- Email: [email protected]
Articaine for Supplemental Intraosseous Anesthesia in Patients With Irreversible Pulpitis
Clinical Research
Articaine for Supplemental Intraosseous Anesthesia in Patients With Irreversible Pulpitis Jason Bigby, DDS, MS, Al Reader, DDS, MS, John Nusstein, DDS, MS, Mike Beck, DDS, MA, and Joel Weaver, DDS, PhD Abstract The purpose of this study was to determine the anesthetic efficacy and heart rate effect of 4% articaine with 1:100,000 epinephrine for supplemental intraosseous injection in mandibular posterior teeth diagnosed with irreversible pulpitis. Thirty-seven emergency patients, diagnosed with irreversible pulpitis of a mandibular posterior tooth, received an inferior alveolar nerve block and had moderate-to-severe pain upon endodontic access. The Stabident system was used to administer 1.8 ml of 4% articaine with 1:100,000 epinephrine. Success of the intraosseous injection was defined as none or mild pain upon endodontic access or initial instrumentation. The results demonstrated that anesthetic success was obtained in 86% (32 of 37) of the patients. Maximum mean heart rate was increased 32 beats/minute during the intraosseous injection. We can conclude that when the inferior alveolar nerve block fails to provide profound pulpal anesthesia, the intraosseous injection of 4% articaine with 1:100,000 epinephrine would be successful 86% of the time in achieving pulpal anesthesia in mandibular posterior teeth of patients presenting with irreversible pulpitis. (J Endod 2006;32:1044 –1047)
S
upplemental injections are essential when, as frequently occurs in patients diagnosed with irreversible pulpitis, pulpal anesthesia from the inferior alveolar nerve (IAN) block is inadequate and the pain is too severe for the endodontist to proceed. Previous studies (1–5) have shown success rates of only 19% to 56% for inferior alveolar nerve blocks in patients with irreversible pulpitis. Therefore, practitioners need to consider supplemental techniques when an inferior alveolar nerve block fails to provide pulpal anesthesia for patients with irreversible pulpitis. The Stabident or X-Tip intraosseous injection allows placement of a local anesthetic solution directly into the cancellous bone adjacent to the tooth to be anesthetized. The success of these supplemental intraosseous injections in achieving pulpal anesthesia in patients with irreversible pulpitis has been reported to be 82% to 98% (2, 3, 6, 7). Traditionally, solutions of lidocaine or mepivacaine have been administered with the intraosseous injection. In April 2000, articaine was introduced in the United States (8). The structure, pharmacology and studies of articaine can be reviewed in previous publications (8 –23). Articaine has a reputation of providing an improved local anesthetic effect (24). No study has investigated the efficacy of articaine when used as a supplemental intraosseous injection in patients with irreversible pulpitis. The purpose of this study was to determine the anesthetic efficacy and heart rate effect of the supplemental intraosseous injection of 4% articaine with 1:100,000 epinephrine in mandibular posterior teeth diagnosed with irreversible pulpitis when the conventional IAN block failed.
Key Words Articaine, intraosseous anesthesia, irreversible pulpitis
From the Section of Endodontics, College of Dentistry, The Ohio State University, Columbus, Ohio. This study was supported by research funding from the Graduate Student Research Fund, Department of Endodontics, The Ohio State University This article was adapted from a thesis submitted by Dr. Jason Bigby in partial fulfillment of the requirements for the MS degree at The Ohio State University. A portion of this article was presented at the 2005 Annual Session of the American Association of Endodontists, Dallas, Texas Address requests for reprints to Dr. Al Reader, Section of Endodontics, College of Dentistry, 305 W. 12th Avenue, The Ohio State University, Columbus, OH 43218. E-mail address: [email protected]. 0099-2399/$0 - see front matter Copyright © 2006 by the American Association of Endodontists. doi:10.1016/j.joen.2006.06.006
1044
Bigby et al.
Materials and Methods Forty-nine initial adult patients participated in this study. All were emergency patients of the College of Dentistry and were in good health as determined by a health history and oral questioning. The Ohio State University Human Subjects Review Committee approved the study and written informed consent was obtained from each patient. To qualify for the study, each patient had a vital mandibular posterior tooth (molar or premolar), was actively experiencing moderate-to-severe pain, and had a prolonged response to cold testing with Endo-Ice (1,1,1,2 tetrafluoroethane; Hygenic Corp., Akron OH). Patients with no response to cold testing or periradicular pathosis (other than a widened periodontal ligament) were excluded from the study. Therefore, each patient had a tooth that fulfilled the criteria for a clinical diagnosis of irreversible pulpitis. All teeth had vital coronal pulpal tissue upon endodontic access. Patients received standard IAN blocks and long buccal injections. All patients recorded profound lip numbness. At 15 minutes after the inferior alveolar nerve block, the teeth were isolated with a rubber dam and access performed. The patients were instructed to definitively rate any discomfort during access using a Heft-Parker visual analogue scale (VAS) (25). The VAS scale was divided into four 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.
