efficacy of dental local anaesthesia in mandibular teeth: current views dds, mphil, phd specialty...

Efficacy Of Dental Local Anaesthesia In Mandibular Teeth: Current Views

DDS, MPhil, PhDSpecialty Doctor OMFS: Kettering General Hospital

PhD Clinical Research ProjectNewcastle University, UK

Dr Mohammad Dib KanaaDr Mohammad Dib Kanaa

O M I C SO M I C SDubai 2015Dubai 2015

Support and Sponsorship: Support and Sponsorship: •Kettering General HospitalKettering General Hospital•SASSAS•OMICSOMICS

Introduction ““Anaesthesia is the art or science of Anaesthesia is the art or science of

removing sensation of and reaction removing sensation of and reaction

to a surgical procedure. to a surgical procedure.

Anaesthesia means loss of all forms Anaesthesia means loss of all forms

of sensation whether it is the sense of sensation whether it is the sense

of pain, touch, temperature or of pain, touch, temperature or

position sense”position sense”

(Healy and Pollard, 1999)


IntroductionIntroduction Local anaesthesia is the method of choice for pain control during Local anaesthesia is the method of choice for pain control during

operative dental treatment;operative dental treatment; It was reported that half of the local anaesthetic injections in the It was reported that half of the local anaesthetic injections in the

United States each year were IANB injections;United States each year were IANB injections;

IANB is reported to be successful in 85-95% of casesIANB is reported to be successful in 85-95% of cases (100,000 -(100,000 -300,000 of injections were failure)300,000 of injections were failure); ;

The success rate of mandibular anaesthesia with IANB extremely The success rate of mandibular anaesthesia with IANB extremely varied in the literature, it ranged between 30% to 97%.varied in the literature, it ranged between 30% to 97%.

IANB injection alone does not secure satisfactory pain free IANB injection alone does not secure satisfactory pain free treatment.treatment.

(Montagnese (Montagnese et alet al., 1984; Donkor ., 1984; Donkor et alet al., 1990; Nist ., 1990; Nist et alet al., 1992; Wong & Jacobsen 1992; ., 1992; Wong & Jacobsen 1992; McLean McLean et alet al., 1993; Bou Dagher ., 1993; Bou Dagher et alet al., 1997; Yared and Bou Dagher, 1997; Hannan ., 1997; Yared and Bou Dagher, 1997; Hannan et alet al., ., 1999; Yonchak 1999; Yonchak et alet al., 2001; ., 2001; Kaiser & Hargreaves, 2002; Kanaa et al., 2006; Whitworth et al., Kaiser & Hargreaves, 2002; Kanaa et al., 2006; Whitworth et al., 2007; Corbett et al., 2008; Kanaa et al., 2009; Kanaa et al., 2012., Gazal et al., 2015)2007; Corbett et al., 2008; Kanaa et al., 2009; Kanaa et al., 2012., Gazal et al., 2015)


IntroductionIntroductionRelevant variables of IANB failure:Relevant variables of IANB failure:

Obese; those with large and laterally flaring mandibles; Obese; those with large and laterally flaring mandibles;

Very anxious; Very anxious;

Edentulous patients;Edentulous patients;(Wong and Jacobsen, 1992)(Wong and Jacobsen, 1992)


Causes of LA failure

AnatomicalAnatomical

PathologicalPathological

PharmaceuticalPharmaceutical

PharmacologicalPharmacological

PsychologicalPsychological

TechnicalTechnical

(Haas et al., 1990; Reisman et al., Wong & Jacobsen 1992; 1997; Nusstein et al., 1998; Yonchak et al., 2001; Meechan & Ledvinka, 2002; Kaiser & Hargreaves, 2002 ;Kanaa et al., 2006; Kanaa et al, 2009, Kanaa 2011)


IntroductionIntroduction Injection speedInjection speed

There are conflicting views on the There are conflicting views on the influence of rate of injection on the influence of rate of injection on the distribution of local anaesthetic drugs and distribution of local anaesthetic drugs and its likely effect on securing anaesthesia.its likely effect on securing anaesthesia.

