Efficacy of articaine versus lidocaine as a supplemental buccal infiltration in mandibular molars with irreversible pulpitis: a prospective, randomized, double-blind study

Primary and supplementary anesthetic efficacy of a modified two-step buccal infiltration of 4% articaine in mandibular molars with symptomatic irreversible pulpitis: a randomized clinical trial

OBJECTIVES

To evaluate a modified two-step buccal infiltration (MBI) of 1.7 mL 4% articaine as primary or supplemental anesthesia in mandibular first and second molars diagnosed with symptomatic irreversible pulpitis (SIP).

MATERIALS AND METHODS

One hundred and eight patients with SIP were randomly assigned to one of three groups (n = 36). They were given an inferior alveolar nerve block (IANB) of 2% lidocaine with 1:80.000 epinephrine or a primary MBI of 4% articaine with 1:100.000 epinephrine in the IANB and MBI groups, respectively. Patients in the IANB + MBI group received an IANB followed by an MBI. Pain levels during the injection, access cavity preparation, and initial filing were recorded on the Heft-Parker visual analog scale (HP-VAS). No or mild pain (HP-VAS ≤ 54) upon access cavity preparation and initial filing was considered a success. Chi-square and Kruskal-Wallis tests were used to analyze the data.

RESULTS

MBI (77.8%) and IANB + MBI (94.4%) had both significantly higher success rates than IANB (50.0%) (P < .001). However, when the Bonferroni adjustment was applied, there was no statistically significant difference between the MBI and IANB + MBI techniques (P = .041 > .017). MBI was associated with significantly less injection pain than IANB (P < .001).

CONCLUSIONS

Both primary and supplemental MBI with 4% articaine were superior to IANB with 2% lidocaine in mandibular first and second molars diagnosed with SIP. Further research may be needed to confirm the findings of this study.

CLINICAL RELEVANCE

The findings of this study suggest that supplemental or primary MBI can be a clinically viable alternative to IANB, which has a relatively low success rate when managing mandibular molars diagnosed with SIP.

Anaesthetic efficacy and influence on cardiovascular parameters change of intraosseous computerised anaesthesia versus inferior alveolar nerve block anaesthesia in acute irreversible pulpitis of mandibular molars: study protocol for a prospective randomised controlled trial

BACKGROUND

Irreversible pulpitis is a highly painful inflammatory condition of the dental pulp. The recommended care is the removal of the coronal pulp (pulpotomy) for emergency treatment in multi-rooted teeth. However, achieving adequate analgesia in the case of mandibular molars presents many difficulties according to the dental literature. Intraosseous computerised anaesthesia (ICA), in particular, the QuickSleeper™ system, has already been demonstrated to be clinically efficient, but ICA is known to increase the heart rate reversibly in a manner that depends on the speed of injection. Therefore, accelerated heart rate was examined as a potential adverse effect of this injection. This trial aims to compare the cardiovascular effects and the anaesthetic efficacy of ICA versus inferior alveolar nerve block anaesthesia (IANB) in acute irreversible pulpitis of mandibular molars.

METHODS

This study is a non-inferiority prospective, randomised, controlled, single-blind, two-group trial conducted at the Nantes University Hospital. The study design included two parallel arms at a ratio of 1:1 that will allocate seventy-two patients into two groups: the first group will receive QuickSleeper™ intraosseous anaesthesia; the second will receive an inferior alveolar nerve block before emergency treatment (pulpotomy). This study will include patients requiring emergency dental care under local anaesthesia with confirmed irreversible pulpitis in mandibular molars. The primary outcome is the time taken for the fluctuations in the cardiovascular parameters to return to baseline values during endodontic treatment in two different anaesthetic techniques. The secondary outcomes include efficacy of the technique, patient's pain perception before and after care, any post-operative effects, and factors associated with the delay of recovery of cardiovascular parameters between the 2 anaesthetic techniques.

DISCUSSION

This trial will evaluate the factors associated with heart rate increase during local anaesthesia administration. The use of blood pressure and cardiovascular measurements can be considered an asset and additional safety in managing local anaesthesia. Detecting early signs of potential adverse events (AEs), particularly patients with certain medical conditions (cardiac rhythm disorders), would suggest caution in administering anaesthesia.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT03802305 registered January 14, 2019. (version no. 1.2; 5 November 2021).

Efficacy of articaine versus mepivacaine administered as different supplementary local anesthetic techniques after a failed inferior alveolar nerve block with lidocaine in patients with irreversible pulpitis: An in vivo study

Aim

The aim of the present study was to assess the efficacy of articaine versus mepivacaine administered as different supplementary local anesthetic techniques after a failed inferior alveolar nerve block (IANB) with lidocaine in patients with irreversible pulpitis.

Materials and Methods

A total of 120 patients were included in the study. Patients were given IANB with 2 ml of 2% lidocaine hydrochloride with 1:80,000 epinephrine. Patients who showed subjective symptoms of IANB but did not secure pulpal anesthesia were randomly allocated to one of the following four groups by random sampling for supplementary local anesthesia - Group 1: buccal infiltration (BI) with 4% articaine with 1:100,000 epinephrine, Group 2: four-site intraligamentary (IL) injection with 4% articaine with 1:100,000 epinephrine, Group 3: BI with 2% mepivacaine with 1:100,000 epinephrine, and Group 4: four-site IL injection with 2% mepivacaine with 1:100,000 epinephrine.

Results

Group 1 - BI with articaine provided anesthesia success in 27 cases (90%, n = 30). Group 2 - IL injection with articaine provided anesthesia success in 20 cases (66.67%, n = 30). Group 3 - BI with mepivacaine provided anesthesia success in 21 cases (70%, n = 30). Group 4 - IL injection with mepivacaine provided anesthesia success in 15 cases (50%, n = 30). A significant difference between the four groups was found.

Conclusion

In patients with a mandibular first molar exhibiting symptomatic irreversible pulpitis, block injection with lidocaine along with supplemental BI with articaine allowed more pain-free treatments. Articaine showed better results when compared with mepivacaine.

Anesthetic efficacy of supplemental buccal infiltration versus intraligamentary injection in mandibular first and second molars with irreversible pulpitis: a prospective randomized clinical trial

Background

To compare the anesthetic efficacy of supplemental buccal infiltration (BI) (1.7 ml) versus intraligamentary (IL) injection containing 0.4 ml of 4% articaine with 1:100.000 epinephrine after an inferior alveolar nerve block (IANB) with 1.7 ml 2% lidocaine in the first and second mandibular molars diagnosed with irreversible pulpitis (IP).

Methods

One hundred subjects diagnosed with IP of either the mandibular first (n = 50) or second molars (n = 50) and failed profound anesthesia following an IANB were selected. They randomly received either the IL or BI techniques of anesthesia. Pain scores on a 170 mm Heft-Parker visual analog scale were recorded initially, before, and during supplemental injections. Furthermore, pulse rate was measured before and after each supplemental injection. During the access cavity preparation and initial filing, no or mild pain was assumed to indicate anesthetic success. The chi-square test, Mann-Whitney U test, and independent samples t-test were used for the analyses.

