Clinical use of an epinephrine-reduced (1/400,000) articaine solution in short-time dental routine treatments--a multicenter study

Intraoral perfusion assessment using endoscopic hyperspectral imaging (EHSI)- first description of a novel approach

OBJECTIVES

This study aimed to establish a method to detect and quantify mucosal malperfusion intraorally using state-of-the-art Endoscopic Hyperspectral Imaging (EHSI). For this purpose, mucosal ischemia was selectively induced by intraligamentary anesthesia (ILA) with and without + epinephrine using a standardized protocol.

MATERIALS AND METHODS

EHSI was performed using a novel endoscopic hyperspectral imaging system. Parameters assessed were Tissue Oxygen Saturation (StO2 [%]), Tissue Hemoglobin Index (THI), Near Infrared Perfusion Index (NPI) and Tissue Water Index (TWI). Fifty-seven healthy subjects received ILA using Articaine 4% with (ILA+) and without (ILA-) epinephrine at a dosage of 1:200,000 administered mesially and distally to the target tooth 42 (Universal No. 26). Mucosal perfusion was assessed using EHSI for 45 min post-injection.

RESULTS

After ILA+, a distinct ischemia of the mucosa was already clinically apparent after 30 s with significant reduction of THI and StO2 by an average of 57% (p < 0.001) and 7% (p < 0.040) compared to baseline values. Persistent hypoperfusion of the oral mucosa was observed throughout the monitoring period, exhibiting a gradual resolution at the 30-minute mark, and nearing baseline perfusion approximately 45 min post-injection. There was no papillary necrosis after ILA + injection.

CONCLUSION

EHSI is suitable to adequately detect and visualize actual perfusion of the intraoral mucosa. The study revealed that LA with epinephrine (1:200,000) induce temporary hypoxia in the dental papilla but without causing severe ischemia.

CLINICAL RELEVANCE

EHSI will enable promising applications in the future, i.a. success monitoring of periodontal therapies, intraoral free flap monitoring and the assessment of cancer margins.

Buffered 4% Articaine Reduces Pain and Enhances Anesthesia in Maxillary Third Molar Extractions: A Randomized, Double-Blind Split-Mouth Study

Background/Objectives: Buffered local anesthetics are suggested to enhance patient comfort and anesthetic efficacy during dental procedures. However, their advantages over non-buffered solutions in maxillary third molar extractions remain under-investigated. This prospective, randomized, double-blind, split-mouth study aimed to compare the efficacy of buffered versus non-buffered 4% articaine in terms of pain, anesthetic onset, and the duration of anesthesia during maxillary third molar extractions. Methods: Each participant randomly received two buccal infiltrations on two single appointments to extract maxillary third molars: one with 4% articaine buffered with sodium bicarbonate and the other with non-buffered 4% articaine. Pain during injection, post-extraction pain, onset time, and the duration of anesthesia were assessed using a visual analog scale (VAS; 0-10). Results: Fifty adult participants (23 males and 27 females) with a mean age of 21.6 years were included in the study. Buffered 4% articaine significantly reduced injection pain (mean VAS: 3.12 ± 1.36 vs. 4.2 ± 0.3, p = 0.0001) and post-extraction pain (mean VAS: 4.4 ± 1.75 vs. 5.76 ± 1.78, p = 0.0002) compared to non-buffered articaine. Additionally, buffered articaine demonstrated a faster onset of anesthesia (mean time (seconds): 85.92 ± 27.37 vs. 126.86 ± 33.15, p < 0.0001) and a longer duration of anesthesia (mean duration (minutes): 70.4 ± 13.64 vs. 51.4 ± 7.2, p < 0.0001). Regarding gender's factor, the comparisons revealed no statistically significant differences (p < 0.05) in pain perception between males and females for either injection pain or post-extraction pain. Conclusions: Buffered 4% articaine provides superior anesthetic efficacy compared to non-buffered 4% articaine, enhancing patient comfort by reducing pain, accelerating onset, and prolonging the duration of anesthesia during maxillary third molar extractions.

