CONSORT Randomized Clinical Trial

Anesthetic Efficacy of a Primary Articaine Infiltration and
a Repeat Articaine Infiltratio...
CONSORT Randomized Clinical Trial
articaine in the incisive/mental nerve region of the mandibular second
premolar and to d...
CONSORT Randomized Clinical Trial
No response from the subject at the maximum output (80
reading) of the pulp tester was u...
CONSORT Randomized Clinical Trial
TABLE 2. Percentages and Number of Subjects Who Experienced Anesthetic
Success with the ...
CONSORT Randomized Clinical Trial
TABLE 3. Pain Ratings for Each Injection Phase for the Initial Infiltrations and Repeat I...
CONSORT Randomized Clinical Trial
pain for an articaine formulation using a similar design to the current
study for delive...
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  1. 1. CONSORT Randomized Clinical Trial Anesthetic Efficacy of a Primary Articaine Infiltration and a Repeat Articaine Infiltration in the Incisive/Mental Nerve Region of Mandibular Premolars: A Prospective, Randomized, Single-blind Study Anna Smothers Dressman, DMD, MS,* John Nusstein, DDS, MS,† Melissa Drum, DDS, MS,† and Al Reader, DDS, MS† Abstract Introduction: The authors conducted a prospective, randomized, single-blind study to determine the degree of pulpal anesthesia obtained with a primary infiltration of 1 cartridge of articaine in the incisive/mental nerve region of the mandibular second premolar and to determine the anesthetic efficacy of a repeat articaine infiltration 20 minutes after the primary infiltration. Methods: One hundred asymptomatic adult subjects randomly received 2 sets of injections consisting of a primary mandibular second premolar infiltration of 1 cartridge of 4% articaine with 1:100,000 epinephrine plus a repeat infiltration 20 minutes later (using the same volume of articaine) or a mock repeat infiltration in 2 separate appointments spaced at least 1 week apart. The authors used an electric pulp tester to test the first molar, premolars, canine, and incisors for anesthesia in 4-minute cycles for 120 minutes. Results: The success rates of the initial infiltrations for the first molar, canine, and incisor teeth ranged from 59% to 19%. The premolar success rates were moderately successful (ie, 80%– 87%), but anesthesia declined after 20–25 minutes. The repeat infiltration at 20 minutes significantly increased the success rate (92%–94%) and the duration of pulpal anesthesia for the premolars. Conclusions: The initial infiltration was not effective in anesthetizing the first molar, canine, or incisor teeth and was only moderately successful in the premolars. Although the repeat infiltration significantly increased the success rate and duration in the premolars, the initial infiltration success rates were not high enough to support the use of this regimen as a combined anesthetic technique. (J Endod 2013;39:313–318) Key Words Articaine, incisive/mental nerve block, infiltration, mandibular, repeat infiltration T he incisive/mental nerve block has been studied by a number of authors (1–4). Essentially, all these studies have found that injecting into or outside the incisive/ mental foramen resulted in a moderate success rate (no subject response to an 80 reading with an electric pulp tester) of 81% for the second premolar and 83% for the first premolar. However, it did not predictably anesthetize the first molar (55% success), canine (56% success), lateral incisor (38% success), or central incisor (27% success). Although referred to as a nerve block, the incisive nerve is not effectively blocked anterior to the premolars. Perhaps, it is more accurate to refer to this injection technique as an infiltration in the incisive/mental foramen area. A number of studies have shown the superiority of 4% articaine with 1:100,000 epinephrine compared with 2% lidocaine with 1:100,000 epinephrine when used as a primary buccal infiltration of the mandibular first molar (5–9). Only 1 study (4) compared articaine with lidocaine when administering an incisive/mental nerve infiltration. Batista da Silva et al (4) compared the anesthetic efficacy of 0.6 mL 4% articaine with 1:100,000 epinephrine with 0.6 mL 2% lidocaine with 1:100,000 epinephrine and found that articaine had higher success rates (no subject response to 2 consecutive 80 readings) (72% first premolar and 80% second premolar) than lidocaine (50% first premolar and 70% second premolar), but the anesthetic duration was only 10 minutes with lidocaine and 20 minutes with articaine. Longer durations of pulpal anesthesia for the incisive/mental nerve infiltration have been reported using 1.8 mL 2% lidocaine with 1:100,000 epinephrine and 1.8 mL 2% lidocaine with 1:80,000 epinephrine (1, 2). However, the duration of the anesthetic was only around 30 minutes (1, 2). Pabst et al (10) found that a repeat