Results

The overall success rates were 80% in the IL group and 74% in the BI group, with no significant difference (P = 0.63). In the first molars, there was no significant difference between the two techniques (P = 0.088). In the second molars, IL injection resulted in a significantly higher success rate (P = 0.017) than BI. IL injection was statistically more successful (P = 0.034) in the second molars (92%) than in the first molars (68%). However, BI was significantly more successful (P = 0.047) in the first molars (88%) than in the second molars (64%). The mean pulse rate increase was significantly higher in the IL group than in the BI group (P < 0.001).

Conclusions

Both the IL and BI techniques were advantageous when used as supplemental injections. However, more favorable outcomes were observed when the second molars received IL injection and the first molars received BI.

Inferior Alveolar Nerve Block Success of 2% Mepivacaine versus 4% Articaine in Patients with Symptomatic Irreversible Pulpitis in Mandibular Molars: A Randomized Double-Blind Single-Centre Clinical Trial

AIM

To assess inferior alveolar nerve block (IANB) success of 2% mepivacaine (Scandonest 2%, Septodont, France) and 4% articaine (Septanest 4%, Septodont) in patients with symptomatic irreversible pulpitis (SIP) in mandibular molars during access cavity preparation and instrumentation.

METHODOLOGY

Three hundred and thirty patients with moderate-to-severe pain in mandibular molars with SIP randomly received either 3.6 mL 2% mepivacaine hydrochloride with 1:100 000 adrenalin or 3.4mL 4% articaine hydrochloride with 1:100 000 adrenalin (n=165). Intraoperative pain (IOP) intensity was assessed during access cavity preparation and canal instrumentation using 11-point numerical rating scale (NRS). Overall success was considered if the patient felt no-to-mild pain without the need of supplemental anaesthesia throughout treatment; the incidence of need for supplemental anaesthesia was also recorded. Data were statistically analyzed using Mann Whitney U and Chi² (χ² ) tests. Relative risk (RR) and 95% confidence interval (CI) of anaesthetic failure was calculated. The effect of predisposing factors on outcome variables was assessed using multivariable regression analyses. None of the participants reported any adverse effects.

RESULTS

Baseline variables were balanced between groups (p>0.05). The IOP intensity during access cavity preparation and canal instrumentation was similar for both groups (p>0.05). IOP intensity was associated with preoperative pain intensity and tooth type (p<0.05). Overall anaesthetic success rate was 35.8% for mepivacaine and 41.2% for articaine (p>0.05) with a relative risk of failure [95%CI] 1.09 [0.92, 1.30]. The need for supplemental anaesthesia occurred 43.6% and 38.2% with mepivacaine and articaine respectively (p>0.05; RR [95%CI]: 1.14 [0.88, 1.48]). Preoperative pain level and age were associated with the need for supplemental anaesthesia.

CONCLUSIONS

2% mepivacaine and 4% articaine demonstrate similar IANB success rates for mandibular molars with SIP. Intraoperative pain experience during endodontic treatment can be associated with preoperative pain, tooth type and age.

A Prospective Clinical Study Evaluating the Efficacy of Intra-Ligamentary Anesthetic Solutions in Mandibular Molars Diagnosed as Symptomatic Irreversible Pulpitis with Symptomatic Apical Periodontitis

Accomplishing painless endodontic treatment, especially in the mandibular molar region, is challenging. Hence, the aim of the study was to compare the efficacy of 2% lidocaine and 4% articaine when used as supplemental intra-ligamentary (IL) anesthesia in mandibular molars having symptomatic irreversible pulpitis with symptomatic apical periodontitis after failed Inferior Alveolar Nerve Block (IANB) injection. In this prospective study, one-hundred and forty-seven adult patients diagnosed with irreversible pulpitis in a mandibular tooth were included who received IANB with 1.8 mL of 2% lidocaine with 1:100,000 epinephrine. Patients who experienced pain were recorded using the Heft–Parker visual analog scale (HP-VAS score ≥ 55 mm) and received supplement intra-ligament injection with either4% articaine or 2% lidocaine with 1:100,000 epinephrine. Supplementary intra-ligament injections resulted in 82.6% and 91.3% of profound anesthesia in the first molar region for 2% lidocaine and 4% articaine, respectively. Similarly, an additional IL injection of articaine success percent (78.9%) in the second molar region was higher than lidocaine (63.1%). The overall success ratio revealed no significant difference in achieving profound anesthesia of either solution. In this study population, there was no difference in the success ratio of anesthesia between 2% lidocaine and 4% articaine when used as supplemental IL injection.

Effect of preoperative tramadol, ibuprofen, ibuprofen/acetaminophen on the anaesthetic efficacy of inferior alveolar nerve block in patients with symptomatic irreversible pulpitis

The purpose of this double-blind clinical trial was to compare the effect of preoperative tramadol 50 mg, tramadol 100 mg, ibuprofen 600 mg, ibuprofen 600 mg/acetaminophen 1000 mg or placebo 60 min before the administration of inferior alveolar nerve blocks (IANB) of mandibular teeth in patients experiencing symptomatic irreversible pulpitis (SIP). Two hundred and fifty emergency patients diagnosed with SIP were randomly divided into five groups and received medications. Endodontic access was begun 15 min after completion of the IANB, and all patients had profound lip numbness. The Heft-Parker visual analogue scale was used to evaluate pain. Premedication with tramadol 100 mg significantly increased the success rate to 62% than the other groups (p < 0.05). The success rates of ibuprofen, ibuprofen/acetaminophen and tramadol 50 mg groups were not significantly different (p > 0.05). Premedication with tramadol 100 mg enhanced the anaesthetic success of IANB in mandibular molars with SIP.

Present status and future directions - Mechanisms and management of local anaesthetic failures

Pain control during root canal treatment is of utmost importance for both the patient and the dental practitioner and many studies have investigated ways of overcoming problems with gaining adequate anaesthesia during treatment. The PubMed and Cochrane databases were searched for evidence-based studies regarding local anaesthesia for root canal treatment. Many variables, including premedication, pain during needle insertion, pain on injection, premedication with various types of drugs, volume of anaesthetic solutions, supplemental anaesthetic techniques, and additives to the anaesthetic solutions, may influence pain perception during root canal treatment. Differences between teeth with healthy pulps versus those with irreversible pulpitis should be considered when the effects of variables are interpreted. There are several concerns regarding the methodologies used in studies that have evaluated anaesthesia success rates. There are some conditions that may help to predict a patient's pain during root canal treatment and these conditions could be overcome either by employing methods such as premedication with a non-steroidal anti-inflammatory drug prior to the treatment visit or by using supplementary anaesthetic techniques before or during the treatment. However, authors need to be more careful when reporting details of their studies to reduce concerns regarding their study bias.

Efficacy of four local anaesthesia protocols for mandibular first molars with symptomatic irreversible pulpitis: A randomized clinical trial

AIM

To examine the efficacy rate of four anaesthetic protocols in mandibular first molars with symptomatic irreversible pulpitis (SIP).

