Comparison of clonidine and epinephrine in lidocaine anaesthesia for lower third molar surgery

Clonidine versus Adrenaline as an Adjunct to Lignocaine on Haemodynamic Parameters during Nerve Block for Third Molar Surgical Removal - A Systematic Review and Meta-Analysis

Background

Adrenaline or clonidine is used as adjuncts in conjunction with lignocaine to improve the depth of local anaesthesia in dental procedures.

Objectives

This systematic review and meta-analysis intends to compare the haemodynamic parameters when clonidine or adrenaline is used in conjunction with lignocaine for third-molar surgical removal.

Data Sources

Cochrane, PubMed and Ovid SP databases were searched using "MeSH" terms (((nerve block) OR (IANB)) AND ((clonidine) OR (adrenaline))) AND (lignocaine).

Study Eligibility Criteria

Clinical studies where Clonidine + lignocaine and Adrenaline + lignocaine were compared directly during nerve block administration exclusively for third molar surgical removal were selected.

Participants Study Appraisal

This current systematic review is registered in Prospero database CRD42021279446. Two independent reviewers were involved in collection, segregation and analysis of electronic data. The data were compiled in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Search was conducted till June 2021.

Synthesis Methods

Qualitative analysis of the selected articles was performed for systematic review. Meta-analysis is performed using RevMan 5 Software. Heterogeneity through the I2 statistics. Change in the haemodynamic parameters was the primary outcome evaluated, and secondary outcomes evaluated were onset and duration of anaesthesia in both the groups.

Results

In all databases, 1141 records were screened, out of which a total of 21 articles were included for the evaluation for full-text analysis. Out of these, 16 articles were excluded and 5 articles were included for the final systematic review. Meta-analysis was performed only for 4 studies.

Conclusion

Amongst the evaluated haemodynamic parameters, there was a significant reduction in the heart rate (baseline to intraoperative period) in clonidine and lignocaine groups than in adrenaline and lignocaine groups during nerve block administration for third molar surgical removal. There was no significant difference between other primary and secondary outcomes evaluated.

Limitations

Blinding was not performed in all the studies, randomisation was performed in only three studies. The volume of local anaesthesia deposited varied in the studies (2 mL in three studies and 2.5 mL in two studies). Most of the studies (n = 4) were evaluated on normal adults and only one study evaluated mild hypertensive patients.

Comparative Evaluation of Effectiveness of 2% Lignocaine Hydrochloride with Clonidine Hydrochloride versus 2% Lignocaine Hydrochloride with Adrenaline Bitartrate as Local Anesthetic for Adult Patients Undergoing Surgical Extraction of Impacted Mandibular Third Molars: A Randomized Controlled Clinical Study

Background and Objectives:

Clonidine is a common additive to local anesthetics for various regional and local nerve blocks. However, its effectiveness in dentistry has not yet been fully explored. Thus, this study was performed to evaluate the quality of anesthesia, vasoconstrictive effects, hemodynamic response, and pain control using a solution of 2% lignocaine hydrochloride with clonidine hydrochloride in comparison with the standard solution of 2% lignocaine hydrochloride and adrenaline bitartrate for pterygomandibular nerve blocks.

Materials and Methods:

A parallel arm, triple-blind randomized controlled study was conducted on 152 patients belonging to ASA-I (American Society of Anesthesiologists) category in the age group of 18-45 years, requiring surgical extraction of impacted mandibular third molars. The patients were divided equally into two groups randomly by computer-generated sequence; Group 1: 2% lignocaine hydrochloride with 1 ml of clonidine hydrochloride (150 μg/ml) and Group 2: 2% lignocaine hydrochloride with adrenaline bitartrate 1: 80,000 (12.5 μg/ml). The variables evaluated were systolic, diastolic, and mean arterial blood pressures, heart rate (HR), blood loss, onset, depth (pain), and duration of anesthesia.

Results:

There was a statistically nonsignificant difference seen between the two groups (P > 0.05) for the onset of anesthesia, pain assessed, and blood loss, whereas a statistically highly significant difference was seen for cardiovascular variables (systolic, diastolic and mean arterial blood pressures, and HR) at various intervals with higher values for Group 2 (P < 0.001) and for the duration of action of local anesthesia (LA), with higher values for Group 1 (P < 0.001).