infiltration of 1 cartridge of 4% articaine with 1:100,000 epinephrine 25 minutes after the initial buccal infiltration of the mandibular first molar prolonged the duration of pulpal anesthesia. Perhaps, a similar effect would be observed in the premolars. No objective study of a primary infiltration of a full cartridge of articaine in the incisive/mental nerve region of the mandibular premolars has been reported. Because of the superiority of articaine over lidocaine in mandibular infiltrations (5–9), we anticipated higher success rates of infiltration in the incisive/mental region than have been shown with lidocaine (1–4). Additionally, no study has addressed the use of repeat infiltration to increase the duration of pulpal anesthesia for the premolars. The objective would be to have complete pulpal anesthesia within 5 to 10 minutes of injection and have an anesthetic duration of 60 minutes. Therefore, the purpose of this prospective, randomized, single-blind, crossover study was to determine the degree of pulpal anesthesia obtained with a primary buccal infiltration of 1 cartridge of From *Private Practice, Dayton and Mason, Ohio; and †Division of Endodontics, The Ohio State University, Columbus, Ohio. Address requests for reprints to Dr Al Reader, Division of Endodontics, College of Dentistry, The Ohio State University, 305 West 12th Avenue, Columbus, OH 43210. E-mail address: reader.2@osu.edu 0099-2399/$ - see front matter Copyright ª 2013 American Association of Endodontists. http://dx.doi.org/10.1016/j.joen.2012.11.039 JOE — Volume 39, Number 3, March 2013 Primary and Repeat Mandibular Premolar Anesthesia 313
  2. 2. CONSORT Randomized Clinical Trial articaine in the incisive/mental nerve region of the mandibular second premolar and to determine the anesthetic efficacy of a repeated articaine infiltration 20 minutes after the primary infiltration. We also recorded the pain associated with the injection and postoperative pain. Materials and Methods One hundred adult subjects participated in this study. All subjects were in good health and were not taking any medication that would alter pain perception as determined by a written health history and oral questioning. Exclusion criteria were as follows: younger than 18 years of age or older than 65 years of age, allergies to local anesthetics or sulfites, pregnancy, a history of significant medical conditions (American Society of Anesthesiologists class II or higher), taking any medications (ie, over-the-counter pain-relieving medications, narcotics, sedatives, antianxiety, or antidepressant medications) that may affect anesthetic assessment, active sites of pathosis in the area of injection, and the inability to give informed consent. The Ohio State University Human Subjects Review Committee approved the study, and written informed consent was obtained from each subject. Using a crossover design, 100 subjects received 2 sets of injections consisting of a primary mandibular second premolar infiltration of 1 cartridge of 4% articaine with 1:100,000 epinephrine (Septocaine; Septodont, New Castle, DE) plus a repeat infiltration at the same site 20 minutes later using 1 cartridge of 4% articaine with 1:100,000 epinephrine and a primary mandibular second premolar infiltration of 1 cartridge of 4% articaine with 1:100,000 epinephrine plus a repeat mock infiltration at the same site 20 minutes later in 2 separate appointments spaced at least 1 week apart. With the crossover design, 200 sets of infiltrations were administered, and each subject served as his/her own control. The sets of infiltrations were equally balanced between the left and right sides. The same side chosen for the first set of infiltrations was used again for the second set of infiltrations. The test teeth chosen for the experiment were the mandibular first molar, second premolar, first premolar, canine, lateral, and central incisors. The mandibular, contralateral canine was used as the control to ensure that the pulp tester was operating properly and that the subject was responding appropriately. Visual and clinical examinations were conducted to ensure that all teeth were free of caries, large restorations, crowns, and periodontal disease and that none had a history of trauma or sensitivity. At both appointments before the infiltrations, the experimental teeth and the contralateral canines (control) were tested 2 times with the electric pulp tester (Kerr; Analytic Technology Corp, Redmond, WA) to ensure tooth vitality and obtain baseline information. The teeth were isolated with cotton rolls and dried with gauze. Toothpaste was applied to the probe tip, which was placed in the middle third of the buccal or labial surface of the tooth being tested. The value at the initial sensation was recorded. The current rate was set at 25 seconds to increase from no