((Rucci Rucci et alet al., 1995; ., 1995; Kaiser & Hargreaves, 2002; Kaiser & Hargreaves, 2002; Oliveira et al., Oliveira et al., 20042004))


IntroductionIntroductionSummarySummary

Therefore an investigation to establish Therefore an investigation to establish if there is an association between if there is an association between speed injection (slow & rapid) and speed injection (slow & rapid) and IANB,IANB, is required. is required.


Materials and MethodsMaterials and Methods Study designStudy design

A double blind randomized A double blind randomized crossover study design was crossover study design was employed employed using healthy volunteers using healthy volunteers aged over 18 yearsaged over 18 years at the at the presentation of this research.presentation of this research.


Official clearances

NHS TrustNHS Trust

MHRAMHRA

LRECLREC


Materials and MethodsMaterials and Methods Power calculationPower calculation

Using 38 volunteers the study would have Using 38 volunteers the study would have 80% power to detect an effect size of 0.9 (a 80% power to detect an effect size of 0.9 (a shift of 0.9 standard deviations) in a shift of 0.9 standard deviations) in a continuous outcome measure assuming a continuous outcome measure assuming a significance level of 5% and a correlation significance level of 5% and a correlation of 0.5 between responses from the same of 0.5 between responses from the same subject.subject.


Materials and MethodsMaterials and Methods Sampling rSampling randomisedandomised procedure procedure

The 38 volunteers were randomly The 38 volunteers were randomly allocated for their first injection using allocated for their first injection using web-based program web-based program (1)(1) to receive slow or to receive slow or rapid injection at the first visit. At the rapid injection at the first visit. At the second visit, the other IANB was second visit, the other IANB was provided. provided.

(1) ((1) (http://department.obg.cuhk.edu.hk/researchsupport/Random_integer.asp ))


Materials and MethodsMaterials and MethodsInclusion criteriaInclusion criteria

Healthy volunteersHealthy volunteers;

Over 18 years;

Standing vital 1st molar, premolar (1st or 2nd) and lateral incisor in at least one side of the mandible;

Volunteers who accept to participate in the trial after reading the information sheet and signed the consent.


Materials and MethodsMaterials and Methods

Application techniquesApplication techniques

The local The local anaestheticanaesthetic needle was inserted midway between needle was inserted midway between the internal oblique ridge and the pterygomandibular raphe the internal oblique ridge and the pterygomandibular raphe and advanced until an adequate bony contact was achieved and advanced until an adequate bony contact was achieved ((direct or Halstead approachdirect or Halstead approach).). Blinded and randomisedBlinded and randomised application with 2mL of 2% lidocaine with 1:80,000 application with 2mL of 2% lidocaine with 1:80,000 epinephrineepinephrine for each for each volunteer was employed on two volunteer was employed on two occasions after an adequate aspiration:occasions after an adequate aspiration:

Rapid Rapid IANBIANB delivery delivery over 15s, the needle remained in place over 15s, the needle remained in place for a further 45s;for a further 45s;

Slow Slow IANBIANB delivery delivery over 60s. over 60s.


Standard electronic pulp tester (1Standard electronic pulp tester (1stst molar, 1 molar, 1stst or 2 or 2ndnd premolar & premolar & lateral incisor pulps); lateral incisor pulps);

((Analytic Technology, Analytic Technology, Washington, USA)Washington, USA)

Unanaesthetised tooth on the other side of the lower jaw had Unanaesthetised tooth on the other side of the lower jaw had

been had pulp sensitivity readings performed twice at base lines been had pulp sensitivity readings performed twice at base lines and once at 10 and 45 minutes post injection;and once at 10 and 45 minutes post injection;

An absence of pulp sensation when stimulated at the maximum An absence of pulp sensation when stimulated at the maximum output (80 reading) was the criterion for pulpal anaesthesia.output (80 reading) was the criterion for pulpal anaesthesia.

