Comparison of the anaesthetic efficacy of and heart rate changes after periodontal ligament or intraosseous X-Tip injection in mandibular molars: a randomized controlled clinical trial

Influence of computerized intraosseous anesthesia compared with traditional mandibular nerve block on children's behavior: A randomized clinical trial

BACKGROUND

Effective pain management is crucial for the successful completion of dental procedures in children. Research has examined whether computerized intraosseous anesthesia (CIOA) could serve as a safe and viable substitute for the conventional inferior alveolar nerve block (IANB) technique in pediatric patients. This study investigates the efficacy of CIOA, aiming to determine its effectiveness as an alternative anesthesia method.

AIM

This study compared the efficacy of local intraosseous anesthesia using a computerized device (QuickSleeper 5) to conventional IANB anesthesia on cooperation and pain perception in children, using a randomized controlled trial design.

DESIGN

The study included 88 healthy children, aged between 6 and 9 years, who required pulpotomy for their mandibular second primary molars. The study was approved by the local research ethics committee and registered at clinicaltrials.gov (NCT05193487). The heart rate and Venham behavior rating scale were recorded and analyzed. Categorical data were analyzed using Fisher's exact test. Age and heart rate were compared using an independent t-test for intergroup comparison. The intragroup comparison was carried out using repeated measures ANOVA, followed by the Bonferroni post hoc test. The Mann-Whitney U-test was used to analyze the Venham scale scores. The significance level was set at p < .05 RESULTS: The mean Venham score was slightly higher in the IANB group than in the CIOA group, but was not statistically significant (p = .852). One minute after anesthesia administration, the heart rate (beats per minute [BPM]) was significantly higher in the IANB group (92.30 ± 13.45) than in the CIOA group (83.20 ± 10.40) (p < .001). Additionally, there was a significant difference in heart rate values measured at different intervals within the IANB group.

CONCLUSION

The QuickSleeper 5 device was found to be a feasible alternative for IANB in children over 6 years old.

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).

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.

Effect of a Combination of Nitrous Oxide and Intraligamentary Injection on the Success of the Inferior Alveolar Nerve Block in Patients with Symptomatic Irreversible Pulpitis

INTRODUCTION

The purpose of this prospective study was to determine the effect of a combination of nitrous oxide/oxygen and 1 set of supplemental intraligamentary/periodontal ligament (PDL) injections followed by a second set of PDL injections on anesthetic success in patients with symptomatic irreversible pulpitis (SIP).

METHODS

Ninety-four patients with a mandibular posterior tooth diagnosed with SIP received nitrous oxide/oxygen and an inferior alveolar nerve block (IANB) with 2% lidocaine with 1:100,000 epinephrine. Patients rated the pain of PDL injections and endodontic access on a visual analog scale. If moderate to severe pain was felt during treatment, the operator administered 1 set of supplemental PDL injections with 4% articaine with 1:100,000 epinephrine. If moderate to severe pain was felt again during treatment, the operator administered a second set of supplemental PDL injections. Anesthetic success was defined as having no to mild pain during endodontic treatment.

RESULTS

The success of the IANB with nitrous oxide was 44% (95% confidence interval [CI], 34%-54%). The overall anesthetic success rate (IANB with PDL injections) was increased from 69% (95% CI, 60%-78%) with 1 set of PDL injections to 80% (95% CI, 72%-88%) with a second set of PDL injections.

CONCLUSIONS

Although the second set of PDL injections increased anesthetic success, it was not sufficient to ensure complete pulpal anesthesia.

Effect of Transcodent painless needles on injection pain in maxillary anterior infiltration: a split-mouth controlled randomized clinical trial

Objectives

The present study aimed to determine the pain perceived during supraperiosteal (infiltration) injection in anterior maxillary region by Transcodent painless needle tips in comparison to the regular needle tips.

Material and methods

In this split‐mouth controlled randomised clinical trial, 30 patients were selected as candidates for cosmetic treatment who needed infiltration injections on both sides of canine area. They were each administered 0.9 mL of Lidocaine HCl 2% with epinephrine 1:100,000 in the buccal vestibules using two types of needle tips, Transcodent painless needle tip or regular needle tip. Immediately after the injection, the pain was measured using a 100 mm visual analog scale. The level of pain was statistically analyzed in the two groups using the parametric paired t‐test. A 5% significance level was considered for statically significant difference between two means.

Results

In accordance with the results, the patients' level of pain were estimated as 18.3 ± 10.7 mm with Transcodent painless needle tips and 43.1 ± 13.1 mm in regular needle tip (p < 0.05).