JOE — Volume 32, Number 11, November 2006
Clinical Research TABLE 1. Percentages and number of patients who achieved anesthetic success and failure with the supplemental intraosseous injection of 4% articaine with 1:100,000 epinephrine Intraosseous injection
Anesthetic success
Anesthetic failure
86% (32 of 37) (CI ⫽ 71% to 96%)*
14% (5 of 37) (CI ⫽ 4% to 29%)a
n ⫽ 37. a 95% confidence interval.
The 39 patients who had moderate-or-severe pain (VAS rating greater than 54 mm) during access into dentin, when entering the pulp chamber or with initial file placement, received supplemental intraosseous injections using 4% articaine with 1:100,000 epinephrine. The intraosseous injection was administered with the Stabident system (Fairfax Dental Inc., Miami, FL) in the following manner. After rubber dam removal, with the subjects in a reclining position, the area of perforation was determined to be in attached gingiva (just above the junction of the attached gingiva and alveolar mucosa) and at a site distal to the first molar or premolars, or at a mesial site in second molars. The perforator was pushed through the alveolar mucosa until the Stabident tip contacted bone. Holding the drill at a 90-degree angle to the bone, the slow-speed handpiece was activated in a series of short bursts, using light pressure, until a break through feeling was observed or until 2 to 5 seconds had elapsed. The handpiece was always activated while the perforator was within bone to prevent lodging or breakage that might occur if the perforator was allowed to stop rotating. Before inserting the 27-gauge ultrashort Stabident needle, the needle was bent at the hub to a 60- to 80-degree angle to allow for ease of insertion. A standard aspirating syringe was held in a pen-gripping fashion and the needle was inserted into the hole made by the perforator. One and eight tenths milliliter of 4% articaine with 1:100,000 epinephrine (Septocaine, Septodont, New Castle, DE) was deposited over a 1-minute time period. If there was backflow of the anesthetic solution into the oral cavity (two patients), their data was excluded from the study. Therefore, the final number of patients used for data analysis was 37. Before administering the intraosseous injection, the subjects were instructed to rate the pain of perforation and solution deposition using the Heft-Parker VAS. Each subject had his or her pulse rate monitored using a pulse oximeter (Criticare Systems, Inc., Waukesha, WI). The sensor was attached to the nail of the forefinger before administration of any injections. Pulse rate recordings were grouped into three time periods. Period 1 (baseline) readings were recorded at 15-second intervals for 2 minutes before the intraosseous injection. Period 2 readings were recorded at 15second intervals during the 1-minute anesthetic solution deposition. Period 3 readings were recorded at 15-second intervals for 3 minutes after anesthetic solution deposition. Patients were also asked if they noticed an increase in their heart rate after anesthetic solution deposition. After rubber dam placement, endodontic access was continued. The success of the supplemental intraosseous injection was defined as the ability to access the pulp chamber, place initial files and instrument the tooth without pain (VAS score of zero) or mild pain (VAS rating less than or equal to 54 mm). If the patient had moderate-to-severe pain (VAS rating greater than 54 mm) during access or initial instrumentation, the intraosseous injection was judged as a failure and an intrapulpal injection was administered. The total time of instrumentation was recorded in minutes. The data were statistically analyzed. Confidence intervals were calculated for anesthetic success and failure and subjective increase in pulse rate. Bonferroni-adjusted, multiple, Wilcoxon, matched-pairs,
JOE — Volume 32, Number 11, November 2006
signed-ranks tests were used to analyze objective heart rate increase. Comparisons were considered significant if p ⬍ 0.05.
Results Thirty-seven adult patients, 14 men and 23 women, from age 18 to 53 years with an average age of 30 years participated. Fifteen of the mandibular teeth were first molars, 13 were second molars, 4 were second premolars, and 5 were first premolars. Anesthetic success and failure of the intraosseous injection is presented in Table 1. Subjective and objective pulse rate increase is presented in Table 2. Discomfort ratings of intraosseous perforation and solution deposition are presented in Table 3. The total time of instrumentation averaged 35 minutes.
Discussion The success rate of 86% in the current study for the supplemental intraosseous injection of 1.8 ml of 4% articaine with 1:100,000 epinephrine is similar to the success rates of 82% to 91% reported for the supplemental intraosseous injection of 1.8 ml of 2% lidocaine with 1:100,000 epinephrine in the posterior mandible (3, 6, 7). While no other study has compared articaine to lidocaine as a supplemental intraosseous injection in patients with irreversible pulpitis, many studies have compared these two solutions (8 –22). Basically, the authors have found articaine to be a safe and effective local anesthetic agent (8 –22). Repeated clinical trials have failed to detect any superiority of articaine over lidocaine in mandibular anesthesia (5, 14, 15, 21, 22). Infiltration anesthesia in the maxilla has shown an equivalent effect for articaine and prilocaine/lidocaine (15–20) except for one recent study by Costa et al. (23), which showed a TABLE 2. Subjective and objective increases in heart rate (pulse rate). Subjective Increase Number/Percentage Confidence interval Subjective increase Yes No
Objective Increase Injection phase Baseline Solution depositionc 1-Minute postdepositionc 3-Minutes postdepositionc Maximum heart ratec Mean maximum increase
30 (81%) 7 (19%)
Meanb
(CI ⫽ 64% to 91%)a (CI ⫽ 9% to 37%)a
Minimum Maximum
70 (⫾11.5) 86 (⫾24.0)
47.5 53.5
90.6 212.0
91 (⫾18.6)
66.3
152.0
83 (⫾14.6)
62.8
137.3
102 (⫾23.1)
66.3
212.0
32 beats/minute
n ⫽ 37. a 95% confidence interval. b Standard deviation. c Significantly different from baseline (p ⬍ 0.05).