METHODOLOGY

One hundred and sixty patients with a diagnosis of SIP were included in this randomized clinical trial. Patients were randomly allocated into four treatment groups (N = 40) according to the administered technique: Group 1 (IANB): standard inferior alveolar nerve block (IANB) injection; Group 2 (IANB + IO): standard IANB followed by a supplemental intraosseous infusion (IO) injection; Group 3 (IANB + PDL): standard IANB followed by a supplemental periodontal ligament (PDL) injection; Group 4 (IANB + BI): standard IANB followed by a supplemental buccal infiltration. Patients rated pain intensity using a verbal rating scale when the root canal treatment procedure was initiated, that is, during caries removal, access preparation and pulpectomy. Heart rate changes were recorded before, during and after each injection. The anaesthetic efficacy rates were analysed using chi-square tests, age differences using one-way anova, gender differences using Fischer Exact tests whilst heart rate changes were analysed using Kruskal-Wallis tests. Statistical significances were set at p < .05 level.

RESULTS

All the included patients were analysed. No differences in the efficacy rate were found in relation to the age or gender of the participants amongst the study groups (p > .05). IANB + IO injections had a significantly higher efficacy rate (92.5%) when compared to other techniques (p < .05), followed by IANB + PDL injections (72.5%), IANB + BI injections (65.0%), with no significant differences between the IANB + PDL or IANB + BI injections (p > .05). IANB injection alone had a significantly lower rate (40%) compared to the other techniques (p < .05). A transient but significant rise in the heart rate was recorded in 60% (24/40) of patients who received the IANB + IO injection compared to other groups (p < .05).

CONCLUSIONS

Inferior alveolar nerve block injection alone did not reliably permit pain-free treatment for mandibular molars with SIP. The use of an additional IO supplemental injection provided the most effective anaesthesia for patients requiring emergency root canal treatment for SIP in mandibular posterior teeth.

Is Inferior Alveolar Nerve Block Needed to Perform Implant Surgery in the Posterior Mandible? A Randomized Controlled Trial

PURPOSE

There is no agreement in the literature on whether inferior alveolar nerve block (IANB) or infiltration (INF) is the anesthetic technique of choice for placing implants in the posterior mandible. This study aimed to compare the efficacy of the 2 techniques using articaine 4% with epinephrine 1:100,000.

MATERIAL AND METHODS

The trial was a comparison between 2 parallel groups of patients, who received implants distal to the mental foramen, either with IANB or INF. The anesthetic technique was the predictor variable. The primary outcome was patients' perceived pain by a numerical rating scale (NRS) in incision, osteotomy and suture. The secondary outcome, patients' satisfaction, was equally recorded 12 hours after surgery. The dataset were first analyzed by descriptive statistics. Then, Mann-Whitney test, Spearman's coefficient and regression models were used. This trial followed the recommendations of the Consort Statement for reporting RCTs.

RESULTS

Ninety-six patients (41 men, 55 women, mean age 55.76 years) were randomly assigned to either group, IANB or INF, of 48 patients each. Only 20% of patients reported pain values >0 (range 0-4 of 10). Medians were: 0 (0-0) for both groups (P = .956, .175 and .908, incision, osteotomy and suture, respectively). Mean satisfaction was high in both groups, 9.0 ± 1.0, median 10; and 8.8 ± 1.7, median 9, for IANB and INF (P = .695). Hence, the anesthetic technique did not generate statistically significant differences. Five potential influencing variables that were measured did not significantly affect pain levels or patient satisfaction in either group.

CONCLUSIONS

According to the results, an IANB might not be necessary for standard implant surgery in the posterior mandible, and infiltration of articaine 4% with epinephrine 1:100,000 appears to be sufficient. Further research is needed to check if these results are extensible to other anesthetic drugs.

Efficacy of 4% articaine vs 2% lidocaine in mandibular and maxillary block and infiltration anaesthesia in patients with irreversible pulpitis: a systematic review and meta-analysis

OBJECTIVE

The goal of this systematic review and meta-analysis is to determine the performance of 4% Articaine vs. 2% Lidocaine for mandibular and maxillary block and infiltration anaesthesia in patients with irreversible pulpitis (IP).

METHODS

PubMed/MEDLINE, Cochrane Central Register of Controlled Trials, Web of Science, Google Scholar, and Open Gray were used to conduct a thorough literature search. A manual search of the reference lists of the publications found was also carried out. Two reviewers critically evaluated the papers for inclusion and exclusion criteria, and data extraction was done on the selected publications. The Cochrane Collaboration Tool and the Minors checklist were used to assess the quality of the selected studies for randomised controlled trials (RCTs) and non-randomised studies, respectively. The RevMan software was used to perform a meta-analysis of the pooled data and subgroups according to the technique of anaesthetic solution delivery, as well as a sensitivity analysis (P < 0.05).

RESULTS

A total of twenty-six papers were included in the qualitative synthesis, with twenty-two of them being included in the meta-analysis. There were fifteen studies with a low potential for bias, three with a moderate potential for bias, and seven with a high potential for bias. The combined results of the 19 trials in the tooth level unit revealed that 4% articaine had a success rate 1.37 times greater than 2% lidocaine for mandibular teeth (RR, 1.37; 95% CI [1.17-1.62]; P = 0.0002). For the maxillary buccal infiltration method, the combined results from the three trials revealed that 4% articaine resulted in a success rate 1.06 times greater than 2% lidocaine (RR, 1.06; 95% CI [0.95-1.2]; P = 0.3). Excluding subgroups with a single study in sensitivity analysis for mandibular teeth revealed a substantial improvement in the success rate of the articaine group in treating IP when compared to the lidocaine group.

CONCLUSION

The findings of this meta-analysis back up the claim that articaine is more effective than lidocaine in providing anaesthesia in patients with IP. PROSPERO Registration No.: CRD42020204606 (https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020204606).

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.

Anesthetic efficacy of primary and supplemental buccal/lingual infiltration in patients with irreversible pulpitis in human mandibular molars: a systematic review and meta-analysis

Achieving profound anesthesia in mandibular molars with irreversible pulpitis is a tedious task. This review aimed at evaluating the success of buccal/lingual infiltrations administered with a primary inferior alveolar nerve block (IANB) injection or as a supplemental injection after the failure of the primary injection in symptomatic and asymptomatic patients with irreversible pulpitis in human mandibular molars. The review question was “What will be the success of primary and supplemental infiltration injection in the endodontic treatment of patients with irreversible pulpitis in human mandibular molars?” We searched electronic databases, including Pubmed, Scopus, and Ebsco host and we did a comprehensive manual search. The review protocol was framed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist. We included clinical studies that evaluated and compared the anesthetic outcomes of primary IANB with primary and/or supplementary infiltration injections. Standard evaluation of the included studies was performed and suitable data and inferences were assessed. Twenty-six studies were included, of which 13 were selected for the meta-analysis. In the forest plot representation of the studies evaluating infiltrations, the combined risk ratio (RR) was 1.88 (95% CI: 1.49, 2.37), in favor of the secondary infiltrations with a statistical heterogeneity of 77%. The forest plot analysis for studies comparing primary IANB + infiltration versus primary IANB alone showed a low heterogeneity (0%). The included studies had similar RRs and the combined RR was 1.84 (95% CI: 1.44, 2.34). These findings suggest that supplemental infiltrations given along with a primary IANB provide a better success rate. L'Abbe plots were generated to measure the statistical heterogeneity among the studies. Trial sequential analysis suggested that the number of patients included in the analysis was adequate. Based on the qualitative and quantitative analyses, we concluded that the infiltration technique, either as a primary injection or as a supplementary injection, given after the failure of primary IANB, increases the overall anesthetic efficacy.

