Citanest Shortage: What Providers and Prescribers Need to Know in 2026

The discontinuation of Citanest Plain Dental (4% prilocaine HCl without vasoconstrictor) from the US market represents a meaningful clinical challenge for dental providers who rely on this agent for specific patient populations. This guide is intended for dentists, oral surgeons, periodontists, endodontists, and dental hygienists to help navigate the supply change, identify appropriate substitutes, and update clinical protocols in 2026.

Clinical Summary: What Has Changed

Citanest Plain Dental (NDC 66312-630-14): Formally discontinued in the US market. Not available from any distributor. No approved generics remain on the market.

Citanest Forte Dental (NDC 66312-580-16, 4% prilocaine with epinephrine 1:200,000): May be available through dental supply distributors on an inconsistent basis. Clinicians should not rely on consistent supply.

Patient Populations Most Affected by the Discontinuation

Citanest Plain was the preferred agent for:

• Cardiovascular-compromised patients: Those with unstable angina, recent MI, uncontrolled hypertension, or significant arrhythmias where even low doses of epinephrine carry elevated risk.
• Patients on MAO inhibitors or tricyclic antidepressants: These drug classes potentiate the pressor effects of vasoconstrictors and increase the risk of hypertensive crisis with epinephrine-containing formulations.
• Patients with bisulfite allergy: Citanest Forte contains sodium metabisulfite. Citanest Plain was sodium metabisulfite-free, making it the choice for bisulfite-sensitive patients. These patients also cannot use most formulations with epinephrine or levonordefrin.
• Short maxillary anterior procedures: Citanest Plain's short pulpal duration (approximately 10 minutes) was ideal for procedures expected to take less than 15-20 minutes, where prolonged anesthesia was undesirable.
• Pediatric patients: Prilocaine's lower systemic toxicity compared to other amides made it a preferred option for children. The maximum dose for a 5-year-old weighing 50 lbs is approximately 150-200 mg (6.6-8.8 mg/kg per Clark's rule).

Evidence-Based Substitution Strategies

For epinephrine-free requirement: Switch to mepivacaine 3% plain (Carbocaine, Polocaine). This is the most broadly stocked vasoconstrictor-free dental local anesthetic in the US. Duration for infiltration: 20-40 minutes pulpal, 2-3 hours soft tissue. Duration for nerve block: 40-60 minutes pulpal, 3-5 hours soft tissue.

For bisulfite allergy only (epinephrine acceptable): Lidocaine 2% with epinephrine 1:100,000 is formulated without sodium metabisulfite in most preparations. Verify with your distributor.

For general substitution (patients who tolerate epinephrine): Articaine 4% with epinephrine 1:100,000 or 1:200,000 (Septocaine, Zorcaine) is the most clinically versatile substitute. Its thiophene ring structure enhances lipid solubility and tissue diffusion, making it especially effective for mandibular infiltrations and hard-to-anesthetize patients. Half-life of approximately 27-42 minutes provides a favorable safety margin.

Updating Your Practice Protocols

We recommend dental practices take the following steps:

1. Audit your patient charts to identify anyone whose records indicate a contraindication to epinephrine or vasoconstrictors
2. Update your anesthetic tray protocols to include mepivacaine 3% plain as a standard backup
3. Brief your clinical team on the discontinuation so they do not inadvertently order or expect Citanest Plain
4. Check your existing inventory — do not use expired Citanest cartridges; inspect for discoloration or particulate matter before any use
5. Communicate with high-risk patients before their next appointment so they are not surprised by a different anesthetic

Methemoglobinemia Risk: A Note for Clinicians

One reason to be aware of when switching away from prilocaine entirely is that mepivacaine does not carry the methemoglobinemia risk that prilocaine does at higher doses. This is a clinical advantage in patients with G6PD deficiency, respiratory compromise, or sickle cell anemia. For these patients, the switch to mepivacaine or articaine actually removes a risk that prilocaine carried.

Helping Patients Source Medications

If your practice needs help locating Citanest Forte or alternative anesthetics, medfinder for providers can help you quickly check availability at multiple supply sources. medfinder calls distributors and supply networks on your behalf, saving your team valuable time.

See also: How to help your patients find Citanest in stock: A provider's guide.