Title Preemptive Nonsteroidal Anti-Inflammatory Drugs May Increase the Success Rate of Inferior Alveolar Nerve Blocks in Mandibular Posterior Teeth with Symptomatic Irreversible Pulpitis
Clinical Question In mandibular posterior teeth with symptomatic irreversible pulpitis, does a preemptive dose of an oral nonsteroidal anti-inflammatory drug (NSAID) increase the success rate of an inferior alveolar nerve block (IANB) compared to placebo?
Clinical Bottom Line For patients with irreversible pulpitis in a mandibular posterior tooth, a single preemptive dose of NSAID may increase the success of IANB compared to placebo. This is supported by a meta-analysis of seven clinical trials in addition to a double-blind randomized clinical trial. This treatment intervention is simple for clinicians to implement and safe for many patients with no contraindication for NSAID use.
Best Evidence  
PubMed ID Author / Year Patient Group Study type
(level of evidence)
22299121Li/2012Patients (18-65 yrs old) diagnosed with a mandibular posterior tooth with irreversible pulpitisMeta-Analysis
Key resultsPreemptive ibuprofen dosages 600 to 800 mg showed a significant increase in IANB success rate (relative risk [RR], 1.52; 95% CI 1.17-1.98; P=0.002). Other oral NSAIDs such as indomethacin, Iornoxicam, and diclofenac were tested and showed similar success; however, combinations of these with acetaminophen as well as acetaminophen alone did not show statistically significant success over placebo.
23716973Jena/2013Patients (> 18 yrs old) diagnosed with a mandibular posterior tooth with irreversible pulpitisRandomized Controlled Trial
Key resultsPreemptive ibuprofen dose of 600 mg showed a IANB success rate of 55% (95% CI: 20.9%-71.69%; P=0.866); etodolac 400 mg + paracetamol 500 mg success rate of 50% (95% CI: 22.58%-70.41%; P= 0.871), whereas ketorolac dosage of 10 mg produced a success rate of 70% (95% CI: 5.79%-49.6%; P=0.229). Lastly, acelofenac 100 mg + paracetamol 500 mg was shown to be 55% successful (95% CI: 15.49%-64.2%; P=0.650). There were no statistically significant differences between any of the preemptive NSAIDs combinations and the placebo group (success rate 40%; 95% CI: 36.4%-88.26%).
Evidence Search (preoperative[All Fields] AND ("analgesics"[Pharmacological Action] OR "analgesics"[MeSH Terms] OR "analgesics"[All Fields] OR "analgesic"[All Fields])) AND (("mandibular nerve"[MeSH Terms] OR ("mandibular"[All Fields] AND "nerve"[All Fields]) OR "mandibular nerve"[All Fields] OR ("inferior"[All Fields] AND "alveolar"[All Fields] AND "nerve"[All Fields]) OR "inferior alveolar nerve"[All Fields]) AND block[All Fields])
Comments on
The Evidence
The meta-analysis included seven randomized clinical trials ranging from 40 to 150 patients. Each study type varied slightly in design. Several studies contained multiple intervention groups with relatively small sample sizes, resulting in statistically insignificant results within each study. However, the use of preemptive NSAIDs was found to provide a statistically significant higher anesthesia success when the data from the included studies were analyzed collectively. The study by Jena and Shashireka (2013), which was not included in the meta-analysis, highlights the need for larger sample sizes in these studies, since a difference of over 75% between the preemptive NSAID (ketorolac) and the placebo groups was found not to be significant due to the inherent variability normally found in clinical trials. Thus, studies with larger sample sizes, perhaps from multicenter clinical trials, are needed to increase the confidence of these findings.
Applicability The diagnosis of symptomatic irreversible pulpitis in a mandibular posterior tooth is a common presentation in many dental settings. Due to the difficulty in anesthetizing these teeth, clinicians and patients alike would benefit from a treatment modality to increase the IANB success rate. Preemptive NSAIDs, especially over-the-counter medications, are inexpensive, easy to administer orally, and are tolerated well by many patients. Lastly, patients without contraindication to NSAIDs use will likely be in a postoperative regimen with this drug class. Therefore preemptive medication with NSAIDs ensures analgesic coverage for when the anesthesia wears off in addition to the possible increase in adequate anesthesia success.
Specialty (Endodontics) (General Dentistry)
Keywords Preemptive analgesic, symptomatic irreversible pulpitits, mandibular posterior tooth, inferior alveolar nerve block
ID# 2807
Date of submission 02/25/2015
E-mail middletong@livemail.uthscsa.edu
Author Gary Middleton
Co-author(s) e-mail
Faculty mentor Anibal Diogenes, DDS, MS, PhD
Faculty mentor e-mail DIOGENES@uthscsa.edu
Basic Science Rationale
(Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?)
None available
Comments and Evidence-Based Updates on the CAT
None available