Sara Fowler

Is a Volume of 3.6 mL Better than 1.8 mL for Inferior Alveolar Nerve Blocks in Patients with Symptomatic Irreversible Pulpitis

INTRODUCTION The purpose of this retrospective study was to determine the success of the inferior alveolar nerve (IAN) block using either 3.6 mL or 1.8 mL 2% lidocaine with 1:100,000 epinephrine in patients presenting with symptomatic irreversible pulpitis. METHODS As part of 7 previously published studies, 319 emergency patients presenting with symptomatic irreversible pulpitis received either a 1.8-mL volume or 3.6-mL volume of 2% lidocaine with 1:100,000 epinephrine in an IAN block. One hundred ninety patients received a 1.8-mL volume, and 129 received a 3.6-mL volume. Endodontic emergency treatment was completed on each subject. Success was defined as the ability to access and instrument the tooth without pain (visual analog scale score of 0) or mild pain (VAS rating ≤54 mm). RESULTS Success of the 1.8-mL volume was 28%, and for the 3.6-mL volume it was 39%. There was no statistically significant difference between the 2 volumes. CONCLUSIONS In conclusion, for patients presenting with irreversible pulpitis, success was not significantly different between a 3.6-mL volume and a 1.8-mL volume of 2% lidocaine with 1:100,000 epinephrine. The success rates (28%-39%) with either volume were not high enough to ensure complete pulpal anesthesia.

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.

INTRODUCTION Medical studies have suggested that buffering local anesthetic may increase the ability to achieve anesthesia. The purpose of this study was to determine the effect of 4% buffered lidocaine on the anesthetic success of the inferior alveolar nerve (IAN) block in patients experiencing symptomatic irreversible pulpitis. METHODS One hundred emergency patients diagnosed with symptomatic irreversible pulpitis of a mandibular posterior tooth randomly received a conventional IAN block using either 2.8 mL 4% lidocaine with 1:100,000 epinephrine or 2.8 mL 4% lidocaine with 1:100,000 epinephrine buffered with sodium bicarbonate in a double-blind manner. For the buffered solution, each cartridge was buffered with 8.4% sodium bicarbonate using the OnPharma (Los Gatos, CA) system to produce a final concentration of 0.18 mEq/mL sodium bicarbonate. Fifteen minutes after administration of the IAN block, profound lip numbness was confirmed, and endodontic access was initiated. Success was defined as no or mild pain (≤54 mm on a 170-mm visual analog scale) on access or instrumentation of the root canal. RESULTS The success rate for the IAN block was 32% for the buffered group and 40% for the nonbuffered group, with no significant difference (P = .4047) between the groups. Injection pain ratings for the IAN block were not significantly (P = .9080) different between the 2 formulations. CONCLUSIONS For mandibular posterior teeth, a 4% buffered lidocaine formulation did not result in a statistically significant increase in the success rate or a decrease in injection pain of the IAN block in patients with symptomatic irreversible pulpitis.

Incidence of Missed Inferior Alveolar Nerve Blocks in Vital Asymptomatic Subjects and in Patients with Symptomatic Irreversible Pulpitis

INTRODUCTION The purpose of this retrospective study was to determine the incidence of missed inferior alveolar nerve (IAN) blocks by using a 1- or 2-cartridge volume of 2% lidocaine with 1:100,000 epinephrine in vital asymptomatic teeth and in emergency patients with symptomatic irreversible pulpitis. METHODS As part of 37 studies, 3169 subjects/patients were evaluated for missed IAN blocks. The study included 2450 asymptomatic subjects and 719 emergency patients presenting with symptomatic irreversible pulpitis. Each subject or patient received either a 1- or 2-cartridge volume of 2% lidocaine with 1:100,000 epinephrine. A missed block was defined as no lip numbness at 15-20 minutes after the IAN block. The effect of anesthetic volume on the incidence of missed blocks was assessed by using mixed models logistic regression with individual studies as a random effect. RESULTS The incidence of missed blocks for asymptomatic subjects was 6.3% for the 1-cartridge volume and 3.8% for the 2-cartridge volume. For patients presenting with irreversible pulpitis, the incidence of missed blocks was 7.7% for the 1-cartridge volume and 2.3% for the 2-cartridge volume. In both asymptomatic subjects and patients with irreversible pulpitis, the 2-cartridge volume was significantly (P = .0395) better than the 1-cartridge volume. There were no significant effects for pulpal diagnosis (P = .7523) or the pulpal diagnosis and anesthetic volume interaction (P = .3973). CONCLUSIONS Concerning missed IAN blocks, we concluded that administration of a 2-cartridge volume was significantly better (P = .0395) than a 1-cartridge volume in both asymptomatic subjects and emergency patients presenting with irreversible pulpitis.