Conclusions:

Clonidine as an additive to lignocaine has proved to have the onset of action, vasoconstrictive properties, and pain control, equivalent to adrenaline. However, with better stability of hemodynamic variables and prolonged duration of action of LA with clonidine, it can be considered as a better, safer, and more effective additive to lignocaine than adrenaline

Local anesthesia in oral and maxillofacial surgery: A review of current opinion

Local anesthesia (LA) is the most important pain management process in oral and maxillofacial surgery. Safe and effective LA not only enable patients to obtain high-quality treatment, but also relieve the anxiety of patients when they come to the clinic. The choices of local anesthetic and injection methods determine the success of LA to a great extent. At present, in most countries or regions, common local anesthetics used in oral and maxillofacial surgery belong to amides and they are injected into patients' body mainly through block or infiltration anesthesia. In addition, the operators' technique level, patient's subjective psychology and anatomical variation of maxillofacial structure also have a strong influence on LA in dental clinic. Due to the existence of above factors, the worldwide success rates of LA in oral and maxillofacial surgery is very different. There are no specific LA methods that ensure 100% successful LA rates. Fortunately, the development of new local anesthetic and injection technology are providing us with new ideas to solve this problem. This review mainly report the new research progress on LA in oral and maxillofacial surgery in recent decades and help clinicians with dental LA operation.

The additive effect of clonidine to lidocaine on postoperative pain management after root canal treatment on mandibular molars with symptomatic irreversible pulpitis: A prospective randomised double-blind clinical trial

Context:

Postoperative pain control has been a common challenge to clinicians in endodontics.

Aims:

This double-blind randomized clinical trial assessed the efficacy of clonidine added to lidocaine for postoperative pain following endodontic treatment of mandibular molars with symptomatic irreversible pulpitis (SIP).

Methods:

One hundred participants with lower molars experiencing SIP were recruited and randomly assigned to two groups. 1.8 mL of 2% lidocaine with either epinephrine (1:80,000) or clonidine (15 µg/mL) was administered to each group via an inferior alveolar nerve block. A Heft–Parker Visual Analog Scale was used to rate preoperative pain and at 6, 12, 24, 36, 48, and 72 h following endodontic treatment. Their postoperative analgesic consumption was recorded.

Statistical Analysis Used:

The analgesic efficacy was analyzed by Chi-square test, paired t-test, and repeated measures ANOVA (P < 0.05).

Results:

Early postoperative pain was significantly lower in the lidocaine/clonidine group than the lidocaine/epinephrine group (6 h: P = 0.038; 12 h: P = 0.031). The lidocaine/clonidine group consumed a significantly lower amount of analgesics (P = 0.048).

Conclusions:

The administration of clonidine added to lidocaine may reduce early postoperative pain and consumption of analgesics following endodontic treatment in lower molars with SIP.

Anesthetic Success Using Nitrous Oxide and a Combination of Lidocaine/Clonidine for the Inferior Alveolar Nerve Block and the Effects on Blood Pressure and Pulse in Patients with Symptomatic Irreversible Pulpitis: A Prospective, Randomized, Double-blind Study

INTRODUCTION

The pulpal anesthetic success rates for an inferior alveolar nerve block (IANB) alone in patients presenting with symptomatic irreversible pulpitis are less than adequate. Nitrous oxide and clonidine have shown increases in IANB success when administered individually, but their success has not been evaluated when used together. The purpose of this prospective, randomized, double-blind study was to determine the effect of nitrous oxide/oxygen plus an IANB using lidocaine/clonidine on the success of the IANB in patients with symptomatic irreversible pulpitis and to evaluate the effect of clonidine on blood pressure and pulse.

METHODS

Sixty-two emergency patients experiencing moderate to severe pain and a diagnosis of symptomatic irreversible pulpitis were enrolled. Subjects were randomly divided into 2 groups and received nitrous oxide/oxygen and an IANB using 2% lidocaine with either 27 μg clonidine or 18 μg epinephrine as vasoconstrictors. Blood pressure and pulse were recorded before and during the emergency endodontic treatment. Anesthetic success was defined as no or mild pain upon access and instrumentation of the canals.

RESULTS

The pulpal anesthetic success rate in both treatments was 58%, with no significant difference between the groups. There was no statistically significant difference in pulse or systolic blood pressure with the use of clonidine compared with epinephrine. Diastolic blood pressure was significant.

