Inferior alveolar nerve block; Heft-Parker "visual analogue scale" pain scale; intraosseous anesthesia; stabident; X-Tip, ">
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Table of Contents   
ORIGINAL ARTICLE  
Year : 2014  |  Volume : 17  |  Issue : 5  |  Page : 432-435
Intraosseous injection as an adjunct to conventional local anesthetic techniques: A clinical study


1 Department of Conservative Dentistry and Endodontics, Rajarajeswari Dental College and Hospital, Bangalore, India
2 Department of Endodontist, Department of Dentistry, Kerala Institute of Medical Sciences, Thiruvananthapuram, Kerala, India
3 Department of Conservative Dentistry and Endodontics, Nehru Smaraka Vidya Kendra Sri Venkateshwara Dental College and Hospital, Bangalore, Karnataka, India

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Date of Submission16-Mar-2014
Date of Decision26-Jun-2014
Date of Acceptance07-Jul-2014
Date of Web Publication1-Sep-2014
 

   Abstract 

Background: The achievement of successful local anesthesia is a continual challenge in dentistry. Adjunctive local anesthetic techniques and their armamentaria, such as intraosseous injection (the Stabident system and the X-tip system) have been proposed to be advantageous in cases where the conventional local anesthetic techniques have failed.
Aim: A clinical study was undertaken using intraosseous injection system by name X-tip to evaluate its effectiveness in cases where inferior alveolar nerve block has failed to provide pulpal anesthesia.
Materials and Methods: Sixty adult patients selected were to undergo endodontic treatment for a mandibular molar tooth. Inferior alveolar nerve block was given using 4% articaine with 1:100,000 epinephrine. Twenty-four patients (40%) had pain even after administration of IAN block; intraosseous injection was administered using 4% articaine containing 1:100,000 epinephrine, using the X-tip system. The success of X-tip intraosseous injection was defined as none or mild pain (Heft-Parker visual analog scale ratings ≤ 54 mm) on endodontic access or initial instrumentation.
Results: Intraosseous injection technique was successful in 21 out of 24 patients (87.5%), except three patients who had pain even after supplemental X-tip injection.
Conclusion: Within the limits of this study, we can conclude that supplemental intraosseous injection using 4% articaine with 1:100,000 epinephrine has a statistically significant influence in achieving pulpal anesthesia in patients with irreversible pulpitis.

Keywords: Inferior alveolar nerve block; Heft-Parker "visual analogue scale" pain scale; intraosseous anesthesia; stabident; X-Tip

How to cite this article:
Idris M, Sakkir N, Naik KG, Jayaram NK. Intraosseous injection as an adjunct to conventional local anesthetic techniques: A clinical study. J Conserv Dent 2014;17:432-5

How to cite this URL:
Idris M, Sakkir N, Naik KG, Jayaram NK. Intraosseous injection as an adjunct to conventional local anesthetic techniques: A clinical study. J Conserv Dent [serial online] 2014 [cited 2021 Apr 18];17:432-5. Available from: https://www.jcd.org.in/text.asp?2014/17/5/432/139828

   Introduction Top


Effective pain control during endodontic treatment is necessary to allow for patient comfort as well as to reduce operator stress. Although local anesthetics are highly effective in producing anesthesia in normal tissue, local anesthetics commonly fail in endodontic patients with inflamed tissue. [1] For instance, the inferior alveolar nerve (IAN) block is associated with a failure rate of 15% in patients with normal tissue, [2] whereas IAN block fails 44-81% of the time in patients with irreversible pulpitis. [3] Similarly, it has been reported that the failure rate of a maxillary infiltration injection is as high as 30% in teeth with irreversible pulpitis. [2] All patients in these studies expressed 100% lip numbness, but some had positive results to electric pulp testing, cold testing, or pain on access. [2],[3] Several hypotheses have been proposed regarding the causes of local anesthetic failure in endodontic patients with irreversible pulpitis. It has been suggested that pulpal and periapical inflammation and infection can lower the tissue pH in the affected region limiting the ability of the local anesthetic to provide pain control; others have hypothesized that inflammation products enhance nerve conduction. [4] Unusual vasodilation caused by inflammation may also lead to systemic uptake of anesthetic solution from the local site of infiltration, thus, reducing its local effectiveness. [4]

