Volume of Anesthetic Agents and IANB Success: A Systematic Review

Cervical-Level Regional Paraspinal Nerve Block in Cervical Spine Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Regional paraspinal nerve block techniques have shown promise in cervical spine surgery pain relief and opioid reduction. The study aims to evaluate cervical-level regional paraspinal nerve block techniques in cervical spine surgery.

METHODS

Systematic randomized controlled trial (RCT) searches in ScienceDirect, PubMed, Embase, and Cochrane was conducted until March 2024. Key outcome measures included postoperative pain scores and postoperative opioid utilization. Techniques assessed were erector spinae plane block (ESPB), inter-semispinal plane block (ISPB), and superficial cervical plexus block (CPB).

RESULTS

The study included 6 RCTs and 648 participants. Regional paraspinal nerve block significantly reduced postoperative pain scores at 4, 6, 8, 12, and 24 hours. Postoperative opioid usage was lower in the block group (mean difference [MD]: -1.68; 95% CI: -3.14 to -0.21; P = 0.02), with fewer complications (odds ratio: 0.51; 95% CI: 0.40-0.66; P = 0.001). Patients using fentanyl as postoperative opioid had significantly lower opioid usage with the block (MD: -1.39; 95% CI: -1.76 to -1.01; P < 0.001). Dosage >10 mL correlated with decreased opioid usage (MD: -2.78; 95% CI: -5.25 to -0.31; P < 0.001). ESPB (MD: -1.37; 95% CI: -1.83 to -0.90; P < 0.001) and ISPB (MD: -3.52; 95% CI: -7.09-0.00; P = 0.05) effectively reduced opioid consumption. Posterior approach (MD: -2.78; 95% CI: -5.25 to -0.31; P < 0.001), bilateral administration (MD: -2.14; 95% CI: -4.26 to -0.03; P < 0.001), and ultrasound-guided intervention (MD: -2.68; 95% CI: -5.24 to -0.12; P < 0.001) resulted in a significant reduction of opioid usage.

CONCLUSIONS

Cervical-level regional paraspinal nerve block effectively reduces postoperative pain and opioid usage, particularly with a dosage exceeding 10 mL, utilizing ESPB and ISPB techniques, administered posteriorly, bilaterally, and under ultrasound guidance.

Intrapulpal anesthesia in endodontics: an updated literature review

Effective pain management is crucial for the successful performance of various endodontic procedures. Painless treatments are made possible by anesthetizing the tooth to be treated using various nerve-block techniques. However, certain circumstances necessitate supplemental anesthetic techniques to achieve profound anesthesia, especially in situations involving a "hot tooth" in which intrapulpal anesthesia (IPA) is employed. IPA is a technique that involves the injection of an anesthetic solution directly into the pulp tissue and is often utilized as the last resort when all other anesthetic techniques have been unsuccessful in achieving complete pulpal anesthesia. This review focuses on the IPA procedure and the factors that influence its success. Additionally, the advantages, limitations, disadvantages, and future directions of IPA are discussed.

Influence of needle gauge on pain perception and use of obturators in achieving profound pulpal anesthesia - A double-blinded in vivo study

Introduction

Achieving profound pupal anesthesia and pain management is key in endodontic practice. However, inferior alveolar nerve block (IANB) does not always result in successful pulpal anesthesia, during symptomatic irreversible pulpitis and has a high failure rate between 35% and 45%. Intrapulpal (IP) injection has been found to have increased efficiency and pain. The study aims to find the pain perception of 26G and 31G and the use of obturators in improving the efficacy of IP anesthesia.

Materials and Methods

Eighty patients with symptomatic irreversible pulpitis after the failure of IANB were recruited and divided into four groups to receive IP with Group I A: 26G with obturators, Group I B: 26G without obturators, Group IIA: 31G with obturators, and Group IIB: 31G without obturators. The pain was measured using the visual analog scale and the effectivity of anesthetic injection by the duration of action.

Results

A 31G needle produced the least pain perception compared to the 26G needle during IP injection. A 31G with an obturator was the most efficient, acting in less than a minute and 26G without an obturator showed the least.

Conclusion

Within the limitation of this trial, it can be concluded that lesser gauge needles reduce pain perception during IP, and obturators achieve adequate back pressure.

