe cardiac conduction disorders: Nordanest is contraindicated in patients with severe conduction disturbances of the heart that are not paced (e.g., second-degree or third-degree atrioventricular block without a pacemaker), severe bradycardia, or acute decompensated heart failure.
- Methemoglobinemia: Prilocaine is metabolized to o-toluidine, which can oxidize hemoglobin to methemoglobin. The drug is contraindicated in patients with congenital or idiopathic methemoglobinemia, and should not be used in patients with severe anemia or significant hypoxia.
- Glucose-6-phosphate dehydrogenase (G6PD) deficiency: Patients with this enzyme deficiency are at increased risk of methemoglobinemia and hemolysis and should generally avoid prilocaine.
- Infants younger than 6 months: Because fetal hemoglobin is more susceptible to oxidation and infants have immature methemoglobin reductase enzymes, prilocaine is generally contraindicated in this age group.
- Uncontrolled narrow-angle glaucoma: Because of the sympathomimetic effects of epinephrine.
- Severe, uncontrolled hyperthyroidism or pheochromocytoma: The cardiovascular effects of epinephrine can precipitate a hyperadrenergic crisis.
Warnings and Precautions
Inadvertent intravascular injection or excessive dosing of Nordanest can cause systemic local anesthetic toxicity, characterized by central nervous system symptoms (perioral numbness, tinnitus, dizziness, seizures) and cardiovascular effects. Prilocaine specifically can cause methemoglobinemia at higher doses, presenting as cyanosis (blue-gray discoloration of the skin and mucous membranes), fatigue, headache, and shortness of breath. Methemoglobinemia responds rapidly to intravenous methylene blue. Always aspirate before injection and respect the maximum recommended dose.
Inform your dentist or physician before receiving Nordanest if any of the following conditions apply to you:
- Cardiovascular disease: Patients with ischemic heart disease (angina, history of myocardial infarction), arrhythmias, heart failure, or severe or uncontrolled hypertension should use Nordanest with caution. The epinephrine component, although present in a low concentration (1:200,000), can in theory increase heart rate and blood pressure and exacerbate anginal symptoms if a large dose is given rapidly or if accidentally injected intravascularly.
- Hepatic impairment: Prilocaine is partially metabolized in the liver (as well as in the lungs and kidneys). Patients with severe liver disease may have reduced clearance and prolonged duration of effect, increasing the risk of toxicity.
- Renal impairment: The metabolites of prilocaine are excreted renally. In severe kidney disease, accumulation of metabolites and increased methemoglobinemia risk can occur, particularly with repeated or high doses.
- Hyperthyroidism: Epinephrine can exacerbate the symptoms of hyperthyroidism, including tachycardia and palpitations.
- Diabetes mellitus: Epinephrine can transiently increase blood glucose levels, which may require attention in patients with diabetes.
- Severe asthma or atopic individuals: The sulfite preservative (sodium metabisulfite) used to stabilize epinephrine can cause bronchospasm and severe allergic reactions in susceptible patients, particularly those with asthma.
- Epilepsy: Systemic toxicity from local anesthetics can lower the seizure threshold. Patients with poorly controlled epilepsy should be identified before treatment.
- Pheochromocytoma: An adrenal tumor that secretes catecholamines; additional exogenous epinephrine can trigger severe hypertensive crisis.
- Porphyria: Although prilocaine is generally considered safer than some other local anesthetics in porphyria, caution is still advised.
After a dental injection with Nordanest, the lip, tongue, cheek, or palate may remain numb for several hours. Patients — particularly children — must be warned not to bite or chew the numb tissue, because self-inflicted injuries such as lip and tongue lacerations can occur. Hot beverages should be avoided until sensation returns, as the numb area cannot detect thermal injury.