output (0) to the maximum output (80). Trained personnel who were blinded to the infiltrations administered all preinjection and postinjection tests. Before the experiment, the 2 sets of infiltrations were randomly assigned 6-digit numbers from a random number table. Each subject was randomly assigned to the 2 sets of infiltrations to determine which set was to be administered at each appointment. Only the random numbers were recorded on the data collection sheets to further blind the experiment. Before the infiltrations were administered, each subject was instructed on how to rate the pain for each phase of the injection (ie, needle insertion, needle placement, and deposition of anesthetic solution) 314 Dressman et al. using a 170 mm Heft-Parker visual analog scale (VAS) (11). The VAS was divided into 4 categories. No pain corresponded to 0 mm. Mild pain was defined as greater than 0 mm and less than or equal to 54 mm. Mild pain included the descriptors of faint, weak, and mild pain. Moderate pain was defined as greater than 54 mm and less than 114 mm. Severe pain was defined as equal to or greater than 114 mm. Severe pain included the descriptors of strong, intense, and maximum possible. During each phase of the initial, repeat, or mock infiltrations, the principal investigator informed the subject when each phase of the injection was complete. Immediately after the infiltration, the subject rated the pain for each injection phase on the VAS. Before each injection, the mucosa was dried, and 0.2 mL topical anesthetic gel (20% benzocaine; Patterson Dental Supply, Inc, St Paul, MN) was passively placed with a cotton tip applicator for 60 seconds at the injection site. A mandibular second premolar infiltration was administered using a cartridge of 4% articaine with 1:100,000 epinephrine and a standard aspirating syringe equipped with a 27-G 1½-inch needle. All anesthetic cartridges were checked to ensure that the anesthetic solution had not expired. The needle was gently placed into the alveolar mucosa (needle insertion). The direction of needle insertion was from a superior, anterior, and lateral direction into the alveolar mucosa of the buccal vestibule. The needle was advanced (needle placement) within 2–3 seconds until the needle was estimated to approximate the incisive canal as outlined by Nist et al (1). No attempt was made to enter the incisive canal. No anesthetic solution was deposited during needle placement. The anesthetic solution was deposited over a period of 1 minute (solution deposition phase). Immediately after the infiltration, finger pressure was applied over the infiltration site for 1 minute. At 20 minutes after the initial infiltration, the repeat infiltration or mock infiltration was administered in the manner described for the initial infiltration and at the same site. For the mock infiltration, the part of the needle that engaged the anesthetic cartridge inside the syringe was bent over so it could not penetrate the rubber diaphragm of the cartridge. Therefore, no anesthetic solution could be deposited. For the repeat and mock infiltrations, a new 27-G needle was attached to the syringe. When the repeat infiltration was given, a full cartridge of articaine was deposited over a period of 1 minute at the target site. For the mock infiltration, once the needle reached the target site, the needle was held in position for 1 minute to mimic the time of the solution deposition. All subjects were blindfolded during both the repeat and mock infiltrations. All initial and repeat infiltrations were administered by the senior author (ASD). The depth of anesthesia was monitored with the electric pulp tester. At 1 minute after the initial infiltration injection, pulp test readings were obtained for the mandibular first molar and second premolar. At 2 minutes, the first premolar and canine were tested. At 3 minutes, the lateral and central incisors were tested, and at 4 minutes the contralateral control canine was tested. The testing continued in 4-minute cycles for a total of 20 minutes. At every fourth cycle, the control tooth, the contralateral canine, was tested by an inactivated electric pulp tester to test the reliability of the subject. If the subject responded positively to an inactivated pulp tester, then they were not reliable and could not be used in the study. At minute 20, the repeat infiltration or mock infiltration was given. Pulp testing resumed at the 24th minute repeating in cycles of 4 minutes for 120 minutes. All subjects were asked to complete postinjection pain surveys using the same VAS as previously described after each appointment, immediately after the numbness wore off, and again each morning upon rising for the next 3 days. Patients were also instructed to describe and record any problems they experienced. JOE — Volume 39, Number 3, March 2013
