A prospective, randomized, double-blind study of the anesthetic efficacy of sodium bicarbonate buffered 2% lidocaine with 1:100,000 epinephrine in inferior alveolar nerve blocks

Assessing the Efficacy of Buffered Versus Nonbuffered Lidocaine in Dental Extractions: A Double-Blinded Randomized Controlled Trial

BACKGROUND

Injections using buffered lidocaine may decrease discomfort, have a quicker onset, and be a more efficacious local anesthetic. Previous studies have been inconclusive in the oral context.

PURPOSE

To address if bicarbonate buffered 2% lidocaine can decrease pain from the use of local anesthesia, has a quicker onset time, and is more efficacious.

STUDY DESIGN

The design was a single-center double-blinded randomized control trial, set in an outpatient oral and maxillofacial clinic housed in the University of Cincinnati Medical Center. Inclusion criteria for the study were patients requiring a single tooth extraction due either to caries or periodontal disease.

PREDICTOR VARIABLE

The predictor variable was the local anesthetic used either nonbuffered 2% lidocaine with 1:100,000 epinephrine (control) or bicarbonate buffered 2% lidocaine with 1:100,000 epinephrine (study) was randomly assigned.

MAIN OUTCOME VARIABLES

Primary outcome variables were injection pain score, and postoperative pain, time to anesthetic onset, and the number of rounds of injections required to achieve adequate anesthesia.

COVARIATES

The covariates were jaw involved, age, sex, and race, American Society of Anesthesiologists score, body mass index, current tobacco use, history of psychiatric illness, chronic pain, and preoperative pain score.

ANALYSES

Test statistics were calculated using Wilcoxon rank-sum test, Kruskal-Wallis test, Spearman rank correlation test, χ2 test for bivariate analyses, and Fisher's exact test. P values ≤ .05 were considered statistically significant.

RESULTS

The final sample was 114 subjects. The mean age of the sample was 42.97 years, standard deviation ±13.43 years. The sample was 39.47% male. The racial demographics were Caucasian (62.28%) and African American (33.33%). Buffered lidocaine did not have a statistically significant relationship with any of the outcomes. The jaw involved had a statistically significant association to the injection pain score (P value = .006), and the number of rounds of anesthetic required (P value = .047). Age showed a statistically significant association to injection pain score (P value = .032), and the number of rounds of anesthetic required (P value = .027). Finally, preoperative pain had a statistically significant relationship with injection pain score (P value = < .001).

CONCLUSION AND RELEVANCE

In this study, bicarbonate buffered lidocaine did not exhibit any discernible advantages over nonbuffered lidocaine for any study outcomes.

Buffered versus Non-buffered Local Anaesthesia in Minor Oral Surgery - A Comparative Study

Introduction

Commercially available local anaesthetics are acidic solutions associated with the vasopressor sting on injection, relatively slower onset of action and pain during palatal injections. The above drawbacks can be addressed by anaesthetic buffering. This prospective study was aimed at comparing the efficacy of buffered and non-buffered local anaesthesia in the extraction of grossly decayed maxillary molar teeth in relation to pain on local infiltration, onset and duration of action of local anaesthesia.

Materials and Methods

This is a prospective randomised controlled trial done on 100 patients who required bilateral extraction of maxillary molar teeth. In the study group, patients were given buffered local anaesthesia (which was prepared by mixing 2% lignocaine with 1:80,000 adrenaline and 8.4% sodium bicarbonate) before extraction. In the control group, non-buffered local anaesthesia (2% lignocaine with 1:80,000 adrenaline) was given before extraction.

Results

Statistical data confirmed that buffering reduces pain on infiltration, decreases the onset and increases the duration of action of the local anaesthesia compared to non-buffered local anaesthesia. All the parameters measured were statistically significant (P = 0.001).

Discussion

The study concludes that buffered local anaesthesia was more beneficial than non-buffered local anaesthesia in reducing pain on injection, providing a quicker onset of local anaesthesia and increasing the duration of action of the local anaesthesia. Buffering is a safe, easy and efficient process and should be routinely followed to provide a better experience to the patients.

Buffered 2% articaine in buccal infiltration of mandibular molars: a randomized triple-blind clinical trial

This crossover study aimed to compare the anesthetic effects of buffered 2% articaine with 1:200,000 epinephrine with that of non-buffered 4% articaine with 1:200,000 epinephrine. Forty-seven volunteers were administered two doses of anesthesia in the buccal region of the second mandibular molars in two sessions using 1.8 mL of different local anesthetic solutions. The onset time and duration of pulp anesthesia, soft tissue pressure pain threshold, and the score of pain on puncture and burning during injection were evaluated. The operator, volunteers, and statistician were blinded. There were no significant differences in the parameters: onset of soft tissue anesthesia (p = 0.80), duration of soft tissue anesthesia (p = 0.10), onset of pulpal anesthesia in the second (p = 0.28) and first molars (p = 0.45), duration of pulp anesthesia of the second (p = 0.60) and first molars (p = 0.30), pain during puncture (p = 0.82) and injection (p = 0.80). No significant adverse events were observed. Buffered 2% articaine with 1:200,000 epinephrine did not differ from non-buffered 4% articaine with 1:200,000 epinephrine considering anesthetic success, safety, onset, duration of anesthesia, and pain on injection.