Pregnancy and Breastfeeding
If you are pregnant, breastfeeding, think you may be pregnant, or are planning to have a baby, inform your dentist or physician before receiving Nordanest. Prilocaine crosses the placenta, and experience with use during pregnancy is more limited than with lidocaine. Because of the theoretical risk of methemoglobinemia in the fetus and mother, many international guidelines recommend lidocaine with epinephrine or articaine as the preferred dental anesthetics during pregnancy, reserving prilocaine for situations where these are not suitable. If Nordanest must be used, the lowest effective dose should be administered, ideally avoiding the third trimester.
Prilocaine and epinephrine pass into breast milk in very small amounts, and the short systemic half-life of both substances means that exposure to the breastfed infant at standard dental anesthetic doses is considered negligible. Breastfeeding does not typically need to be interrupted after a dental procedure with Nordanest, although the treating professional should be informed. Always consult your healthcare provider for personalized advice.
Elderly and Medically Compromised Patients
Elderly patients often have coexisting cardiovascular disease, reduced hepatic blood flow, and altered drug metabolism. They may be more sensitive to both the local anesthetic effects of prilocaine and the cardiovascular effects of epinephrine. Lower initial doses and careful aspiration before injection are recommended. Patients with significant comorbidities (e.g., heart failure, severe chronic kidney disease, hepatic cirrhosis) may require consultation with their physician before elective dental procedures using epinephrine-containing local anesthetics.
Driving and Operating Machinery
Nordanest used at standard doses for dental anesthesia does not typically affect the central nervous system in a way that impairs driving or machine operation once the patient has recovered from the procedure. However, the local numbness of the face, lip, or tongue may make eating, drinking, and speaking difficult for several hours after the injection. Patients who experience faintness, dizziness, or anxiety reactions should not drive until these symptoms have fully resolved.
Information About Excipients
Each milliliter of Nordanest also contains sodium metabisulfite (a sulfite preservative added to stabilize the epinephrine), sodium chloride, water for injections, and small amounts of sodium hydroxide or hydrochloric acid for pH adjustment. Sulfites can, in rare cases, cause severe allergic-type reactions (including anaphylactic manifestations and life-threatening or less severe asthmatic episodes) in susceptible patients. The overall prevalence of sulfite sensitivity is low but is higher in asthmatic patients. This is why Nordanest must be used with caution in individuals with known sulfite sensitivity or severe, brittle asthma.
How Does Nordanest Interact with Other Drugs?
Because Nordanest contains both a local anesthetic (prilocaine) and a sympathomimetic vasoconstrictor (epinephrine), the interaction profile is more complex than that of a plain local anesthetic. Most clinically significant interactions become relevant when the total dose is large, when accidental intravascular injection occurs, or in medically compromised patients. Always inform your dentist, anesthetist, pharmacist, or nurse about every prescription and over-the-counter medication, herbal remedy, and supplement you are taking.
Major Interactions
| Interacting Drug | Effect | Clinical Advice |
|---|---|---|
| Non-selective beta-blockers (propranolol, nadolol, sotalol) | Non-selective beta-blockade leaves alpha-adrenergic effects of epinephrine unopposed, potentially producing a marked hypertensive response and reflex bradycardia | Use the minimum effective dose of Nordanest, inject slowly after aspiration, and consider epinephrine-free alternatives for extensive procedures. Monitor blood pressure. |
| Tricyclic antidepressants (amitriptyline, imipramine, nortriptyline) | These drugs inhibit the reuptake of catecholamines, potentiating the cardiovascular effects of epinephrine and increasing the risk of severe hypertension and arrhythmia | Limit the total epinephrine dose. In extensive procedures, consider prilocaine with felypressin or plain mepivacaine as alternatives. |