  3. 3. CONSORT Randomized Clinical Trial No response from the subject at the maximum output (80 reading) of the pulp tester was used as the criterion for pulpal anesthesia. Anesthetic success was the total number of subjects with an 80 reading. The time for the onset of pulpal anesthesia was recorded as the first of 2 consecutive 80 readings. With a nondirectional alpha risk of 0.05 and a power of 85%, a sample size of 95 subjects was required to show a difference in anesthetic success of Æ20 percentage points. Comparisons between the primary infiltrations and repeat infiltrations for anesthetic success and the incidence of anesthesia (80/80 readings) were made using multiple McNemar exact tests adjusted using the step-down Bonferroni method of Holm. Between-group comparisons for needle insertion pain, needle placement pain, solution deposition pain, and postoperative pain were made using analysis of variance with the Tukey-Kramer multiple-comparison test. Comparisons were considered significant at P < .05. Results One hundred adult subjects, 50 men and 50 women ranging in age from 20 to 42 years with an average age of 25 years, participated in this study. Table 1 shows the percentages of successful pulpal anesthesia for the initial infiltrations. The first molar and canine had success rates ranging from 50% to 59%, and the lateral and central incisors had success rates ranging from 19% to 25%. For the premolars, anesthetic success ranged from 80% to 87%. There were no significant differences between the 2 initial infiltrations for anesthetic success or the incidence of anesthesia (percentage of 80 readings) across time for the first 20 minutes. The mean time of onset of pulpal anesthesia for the first premolars was 6.2 minutes, and for the second premolar it was 5.2 minutes. No onset times were reported for the other teeth because of the low number of anesthetic successes. Table 2 presents the percentages of anesthetic success for the repeat infiltration of articaine. The highest success rates were recorded for the premolars (ie, 92%–94%). The incidence of pulpal anesthesia (80 readings across time) for the initial infiltration plus the repeat infiltration of 1 cartridge of 4% articaine with 1:100,000 epinephrine or mock infiltration is presented in Figure 1. Significant differences (percentage of 80 readings) when compared with the initial infiltration plus repeat articaine or mock infiltrations are reported in Table 2. The pain of the initial infiltrations and repeat infiltrations are presented in Table 3. All mean pain ratings were in the mild category. Pain ratings were very low for the repeat or mock infiltrations. Postoperative pain ratings are presented in Table 4. All mean pain ratings were in the mild category. Although there were no significant differences in pain of injection between the initial plus repeat or the initial plus mock infiltrations, there were significant differences between the initial plus mock and initial plus repeat infiltrations of articaine for postoperative pain at each postoperative day. The postinjection complications reported were initial tenderness (7%–19%) and slight subjective swelling (1%–7%) in the area of the injection with decreasing percentages over 3 days. Discussion The success rates of the initial 200 infiltrations in the incisive/ mental nerve region for the first molar, canine, and incisor teeth confirm previous studies (1–4) of the ineffectiveness of this injection technique in predictably anesthetizing these teeth (Table 1 and Fig. 1). Although we were aware of these findings, no study had used a full cartridge of 4% articaine with 1:100,000 for this injection, so it was important to investigate its effect on these teeth. Clinically, the first molar can be adequately anesthetized in asymptomatic teeth by combining an inferior alveolar nerve block with a buccal infiltration of a cartridge of 4% articaine with 1:100,000 epinephrine (12, 13) or a supplemental intraosseous injection (14–17). Incisor teeth can be successfully anesthetized by combining the inferior alveolar nerve block with local infiltrations of articaine (1, 18–20). The success rates of the 2 initial infiltrations were not significantly different (Table 1). We would expect no difference because each infiltration was administered in an identical manner. The success rates of the initial infiltration for the second premolar (80%–82%) (Table 1) were similar to the success rates of Batista da Silva et al (4) at 80% and Whitworth et al (3) at 79%–84% but higher than Joyce and Donnelly (2) at 74% and lower than the results of Nist et al (1) at 90%. These previous studies evaluated the success of the incisive/mental nerve block or infiltration at this site. Although the success rates were moderately successful, complete anesthesia was not obtained. The