Effectiveness of buffered and non-buffered local anaesthetic in inferior alveolar nerve block: a randomised study

The objective of this study was to compare the effectiveness of buffered and non-buffered local anaesthetic (LA) following inferior alveolar nerve block (IANB). This study was conducted at Usmanu Danfodiyo University Teaching Hospital Sokoto from June 2020 to January 2021. Subjects were randomised into Groups A and B. Group A received 2 ml of freshly prepared 2% lignocaine with 1:100,000 adrenaline buffered with 0.18 ml of 8.4% sodium bicarbonate solution while those in Group B received non-buffered 2% lignocaine with 1:100,000 adrenaline LA solutions. The onset of action of the LA was assessed by subjective and objective methods, while pain at the injection site was assessed using a numerical rating scale. Data obtained were analysed using statistical package for social sciences (IBM SPSS) version 21. The mean (SD) ages for Groups A and B were 37.4 (14.9) and 40.1 (14.4) years, respectively. The mean (SD) onset times of the LA by subjective testing were 126 (31.7) and 201 (66.8) seconds for Groups A and B, respectively. Similarly, the mean (SD) onset times of the local anaesthesia by objective testing for Groups A and B were 186 (41.0) and 287 (85.0) seconds, respectively, and both were significant (p<0.001). Pain at the injection site assessed objectively and subjectively were also statistically different (p<0.001). The findings of this study suggest that buffered LA is more effective than non-buffered LA of the same composition when used for IANB particularly concerning a significantly faster rate of onset and less pain at the injection site.

Efficacy of intraosseous saline injection for pain management during surgical removal of impacted mandibular third molars: a randomized double-blinded clinical trial

Background

Surgical extraction of impacted mandibular third molars is the most common procedure performed by oral surgeons. The procedure cannot be performed effectively without achieving profound anesthesia. During this procedure, patients may feel pain during surgical bone removal (at the cancellous level) or during splitting and luxation of the tooth, despite administration of routine nerve blocks. Administration of intraosseous (IO) lignocaine injections during third molar surgeries to provide effective anesthesia for pain alleviation has been documented. However, whether the anesthetic effect of lignocaine is the only reason for pain alleviation when administered intraosseously remains unclear. This conundrum motivated us to assess the efficacy of IO normal saline versus lignocaine injections during surgical removal of impacted mandibular third molars. The aim of this study was to assess the efficacy of IO normal saline as a viable alternative or adjunct to lignocaine for alleviation of intraoperative pain during surgical removal of impacted mandibular third molars.

Methods

This randomized, double-blind, interventional study included 160 patients who underwent surgical extraction of impacted mandibular third molars and experienced pain during surgical removal of the buccal bone or sectioning and luxation of the tooth. The participants were divided into two groups: the study group, which included patients who would receive IO saline injections, and the control group, which included patients who would receive IO lignocaine injections. Patients were asked to complete a visual analog pain scale (VAPS) at baseline and after receiving the IO injections.

Results

Of the 160 patients included in this study, 80 received IO lignocaine (control group), whereas 80 received IO saline (study group) following randomization. The baseline VAPS score of the patients and controls was 5.71 ± 1.33 and 5.68 ± 1.21, respectively. The difference between the baseline VAPS scores of the two groups was not statistically significant (P > 0.05). The difference between the numbers of patients who experienced pain relief following administration of IO lignocaine (n=74) versus saline (n=69) was not statistically significant (P > 0.05). The difference between VAPS scores measured after IO injection in both groups was not statistically significant (P >0.05) (1.05 ± 1.20 for the control group vs. 1.72 ± 1.56 for the study group).

Conclusion

The study demonstrates that IO injection of normal saline is as effective as lignocaine in alleviating pain during surgical removal of impacted mandibular third molars and can be used as an effective adjunct to conventional lignocaine injection.

Anesthetic efficacy of buffered 4% articaine for mandibular first molar infiltration: a crossover clinical trial

Background

The limited studies on the effect of buffering on the clinical efficacy of articaine have reported controversial results. The purpose of this study was to clinically compare the pain of injection, anesthetic success, onset, and duration of pulpal anesthesia of buffered 4% articaine with epinephrine 1:100000 versus a non-buffered 4% articaine with epinephrine 1:100000 formulation for buccal infiltration of the mandibular first molar.

Methods

Sixty-three volunteers were enrolled in the study. All volunteers received two injections consisting of a single mandibular first molar buccal infiltration with 1.8 ml of 4% articaine with epinephrine 1:100000 and 1.8 ml of 4% articaine with epinephrine 1:100000 buffered with 8.4% sodium bicarbonate. The infiltrations were applied in two separate appointments spaced at least one week apart. After injection of the anesthetic solution at the examined site, the first molar was pulp-tested every 2 min for the next 60 min.

Results

Successful pulpal anesthesia was recorded in 69.8% of cases using non-buffered articaine solution and 76.2% of cases using buffered articaine solution, with no significant difference between the formulations (P = 0.219). The mean time of anesthesia onset for the volunteers with successful anesthetic outcome in both formulations (n = 43) was 6.6 ± 1.6 min for the non-buffered articaine solution and 4.5 ± 1.6 min for the buffered solution, which differed significantly (P = 0.001). In the same volunteers, the mean duration of pulpal anesthesia was 28.4 ± 7.1 min for non-buffered articaine solution and 30.2 ± 8.5 min for buffered articaine solution, with no significant difference between the formulations (P = 0.231). Considering the pain of injection, regardless of the anesthetic success, the mean values of VAS were 11.3 ± 8.2 mm for the non-buffered articaine solution and 7.8 ±6.5 mm for the buffered articaine solution, which differed significantly (P = 0.001 < 0.05).

Conclusion

According to the present study, 4% articaine with epinephrine can benefit from buffering and provide better anesthetic behavior, with improved onset and less pain during injection.