Reversal of Soft-tissue Anesthesia in Asymptomatic Endodontic Patients: A Preliminary, Prospective, Randomized, Single-blind Study

INTRODUCTION Phentolamine has been reported to be an effective local anesthetic reversal agent for soft tissue but has not been studied in endodontics. The purpose of this preliminary, prospective, randomized, single-blind study was to evaluate the reversal of soft-tissue anesthesia using phentolamine in asymptomatic endodontic patients. METHODS Eighty-five adult subjects having a maxillary or mandibular asymptomatic tooth requiring endodontic therapy received either phentolamine or sham treatment(s) at the end of the endodontic treatment appointment. Soft-tissue anesthesia was monitored by subjects every 15 minutes for 5 hours. Subjects reported postoperative injection site pain and tooth pain using a Heft-Parker visual analog score every 30 minutes for the first 2 postoperative hours and every hour for 3 hours. RESULTS There was a statistically significant difference in time to return-to-normal sensation for the maxillary lip/cheek and mandibular lip. Subjects who received phentolamine experienced an 88-minute decrease in time to return-to-normal maxillary lip/cheek sensation and a 47-minute decrease in time to return-to-normal mandibular lip sensation. The administration of phentolamine was not significantly more painful than administration of a sham treatment, and patients who received phentolamine did not experience significantly more postoperative pain at the injection site. Postoperative complications were minimal, and no clinically significant adverse reactions to the phentolamine were reported. CONCLUSIONS Phentolamine would be beneficial for asymptomatic endodontic patients who would like to experience a faster return-to-normal soft-tissue function and sensation after the administration of local anesthesia.

Does the combination of 3% mepivacaine plain plus 2% lidocaine with epinephrine improve anesthesia and reduce the pain of anesthetic injection for the inferior alveolar nerve block? A prospective, randomized, double-blind study.

INTRODUCTION In theory, using 3% mepivacaine initially for an inferior alveolar nerve (IAN) block would decrease the pain of injection, provide faster onset, and increase anesthetic success. The purpose of this prospective, randomized, double-blind study was to compare the degree of pulpal anesthesia obtained with a combination of 3% mepivacaine/2% lidocaine (1:100,000 epinephrine) versus a combination of 2% lidocaine (1:100,000 epinephrine)/2% lidocaine (1:100,000 epinephrine) in IAN blocks. Injection pain was also studied. METHODS One hundred asymptomatic subjects were randomly given a combination of a 1-cartridge volume of 3% mepivacaine plus a 1-cartridge volume of 2% lidocaine with 1:100,000 epinephrine and a combination of a 1-cartridge volume of 2% lidocaine with 1:100,000 epinephrine plus a 1-cartridge volume of 2% lidocaine with 1:100,000 epinephrine for the IAN block at 2 separate appointments. Subjects rated the pain of injection. The molars, premolars, and incisors were tested with an electric pulp tester in 4-minute cycles for 60 minutes. Anesthetic success was defined as the subject achieving 2 consecutive 80 readings within 15 minutes after completion of the IAN blocks and sustaining the 80 reading for 60 minutes. RESULTS Success was not significantly different (P > .05) between the 2 combinations. No statistical differences in injection pain or onset times were found. CONCLUSIONS The combination of 3% mepivacaine plus 2% lidocaine with 1:100,000 epinephrine was equivalent to the combination of 2 cartridges of 2% lidocaine with 1:100,000 epinephrine in terms of injection pain, onset time, and pulpal anesthetic success for the IAN block.