Cardiovascular and Vector-Cardiographic Effects of Articaine Anesthesia with Epinephrine

The aim was to investigate the vector-cardiographic effects in patients submitted to dental extraction under local anesthesia. Twenty-one patients aged 36.6 ± 12.4 years with a clinical and radiographic indication of mandibular or maxillary tooth extraction were enrolled. The intervention was a local or mandibular nerve block anesthesia with 4% articaine hydrochloride containing epinephrine (1 : 100,000; 40 mg/ml + 10 μg/ml). Blood pressure (BP), heart rate (HR), pulse wave transit time, and vector-cardiography data were recorded throughout 3 min before and 5 min after injection. QRS- and T-wave area under the curve (QRS AUC/T AUC) were calculated from the X/Y/Z QRS-vector or T-vector. T-wave amplitude (T AM), T AUC values, and diastolic BP decreased, and HR significantly increased 4 min after injection. A transient moderate HR drop and a corresponding small increase in T AM and T AUC immediately after the injection procedure may be explained by a decreased sympathetic tone due to psychological relief. In dental anesthesia, the systemic epinephrine effects are represented by a decrease in T AUC. These effects are most pronounced in the X- and Y-leads. The 3D determination of vector planes or amplitudes is a simple method to register the sympathetic tone in local anesthesia independently of possible effects on T-wave characteristics in single leads. In conclusion, T-wave determination may help to detect even small increases in systemic adrenaline concentration in case of accidental intravascular injection. At the same time, full rhythm and spatial ischemia control is provided.

Comparison of spinal anaesthesia and erector spinae plane block in unilateral inguinal hernia: Randomised clinical trial

INTRODUCTION

The objective of our study was to compare erector spinae plane block (ESP) with spinal anaesthesia (SA) for inguinal hernia repair with respect to anaesthetic efficacy, post-operative analgesia, mobilisation, discharge, complication and side effects.

PATIENTS AND METHODS

The study included 52 patients over 50 years of age, with the American Society of Anaesthesia physical status Class I-III. Group ESP ( n = 26) was applied 30 ml of mixed local anaesthetic mixture applied at the L1 level to the plane of the erector spinae and 10 ml of tumescent when necessary, while Group SA ( n = 26) was applied 3 ml of 0.5% bupivacaine at the L3-L4/L2-L3 level.

RESULTS

Intraoperative Visual Analogue Scale (VAS) value was lower in Group S, whereas the 6 th -h VAS value was lower in Group ESP ( P < 0.05). There was no significant difference between the VAS values at hour 12 and 24 ( P > 0.05). Reaching post-anaesthesia discharge criteria 9 and time to mobilisation and oral feeding was shorter in Group ESP, whereas post-procedure waiting time was shorter in Group S ( P < 0.05). While the need for post-operative analgesics was higher in Group S ( P < 0.05), there was a high level of patient satisfaction in Group ESP ( P = 0.05). Intraoperative midazolam requirement was lower in Group S, post-operative diclofenac requirement was lower in Group ESP ( P < 0.05), post-operative urinary retention and tremor were higher in Group S ( P = 0.05).

CONCLUSION

ESP block provides adequate surgical anaesthesia compared to SA (non-inferiority) for inguinal hernia repair. It is associated with less analgesic requirement, low post-operative pain, less complication rate and high patient satisfaction in the post-operative period.

Hyperspectral Imaging to Study Dynamic Skin Perfusion after Injection of Articaine-4% with and without Epinephrine-Clinical Implications on Local Vasoconstriction

This study aimed to investigate the dynamic skin perfusion via hyperspectral imaging (HSI) after application of Articaine-4% ± epinephrine as well as epinephrine only. After the subcutaneous injection of (A100) Articaine-4% with epinephrine 1:100,000, (A200) Articaine-4% with epinephrine 1:200,000, (Aw/o) Articaine-4% without epinephrine, and (EPI200) epinephrine 1:200,000, into the flexor side of the forearm in a split-arm design, dynamic skin perfusion measurement was performed over 120 min by determining tissue oxygen saturation (StO₂) using HSI. After injection, all groups experienced a reactive hyperaemia. With A200, it took about three min for StO₂ to drop below baseline. For Aw/o and EPI200, perfusion reduction when compared to baseline was seen at 30 min with vasoconstriction >120 min. A100 caused vasodilation with hyperaemia >60 min. After three minutes, the perfusion pattern differed significantly (p < 0.001) between all groups except Aw/o and EPI200. The vasoactive effect of epinephrine-containing local anaesthetics can be visualised and dynamically quantified via StO2 using HSI. Aw/o + epinephrine 1:100,000 and 1:200,000 leads to perfusion reduction and tissue ischaemia after 30 min, which lasts over 120 min with no significant difference between both formulations. When using Aw/o containing epinephrine in terms of haemostasis for surgical procedures, a prolonged waiting time before incision of 30 or more min can be recommended.

