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

Comparison of Preoperative Analgesics on the Efficacy of Inferior Alveolar Nerve Block with Patients Having Symptomatic Irreversible Pulpitis: A Double-Blinded, Randomized Controlled Trial

OBJECTIVE

The objective of this study was to evaluate the effectiveness of preoperative analgesics on inferior alveolar nerve blocks (IANB) during root canal treatment in patients with symptomatic irreversible pulpitis of the mandibular molars.

METHODS

This study was a randomized, double-blinded, superiority trial with a parallel study design. A total of 120 subjects with symptomatic irreversible pulpitis were randomly assigned to one of four groups: group A (con- trol, Vitamin E, Evion 400 mg), group B (Diclofenac sodium, Voltral SR100 100 mg), group C (Piroxicam, Feldene 20 mg), and group D (Tramadol, Tramal 50 mg). The patients recorded preoperative pain levels, and after admin- istration of local anaesthesia intraoperative pain levels using the Heft-Parker visual analogue scale before and after the oral administration of the analgesics. Statistical analysis was performed using the Kruskal-Wallis test.

RESULTS

All the analgesic groups showed a significant effect on the efficacy of the inferior alveolar nerve block in contrast to the control group (p<0.05). However, no significant difference was found between the drug groups on the effectiveness of the inferior alveolar nerve block (p>0.05). No side effects were reported in the present study.

CONCLUSION

Preoperative analgesics significantly increase the effectiveness of inferior alveolar nerve block in patients with symptomatic irreversible pulpitis. Therefore, preoperative analgesics should be considered to increase the effectiveness of inferior alveolar nerve block in patients with symptomatic irreversible pulpitis on the mandibular molars. (EEJ-2023-02-033).

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.

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.

Effectiveness of different anesthetic methods for mandibular posterior teeth with symptomatic irreversible pulpitis: a systematic review and meta-analysis

OBJECTIVE

This systematic review aimed to assess the effectiveness of anesthetic methods for mandibular posterior teeth with symptomatic irreversible pulpitis, comparing to the inferior alveolar nerve block (IANB) by meta-analysis.

MATERIALS AND METHODS

Studies were identified from Cochrane Library, Embase, Lilacs, PubMed, Scopus, and Web of Science databases up to May 2021. Randomized clinical trials comparing the anesthetic success rate of IANB and any other alternative anesthetic method were included. The quality of the selected studies was assessed by the Cochrane Risk of Bias 2.0 tool. Meta-analyses using Mantel-Haenszel method and random-effect models were performed to find the pooled estimates of risk ratio (RR) with 95% confidence interval (CI). The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation approach.

RESULTS

Twenty-two studies were selected, which included fourteen anesthetic methods. Two studies were classified as high risk of bias, five as uncertain risk and fifteen as low risk. Vazirani-Akinosi nerve block (VANB) [RR = 1.27; p = 0.007; 95% CI, 1.07-1.52; I² = 0%] and intraosseous injection (IOI) [RR = 1.48; p = 0.04; 95% CI, 1.02-2.15; I² = 46%] had superior effectiveness compared to IANB, with low certainty of evidence, as well as buccal infiltrations associated with IANB (BI + IANB) [RR = 1.84; p = 0.004; 95% CI, 1.22-2.79; I² = 52%], with very low certainty.

CONCLUSION

Evidence suggests that buccal infiltrations associated with IANB, VANB, and IOI are more effective than IANB at anesthetizing posterior mandibular teeth with symptomatic irreversible pulpitis.

CLINICAL SIGNIFICANCE

Alternative primary methods of anesthesia might be indicated for mandibular posterior teeth presenting symptomatic irreversible pulpitis.

The diagnostic value of orthopantomograms in detecting resorption of lateral incisors associated with ectopic canines: a CBCT study

OBJECTIVE

To examine the diagnostic value of orthopantomograms (OPG) in the identification of root resorption of lateral incisors, secondary to an impacted canine, as confirmed by a cone-beam computed tomography (CBCT) scan.

DESIGN

Retrospective observational cohort study.

SETTING

South Wales secondary care setting: Royal Gwent Hospital, Newport and Nevill Hall Hospital, Abergavenny.

METHODS

A total of 40 consecutive patients with impacted canines between January 2018 and December 2019 were selected. For each patient, one consultant orthodontist examined the OPG in isolation to detect the presence and extent of resorption of lateral incisors. The CBCT report was then studied to confirm the presence and extent of pathology. Sensitivity, specificity, accuracy, positive predictive values and negative predictive values were calculated.

