Background: Inferior alveolar nerve block (IANB) is the standard anesthetic approach for mandibular first molars;however, it has well-documented limitations, including variable success rates, delayed onset, higher anesthetic dose requirements, and potential complications. The TuttleNumbNow (TNN) anesthesia protocol introduces intraosseous (IO) injections as the primary anesthetic modality, followed by infiltration and IANB as a last resort. This approach seeks to provide rapid site-specific anesthesia at reduced pharmacological doses. This study evaluated the clinical efficacy of the TNN protocol for mandibular first molar procedures in a private practice setting. Methods: This retrospective observational study reviewed patient records from Tuttle Family Dental (Orem, Utah, USA) between January and December 2023. Eligible cases included patients undergoing composite restorations, crown preparations, or crown seating on the mandibular first molars, where anesthesia was administered according to the TNN protocol. Data were extracted from Eaglesoft electronic dental records and categorized as follows:no anesthetic, single-agent TNN (articaine 4% with epinephrine 1:100,000 or mepivacaine 3% without epinephrine), dual-agent TNN, or conversion to IANB. Descriptive statistics summarized the anesthetic regimens, and Fisher’s exact test assessed the association between procedure type and IANB conversion. Results: In total, 184 cases (74 composites, 57 crown preparations, and 53 crown seats) were included. One-quarter of the procedures (47; 24.9%) required no local anesthesia. Of the 137 cases requiring anesthesia, 88 (64.2%) were managed with a single agent, 41 (29.9%) with dual agents, and 8 (5.8%) required an IANB. Overall, 129 of the 137 cases (94.2%) were successfully completed without IANB. The need for IANB was significantly associated with procedure type (P = 0.0008), occurring most frequently during crown preparations (7 of 57 cases, 12.3%). Conclusion The TNN anesthesia protocol achieved profound anesthesia in 94.2% of mandibular first molar cases without requiring IANB, demonstrating its effectiveness as a primary anesthetic strategy. Compared with traditional IANB, the TNN approach offers rapid-onset, site-specific anesthesia while reducing patient anesthetic exposure and postoperative complications. These findings support reframing IO anesthesia from a secondary “rescue” technique to an effective first-line modality. Prospective multicenter studies are warranted to validate its efficacy in broader patient populations.

Incidental findings are commonly noted in advanced imaging studies. Few data exist regarding the rate of incidental findings on computed tomography (CT) for preoperative shoulder arthroplasty planning. This study aims to identify the incidence of these findings and the rate at which they warrant further work-up to help guide orthopedic surgeons in counseling patients. Methods: A retrospective review was performed to identify patients with available preoperative shoulder CT who subsequently underwent shoulder arthroplasty procedures at a single institution between 2015 and 2021. Data including age, sex, and smoking status were obtained. Radiology reports for CTs were reviewed for incidental findings and categorized based on location, tissue type, and/or body system. The rate of incidental findings and the rate at which further follow-up was recommended by the radiologist were determined. Results: A total of 617 patients was identified. There were 173 incidental findings noted in 146 of these patients (23.7%). Findings ranged from pulmonary (59%), skin/soft tissue (16%), thyroid (13%), vascular (9%), spinal (2%), and abdominal (1%) areas. Of the pulmonary findings, 50% were pulmonary nodules and 47% were granulomatous disease. Overall, the final radiology report recommended further follow-up for 50% of the patients with incidental findings. Conclusions: Incidental findings are relatively common in preoperative CTs obtained for shoulder arthroplasty, occurring in nearly one-quarter of patients. Most of these findings are pulmonary in nature. Overall, half of the patients with incidental findings were recommended for further follow-up. These results establish population data to guide orthopedic surgeons in patient counseling. Level of evidence: III.