Efficacy of Sodium Bicarbonate-Buffered Local Anesthetic Solution in Cases Requiring Bilateral Maxillary Premolar Orthodontic Extraction: A Comparative Split-Mouth Study

Aims and objectives This study was carried out to evaluate the efficacy of 8.4% sodium bicarbonate-buffered local anesthetic solution and conventional local anesthetic in patients requiring bilateral maxillary orthodontic extractions in terms of pain on injection, onset of action, and duration of action. Methods 102 patients requiring bilateral maxillary orthodontic extractions were included in the study. Buffered local anesthetic was administered on one side while conventional local anesthesia (LA) was administered on the other side. Pain on injection was measured using a visual analogue scale, while onset of action was measured by probing the buccal mucosa after 30 seconds of administration and duration of action was measured by the time after which the patient experienced pain or took a rescue analgesic. The data was statistically analyzed to determine the significance. Results The pain during injection was found to be lesser at sites where buffered local anesthetic was administered (mean visual analogue scale (VAS) score = 2.4) as compared to conventional local anesthetic (mean VAS score = 3.9). The onset of action was faster with buffered local anesthetic (mean value = 62.3 seconds) as compared to conventional local anesthetic (mean value = 157.16 seconds). Lastly, the duration of action was found to be longer for buffered local anesthetic group (mean value = 225.65 minutes) as compared to conventional local anesthetic (mean value = 187 minutes). Conclusion 8.4% sodium bicarbonate-buffered local anesthetic was found to be more efficient than conventional local anesthetic in terms of reduction in pain on injection as well as faster onset and longer duration of action.

A Comparative Study to Evaluate the Anesthetic Efficacy of Buffered Versus Non-buffered 2% Lidocaine During Inferior Alveolar Nerve Block

BACKGROUND

The study aimed to compare the clinical efficacy, safety, and acceptability of buffered lidocaine (8.4% sodium bicarbonate and 2% lidocaine with 1:80,000 adrenaline) versus non-buffered lidocaine (2% lidocaine with 1:80,000 adrenaline) during inferior alveolar nerve block.

MATERIALS AND METHODS

Fifty patients who required bilateral extractions in a single arch were included in this study. One hundred extractions were carried out, and all of the patients had nerve blocks during the procedure. We also took note of the patient's pain level as measured on a visual analog scale, as well as the start of the action, duration of postoperative analgesia, and occurrence of any problems. The duration of anesthesia was assessed by the feeling of numbness and the first sign of pain.

RESULT

All the patients in both study groups reported subjective numbness of the lips and tongue. The depth of anesthesia was evaluated by pain and comfort during the procedure with a visual analog scale and showed no significant difference between the two groups. The onset of action for the pterygomandibular nerve block was 1.240.31 minutes (buffered) and 1.710.51 minutes (non-buffered). When compared, the duration of anesthesia was 327.18102.98 minutes (buffered) and 129.0826.85 minutes (non-buffered).

CONCLUSION

This study concludes that the buffered solution has a faster onset of action than the non-buffered solution. Both solutions exhibit similar intraoperative efficacy. The duration of postoperative anesthesia was prolonged with buffering. Buffering also reduced pain scores during the early postoperative period.

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.

Nitrous Oxide/Oxygen Effect on IANB Injection Pain and Mandibular Pulpal Anesthesia in Asymptomatic Subjects

The inferior alveolar nerve block (IANB) does not always result in successful pulpal anesthesia. Nitrous oxide may increase the success of the IANB. The purpose of this investigation was to study the effect of nitrous oxide/oxygen (N2O/O2) on IANB injection pain and mandibular pulpal anesthesia in asymptomatic subjects. One hundred five asymptomatic subjects received an IANB after the administration of N2O/O2 or room air/oxygen (air/O2) at 2 separate appointments. After the IANB, subjects rated their level of pain for each phase of the injection (needle insertion, needle placement, and solution deposition) using a Heft Parker visual analog scale. Pulpal anesthesia was evaluated with an electric pulp tester for 60 minutes. The mean pain rating for all 3 injection phases showed a statistically significant reduction in pain when N2O/O2 was used compared with Air/O2 (P < .05). Odds ratios demonstrated a statistically significant increase in IANB success for the N2O/O2 group compared with the air/O2 group. N2O/O2 administration statistically decreased pain for all 3 injection phases of the IANB. In addition, nitrous oxide statistically increased the likelihood of pulpal anesthesia for posterior mandibular teeth. However, the incidence of pulpal anesthesia was not 100%.

Buffered versus unbuffered local anesthesia for inferior alveolar nerve block injections in children: a systematic review

Background

The present study aimed to evaluate and compare the efficacy of buffered and unbuffered local anesthesia solutions during inferior alveolar nerve block (IANB) administration in children.

Methods

PubMed, Ovid SP, and Cochrane databases were searched separately by two independent reviewers for potential papers published between 1980 and April 2020 using relevant MeSH terms and pre-specified inclusion and exclusion criteria. T Studies of IANB administration in children comparing buffered and unbuffered local anesthesia solutions were evaluated. The primary outcome evaluated was pain (perception and reaction), while the secondary outcome was the onset of anesthesia.

Results

A total of five articles were included in a qualitative analysis; among them, four qualified for quantitative analysis of the primary outcome and three for quantitative analysis of the secondary outcome. A fixed-effects model was used to perform the meta-analysis.

Pain perception (child-reported pain): Significantly lower pain scores were reported with buffered local anesthesia solution than with unbuffered solution (P = 0.006, MD: −0.32, 95% CI: −0.55 to −0.09).

Pain reaction (observer-reported pain reaction in child): No significant difference was found between buffered and unbuffered solution in terms of observer-reported pain behavior in the child (P = 0.09, MD: −0.21, 95% CI: −0.46 to 0.04).