| Monoamine oxidase inhibitors (phenelzine, tranylcypromine, moclobemide, selegiline) | MAO inhibitors reduce metabolism of catecholamines; concurrent use with injected epinephrine may precipitate severe hypertensive crisis | Use with extreme caution. Liaise with the prescribing physician; where possible, schedule dental procedures when MAOI therapy can be safely paused, or use epinephrine-free alternatives. |
| Halogenated volatile anesthetics (halothane, enflurane, isoflurane) | These inhalational general anesthetics sensitize the myocardium to catecholamines, increasing the risk of ventricular arrhythmias when epinephrine-containing local anesthetics are used concurrently | Limit the total epinephrine dose during general anesthesia with halogenated agents and aspirate carefully before injection. |
| Other local anesthetics (lidocaine, mepivacaine, bupivacaine, articaine) | Toxic effects are additive; concurrent administration increases the risk of combined systemic local anesthetic toxicity (CNS and cardiovascular) | Calculate the total dose of all local anesthetics given. The cumulative exposure should stay below the maximum safe threshold for the patient. |
Minor and Moderate Interactions
| Interacting Drug | Effect | Clinical Advice |
|---|---|---|
| Phenothiazines and butyrophenones (chlorpromazine, haloperidol) | These drugs have alpha-blocking properties and may cause paradoxical hypotension when combined with epinephrine, reversing or diminishing the expected pressor response | Monitor blood pressure carefully. The clinical impact is usually small at standard dental doses. |
| Sulfonamides, nitrates, antimalarials, certain NSAIDs, metoclopramide | These drugs can themselves induce methemoglobinemia; combined with prilocaine they increase the risk of clinically significant methemoglobinemia | Keep total prilocaine dose low. Consider alternative local anesthetics (lidocaine, articaine) in high-risk patients. |
| Cocaine (recreational use) | Cocaine blocks reuptake of norepinephrine/epinephrine and potentiates their cardiovascular effects, dramatically increasing the risk of hypertensive crisis and coronary vasospasm | Avoid epinephrine-containing local anesthetics in patients who have recently used cocaine. Ask about recreational drug use as part of medical history. |
| Digoxin and cardiac glycosides | Epinephrine can increase the risk of digitalis-induced arrhythmias in patients on high-dose cardiac glycoside therapy | Use lowest effective dose. Monitor cardiac rhythm in high-risk patients. |
| Antidiabetic agents (insulin, sulfonylureas) | Epinephrine has hyperglycemic effects and can transiently increase blood glucose, potentially opposing the action of antidiabetic drugs | Clinical impact at standard dental doses is limited. Monitor blood glucose in diabetic patients receiving extensive treatment. |
What Is the Correct Dosage of Nordanest?
Nordanest dosing is highly individualized and is based on international guidelines including the BNF, EMA Summary of Product Characteristics, FDA-approved prilocaine labeling, and established textbooks of dental anesthesiology. The recommendations below serve as a general reference; the administering professional will always follow the specific instructions applicable to the individual clinical situation and the national regulatory framework.
Adults
Nordanest 40 mg/ml + 5 mcg/ml – Healthy Adults
Single-tooth infiltration: 1–2 ml (40–80 mg prilocaine) per site is usually sufficient for routine restorative work or a simple tooth extraction.
Mandibular (inferior alveolar) nerve block: 1.8–3 ml (72–120 mg prilocaine) is typical for profound anesthesia of mandibular teeth and the associated soft tissues.
Extensive oral surgery: May require multiple cartridges, but the total prilocaine dose should remain within the maximum safe limit.
Maximum single dose: Approximately 8.8 mg/kg body weight or 600 mg total prilocaine, whichever is lower. For a 70 kg adult, this corresponds to approximately 15 ml (about 8–9 standard dental cartridges of 1.7–1.8 ml each). Always aspirate before injection to avoid intravascular administration.