The Pterygomandibular Space: A Volumetric Evaluation Using the Novel A-Silicone Injections Method

Inferior alveolar nerve block (IANB) is one of the most common procedures in operative dentistry, and a deep understanding of the normal anatomical variation of the pterygomandibular space (PM) is essential for its safe and successful administration. This cadaveric anatomical study aimed to use A-silicone injections to evaluate the volume of the PM. This study was conducted using 46 human cadaver heads (25 males and 21 females). A craniometric analysis was performed using the cadavers' ages, the number of silicone cartridges (carpules) used to fill the pterygomandibular space, Izard's Facial Index (FI), and the Cranial Index (CI). A Halstead mandibular block was performed by injecting 1.7 mL A-silicone cartridges (as an equivalent to standard local aesthetic carpules volume) into the PM. The cured silicone was extracted from the dissected mandibles. The volume (length, width, and thickness) of the extracted silicone and the number of silicone cartridges used to fill the space were evaluated. The results showed that there are statistically significant positive correlations between the CI and the width of the right PM, as well as the width and length of the left PM. A statistically significant correlation was found between the width of the left PM and the age of the cadaveric heads; the higher the age, the thicker the space on both sides. The volume of the PM corresponded to 1.5 cartridges on average.

Effect of preemptive use of a nonsteroidal anti-inflammatory drug and a corticosteroid on the efficacy of inferior alveolar nerve blockade and postoperative pain control in endodontic treatment of molars with symptomatic pulpitis: A randomized double-blind placebo-controlled clinical trial

AIM

The anaesthetic success rate of an inferior alveolar nerve block (IANB) in mandibular molars with irreversible symptomatic pulpitis can be low, and postoperative pain control in teeth with this diagnosis can be challenging. This study aimed to evaluate the influence of preemptive use of dexamethasone and oral potassium diclofenac on the success of IANB. The influence of these drugs on the intensity of postoperative pain was assessed as a secondary outcome.

METHODOLOGY

Eighty-four patients with mandibular molars diagnosed with irreversible symptomatic pulpitis recorded preoperative pain intensity using a cold thermal test and a modified Numerical Rating Scale (mNRS). Sixty minutes before the anaesthetic procedure, patients were randomly assigned to one of three groups based on the medication they received: dexamethasone (4 mg), diclofenac potassium (50 mg), or placebo. All patients received IANB with 4% articaine (1:200 000 epinephrine), and 15 min later, they were evaluated for pain intensity using the cold thermal test. Anaesthetic success was analysed. The pain intensity was then recorded, and endodontic treatment and provisional restoration of the tooth were executed in a single session. Patients were monitored for 6, 12, 24, 48 and 72 h using the mNRS to assess the intensity of postoperative pain.

RESULTS

There was a statistically significant increase in anaesthetic success when 4 mg dexamethasone (39.3%) or 50 mg diclofenac potassium (21.4%) was used compared to the placebo group (3.6%) (p < .001), with no significant difference between the two drugs. Regarding postoperative pain, dexamethasone was superior to placebo at 6 h (p < .001), with diclofenac having an intermediate behaviour, not differing between dexamethasone and placebo (p > .05). There was no significant difference amongst the groups at 12 h (p > .05). At 24, 48 and 72 h, the effectiveness of dexamethasone and diclofenac were comparable, and both were superior to placebo (p < .001).

CONCLUSION

The use of dexamethasone or diclofenac potassium was favourable in terms of increasing the success rate of inferior alveolar nerve block in cases of mandibular molars with irreversible symptomatic pulpitis and decreased the occurrence of postoperative pain when compared to the use of a placebo.

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.

Application of ultrasound guidance in the oral and maxillofacial nerve block

Introduction

Nerve block technology is widely used in clinical practice for pain management. Conventional nerve localization methods, which only rely on palpation to identify anatomical landmarks, require experienced surgeons and can be risky. Visualization technologies like ultrasound guidance can help prevent complications by helping surgeons locate anatomical structures in the surgical area and by guiding the operation using different kinds of images. There are several important and complex anatomical structures in the oral and maxillofacial regions. The current article reviews the application of ultrasound guidance in oral and maxillofacial nerve blocks.

