Effectiveness and Safety of Computer-controlled Periodontal Ligament Injection System in Endodontic Access to the Mandibular Posterior Teeth

Chin Med Sci J March 2014

Vol. 29, No. 1 P. 23-27

CHINESE MEDICAL SCIENCES JOURNAL ORIGINAL ARTICLE

Effectiveness and Safety of Computer-controlled Periodontal Ligament Injection System in Endodontic Access to the Mandibular Posterior Teeth Quan Jing1, Kuo Wan1*, Xiao-jun Wang2, and Lin Ma1 1

Department of Dentistry, 2Department of Plastic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China

Key words: periodontal ligament injection; endodontic access; irreversible pulpitis Objective To evaluate the effectiveness and safety of a computer-controlled periodontal ligament (PDL) injection system to the local soft tissues as the primary technique in endodontic access to mandibular posterior teeth in patients with irreversible pulpitis. Methods A total of 162 Chinese patients who had been diagnosed with irreversible pulpitis in their mandibular posterior teeth without acute infection or inflammation in the periodontal tissues were enrolled in this clinical study. The patients were divided into 3 groups according to the position of the involved tooth: the premolar group (PM, n=38), first molar group (FM, n=66), and second molar group (SM, n=58). All the patients received computer-controlled PDL injection with 4% articaine and 1∶100 000 epinephrine. Immediately after the injection, endodontic access was performed, and the degree of pain during the treatment was evaluated by the patients using Visual Analogue Scale for pain. The success rates were compared among the 3 groups. The responses of local soft tissues were evaluated 3-8 days and 3 weeks after the procedure. Results The overall success rate was 76.5%. There was a significant difference in success rates among the PM, FM, and SM groups (92.1%, 53.0%, 93.1%, respectively; χ2=34.3, P<0.01). Both the PM and SM groups showed higher success rates than that of the FM group (v=1, χ2=16.73, P<0.01; v=1, χ2=24.5, P<0.01). No irreversible adverse effects on the periodontal soft tissues at the injection sites were observed in the follow-up visits in any of the groups. Conclusion The computer-controlled PDL injection system demonstrates both satisfactory anesthetic effects and safety in local soft tissues as primary anesthetic technique in endodontic access to the mandibular posterior teeth in patients with irreversible pulpitis.

Chin Med Sci J 2014; 29(1):23-27 Received for publication August 9, 2013. *Corresponding author Tel: 86-10-69155256, E-mail: [email protected]

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CHINESE MEDICAL SCIENCES JOURNAL

I

March 2014

RREVERSIBLE pulpitis could be caused by caries,

Department of Dentistry, Peking Union Medical College

non-caries lesions, and combined periodontal-pulpal

Hospital from August 2010 to August 2012. The study

lesions. The clinical strategy of treating irreversible

protocol was approved by the Institutional Review Board of

pulpitis is mainly pulp extirpation. Because the

the Hospital and signed informed consents were obtained

dental nerve is still sensitive to mechanical or thermal

from the selected patients.

stimulation at this stage, it is necessary to adopt local

All the included patients had been clinically diagnosed

anesthesia during endodontic access. The most common

as irreversible pulpitis in mandibular premolars or 1st/2nd

method in treating mandibular molars is inferior alveolar

molars. The exclusion criteria were: American Society of

nerve block (IANB), but there are some inherent drawbacks in

Anesthesiologists (ASA) physical status classification >2;

IANB due to multiple factors.