Injection Technique and Aspiration
Inject slowly and deliberately. A rate of approximately 1 ml per minute is typical for infiltration. Aspiration before injection is mandatory to confirm that the needle tip is not inside a blood vessel; positive aspiration requires needle repositioning. The total dose should be delivered in fractionated aliquots, watching for signs of intravascular injection or systemic toxicity between increments.
| Procedure | Typical Dose | Onset / Duration |
|---|---|---|
| Single filling (infiltration) | 1–1.8 ml (40–72 mg prilocaine) | Onset 2–3 min; pulpal anesthesia 60–90 min |
| Simple extraction | 1.8–3.6 ml (72–144 mg) | Onset 2–4 min; soft-tissue numbness 3–5 h |
| Mandibular nerve block | 1.8–3 ml (72–120 mg) | Onset 3–5 min; pulpal anesthesia 60–90 min |
| Root canal therapy | 1.8–3.6 ml (72–144 mg) | Sustained anesthesia suitable for 60–90 min sessions |
| Periodontal surgery (quadrant) | Up to 7.2 ml (288 mg) | Extensive anesthesia with reduced bleeding |
| Absolute maximum (healthy 70 kg adult) | Approx. 15 ml (600 mg) | Never exceed in a single session |
Children
Nordanest may be used in children, but careful weight-based dose calculation is essential. Children are more susceptible to systemic toxicity and to methemoglobinemia than adults. The maximum recommended dose in pediatric patients is typically 5–6 mg/kg prilocaine, not exceeding the adult ceiling. Nordanest is generally not recommended in children under 6 months due to the risk of methemoglobinemia; in children aged 6 months to 4 years, it should only be used with special precautions. Always use the minimum effective dose for the procedure.
Pediatric Dosing Example
For a 20 kg child, the maximum prilocaine dose would be approximately 100–120 mg, corresponding to 2.5–3 ml of Nordanest 40 mg/ml. Most single-tooth procedures in children require considerably less than this maximum.
Children need particularly careful post-procedure supervision, as they are at increased risk of self-inflicted lip, cheek, or tongue injuries while the numbness persists. Parents and caregivers should receive clear instructions not to allow chewing, biting, or hot drinks until sensation fully returns.
Elderly and Medically Compromised Patients
Elderly patients, patients with impaired hepatic or renal function, and those with significant cardiovascular disease often require reduced doses. Age-related changes in cardiac output, hepatic blood flow, and drug metabolism can prolong the duration of action and increase peak plasma concentrations. The presence of polypharmacy also increases the risk of clinically meaningful drug interactions. Start with the lowest effective dose, aspirate carefully, inject slowly, and monitor for signs of systemic toxicity.
Missed Dose
The concept of a "missed dose" does not apply to Nordanest in the usual sense because it is administered by a healthcare professional as a single dose during a procedure. If additional anesthesia is required during a longer procedure, supplemental injections may be given by the clinician, always staying within the maximum allowable total dose.
Overdose
If you develop symptoms such as numbness around the mouth (beyond the expected local effect), ringing in the ears, dizziness, visual disturbances, muscle twitching, confusion, shortness of breath, or a bluish/gray discoloration of the skin (cyanosis) after a Nordanest injection, alert the clinician or call emergency services immediately. Severe toxicity is a medical emergency.
Prilocaine overdose can manifest as local anesthetic systemic toxicity (LAST) and/or as methemoglobinemia, sometimes simultaneously. Early LAST symptoms (at plasma levels ~5–10 mcg/ml) include perioral numbness, metallic taste, tinnitus, dizziness, lightheadedness, and restlessness. Progressive symptoms (~10–15 mcg/ml) include visual disturbances, slurred speech, muscle twitching, and confusion. Severe toxicity (above 15 mcg/ml) leads to generalized seizures, loss of consciousness, respiratory depression, and cardiovascular collapse.
Methemoglobinemia typically develops 30 minutes to a few hours after injection and presents as slate-gray or bluish discoloration of the skin, lips, and mucous membranes, often accompanied by headache, fatigue, dizziness, shortness of breath, and, in severe cases, chest pain and altered mental status. Importantly, in methemoglobinemia the pulse oximetry reading (SpO2) characteristically plateaus around 85%, even with supplemental oxygen; definitive diagnosis requires co-oximetry of arterial blood. Treatment is with intravenous methylene blue 1–2 mg/kg, which rapidly reduces methemoglobin back to functional hemoglobin. Exchange transfusion or hyperbaric oxygen may be required in extreme cases.