CONCLUSIONS

The use of nitrous/oxide plus the addition of lidocaine/clonidine for the IANB in teeth with symptomatic irreversible pulpitis resulted in no statistically significant difference in anesthetic success of the IANB. There were no statistically significant differences in pulse or systolic blood pressure with the use of clonidine compared with epinephrine; diastolic blood pressure was significant.

Effectiveness of anesthetic solutions for pain control in lower third molar extraction surgeries: a systematic review of randomized clinical trials with network meta-analysis

OBJECTIVE

To assess the effectiveness of different anesthetic solutions for pain control immediately after the extraction of lower third molars.

METHODS

Nine databases were used to identify randomized clinical trials, without restriction of language or year of publication. The "JBI Critical Appraisal Tools for Systematic Reviews" was used to assess the risk of bias in the studies. The network meta-analysis was performed to compare the effectiveness of different anesthetics to control the pain immediately after the surgery of lower third molars, using the standardized mean difference (SMD) as the effect estimate. The GRADE approach was used to assess the certainty of evidence.

RESULTS

The search presented 13,739 initial results, from which 45 met the eligibility criteria and presented low to moderate risk of bias. Thirteen studies were included in the meta-analysis. The 2% lidocaine + clonidine presented the lowest pain scores (SMD = - 1.44; - 2.72 to - 0.16) compared to 4% articaine + adrenaline, followed by 0.5% bupivacaine + adrenaline (SMD = - 1.36; - 2.13 to - 0.59). The certainty of evidence varied between very low to moderate.

CONCLUSION

2% lidocaine + clonidine and 0.5% bupivacaine + adrenaline were the anesthetics with the highest probability for pain control immediately after the surgical procedure of removing impacted lower third molars.

CLINICAL SIGNIFICANCE

The use of an adequate anesthetic with effective pain control can contribute to a more comfortable postoperative period.

Which is the most suitable local anaesthetic when inferior nerve blocks are used for impacted mandibular third molar extraction? A network meta-analysis

The aim of this study was to compare the efficacy and safety of the different local anaesthetic agents for the extraction of impacted lower third molars. A network meta-analysis was performed of all published reports of randomized controlled clinical trials assessing efficacy (anaesthetic success and absence of need for supplementary anaesthesia during the surgical procedure) and/or safety (number of adverse events) of anaesthetic agents. Three electronic databases were searched, from their earliest records up to April 2019. Additionally, the grey literature was searched to identify further potential candidates for inclusion. Anaesthesia had to be delivered by an inferior alveolar nerve block, complemented with infiltration anaesthesia of the buccal nerve. The quality of the studies was assessed using the Cochrane Collaboration tool. This study included a total of 21 trials (2021 molars) assessing the efficacy and 19 trials (1977 molars) assessing the safety of 11 anaesthetic solutions. Seven of the studies included were considered to have a high risk of bias. The most effective local anaesthetic for the extraction of impacted mandibular third molars appeared to be 4% articaine, with significant differences when compared with 2% lidocaine, 0.5% bupivacaine, and 1% ropivacaine. Lidocaine is the safest local anaesthetic, although all investigated solutions can be used safely.

Clonidine: An Adjuvant to Adrenaline in Local Anesthesia for Third Molar Surgery

Purpose:

The aim of the study is to compare the efficacy of anesthesia and hemodynamic parameters of clonidine and epinephrine in lignocaine for lower third molar surgery.

Materials and Methods:

Thirty healthy controls with impacted mandibular third molar were randomly selected from both sexes between the age group of 20–47 years. Patients were divided equally into two groups: Group I (Adrenaline group) and Group II (Clonidine group). Patients received 2.5 ml of 2% lignocaine with adrenaline (12.5 μg/ml) in Adrenaline group and 2.5 ml of 2% lignocaine with clonidine (15 μg/ml) in Clonidine group. Hemodynamic parameters (heart rate, systolic blood pressure [SBP], diastolic blood pressure [DBP], and mean arterial pressure [MAP]) were recorded preoperatively, intraoperatively, and postoperatively. The onset of anesthesia and duration of anesthesia were recorded using pinprick test for both groups. Postoperatively, patients were evaluated for pain experience by the visual analog scale and verbal rating scale.