Methods

We searched the literature on the use of ultrasound guidance for the main nerve block techniques in the oral and maxillofacial regions using both PubMed and MEDLINE and summarized the findings.

Results and Discussion

A review of the literature showed that ultrasound guidance improves the safety and effectiveness of several kinds of puncture procedures, including nerve blocks. There are two approaches to blocking the mandibular nerve: intraoral and extraoral. This review found that the role of ultrasound guidance is more important in the extraoral approach. There are also two approaches to the blocking of the maxillary nerve and the trigeminal ganglion under ultrasound guidance: the superazygomatic approach and the infrazygomatic approach. The infrazygomatic approach can be further divided into the anterior approach and the posterior approach. It is generally believed that the anterior approach is safer and more effective. This review found that the effectiveness and safety of most oral and maxillofacial nerve block operations can be improved through the use of ultrasound guidance.

The impact of cigarette smoking on the efficiency of local anesthesia during simple tooth extraction

Smoking is harmful to all organs of the human body and can affect nerve response to local anesthesia.

This study aimed to determine the effect of cigarette smoking on the amount and onset of local anesthesia, as well as the chief complaint (symptomatic and asymptomatic), number of cigarettes, and duration of smoking.

Materials and methods

A selective clinical case-control study carried out at the Oral Surgery Clinic of the Teaching Hospital at the College of Dentistry. One hundred and three male patients participated in the study, and they were divided into two groups (55 smokers and 48 nonsmokers). The patients received a local anesthetic agent (2% Lidocaine) in a 1.8 ml dental cartridge. The number of cartridges and the onset time of local anesthesia were detailed for each patient in a special case sheet prepared for this study.

Results

There was a statistically significant difference between the smoker and nonsmoker groups regarding the amount of local anesthetic solution (p = .041) with a higher amount needed in the smoker group; however, the onset of action showed no significant difference between the two groups (p = 0.983). The symptomatic cases in smokers needed a higher amount of local anesthesia than the asymptomatic cases with a statistically significant difference (p = 0.002). There was no relationship between daily cigarette consumption and the amount of local anesthetic solution (p = .054) and also the onset of local anesthesia (p = .938). The duration of smoking has no significant relationship with onset time (p = .480) and the amount of local anesthesia (p = .418).

Conclusion

The amount of local anesthesia used in smoker patients was higher than that in nonsmoker patients, especially if there were symptoms like pain. The duration of smoking and daily cigarette consumption had no effect on the amount and the onset of local anesthesia.

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.

Influence of Lignocaine Hydrochloride with Adrenaline on Free Active Chlorine Content of Sodium Hypochlorite Solution Admixed in Various Proportions

Objective:

Local anaesthetic solution that is commonly employed for supplemental intrapulpal injection (IPI) may routinely come in contact with subsequently used sodium hypochlorite (NaOCl) during endodontic treatment of symptomatic irreversible pulpitis cases. This in vitro study investigated the available free active chlorine (FAC) content of 3% NaOCl after mixing with 2% lignocaine hydrochloride with adrenaline (LA) solution in three different proportions using iodometric titration analysis.

Methods:

Aliquots of 3% NaOCl (control) in different measures (30 mL, 27 mL, 21 mL and 15 mL) served as the effective concentrate of various proportions of NaOCl admixed with the test solutions, i.e., demineralised water (DM) and LA. The mixed aliquots containing NaOCl-DM and NaOCl-LA combination solutions admixed in various proportions (9:1, 7:3 and 1:1 w/v) respectively served as the experimental groups. Iodometric titration was performed to determine the FAC of each independent solution.The results were then evaluated using one-way ANOVA and Tukey’s post hoc analysis to determine the differences between various groups and amongst the individual admixtures. The level of significance was set at P<0.05.

Results:

Inter-group comparisons revealed statistically significant differences (P<0.05) between all the test groups. An intra-group analysis revealed significant differences (P<0.05) in group 2, whereas no differences (P>0.05) were observed in group 3. Further, there was a dose dependent reduction in FAC content in both the experimental groups with lowest FAC values were observed in 1:1 solution admixtures followed by 7:3 and 9:1 proportions.

