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Title Supplemental Intraosseous Anesthesia Improves the Success Rate of Inferior Alveolar Nerve Blocks in Molars with Irreversible Pulpitis.
Clinical Question In patients receiving treatment for irreversible pulpitis of mandibular molars, does the supplemental intraosseous anesthesia provide a superior clinical success rate compared to an inferior alveolar nerve block alone?
Clinical Bottom Line In cases with patients being treated for irreversible pulpitis, a supplemental delivery of local anesthetic by means of intraosseous injection following an initial inferior alveolar nerve block aids in achieving successful pain free treatment.
Best Evidence (you may view more info by clicking on the PubMed ID link)
PubMed ID Author / Year Patient Group Study type
(level of evidence)
#1) 22414822Kanaa/2012182 patients (73.1% male, 26.9% female) with average age of 31.9 with cases of irreversible pulpitis.Randomized Controlled Trial
Key resultsA significant difference was found in the success of treatment of mandibular molars diagnosed with irreversible pulpitis after 4 supplementary injection techniques: repeated inferior alveolar nerve block (rIANB), articaine buccal infiltration (ABI), intraligamentary injection (PDL), or intraosseous injection (IO); (χ2, P=.001). Success rates were greater with the use of ABI (84%) & IO (68%) compared to PDL injections (48%) or rIANB (32%).
#2) 22506833Zarei/201240 patients (22 female, 18 male) with irreversible pulpitisRandomized Controlled Trial
Key resultsForty patients who experienced a failed inferior alveolar nerve block were divided into 2 groups to receive supplemental anesthesia with an intraossesous or intraligamentary (PDL) injection. Pain levels using the VAS score were recorded before and after supplemental anesthesia was given. After the first injections, the use of the X-tip intraosseous injection (IO) provided 100% (n=20) success in pulpal anesthesia compared to the use of a PDL injection, which recorded a 70% (n=14) success rate. These findings were statistically significant (Mann-Whitney U-test, p=0.02).
#3) 14651278Nusstein/200333 adult patients (16 male, 17 female) with irreversible pulpitis of mandibular posterior teeth.Case Series
Key resultsPatients who received a supplemental intraosseous injection after a failed inferior alveolar nerve block were found to have an anesthetic success rate of 82% (27 of 33, 95% confidence interval = 65-93%). Pain levels were recorded using Heft-Parker VAS scores prior to supplemental injection and throughout the procedure. A successful treatment was defined with a VAS score of less than or equal to 54. VAS score of zero correlates to no pain, where mild pain is defined by a VAS score less than or equal to 54. No statistics for significance were reported.
#4) 22414822Verma/201330 patients (16 male, 14 female) diagnosed with irreversible pulpitis of mandibular posterior teeth.Case Series
Key resultsPatients who received an inferior alveolar nerve block and experienced moderate to severe pain during endodontic treatment were given supplemental intraosseous (IO) anesthesia. A success rate of 93% was recorded for patients receiving supplemental IO anesthesia (n=28, 95% confidence interval = 77-98%, Z value = 4.55, P<0.001). “Z test for single proportion was used for anesthetic success and failure and confidence interval was calculated by the Wilson method.”
Evidence Search intraosseous[All Fields] AND ("anaesthesia"[All Fields] OR "anesthesia"[MeSH Terms] OR "anesthesia"[All Fields]) ; supplemental[All Fields] AND intraosseous[All Fields] AND ("anaesthesia"[All Fields] OR "anesthesia"[MeSH Terms] OR "anesthesia"[All Fields])
Comments on
The Evidence
Validity: The sample sizes of the listed studies were relatively small, but each study was well-designed. The studies had a greater than 80% completion rate. Patients were enrolled in the study following a strict inclusion criteria that included diagnosis of irreversible pulpitis. The dichotomous outcome for successful anesthesia (yes or no) was recorded blinded to the treatment provided when applicable. Perspective: Intraosseous inject of local anesthetics should be considered as a supplemental anesthesia for patients being endodontically treated for irreversible pulpitis in a mandibular molar. Research has proven that supplemental intraosseous anesthesia provides a successful means to achieve pulpal anesthesia when inferior alveolar nerve blocks fail. However, the health care provider must be trained and familiarized with technique since damage to the bone and surrounding structures could happen if the correct technique is not used.
Applicability This information is greatly beneficial to practitioners performing endodontic procedures and reviewing different anesthetic techniques in cases involving molars with irreversible pulpitis.
Specialty/Discipline (Endodontics) (General Dentistry)
Keywords Intraosseous; inferior alveolar nerve; anesthesia; molars; irreversible pulpitis
ID# 2689
Date of submission: 03/24/2014spacer
E-mail thayer@livemail.uthscsa.edu
Author Scott Thayer
Co-author(s) e-mail
Faculty mentor/Co-author Anibal Diogenes, DDS, PhD
Faculty mentor/Co-author e-mail diogenes@uthscsa.edu
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