Accepted Article
Received Date : 04-Nov-2013 Revised Date : 25-Jan-2014 Accepted Date : 18-Mar-2014 Article type
: Original Scientific Article
Comparison of the anaesthetic efficacy of different volumes of 4% articaine (1.8mL and 3.6mL) as supplemental buccal infiltration after failed inferior alveolar nerve block
M Singla1, A Subbiya2, V Aggarwal3, P Vivekanandhan2, S Yadav1, H Yadav1, A Venkatesh2, N
Geethapriya2, V Sharma1
1
Department of Conservative Dentistry & Endodontics, SGT Dental College, Gurgaon,
2
Department of Conservative Dentistry & Endodontics, Sree Balaji Dental College and Hospital,
Chennai, 3Department of Conservative Dentistry & Endodontics, Faculty of Dentistry, Jamia
Millia Islamia, New Delhi, India.
Running Head: effect of increasing volume of articaine
Keywords: Buccal infiltrations; inferior alveolar nerve block; anaesthetic success; irreversible pulpitis.
This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process which may lead to differences between this version and the Version of Record. Please cite this article as an 'Accepted Article', doi: 10.1111/iej.12283 This article is protected by copyright. All rights reserved.
Accepted Article
Corresponding author: Dr. Vivek Aggarwal Department of Conservative Dentistry & Endodontics, Faculty of Dentistry. Jamia Millia Islamia, New Delhi 110024, India Email: [email protected] The authors deny any conflicts of interests.
Abstract Aim To compare the anaesthetic efficacy of different volumes (1.8mL vs. 3.6 mL) of 4% articaine with 1:100,000 epinephrine injected as buccal infiltrations after a failed inferior alveolar nerve block (IANB) in patients with symptomatic irreversible pulpitis.
Methodology Two-hundred thirty-four adult patients, diagnosed with irreversible pulpitis in a mandibular tooth, participated in this multi-centre, randomized, double-blinded trial. Patients received IANB with 1.8mL of 4% articaine with 1:100,000 epinephrine. Pain during treatment was recorded using the Heft-Parker visual analog scale (HP VAS). The primary outcome measure, and the definition of ‘success’ was the ability to undertake pulp chamber access and canal instrumentation with no or mild pain (HP VAS score < 55 mm). Patients who experienced ‘moderate-to-severe’ pain (HP VAS score ≥ 55 mm) were randomly allocated into 2 groups and received buccal infiltrations with either 1.8mL or 3.6mL of 4% articaine with 1:100,000 epinephrine. Root canal treatment was re-initiated after 10 minutes. Success was again defined as no pain or weak/mild pain during endodontic access preparation and instrumentation. Statistical analysis was performed using Mann-Whitney U and chi-square test.
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Results The initial IANB of 4% articaine gave an overall success rate of 37%. The success rate with supplementary buccal infiltration with 1.8mL and 3.6 mL volumes were 62% and 64%
respectively. The difference between the success rates of the two volumes was not statistically significant.
Conclusions Increasing the volume of 4% articaine with 1:100,000 epinephrine from 1.8mL to 3.6mL, given as supplementary buccal infiltrations after a failed primary IANB with 1.8mL of 4% articaine with 1:100,000, did not improve the anaesthetic success rates in patients with symptomatic irreversible pulpitis.
Introduction Inferior alveolar nerve block has a high failure rate, especially in patients presenting with pain in endodontically involved mandibular molars (Hargreaves & Keiser 2002, Claffey et al. 2004, Aggarwal et al. 2009, Kanaa et al. 2012). Many studies have focused on enhancing the
anaesthetic success rate of IANB, but have encountered limited success rates (Claffey et al. 2004, Aggarwal et al. 2009, Kanaa et al. 2012, Kreimer et al. 2012). Various mechanisms have been proposed to explain the phenomenon of reduced success rate; with the most plausible explanation being the inflammatory activation of tetrodotoxin (TTX) and capsaicin-sensitive transient receptor potential vanilloid (TRPV) type 1 & type 4 (Hargreaves & Keiser 2002). The firing threshold of these nociceptors is reduced to a point that a minor stimulus activates these receptors (Hargreaves & Keiser 2002). Results of several clinical studies have suggested depositing the local anaesthetic solution in the vicinity of the involved tooth (in the form of
This article is protected by copyright. All rights reserved.
Accepted Article
buccal/lingual infiltrations) to effectively block the activated nociceptors (Jung et al. 2008, Mathhews et al. 2009, Aggarwal et al. 2009, Kanaa et al. 2012).