Onset of anesthesia: A significantly lower duration of anesthesia onset was reported with buffered local anesthesia solution than with unbuffered solution (P = 0.00001, MD: −12.38, 95% CI: −17.64 to −7.13].

Conclusion

Buffering local anesthesia solution may reduce discomfort due to IANB injection administration and lower the initial onset time of anesthesia. More randomized control trials with adequate sample sizes should be carried out to validate the accuracy of these results.

Pain perception of a new Ahmad-Humayun solution for local anesthesia in hair transplantation: One step ahead

BACKGROUND

Local anesthetic is one of the major ways to obtain satisfactory anesthesia in majority of plastic surgical procedures.

OBJECTIVES

To compare the effect on pain while injecting buffered vs nonbuffered local anesthetic.

MATERIALS AND METHODS

The single-blind, split-scalp study was conducted in 25 patients undergoing first hair transplant surgery after informed consent and ethics committee approval using two solutions. Solution A was composed of normal saline (200 mL), 2% lidocaine (40 mL), 1 mL of epinephrine 1:1000, and triamcinolone acetate (40 mg). Solution B was composed of normal saline (200 mL), 2% lidocaine (40 mL), 1 mL of epinephrine 1:1000, triamcinolone acetate (40 mg), and 8.4% soda bicarbonate (5 mL). A 3-mL syringe with 30-G needle was used. On one side of the scalp, solution A was used and solution B on the other side. The pain response was recorded using Wong-Baker Faces Pain Scale corresponding to 0-10 scale. The data were analyzed statistically. No preoperative analgesic was used in any patient. The injections were administered by the 2nd author.

RESULTS

A total of 25 patients were included in the study. The mean age of the patients was 33.4 years (range; 28 to 41 years). The average pain score was 4.96 (range, 3-7) with solution A whereas 3.28 (range, 2-6) using the solution B (P < .05). Eleven of the patients (44%) were smokers. The average pain score in smokers was 5.82 with solution A and 3.73 with solution B. The pain score in nonsmokers was 4.29 with solution A and 2.93 with solution B (P < .05).

A Prospective, Randomized Double-Blinded Study to Evaluate the Efficacy of Buffered Local Anesthetics in Infected and Inflamed Pulp and Periapical Tissues

Aim

The aim of this study is to evaluate the efficacy of sodium bicarbonate as an additive alkalizing agent to local anesthetic solutions in inflamed and infected pulpal and periapical tissues.

Type of Study

A prospective, randomized crossover double-blinded study was carried out in a university-affiliated hospital in Chennai.

Materials and Methods

A randomized crossover double-blinded study was designed wherein ninety-six patients were enrolled for the study. 1.8 ml of 2% lignocaine with 1:200,000 adrenaline was administered. The latency time period was found to be 5-10 min and extraction was attempted. During extraction, if the patient experienced pain, 0.5 ml of 8.4% sodium bicarbonate was injected into the previously injected local anesthesia site. A time period of 3 min was allowed for the alkalinization to occur. Extraction was carried out only when the patient did not complain of pain. Pain score was assessed before and after administration of 8.4% sodium bicarbonate using visual analog scale. Pulse rate at the baseline, before and after administration of 8.4% sodium bicarbonate, was recorded and the pain scale values were correlated with pulse rate.

Results

It was found that there was a significant decrease in pain after injecting buffered local anesthetics (p < 0.1). Pain score before injecting sodium bicarbonate was higher when compared to post-injection of sodium bicarbonate. There was also significant reduction in pulse rate following the administration of sodium bicarbonate.

Conclusion

Buffered 2% lignocaine with 1:200,000 epinephrine had early onset of anesthesia when compared to unbuffered form. Injecting 2% buffered lignocaine pain was significantly reduced during extraction in the teeth.

Do buffered local anesthetics provide more successful anesthesia than nonbuffered solutions in patients with pulpally involved teeth requiring dental therapy?: A systematic review

BACKGROUND

The authors conducted a systematic review that addresses the following population, intervention, comparison, outcome question: "In adults requiring dental therapy with pulpally involved teeth, what is the comparative efficacy of buffered local anesthetics (LAs) compared with that of nonbuffered LAs in achieving anesthetic success?"

TYPES OF STUDIES REVIEWED

The authors searched MEDLINE, Scopus, Cochrane Library, ClinicalTrials.gov, World Health Organization International Trials Registry Platform, OpenGrey, Google Scholar Beta, and 2 textbooks to identify double-blinded randomized controlled trials in which researchers directly compared the efficacy of buffered and nonbuffered LAs in adult participants, as well as any associated side effects. Furthermore, they checked the reference lists of all included and excluded studies to identify any further trials. Weighted anesthesia success rates were estimated and compared by using a random-effects model.

RESULTS

A total of 14,011 studies were initially identified from the search; 5 double-blinded randomized clinical trials met inclusion criteria. Buffered LAs were more likely to achieve successful anesthesia than nonbuffered LAs (odds ratio, 2.29; 95% confidence interval, 1.11 to 4.71; P = .0232; I² = 66%).

CONCLUSIONS AND PRACTICAL IMPLICATIONS

This investigation revealed that buffered LAs are more effective than nonbuffered LAs when used for mandibular or maxillary anesthesia in pulpally involved teeth. Buffering of LAs has 2.29 times greater likelihood of achieving successful anesthesia.

Pain perception and efficacy of local analgesia using 2% lignocaine, buffered lignocaine, and 4% articaine in pediatric dental procedures

Background

The purpose of this study was to compare the pain perception and anesthetic efficacy of 2% lignocaine with 1:200,000 epinephrine, buffered lignocaine, and 4% articaine with 1:200,000 epinephrine for the inferior alveolar nerve block.