Various means of supplemental anesthesia have been advocated to obtain profound pulpal anesthesia before the initiation of endodontic therapy. The intraosseous injection allows placement of a local anesthetic solution directly into the cancellous bone adjacent to the tooth to be anesthetized. There are two intraosseous systems that have been studied clinically-the Stabident® system (Fairfax Dental Inc., Miami, FL) and the X-tip® system (Dentsply, York, PA). Recently, two other anesthetic systems have been introduced-the IntraFlow® (Pro-Dex Inc., Santa Ana, CA) and the Comfort Control Syringe® (Dentsply International, York, PA). The Stabident® system is comprised a slow-speed handpiece driven perforator, a solid 27-G wire with a beveled end that when activated, drills a small hole through the cortical plate. The anesthetic solution is delivered to cancellous bone through the 27-G ultra-short injector needle placed into the hole made by the perforator. The X-tip® anesthesia delivery system consists of an X-tip® that separates into two parts: the drill and guide sleeve component. The drill (a special hollow needle) leads the guide sleeve through the cortical plate, whereupon it is separated and withdrawn. The guide sleeve is designed to accept a 27-G needle to inject the anesthetic solution. The guide sleeve is removed after the intraosseous injection is complete.

Aim of the study

A clinical study was undertaken in the Department of Conservative Dentistry and Endodontics, using intraosseous injection system by name X-tip to evaluate its effectiveness in cases where inferior alveolar nerve block has failed to provide pulpal anesthesia. In this article the technique and the results of the study are presented.


   Materials and methods Top


Sixty adult patients participated in the study: 34 men and 26 women, aged 18-43 years, with an average age of 25 years. The subjects were in good health and were not taking any medications that would alter pain perception. All the patients selected were to undergo endodontic treatment for a mandibular molar tooth. Mandibular molar with pulpalgia were included in the study. Patients with no response to cold testing or periradicular pathosis and patients with compromised medical health were excluded from the study. Therefore, every selected patient had one tooth that fulfilled the criteria for a clinical diagnosis of symptomatic irreversible pulpitis.

Patients received standard Inferior Alveolar Nerve blocks using 4% articaine with 1:100,000 epinephrine. Fifty-six patients recorded profound lip numbness after single injection using 1.5 ml of solution. Remaining four patients were given a second IANB. After ensuring the subjective and objective signs of anesthesia in all the patients, the mandibular molar tooth was isolated with a rubber dam and the access cavity preparation was started. Patients were instructed to rate any discomfort during access using a Heft-Parker visual analogue scale (HP VAS). [5]

The HP VAS, with 170 mm, was divided into four categories. No pain corresponded to 0 mm. Mild pain was greater than 0 mm and less than or equal to 54 mm. Mild pain included descriptors of faint, weak and mild pain. Moderate pain was greater than 54 mm and less than 114 mm. Severe pain was greater than or equal to 114 mm. Severe pain included descriptors of strong, intense and maximum possible. [6] Twenty-four out of 60 patients had moderate or severe pain (HP VAS rating > 54 mm) on access into dentin, when entering the pulp chamber or with initial file placement, and received a supplemental intraosseous X-tip injection using 4% articaine containing 1:100,000 epinephrine.

Procedure

The X-tip intraosseous system instructs the user to locate the perforation site in attached gingiva. This allows the perforation to be made through a minimal thickness of cortical bone and is generally equidistant between adjacent root structures. The guide sleeve of the X-Tip system is secured against the drill. Place X-tip drill and guide sleeve in a slow speed hand piece. Holding the drill at a 90-degree angle to the bone, the slow-speed handpiece was activated, while pushing the perforator with light pressure against bone and then slightly withdrawing the perforator and then pushing it again against bone. This action was continued until a "break through" feeling was observed or the perforator was placed to full length. Penetration of bone should take no longer than 2-4 seconds. X-tip drill and guide sleeve will drop into cancellous bone. The drill was then withdrawn from the guide sleeve, leaving the guide sleeve in place. The catridge syringe with X-tip needle was inserted into the guide sleeve to its hub and 0.9 ml of 4% Articaine with 1:100,000 epinephrine was delivered slowly. The guide sleeve was then removed using a hemostat or needle holder. If desired, the guide sleeve can be left in place throughout procedure for re-injections as needed.

