Comparative evaluation of the efficacy, safety, and hemostatic effect of 2% lidocaine with various concentrations of epinephrine

Physiology of pregnancy and oral local anesthesia considerations

Background

Safe and effective local anesthesia is a prerequisite for emergency oral surgeries and most dental treatments. Pregnancy is characterized by complex physiological changes, and increased sensitivity to pain. Pregnant women are particularly vulnerable to oral diseases, such as caries, gingivitis, pyogenic granuloma and third molar pericoronitis. Maternally administered drugs can affect the fetus through the placenta. Therefore, many physicians and patients are reluctant to provide or accept necessary local anesthesia, which leads to delays in the condition and adverse consequences. This review is intended to comprehensively discuss the instructions for local anesthesia in the oral treatment of pregnant patients.

Methodology

An in-depth search on Medline, Embase, and the Cochrane Library was performed to review articles concerned with maternal and fetal physiology, local anesthetic pharmacology, and their applications for oral treatment.

Results

Standard oral local anesthesia is safe throughout the pregnancy. At present, 2% lidocaine with 1:200,000 epinephrine is considered to be the anesthetic agent that best balances safety and efficacy for pregnant women. Maternal and fetal considerations must be taken into account to accommodate the physiological and pharmacological changes in the gestation period. Semi-supine position, blood pressure monitoring, and reassurance are suggested for high-risk mothers to reduce the risk of transient changes in blood pressure, hypoxemia, and hypoglycemia. For patients with underlying diseases, such as eclampsia, hypertension, hypotension, and gestational diabetes, the physicians should use epinephrine cautiously and control the dose of anesthetic. New local anesthesia formulations and equipment, which contribute to minimizing injection pain and relieving the anxiety, have and are being developed but remain understudied.

Conclusions

Understanding the physiological and pharmacological changes during pregnancy is essential to ensure the safety and efficiency of local anesthesia. Optimal outcomes for the mother and fetus hinge on a robust understanding of the physiologic alterations and the appropriate selection of anesthetic drugs and approaches.

Comparison of the success of inferior alveolar nerve anesthesia in the mandibular first molars with symptomatic irreversible pulpitis using two anesthetic solutions of prilocaine and mepivacaine: A randomized controlled clinical trial

Background

This study aimed to compare the success rate of inferior alveolar nerve (IAN) anesthesia in the mandibular first molars with symptomatic irreversible pulpitis using two anesthetic solutions of prilocaine and mepivacaine.

Materials and Methods

The current randomized controlled clinical trial was conducted on 100 patients in two groups (n = 50). Standard injection of IAN block (IANB) was performed using two cartridges of 3% mepivacaine plain in the first group and using two cartridges of 3% prilocaine with 0.03 IU felypressin in the second group. Fifteen minutes after injection, the patients were asked about lip anesthesia. In case of a positive answer, the tooth was isolated with a rubber dam. Success was defined as no or mild pain on the basis of the visual analog scale recording upon access cavity preparation, entry into the pulp chamber, and initial instrumentation. Data were analyzed with SPSS 17 using the Chi-square test, and P < 0.05 was set as statistically significant.

Results

The patients' pain severities during the three stages were significantly different (P = 0.001, 0.0001, and 0.001, respectively). The success rate of IANB during access cavity preparation was 88% with prilocaine and 68% with mepivacaine. This rate during entry into the pulp chamber was 78% and 24%, respectively, which was 3.25 times higher with prilocaine than mepivacaine. The success rates during instrumentation were 32% and 10%, respectively, which was 3.2 times higher with prilocaine than mepivacaine.

Conclusion

The success rate of IANB in the teeth with symptomatic irreversible pulpitis was higher using 3% prilocaine with felypressin than using 3% mepivacaine.

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.

Effects of Remifentanil on Cardiovascular Stimulation Caused by Local Anesthetic With Epinephrine: A Power Spectral Analysis

The objectives of this research were to investigate (a) what was the most effective infusion rate of remifentanil and (b) the degree to which sympathomimetic effects were involved with cardiovascular stimulation by using a power spectral analysis of heart rate variability (HRV). A total of 63 healthy individuals scheduled for sagittal split ramus osteotomy were enrolled and randomly allocated to 1 of 3 groups: remifentanil infusion rate of 0.1, 0.2, or 0.4 μg/kg/min. Anesthesia was maintained with remifentanil and propofol. Before the surgical procedure, 2% lidocaine containing 12.5 μg/mL epinephrine was administered in the surgical field for local anesthesia. Systolic blood pressure (SBP), heart rate (HR), low-frequency (LF) and high-frequency (HF) components in HRV power spectral analysis, and the LF/HF ratio were analyzed. Increases in SBP and HR were observed after local anesthesia in all 3 groups, but no significant differences were observed between the groups. Remifentanil infusion at 0.1 μg/kg/min may be appropriate to minimize cardiovascular stimulation caused by exogenous epinephrine from local anesthesia. Although a rise in the LF/HF ratio was observed after local anesthesia in all groups, no relationship was observed between the cardiovascular changes and the increase in LF/HF ratio. This suggests that sympathomimetic effects are involved to a lesser extent with the cardiovascular stimulation caused by exogenous epinephrine.

Epinephrine penetrates through gingival sulcus unlike keratinized gingiva and evokes remote vasoconstriction in human

Background

It has been demonstrated in non-oral tissues that the locally evoked vasoconstriction could elicit remote vasoconstriction. This study aimed to investigate the spreading vasoconstrictor effects of epinephrine in the gingiva.