Reversal of Pulpal and Soft Tissue Anesthesia by Using Phentolamine: A Prospective Randomized, Single-blind Study

INTRODUCTION Phentolamine mesylate has been reported to be an effective local anesthetic reversal agent for soft tissue but has not been studied regarding reversal of pulpal anesthesia. The authors conducted a prospective randomized, single-blind study comparing the reversal of pulpal and soft tissue anesthesia when phentolamine was administered at 30 minutes versus 60 minutes after the administration of an inferior alveolar nerve (IAN) block. METHODS Ninety adult subjects received 2 sets of injections consisting of an IAN block followed by an injection of phentolamine at 30 minutes and a sham injection at 60 minutes or a sham injection given at 30 minutes and a phentolamine injection given at 60 minutes in 2 separate appointments. The authors used an electric pulp tester to test the first and second molars, premolars, and incisors for pulpal anesthesia in 4-minute cycles for 120 minutes. Lip and tongue soft tissue anesthesia was also monitored. RESULTS Phentolamine significantly (P < .05) reduced duration of both pulpal and soft tissue anesthesia when administered at either 30 or 60 minutes after an IAN block. CONCLUSIONS Phentolamine would be beneficial for patients who would like to experience a faster return to normal soft tissue function and sensation after the administration of local anesthesia. However, because pulpal anesthesia is also reversed fairly rapidly, phentolamine should be administered at the end of the dental appointment.

Successful pulpal anesthesia for symptomatic irreversible pulpitis

BACKGROUND AND OVERVIEW Profound pulpal anesthesia after a successful inferior alveolar nerve block can be difficult to achieve when the clinical condition is a pulpal diagnosis of symptomatic irreversible pulpitis. The authors reviewed the literature as it relates to the anesthesia necessary for endodontic therapy of patients with painful, vital, mandibular teeth diagnosed with symptomatic irreversible pulpitis. CONCLUSIONS Supplemental anesthetic techniques and medications are available that can be used to improve pulpal anesthesia for patients with the clinical condition of symptomatic irreversible pulpitis. PRACTICAL IMPLICATIONS The authors identified treatment recommendations for anesthesia in the case of symptomatic irreversible pulpitis based on a review of the available evidence.

Anesthetic Efficacy of a Combination of 4% Prilocaine/2% Lidocaine with Epinephrine for the Inferior Alveolar Nerve Block: A Prospective, Randomized, Double-blind Study

Introduction: Prilocaine plain has a high pH and concentration (4%), which could decrease the pain of injection and increase success. The purpose of this study was to compare pain associated with anesthetic solution deposition and the degree of pulpal anesthesia obtained with the combination of prilocaine and lidocaine versus a lidocaine and lidocaine combination when used for inferior alveolar nerve blocks (IANBs). Methods: One hundred eighteen asymptomatic subjects were randomly given a combination of 1 cartridge of 4% prilocaine plain plus 1 cartridge of 2% lidocaine with 1:100,000 epinephrine or a combination of 2 cartridges of 2% lidocaine with 1:100,000 epinephrine for the IANB at 2 separate appointments. Subjects rated the pain associated with anesthetic solution deposition of injection. Mandibular teeth were tested with an electric pulp tester every 4 minutes for 57 minutes. Anesthesia was considered successful when 2 consecutive 80 readings were obtained within 17 minutes and the 80 reading was continuously sustained for 57 minutes. Comparisons for anesthetic success were analyzed using the exact McNemar test, and pain ratings associated with anesthetic solution deposition were analyzed using multiple Wilcoxon matched pairs signed rank tests; both were adjusted using the step‐down Bonferroni method of Holm. Results: Four percent prilocaine plain was significantly less painful upon anesthetic solution deposition. Pulpal anesthetic success was not significantly different between the 2 combinations. Conclusions: The combination of 4% prilocaine plain plus 2% lidocaine with 1:100,000 epinephrine did not increase pulpal anesthetic success for IANBs compared with a combination of 2 cartridges of 2% lidocaine with 1:100,000 epinephrine. Pain associated with anesthetic solution deposition from the first cartridge of 4% prilocaine plain was significantly less when compared with the first cartridge of 2% lidocaine with 1:100,000 epinephrine.