Baseline (twice)

Materials and Methods Objective measurement of anaesthetic efficacy

At intervals of 2 minsfor first 10 mins

Then at intervals of 5 mins for 45 mins

O M I C O M I C SSDubai Dubai 20152015

Criterion for success

An absence of pulp sensation An absence of pulp sensation

when stimulated at the maximum when stimulated at the maximum

output (output (8080 reading) ) of tooth pulp of tooth pulp

testingtesting


Materials and MethodsMaterials and MethodsThe statistical analysis of the studyThe statistical analysis of the study

Frequencies;Frequencies; Descriptions;Descriptions; Crosstabulation;Crosstabulation; Pearson Chi-SquarePearson Chi-Square; ; Fisher’s Exact TestFisher’s Exact Test;; McNemar Test; McNemar Test; Paired T test. Paired T test.


Objective assessment of pulpal anaesthesia Objective assessment of pulpal anaesthesia

after after slowslow & & rapidrapid IANB IANB injectioninjection

Results


Slow vs. Rapid IANB in 1Slow vs. Rapid IANB in 1stst molar teeth molar teeth

Results

Percentage of frequency of 80 reading of 1st molar pulp anaesthesia (without sensation) at time intervals after Slow and rapid IANB

0

10

20

30

40

50

60

70

80

90

100

2 4 6 8 10 15 20 25 30 35 40 45

Time after injection (min)

% o

f vo

lun

teer

s ex

per

ien

cin

g n

o

resp

on

se t

o m

axim

al (

80 r

ead

ing

) st

imu

lati

on

Slow IANB

Rapid IANB


Slow vs. Rapid IANB in premolar teethSlow vs. Rapid IANB in premolar teeth

Results

Percentage of frequency of 80 reading of premolar pulp anaesthesia (without sensation) at time intervals after Slow and rapid IANB

0

10

20

30

40

50

60

70

80

90

100

2 4 6 8 10 15 20 25 30 35 40 45


% o

f vo

lun

teer

s ex

per

ien

cin

g n

o

resp

on

se t

o m

axim

al (

80 r

ead

ing

) st

imu

lati

on

Slow IANB

Rapid IANB


Slow vs. Rapid IANB in lateral incisorsSlow vs. Rapid IANB in lateral incisors

Results

Percentage of frequency of 80 reading of lateral incisor pulp anaesthesia (without sensation) at time intervals after Slow and rapid IANB

0

10

20

30

40

50

60

70

80

90

100

2 4 6 8 10 15 20 25 30 35 40 45


% o

f vo

lun

teer

s ex

per

ien

cin

g n

o

resp

on

se t

o m

axim

al (

80 r

ead

ing

) st

imu

lati

on

Slow IANB

Rapid IANB


11stst molar vs. premolar vs. lateral incisor after Slow IANB molar vs. premolar vs. lateral incisor after Slow IANB

Results

Percentage of frequency of 80 reading of 1st molar, premolar and lateral incisor pulp anaesthesia (without sensation) at time intervals after Slow IANB


010

2030

4050

6070

8090

100

2 4 6 8 10 15 20 25 30 35 40 45


% o

f vol

unte

ers

expe

rien

cing

no

resp

onse

to

max

imal

(80r

eadi

ng) s

tim

ulat

ion

First molar

Premolar

Lateral incisor

11stst molar vs. premolar vs. lateral incisor after Rapid IANB molar vs. premolar vs. lateral incisor after Rapid IANB

Results

Percentage of frequency of 80 reading of 1st molar, premolar and lateral incisor pulp anaesthesia (without sensation) at time intervals after Rapid IANB


0

10

20

30

40

50

60

70

80

90

100

2 4 6 8 10 15 20 25 30 35 40 45


% o

f vol

unte

ers

expe

rien

cing

no

resp

onse

to

max

imal

(80r

eadi

ng) s

tim

ulat

ion

First molar

Premolar

Lateral incisor

ConclusionConclusion Slow IANB produced more episodes of no sensation on

maximal electronic pulp stimulation in first molars, premolars

and lateral incisors than rapid IANB injection.

Premolars were more likely to have successful pulpal

anaesthesia than first molars and lateral incisors following

IANB (either slowly or rapidly).


The outcomeThe outcome

This study will help to inform: This study will help to inform:

what and how best practice in what and how best practice in

everyday dental procedure everyday dental procedure

should be. should be.