Postanesthetic Cold Sensibility Test as an Indicator for the Efficacy of Inferior Alveolar Nerve Block in Patients with Symptomatic Irreversible Pulpitis of Mandibular Molars

Materials and Methods

This study was conducted on the mandibular first molars of 54 patients (35 males and 19 females) with signs and symptoms of SIP. To anesthetize the affected molars, all patients received a single carpule of 2% lidocaine with 1 : 100000 epinephrine using a standardized inferior alveolar nerve block (IANB) technique. The cold test was conducted before beginning the endodontic procedures and after gaining lip numbness, and the results were reported as either positive or negative response. The root canal preparation (RCP) was then initiated and the patients' responses were documented (Gold standard test). True pulpal anesthetic failure was described as a pain perception during the access cavity and pulp tissue removal. True pulpal anesthesia was defined as no pain or discomfort during the access cavity and pulp extirpation. The qualitative variables frequencies and percentages of patients with true/false positive and negative responses were determined and then compared using the Chi-square test. The pain perception of male and female patients during the cold test and gold standard was compared using the Fisher exact test. The following diagnostic parameters were calculated using an online statistical calculator: sensitivity, specificity, predictive values, accuracy, and Youden index. In addition, a receiver operating characteristic curve (ROC) was constructed and the area under the curve (AUC) was calculated.

Results

The overall percentage of actual failure of pupal anesthesia was 57%. The sensitivity, specificity, positive predictive value, negative predictive value, accuracy, and Youden index for the cold test were 0.87, 0.91, 0.93, 0.84, 0.89, and 0.78, respectively. There was no statistically significant difference between male and female patients regarding their responses to cold testing and the gold standard test (P > 0.05). Besides, the patients' reactions to the cold test were significantly matched with their reactions to the gold standard test (P < 0.05). The area under the ROC was mostly 0.9.

Conclusion

The cold test could be a valuable and accurate method for predicting the potential pupal anesthesia before beginning the endodontic treatment of mandibular molars with symptomatic irreversible pulpitis, particularly after obtaining postanesthetic soft tissue numbness.

Anaesthetic Efficacy of 4% Articaine in Comparison with 2% Lidocaine as Intraligamentary Injections after an Ineffective Inferior Alveolar Nerve Block in Mandibular Molars with Irreversible Pulpitis: A Prospective Randomised Triple-Blind Clinical Trial

The objective of the current study was to compare the anaesthetic efficacy of supplemental intraligamentary (IL) injection of 4% articaine with that of 2% lidocaine in the mandibular first and second molars with irreversible pulpitis after an ineffective inferior alveolar nerve block injection (IANB) using the same anaesthetic in a randomised triple-blind clinical trial. Seventy-six adult patients, who were diagnosed with irreversible pulpitis in the mandibular first or second molars, were divided into 2 groups and received IANB randomly. In patients with lip numbness, anaesthesia was evaluated with the cold and electrical pulp (EPT) tests, and if the reported number on EPT was below 100, supplemental IL injection was administered using the same anaesthetic. The teeth were retested after 5 minutes. The Heft-Parker visual analogue scale was used to evaluate pain after IANB and IL injections. Statistical analysis was performed using repeated measures ANOVA, chi-square, and independent-sample and paired-sample t-tests. The results showed that there was no significant difference in the success rates of supplemental IL and IANB injections between articaine and lidocaine. Furthermore, there was no significant difference in the success rates of supplemental IL injection with lidocaine between the mandibular first and second molars. However, there was a significant difference in the success rates of supplemental IL injection with articaine between the mandibular first and second molars. Moreover, supplemental IL injections indicated no significant difference in the anaesthetic efficacy between articaine and lidocaine; nevertheless, they were more effective in the mandibular second molars, especially with articaine.

Efficacy of buccal piroxicam infiltration and inferior alveolar nerve block in patients with irreversible pulpitis: a prospective, double-blind, randomized clinical trial

Objectives

This randomized clinical trial aimed to assess the effectiveness of buccal infiltration with piroxicam on the anesthetic efficacy of inferior alveolar nerve block (IANB) with buccal infiltration in irreversible pulpitis, with pain assessed using the Heft-Parker visual analogue scale (HP-VAS).

Materials and Methods

This study included 56 patients with irreversible pulpitis in mandibular molars, randomly distributed between 2 groups (n = 28). After evaluating the initial pain score with the HP-VAS, each patient received IANB followed by buccal infiltration of 2% lignocaine with adrenaline (1:80,000). Five minutes later, the patients in groups 1 and 2 were given buccal infiltration with 40 mg/2 mL of piroxicam or normal saline, respectively. An access opening procedure (AOP) was performed 15 minutes post-IANB once the individual showed signs of lip numbness as well as 2 negative responses to electric pulp testing. The HP-VAS was used to grade the patient's pain during caries removal (CR), AOP, and working length measurement (WLM). Successful anesthesia was identified either by the absence of pain or slight pain through CR, AOP, and WLM, with no requirement of a further anesthetic dose. A statistical analysis was done using the Shapiro-Wilk and Mann-Whitney U tests.

Results

The piroxicam group presented a significantly lower (p < 0.05) mean pain score than the saline group during AOP.

Conclusions

Buccal infiltration with piroxicam enhanced the efficacy of anesthesia with IANB and buccal infiltration with lignocaine in patients with irreversible pulpitis.

Pulpal-anesthesia of a mandibular first molar with irreversible pulpitis by inferior alveolar nerve block plus buccal infiltration using articaine or lignocaine

Introduction:

This study aims to compare the efficacy of a combination of an inferior alveolar nerve block (IANB) plus buccal infiltration using 4% articaine versus 2% lignocaine in achieving anesthesia of lower first molar teeth with irreversible pulpitis.

Materials and Methods:

Seventy adult patients were selected. A random sequence list was employed to administer IANB plus buccal infiltration. After the onset of lip numbness, cold test and electric pulp testing were performed. Five patients, four missed blocks and one no bleeding, were excluded. Heft Parker Visual Analog Scale scores during pulp extirpation were recorded. The data of sixty-five patients were statistically analyzed using Chi-square and Mann–Whitney U-test.

Results:

The success rate after lip-numbness for articaine is 91.42% and for lignocaine is 94.28%. The difference is statistically, not significant (P = 0.6425). During access, the success rate for lignocaine is 96.87%, whereas 96.96% for articaine. This difference is also not significant (P = 0.982366).