success rates of the initial infiltration for the first premolar (87%, Table 1) were similar to the success rates of Whitworth et al (3) at 79%–84% but higher than Joyce and Donnelly (2) at 78% and Batista da Silva et al (4) at 72% and lower than the results of Nist et al (1) at 100%. Generally, the success rates were higher than the second premolar but would not ensure complete anesthesia in the first premolar. Differences in premolar success rates among studies may relate to using an anesthetic volume of 0.6 mL (4), 0.9 mL (2), 1.8 mL (1), or 2.0 mL (3); using anesthetic solutions of lidocaine (1–3) versus articaine (4); entering the mental foramen (1, 2); and population variation. A major disadvantage with the initial infiltration in the premolars is the decline of pulpal anesthesia after 20 minutes in the second premolar and after approximately 25 minutes in the first premolar (Fig. 1). Other authors (1, 3, 4) have also reported similar incidences of declining pulpal anesthesia after an incisive/mental nerve block or infiltration at this site. A repeat infiltration at 20 minutes significantly increased the rate success (92%–94%) and the duration of pulpal anesthesia for the premolars (Table 2 and Fig. 1). Although a similar observation was made in the first molar, canine, and incisors, success rates were not high enough to predictably anesthetize these teeth (Table 2 and TABLE 1. Percentages and Number of Subjects Who Experienced Anesthetic Success (within the first 20 minutes) for the 2 Initial Infiltrations of Articaine Initial infiltration (%, n) Second premolar*† First premolar*† First molar* Canine* Lateral incisor* Central incisor* Initial infiltration (%, n) P value 82 (81/99) 87 (83/95) 54 (54/100) 53 (53/100) 25 (25/100) 20 (20/100) 80 (79/99) 87 (83/95) 59 (59/100) 50 (50/100) 23 (23/100) 19 (19/100) 1.000 1.000 1.000 1.000 1.000 1.000 *There were no significant differences (P > .05) between the 2 initial infiltrations. † Some teeth were missing because of orthodontic extractions. JOE — Volume 39, Number 3, March 2013 Primary and Repeat Mandibular Premolar Anesthesia 315
  4. 4. CONSORT Randomized Clinical Trial TABLE 2. Percentages and Number of Subjects Who Experienced Anesthetic Success with the Repeat Injection of Articaine and the Significant Differences (percentage of 80 readings) When Comparing the Initial Infiltration Plus Mock Infiltration with the Initial Infiltration Plus Repeat Articaine Infiltration Repeat infiltration (%, n) Significant differences (min) 92 (91/99) 94 (89/95) 79 (79/100) 76 (76/100) 42 (42/100) 30 (30/100) 28–116 37–117 28–96 29–97 30–78 34–62 Second premolar* First premolar* First molar Canine Lateral incisor Central incisor *Some teeth were missing because of orthodontic extractions. Fig. 1). Previous studies by Pabst et al (10) and Scott et al (21) showed a higher level of pulpal anesthesia after the administration of a repeat infiltration. If the repeat infiltration provided the same effect as the initial infiltration, we would not necessarily expect a higher incidence of pulpal anesthesia. A drug’s enhanced effectiveness when given within a reasonable time as anesthesia is close to wearing off is called augmentation (22, 23). Judging from Figure 1, it took approximately 4–5 minutes for the repeat infiltration to reach its full effect in the premolars. The duration was significantly increased through the 116–117 minute (Table 2). However, the clinical duration of an effect (sustained 80 readings at the highest success rate) was operational through approximately 52 Initial + Repeated Infiltration Initial + Mock Repeated Infiltration P ercen ta g e o f 8 0 R ea d in g s P ercen tag e o f 8 0 R ea d in g s 100 75 50 25 0 Initial + Repeated Infiltration 100 Initial + Mock Repeated Infiltration Percentage of 80 Readings Initial + Repeated Infiltration 100 minutes in the premolars before pulpal anesthesia started to decline (Fig. 1). Although we anticipated higher success rates in the premolars with the initial infiltration of articaine (because of its superiority over lidocaine in mandibular infiltrations) when the study was designed, it is apparent that success rates were only moderate (Table 1 and Fig. 1). Although the repeat infiltration significantly increased the success rate and the duration in the premolars, the initial infiltration success would have to be higher to have clinical usefulness. To increase success, it may be advisable to administer an inferior alveolar nerve block and then add an infiltration of articaine in the premolars. Nist et al (1), using a lidocaine formulation, showed very good success rates and a duration of 60 minutes when this regimen was used in the premolars. Because we studied a young adult population, the results of this study may not apply to children or the elderly. We believed that it