Modified PDL anesthetic injection technique in the pediatric dental practice

Relevance. Effective pain relief is required for high-quality outpatient dental treatment in children. Infiltration and PDL local anesthetic injection techniques are easier and safer for young patients. Purpose – to determine the effectiveness and safety of the modified PDL anesthetic injection technique in the pediatric dental practice. Materials and methods. The study involved 100 children aged 4 to 7 years, in need of caries and pulpitis treatment in the primary dentition. 4% articaine solutions with 1: 200000 and 1: 400000 epinephrine were administered as a local anesthetic. The effectiveness of the treatment was determined by the visual analogue scale.Results. The study determined the high effectiveness and safety of the modified technique of PDL anesthetic injection of 4% articaine solution with epinephrine ratio 1:200 000 and 1:400 000 for the treatment of caries and pulpitis in 100 children aged 4-7 years.Conclusions. The conducted studies have demonstrated the high ffectiveness and safety of the modified PDL anesthetic injection technique of a 4% solution of articaine with epinephrine both at a concentration of 1:200 000 and 1:400 000.

Comparison of spinal anaesthesia versus ilioinguinal-iliohypogastric nerve block applied with tumescent anaesthesia for single-sided inguinal hernia

BACKGROUND & AIMS

Primary aim of this study is to determine whether the use of local anaesthesia performed with IINB and IHNB against spinal anaesthesia in inguinal hernia repair is accepted as an alternative medicine.

METHODS

75 cases in the class of American Society of Anesthesia physical status (ASA) I-III between the ages of 18 and 75 diagnosed with single-sided inguinal hernia and hospitalized for surgery in general surgery clinic were prospectively and randomly included in this study.

RESULTS

There was statistically significant difference between the groups (30.14 ± 8.2 and 35.51 ± 9.39) in terms of the duration of the surgery. The duration was shorter in Group 1 (p < 0.001). There was statistically significant difference between the groups in terms of the duration of the first mobilization. It was significantly shorter in Group 2 than in Group 1 (5.71 ± 1.7 and 2.70 ± 1.53 min) (p < 0.001). Mean duration of length of hospital stay criteria was significantly shorter in Group 2 than in Group 1 (26.00 ± 6.43 and 14.23 ± 5.40 h) (p < 0.001). Throughout the follow-up period in postoperative 24 h, the number of patients who needed analgesia was significantly higher in Group 1 than in Group 2 (91.4% and 45.7%) There was statistically significant difference between the groups in terms of patient satisfaction and urinary retention development (p < 0.005). Hematoma development or postoperative bleeding was not observed in either group. The time of sensory block onset was significantly higher in Group 2 than in Group 1 (9.66 ± 1.41 and 9.03 ± 0.98 min) (p < 0.005) CONCLUSION: The results of our study show that IINB and IHNB applied with local anaesthesia are superior to spinal anaesthesia in unilateral inguinal hernia repairs.

Comparison of anesthetic efficacy of 2 and 4 % articaine in inferior alveolar nerve block for tooth extraction-a double-blinded randomized clinical trial

OBJECTIVES

The purpose of this clinical prospective, randomized, double-blind trial was to compare the anesthetic efficacy of 2 % articaine and 4 % articaine in inferior alveolar nerve block anesthesia for extraction of mandibular teeth.

MATERIALS AND METHODS

In 95 patients, 105 lower molar and premolar teeth were extracted after intraoral inferior alveolar nerve block. In 53 cases, 2 % articaine (group I) and, in 52 cases, 4 % articaine (group II) was administered. The primary objective was to analyze the differences of anesthetic effects between the two groups (complete/sufficient vs. insufficient/none). Furthermore, differences in pulpal anesthesia (onset and depth, examined with pulp vitality tester (min)), as well as in length of soft tissue anesthesia (min), were evaluated. Additionally, the need of a second injection, pain while injecting (numeric rating scale (NRS)), pain during treatment (NRS), pain after treatment (NRS), and other possible complications (excessive pain, bleeding events, prolonged deafness) were analyzed.