Conclusion:

There was a significant reduction in NaOCl FAC content when admixed with lignocaine HCl even in small proportions. Hence, adequate measures should be taken to remove the residual LA from the pulpal space, before the use of NaOCl after IPI administration.

Comparative evaluation of ropivacaine and lidocaine as dental pulp anaesthesia

Root canal therapy linked to pulpal diseases or trauma is common in modern dental care. The 2% Lidocaine which is considered as the gold standard has some drawbacks in pulpal anaesthesia. Ropivacaine has beneficial anaesthetic effects on pulpal anaesthesia. Therefore, it is of interest to compare and evaluate the pulpal aesthetic effect using 0.5% Ropivacaine and 2% Lidocaine in symptomatic irreversible pulpitis. A double blinded randomized controlled clinical trial consisting of 110 lower molar and premolar tooth with irreversible pulpitis cases for root canal therapy were selected and randomly divided into 2 groups. Group A: 2% lidocaine with epinephrine and Group B: 0.5% ropivacaine. The pulp sensibility tests with heat test, cold test and electric pulp test were completed. The preoperative pain score was measured with Visual Analogue Scale (VAS) pain scale. The classical inferior alveolar nerve block (IANB) technique was administered to all patients by a single operator. Subjects were asked for lip numbness and presence or absence of lip numbness. Postoperative pain scores were recorded during access opening and on placing files in the canal. There is no statistical difference between the groups during pre operative conditions. The mean pain scores within group A and group B is recorded. The difference was found to be statistically significant with p value ≤ 0.05. Significant difference between the mean values after and before the treatment is observed. However, there is no statistical significance between the mean pain scores between the access and pulp. The 0.5% Ropivacaine and 2% Lidocaine with epinephrine does not have any significant difference during access opening. However, 0.5% Ropivacaine groups were effective while placing the file in the canal. Thus, 0.5% Ropivacaine showed better results even though it was not statistically significant for further consideration in this context.

Comparing the anaesthetic efficacy of 1.8 mL and 3.6 mL of anaesthetic solution for inferior alveolar nerve blocks for teeth with irreversible pulpitis: a systematic review and meta-analysis with trial sequential analysis

BACKGROUND

The scientific literature is contradictory in relation to selecting the appropriate volume of local anaesthetic solution for inferior alveolar nerve blocks (IANB) when attempting to anaesthetize mandibular teeth with irreversible pulpitis.

OBJECTIVES

To compare the efficacy of 1.8 and 3.6 mL of the same anaesthetic solution for IANBs when treating mandibular teeth with irreversible pulpitis.

METHODS

A literature search was performed in PubMed, Scopus and EBSCOhost databases until May 2020. Randomized clinical trials published in English, comparing 1.8 with 3.6 mL of the same anaesthetic solution for IANBs in permanent mandibular teeth with irreversible pulpitis, were included. The risk of bias of the included trials was appraised using the revised Cochrane risk of bias tool. A meta-analysis was performed using the random-effects model. The effect of random errors on the results of the meta-analysis was evaluated by trial sequential analysis and the quality of evidence was appraised using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.

RESULTS

Four clinical trials involving 280 teeth from patients with ages ranging from 18 to 65 years were included. Among the four trials, three were categorized as having a 'low' risk of bias and one was categorized as having 'some concerns'. The primary meta-analysis revealed that 3.6 mL of anaesthetic solution when administered for IANBs was associated with significantly greater success rates compared with 1.8 mL (RR = 1.94; 95% CI, 1.07, 3.52; I²  = 77%). Similarly, the results of the sensitivity analysis (restricting trials only to those that used the Heft-Parker visual analogue pain scale) revealed that the use of 3.6 mL significantly increased the success of IANBs compared with 1.8 mL. The trial sequential analysis confirmed the evidence for the beneficial effect of 3.6 mL to achieve success for IANBs was 'conclusive'. The quality of evidence was graded as 'high'.

CONCLUSION

Increasing the volume of anaesthetic solution from 1.8 to 3.6 mL improved the success rate for IANBs in mandibular molars with irreversible pulpitis. The quality of the evidence was 'high'. Future high-quality clinical trials are required with different types of anaesthetic solutions and other types of teeth.

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.

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