Articaine for Supplemental Intraosseous Anesthesia
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Clinical Research TABLE 3. Discomfort ratings for patients receiving the intraosseous injection of 4% articaine with 1:100,000 epinephrine Phase
None (0 mm)
Mild (1–54 mm)
Moderate (55–113 mm)
Severe (114 or greater)a
Perforation Solution deposition
32% (12/37) 16% (6/37)
51% (19/37) 62% (23/37)
11% (4/37) 14% (5/37)
5% (2/37) 8% (3/37)
n ⫽ 37. a Heft Parker VAS Ratings.
prolonged duration with articaine. A recent study by Kanaa et al. (26) found 4% articaine with 1:100,000 epinephrine was significantly better than 2% lidocaine with 1:100,000 epinephrine for buccal infiltration of the mandibular first molar. However, the anesthetic success rate was only 64% for the articaine solution that would not provide predictable pulpal anesthesia for all patients requiring profound anesthesia. The perceived subjective increase (in response to questioning) in pulse rate of 81% and the mean maximum objective pulse rate increase of 32 beats/minute (Table 2) using 4% articaine with 1:100,000 epinephrine were similar to other studies of intraosseous anesthesia (27– 31). Because the concentration of epinephrine with articaine was identical to that used in other studies, we would expect an increase in pulse rate that was comparable. One patient had a maximum pulse rate of 212 beats per minute, which was 77 beats higher than the maximum for any other patient. While not significant in a healthy individual (27), the maximum pulse rate could be significant in a medically compromised individual. The use of 3% mepivacaine would be a prudent choice for these individuals (27). In the current study, 16% of the patients reported moderate-tosevere pain on perforation (Table 3). Solution deposition pain resulted in 22% reporting moderate-to-severe pain (Table 3). Reisman et al. (2) found a 9% incidence and Nusstein et al. (3) a 0% incidence of moderate-to-severe perforation pain, using the Stabident system, in mandibular posterior teeth in patients with irreversible pulpitis. In the current study, pain upon perforation only lasted a few seconds and usually occurred upon entering the cancellous bone. In a similar group of patients with irreversible pulpitis, solution deposition pain has been reported by Nusstein et al. (3) as 5% using 1.8 ml of 2% lidocaine with 1:100,000 epinephrine. Reisman et al. (2) reported a 31% incidence of moderate-to-severe deposition pain using 3% mepivacaine. In the current study, solution deposition pain usually occurred during the initial deposition of solution and lasted a few seconds. None of the patients withdrew from the study because of pain with perforation or solution deposition. In summary, the use of intraosseous anesthesia may result in some reports of moderate-to-severe pain in patients with irreversible pulpitis. The onset of anesthesia was immediate for those patients receiving successful intraosseous injections. That is, endodontic access was begun as soon as the rubber dam was replaced and the patients experienced none or mild pain upon endodontic treatment. The duration of anesthesia was maintained for the duration of the emergency endodontic treatment for those patients receiving successful intraosseous injections. The length of time for complete endodontic debridement averaged 35 minutes. Therefore, the intraosseous technique, when successful, provided adequate anesthesia for the debridement appointment. Generally, we can conclude that when the inferior alveolar nerve block fails to provide profound pulpal anesthesia, the intraosseous injection of 4% articaine with 1:100,000 epinephrine would be successful 86% of the time in achieving pulpal anesthesia in mandibular posterior teeth of patients presenting with irreversible pulpitis. 1046
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References 1. Cohen HP, Cha BY, Spangberg LSW. Endodontic anesthesia in mandibular molars: a clinical study. J Endod 1993;19:370 –3. 2. Reisman D, Reader A, Nist R, Beck M, Weaver J. Anesthetic efficacy of the supplemental intraosseous injection of 3% mepivacaine in irreversible pulpitis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;84:676 – 82. 3. Nusstein J, Reader A, Nist R, Beck M, Meyers WJ. Anesthetic efficacy of the supplemental intraosseous injection of 2% lidocaine with 1:100,000 epinephrine in irreversible pulpitis. J Endod 1998;24:487–91. 4. Kennedy S, Reader A, Nusstein J, Beck M, Weaver J. The significance of needle deflection in success of the inferior alveolar nerve block in patients with irreversible pulpitis. J Endod 2003;29:630 –3. 