Conclusion:

IANB plus buccal infiltration using articaine or lignocaine is equally effective in anesthetizing mandibular first molar with irreversible pulpitis.

Comparison of articaine, lidocaine and mepivacaine for buccal infiltration after inferior alveolar nerve block in mandibular posterior teeth with irreversible pulpitis

Aims To compare the anaesthetic efficacy of articaine, lidocaine and mepivacaine for buccal infiltration (BI) following lidocaine inferior alveolar nerve block (IANB) in mandibular posterior teeth with irreversible pulpitis.Materials and methods Patients with irreversible pulpitis in mandibular posterior teeth and unsuccessful IANB were randomly assigned to three groups: articaine group (n = 52), lidocaine group (n = 52) and mepivacaine group (n = 52). They were instructed to rate the pain experienced at four phases (before the injection, after IANB, after BI and during endodontic access) on a Heft-Parker visual analogue scale (VAS). Success was defined as the ability to access and instrument the tooth with no pain or mild pain (VAS rating ≤54 mm) after BI.Results Multivariate logistic regression analysis showed that articaine was associated with a higher success rate compared with lidocaine (OR = 3.89, 95% CI: 1.35-11.27; P = 0.02) and mepivacaine (OR = 3.67, 95% CI: 1.24-9.75; P = 0.01), after controlling for age, gender and initial pain. VAS ratings were significantly lower in the articaine group compared with those in the lidocaine group and mepivacaine group after BI and during endodontic access (P <0.01).Conclusion Articaine as a supplemental BI following IANB is a more successful anaesthetic agent in mandibular posterior teeth with irreversible pulpitis compared with lidocaine and mepivacaine.

Efficacy of Infiltration Anaesthesia of 4% Articaine HCl (buccal) Versus 2% Lignocaine HCl (buccolingual) in Extraction of Mandibular Premolars: A Single Centred, Randomised, Crossover Group Study

Purpose

The purpose of the study was to evaluate and compare the efficacy of buccal and lingual infiltration (B/L I) of 2% lignocaine HCl and buccal infiltration (BI) of 4% articaine for orthodontic extraction of mandibular premolars.

Materials and Method

One hundred and four patients (age group 14-26 years) were selected with the indication of bilateral mandibular first or second premolar extraction for orthodontic treatment. Patients were randomly distributed in 2 groups. Group A received B/L I with lignocaine and Group B for BI with articaine in two different appointments in 2-week interval. The pain scores for each patient were evaluated during extraction using the visual analogue scale (VAS) and verbal pain scale (VPS). Statistical analysis was performed by descriptive and inferential statistics using Chi-square test. The agreement between VAS and VPS was obtained by applying intra-class correlation coefficient.

Results

No pain was experienced during extraction in 77% (VAS) and 79% (VPS) patients infiltrated in group A and 84% (VAS) and 90% (VPS) patients of group B with articaine. The difference between the groups was statistically significant. A strong positive correlation was found between VAS and VPS scores in the both groups.

Conclusion

Buccal infiltration with articaine proved to be an effective alternative to buccal and lingual infiltration with lignocaine in the extraction of mandibular premolars.

How Successful is Supplemental Intraseptal and Buccal Infiltration Anaesthesia in the Mandibular Molars of Patients Undergoing Root Canal Treatment or Tooth Extraction?

Objectives

To investigate the success rate of supplemental intraseptal and buccal infiltration anaesthesia in mandibular molars undergoing endodontic therapy/extraction when the inferior alveolar nerve block has failed.

Material and Methods

A prospective clinical trial including 200 patients undergoing lower molar root canal treatment/teeth extraction was conducted. Only 80 patients of the participants who had profound lower lip anaesthesia after the administration of inferior alveolar nerve block (IANB) were in pain within treatment. Patients experiencing moderate to severe pain upon using elevators, forceps, bur, or endodontic file were randomly allocated to the 2% lidocaine intraseptal injection and 4% articaine buccal infiltration groups. Level of pain was assessed every 2 to 10 min on standard 100 mm visual analogue scales.

Results

Overall, 55 (69%) of patients who were given either intraseptal injection of 2% lidocaine or buccal infiltration of 4% articaine had successful anaesthesia of lower molar teeth within 10 min. However, 25 (31%) of participating patients in the buccal infiltration and the intraseptal groups had failed anaesthesia within the study duration (10 min), and they received additional local anaesthetic. IANBs were more painful than buccal and intraseptal injections. However, buccal articaine injections were significantly more comfortable than intraseptal lidocaine injections (P > 0.001).

Conclusions

Supplemental intraseptal injection of 2% lidocaine and buccal infiltration of 4% articaine achieved profound pulpal anaesthesia in 69% of patients when the inferior alveolar nerve block failed. Recommendations can be given to dental practitioners to use infiltration of 4% articaine in conjunction with intraseptal injection of 2% lidocaine to anaesthetize the lower molar teeth when inferior alveolar nerve block fails.

Is articaine more effective than lidocaine in patients with irreversible pulpitis? An umbrella review

BACKGROUND

Pain management can be challenging during root canal treatment of teeth with irreversible pulpitis.

AIM

To identify whether articaine or lidocaine is the most appropriate local anaesthetic solution for teeth with irreversible pulpitis undergoing root canal treatment.

DATA SOURCE

The protocol of this umbrella review is registered in the PROSPERO database (CRD42019137624). PubMed, EBSCHO host and Scopus databases were searched until June 2019.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS

Systematic reviews published in English comparing the effectiveness of local anaesthesia following administration of articaine or lidocaine in patients undergoing root canal treatment of teeth diagnosed with irreversible pulpitis were included. Two independent reviewers selected the studies and carried out the data extraction and the appraisal of the included reviews. Disagreements were resolved in consultation with a third reviewer.

STUDY APPRAISAL AND SYNTHESIS METHODS

The quality of the included reviews was appraised by two independent reviewers using the AMSTAR tool (a measurement tool to assess systematic reviews). Each of the 11 AMSTAR items was given a score of 1 if the specific criterion was met, or 0 if the criterion was not met or the information was unclear.

RESULTS

Five systematic reviews with meta-analyses were included. The AMSTAR score for the reviews ranged from 8 to 11, out of a maximum score of 11, and all reviews were categorized as 'high' quality. Two reviews scored 0 for item 8 in AMSTAR because the scientific quality of the clinical trials included in these reviews was not used in the formulation of the conclusions.

LIMITATIONS

Systematic reviews published only in the English language were included. Only a small number of studies were available to assess pain intensity during the injection phase, the time until the onset of anaesthesia and the occurrence of adverse events.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Articaine is more effective than lidocaine for local anaesthesia of teeth with irreversible pulpitis undergoing root canal treatment. There is limited evidence that injection of articaine is less painful, has more rapid onset and has fewer adverse events compared with lidocaine.