2%4%

1.8ml

Articaine vs. Lidocaine

In

Mandibular buccal plus lingual infiltration(Haas et al., 1990; Yonchak et al., 2001; Meechan & Ledvinka,

2002; Kanaa et al., 2006)


Aim

To evaluate the efficacy of To evaluate the efficacy of

articaine and lidocaine buccal articaine and lidocaine buccal

plus lingual infiltrations in plus lingual infiltrations in

securing pulp anesthesia in vital securing pulp anesthesia in vital

mandibular first molarsmandibular first molars


Research question (H0)

Articaine

B & LInfiltrations

Lidocaine


Materials and Methods


Study design

Prospective Prospective

Randomized Randomized

Double blind Double blind

CrossoverCrossover


Power calculation

Using 31 subjects would have 90% Using 31 subjects would have 90%

power to detect an effect size of 0.83 (a power to detect an effect size of 0.83 (a

change of 0.83 standard deviations) in a change of 0.83 standard deviations) in a

continuous outcome measure assuming continuous outcome measure assuming

a significance level of 5%a significance level of 5%


Official clearances

NHS TrustNHS Trust

MHRAMHRA

LRECLREC


Inclusion criteria

Healthy adult volunteersHealthy adult volunteers

18 years old and over18 years old and over

Vital mandibular 1st molar

Signed the consent form


Anesthetic DeliveryBuccal & lingual infiltration

2% 2% Lidocaine with Lidocaine with 1:100,0001:100,000 epinephrine epinephrine

4% 4% Articaine with Articaine with

1:100,0001:100,000 epinephrine epinephrine One week


Buccal infiltration

0.9 mL

Lingual infiltration

0.9 mL


Objective measurement

Base-line (twice) At intervals of 2 mins until 30 mins

Mandibular first molarMandibular first molar

Unanesthetised toothUnanesthetised tooth


Criterion for success



output (output (8080 reading) ) on two or more on two or more

consecutive episodes of testingconsecutive episodes of testing


Statistical analysis of the study

McNemar Test McNemar Test

Paired T testPaired T test


Results


Changes from baseline pulp tester reading at first sensation (reading) in lower first molars

Paired T test, t=14, P < 0.001

0

5

10

15

20

25

30

35

40

2 4 6 8 10 12 14 16 18 20 22 24 26 28 30

Registration point (min after injection)

Ch

ang

es f

rom

bas

elin

e p

ulp

tes

ter

re

adin

g a

t fi

rst

sen

sati

on

(µ

A)

Articaine (B&L)

Lidocaine (B&L)


Episodes of no response to maximal (80 reading) stimulation at time intervals using articaine and lidocaine

Articaine Articaine vs.vs. Lidocaine: Lidocaine: 242242, , 114114 respectively, respectively, McNemar Test,McNemar Test, P < 0.001P < 0.001

0

10

20

30

40

50

60

70

80

90

100

2 4 6 8 10 12 14 16 18 20 22 24 26 28 30

Registration point (min after injection)

% o

f vo

lun

teer

s ex

per

ien

cin

g n

o

resp

on

se t

o m

axim

al (

80μ

A)

stim

ula

tio

n

Articaine (B&L)

Lidocaine (B&L)


Articaine

B & LInfiltrations

Lidocaine

Anesthetic success

(P = 0.001)

(21/31)

68%(10/31)

32%


Conclusions


Articaine produced Articaine produced more episodes of no

response to maximal (8080 reading reading) stimulation

at time intervals post injectionpost injection than lidocaine than lidocaine

Articaine wasArticaine was more successful more successful than lidocaine than lidocaine

in producing anaesthesia in lower first in producing anaesthesia in lower first

molars after buccal plus lingual infiltrationsmolars after buccal plus lingual infiltrations


Irreversible Pulpitis Irreversible Pulpitis

in Mandibular Permanent Teethin Mandibular Permanent Teeth


Objectives

To compare the efficacy of supplementary repeat To compare the efficacy of supplementary repeat

lidocaine IANB, ABI, lidocaine PDL and lidocaine lidocaine IANB, ABI, lidocaine PDL and lidocaine