5. Claffey E, Reader A, Nusstein J, Beck M, Weaver J. Anesthetic efficacy of articaine for inferior alveolar nerve blocks in patients with irreversible pulpitis. J Endod 2004;30:568 –71. 6. Nusstein J, Kennedy S, Reader A, Beck M, Weaver J. Anesthetic efficacy of the supplemental X-tip intraosseous injection in patients with irreversible pulpitis. J Endod 2003;29:724 – 8. 7. Parente SA, Anderson RW, Herman WW, Kimbrough WF, Weller RN. Anesthetic efficacy of the supplemental intraosseous injection for teeth with irreversible pulpitis. J Endod 1998;24:826 – 8. 8. Malamed SF, Gagnon S, LeBlanc D. Articaine hydrochloride: a study of the safety of a new amide local anesthetic. J Am Dent Assoc 2001;132:177– 85. 9. van Oss GE, Vree TB, Baars AM, Termond EF, Booij LH. Pharmacokinetics, metabolism, and renal excretion of articaine and its metabolite articainic acid in patients after epidural administration. Eur J Anaesthesiol 1989;6:49 –56. 10. Oertel R, Rahn R, Kirch W. Clinical pharmacokinetics of articaine. Clin Pharmacokinet 1997;33:417–25. 11. Wright GZ, Weinberger SJ, Friedman CS, Plotzke OB. The use of articaine local anesthesia in children under 4 years of age: a retrospective report. Anesth Prog 1989;36:268 –71. 12. Oertel R, Ebert U, Rahn R, Kirch W. The effect of age on pharmacokinetics of the local anesthetic drug articaine. Reg Anesth Pain Med 1999;24:524 – 8. 13. Malamed SF, Gagnon S, Leblanc, D. A comparison between articaine HCl and lidocaine HCl in pediatric dental patients. Pediatr Dent 2000;22:307–11. 14. Malamed SF, Gagnon S, Leblanc D. Efficacy of articaine: a new amide local anesthetic. J Am Dent Assoc 2000;131:635– 42. 15. Donaldson D, James-Perdok L, Craig BJ, Derkson GD, Richardson AS. A comparison of Ultracaine DS (articaine HCl) and Citanest forte (prilocaine HCl) in maxillary infiltration and mandibular nerve block. J Can Dent Assoc 1987;53:38 – 42. 16. Haas DA, Harper DG, Saso MA, Young ER. Comparison of articaine and prilocaine anesthesia by infiltration in maxillary and mandibular arches. Anesth Prog 1990;37:230 –7. 17. Haas DA, Harper DG, Saso MA, Young ER. Lack of differential effect by Ultracaine (articaine) and Citanest (prilocaine) in infiltration anaesthesia. J Can Dent Assoc 1991;57:217–23. 18. Wright GZ, Weinberger SJ, Marti R, Plotzke O. The effectiveness of infiltration anesthesia in the mandibular primary molar region. Pediatr Dent 1991;13:278 – 83. 19. Vahatalo K, Antila H, Lehtinen R. Articaine and lidocaine for maxillary infiltration anesthesia. Anesth Prog 1993;40:114 – 6. 20. Oliveria PC, Volpato MC, Ramacciato JC, Ranali J. Articaine and lignocaine in infiltration anaesthesia: a pilot study. Br Dent J 2004;197:45– 6. 21. Berlin J, Nusstein J, Reader A, Beck M, Weaver J. Efficacy of articaine and lidocaine in a primary intraligamentary injection administered with a computer-controlled local anesthetic delivery system. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;99:361– 6. 22. Mikesell P, Nusstein J, Reader A, Beck M, Weaver J. A comparison of articaine and lidocaine for inferior alveolar nerve blocks. J Endod 2005;31:265–70. 23. Costa CG, Tortamano IP, Rocha RG, Francishone CE, Tortamano N. Onset and duration periods of articaine and lidocaine on maxillary infiltration. Quintessence Int 2005;36:197–201. 24. Schertzer ER, Malamed SF. Articaine vs. lidocaine. J Am Dent Assoc 2000;131:1248, 1250.
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Clinical Research 25. Heft MW, Parker SR. An experimental basis for revising the graphic rating scale for pain. Pain 1984;19:153– 61. 26. Kannaa MD, Whitworth JM, Corbett IP, Meechan JG. Articaine and lidocaine mandibular buccal infiltration anesthesia: a prospective randomized double-blind crossover study. J Endod 2006;32:296 – 8. 27. Replogle K, Reader A, Nist R, Beck M, Weaver J, Meyers W. Cardiovascular effects of intraosseous injections of 2 percent lidocaine with 1:100,000 epinephrine and 3 percent mepivacaine. J Am Dent Assoc 1999;130:649 –57. 28. Chamberlain TM, Davis RD, Murchison DF, Hansen SR, Richardson BW. Systemic effects of an intraosseous injection of 2% lidocaine with 1:100,000 epinephrine. Gen Dent 2000;May-June:299 –302.
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29. Guglielmo A, Reader A, Nist R, Beck M, Weaver J. 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. 30. Stabile P, Reader A, Gallatin E, Beck M, Weaver J. 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. 31. Wood M, Reader A, Nusstein JM, Beck M, Padgett D, Weaver J. Comparison of intraosseous and infiltration injections for venous lidocaine blood concentrations and heart rate changes after injection of 2% lidocaine with 1:100,000 epinephrine. J Endod 2005;31:435– 8.