RESULTS

Anesthesia was sufficient for dental extractions in both groups without significant differences (p = 0.201). The onset of anesthesia did not differ significantly (p = 0.297). A significantly shorter duration of soft tissue anesthesia was seen in group I (2.9 vs. 4 h; p < 0.001). There was no significant difference in the need for a second injection (p = 0.359), in injection pain (p = 0.386), as well as in pain during (p = 0.287) or after treatment (p = 0.121). In both groups, no complications were seen.

CONCLUSIONS

The local anesthetic effect of the 4 % articaine solution is not significantly better when compared to 2 % articaine.

CLINICAL RELEVANCE

For mandibular tooth extraction, articaine 2 % may be used as alternative as well.

Movement control during aspiration with different injection systems via video monitoring-an in vitro model

OBJECTIVES

The aim of the present study was an evaluation of movement during double aspiration by different manual syringes and one computer-controlled local anesthesia delivery system (C-CLAD).

MATERIALS AND METHODS

With five different devices (two disposable syringes (2, 5 ml), two aspirating syringes (active, passive), one C-CLAD), simulation of double aspiration in a phantom model was conducted. Two experienced and two inexperienced test persons carried out double aspiration with the injection systems at the right and left phantom mandibles in three different inclination angles (n = 24 × 5 × 2 for each system). 3D divergences of the needle between aspiration procedures (mm) were measured with two video cameras.

RESULTS

An average movement for the 2-ml disposal syringe of 2.85 mm (SD 1.63), for the 5 ml syringe of 2.36 mm (SD 0.86), for the active-aspirating syringe of 2.45 mm (SD 0.9), for the passive-aspirating syringe of 2.01 mm (SD 0.7), and for the C-CLAD, an average movement of 0.91 mm (SD 0.63) was seen. The movement was significantly less for the C-CLAD compared to the other systems (p < 0.001). The movement of the needle in the soft tissue was significantly less for the C-CLAD compared to the other systems (p < 0.001).

CONCLUSIONS

A difference in involuntary movement of the syringe could be seen in comparison between manual and C-CLAD systems. Launching the aspiration by a foot pedal in computer-assisted anesthesia leads to a minor movement.

CLINICAL RELEVANCE

To solve the problem of movement during aspiration with possibly increased false-negative results, a C-CLAD seems to be favorable.

Tracking local anesthetic effects using a novel perceptual reference approach

Drug effects of loco-regional anesthetics are commonly measured by unidimensional pain rating scales. These scales require subjects to transform their perceptual correlates of stimulus intensities onto a visual, verbal, or numerical construct that uses a unitless cognitive reference frame. The conceptual understanding and execution of this magnitude estimation task may vary among individuals and populations. To circumvent inherent shortcomings of conventional experimental pain scales, this study used a novel perceptual reference approach to track subjective sensory perceptions during onset of an analgesic nerve block. In 34 male subjects, nociceptive electric stimuli of 1-ms duration were repetitively applied to left (target) and right (reference) mandibular canines every 5 s for 600 s, with a side latency of 1 ms. Stimulus strength to the target canine was programmed to evoke a tolerable pain intensity perception and remained constant at this level throughout the experiment. A dose of 0.6 ml of articaine 4% was submucosally injected at the left mental foramen. Subjects then reported drug effects by adjusting the stimulus strength (in milliamperes) to the reference tooth, so that the perceived intensity in the reference tooth was equi-intense to the target tooth. Pain and stimulus perception offsets were indicated by subjects. Thus, the current approach for matching the sensory experience in one anatomic location after regional anesthesia allows detailed tracking of evolving perceptual changes in another location. This novel perceptual reference approach facilitates direct and accurate quantification of analgesic effects with high temporal resolution. We propose using this method for future experimental investigations of analgesic/anesthetic drug efficacy.

Evaluation of the anesthetic effect of epinephrine-free articaine and mepivacaine through quantitative sensory testing

Introduction

Long lasting anesthesia of the soft tissue beyond the dental treatment affects patients in daily routine. Therefore a sophisticated local anesthesia is needed. The purpose of this study was an evaluation of the clinical use of epinephrine-free local anesthetic solutions in routine short-time dental treatments.

Materials and methods

In a prospective, single-blind, non-randomized and controlled clinical trial, 31 patients (16 male, 15 female patients) undergoing short-time dental treatment under local anesthesia (plain solutions of articaine 4% and mepivacaine 3%) in area of maxillary canine were tested with quantitative sensory testing QST. Paired-Wilcoxon-testing (signed-rank-test) and Mc Nemar tests have been used for statistical results.