Interventions for anesthetic success in symptomatic irreversible pulpitis: A network meta-analysis of randomized controlled trials

Background

Local anesthetics alone or in combination with adjuncts, such as oral medications, have routinely been used for pain control during endodontic treatment. The best clinical choice amongst the vast numbers of agents and techniques available for pain control for irreversible pulpitis is unclear. This network meta-analysis combined the available evidence on agents and techniques for pulpal anesthesia in the maxilla and mandible, in order to identify the best amongst these approaches statistically, as a basis for future clinical trials.

Methods

Randomized trials in MEDLINE, DARE, and COCHRANE databases were screened based on inclusion criteria and data were extracted. Heterogeneity was assessed and odds ratios were used to estimate effects. Inconsistencies between direct and indirect pooled estimates were evaluated by H-statistics. The Grading of Recommendation, Assessment, Development, and Evaluation working group approach was used to assess evidence quality.

Results

Sixty-two studies (nine studies in the maxilla and 53 studies in the mandible) were included in the meta-analysis. Increased mandibular pulpal anesthesia success was observed on premedication with aceclofenac + paracetamol or supplemental 4% articaine buccal infiltration or ibuprofen+paracetamol premedication, all the above mentioned with 2% lignocaine inferior alveolar nerve block (IANB). No significant difference was noted for any of the agents investigated in terms of the success rate of maxillary pulpal anesthesia.

Conclusion

Direct and indirect comparisons indicated that some combinations of IANB with premedication and/or supplemental infiltration had a greater chance of producing successful mandibular pulpal anesthesia. No ideal technique for maxillary anesthesia emerged. Randomized clinical trials with increased sample size may be needed to provide more conclusive data. Our findings suggest that further high-quality studies are required in order to provide definitive direction to clinicians regarding the best agents and techniques to use for mandibular and maxillary anesthesia for irreversible pulpitis.

The influence of endodontic treatment on blood pressure reduction in patients with vital irreversible pulpitis

Background

During endodontic treatment, endodontists must be aware of the various factors that may decrease or increase blood pressure. This study aimed to assess the mean percentages of systolic, diastolic, and arterial blood pressure (MSBP, MDAP, MABP) reduction in patients with vital irreversible pulpitis in teeth and who were treated at three visits to endodontists in three age groups (20–34 years, 35–50 years, 51–65 years).

Materials and methods

A total of 100 teeth with vital irreversible pulpitis from 100 patients were included. All patients underwent 3 visits for endodontic treatment. The 1st visit included removal of vital pulp tissue and a determination of working length, the 2nd visit included canal preparation and widening, and at the 3rd visit the canal was obturated and sealed by gutta percha and sealer. Blood pressure for all patients was checked and documented once before starting treatment and three times during treatment at different intervals during all visits.

Results

There were significantly higher percentage reductions in MSBP, MDBP, and MABP at the 1st visit for endodontic treatment in comparison to other visits (2nd and 3rd) for all patients. Additionally, there were significantly higher percentage reductions in MSBP, MDBP, and MABP at the 1st visit for endodontic treatment in comparison to other visits in males and females, for all age groups, both anesthesia injection-type groups (infiltration and block), and all treated tooth types except mandibular anterior teeth, and there were nonsignificant differences among groups. However, there were nonsignificant differences in MSBP, MDBP, and MABP between males and females, between infiltration and block injection groups and in relation to teeth types at all visits.

Conclusions

The reduction of blood pressure in patients undergoing endodontic treatment of vital teeth with irreversible pulpits is common, especially at the 1st visit for pulp extirpation.

Efficacy of dental local anesthetics: A review

The objective of this review was to investigate the efficacy of dental local anesthetics, as it is well known among clinicians that local anesthesia may be challenging in some circumstances. Therefore, the focus of this review was on the efficacy of the products used in dental local anesthesia.

In a Pubmed database literature search conducted, a total of 8646 articles were found to be related to dental local anesthetics. After having applied the inclusion criteria (human research, performed in the last 10 years, written in English language, and focus on dental local anesthetics) and having assessed the quality of the papers, 30 were deemed eligible for inclusion in this review.

The conclusion of this review is that none of the dental local anesthetic amides provide 100% anesthesia. The problem appears to be more pronounced when mandibular teeth are attempted to be anaesthetized and especially if there is irreversible pulpitis involved. The authors conclude that this finding suggest exploration of more efficient techniques to administer dental local anesthesia, especially in the mandible, to establish a 100% efficacy, is needed.

Efficacy of Endo-Ice followed by intrapulpal ice application as an adjunct to inferior alveolar nerve block in patients with symptomatic irreversible pulpitis-a randomized controlled trial

OBJECTIVE

The purpose of the present study was to evaluate the effect of Endo-Ice followed by intrapulpal ice application for reducing pain during pulp extirpation in mandibular molars with symptomatic irreversible pulpitis.

MATERIALS AND METHODS

Sixty patients diagnosed with symptomatic irreversible pulpitis participated in the present study. Subjects were randomly allocated to any one of the following groups: control group-inferior alveolar nerve block with lignocaine (2%) adrenaline (1:80000), articaine group-inferior alveolar nerve block with lignocaine (2%) adrenaline (1:80000) + Buccal infiltration with articaine (4%) with adrenaline (1:100000); or cold group-inferior alveolar nerve block with lignocaine (2%) adrenaline (1:80000) + cold application. The outcome assessor measured the level of pain during access opening and pulp extirpation using the visual analogue scale. The anxiety level of the patient was also measured.

RESULTS

During access opening, there was a significant difference in the pain reduction in the articaine group when compared to cold and control group (p value = 0.02). During pulp extirpation, cold group and articaine group showed a significant reduction in pain levels as compared to the control group (p value = 0.001). There was no difference in the pain level during pulp extirpation among the two test arms (articaine and cold) (p value = 0.99). Further, cold significantly reduced the level of anxiety when compared to the articaine or control group (p value = 0.001).

CONCLUSION

Hence, cold is a simple, supplementary technique in reducing pain during pulp extirpation.

CLINICAL RELEVANCE

Application of cold may help in minimizing the fear of additional injection in managing pain during endodontic treatment.

Effects of Ibuprofen Compared to Other Premedication Drugs on the Risk and Intensity of Postendodontic Pain: A Systematic Review

Objective

This systematic review aims to evaluate the effects of ibuprofen compared to other drugs on the risk and intensity of postoperative pain resulting from endodontic treatment in adult patients.

Methods

A systematic search was carried out through Medline databases (Pubmed, Scopus, Web of Science, Cochrane, Lilacs, and BBO). There was no restriction on the publication year or idiom. The gray literature was explored. The Periodicos Capes Theses Databases and ProQuest Dissertations were also searched, as well as the unpublished and ongoing trials registry and the IADR abstracts (1990-2016). Solely randomized clinical trials that compared the risk or intensity of pain resulting from endodontic treatment in adult patients were included in this systematic review. The risk of bias of the articles was evaluated using the Cochrane Collaboration's tool. A random-effect meta-analysis was conducted for ibuprofen versus placebo and ibuprofen versus other drugs at 6, 8, and 24 hours. The GRADE approach was used to assess the quality of the evidence.