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Articaine for Supplemental Intraosseous Anesthesia in Patients With Irreversible Pulpitis Jason Bigby, DDS, MS, Al Reader, DDS, MS, John Nusstein, DDS, MS, Mike Beck, DDS, MA, and Joel Weaver, DDS, PhD Abstract The purpose of this study was to determine the anesthetic efficacy and heart rate effect of 4% articaine with 1:100,000 epinephrine for supplemental intraosseous injection in mandibular posterior teeth diagnosed with irreversible pulpitis. Thirty-seven emergency patients, diagnosed with irreversible pulpitis of a mandibular posterior tooth, received an inferior alveolar nerve block and had moderate-to-severe pain upon endodontic access. The Stabident system was used to administer 1.8 ml of 4% articaine with 1:100,000 epinephrine. Success of the intraosseous injection was defined as none or mild pain upon endodontic access or initial instrumentation. The results demonstrated that anesthetic success was obtained in 86% (32 of 37) of the patients. Maximum mean heart rate was increased 32 beats/minute during the intraosseous injection. We can conclude that when the inferior alveolar nerve block fails to provide profound pulpal anesthesia, the intraosseous injection of 4% articaine with 1:100,000 epinephrine would be successful 86% of the time in achieving pulpal anesthesia in mandibular posterior teeth of patients presenting with irreversible pulpitis. (J Endod 2006;32:1044 –1047)
S
upplemental injections are essential when, as frequently occurs in patients diagnosed with irreversible pulpitis, pulpal anesthesia from the inferior alveolar nerve (IAN) block is inadequate and the pain is too severe for the endodontist to proceed. Previous studies (1–5) have shown success rates of only 19% to 56% for inferior alveolar nerve blocks in patients with irreversible pulpitis. Therefore, practitioners need to consider supplemental techniques when an inferior alveolar nerve block fails to provide pulpal anesthesia for patients with irreversible pulpitis. The Stabident or X-Tip intraosseous injection allows placement of a local anesthetic solution directly into the cancellous bone adjacent to the tooth to be anesthetized. The success of these supplemental intraosseous injections in achieving pulpal anesthesia in patients with irreversible pulpitis has been reported to be 82% to 98% (2, 3, 6, 7). Traditionally, solutions of lidocaine or mepivacaine have been administered with the intraosseous injection. In April 2000, articaine was introduced in the United States (8). The structure, pharmacology and studies of articaine can be reviewed in previous publications (8 –23). Articaine has a reputation of providing an improved local anesthetic effect (24). No study has investigated the efficacy of articaine when used as a supplemental intraosseous injection in patients with irreversible pulpitis. The purpose of this study was to determine the anesthetic efficacy and heart rate effect of the supplemental intraosseous injection of 4% articaine with 1:100,000 epinephrine in mandibular posterior teeth diagnosed with irreversible pulpitis when the conventional IAN block failed.
Key Words Articaine, intraosseous anesthesia, irreversible pulpitis
From the Section of Endodontics, College of Dentistry, The Ohio State University, Columbus, Ohio. This study was supported by research funding from the Graduate Student Research Fund, Department of Endodontics, The Ohio State University This article was adapted from a thesis submitted by Dr. Jason Bigby in partial fulfillment of the requirements for the MS degree at The Ohio State University. A portion of this article was presented at the 2005 Annual Session of the American Association of Endodontists, Dallas, Texas Address requests for reprints to Dr. Al Reader, Section of Endodontics, College of Dentistry, 305 W. 12th Avenue, The Ohio State University, Columbus, OH 43218. E-mail address: [email protected]. 0099-2399/$0 - see front matter Copyright © 2006 by the American Association of Endodontists. doi:10.1016/j.joen.2006.06.006
1044
Bigby et al.
Materials and Methods Forty-nine initial adult patients participated in this study. All were emergency patients of the College of Dentistry and were in good health as determined by a health history and oral questioning. The Ohio State University Human Subjects Review Committee approved the study and written informed consent was obtained from each patient. To qualify for the study, each patient had a vital mandibular posterior tooth (molar or premolar), was actively experiencing moderate-to-severe pain, and had a prolonged response to cold testing with Endo-Ice (1,1,1,2 tetrafluoroethane; Hygenic Corp., Akron OH). Patients with no response to cold testing or periradicular pathosis (other than a widened periodontal ligament) were excluded from the study. Therefore, each patient had a tooth that fulfilled the criteria for a clinical diagnosis of irreversible pulpitis. All teeth had vital coronal pulpal tissue upon endodontic access. Patients received standard IAN blocks and long buccal injections. All patients recorded profound lip numbness. At 15 minutes after the inferior alveolar nerve block, the teeth were isolated with a rubber dam and access performed. The patients were instructed to definitively rate any discomfort during access using a Heft-Parker visual analogue scale (VAS) (25). The VAS scale was divided into four 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.