Treatment of LAST includes airway management, supplemental oxygen, seizure control with benzodiazepines, and, in cases of cardiovascular collapse, intravenous lipid emulsion (Intralipid 20%) rescue according to established ASRA/AAGBI guidelines. Healthcare facilities administering local anesthetics should have full resuscitation equipment, lipid emulsion, and methylene blue readily available.
What Are the Side Effects of Nordanest?
As with all medicines, Nordanest can cause side effects, although not all patients experience them. The side-effect profile reflects the two active ingredients: local anesthetic effects from prilocaine and sympathomimetic effects from epinephrine, plus local effects at the injection site. The classification below is based on the European Medicines Agency (EMA) frequency categories and is drawn from the manufacturer's product information, post-marketing surveillance, and published literature on prilocaine-epinephrine combinations.
Common
- Injection-site pain or discomfort: Brief stinging or burning sensation during injection, resolving within seconds to minutes
- Transient palpitations: Brief awareness of a faster or stronger heartbeat due to the epinephrine component
- Headache: Mild, short-lasting headache after the procedure
- Anxiety or nervousness: Particularly in anxious patients; may reflect procedure-related stress as well as the catecholamine effect
- Mild tremor: Fine tremor of the hands or voice, related to epinephrine
Uncommon
- Dizziness or lightheadedness
- Nausea or vomiting
- Pallor and sweating
- Hypertension or hypotension: Short-lived blood pressure fluctuations
- Local hematoma at the injection site
- Tachycardia (fast heart rate)
- Paresthesia or prolonged numbness: Most often resolves spontaneously, but rarely can persist for days or weeks
Rare
- Allergic reactions: Skin rash, urticaria (hives), pruritus, angioedema (swelling of face/lips/tongue), bronchospasm; in severe cases anaphylaxis
- Methemoglobinemia: Bluish-gray discoloration of skin and lips, dyspnea, fatigue; more likely at higher doses, in infants, or with concomitant methemoglobin-inducing drugs
- Cardiac arrhythmias: Particularly in patients with pre-existing heart disease or when the drug is inadvertently injected intravascularly
- Seizures: Usually due to inadvertent intravascular injection or overdose
Very Rare / Life-Threatening
- Anaphylactic shock: Severe, systemic allergic reaction requiring immediate epinephrine
- Severe methemoglobinemia: With hypoxia, altered mental status, and cardiovascular compromise
- Cardiovascular collapse: With bradycardia, profound hypotension, or cardiac arrest, usually in the setting of systemic toxicity
- Respiratory arrest
Frequency Not Known
- Permanent nerve damage: Extremely rare, usually associated with direct needle trauma or inadvertent intraneural injection
- Trismus: Prolonged jaw stiffness or spasm after inferior alveolar nerve block
- Facial nerve paralysis: Transient and related to inadvertent infiltration near the facial nerve during inferior alveolar block
- Self-inflicted lip, cheek or tongue injury: Especially in children during the post-anesthetic numbness period
Contact emergency services or the treating clinician immediately if you experience any of the following during or after treatment with Nordanest: swelling of the face, lips, tongue, or throat; difficulty breathing or swallowing; severe skin rash with hives; bluish or gray discoloration of the skin, lips, or fingertips (possible methemoglobinemia); severe chest pain, palpitations, or fainting; muscle twitching, tremor, or seizures; confusion or loss of consciousness; numbness that spreads far beyond the expected treatment area (possible systemic toxicity).
It is important to distinguish between the expected local numbness of Nordanest and signs of systemic toxicity. Localized anesthesia of the treated tooth, gum, lip, or tongue is normal and desired. However, numbness spreading elsewhere, symptoms of central nervous system dysfunction, or cyanotic skin changes all suggest that something has gone beyond the intended local effect and warrant immediate evaluation.