Methods

This was a double-blind crossover study involving 48 children aged 5–10 years, who received three inferior alveolar nerve block injections in three appointments scheduled one week apart from the next. Pain on injection was assessed using the Wong-Baker Faces pain scale and the sound eye motor scale (SEM). Efficacy of anesthesia was assessed by subjective (tingling or numbness of the lip, tongue, and corner of mouth) and objective signs (pain on probing).

Results

Pain perception on injection assessed with Wong-Baker scale was significantly different between buffered lignocaine and lignocaine (P < 0.001) and between buffered lignocaine and articaine (P = 0.041). The onset of anesthesia was lowest for buffered lignocaine, with a statistically significant difference between buffered lignocaine and lignocaine (P < 0.001). Moreover, the efficacy of local analgesia assessed using objective signs was significantly different between buffered lignocaine and lignocaine (P < 0.001) and between lignocaine and articaine.

Conclusion

Buffered lignocaine was the least painful and the most efficacious anesthetic agent during the inferior alveolar nerve block injection in 5–10-year-old patients.

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 sodium bicarbonate buffered versus non-buffered lidocaine with epinephrine in inferior alveolar nerve block: A meta-analysis

Introduction

This systematic review evaluated the use of buffered versus non-buffered lidocaine to increase the efficacy of inferior alveolar nerve block (IANB).

Materials and Methods

Randomized, double-blinded studies from PubMed, Web of Science, Cochrane Library, Embase, and ProQuest were identified. Two of the authors assessed the studies for risk of bias. Outcomes included onset time, injection pain on a visual analog scale (VAS), percentage of painless injections, and anesthetic success rate of IANB.

Results

The search strategy yielded 19 references. Eleven could be included in meta-analyses. Risk of bias was unclear in ten and high in one study. Buffered lidocaine showed 48 seconds faster onset time (95% confidence interval [CI], −42.06 to −54.40; P < 0.001) and 5.0 units lower (on a scale 0–100) VAS injection pain (95% CI, −9.13 to −0.77; P=0.02) than non-buffered. No significant difference was found on percentage of people with painless injection (P = 0.059), nor success rate (P = 0.290).

Conclusion

Buffered lidocaine significantly decreased onset time and injection pain (VAS) compared with non-buffered lidocaine in IANB. However due to statistical heterogeneity and low sample size, quality of the evidence was low to moderate, additional studies with larger numbers of participants and low risk of bias are needed to confirm these results.

Comparative evaluation of anesthetic efficacy of warm, buffered and conventional 2% lignocaine for the success of inferior alveolar nerve block (IANB) in mandibular primary molars: A randomized controlled clinical trial

Background: Maintaining primary teeth in the oral cavity is of prime importance, and grossly carious teeth may require pulp therapy for the same. Pain on injection and incomplete anesthesia causes failure of the procedure and result in fear and anxiety. Various methods have evolved to overcome this; such as distraction, topical anesthesia, etc. A few techniques regaining popularity in dentistry in recent times is the warming or buffering of the solution prior to administration. This study thus aimed to compare and evaluate the anesthetic efficacy and the patient’s pain reaction to pre-warmed, buffered and conventional 2% lignocaine for the success of Inferior Alveolar Nerve Block in mandibular primary molars undergoing pulp therapy.

Methods: The study is a randomized, split-mouth trial. Sixty children between six -12 years, requiring pulp therapy bilaterally on mandibular primary molars, were administered conventional, buffered or pre-warmed 2% lignocaine on two separate appointments. Various parameters were assessed using objective and subjective scales.

Results: Pre-warmed and buffered anesthetics had lesser pain on injection (p<0.001, p<0.001) and pulp therapy (p=0.001, p=0.014), faster onset of action (p=0.004, p=0.001), lower SEM Sound (p=0.035, p=0.028), Eye (p< 0.001, p=0.013) and Motor (p=0.008, p=0.021) scores and shorter duration of action (p< 0.001, p=0.015). No significant difference was found between the two modified solutions. Thus pre-warmed and buffered anesthetic solutions fared better than the conventional solution for all parameters but had no advantage over each other.

Conclusion: Buffering or pre-warming the anesthetic solution reduces pain on administration and during procedures in children.

Trial registration number: CTRI/2017/02/007922

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.

4% lidocaine versus 4% articaine for inferior alveolar nerve block in impacted lower third molar surgery

Background

No study has compared lidocaine with articaine, each at a concentration of 4% and combined with epinephrine. The purpose of this study was to compare the effectiveness of 4% lidocaine with that of 4% articaine, with a concentration of 1:100,000 epinephrine added to each, in an inferior alveolar nerve block for surgery on impacted lower third molars.

Method

This study was conducted at the Faculty of Dentistry, Mahidol University in Bangkok, Thailand. The randomized, single-blind, comparative split-mouth study was carried out in patients with symmetrically impacted lower third molars, as identified on panoramic radiographs. Each patient underwent surgery for the removal of the lower third molars by the same surgeon under local anesthesia at two separate visits, 3 weeks apart. The onset and duration of local anesthesia, intra-operative pain, surgical duration, and number of additional anesthetics administered were recorded.

Results

The subjective and objective onset of action for the local anesthetics showed statistically significant differences (P < 0.05). However, the intra-operative pain, surgical duration, duration of local anesthesia, and number of additional anesthetics administered did not show statistically significant differences.

Conclusion

The use of 4% articaine for the inferior alveolar nerve block was clinically more effective in the onset of subjective and objective anesthesia as compared with the use of 4% lidocaine. Based on the pain scores from the visual analogue scale, 4% lidocaine provided more analgesia during the procedure, and patients noted less intra-operative pain than with 4% articaine; however, the difference was not clinically significant.