JOE — Volume 32, Number 11, November 2006
Clinical Research TABLE 1. Percentages and number of patients who achieved anesthetic success and failure with the supplemental intraosseous injection of 4% articaine with 1:100,000 epinephrine Intraosseous injection
Anesthetic success
Anesthetic failure
86% (32 of 37) (CI ⫽ 71% to 96%)*
14% (5 of 37) (CI ⫽ 4% to 29%)a
n ⫽ 37. a 95% confidence interval.
The 39 patients who had moderate-or-severe pain (VAS rating greater than 54 mm) during access into dentin, when entering the pulp chamber or with initial file placement, received supplemental intraosseous injections using 4% articaine with 1:100,000 epinephrine. The intraosseous injection was administered with the Stabident system (Fairfax Dental Inc., Miami, FL) in the following manner. After rubber dam removal, with the subjects in a reclining position, the area of perforation was determined to be in attached gingiva (just above the junction of the attached gingiva and alveolar mucosa) and at a site distal to the first molar or premolars, or at a mesial site in second molars. The perforator was pushed through the alveolar mucosa until the Stabident tip contacted bone. Holding the drill at a 90-degree angle to the bone, the slow-speed handpiece was activated in a series of short bursts, using light pressure, until a break through feeling was observed or until 2 to 5 seconds had elapsed. The handpiece was always activated while the perforator was within bone to prevent lodging or breakage that might occur if the perforator was allowed to stop rotating. Before inserting the 27-gauge ultrashort Stabident needle, the needle was bent at the hub to a 60- to 80-degree angle to allow for ease of insertion. A standard aspirating syringe was held in a pen-gripping fashion and the needle was inserted into the hole made by the perforator. One and eight tenths milliliter of 4% articaine with 1:100,000 epinephrine (Septocaine, Septodont, New Castle, DE) was deposited over a 1-minute time period. If there was backflow of the anesthetic solution into the oral cavity (two patients), their data was excluded from the study. Therefore, the final number of patients used for data analysis was 37. Before administering the intraosseous injection, the subjects were instructed to rate the pain of perforation and solution deposition using the Heft-Parker VAS. Each subject had his or her pulse rate monitored using a pulse oximeter (Criticare Systems, Inc., Waukesha, WI). The sensor was attached to the nail of the forefinger before administration of any injections. Pulse rate recordings were grouped into three time periods. Period 1 (baseline) readings were recorded at 15-second intervals for 2 minutes before the intraosseous injection. Period 2 readings were recorded at 15second intervals during the 1-minute anesthetic solution deposition. Period 3 readings were recorded at 15-second intervals for 3 minutes after anesthetic solution deposition. Patients were also asked if they noticed an increase in their heart rate after anesthetic solution deposition. After rubber dam placement, endodontic access was continued. The success of the supplemental intraosseous injection was defined as the ability to access the pulp chamber, place initial files and instrument the tooth without pain (VAS score of zero) or mild pain (VAS rating less than or equal to 54 mm). If the patient had moderate-to-severe pain (VAS rating greater than 54 mm) during access or initial instrumentation, the intraosseous injection was judged as a failure and an intrapulpal injection was administered. The total time of instrumentation was recorded in minutes. The data were statistically analyzed. Confidence intervals were calculated for anesthetic success and failure and subjective increase in pulse rate. Bonferroni-adjusted, multiple, Wilcoxon, matched-pairs,
JOE — Volume 32, Number 11, November 2006
signed-ranks tests were used to analyze objective heart rate increase. Comparisons were considered significant if p ⬍ 0.05.
Results Thirty-seven adult patients, 14 men and 23 women, from age 18 to 53 years with an average age of 30 years participated. Fifteen of the mandibular teeth were first molars, 13 were second molars, 4 were second premolars, and 5 were first premolars. Anesthetic success and failure of the intraosseous injection is presented in Table 1. Subjective and objective pulse rate increase is presented in Table 2. Discomfort ratings of intraosseous perforation and solution deposition are presented in Table 3. The total time of instrumentation averaged 35 minutes.
Discussion The success rate of 86% in the current study for the supplemental intraosseous injection of 1.8 ml of 4% articaine with 1:100,000 epinephrine is similar to the success rates of 82% to 91% reported for the supplemental intraosseous injection of 1.8 ml of 2% lidocaine with 1:100,000 epinephrine in the posterior mandible (3, 6, 7). While no other study has compared articaine to lidocaine as a supplemental intraosseous injection in patients with irreversible pulpitis, many studies have compared these two solutions (8 –22). Basically, the authors have found articaine to be a safe and effective local anesthetic agent (8 –22). Repeated clinical trials have failed to detect any superiority of articaine over lidocaine in mandibular anesthesia (5, 14, 15, 21, 22). Infiltration anesthesia in the maxilla has shown an equivalent effect for articaine and prilocaine/lidocaine (15–20) except for one recent study by Costa et al. (23), which showed a TABLE 2. Subjective and objective increases in heart rate (pulse rate). Subjective Increase Number/Percentage Confidence interval Subjective increase Yes No
Objective Increase Injection phase Baseline Solution depositionc 1-Minute postdepositionc 3-Minutes postdepositionc Maximum heart ratec Mean maximum increase
30 (81%) 7 (19%)
Meanb
(CI ⫽ 64% to 91%)a (CI ⫽ 9% to 37%)a
Minimum Maximum
70 (⫾11.5) 86 (⫾24.0)
47.5 53.5
90.6 212.0
91 (⫾18.6)
66.3
152.0
83 (⫾14.6)
62.8
137.3
102 (⫾23.1)
66.3
212.0
32 beats/minute
n ⫽ 37. a 95% confidence interval. b Standard deviation. c Significantly different from baseline (p ⬍ 0.05).