Conclusion

The Transcodent painless needle showed considerable reduction of pain in the anterior maxillary infiltration when compared to the regular needle tips.

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.

Anaesthetic efficacy of 2% lidocaine with different concentrations of epinephrine (1:80,000 and 1:200,000) in intraligamentary injection after a failed primary inferior alveolar nerve block: a randomized double-blind study

Introduction: The present study evaluated the anaesthetic efficacy of 2% lidocaine with 1:80,000 epinephrine vs. 2% lidocaine with 1:200,000 given as supplemental intraligamentary injections after a failed inferior alveolar nerve block (IANB) in patients with symptomatic irreversible pulpitis. The effect of these solutions on the heart rate was also evaluated.Methods: One-hundred-eighteen adult patients with symptomatic irreversible pulpits in a mandibular first or second molar, received an initial IANB with 2% lidocaine with 1:80,000 epinephrine. Pain during the endodontic treatment was assessed using a visual analogue scale (Heft-Parker VAS). Eighty-eight patients with unsuccessful anaesthesia were randomly allocated to one of the two treatment groups: one group received 0.6 mL/root of supplementary intraligamentary injection of 2% lidocaine with 1:80,000 epinephrine; while the second group received 2% lidocaine with 1:200,000 epinephrine. Endodontic treatment was re-initiated. Success after primary injection or supplementary injection was defined as no or mild pain (pain score ≤54 mm on HP VAS) during access preparation and root canal instrumentation. Heart rate was monitored using a finger pulse oximeter. The anaesthetic success rates were analyzed with the Pearson chi-square test at 5% significance levels. The heart rate changes were analyzed using the t-test.Results: The anaesthetic success rate in patients receiving supplementary intraligamentary injections in 1:80,000 epinephrine group was 82%, while the intraligamentary injections with 2% lidocaine with 1:200,000 epinephrine were successful in 57% of cases. The difference was statistically significant (χ²=6.4, p = .011). There was no significant effect of both the anaesthetic agents on the mean heart rate.Conclusions: Both 2% lidocaine with 1:80,000 epinephrine and 2% lidocaine with 1:200,000 epinephrine improved the success rates after a failed primary anaesthetic injection. The 1:80,000 epinephrine group was significantly more successful.

Comparative evaluation of anesthetic efficacy of 1.8 mL and 3.6 mL of articaine in irreversible pulpitis of the mandibular molar: A randomized clinical trial

Objective

The aim of this study was to compare the anesthetic efficacy of two volumes of articaine in conventional inferior alveolar nerve block (IANB) of mandibular molars with irreversible pulpitis, and in cases of anesthetic failure, its complementation with periodontal ligament injection (PDL).

Methods

Ninety patients with irreversible pulpitis in mandibular molars received conventional IANB with 1.8 mL or 3.6 mL of 4% articaine with 1:100,000 epinephrine. In cases of IANB failure, the same volumes were administered in the PDL. Presence of pulpal anesthesia and absence/presence of pain during pulpectomy were evaluated by electric pulp stimulation and verbal analogue scale, respectively. Relative risks (RR) with corresponding 95% confidence intervals (95% CI) were calculated for each outcome.

Results

27% and 42% of the patients achieved pulpal anesthesia following IANB with 1.8 mL and 3.6 mL, respectively (RR = 0.63, CI 95% 0.35 to 1.14, p = 0.12). Analgesia during pulpectomy was present in 64% and 73% of the patients, respectively, for 1.8 mL and 3.6 mL (RR = 0.87, CI 95% 0.66 to 1.16, p = 0.36). In cases of IANB failure, 75% and 42% of the patients that received 1.8 mL and 3.6 mL of PDL injection, respectively, achieved pulpal anesthesia (RR = 1.80, CI 95% 0.87 to 3.72, p = 0.11). During a new attempt at the pulpectomy procedure, analgesia was present in 69% and 75% of the patients, respectively, for 1.8 mL and 3.6 mL (RR = 0.91, CI 95% 0.57 to 1.45, p = 0.71).

Conclusion

Increasing the volume from 1.8 mL to 3.6 mL of the 4% articaine with 1:100,000 epinephrine in the IANB and in the PDL, did not significantly increase the success rate of pulpal anesthesia and clinical analgesia during the pulpectomy procedure. Therefore, both volumes presented a similar efficacy, though neither resulted in effective pain control during irreversible pulpitis treatment.

Trial registration

ClinicalTrials.gov NCT02422823.