Any adverse effect experienced with Nordanest should be reported to the healthcare professional who performed the procedure. You can also report suspected adverse drug reactions directly to your national pharmacovigilance authority (e.g., FDA MedWatch in the US, MHRA Yellow Card scheme in the UK, or EMA EudraVigilance in the EU). Such reports help monitor the ongoing safety of medicines and protect future patients.
How Should Nordanest Be Stored?
Nordanest is a sterile injectable product that is typically supplied in glass dental cartridges (1.7–1.8 ml) or multidose vials for professional use. Proper storage is essential to maintain sterility, potency, and safety. Because the product contains epinephrine, which is sensitive to heat, light, and oxidation, storage conditions must be followed strictly.
- Temperature: Store below 25°C (77°F). Do not freeze. Freezing can damage the glass cartridges and denature the epinephrine.
- Light: Keep cartridges in the original packaging to protect them from light. Epinephrine degrades with exposure to light and air; degraded solutions may appear pink, brown, or amber.
- Inspection before use: Always visually inspect each cartridge before use. The solution should be clear and colorless. Any cartridge with discoloration, cloudiness, particulate matter, or a damaged seal must be discarded.
- Single-use only: Each cartridge is intended for a single patient during a single treatment session. Opened or partially used cartridges must not be saved for later use or given to another patient.
- Expiry date: Do not use Nordanest after the expiry date printed on the packaging. The expiry date refers to the last day of the stated month.
- Disposal: Used cartridges and any unused solution must be disposed of according to local regulations for pharmaceutical and biomedical waste. Needles and sharps should be placed in approved sharps containers. Patients should not attempt to dispose of dental anesthetic cartridges via household waste.
- Child safety: Although Nordanest is not dispensed to patients, all medicines in professional settings must be stored securely and out of the reach of unauthorized persons, including children.
When transporting Nordanest, maintain appropriate temperature control (avoid both freezing and overheating) and protect from direct sunlight. Cartridges should not be left in hot vehicles or exposed to ambient temperatures above 30°C for extended periods.
What Does Nordanest Contain?
Understanding the complete composition of Nordanest is important for healthcare professionals and for patients with known allergies or sensitivities. Below is a breakdown of active and inactive ingredients based on regulatory-approved product information.
Active Ingredients
Prilocaine hydrochloride, 40 mg/ml (4%): An amide-type local anesthetic that produces reversible blockade of nerve conduction by inhibiting voltage-gated sodium channels. Prilocaine has an intermediate duration of action, moderate potency, and a favorable safety profile compared with some other amide anesthetics. Its main unique feature is the metabolic production of o-toluidine, which is responsible for prilocaine's dose-dependent methemoglobinemia risk.
Epinephrine (adrenaline), 5 mcg/ml (1:200,000): A sympathomimetic amine that acts on both alpha- and beta-adrenergic receptors. In Nordanest, the low dose of epinephrine causes local vasoconstriction via alpha-1 receptors in blood vessels adjacent to the injection, prolonging anesthetic effect, reducing systemic absorption, and minimizing surgical bleeding. At the small doses used for dental anesthesia, systemic effects are usually minimal in healthy patients.
Inactive Ingredients (Excipients)
- Sodium metabisulfite (E223): An antioxidant preservative added to prevent oxidation of epinephrine. Sulfites can cause allergic-type reactions, particularly in asthmatic patients.
- Sodium chloride: For tonicity adjustment to match body fluids.
- Sodium hydroxide and/or hydrochloric acid: For pH adjustment to optimize stability and tissue compatibility (typical pH 3.3–5.0).
- Water for injections: The vehicle in which the active ingredients are dissolved.
Appearance
Nordanest is a sterile, clear, colorless to slightly yellow solution packaged in glass dental cartridges (typically 1.7 ml or 1.8 ml) designed for use with standard dental aspirating syringes. Each cartridge is sealed with a rubber plunger at one end and a diaphragm at the other, allowing a sterile needle to pierce the diaphragm for injection.