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Clinical Research TABLE 3. Discomfort ratings for patients receiving the intraosseous injection of 4% articaine with 1:100,000 epinephrine Phase
None (0 mm)
Mild (1–54 mm)
Moderate (55–113 mm)
Severe (114 or greater)a
Perforation Solution deposition
32% (12/37) 16% (6/37)
51% (19/37) 62% (23/37)
11% (4/37) 14% (5/37)
5% (2/37) 8% (3/37)
n ⫽ 37. a Heft Parker VAS Ratings.
prolonged duration with articaine. A recent study by Kanaa et al. (26) found 4% articaine with 1:100,000 epinephrine was significantly better than 2% lidocaine with 1:100,000 epinephrine for buccal infiltration of the mandibular first molar. However, the anesthetic success rate was only 64% for the articaine solution that would not provide predictable pulpal anesthesia for all patients requiring profound anesthesia. The perceived subjective increase (in response to questioning) in pulse rate of 81% and the mean maximum objective pulse rate increase of 32 beats/minute (Table 2) using 4% articaine with 1:100,000 epinephrine were similar to other studies of intraosseous anesthesia (27– 31). Because the concentration of epinephrine with articaine was identical to that used in other studies, we would expect an increase in pulse rate that was comparable. One patient had a maximum pulse rate of 212 beats per minute, which was 77 beats higher than the maximum for any other patient. While not significant in a healthy individual (27), the maximum pulse rate could be significant in a medically compromised individual. The use of 3% mepivacaine would be a prudent choice for these individuals (27). In the current study, 16% of the patients reported moderate-tosevere pain on perforation (Table 3). Solution deposition pain resulted in 22% reporting moderate-to-severe pain (Table 3). Reisman et al. (2) found a 9% incidence and Nusstein et al. (3) a 0% incidence of moderate-to-severe perforation pain, using the Stabident system, in mandibular posterior teeth in patients with irreversible pulpitis. In the current study, pain upon perforation only lasted a few seconds and usually occurred upon entering the cancellous bone. In a similar group of patients with irreversible pulpitis, solution deposition pain has been reported by Nusstein et al. (3) as 5% using 1.8 ml of 2% lidocaine with 1:100,000 epinephrine. Reisman et al. (2) reported a 31% incidence of moderate-to-severe deposition pain using 3% mepivacaine. In the current study, solution deposition pain usually occurred during the initial deposition of solution and lasted a few seconds. None of the patients withdrew from the study because of pain with perforation or solution deposition. In summary, the use of intraosseous anesthesia may result in some reports of moderate-to-severe pain in patients with irreversible pulpitis. The onset of anesthesia was immediate for those patients receiving successful intraosseous injections. That is, endodontic access was begun as soon as the rubber dam was replaced and the patients experienced none or mild pain upon endodontic treatment. The duration of anesthesia was maintained for the duration of the emergency endodontic treatment for those patients receiving successful intraosseous injections. The length of time for complete endodontic debridement averaged 35 minutes. Therefore, the intraosseous technique, when successful, provided adequate anesthesia for the debridement appointment. Generally, we can conclude that when the inferior alveolar nerve block fails to provide profound pulpal anesthesia, the intraosseous injection of 4% articaine with 1:100,000 epinephrine would be successful 86% of the time in achieving pulpal anesthesia in mandibular posterior teeth of patients presenting with irreversible pulpitis. 1046
Bigby et al.