Results

A total of 1132 studies were identified, and only seven meet the eligibility criteria. No difference between the groups was detected in any of the meta-analysis. An exception was observed when one study was removed from the meta-analysis of pain intensity at 24 hours for ibuprofen versus placebo, favoring ibuprofen (SMD -0.67; 95% CI -1.05 to -0.17). The quality of evidence in all meta-analyses was graded as low or very low.

Conclusion

Results of the present systematic review indicate that there is no clear evidence supporting that preoperative ibuprofen is better than other drugs in reducing the risk and intensity of postendodontic pain.

Efficacy of articaine infiltration versus lidocaine inferior alveolar nerve block for pulpotomy in mandibular primary second molars: A randomized clinical trial

Background: Successful anesthesia is a major concern in during pulpotomy treatment. The aim of this study was to compare the anesthetic efficacy of inferior alveolar nerve block using 2% lidocaine and buccal infiltration using 4% articaine for pulpotomy of mandibular primary second molars.

Methods: This randomized cross-over clinical trial was performed in 23 children (five to eight-year-old) from July through November 2016, referred to the Department of Pediatric Dentistry, Tehran University of Medical Sciences who needed pulpotomy treatment in both mandibular primary second molars. The Patients’ feeling during injection and their behavior during pulpotomy and post-treatment complications were registered. Wilcoxon Signed Ranks test was used for analyzing the data. A significant level of differences was taken as p≤ 0.05.

Results: Patients’ feeling during injection and post-treatment complications did not significantly differ between two groups (p>0.05). Patients’ behavior during pulpotomy was significantly better in articaine group (p=0.004).

Conclusion: Articaine buccal infiltration can be used successfully in pulpotomy of mandibular primary second molars. Iranian Registry of Clinical Trial: (IRCT2015042321484N2).

Efficacy of Articaine versus Lidocaine in Supplemental Infiltration for Mandibular First versus Second Molars with Irreversible Pulpitis: A Prospective, Randomized, Double-blind Clinical Trial

INTRODUCTION

Profound pulpal anesthesia is difficult to achieve in mandibular molars with irreversible pulpitis (IP). However, there are no published randomized controlled clinical trials comparing the success of supplemental buccal infiltration (BI) in mandibular first versus second molars with IP. The purpose of this prospective, randomized, double-blind study was to compare the efficacy of 4% articaine with 2% lidocaine for supplemental BIs in mandibular first versus second molars with IP after a failed inferior alveolar nerve block (IANB). This study's sample was combined with data from a previous trial.

METHODS

One hundred ninety-nine emergency subjects diagnosed with IP of a mandibular molar were selected and received an IANB with 4% articaine. Subjects who failed to achieve profound pulpal anesthesia, determined by a positive response to cold or pain upon access, randomly received 4% articaine or 2% lidocaine as a supplemental BI. Endodontic access was begun 5 minutes after infiltration. Success was defined as less than mild pain during endodontic access and instrumentation on the Heft-Parker visual analog scale.

RESULTS

There was a 25% IANB success rate with 4% articaine. The success rate for articaine supplemental BI in first molars was 61% versus 63% for second molars (P > .05). The success of lidocaine in first molars was 66%, but for second molars it was 32% (P = .004).

CONCLUSIONS

The success rate for IANB with 4% articaine was 25%. Articaine and lidocaine had similar success rates for supplemental infiltration in first molars, whereas articaine was significantly more successful for second molars. However, because BI often did not provide profound pulpal anesthesia, additional techniques including intraosseous anesthesia may still be required.

Sensitivity, Specificity, Predictive Values, and Accuracy of Three Diagnostic Tests to Predict Inferior Alveolar Nerve Blockade Failure in Symptomatic Irreversible Pulpitis

INTRODUCTION

The inferior alveolar nerve block (IANB) is the most common anesthetic technique used on mandibular teeth during root canal treatment. Its success in the presence of preoperative inflammation is still controversial. The aim of this study was to evaluate the sensitivity, specificity, predictive values, and accuracy of three diagnostic tests used to predict IANB failure in symptomatic irreversible pulpitis (SIP).

METHODOLOGY

A cross-sectional study was carried out on the mandibular molars of 53 patients with SIP. All patients received a single cartridge of mepivacaine 2% with 1 : 100000 epinephrine using the IANB technique. Three diagnostic clinical tests were performed to detect anesthetic failure. Anesthetic failure was defined as a positive painful response to any of the three tests. Sensitivity, specificity, predictive values, accuracy, and ROC curves were calculated and compared and significant differences were analyzed.

RESULTS

IANB failure was determined in 71.7% of the patients. The sensitivity scores for the three tests (lip numbness, the cold stimuli test, and responsiveness during endodontic access) were 0.03, 0.35, and 0.55, respectively, and the specificity score was determined as 1 for all of the tests. Clinically, none of the evaluated tests demonstrated a high enough accuracy (0.30, 0.53, and 0.68 for lip numbness, the cold stimuli test, and responsiveness during endodontic access, resp.). A comparison of the areas under the curve in the ROC analyses showed statistically significant differences between the three tests (p < 0.05).

CONCLUSION

None of the analyzed tests demonstrated a high enough accuracy to be considered a reliable diagnostic tool for the prediction of anesthetic failure.

Effective anaesthesia of the acutely inflamed pulp: part 2. Clinical strategies

Achieving profound pulpal anaesthesia in a mandibular molar diagnosed with irreversible pulpitis can be argued to be the most testing of dental anaesthetic challenges. Following discussion on the possible reasons for this occurrence in part 1, part 2 outlines the various local anaesthetic techniques that practitioners can use to overcome the acutely inflamed mandibular molar. They should then be able to apply these same principles to help anaesthetise any other tooth presenting with an acutely inflamed pulp. Techniques are discussed in detail along with key variables that have been associated with having an impact on the anaesthetic efficacy. This is to bring to light factors that can aid anaesthetic success as well as dispel common misnomers.

Anesthetic Efficacy in Irreversible Pulpitis: A Randomized Clinical Trial

Abstract Inferior alveolar nerve block has a high failure rate in the treatment of mandibular posterior teeth with irreversible pulpitis. The aim of this study was to compare the anesthetic efficacy of 4% articaine, 2% lidocaine and 2% mepivacaine, all in combination with 1:100,000 epinephrine, in patients with irreversible pulpitis of permanent mandibular molars during a pulpectomy procedure. Sixty-six volunteers from the Emergency Center of the School of Dentistry, University of São Paulo, randomly received 3.6 mL of local anesthetic as a conventional inferior alveolar nerve block (IANB). The subjective signal of lip numbness, pulpal anesthesia and absence of pain during the pulpectomy procedure were evaluated respectively, by questioning the patient, stimulation using an electric pulp tester and a verbal analogue scale. All patients reported the subjective signal of lip numbness. Regarding pulpal anesthesia success as measured with the pulp tester, the success rate was respectively 68.2% for mepivacaine, 63.6% for articaine and 63.6% for lidocaine. Regarding patients who reported no pain or mild pain during the pulpectomy, the success rate was, respectively 72.7% for mepivacaine, 63.6% for articaine and 54.5% for lidocaine. These differences were not statistically significant. Neither of the solutions resulted in 100% anesthetic success in patients with irreversible pulpitis of mandibular molars.