Buffered Versus Non-Buffered Lidocaine With Epinephrine for Mandibular Nerve Block: Clinical Outcomes

PURPOSE

Outcomes for peak blood levels were assessed for buffered 2% lidocaine with 1:100,000 epinephrine compared with non-buffered 2% lidocaine with 1:100,000 epinephrine.

PATIENTS AND METHODS

In this institutional review board-approved prospective, randomized, double-blinded, crossover trial, the clinical impact of buffered 2% lidocaine with 1:100,000 epinephrine (Anutra Medical, Research Triangle Park, Cary, NC) was compared with the non-buffered drug. Venous blood samples for lidocaine were obtained 30 minutes after a mandibular nerve block with 80 mg of the buffered or unbuffered drug. Two weeks later, the same subjects were tested with the alternate drug combinations. Subjects also reported on pain on injection with a 10-point Likert-type scale and time to lower lip numbness. The explanatory variable was the drug formulation. Outcome variables were subjects' peak blood lidocaine levels, subjective responses to pain on injection, and time to lower lip numbness. Serum lidocaine levels were analyzed with liquid chromatography-mass spectrometry. Statistical analyses were performed using Proc TTEST (SAS 9.3; SAS Institute, Cary, NC), with the crossover option for a 2-period crossover design, to analyze the normally distributed outcome for pain. For non-normally distributed outcomes of blood lidocaine levels and time to lower lip numbness, an assessment of treatment difference was performed using Wilcoxon rank-sum tests with Proc NPAR1WAY (SAS 9.3). Statistical significance was set at a P value less than .05 for all outcomes.

RESULTS

Forty-eight percent of subjects were women, half were Caucasian, 22% were African American, and 13% were Asian. Median age was 21 years (interquartile range [IQR], 20-22 yr), and median body weight was 147 lb (IQR, 130-170 lb). Median blood levels (44 blood samples) at 30 minutes were 1.19 μg/L per kilogram of body weight. Mean blood level differences of lidocaine for each patient were significantly lower after nerve block with the buffered drug compared with the non-buffered agent (P < .01). Mean score for pain on injection for nerve block (n = 46 scores) was 3.3 (standard deviation, 0.9). Seventy-eight percent of subjects reported lower or the same pain scores with the buffered drug; 61% of subjects reported a shorter time to lower lip numbness with the buffered drug.

CONCLUSIONS

Buffering 2% lidocaine with epinephrine can produce clinical outcomes favorable for subjects and clinicians without clinically detrimental peak blood lidocaine levels.

Buffered Lidocaine With Sodium Bicarbonate did not Increase Inferior Alveolar Nerve Block Success Rate in Patients Having Symptomatic Irreversible Pulpitis

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION

Effect of buffered 4% lidocaine on the success of the inferior alveolar nerve block in patients with symptomatic irreversible pulpitis: a prospective, randomized, double-blind study. Schellenberg J, Drum M, Reader A, Nusstein J, Fowler S, Beck M. J Endod 2015;41(6):791-6.

SOURCE OF FUNDING

The study was supported by Meyers/Reader Graduate Endodontic Support Fund

TYPE OF STUDY/DESIGN

Double blinded randomized controlled trial.

A brief review on the efficacy of different possible and nonpharmacological techniques in eliminating discomfort of local anesthesia injection during dental procedures

Dental anxiety and fear of needle injection is one of the most common problems encountered by dental practitioners, especially in the pediatric patient. In consequences, it might affect the patient's quality of life. Several methods are suggested to lower the discomfort of local anesthesia injection during dental procedures. Desensitization of injection site is one of the recommended strategies. Among chemical anesthetic topical agents that are effective but might have allergic side effects, using some nonpharmacological and safe techniques might be useful. This study aimed to overview the efficacy of using cooling techniques, mostly by ice or popsicles, warming or pH buffering of drug, and using modern devices to diminish the discomfort of local anesthesia injection during dental procedures.

Efficacy of a Buffered 4% Lidocaine Formulation for Incision and Drainage: A Prospective, Randomized, Double-blind Study

INTRODUCTION

Incision and drainage of symptomatic emergency patients with facial swelling is painful even after local anesthetics are administered. The purpose of this prospective, randomized, double-blind study was to compare the pain of infiltration and the pain of an incision and drainage procedure of a buffered versus a nonbuffered 4% lidocaine formulation in symptomatic emergency patients presenting with a diagnosis of pulpal necrosis, associated periapical area, and an acute clinical swelling.

METHODS

Eighty-eight emergency patients were randomly divided into 2 groups to receive 2 intraoral infiltration injections (mesial and distal to the swelling) of either 4% lidocaine with 1:100,000 epinephrine buffered with 0.18 mL 8.4% sodium bicarbonate using the Onpharma (Los Gatos, CA) buffering system or 4% lidocaine with 1:100,000 epinephrine. Subjects rated the pain of needle insertion, needle placement, and solution deposition for each injection using a 170-mm visual analog scale. An incision and drainage procedure was performed, and subjects rated the pain of incision, drainage, and dissection on a 170-mm visual analog scale.

RESULTS

No significant differences between the buffered and nonbuffered 4% lidocaine formulations were found for needle insertion, placement, and solution deposition of the infiltration injections or for the treatment phases of incision, drainage, and dissection.

CONCLUSIONS

Buffering a 4% lidocaine formulation did not significantly decrease the pain of infiltrations or significantly decrease the pain of the incision and drainage procedure when compared with a nonbuffered 4% lidocaine formulation in symptomatic patients with a diagnosis of pulpal necrosis and associated acute swelling.