Various authors have evaluated the anaesthetic efficacy of buccal infiltrations with or without a primary IANB (Kanaa et al. 2006, Jung et al. 2008, Mathhews et al. 2009, Aggarwal et al. 2009, McEntire et al. 2011, Kanaa et al. 2012, Ashraf et al. 2013). While evaluating the efficacy of a primary buccal infiltration, without an IANB, it has been demonstrated that a primary buccal infiltration of 4 % articaine results in a higher success rate than buccal infiltration of 2 % lidocaine in asymptomatic molars (Jung et al. 2008, McEntire et al. 2011, Kanaa et al. 2012). Though success rates as high as 92% were achieved, the success rates were drastically reduced in patients with irreversible pulpitis. A study reported a success rate of 27% while evaluating buccal-and-lingual infiltrations of 4% articaine without an IANB in patients with irreversible pulpitis (Aggarwal et al. 2011). Several recent clinical trials have suggested using 4% articaine as a supplemental buccal infiltration either along with a primary IANB or as a secondary measure when primary IANB fails (Fan et al. 2009a, Mathhews et al. 2009, Aggarwal et al.
2009, Krzemiński et al. 2011, Ashraf et al. 2013, Dou et al. 2013). Matthews et al. (2009) evaluated anaesthetic efficacy of the supplemental buccal infiltration injection of a 4% articaine with 1:100,000 when the IANB failed and found that 58% of patients with failed IANB had a
successful anaesthesia after articaine infiltrations. Kanaa et al. (2012) reported a success rate of 84% with articaine buccal infiltration after a failed IANB. Another study reported that supplemental articaine infiltration along with an IANB injection had significantly higher success rate that IANB alone in patients with irreversible pulpitis (Aggarwal et al. 2009). Regarding the amount of articaine solution to be injected as buccal infiltrations, volumes ranging from 0.4ml -
This article is protected by copyright. All rights reserved.
Accepted Article
3.6ml have been used (Mathhews et al. 2009, McEntire et al. 2011, Kanaa et al. 2012, Dou et al. 2013). However there is no study comparing the different volumes of 4% articaine to be used as buccal infiltration secondary to an IANB in patients with symptomatic irreversible pulpitis.
The purpose of the present multi-centre randomized, double-blinded trial was to comparatively evaluate the anaesthetic efficacy of different volumes (1.8mL vs. 3.6 mL) of 4% articaine with 1:100,000 epinephrine injected as buccal infiltrations after a failed initial IANB injection in patients with symptomatic irreversible pulpitis in mandibular permanent molars. This study tested the null hypothesis that different volumes of supplemental articaine injection will have no effect on the anaesthetic success rate.
Materials and methods This study was carried out at two centres at different cities (SGT dental college, Gurgaon, India and SB dental college, Chennai, India). Two-hundred thirty-four adult patients (128 at Gurgaon and 106 at Chennai) participated in this, randomized, double-blinded trial. The primary outcome (end point) was defined as success or failure which was indicated as the ability to undertake pulp access and canal instrumentation into the apical third with no or mild pain (Heft-Parker visual analog scale [HP VAS] score 0.05).
G- Gurgaon, CN- Chennai
Centre 1 (G)
Centre 2 (CN)
Age (mean, SD) *
Gender *
Age (mean, SD) *
Gender *
1.8mL 4% articaine
3.6mL 4% articaine
38 years, 5.2 years,
32 years, 4.4 years,
range- 24-51 years
range- 21-43 years
17 males
19 males
21females
20 females
31 years, 4.7 years,
37 years, 3.8 years,
range- 20-48 years
range- 24-44 years
20 males
16 males
15 females
19 females
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Accepted Article
Table 3: Anaesthetic success rate of supplemental buccal infiltrations after failed primary IANB
Successful anaesthesia
1.8mL 4% articaine (%)
3.6mL 4% articaine (%)
23 out of 38 patients (60%)*
21 out of 39 patients (54 %)*
22 out of 35 patients (63%)$
26 out of 35 patients (74 %)$
obtained at G centre Successful anaesthesia obtained at CN centre
*
There was no statistically significant difference between the groups (χ2 =0.35, p=0.55)
$
There was no statistically significant difference between the groups (χ2 =1.06, p=0.30).