Results

Significant differences in all tested parameters to the time of measurements were found. Mepivacaine showed a significantly stronger impact for the whole period of measurement (128 min) on thermal and mechanical test parameters and to the associated nerve fibers.

Conclusion

Plain articaine shows a faster onset of action associated with a shorter time of activity in comparison to plain mepivacaine. In addition to this articaine shows a significant low-graded effect on the tested nerve-fibers and therefore a least affected anesthesia to the patient. The clinical use of an epinephrine-free anesthetic solution can be stated as possible option in short dental routine treatments to the frequently used vasoconstrictor containing local anesthetics. Patients may benefit from shorter numbness.

Periodontal intraligament injection as alternative to inferior alveolar nerve block--meta-analysis of the literature from 1979 to 2012

OBJECTIVES

In a first meta-analysis, inferior alveolar nerve block (IANB) and periodontal intraligamentary injection anesthesia (ILA) were compared with focus on the failure rate of local anesthesia, pain during injection, additional injections, cardiovascular disturbances (CVD), and method-inherent differences (unwanted side effects, latency time, amount of anesthetic solution, duration of anesthesia) in adult patients.

MATERIALS AND METHODS

Prospective and retrospective studies with clinical comparison of both injection techniques considering the relevant outcome parameters in adult patients from 1979 to 2012 were included. A specific tool for assessing risk of bias in each included study was adopted. Data were assessed for methodological reliability and extracted and supplemented by sensitivity analysis by two independent reviewers.

RESULTS

Seven studies were included [evidence grade Ib (n=1), IIb (n=3), and III (n=3)]. For other parameter than CVD, the significant heterogeneity of the random effects did not allow the reporting of pooled summary effect estimates. CVD were found significantly more often after IANB [odds ratio (OR): 0.12 (0.02-0.69)]. Further analysis revealed less injection pain in cases of ILA [OR: 0.32 (0.1-1)]. For failure rates as well as for needed additional injections, no significant differences were detected. IANB showed a latency of >3 min, whereas ILA had nearly none. The effect of IANB is longer than for ILA.

CONCLUSIONS

Methodological and reporting flaws were consistently observed in the included articles. Except for CVD, it could not be shown that ILA is neither superior nor inferior compared to IANB.

CLINICAL RELEVANCE

IANB as "gold standard" for routine dental treatments should be discussed.

Pharmacology of local anesthetics used in oral surgery

This article provides a comprehensive review of the pharmacology of local anesthetics as a class, and provides details of the individual drugs available in dental cartridges. Maximum recommended doses of local anesthetics and vasoconstrictors are presented for healthy adult and pediatric patients, and for patients with cardiovascular system impairments. Various complications and reasons for failure of local anesthesia effectiveness are discussed, and current and future trends in local anesthesia are presented to provide an overview of current research in local anesthesia.

Epinephrine-reduced articaine solution (1:400,000) in paediatric dentistry: a multicentre non-interventional clinical trial

AIM

In paediatric dentistry, epinephrine may contribute to systemic and local side-effects. On the other hand it is necessary to provide good and safe local analgesia. Therefore, an articaine solution with reduced epinephrine concentration was tested in a clinical setting.

METHODS

In a non-interventional clinical study, dental treatment was performed in children and adolescents (4-17 years). For local analgesia, articaine 4 % plus epinephrine 1:400,000 was used in the technique chosen by the dentist. Efficacy and tolerance as well as duration of soft tissue analgesia and side-effects were evaluated.

RESULTS

999 patients (50.5 % male, 49.5 % female) with a mean age of 7.9 (SD 2.34) years were treated. Two hundred seventy six patients (27.6 %) received sedation prior to treatment. The mean treatment time was 15 min (SD 10). In 93.5 % of cases, initial local analgesia was sufficient to perform the planned treatment. In 99 % of cases (n = 989) the planned treatment could be completed. A second injection was necessary in 6.5 % of cases. A mean duration of soft tissue analgesia of 2.19 h (SD 1.01) was seen. Slight side-effects occurred in 3.1 % of subjects.

CONCLUSIONS

Due to high efficacy, tolerance and safety, the articaine 4 % solution with the reduced epinephrine concentration (1:400,000) was a safe and suitable drug for paediatric routine treatment.