was important to first test the efficacy of articaine for anesthetizing the premolars in subjects with normal pulps. If it had a clinical application in normal teeth, we could then apply the methods for teeth with irreversible pulpitis. Because complete pulpal anesthesia was not obtained initially in the premolars, the use of articaine in patients with irreversible pulpitis may not be applicable. The time of onset of pulpal anesthesia averaged 6.2 minutes for the first premolar and 5.2 minutes for the second premolar. The onset times for the adjacent teeth were not considered because of the clinically low number of anesthetic successes. The results of the current study were similar to the 5.1-minute onset time for the premolars reported by Whitworth et al (3) using 2 mL 2% lidocaine with 75 50 25 75 50 25 0 1 13 24 36 48 60 72 84 96 108 120 Initial + Mock Repeated Infiltration 0 2 1 13 24 36 48 60 72 84 96 108 120 103 112 14 25 37 49 61 73 85 97 109 120 Time (Minutes) Time (Minutes) Time (Minutes) First Molar Second Premolar First Premolar Initial + Repeated Infiltration P erc e n ta g e o f 8 0 R ea d in g s P e rc e n ta g e o f 8 0 R e a d in g s 100 Initial + Mock Repeated Infiltration 75 50 25 0 75 50 25 Time (Minutes) Canine Initial + Mock Repeated Infiltration 75 50 25 0 0 2 14 25 37 49 61 73 85 97 109 120 Initial + Repeated Infiltration 100 Initial + Mock Repeated Infiltration P ercen ta g e o f 8 0 R ea d in g s Initial + Repeated Infiltration 100 3 15 26 38 50 62 74 86 98 110 122 3 15 26 38 50 62 74 86 98 110 120 Time (Minutes) Time (Minutes) Lateral Incisor Central Incisor Figure 1. The incidence of pulpal anesthesia for the first molar, first and second premolars, canine, lateral, and central incisor as determined by a lack of response to electrical pulp testing at the maximum setting (percentage of 80 readings) at each postinjection time interval for the initial infiltration of 1 cartridge of 4% articaine with 1:100,000 epinephrine plus a repeat infiltration at 20 minutes of 1 cartridge of 4% articaine with 1:100,000 epinephrine or a mock infiltration. 316 Dressman et al. JOE — Volume 39, Number 3, March 2013
  5. 5. CONSORT Randomized Clinical Trial TABLE 3. Pain Ratings for Each Injection Phase for the Initial Infiltrations and Repeat Infiltrations of Articaine or Mock Infiltrations Injection phase Initial infiltrations* Needle insertion† Cartridge of articaine Cartridge of articaine Needle placement† Cartridge of articaine Cartridge of articaine Solution deposition† Cartridge of articaine Cartridge of articaine Repeat infiltrations Needle insertion† Cartridge of articaine Mock articaine Needle placement† Cartridge of articaine Mock articaine Solution deposition† Cartridge of articaine Mock articaine None (%, n) Mild (%, n) Moderate (%, n) Severe (%, n) Mean ± SD (mm) 10 (10/100) 9 (9/100) 80 (80/100) 80 (80/100) 10 (10/100) 11 (11/100) 0 (0/100) 0 (0/100) 31 Æ 20 31 Æ 21 27 (27/100) 33 (33/100) 64 (64/100) 59 (59/100) 9 (9/100) 8 (8/100) 0 (0/100) 0 (0/100) 26 Æ 23 22 Æ 25 21 (21/100) 22 (22/100) 61 (61/100) 56 (56/100) 18 (18/100) 22 (22/100) 0 (0/100) 0 (0/100) 32 Æ 28 34 Æ 28 96 (96/100) 96 (96/100) 4 (4/100) 4 (4/100) 0 (0/100) 0 (0/100) 0 (0/100) 0 (0/100) 0.4 Æ 2 0.6 Æ 4 94 (94/100) 97 (97/100) 6 (6/100) 3 (3/100) 0 (0/100) 0 (0/100) 0 (0/100) 0 (0/100) 0.8 Æ 3 0.4 Æ 3 94 (94/100) 94 (94/100) 6 (6/100) 6 (6/100) 0 (0/100) 0 (0/100) 0 (0/100) 0 (0/100) 0.7 Æ 3 1.3 Æ 7 SD, standard deviation. *Initial infiltrations (first or second appointment). † There were no significant differences (P > .05) between the 2 sets of anesthetic infiltrations. 1:80,000 epinephrine for infiltration in the premolar region. However, Batista da Silva et al (4) recorded faster onset times for the first premolar (4 minutes) and the second premolar (2 minutes) using 0.6 mL 4% articaine with 1:100,000 epinephrine and a similar design to the current study for delivering anesthetic solution in the premolar region. Perhaps, differences in methodology or populations may account for the different onset times. The mean VAS pain values for the initial infiltration were all in the mild range (Table 3). There was an incidence of 10%–11% moderate pain for needle insertion, 8%–9% for needle placement, and 18%–22% for solution deposition. There were no reports of severe pain. Nist et al (1) reported a 5% incidence of moderate pain for needle insertion and a 15% incidence of moderate pain and 3% incidence of severe pain for solution deposition when administering the incisive nerve block within the mental foramen. Joyce and Donnelly (2) reported an incidence of 27% moderate pain and a 2% incidence of severe pain for the incisive nerve block using a patient questionnaire. Joyce and Donnelly did not divide the injection into 3 phases. Whitworth et al (3) found a slow infiltration (60 seconds) in