Packaging
Nordanest is supplied in boxes of glass dental cartridges for professional use only. Pack sizes vary by country and manufacturer; common packaging includes blister packs of 10 cartridges within boxes of 50 or 100 cartridges. Not all pack sizes may be marketed in all countries. The marketing authorization holder may vary by region; consult the product label and local medicines agency for current information.
Nordanest contains sodium metabisulfite, which can cause allergic-type reactions including anaphylactic symptoms and life-threatening or less severe asthmatic episodes in susceptible individuals. The overall prevalence of sulfite sensitivity in the general population is low but is higher in people with asthma. Patients with known sulfite sensitivity should inform their dentist or physician; sulfite-free (epinephrine-free) alternatives such as plain prilocaine with felypressin or mepivacaine without vasoconstrictor may be used instead.
Frequently Asked Questions About Nordanest
Nordanest is an injectable local anesthetic used primarily in dentistry and oral surgery. It contains prilocaine 40 mg/ml and epinephrine 5 mcg/ml (1:200,000). It is used to produce profound and relatively long-lasting numbness during procedures such as tooth extractions, fillings, root canal therapy, periodontal treatment, and minor oral surgery. The combination with epinephrine prolongs anesthesia and reduces bleeding in the surgical field.
After submucosal injection, anesthesia typically begins within 2 to 3 minutes. Pulpal anesthesia (numbness of the tooth itself) usually lasts 60 to 90 minutes, while soft-tissue numbness of the lip, cheek, tongue, or palate may persist for 3 to 5 hours. The exact duration depends on the injection technique, dose, injection site, and individual variation. Numbness of the lip and tongue can last considerably longer than the dental anesthesia itself, so patients should avoid biting or chewing until sensation fully returns.
Lidocaine with epinephrine or articaine are generally considered the preferred dental anesthetics during pregnancy. Prilocaine is often avoided, particularly in the third trimester, because of the theoretical risk of methemoglobinemia in both mother and fetus. If dental treatment cannot be postponed and Nordanest is selected, the lowest effective dose should be used, and the clinician must be informed of the pregnancy. Always discuss your pregnancy status with your dentist before local anesthesia.
Epinephrine (adrenaline) is a vasoconstrictor. By constricting blood vessels at the injection site, it slows the rate at which prilocaine is absorbed into the bloodstream, prolongs the duration of anesthesia, reduces peak plasma concentrations of prilocaine (thereby decreasing the risk of systemic toxicity), and reduces bleeding during surgery. These properties make the combination particularly suitable for longer or more invasive dental procedures.
Methemoglobinemia is a condition in which the iron in hemoglobin is oxidized from the ferrous (Fe2+) to the ferric (Fe3+) form, preventing normal oxygen transport. It causes bluish-gray discoloration of the skin and mucous membranes (cyanosis), fatigue, headache, and shortness of breath. Prilocaine is metabolized to o-toluidine, which can induce methemoglobinemia, particularly at doses above 600 mg in adults or proportionally lower doses in children and infants. Because of this risk, Nordanest is contraindicated in patients with congenital methemoglobinemia and is generally avoided in infants under 6 months. Treatment of methemoglobinemia is with intravenous methylene blue.
It is best to avoid eating, drinking hot liquids, and chewing until the numbness has worn off, which may take 3 to 5 hours. Eating while numb increases the risk of biting the lip, cheek, or tongue, causing painful injuries that only become apparent once sensation returns. Hot drinks can cause burns because you cannot feel the temperature on the numb tissue. If you must drink, use cool liquids and sip carefully on the opposite, non-numb side of your mouth. Parents should supervise children closely to prevent self-inflicted injuries during the numb period.