RESULTS

In total, 19 maxillary right canines, 18 maxillary left canines, one mandibular right canine and two mandibular left canines were examined. Impactions were more prevalent in the maxilla (92.5%) with higher predilection towards female patients (65%). There was higher prevalence of root resorption in the maxillary right quadrant (57.1%), in concordance with other studies. OPGs were found to have a sensitivity of 81.0% and a specificity of 10.5%, with an accuracy value of 47.5%. Positive and negative predictive values were found to be 50.0% and 33.3%, respectively. The extent of root resorption was incorrectly estimated from the OPG in 84% of cases. Correct estimation occurred in 16% of cases, with overestimation and underestimation occurring in equal proportion (42%).

CONCLUSION

This study demonstrates the limitations of plain film radiographs and the merits of using CBCT in the accurate diagnosis of resorption of lateral incisors with an associated impacted canine. It also gives an indication into the location prevalence of resorption in a small cohort of patients. This preliminary study establishes the basis for future, larger-scale studies where outcomes can be generalisable at a population level.

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.

Different anesthetics on the efficacy of inferior alveolar nerve block in patients with irreversible pulpitis: A network systematic review and meta-analysis

BACKGROUND

The authors of this systematic review and meta-analysis aimed to evaluate the effect of different anesthetics on the efficacy of inferior alveolar nerve block (IANB) in patients with irreversible pulpitis.

TYPES OF STUDIES REVIEWED

The authors conducted a search of MEDLINE databases (PubMed, Scopus, Web of Science, Cochrane Central Register of Controlled Trials, Latin American and Caribbean Health Sciences Literature, and Brazilian Library of Dentistry). There was no restriction on publication year or idiom. The gray literature was also explored. The authors included only randomized clinical trials that compared different anesthetics in the efficacy of IANB in patients with irreversible pulpitis. The risk of bias was evaluated by using the Cochrane Collaboration's tool. A random-effects Bayesian mixed treatment comparison model was used to compare different anesthetic solutions in randomized clinical trials with low or unclear risk of bias. Heterogeneity was assessed by using Cochran Q test and I² statistics. Quality of evidence was assessed by using the Grading of Recommendations Assessment, Development and Evaluation approach.

RESULTS

A total of 7,981 studies were identified; only 16 met the eligibility criteria, and they were all meta-analyzed. A significant difference was observed in the pair lidocaine versus articaine, with higher success with articaine (risk ratio, 0.76; 95% confidence interval, 0.63 to 0.88) in the mixed treatment comparison analysis, as this comparison was graded as high-quality evidence. The probability of success for each treatment was 73% for articaine, 57% for prilocaine, 55% for mepivacaine, 53% for bupivacaine, and 12% for lidocaine. This ranking was considered high quality of evidence.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

The use of articaine can increase the IANB success rate in patients with irreversible pulpitis. Among the anesthetic solutions, lidocaine was the least effective.

Effect of ibuprofen on the efficacy of inferior alveolar nerve block in patients with irreversible pulpitis: A meta-analysis

The aim of this study was to compare preventive ibuprofen administration to placebo on the efficacy of inferior alveolar nerve block in patients with irreversible pulpitis. A search was performed in PubMed, Scopus, Web of Science, LILACS, BBO, Cochrane Library, SIGLE, and grey literature. The risk of bias was evaluated through the Cochrane Collaboration's tool. The quality of evidence was assessed using the GRADE approach. Only seven studies remained for the meta-analysis. Administering ibuprofen before anaesthesia increased the success rate of injectable anaesthesia (RR = 1.79; 95% confidence interval (CI) 1.32-2.42; P = 0.0002) even in cases of symptomatic irreversible pulpitis (RR = 1.55; 95% CI 1.05-2.29; P = 0.03). The intensity of pain was lower for ibuprofen (standardised difference means (SMD) = -3.73; 95% CI -6.43 to -1.04; P = 0.007). Ibuprofen as premedication is beneficial for the success of inferior alveolar nerve block.

Is mepivacaine as effective as lidocaine during inferior alveolar nerve blocks in patients with symptomatic irreversible pulpitis? A systematic review and meta-analysis

This study aimed to compare the effectiveness of mepivacaine and lidocaine for pulpal anaesthesia and pain control when administered via an inferior alveolar nerve block during the root canal treatment of mandibular molars in patients with symptomatic irreversible pulpitis. A research protocol was developed and registered in PROSPERO. The systematic search was conducted during May 2017 in eight databases. The studies were selected based on inclusion and exclusion criteria. Two examiners analysed the sample independently, decided the eligibility for inclusion and classified the articles according to their quality. Statistical analysis was performed with Mantel-Haenszel and I-square (I² ) tests considering a confidence interval of 95%. The initial sample consisted of 1130 articles, out of which four were eligible. The articles were published between 1993 and 2016. For both pulpal anaesthesia and pain control, there was no significant difference between mepivacaine and lidocaine (P = 0.843, I²  = 0%, and P = 0.183, I²  = 21.1%, respectively). Mepivacaine and lidocaine were similarly effective for pulpal anaesthesia and pain control after inferior alveolar nerve blocks for root canal treatment.