The efficacy of an elevated concentration of lidocaine HCl in impacted lower third molar surgery

Background

There have been few studies on the effect of an elevated concentration of lidocaine hydrochloride in the surgical removal of an impacted lower third molar. This study aimed to examine the efficacy of 4% lidocaine along with 1:100,000 epinephrine compared to 2% lidocaine along with 1:100,000 epinephrine as inferior alveolar nerve block for the removal of an impacted lower third molar.

Methods

This single-blind study involved 31 healthy patients (mean age: 23 y; range: 19-33 y) with symmetrically impacted lower third molars as observed on panoramic radiographs. Volunteers required 2 surgical interventions by the same surgeon with a 3-week washout period. The volunteers were assigned either 4% lidocaine with 1:100,000 epinephrine or 2% lidocaine with 1:100,000 epinephrine as local anesthetic during each operation.

Results

We recorded the time of administration, need for additional anesthetic administration, total volume of anesthetic used. We found that the patient's preference for either of the 2 types of local anesthetic were significantly different (P < 0.05). However, the extent of pulpal anesthesia, surgical duration, and duration of soft tissue anesthesia were not significantly different.

Conclusions

Our study suggested that inferior alveolar nerve block using 4% lidocaine HCl with 1:100,000 epinephrine as a local anesthetic was clinically more effective than that using 2% lidocaine HCl with 1:100,000 epinephrine; the surgical duration was not affected, and no clinically adverse effects were encountered.

Buffered 4% Articaine as a Primary Buccal Infiltration of the Mandibular First Molar: A Prospective, Randomized, Double-blind Study

INTRODUCTION

Articaine is superior to lidocaine when used as a primary buccal infiltration of the mandibular first molar. Buffered local anesthetics have been purported to improve anesthetic success. Buffering a 4% articaine formulation may increase the success of a mandibular first molar buccal infiltration. The purpose of this study was to compare the degree of pulpal anesthesia obtained with a buffered 4% articaine with 1:100,000 epinephrine formulation versus a nonbuffered 4% articaine with 1:100,000 epinephrine formulation as a primary buccal infiltration of the mandibular first molar.

METHODS

Eighty adults randomly received mandibular buccal infiltrations using 4% articaine with 100,000 epinephrine buffered with 8.4% sodium bicarbonate (18 mEq) and 4% articaine with 1:100,000 epinephrine in a double-blind manner at 2 separate appointments. An electric pulp tester was used to test the first molar for pulpal anesthesia every 30 seconds for the first 5 minutes and every minute for the remaining 55 minutes. Successful pulpal anesthesia was defined as 2 consecutive 80/80 readings with the electric pulp tester. Pain ratings for each injection were recorded as well as the onset time of pulpal anesthesia.

RESULTS

Anesthetic success rates for buffered articaine and nonbuffered articaine were 71% and 65%, respectively. There was no significant difference between the formulations (P = .3018). No significant differences were found between the 2 formulations for pain of injection or onset of anesthesia.

CONCLUSIONS

Buffered articaine did not provide any advantage over nonbuffered articaine for anesthetic success, anesthesia onset, or pain of injection for a primary buccal infiltration of the mandibular first molar.

Mannitol an adjuvant in local anaesthetic solution: recent concept & changing trends (review)

Various adjuncts have been utilized with lignocaine to decrement tourniquet pain and prolong postoperative analgesia and its efficacy during dental extraction and various other restorative procedures in dentistry. An obligatory part of the dental process is to sanction a patient to feel comfortable and pain-free during operational and remedial dental procedures. The most popular local anaesthetic injection for lower teeth is the inferior alveolar nerve (IAN) block. Instead of this the percentage of ineffectiveness is higher is inferior alveolar nerve block as compared to other local anaesthetic nerve block. The goal of cumulating different drugs is to engender the best therapeutic effects with the fewest or no unpropitious effects. There are fewer researches and evidence present which recommend and promote the application and effectiveness of mannitol other than in the administration in decreasing raised intracranial pressure. It is paramount to know how the drug interacts with each other to minimize the unexpected or perilous effects.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Combating inadequate anesthesia in periapical infections, with sodium bicarbonate: a clinical double blind study

INTRODUCTION

Local anesthetics are generally much less effective when administered in inflamed tissues.

PURPOSE

This study was conducted to validate the addition of sodium bicarbonate in local anesthetics to increase its effectiveness as local infiltrations in teeth associated with periapical infections.

METHODS

Two hundred subjects requiring extraction of maxillary teeth with periapical infections were enrolled. These subjects were divided in two groups of 100 subjects each. One group received local infiltration with 2 % lignocaine and 1:80,000 adrenaline, and the other group received local infiltration with sodium bicarbonate as an adjunct to the above mentioned local anesthetic solution. All extractions were performed using a consistent intra-alveolar technique by a single operator. Both the patient and the operator were blinded to the contents of local anesthetic solution. Data related to the onset of action of local anesthesia, pain experienced by the patient while undergoing extraction on two scales-"the visual analog scale and the verbal response scale", and any requirement of repeated injections during the procedure was recorded.

RESULTS

Clinical and statistical data confirmed that the addition of sodium bicarbonate in local anesthetics did increase the efficacy of local anesthesia in inflamed tissues.

CONCLUSION

It has been observed in this study that the action of sodium bicarbonate in local anesthetics increases the pH levels of these solutions, thus possibly making them more effective in an acidic environment.

Buffered lidocaine for incision and drainage: a prospective, randomized double-blind study

INTRODUCTION

Buffered local anesthetics have not been studied for incision and drainage procedures in dentistry. The purpose of this prospective, randomized, double-blind study was to compare the pain of infiltration and pain of an incision and drainage procedure by using a buffered versus a nonbuffered 2% lidocaine with 1:100,000 epinephrine solution in symptomatic patients with a diagnosis of pulpal necrosis and associated acute swelling.