Results:

Lignocaine with clonidine intraoperatively and postoperatively decreases SBP and DBP and MAP compared to lignocaine with adrenaline. There was no significant difference in the onset and duration of anesthesia in both the groups. There was a statistically significant difference seen in the visual analog scale, but no statistically significant difference was seen in the verbal rating scale.

Conclusion:

Clonidine has similar efficacy as that of adrenaline with better hemodynamic parameters and can be used as an alternative to adrenaline for third molar surgeries.

Effect of clonidine on the efficacy of lignocaine local anesthesia in dentistry: A systematic review and meta-analysis of randomized, controlled trials

Alternatives to adrenaline with lignocaine local anesthesia, such as clonidine, have been trialed in various randomized, controlled trials. Therefore, the aim of the present systematic review was to compile the available evidence on using clonidine with lignocaine for dental anesthesia. Electronic databases were searched for eligible studies. A data-extraction form was created, extracted data were analyzed using non-Cochrane mode in RevMan 5.3 software. Heterogeneity between the studies were assessed using the forest plot, I² statistics (where >50% was considered to have moderate-to-severe heterogeneity), and χ² -test. Random-effects models were used because of moderate heterogeneity. Five studies were included for the final review. While clonidine was found to significantly shorten the onset of local anesthesia when measured subjectively, no significant difference was observed objectively. No significant difference was observed in the duration and postoperative analgesia. Stable hemodynamic parameters within the safe range were observed postoperatively when clonidine was used. Clonidine could be considered as an alternative to adrenaline in cases of contraindications to adrenaline, such as like cardiac abnormalities, hypertension, and diabetes.

Comparative Effects of Clonidine and Adrenaline with Lignocaine during Maxillary Infiltration Anaesthesia for Dental Extraction

INTRODUCTION

Lignocaine is a commonly used local anaesthetic in dental practice. Many practitioners use adrenaline (epinephrine) as additive with lignocaine, and some have used clonidine, instead of adrenaline. Both having benefits and limitations.

AIMS

Hence a study was undertaken in our department to evaluate the advantages and disadvantages of using (plain lidocaine local anaesthetic) versus (lidocaine with adrenaline as additive) versus (lidocaine with clonidine as additive).

STUDY DESIGN

Randomised, prospective, double blind study.

MATERIALS AND METHODS

Seventy five patients requiring extraction of maxillary molar teeth who fall under ASA I category were included and randomly divided into group - I (n=25) (Lignocaine), group - II (n=25) (Lignocaine ± Adrenaline) and group - III (n=25) (Lignocaine ± Clonidine). The observations recorded were, time of onset of anaesthesia, hemodynamic parameters, blood loss during procedure and duration of post operative analgesia.

STATISTICAL ANALYSIS

The statistical analysis was carried out using SPSS 16 software.

RESULTS

A statistically significant difference was seen in blood loss, being higher in group I and duration of anaesthesia, being shortest in group I. There was no statistical difference between the three groups amongst other parameters.

CONCLUSION

Adrenaline at 10 μg/ml and clonidine at 15 μg/ml can be safely used as additives with lignocaine, in maxillary infiltration anaesthesia for dental extraction; with addition of either of these two drugs, having an equal advantage over use of plain lignocaine; in terms of lower blood loss and longer duration of anaesthesia; but, with no difference in the onset of anaesthesia and with no significant hemodynamic changes.

Effect of sodium bicarbonate-buffered lidocaine on the success of inferior alveolar nerve block for teeth with symptomatic irreversible pulpitis: a prospective, randomized double-blind study

INTRODUCTION

The purpose of this prospective, randomized, double-blind study was to compare the anesthetic efficacy of buffered with nonbuffered 2% lidocaine with 1:80,000 epinephrine solution for inferior alveolar nerve (IAN) block in patients with mandibular posterior teeth experiencing symptomatic irreversible pulpitis.

METHODS

Eighty adult patients diagnosed with symptomatic irreversible pulpitis of a mandibular posterior tooth were selected. The patients received 2 cartridges of either 2% lidocaine with 1:80,000 epinephrine buffered with 0.18 mL 8.4% sodium bicarbonate or 2% lidocaine with 1:80,000 epinephrine with 0.18 mL sterile distilled water using conventional IAN block injections. Endodontic access preparation was initiated 15 minutes after injection. Lip numbness was required for all the patients. Success was determined as no or mild pain on the basis of Heft-Parker visual analog scale recordings upon access cavity preparation or initial instrumentation. Data were analyzed by the t, Mann-Whitney, and chi-square tests.