IO following failed lidocaine IANB for securing IO following failed lidocaine IANB for securing

pain free treatment in patients experiencing pain free treatment in patients experiencing

irreversible pulpitis in mandibular permanent teethirreversible pulpitis in mandibular permanent teeth


Research question (HO)

IANBSupplemented

ABI IO PDL rIANB

Supplemented IANB

Supplemented IANB


Materials and Methods

Study design

A prospective randomized A prospective randomized

clinical trial design was clinical trial design was

employedemployed


Power calculation

Based on outcome data for intraosseous Based on outcome data for intraosseous

anaesthesia, a study with at least 21 subjects in anaesthesia, a study with at least 21 subjects in

each supplementary technique group was each supplementary technique group was

reported to have 90% power to detect a difference reported to have 90% power to detect a difference

in success rate of 82% (8% vs. 90%, Nusstein et in success rate of 82% (8% vs. 90%, Nusstein et

al., 1998) assuming a significance level of 5% and al., 1998) assuming a significance level of 5% and

a correlation of 0.5 between subjects a correlation of 0.5 between subjects


Official clearances

NHS TrustNHS Trust

MHRAMHRA

LRECLREC


Inclusion criteria

182 healthy adult patients182 healthy adult patients

18 years old and over18 years old and over

Irreversible pulpitis mandibular

tooth

Signed the consent form O M I C SO M I C SDubai 2015Dubai 2015

Anaesthetic Delivery

LA solution/ technique Pulp testing Every 2 mins until no sensation or 10 mins

Treatment Pain Supplementary LA Pulp testing at 2 & 5 mins Treatment Pain Other treatments

Mandibular teeth with irreversible pulpitis: 182 patients

I A N B: 2% Lidocaine with epinephrine 1:80,000 (2mL): 182 patients

Success Success

PT-

Randomised supplementary techniques

Failure and withdrawn from trial

Pain

Intraosseous injection of 2% lidocaine with epinephrine 1:80,000 (1 mL)

Treatment

Intraligamentary injection of 2% lidocaine with epinephrine 1:80,000 (0.2 mL)

Repeat IANB of 2% lidocaine with epinephrine 1:80,000 (2 mL)

Buccal infiltration of 4% articaine with epinephrine 1:100,000 (2 mL)

PT+

Treatment

No pain

PT+ PT-

Pain

Treatment

No pain

PT-


PT+

Treatment

Pain

PT+ PT-

Pain

Treatment

No pain

Positive to pulp test (PT+)

No pain

Negative to pulp test (PT-)

Pain

No pain


Objective measurement

Base-line (twice)

IANB injectionAt intervals of 2 mins until 10 mins or till 80 reading on pulp test secured

Unanaesthetised toothUnanaesthetised tooth

Tooth with irreversible pulpitis Tooth with irreversible pulpitis

Supplementary TechniquesAt intervals of 2 mins if no 80 reading then at 5 mins


Criterion for LA success



output (output (80 reading80 reading) ) of testingof testing


Criterion treatment success

An absence of any sensation of An absence of any sensation of

pain during the treatment; even pain during the treatment; even

mild painmild pain


Statistical analysis of the study

SPSS software 17.0, SPSS Inc., SPSS software 17.0, SPSS Inc.,

Chicago, USAChicago, USA

Pearson Chi-SquarePearson Chi-Square

Fisher’s Exact TestFisher’s Exact Test


Results


General distributionGeneral distribution

182182 patients with mandibular patients with mandibular irreversible pulpitis teethirreversible pulpitis teeth

133133 males: males: 73.1%73.1%

4949 females: females: 26.9%26.9%

Age range: 18-66 years old (mean Age range: 18-66 years old (mean 31.931.9, , SD SD 10.010.0). ).