1-3

abnormal perception or cognition; severe dental phobia;

The periodontal ligament (PDL) injection as a local

acute periodontal infection or inflammation (or tooth

anesthetic technique was developed a century ago.4 The

movement >2˚) in the affected teeth; analgesics taken

mechanism used in this technique is similar to that in

within 12 hours; previous mandibular operations; severe

intraosseous anesthesia:5 (1) the anesthetic solution is

traumas or bone lesions; trigeminal nerve abnormalities

forced through the cribriform plate into the marrow spaces

and previous adverse reactions to amides of local

and

the vasculature in and around the tooth; (2) the

anesthetic agents. The patients were then trained to grade

primary route is not the periodontal ligament;6,7 and (3)

the intensity of pain with the Visual Analogue Scale (VAS):

the mechanism of the action is not related to the direct

from 0 meaning no pain to 10 meaning the worst pain.

pressure on the nerves.8 Due to the difficulties in sensing the “back-pressure” to ensure that the needle is inside the

Computer-controlled PDL injection

PDL and maintaining adequate pressure (the pressure

A radiographic assessment of the affected tooth was

needed in PDL injection may be 4-5 times of that in palatal

performed. The periodontal condition of the injection site,

injections9), the application of PDL injection is still confined

described as modified gingival index, was evaluated by a

10,11

With the

periodontist to exclude any acute inflammation or ulceration

introduction of computer-controlled local anesthetic delivery

and recorded as the baseline. Large pieces of plaque and

(C-CLAD) systems in the 1980s, the success rate of PDL

calculus were removed manually. The tooth was then

injection as a primary anesthetic technique in mandibular

anesthetized using a C-CLAD system (Single Tooth

teeth was improved, yet still lower than that of IANB.12

Anesthesia, STA, Milestone Scientific, Livingston, NJ, USA)

When it was used as a supplemental anesthetic method

with PDL injection. A 30-gauge needle was inserted at the

when IANB failed, the success rate was 56%.13 In 2006, the

site, the STA was set in the “ControlFlo” mode (1 ml/207

newly developed C-CLAD system offered continuous and

seconds), and the needle penetrated the periodontal

real-time identification of tissues with different densities

ligament slowly. After the yellow light was up on the front

(e.g. free gingiva, attached gingiva, and periodontal

panel, 0.5 ml of 4% articaine with 1∶100 000 epinephrine

ligament) and presented feedback to the operator once it

(Primacaine Adrenaline, Pierre Rolland, France) was

was brought into dental procedures. Owing to its multiple

injected. The injection was terminated when the pressure

improvements

reached the preset limit in the device. Two sites of injection,

to supplemental anesthesia in recent years.

in

design,

this

device

provides

the

possibility of applying PDL injection as a primary anesthetic

one disto-lingual and the other mesio-buccal, were

technique.14 Up to now, however, there have been few

selected for each tooth. Two minutes after the injection,

studies on the evaluation of this device in terms of its

decay removal and pulp access was initiated. The patients

efficacy and safety.

were informed that if the pain during the procedure was ≥

This study aimed to assess the effectiveness and safety

5 in the VAS, or if they were unable to complete the

of PDL injection delivered by the C-CLAD system, which

procedure and required a supplemental injection to achieve

was employed as the primary technique for endodontic

profound anesthesia, they should let the dentist know

access to mandibular posterior teeth in patients with

immediately to stop the procedure, which would be

irreversible pulpitis.

recorded as failures. If the pain was rated < 5 during the entire process, the cases were recorded as successes. All

PATIENTS AND METHODS Patients This clinical study was carried out in outpatients at the

the teeth were divided into 3 groups: premolar group (PM), first molar group (FM), and second molar group (SM). Local soft tissue changes after injection at the injection sites, such as acute inflammation, erosion, ulceration, and

Vol. 29, No.1

CHINESE MEDICAL SCIENCES JOURNAL

25

localized gingival necrosis were evaluated and compared with the baseline data by the same periodontist afte 3-8 days and 3 weeks. Statistical analysis SPSS 11.0 software was used to analyze the data. The success rates of the 3 groups of teeth were compared using Chi-square test. P<0.01 was considered statistically significant. Figure 1. A case with type 2 diabetes developed localized gingival necrosis after PDL injection.