G- Gurgaon, CN- Chennai
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Accepted Article
Figure Legends Figure 1 CONSORT flow diagram
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Received Date : 04-Nov-2013 Revised Date : 25-Jan-2014 Accepted Date : 18-Mar-2014 Article type
: Original Scientific Article
Comparison of the anaesthetic efficacy of different volumes of 4% articaine (1.8mL and 3.6mL) as supplemental buccal infiltration after failed inferior alveolar nerve block
M Singla1, A Subbiya2, V Aggarwal3, P Vivekanandhan2, S Yadav1, H Yadav1, A Venkatesh2, N
Geethapriya2, V Sharma1
1
Department of Conservative Dentistry & Endodontics, SGT Dental College, Gurgaon,
2
Department of Conservative Dentistry & Endodontics, Sree Balaji Dental College and Hospital,
Chennai, 3Department of Conservative Dentistry & Endodontics, Faculty of Dentistry, Jamia
Millia Islamia, New Delhi, India.
Running Head: effect of increasing volume of articaine
Keywords: Buccal infiltrations; inferior alveolar nerve block; anaesthetic success; irreversible pulpitis.
This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process which may lead to differences between this version and the Version of Record. Please cite this article as an 'Accepted Article', doi: 10.1111/iej.12283 This article is protected by copyright. All rights reserved.
Accepted Article
Corresponding author: Dr. Vivek Aggarwal Department of Conservative Dentistry & Endodontics, Faculty of Dentistry. Jamia Millia Islamia, New Delhi 110024, India Email: [email protected] The authors deny any conflicts of interests.
Abstract Aim To compare the anaesthetic efficacy of different volumes (1.8mL vs. 3.6 mL) of 4% articaine with 1:100,000 epinephrine injected as buccal infiltrations after a failed inferior alveolar nerve block (IANB) in patients with symptomatic irreversible pulpitis.
Methodology Two-hundred thirty-four adult patients, diagnosed with irreversible pulpitis in a mandibular tooth, participated in this multi-centre, randomized, double-blinded trial. Patients received IANB with 1.8mL of 4% articaine with 1:100,000 epinephrine. Pain during treatment was recorded using the Heft-Parker visual analog scale (HP VAS). The primary outcome measure, and the definition of ‘success’ was the ability to undertake pulp chamber access and canal instrumentation with no or mild pain (HP VAS score < 55 mm). Patients who experienced ‘moderate-to-severe’ pain (HP VAS score ≥ 55 mm) were randomly allocated into 2 groups and received buccal infiltrations with either 1.8mL or 3.6mL of 4% articaine with 1:100,000 epinephrine. Root canal treatment was re-initiated after 10 minutes. Success was again defined as no pain or weak/mild pain during endodontic access preparation and instrumentation. Statistical analysis was performed using Mann-Whitney U and chi-square test.
This article is protected by copyright. All rights reserved.
Accepted Article
Results The initial IANB of 4% articaine gave an overall success rate of 37%. The success rate with supplementary buccal infiltration with 1.8mL and 3.6 mL volumes were 62% and 64%
respectively. The difference between the success rates of the two volumes was not statistically significant.
Conclusions Increasing the volume of 4% articaine with 1:100,000 epinephrine from 1.8mL to 3.6mL, given as supplementary buccal infiltrations after a failed primary IANB with 1.8mL of 4% articaine with 1:100,000, did not improve the anaesthetic success rates in patients with symptomatic irreversible pulpitis.
Introduction Inferior alveolar nerve block has a high failure rate, especially in patients presenting with pain in endodontically involved mandibular molars (Hargreaves & Keiser 2002, Claffey et al. 2004, Aggarwal et al. 2009, Kanaa et al. 2012). Many studies have focused on enhancing the
anaesthetic success rate of IANB, but have encountered limited success rates (Claffey et al. 2004, Aggarwal et al. 2009, Kanaa et al. 2012, Kreimer et al. 2012). Various mechanisms have been proposed to explain the phenomenon of reduced success rate; with the most plausible explanation being the inflammatory activation of tetrodotoxin (TTX) and capsaicin-sensitive transient receptor potential vanilloid (TRPV) type 1 & type 4 (Hargreaves & Keiser 2002). The firing threshold of these nociceptors is reduced to a point that a minor stimulus activates these receptors (Hargreaves & Keiser 2002). Results of several clinical studies have suggested depositing the local anaesthetic solution in the vicinity of the involved tooth (in the form of
This article is protected by copyright. All rights reserved.