LA solution/ technique Pulp testing Every 2 mins until no sensation or 10 mins

Treatment Pain Supplementary LA Pulp testing at 2 & 5 mins Treatment Pain Other treatments

Mandibular teeth with irreversible pulpitis: 182 patients

I A N B: 2% Lidocaine with epinephrine 1:80,000 (2mL): 182 patients

Success Success

PT- :21

Randomised supplementary techniques: 100 patients


Pain: 40

Intraosseous injection of 2% lidocaine with epinephrine 1:80,000 (1 mL): 25

Treatment: 122

Intraligamentary injection of 2% lidocaine with epinephrine 1:80,000 (0.2 mL): 25

Repeat IANB of 2% lidocaine with epinephrine 1:80,000 (2 mL): 25

Buccal infiltration of 4% articaine with epinephrine 1:100,000 (2 mL): 25

PT+ :4

Treatment: 21

No pain: 17 81%

PT+ :7 PT- :18

Pain: 6

Treatment: 18

No pain: 12 67%

PT- :15


PT+ : 10

Treatment: 15

Pain: 7

PT+ :2 PT- :23

Pain: 2

Treatment: 23

No pain: 21 91%

Positive to pulp test (PT+): 60

No pain: 8 53%

Negative to pulp test (PT-): 122

Pain: 4

No pain: 82 (45%)


Premolars vs. MolarsPremolars vs. Molars

Relationship between treatment outcomes in premolars and molars in 77 Relationship between treatment outcomes in premolars and molars in 77 patients with a negative response to pulp testing after supplementary patients with a negative response to pulp testing after supplementary injections.injections. (Chi-Square p = 0.14, Fisher’s Exact Test p = 0.33) (Chi-Square p = 0.14, Fisher’s Exact Test p = 0.33)

Treatmentoutcomes

SuccessN %

FailureN %

TotalN

Premolars 6 100.0 0 0.0 6

Molars 52 73.2 19 26.8 71

Total 58 75.3 19 24.7 77


Molar tooth & supplementary techniquesMolar tooth & supplementary techniques

Experience of treatment success in 71 mandibular molar teeth after repeat Experience of treatment success in 71 mandibular molar teeth after repeat IANB injection (r IANB), articaine buccal infiltration (ABI), intraligamentary IANB injection (r IANB), articaine buccal infiltration (ABI), intraligamentary (PDL) and intraosseous injection (IO): Pearson Chi-Square p = 0.025, (PDL) and intraosseous injection (IO): Pearson Chi-Square p = 0.025, Likelihood Ratio p = 0.021Likelihood Ratio p = 0.021

Treatmentoutcomesmolars

r IANB

N %

ABI

N %

PDL

N %

IO

N %

Total

N %

Success 7 50.0 21 91.3 9 60.0 15 78.952 73.2

Failure 7 50.0 2 8.7 6 40.0 4 21.1 19 26.8

Total 14 23 15 19 71


Anesthetic success

rIANB

60%

IANBSupplemented (P = 0.04)

Supplemented IANB

Supplemented IANB

PDL72%

IO

84%

ABI

92%


Treatment success

IANBSupplemented

Supplemented IANB

Supplemented IANB

ABI

91%

IO

81%

PDL67%

(P = 0.04)

rIANB

53%


Conclusions


IANB injection alone does not secure satisfactory IANB injection alone does not secure satisfactory

pain free treatment (pain free treatment (45%45%))

Articaine buccal infiltration and intraosseous Articaine buccal infiltration and intraosseous

injections are better supplementary techniques injections are better supplementary techniques

than intraligamentary and repeat IANB injections than intraligamentary and repeat IANB injections

for patients experiencing irreversible pulpitis in for patients experiencing irreversible pulpitis in

the mandibular permanent teeththe mandibular permanent teeth


J.G. MeechanJ.M. Whitworth

M.D. Kanaa


Special Thanks: Special Thanks: Kettering General HospitalKettering General Hospital

SAS Support and SponsorshipSAS Support and SponsorshipOMICSOMICS

The first alphabet and first written musical note were discovered in Ugarit, Syria


Syria: 5000 years of civilization O M I C O M I C SSDubai Dubai 20152015

efficacy of dental local anaesthesia in mandibular teeth: current views dds, mphil, phd specialty...

Documents

i c sdubai

rapid injection

introductionlocal anaesthesia

securing anaesthesia

ianb injectionsianb

kanaa et

methods study

introduction injection