Root canal treatment in elderly patients: A review and clinical considerations

Life expectancy has increased as a result of advancements in health care services; thus, maintaining healthy dentition is an important factor in overall health. Furthermore, the growing desire of elderly patients to maintain their teeth has led to an increased need for the performance of complex dental treatment in elderly patients. Root canal therapy is an essential phase of such treatments. Elderly patients may exhibit one or more systemic conditions that require special care, in addition to other changes that occur within the dentition and oral mucosa as a result of aging. These make root canal treatment in elderly patients a great challenge. The aim of this review was to characterize pathologic and physiologic changes in elderly patients that can interfere with root canal treatment procedures, as well as attitudes of elderly patients toward such treatment, guidelines and clinical considerations for management of root canal treatment in elderly patients.

Does the volume of supplemental intraligamentary injections affect the anaesthetic success rate after a failed primary inferior alveolar nerve block? A randomized-double blind clinical trial

AIM

To investigate the efficacy of 0.2 mL vs. 0.6 mL of 2% lidocaine when given as a supplementary intraligamentary injection after a failed inferior alveolar nerve block (IANB).

METHODOLOGY

Ninety-seven adult patients with symptomatic irreversible pulpits received an IANB and root canal treatment was initiated. Pain during treatment was recorded using a visual analogue scale (Heft-Parker VAS). Patients with unsuccessful anaesthesia (n = 78) randomly received intraligamentary injection of either 0.2 mL or 0.6 mL of 2% lidocaine with 1 : 80 000 epinephrine. Root canal treatment was reinitiated. Success after primary injection or supplementary injection was defined as no or mild pain (HP VAS score ≤54 mm) during access preparation and root canal instrumentation. Heart rate was monitored using a finger pulse oximeter. The anaesthetic success rates were analysed with Pearson chi-square test at 5% significance levels. The heart rate changes were analysed using t-tests.

RESULTS

The intraligamentary injections with 0.2 mL solution gave an anaesthetic success rate of 64%, whilst the 0.6 mL was successful in 84% of cases with failed primary IANB. (χ²  = 4.3, P = 0.03). There was no significant effect of the volume of intraligamentary injection on the change in heart rate.

CONCLUSIONS

Increasing the volume of intraligamentary injection improved the success rates after a failed primary anaesthetic injection.

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.

Indexing of Iranian Publications in Well-known Endodontic Textbooks: A Scientometric Analysis

Introduction:

Quoting an article in well-known textbooks is held as a credit for that paper. The numbers of Iranian publications mentioned in endodontic textbooks have increased during recent years. The aim of this investigation was to evaluate the number of Iranian articles quoted in eminent endodontic textbooks.

Methods and Materials:

Three known textbooks (Ingle’s Endodontics, Seltzer and Bender’s Dental Pulp and Cohen’s Pathways of the Pulp) were chosen and all the editions of the textbooks since 2000 were investigated for quoted Iranian publications. Only Iranian authors with affiliations from a domestic university were chosen. All references at the end of each chapter were read by hand searching, and results were noted. The trend and percentage of Iranian publications in different editions of the textbooks were also calculated. The number of citations of these publications in Google Scholar and Scopus databases were also obtained.

Results:

The number of Iranian publications in all well-known textbooks have notably increased since 2000. The number and percentage of Iranian publications in the latest edition of Cohen’s Pathways of the Pulp was higher compared to other textbooks as well as the previous edition of the same text.

Conclusion:

Number and percentage of Iranian publications in the field of endodontics in all three textbooks have remarkably increased since 2000.

Role of intraseptal anesthesia for pain-free dental treatment

Pain control during the dental procedure is essentials and challenging. A complete efficacious pulp anesthesia has not been attained yet. The regional anesthesia such as inferior alveolar nerve block (IANB) only does not guarantee the effective anesthesia with patients suffering from irreversible pulpitis. This main aim of this review was to discuss various aspects of intraseptal dental anesthesia and its role significance in pain-free treatment in the dental office. In addition, reasons of failure and limitations of this technique have been highlighted. Literature search was conducted for peer-reviewed articles published in English language in last 30 years. Search words such as dental anesthesia, pain control, intraseptal, and nerve block were entered using a web of knowledge and Google scholar databases. Various dental local anesthesia techniques were reviewed. A combination of block anesthesia, buccal infiltration and intraligamentary injection resulted in deep anesthesia (P = 0.003), and higher success rate compared to IANB. For pain-free management of conditions such as irreversible pulpitis, buccal infiltration (4% articaine), and intraosseous injection (2% lidocaine) are better than intraligamentary and IANB injections. Similarly, nerve block is not always effective for pain-free root canal treatment hence, needing supplemental anesthesia. Intraseptal anesthesia is an efficient and effective technique that can be used in maxillary and mandibular adult dentition. This technique is also beneficial when used in conjunction to the regional block or local dental anesthesia.