RESULTS

The success rates were 62.5% and 47.5% for buffered and nonbuffered groups, respectively, with no significant differences between the two groups (P = .381).

CONCLUSIONS

Buffering the 2% lidocaine with 1:80,000 epinephrine with 8.4% sodium bicarbonate did not improve the success of the IAN block in mandibular molars in patients with symptomatic irreversible pulpitis.

Efficacy of lignocaine with clonidine and adrenaline in minor oral surgical procedure

Use of vasoconstrictors in local anaesthesia is well known. The study was done on 30 patients who underwent removal of bilateral impacted third molars. The aim of the study was to compare the efficacy of lignocaine with clonidine and lignocaine with adrenaline in respect to onset, duration of anaesthesia, and postoperative analgesia along with hemodynamic stability (systolic blood pressure, diastolic blood pressure, mean arterial pressure, heart rate in intraoral nerve block. The patients were randomly selected of both sexes (male and female) between the age group of 18–40 years. Patients received 2 mL of 2% lignocaine with adrenaline (12.5 μg/mL) on one side and 2 mL of 2% lignocaine with clonidine (15 μg/mL) on the other side at two different appointments. 2 millilitres of drug was administered in both the test group and the control group. Statistically there was significant decrease in intraoperative and postoperative systolic blood pressure, diastolic blood pressure, mean arterial pressure, and heart rate in the lignocaine with clonidine group. The efficacy of clonidine based on visual analog scale was similar to adrenaline. No significant operative complications were observed.

Clinical study of hemodynamic changes comparing 4% articaine hydrochloride with 1:100,000 and 1:200,000 epinephrine

OBJECTIVE

To evaluate hemodynamic changes with the use of 4% articaine and 2 different concentrations of epinephrine (1:100,000 and 1:200,000) in the surgical removal of symmetrically positioned lower third molars.

STUDY DESIGN

A prospective, randomized, double-blind clinical trial was carried out involving 42 patients each undergoing 2 surgeries on separate occasions under local anesthesia with 4% articaine and either epinephrine 1:100,000 or 1:200,000. The following parameters were assessed at 4 different moments: systolic, diastolic, and mean blood pressure; heart rate; oxygen saturation; rate pressure product (RPP); and pressure rate quotient (PRQ).

RESULTS

The concentration of epinephrine did not affect diastolic blood pressure or oxygen saturation during the surgeries. Significant differences between were detected for heart rate, RPP, and PRQ (P < .05).

CONCLUSIONS

The epinephrine concentration (1:100,000 or 1:200,000) in a 4% articaine solution influences hemodynamic parameters without perceptible clinical changes in healthy patients undergoing lower third molar removal.

Lidocaine+clonidine for maxillary infiltration anaesthesia: parameters of anaesthesia and vascular effects

The local anaesthetic and haemodynamic parameters achieved by lidocaine with clonidine or epinephrine, administered for maxillary infiltration anaesthesia, were studied in 40 patients (American Society of Anesthesiologists, physical status 1) who underwent upper third molar surgery. All patients received 2 ml of 2% lidocaine with clonidine (15 microg/ml; n=20) or epinephrine (12.5 microg/ml; n=20) in a randomized, double-blind fashion. Vascular effects were evaluated on the isolated human infraorbital arteries. The parameters of maxillary infiltration anaesthsia produced by a combination of lidocaine+clonidine were similar to those obtained with lidocaine+epinephrine. In both groups, haemodynamic parameters exhibited similar variations, with the exception of a significant reduction in heart rate and systolic blood pressure in the lidocaine+clonidine group and significant increase in heart rate in the lidocaine+epinephrine group, 10 min after surgery. Clonidine (10(-7), 10(-6) and 10(-5)M) produced an endothelium-independent vasocontractile effect on the isolated human infraorbital arteries. The results of this study indicate for the first time in dental anaesthesia that the lidocaine+clonidine combination could be a useful and safe alternative to lidocaine+epinephrine for intraoral infiltration anaesthesia.