Methods

Gingival blood flow (GBF) was measured by laser speckle contrast imager in 21 healthy volunteers. In group A, two wells were fabricated from orthodontic elastic ligature and placed 2 mm apically to the free gingival margin at the mid buccal line of 12 (test side) and 21 (control side) teeth. The GBF was measured in the wells and tightly apical, coronal, distal and mesial to the wells. In group B, the wells were made on the buccal surface of the same teeth, including the gingival sulcus. Four regions were selected for measurement from the gingival margin reaching the mucogingival line (coronal, midway1, midway2 and apical). After the baseline recording, 3 µg epinephrine was applied into the test, and physiological saline into the control well. The GBF was recorded for 14 min. The gingival thickness was measured with a PIROP Ultrasonic Biometer.

Results

In group A, the GBF did not increase or decrease after the application of epinephrine. In group B, the GBF significantly decreased in all regions of the test side and remained low for the observation period. The vasoconstriction appeared with delays in more apical regions (at min 1 in the coronal and the midway1, at min 2 in the midway2, at min 4 in the apical region). Similarly, the amount of the decrease at 14 min was the largest close to sulcus (− 53 ± 2.9%), followed by the midway1 (− 51 ± 2.8%) and midway2 (− 42 ± 4.2%) and was the lowest in the apical region (− 32 ± 5.8%). No correlation was found between GBF and gingival thickness.

Conclusion

Epinephrine could evoke intense vasoconstriction propagating to the mucogingival junction, indicating the presence of spreading vasoconstriction in the human gingiva. The attached gingiva is impermeable to epinephrine, unlike the gingival sulcus.

This trial was registered in ClinicalTrials.gov titled as Evidence of Spreading Vasoconstriction in Human Gingiva with the reference number of NCT04131283 on 16 October 2019. https://clinicaltrials.gov/show/NCT04131283

Does articaine, rather than prilocaine, increase the success rate of anaesthesia for extraction of maxillary teeth

Objective:

To compare the anesthetic performances of 3% prilocaine and 4% articaine when used for the extraction of the maxillary teeth.

Materials and Methods:

Ninety-five patients, aged between 16 and 70 years, were included in this study. Patients were divided into two groups. Group one received articaine 4% with 1:00.000 adrenaline. Group two received prilocaine with 3% felypressin (0.03 I.U. per ml). Onset time of anesthesia was objectively evaluated by using electronic pulp testing.

Results:

Eighty-five patients in this study had a successful local anesthetic followed by extraction within the study duration time (10 minutes). However, there were six patients with failure anesthesia (5 in prilocaine group and 1 in articaine group). By applying Person's Chi-square test (x2), there were no significant differences in the number of episodes of the anesthetic success between articaine and prilocaine groups at time intervals (P = 0.5). T-test showed that there have been no important variations within the mean onset time of anesthesia for articaine and prilocaine buccal infiltrations (P = 0.1).

Conclusions:

3% Prilocaine with felypressin is as effective as 4% articaine with adrenaline when used for the extraction of maxillary teeth. Recommendations would be given to the dental practitioners to use prilocaine more frequently than articaine because of its low toxicity.

Trial registration number:

NCT04236115.

Is prilocaine safe and potent enough for use in the oral surgery of medically compromised patients

Objectives:

To investigate the potency and speed of action of 2% lidocaine and 3% prilocaine for upper teeth extractions.

Methods:

This prospective clinical study was conducted from November 2016 to May 2017. Ninety-six patients, aged between 16 to 70 years old were recruited in this study. Two regimens were randomly administered over one visit. Patients, treatment group I, received 2% lidocaine with 1:00.000 adrenaline. Patients treatment group II received prilocaine 3% and felypressin 0.03 I.U. per ml. The efficacy of pulp anesthesia was determined by electronic pulp testing. At any point of trial (10 minutes), the anesthetized tooth becomes unresponsive for maximal pulp stimulation (64 reading), the extraction was carried out.

Results:

There were no significant differences in the mean onset time of pulpal anesthesia and extraction between the prilocaine and lidocaine buccal infiltration groups (p=0.28). However, clinically, the patients in prilocaine group recorded faster onset time of anesthesia and teeth extraction than those in lidocaine group.

Conclusion:

Prilocaine has a better clinical performance in terms of providing rapid dental anesthesia and earlier teeth extraction than lidocaine but the differences were not significant. Prilocaine with felypressin could be a good choice for patients who have contraindication to the use of lidocaine with adrenaline.

Is prilocaine safe and potent enough for use in the oral surgery of medically compromised patients

OBJECTIVES

To investigate the potency and speed of action of 2% lidocaine and 3% prilocaine for upper teeth extractions.

METHODS

This prospective clinical study was conducted from November 2016 to May 2017. Ninety-six patients, aged between 16 to 70 years old were recruited in this study. Two regimens were randomly administered over one visit. Patients, treatment group I, received 2% lidocaine with 1:00.000 adrenaline. Patients treatment group II received prilocaine 3% and felypressin 0.03 I.U. per ml. The efficacy of pulp anesthesia was determined by electronic pulp testing. At any point of trial (10 minutes), the anesthetized tooth becomes unresponsive for maximal pulp stimulation (64 reading), the extraction was carried out.  Results: There were no significant differences in the mean onset time of pulpal anesthesia and extraction between the prilocaine and lidocaine buccal infiltration groups (p=0.28). However, clinically, the patients in prilocaine group recorded faster onset time of anesthesia and teeth extraction than those in lidocaine group. Conclusion: Prilocaine has a better clinical performance in terms of providing rapid dental anesthesia and earlier teeth extraction than lidocaine but the differences were not significant. Prilocaine with felypressin could be a good choice for patients who have contraindication to the use of lidocaine with adrenaline.