Clinical efficacy of a computerised device (STA™) and a pressure syringe (VarioJect INTRA™) for intraligamentary anaesthesia

INTRODUCTION

To evaluate the impact of experience whilst using different devices for intraligamentary anaesthesia, dental students tested clinical anaesthetic efficacy of a mechanical (PDL-S) and a computer-controlled (CCLAD) application system in restorative patients.

MATERIAL AND METHODS

In a prospective study, 41 Patients in need of restorative treatment in lower posterior mandible were randomised into three groups (PDL-S: teeth n = 22; CCLAD: teeth n = 20; inferior alveolar nerve block (IANB): teeth n = 20). Dental last year students conducted anaesthesia and dental treatment. Primary objectives were differences in pain during treatment [numeric rating scale (NRS)] as well as in anaesthetic efficacy (complete/sufficient vs. insufficient/no effect) between PDL-S and CCLAD. Pain of injection, need for second injections, amount of anaesthetic solution and duration of local numbness were assessed. IANB as gold standard was compared to each system descriptively.

RESULTS

PDL-S had a significant lower pain during treatment (P = 0.017) but a similar anaesthetic efficacy (P = 0.175) compared to the CCLAD system. Concerning pain of injection (P = 0.42), quantity of second injections (P = 0.232), amount of used solution (P = 0.073) as well as duration of local numbness (P = 0.253), no differences were seen. When comparing both periodontal ligament injection (PDL)-systems with IANB, pain rating was higher when using CCLAD. Injection pain, amount of used solution as well as soft tissue anaesthesia was less for PDL-S and CCLAD.

DISCUSSION

Both PDL techniques showed a good success for dental routine treatments. Although, compared to the mechanic device, the CCLAD system might need more clinical daily experience.

CONCLUSION

We recommend including specific trainings in intraligamentary anaesthesia in the dental curriculum.

Intraosseous vascular access through the anterior mandible--a cadaver model pilot study

Background

Several insertion sites have been described for intraosseous puncture in cases of emergencies when a conventional vascular access cannot be established. This pilot study has been designed to evaluate the feasibility of the mandibular bone for the use of an intraosseous vascular access in a cadaver model.

Methodology/Principal Findings

17 dentistry and 16 medical students participating in a voluntary course received a short introduction into the method and subsequently used the battery powered EZ-IO system with a 15 mm cannula for a puncture of the anterior mandible in 33 cadavers. The time needed to perform each procedure was evaluated. India ink was injected into the accesses and during the anatomy course cadavers were dissected to retrace the success or failure of the puncture. Dental students needed 25.5±18.9(mean±standard deviation)s and medical students 33±20.4 s for the procedure (p = 0.18). Floor of mouth extravasation occurred in both groups in 3 cases. Success rates were 82 and 75% (p = 0.93).

Conclusions/Significance

Despite floor of mouth extravasation of injected fluid into a mandibular intraosseous access might severely complicate this procedure, the anterior mandible may be helpful as an alternative to other intraosseous and intravenous insertion sites when these are not available in medical emergencies.

Efficacy of supplementary buccal infiltrations and intraligamentary injections to inferior alveolar nerve blocks in mandibular first molars with asymptomatic irreversible pulpitis: a randomized controlled trial

AIM

This randomized double-blinded controlled trial was performed to compare the efficacy of inferior alveolar nerve block (IANB) injection for mandibular first molar teeth with irreversible pulpitis with or without supplementary buccal infiltration and intraligamentary injection.

METHODOLOGY

Eighty-two patients with asymptomatic irreversible pulpitis received either a combination of intraligamentary injection + buccal infiltration+ IANB or with traditional IANB injection in mandibular first molar teeth with irreversible pulpitis. Each patient recorded their pain score on a Heft-Parker visual analogue scale before commencing treatment, in response to a cold test 15 min after the designated anaesthetic injection, during access cavity preparation and during root canal instrumentation. No or mild pain at any stage was considered a success. Data were analysed by chi-square test.

RESULTS

At the final stage of treatment, 69 of the 82 patients were eligible to be included in the study. No significant difference was found between age (P = 0.569) and gender (P = 0.570) amongst the patients in the two groups. The success rate of anaesthesia in the IANB and the combination groups were 22% and 58%, respectively. The success rate of anaesthesia in the combination group was significantly higher than the traditional IANB injection (P = 0.003).

CONCLUSION

A combination of anaesthetic techniques can improve the success rate of anaesthesia for mandibular first molar teeth with irreversible pulpitis.