Effect of a Combination of Intranasal Ketorolac and Nitrous Oxide on the Success of the Inferior Alveolar Nerve Block in Patients with Symptomatic Irreversible Pulpitis: A Prospective, Randomized, Double-blind Study

Introduction: Previous studies in patients with irreversible pulpitis have reported increased success of the inferior alveolar nerve block (IANB) using premedication with ketorolac. Preemptive nitrous oxide administration has also shown an increase in the success of the IANB. Recently, ketorolac has been made available for intranasal delivery. Perhaps combining ketorolac and nitrous oxide would increase success. Therefore, the purpose of this prospective, randomized, double‐blind study was to determine the effect of a combination of intranasal ketorolac and nitrous oxide/oxygen on the anesthetic success of the IANB in patients presenting with symptomatic irreversible pulpitis. Methods: One hundred two patients experiencing spontaneous moderate to severe pain with symptomatic irreversible pulpitis in a mandibular posterior tooth participated. Patients were randomly divided into 2 groups and received either 31.5 mg intranasal ketorolac or intranasal saline placebo 20 minutes before the administration of nitrous oxide/oxygen. Ten minutes after the administration of nitrous oxide/oxygen, the IANB was given. After profound lip numbness, endodontic treatment was performed. Success was defined as the ability to perform endodontic access and instrumentation with no pain or mild pain. Results: The odds of success for the IANB was 1.631 in the intranasal saline/nitrous oxide group versus the intranasal ketorolac/nitrous oxide group with no significant difference between the groups (P = .2523). Conclusions: Premedication with intranasal ketorolac did not significantly increase the odds of success for the IANB over the use of nitrous oxide/oxygen alone. Supplemental anesthesia will still be needed to achieve adequate anesthesia.

Postoperative Pain Management with Oral Methylprednisolone in Symptomatic Patients with a Pulpal Diagnosis of Necrosis: A Prospective Randomized, Double-blind Study

Introduction The purpose of this prospective randomized, double‐blind, placebo‐controlled study was to evaluate postoperative pain by using an oral dose regimen of methylprednisolone in symptomatic patients with pulpal necrosis and symptomatic apical periodontitis, a periapical radiolucency, and experiencing preoperative moderate to severe pain. Methods One hundred twenty‐five adult symptomatic patients presenting for emergency endodontic treatment with a pulpal diagnosis of necrosis and symptomatic apical periodontitis, a periapical radiolucency, and experiencing moderate to severe pain participated. All patients received complete endodontic debridement and were randomly divided into 2 groups. In a double‐blind manner, the groups received either an oral regimen of methylprednisolone (96 mg immediately after treatment followed by 48 mg each day for 5 consecutive days) or a lactose placebo. All patients received 600 mg ibuprofen and an opioid‐containing escape medication to take if needed. Patients completed a 7‐day diary to record pain and number of analgesic medications taken each day. Results Moderate to severe pain was experienced by 40%–50% of the patients on day 1 and 31% of the patients on day 2, with the pain ratings decreasing during the next 7 days. There were no statistically significant differences in pain ratings between the methylprednisolone and placebo groups. Conclusions When compared with a placebo, the current regimen of oral methylprednisolone did not significantly reduce postoperative pain after complete debridement of symptomatic patients presenting for emergency endodontic treatment with a pulpal diagnosis of necrosis and symptomatic apical periodontitis, periapical radiolucency, and experiencing moderate to severe pain.