RESULTS

A. The color of interdental papilla between second premolar

A total of 162 patients aged 18-51 years were enrolled in the present study. The overall success rate was 76.5% (124/162). Success rates in the three groups (PM, FM, and SM) are displayed in Table 1. There were significant differences in success rates amongst the 3 groups (v=2, χ2=34.3, P<0.01). Both the PM group and SM group

and first molar turned gray-white 3 days after injection. Localized gingival necrosis was diagnosed; B. The necrotic gingiva healed completely 3 weeks later after surgical debridement and chlorhexidine mouthwash.

DISCUSSION

showed higher success rates than that in the FM group

The traditional method for anesthesia in the mandibular

(v=1, χ2=16.73, P<0.01; v=1, χ2=24.5, P<0.01), while no

posterior teeth is IANB, which has been widely used as a

significant difference in success rate was observed

primary technique. Due to various reasons, for instance,

between the PM group and the SM group (v =1, χ2=0.05,

the anatomical variations of the mandibular nerve and the

P>0.01).

inferior alveolar nerve, the presence of infection, inflammation,

The post-injection adverse reactions were shown in

previous trauma or operations, pharmacological or psychological

Table 2. Six patients (3.7%) exhibited localized gingival

factors, and poor technique, the success rate of IANB is no

necrosis, of which 3 had controlled type 2 diabetes. After

higher than 80%.15 There are also some complications

careful surgical debridement and application with 0.12%

related to this technique, including a relatively high risk of

chlorhexidine mouthwash, all the lesions completely

intravascular injection (10%-15%),2 which may result in

recovered after 3 weeks (Fig. 1). There was no irreversible

series of adverse reactions. The technique of IANB involves

damage on the local periodontal tissues compared with the

obvious injection pain and discomfort;16 post-injection soft

baseline condition after 3 weeks.

tissue tingling or numbness may involve a large area, which could last for hours and cause changes of soft tissue

Table 1. General conditions and success rates of periodontal

contour, even self-biting wounds. In some rare cases,

ligament (PDL) injection in three groups

hematoma, trismus, facial nerve anesthesia or even neuro-

Groups

Success

Success rate

PM (n=38)

35

92.1%

FM (n=66)

35

53.0%

SM (n=58)

54

93.1%

124

76.5%

Total (n=162)

sensory disturbance could occur.2,17 These complications greatly limit the application of this technique, especially in some medically compromised patients. It is also difficult for beginners to well handle this technique. The overall success rate of PDL injection in this study was close to that of IANB (76.5% vs. 80%), and for premolars and the second molars, the success rate of PDL

PM: premolar; FM: first molar; SM: second molar.

injection was even higher (both over 90%). Different Table 2. Post-injection adverse reactions at the injection site Adverse reactions

success rates of PDL injections have been reported with different tooth positions.18,19 The results of this study indicated that PDL injection has better anesthetic effect

Number

Percentage

29

17.9%

molars than in the first molars (92.1% vs. 53.0%, 93.1%

14

8.6%

vs. 53.0%, respectively). The success rates showed such

6

3.7%

Acute periodontal inflammation Ulceration or erosion Localized gingival necrosis

when applying in the mandibular premolars and the second

teeth position-related difference possibly because of the

The adverse reactions were evaluated by the same periodontist 3-8

difference in the width of periodontal ligament, thickness

days and 3 weeks after PDL injection.

and density of the bone, and number of the roots of

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CHINESE MEDICAL SCIENCES JOURNAL

different teeth in mandible. All these factors may affect the depth of the needle tip that could be inserted into the

March 2014

15:247-51. 2.

Rood JP. Some anatomical and physiological causes of

periodontal ligament and the extent that anesthetic

failure to achieve mandibular analgesia. Br J Oral Surg

solution could spread in the cancellous bones, which needs

1977; 15:75-82.

to be confirmed by further studies. In irreversible pulpitis,

3.

Wallace JA, Michanowicz AE, Mundell RD, et al. A pilot

the teeth may have necrotic pulp chambers, but there are

study of the clinical problem of regionally anesthetizing

root canals with vital or inflammatory nerves. Thus, an

the pulp of an acutely inflamed mandibular molar. Oral

electric pulp tester might yield a false result,

20

which

explains why we used subjective rating of pain by the

Surg Oral Med Oral Pathol 1985; 59:517-21. 4.