the incisive/mental nerve area was less painful than a fast injection (10 seconds) for solution deposition. Their VAS scores were lower (11.9–22.6 mm) than recorded in the current study (32–34 mm) for solution deposition. Batista da Silva et al (4) reported a 10% incidence of moderate injection pain using both articaine and lidocaine formulations and a similar design to the current study for delivering anesthetic solution in the premolar region. Therefore, there is a potential for moderate pain of 8%–22% with an initial premolar infiltration in the area of the incisive/mental nerve area. The repeat or mock infiltrations had very low pain ratings (Table 3) because an anesthetic effect had already been established by the initial infiltration. Postinjection pain ratings were statistically different between the 2 sets of anesthetic injections for day 0 through day 3 (Table 4). More postinjection pain was experienced with the repeat infiltration probably because of the 2-cartridge volume. However, the mean pain ratings were still in the mild pain range, and the incidence of pain decreased over the 3 days (Table 4). Pabst et al (10) and Martin et al (24) also reported more postoperative pain when a 2-cartridge volume of articaine was used for a repeat or initial buccal infiltration of the mandibular first molar. Nist et al (1) reported a 2% incidence of postoperative pain when administering the incisive nerve block within the mental foramen. Joyce and Donnelly (2) reported an incidence of 7% moderate postoperative pain for the incisive nerve block using a patient questionnaire. Batista da Silva et al (4) reported a 2% incidence of postinjection TABLE 4. Postinjection Pain Ratings for the Initial Infiltration Plus the Repeat Articaine Infiltration and the Initial Infiltration Plus the Repeat Mock Infiltration Injection Phase None Mild Day 0* (the day of injection when soft-tissue anesthesia wore off) Infiltration plus repeat infiltration 15 (15/100) 61 (61/100) Infiltration plus mock infiltration 26 (26/100) 65 (65/100) Day 1* Infiltration plus repeat infiltration 20 (20/100) 67 (67/100) Infiltration plus mock infiltration 35 (35/100) 63 (63/100) Day 2* Infiltration plus repeat infiltration 31 (31/100) 62 (62/100) Infiltration plus mock infiltration 53 (53/100) 43 (43/100) Day 3* Infiltration plus repeat infiltration 51 (51/100) 45 (45/100) Infiltration plus mock infiltration 66 (66/100) 34 (34/100) Moderate Severe Mean ± SD (mm) 24 (24/100) 9 (9/100) 0 (0/100) 0 (0/100) 39 Æ 29 24 Æ 22 13 (13/100) 2 (2/100) 0 (0/100) 0 (0/100) 31 Æ 24 19 Æ 19 7 (7/100) 4 (4/100) 0 (0/100) 0 (0/100) 39 Æ 29 24 Æ 22 4 (4/100) 0 (0/100) 0 (0/100) 0 (0/100) 39 Æ 29 24 Æ 22 *There were significant differences (P < .05) between the 2 sets of anesthetic infiltrations. JOE — Volume 39, Number 3, March 2013 Primary and Repeat Mandibular Premolar Anesthesia 317
  6. 6. CONSORT Randomized Clinical Trial pain for an articaine formulation using a similar design to the current study for delivering anesthetic solution in the premolar region. Therefore, there is potential for moderate pain of around 24% (Table 4) when anesthesia wears off for a 2-cartridge volume of articaine with decreasing moderate pain on days 1 (13%), 2 (7%), and 3 (4%). Postinjection complications reported were initial tenderness (7%–19%) and slight subjective swelling (1%–7%) in the area of the injection. The higher percentages were associated with the repeat infiltration (2-cartridge volume) as also reported by Pabst et al (10) and Martin et al (24). Nist et al (1) and Bastista da Silva et al (4) reported no complications with the incisive nerve block. Joyce and Donnelly (2) found 2 of 30 subjects had paresthesia after the injection. Although there have been reports of paresthesia associated with articaine use (25–28), no subjects reported any paresthesia in the current study even though the injection site approximated the mental nerve. In conclusion, the initial infiltration in the incisive/mental nerve area was not effective in anesthetizing the first molar, canine, or incisor teeth and was only moderately successful in the premolars. Although the repeat infiltration significantly increased the success rate and the duration in the premolars, the initial infiltration success rates were not high enough to support the use of this regimen as a combined anesthetic technique. Acknowledgments The authors deny any conflicts of interest related to this study. References 1. Nist R, Reader A, Beck M, et al. An evaluation of the incisive nerve block and combination inferior alveolar and incisive nerve blocks in mandibular anesthesia. J Endod 1992;18:455–9. 2. Joyce AP, Donnelly JC. Evaluation of the effectiveness and comfort of incisive nerve anesthesia given inside or outside the mental foramen. J Endod 1993;19:409–11. 