METHODS

Eighty-one adult patients were randomly divided into 2 treatment groups who received 2 infiltrations (mesial and distal to the swelling of the same formulation) by using either 2% lidocaine with 1:100,000 epinephrine buffered with 0.18 mL 8.4% sodium bicarbonate or 2% lidocaine with 1:100,000 epinephrine. Patients rated pain of needle insertion, placement, and solution deposition for each infiltration on a 170-mm visual analog scale. An incision and drainage procedure was performed, and the pain of incision, drainage, and dissection was recorded.

RESULTS

No significant differences were found between the 2 anesthetic formulations for pain of solution deposition for either the mesial or distal site infiltrations. Moderate-to-severe pain was experienced in the majority of patients with the incision and drainage procedure. No significant differences were found between the 2 formulations.

CONCLUSIONS

The addition of a sodium bicarbonate buffer to 2% lidocaine with 1:100,000 epinephrine did not result in significantly decreased pain of infiltrations or significantly decreased pain of the incision and drainage procedure when compared with 2% lidocaine with 1:100,000 epinephrine in symptomatic patients with a diagnosis of pulpal necrosis and associated acute swelling.

Pharmacology of local anesthetics used in oral surgery

This article provides a comprehensive review of the pharmacology of local anesthetics as a class, and provides details of the individual drugs available in dental cartridges. Maximum recommended doses of local anesthetics and vasoconstrictors are presented for healthy adult and pediatric patients, and for patients with cardiovascular system impairments. Various complications and reasons for failure of local anesthesia effectiveness are discussed, and current and future trends in local anesthesia are presented to provide an overview of current research in local anesthesia.

The effect of buffered lidocaine in local anesthesia: a prospective, randomized, double-blind study

PURPOSE

Open carpal tunnel decompression under local anesthesia is routinely done by many surgeons. However, patients complain of pain during the injection of local anesthesia. This prospective, double-blind, randomized study was to compare the pain visual analog scale (VAS) scores of local anesthesia using lidocaine with and without sodium bicarbonate in patients with bilateral carpal tunnel syndrome.

METHODS

Twenty-five patients underwent bilateral simultaneous carpal tunnel decompression. All had topical anesthetic cream applied on the palm and wrist before the lidocaine block. In a randomized manner, half of the hands were blocked with nonbuffered lidocaine and half were blocked with buffered lidocaine. Pain was evaluated on a VAS score.

RESULTS

The mean pain VAS score in the hand with buffered lidocaine was 4.6 ± 1.5 and 6.5 ± 1.5 for the hand with nonbuffered lidocaine. After adjustment for individual threshold of the pain, the mean pain VAS score changed into 4.6 ± 1.3 with buffered lidocaine and 6.6 ± 1.7 without buffered lidocaine.

CONCLUSIONS

In open carpal tunnel surgery, the use of buffered lidocaine for local anesthesia reduces the anesthetic pain effectively.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic I.

A prospective, randomized, double-blind comparison of the injection pain and anesthetic onset of 2% lidocaine with 1:100,000 epinephrine buffered with 5% and 10% sodium bicarbonate in maxillary infiltrations

INTRODUCTION

Local anesthetics can be buffered to a physiological pH before injection to decrease the time of onset and reduce injection pain.

METHODS

Thirty subjects with intact maxillary canines were included. The subjects randomly received, in a double-blind manner, 1 of the 3 maxillary infiltration injections of 1.8 mL 2% lidocaine with 1:100,000 epinephrine and 2% lidocaine with 1:100,000 epinephrine buffered at 5% and 10% with sodium bicarbonate by volume at 3 separate appointments. Pain on needle penetration and deposition of anesthetic solution was recorded by using a Heft-Parker visual analogue scale. Anesthetic onset was determined by 2 consecutive negative responses to electronic pulp test.

RESULTS

The mean anesthetic onset for nonbuffered anesthetics was 119 seconds, 116 seconds for the 5% buffered solutions, and 121 seconds for the 10% buffered solutions. There was no significant difference between the 3 groups. There was also no significant difference in pain on needle penetration or anesthetic deposition between the 3 anesthetic solutions tested.

CONCLUSIONS

Two percent lidocaine with 1:100,000 epinephrine buffered with 5% or 10% sodium bicarbonate did not differ from nonbuffered solutions in anesthetic onset or injection pain in maxillary infiltrations of canines with healthy pulps.

Evaluation of the anaesthetic properties and tolerance of 1:100,000 articaine versus 1:100,000 lidocaine. A comparative study in surgery of the lower third molar

OBJECTIVES

To evaluate the anaesthetic properties and tolerance of articaine versus lidocaine at equal vasoconstrictor concentration.

STUDY DESIGN

A total of 96 male and female patients who underwent surgical treatment of the lower third molar participated. Patients were randomly assigned to articaine hydrochloride with epinephrine 1:100,000 and lidocaine hydrochloride with epinephrine 1:100,000. The variables analysed were latency period, duration of anaesthetic effect, tolerance and adverse reactions.

RESULTS

Both the latency period and the duration of anaesthetic effect were greater for articaine, although the differences were not statistically significant. Latency: mean difference of 2.70 ± 2.12 minutes (95%CI of -1.51 minutes - 6.92 minutes).

DURATION

mean difference of -33 minutes 5 seconds ± 31 minutes (95% CI -1 hour 35 minutes - 29 minutes). There were 4 adverse events that did not require the patients to be withdrawn from the study.

CONCLUSIONS

The anaesthetics in this study have very similar properties for use in surgery and have demonstrated a good safety and tolerability profile.