Efficacy of Articaine and Lidocaine for Buccal Infiltration of First Maxillary Molars with Symptomatic Irreversible Pulpitis: A Randomized Double-blinded Clinical Trial

Introduction:

The aim of the present study was to compare the efficacy of 2% lidocaine to 4% articaine in buccal infiltration of maxillary first molars with irreversible pulpitis. Moreover, the effect of root length on success of anesthesia irrespective of the type of anesthetic agent was assessed.

Methods and Materials:

Fifty patients suffering from painful maxillary first molars with irreversible pulpitis received an infiltration injection of either 4% articaine with 1:100000 epinephrine or 2% lidocaine with 1:80000 epinephrine. Each patient recorded their pain score in response to a cold test on a Heft-Parker visual analogue scale (VAS) before commencing the treatment, 5 min following injection, during access preparation, after pulp exposure and during root canal instrumentation. No or mild pain at any stage was considered a success. Data were analyzed using the multivariate logistic regression analysis, chi-square and t tests.

Results:

Finally, 47 out of 50 patients were eligible to be included in this study. The anesthetic success rates in the lidocaine and articaine groups were 56.52% and 66.67%, respectively and the difference was not significant (P=0.474). Irrespective of the anesthetic agent, the length of the palatal root (Odds Ratio=0.24, P=0.007) had an adverse effect on anesthetic success. There was an association between longer palatal root length and anesthetic failure.

Conclusion:

No significant difference was found between 2% lidocaine and 4% articaine in terms of anesthetic success in maxillary first molars with irreversible pulpitis. The length of the palatal root had a significant negative influence on anesthetic success.

Efficacy of Ketorolac Buccal Infiltrations and Inferior Alveolar Nerve Blocks in Patients with Irreversible Pulpitis: A Prospective, Double-blind, Randomized Clinical Trial

INTRODUCTION

The purpose of this prospective, randomized, double-blind, placebo-controlled study was to determine whether ketorolac buccal infiltrations (BIs) helped to improve the success of inferior alveolar nerve blocks (IANBs) in patients with acute irreversible pulpitis (AIP).

METHODS

Forty adult volunteers with AIP in a mandibular molar were included in this study. Patients were instructed to evaluate their pain by using a Heft-Parker visual analog scale. They were randomly divided into 2 groups (n = 20). All patients received standard IANB injection and after that a BI of 4% articaine with 1:100,000 epinephrine. After 5 minutes, 20 patients received a BI of 30 mg/mL ketorolac, and the other received a BI of normal saline (control group). Endodontic access cavity preparation (ACP) was initiated 15 minutes after the IANB when the patient reported lip numbness and had 2 electric pulp tests with no responses. The patient's pain during caries and dentin removal, ACP, and canal length measurements (CLM) was recorded by using Heft-Parker visual analog scale. Successful anesthesia was defined as no or mild pain during any of these steps, without the need for additional injection. Data were statistically analyzed by using Mann-Whitney U and χ(2) tests.

RESULTS

Successful anesthesia after an IANB plus BI of articaine was obtained in 15% of patients in the control group at the end of CLM. Adding BI of ketorolac significantly increased the success rate to 40% (P < .05). Patient's pain during ACP and CLM was significantly lower in the ketorolac group (P < .05).

CONCLUSIONS

Ketorolac BI can increase the success rate of anesthesia after IANB and BI with articaine in patients with AIP.

The effectiveness of articaine in mandibular facial infiltrations

Four percent articaine local anesthetic has been successfully used to attain local anesthesia for dental procedures. Mandibular block anesthesia may consume longer time to attain and have a higher failure of local anesthesia compared to infiltration. Mandibular facial infiltration has been reported to successfully attain effective local anesthesia for dental procedures. This study involved only several tooth sites and found that 1.8 cc of 4% articaine facial infiltration in the mandible may be effective when the facial mandibular cortex is <2.0–3.0 mm. A waiting time of 5–10 minutes may be required for effective anesthesia. An additional 1.8 cc of dose may be required to attain anesthesia if an initial 1.8 cc of dose fails. The need for additional anesthetic may be predicted by a measurement of the facial cortex using cone beam computerized tomography. A study of mandibular sites is needed to delineate the anatomical dimensions, density of cortical bone, and apical neural location for ensuring successful local anesthetic infiltration.

Anesthetic success of supplemental infiltration in mandibular molars with irreversible pulpitis: A systematic review

Aim:

To systematically review the anesthetic success rates of inferior alveolar nerve block (IANB) injection technique alone with that of combination of IANB and supplemental infiltration (SI) technique when used for pulpal anesthesia of mandibular posterior teeth with irreversible pulpitis during endodontic treatment.

Settings and Design:

The study follows a longitudinal study design involving original research.

Materials and Methods:

Electronic databases were systematically searched for randomized controlled clinical studies. Studies were selected by predefined inclusion and exclusion criteria.

Statistical Analysis Used and Result:

The statistical analysis used was based on the results of the original research. All the included studies showed that there is the difference in the values comparing the two techniques, but the data are not statistically significantly different.

Conclusion:

Based on this review, the better anesthetic efficacy of the SI was observed.

Comparison of speed of action and injection discomfort of 4% articaine and 2% mepivacaine for pulpal anesthesia in mandibular teeth: A randomized, double-blind cross-over trial

Objective:

To compare the injection pain and speed of local anesthetic effect induced by tissue infiltration of mepivacaine 2% with epinephrine 1:100,000 versus articaine 4% with epinephrine 1:100,000 in securing mandibular first molar pulp anesthesia.

Materials and Methods:

Totally, 25 patients were recruited in a crossover, randomized, double-blind study. Each subject received injections of mepivacaine 2% with epinephrine 1:100,000 as inferior alveolar nerve block (IANB) supplemented with either articaine 4% with epinephrine 1:100,000 (septocaine) or mepivacaine 2% buccal infiltration (BI) injection on two visits. The time of first numbness to associated lip, tongue and tooth was recorded by asking the participant directly and using electrical pulp tester. Anesthetic success was considered when two consecutive maximal stimulation on pulp testing readings without sensation. The patients rated the pain of infiltration using a 100 mm visual analog scale immediately after receiving each injection. The pain scores were compared using the paired t-test.

Results:

There were significant differences in the meantime of first numbness to associated lip and tooth of volunteers between mepivacaine and articaine BI groups P = 0.03 and 0.002. Volunteers in articaine group recorded earlier lip and teeth numbness than those in mepivacaine group. There were significant differences between the mean pain scores for volunteers in the post IANB and postbuccal injection groups (t-test: P <0.001). Mepivacaine IANB injection was significantly more painful than articaine/mepivacaine buccal injection.

Conclusions:

About 4% articaine was faster than 2% mepivacaine (both with 1:100,000 adrenaline) in anesthetizing the pulps of lower molar teeth after BIs. Earlier lip and teeth numbness were recorded in articaine group. Articaine and mepivacaine BIs were more comfortable than mepivacaine IANB injections.