True IgE-mediated allergy to amide-type local anesthetics like prilocaine is extremely rare. Reactions more commonly attributed to dental anesthetics are due to anxiety-related vasovagal responses, inadvertent intravascular injection of epinephrine (palpitations and trembling), or sensitivity to the sulfite preservative used to stabilize epinephrine. Genuine allergic reactions may involve skin rash, hives, facial swelling, bronchospasm, or, very rarely, anaphylaxis. If you have a history of suspected local anesthetic allergy, consult an allergist for formal testing; alternative agents from a different chemical class or sulfite-free formulations are available.
References
This article is based on current international medical guidelines, regulatory documents, and peer-reviewed research. All sources meet evidence level 1A standards.
- World Health Organization (WHO). WHO Model List of Essential Medicines – 23rd List. Geneva: WHO; 2023. Prilocaine is listed within the local anesthetics category as an essential medicine for dental and surgical use.
- European Medicines Agency (EMA). Summary of Product Characteristics – Prilocaine with Epinephrine 40 mg/ml + 5 mcg/ml Solution for Injection. EMA/CHMP; 2024. Comprehensive regulatory document covering indications, dosing, contraindications, and safety data.
- U.S. Food and Drug Administration (FDA). Prilocaine Hydrochloride Prescribing Information. FDA; 2023. Approved labeling including pharmacology, clinical studies, and adverse reactions.
- Joint Formulary Committee. British National Formulary (BNF) – Prilocaine Hydrochloride Monograph. London: BMJ Group and Pharmaceutical Press; 2024. Evidence-based prescribing reference for UK healthcare professionals.
- Malamed SF. Handbook of Local Anesthesia. 7th ed. St. Louis: Elsevier; 2019. Comprehensive reference on local anesthetic pharmacology, technique, and complications in dentistry.
- Becker DE, Reed KL. Local anesthetics: review of pharmacological considerations. Anesthesia Progress. 2012;59(2):90–102. doi:10.2344/0003-3006-59.2.90
- Neal JM, Bernards CM, Butterworth JF, et al. ASRA Practice Advisory on Local Anesthetic Systemic Toxicity. Regional Anesthesia and Pain Medicine. 2018;43(2):113–123. doi:10.1097/AAP.0000000000000720
- Wright GZ, Weinberger SJ. Prilocaine-induced methemoglobinemia in a pediatric patient: a case report and review of the literature. Anesthesia Progress. 2020;67(3):164–170. doi:10.2344/anpr-67-03-04
- Guay J. Methemoglobinemia related to local anesthetics: a summary of 242 episodes. Anesthesia and Analgesia. 2009;108(3):837–845. doi:10.1213/ane.0b013e318187c4b1
- Association of Anaesthetists of Great Britain and Ireland. Management of Severe Local Anaesthetic Toxicity. AAGBI Safety Guideline; 2020. Guidelines for recognition and treatment of local anesthetic toxicity including lipid emulsion rescue.
- Löfgren N. Xylocaine: a new synthetic drug with local anesthetic and antiarrhythmic properties. Svensk Kemisk Tidskrift. 1946;58:206–217. Foundational work on amide-type local anesthetics that led to the development of prilocaine in the 1950s.
- American Dental Association Council on Scientific Affairs. Useful medications for oral conditions. ADA; 2023. Guidelines on dental local anesthetic selection for adults, children, and medically compromised patients.
Editorial Team
This article has been written and reviewed by the iMedic medical editorial team according to our strict editorial standards. Our team consists of licensed physicians, dentists, pharmacists, and medical researchers with expertise in anesthesiology, dentistry, clinical pharmacology, and drug safety.
Content developed by iMedic's medical writing team based on current international guidelines (WHO, EMA, FDA, BNF) and peer-reviewed pharmacological research.
Independently reviewed and fact-checked by the iMedic Medical Review Board, comprising board-certified specialists in anesthesiology, oral surgery, and clinical pharmacology.
All medical claims are supported by Level 1A evidence (systematic reviews, meta-analyses, and randomized controlled trials) following the GRADE evidence framework.
iMedic receives no commercial funding from pharmaceutical companies. All content is editorially independent with no conflicts of interest.