Accepted Article
buccal/lingual infiltrations) to effectively block the activated nociceptors (Jung et al. 2008, Mathhews et al. 2009, Aggarwal et al. 2009, Kanaa et al. 2012).
Various authors have evaluated the anaesthetic efficacy of buccal infiltrations with or without a primary IANB (Kanaa et al. 2006, Jung et al. 2008, Mathhews et al. 2009, Aggarwal et al. 2009, McEntire et al. 2011, Kanaa et al. 2012, Ashraf et al. 2013). While evaluating the efficacy of a primary buccal infiltration, without an IANB, it has been demonstrated that a primary buccal infiltration of 4 % articaine results in a higher success rate than buccal infiltration of 2 % lidocaine in asymptomatic molars (Jung et al. 2008, McEntire et al. 2011, Kanaa et al. 2012). Though success rates as high as 92% were achieved, the success rates were drastically reduced in patients with irreversible pulpitis. A study reported a success rate of 27% while evaluating buccal-and-lingual infiltrations of 4% articaine without an IANB in patients with irreversible pulpitis (Aggarwal et al. 2011). Several recent clinical trials have suggested using 4% articaine as a supplemental buccal infiltration either along with a primary IANB or as a secondary measure when primary IANB fails (Fan et al. 2009a, Mathhews et al. 2009, Aggarwal et al.
2009, Krzemiński et al. 2011, Ashraf et al. 2013, Dou et al. 2013). Matthews et al. (2009) evaluated anaesthetic efficacy of the supplemental buccal infiltration injection of a 4% articaine with 1:100,000 when the IANB failed and found that 58% of patients with failed IANB had a
successful anaesthesia after articaine infiltrations. Kanaa et al. (2012) reported a success rate of 84% with articaine buccal infiltration after a failed IANB. Another study reported that supplemental articaine infiltration along with an IANB injection had significantly higher success rate that IANB alone in patients with irreversible pulpitis (Aggarwal et al. 2009). Regarding the amount of articaine solution to be injected as buccal infiltrations, volumes ranging from 0.4ml -
This article is protected by copyright. All rights reserved.
Accepted Article
3.6ml have been used (Mathhews et al. 2009, McEntire et al. 2011, Kanaa et al. 2012, Dou et al. 2013). However there is no study comparing the different volumes of 4% articaine to be used as buccal infiltration secondary to an IANB in patients with symptomatic irreversible pulpitis.
The purpose of the present multi-centre randomized, double-blinded trial was to comparatively evaluate the anaesthetic efficacy of different volumes (1.8mL vs. 3.6 mL) of 4% articaine with 1:100,000 epinephrine injected as buccal infiltrations after a failed initial IANB injection in patients with symptomatic irreversible pulpitis in mandibular permanent molars. This study tested the null hypothesis that different volumes of supplemental articaine injection will have no effect on the anaesthetic success rate.
Materials and methods This study was carried out at two centres at different cities (SGT dental college, Gurgaon, India and SB dental college, Chennai, India). Two-hundred thirty-four adult patients (128 at Gurgaon and 106 at Chennai) participated in this, randomized, double-blinded trial. The primary outcome (end point) was defined as success or failure which was indicated as the ability to undertake pulp access and canal instrumentation into the apical third with no or mild pain (Heft-Parker visual analog scale [HP VAS] score 0.05).
G- Gurgaon, CN- Chennai
Centre 1 (G)
Centre 2 (CN)
Age (mean, SD) *
Gender *
Age (mean, SD) *
Gender *
1.8mL 4% articaine
3.6mL 4% articaine
38 years, 5.2 years,
32 years, 4.4 years,
range- 24-51 years
range- 21-43 years
17 males
19 males
21females
20 females
31 years, 4.7 years,
37 years, 3.8 years,
range- 20-48 years
range- 24-44 years
20 males
16 males
15 females
19 females
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Accepted Article
Table 3: Anaesthetic success rate of supplemental buccal infiltrations after failed primary IANB
Successful anaesthesia
1.8mL 4% articaine (%)
3.6mL 4% articaine (%)
23 out of 38 patients (60%)*
21 out of 39 patients (54 %)*
22 out of 35 patients (63%)$
26 out of 35 patients (74 %)$
obtained at G centre Successful anaesthesia obtained at CN centre
*
There was no statistically significant difference between the groups (χ2 =0.35, p=0.55)
$
There was no statistically significant difference between the groups (χ2 =1.06, p=0.30).
G- Gurgaon, CN- Chennai
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Figure Legends Figure 1 CONSORT flow diagram
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