References 1. Cohen HP, Cha BY, Spangberg LSW. Endodontic anesthesia in mandibular molars: a clinical study. J Endod 1993;19:370 –3. 2. Reisman D, Reader A, Nist R, Beck M, Weaver J. Anesthetic efficacy of the supplemental intraosseous injection of 3% mepivacaine in irreversible pulpitis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;84:676 – 82. 3. Nusstein J, Reader A, Nist R, Beck M, Meyers WJ. Anesthetic efficacy of the supplemental intraosseous injection of 2% lidocaine with 1:100,000 epinephrine in irreversible pulpitis. J Endod 1998;24:487–91. 4. Kennedy S, Reader A, Nusstein J, Beck M, Weaver J. The significance of needle deflection in success of the inferior alveolar nerve block in patients with irreversible pulpitis. J Endod 2003;29:630 –3. 5. Claffey E, Reader A, Nusstein J, Beck M, Weaver J. Anesthetic efficacy of articaine for inferior alveolar nerve blocks in patients with irreversible pulpitis. J Endod 2004;30:568 –71. 6. Nusstein J, Kennedy S, Reader A, Beck M, Weaver J. Anesthetic efficacy of the supplemental X-tip intraosseous injection in patients with irreversible pulpitis. J Endod 2003;29:724 – 8. 7. Parente SA, Anderson RW, Herman WW, Kimbrough WF, Weller RN. Anesthetic efficacy of the supplemental intraosseous injection for teeth with irreversible pulpitis. J Endod 1998;24:826 – 8. 8. Malamed SF, Gagnon S, LeBlanc D. Articaine hydrochloride: a study of the safety of a new amide local anesthetic. J Am Dent Assoc 2001;132:177– 85. 9. van Oss GE, Vree TB, Baars AM, Termond EF, Booij LH. Pharmacokinetics, metabolism, and renal excretion of articaine and its metabolite articainic acid in patients after epidural administration. Eur J Anaesthesiol 1989;6:49 –56. 10. Oertel R, Rahn R, Kirch W. Clinical pharmacokinetics of articaine. Clin Pharmacokinet 1997;33:417–25. 11. Wright GZ, Weinberger SJ, Friedman CS, Plotzke OB. The use of articaine local anesthesia in children under 4 years of age: a retrospective report. Anesth Prog 1989;36:268 –71. 12. Oertel R, Ebert U, Rahn R, Kirch W. The effect of age on pharmacokinetics of the local anesthetic drug articaine. Reg Anesth Pain Med 1999;24:524 – 8. 13. Malamed SF, Gagnon S, Leblanc, D. A comparison between articaine HCl and lidocaine HCl in pediatric dental patients. Pediatr Dent 2000;22:307–11. 14. Malamed SF, Gagnon S, Leblanc D. Efficacy of articaine: a new amide local anesthetic. J Am Dent Assoc 2000;131:635– 42. 15. Donaldson D, James-Perdok L, Craig BJ, Derkson GD, Richardson AS. A comparison of Ultracaine DS (articaine HCl) and Citanest forte (prilocaine HCl) in maxillary infiltration and mandibular nerve block. J Can Dent Assoc 1987;53:38 – 42. 16. Haas DA, Harper DG, Saso MA, Young ER. Comparison of articaine and prilocaine anesthesia by infiltration in maxillary and mandibular arches. Anesth Prog 1990;37:230 –7. 17. Haas DA, Harper DG, Saso MA, Young ER. Lack of differential effect by Ultracaine (articaine) and Citanest (prilocaine) in infiltration anaesthesia. J Can Dent Assoc 1991;57:217–23. 18. Wright GZ, Weinberger SJ, Marti R, Plotzke O. The effectiveness of infiltration anesthesia in the mandibular primary molar region. Pediatr Dent 1991;13:278 – 83. 19. Vahatalo K, Antila H, Lehtinen R. Articaine and lidocaine for maxillary infiltration anesthesia. Anesth Prog 1993;40:114 – 6. 20. Oliveria PC, Volpato MC, Ramacciato JC, Ranali J. Articaine and lignocaine in infiltration anaesthesia: a pilot study. Br Dent J 2004;197:45– 6. 21. Berlin J, Nusstein J, Reader A, Beck M, Weaver J. Efficacy of articaine and lidocaine in a primary intraligamentary injection administered with a computer-controlled local anesthetic delivery system. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;99:361– 6. 22. Mikesell P, Nusstein J, Reader A, Beck M, Weaver J. A comparison of articaine and lidocaine for inferior alveolar nerve blocks. J Endod 2005;31:265–70. 23. Costa CG, Tortamano IP, Rocha RG, Francishone CE, Tortamano N. Onset and duration periods of articaine and lidocaine on maxillary infiltration. Quintessence Int 2005;36:197–201. 24. Schertzer ER, Malamed SF. Articaine vs. lidocaine. J Am Dent Assoc 2000;131:1248, 1250.
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Clinical Research 25. Heft MW, Parker SR. An experimental basis for revising the graphic rating scale for pain. Pain 1984;19:153– 61. 26. Kannaa MD, Whitworth JM, Corbett IP, Meechan JG. Articaine and lidocaine mandibular buccal infiltration anesthesia: a prospective randomized double-blind crossover study. J Endod 2006;32:296 – 8. 27. Replogle K, Reader A, Nist R, Beck M, Weaver J, Meyers W. Cardiovascular effects of intraosseous injections of 2 percent lidocaine with 1:100,000 epinephrine and 3 percent mepivacaine. J Am Dent Assoc 1999;130:649 –57. 28. Chamberlain TM, Davis RD, Murchison DF, Hansen SR, Richardson BW. Systemic effects of an intraosseous injection of 2% lidocaine with 1:100,000 epinephrine. Gen Dent 2000;May-June:299 –302.
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29. Guglielmo A, Reader A, Nist R, Beck M, Weaver J. 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. 30. Stabile P, Reader A, Gallatin E, Beck M, Weaver J. 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. 31. Wood M, Reader A, Nusstein JM, Beck M, Padgett D, Weaver J. Comparison of intraosseous and infiltration injections for venous lidocaine blood concentrations and heart rate changes after injection of 2% lidocaine with 1:100,000 epinephrine. J Endod 2005;31:435– 8.
Articaine for Supplemental Intraosseous Anesthesia
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