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Malamed S. Handbook of Local Anesthesia. 5th ed. St. Louis: Mosby; 2004. p. 255, 228-229, 258.

Clinical and animal studies have demonstrated the

5.

Shepherd PA, Eleazer PD, Clark SJ, et al. Measurement of

safety of PDL injections,21-23 and minor local damage is

intraosseous

limited to the site of needle penetration, thus the adverse

high-pressure periodontal ligament syringe, and the

effects of injecting into an area with periodontal disease are impossible.24 The newly developed STA delivery system

pressures

generated

by

the

Wand,

Stabident system. J Endod 2001; 27:381-4. 6.

Walton RE. Distribution of solutions with the periodontal

has built-in dynamic pressure-sensing technology to limit

ligament injection: clinical, anatomical, and histological

the maximum pressure used, which greatly enhances the

evidence. J Endod 1986; 12:492-500.

safety to the periodontium. In the present study, within the

7.

3-8 days following the injection, the most frequent adverse effect was acute periodontal inflammation, and a few

benefits and limitations. Quintessence Int 2008; 39:e15-25. 8.

patients developed ulcerations or erosions at the injection

Tagger E, Tagger M, Sarnat H, et al. Periodontal ligament injection in the dog primary dentition: spread of local

sites. These adverse effects have also been frequently reported in previous studies.18, 25 Only six patients experienced

Endo T, Gabka J, Taubenheim L. Intraligamentary anesthesia:

anaesthetic solution. Int J Paediatr Dent 1994; 4:159-66. 9.

Hochman MN, Friedman MJ, Williams W, et al. Interstitial

localized gingival necrosis, and diabetes may pose a

tissue pressure associated with dental injections: a

potential risk to the development of this adverse effect.

clinical study. Quintessence Int 2006; 37:469-76.

Although localized gingival necrosis should be considered a serious

complication,

early

detection

and

10.

Fan S, Chen WL, Pan CB, et al. Anesthetic efficacy of

timely

inferior alveolar nerve block plus buccal infiltration or

management would produce a good result. Compared with

periodontal ligament injections with articaine in patients

the baseline modified gingival index, no irreversible

with irreversible pulpitis in the mandibular first molar.

periodontal damage was detected after 3 weeks, which

Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;

showed a long-term safety of STA system for soft tissue.

108:e89-93.

The safety to periodontal hard tissue, i.e. the alveolar bone,

11.

was not tested in this study.

Kanaa MD, Whitworth JM, Meechan JG. A prospective randomized

trial

of

different

supplementary

local

There are some limitations in this study: a control

anesthetic techniques after failure of inferior alveolar

group of IANB or a group of manually delivered PDL

nerve block in patients with irreversible pulpitis in

injection was not included; it is necessary to involve more

mandibular teeth. J Endod 2012; 38:421-5.

evaluation indicators about the safety for periodontal hard

12.

tissues as well as the soft tissues.

therapy: an alternative to inferior alveolar nerve block.

In conclusion, according to the results of this study, the success rate of PDL injections delivered by the C-CLAD STA

Oztaş N, Ulusu T, Bodur H, et al. The wand in pulp Quintessence Int 2005; 36:559-64.

13.

Nusstein J, Claffey E, Reader A, et al. Anesthetic effectiveness

system in endodontic access to mandibular posterior teeth

of the supplemental intraligamentary injection, administered

with irreversible pulpitis is comparable to the conventional

with a computer-controlled local anesthetic delivery system,

IANB technique. The success rate varies with teeth

in patients with irreversible pulpitis. J Endod 2005; 31:

positions. The computer-controlled PDL injection causes no

354-8.

irreversible injuries to local soft tissues.

14.

Hochman MN. Single-tooth anesthesia: pressure-sensing technology provides innovative advancement in the field of dental local anesthesia. Compend Contin Educ Dent

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