3. Whitworth JM, Kanaa MD, Corbett IP, et al. Influence of injection speed on the effectiveness of incisive/mental nerve block: a randomized, controlled, double-blind study in adult volunteers. J Endod 2007;33:1149–54. 4. Batista da Silva C, Berto LA, Volpato MC, et al. Anesthetic efficacy of articaine and lidocaine for incisive/mental nerve block. J Endod 2010;36:438–41. 5. Kanaa MD, Whitworth JM, Corbett IP, et al. Articaine and lidocaine mandibular buccal infiltration anesthesia: a prospective randomized double-blind cross-over study. J Endod 2006;32:296–8. 6. Robertson D, Nusstein J, Reader A, et al. The anesthetic efficacy of articaine in buccal infiltration of mandibular posterior teeth. J Am Dent Assoc 2007;138:1104–12. 7. Jung Y, Kim JH, Kim ES, et al. An evaluation of buccal infiltrations and inferior alveolar nerve blocks in pulpal anesthesia for mandibular first molars. J Endod 2008; 34:11–3. 8. Corbett IP, Kanaa MD, Whitworth JM, et al. Articaine infiltration for anesthesia of mandibular first molars. J Endod 2008;34:514–8. 318 Dressman et al. 9. Abdulwahab M, Boynes S, Moore P, et al. The efficacy of six local anesthetic formulations used for posterior mandibular buccal infiltration anesthesia. J Am Dent Assoc 2009;140:1018–24. 10. Pabst L, Nusstein J, Drum M, et al. The efficacy of a repeated buccal infiltration of articaine in prolonging duration of pulpal anesthesia in the mandibular first molar. Anesth Prog 2009;56:128–34. 11. Heft MW, Parker SR. An experimental basis for revising the graphic rating scale for pain. Pain 1984;19:153–61. 12. Haase A, Reader A, Nusstein J, et al. Comparing anesthetic efficacy of articaine versus lidocaine as a supplemental buccal infiltration of the mandibular first molar after an inferior alveolar nerve block. J Am Dent Assoc 2008;139:1228–35. 13. Kanaa MD, Whitworth JM, Corbett IP, et al. Articaine buccal infiltration enhances the effectiveness of lidocaine inferior alveolar nerve block. Int Endod J 2009;42: 238–46. 14. Dunbar D, Reader A, Nist R, et al. Anesthetic efficacy of the intraosseous injection after an inferior alveolar nerve block. J Endod 1996;22:481–6. 15. Guglielmo A, Reader A, Nist R, et al. Anesthetic efficacy and heart rate effects of the supplemental intraosseous injection of 2% mepivacaine with 1:20,000 levonordefrin. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:284–93. 16. Gallatin E, Stabile P, Reader A, et al. Anesthetic efficacy and heart rate effects of the intraosseous injection of 3% mepivacaine after an inferior alveolar nerve block. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:83–7. 17. Stabile P, Reader A, Gallatin E, et al. Anesthetic efficacy and heart rate effects of the intraosseous injection of 1.5% etidocaine (1:200,000 epinephrine) after an inferior alveolar nerve block. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89: 407–11. 18. Yonchak T, Reader A, Beck M, et al. Anesthetic efficacy of infiltrations in mandibular anterior teeth. Anesth Prog 2001;48:55–60. 19. Nuzum FM, Drum M, Nusstein J, et al. Anesthetic efficacy of articaine for combination labial plus lingual infiltrations versus labial infiltration in the mandibular lateral incisor. J Endod 2010;36:952–6. 20. Jaber A, Whitworth JM, Corbett IP, et al. The efficacy of infiltration anaesthesia for adult mandibular incisors: a randomized double-blind cross-over trial comparing articaine and lidocaine buccal and buccal plus lingual infiltrations. Br Dent J 2010;209:E16. 21. Scott J, Drum M, Reader A, et al. The efficacy of a repeated infiltration in prolonging duration of pulpal anesthesia in maxillary lateral incisors. J Am Dent Assoc 2009; 140:318–24. 22. De Jong RH. Local Anesthetics. St Louis, MO: Mosby; 1994:243–244. 23. Choi RH, Birknes JK, Popitz-Bergez FA, et al. Pharmacokinetic nature of tachyphylaxis to lidocaine: peripheral nerve blocks and infiltration anesthesia in rats. Life Sci 1997;61:177–84. 24. Martin M, Nusstein J, Drum M, et al. Anesthetic efficacy of 1.8 mL versus 3.6 mL of 4% articaine with 1:100,000 epinephrine as a primary buccal infiltration of the mandibular first molar. J Endod 2011;37:588–92. 25. Haas DA, Lennon D. A 21 year retrospective study of reports of paresthesia following local anesthetic administration. J Can Dent Assoc 1995;61:319–320, 323–326, 329–330. 26. Gaffen AS, Haas DA. Retrospective review of voluntary reports of nonsurgical paresthesia in dentistry. J Can Dent Assoc 2009;75:579a–f. 27. Pogrel MA. Permanent nerve damage from inferior alveolar nerve blocks—an update to include articaine. J Calif Dent Assoc 2007;35:271–3. 28. Garisto GA, Gaffen AS, Lawrence HP, et al. Occurrence of paresthesia after dental local anesthetic administration in the United States. J Am Dent Assoc 2010;141: 836–44. JOE — Volume 39, Number 3, March 2013

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