Success of supplemental X-tip technique is defined as "the ability to access the pulp chamber, to place initial files, and instrument the tooth without pain (HP VAS score of zero) or mild pain (HP VAS score less than or equal to 54 mm)." [7] If the patient had moderate to severe pain (HP VAS score greater than 54 mm) during access or initial instrumentation, the X-tip technique was judged as failure and the other methods were used to overcome the pulpal pain, which were successful.

Statistical analysis

The data of number of patients with success and failure of inferior alveolar nerve block and intraosseous anesthesia were collected and statistically analyzed using SPSS Version 18.0. Anesthetic success was calculated by the Paired t-test and P-value < 0.05 was set as significant.


   Results Top


All patients who received standard inferior alveolar nerve blocks using 4% articaine with 1:100,000 epinephrine recorded profound lip numbness. Twenty-four patients (40%) had moderate or severe pain even after administration of IAN block. Intraosseous injection technique was successful in 21 out of 24 patients (87.5%), except three patients who had pain even after supplemental X-tip injection [Table 1].
Table 1: Patients who achieved anesthetic success and failure with the Inferior alveolar nerve block and the
X-tip injection technique


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   Discussion Top


Supplemental injections are essential in patients with irreversible pulpitis when pulpal anesthesia from Inferior alveolar nerve block is inadequate. Traditionally, solutions of lidocaine or mepivacaine have been administered with the intraosseous injection. In April 2000, articaine was introduced in the United States. [8] Articaine has a reputation of providing an improved local anesthetic effect. [9] The onset of pulpal anesthesia was rapid for those patients who received intraosseous injection. [10] The intraosseous injection was more successful than the periodontal ligament injection due to the greater amount of anesthetic solution delivered with the intraosseous injection.

In this study, 4% articaine with 1:100,000 epinephrine was preferred over 2% lignocaine with 1:100,000 epinephrine. It has been suggested that variations in the pharmacology of the local anesthetic, as well as variations in the technique used to administer the anesthetic can markedly affect the success of anesthesia in endodontic patients. For instance, Bigby et al., suggest that a supplemental intraosseous injection of 4% articaine improves the anesthetic efficacy of the IAN block in mandibular posterior teeth with irreversible pulpitis. [11] Another study by Cohen and others [12] found that a supplemental periodontal ligamental injection with 2% lidocaine was 74% successful in achieving pain control in patients with irreversible pulpitis. Kanaa et al., on the other hand have found that 4% articaine with 1:100,000 epinephrine was more effective than 2% lidocaine 1:100,000 epinephrine in achieving anesthesia in mandibular teeth. [13] Makade et al., found that pressure anesthesia was more accepted and preferred by 70% of the patients than traditional needle anesthesia (20%), even though both needle and pressure anesthesia was equally effective for carrying out the dental procedures. [14] Various studies have also shown that the use of preoperative medication improves the anesthetic efficacy for the treatment of teeth diagnosed with irreversible pulpitis. [15],[16]

In a study by Nusstein et al., the success of supplemental X-tip intraosseous injection in achieving pulpal anesthesia in patients with irreversible pulpitis was 82% and the failure rate was 18%. [7] In the current study, the success rate was 87.5% (21/24), whereas 12.5% (3/24) of the patients experienced anesthetic failure. The lack of 100% success with this technique may be related to constricted cancellous spaces that limited the distribution of the anesthetic solution around the apices of the teeth. [6] The onset of anesthesia was immediate for those patients receiving successful X-tip injections, i.e., endodontic access was begun as soon as the rubber dam was placed and the patients experienced none or mild pain. Previous studies of the intraosseous Stabident system have also shown immediate onset. [10],[17],[18] Intraosseous injections provide a shorter duration of anesthesia than with mandibular block or infiltration. However, pulpal anesthesia has duration of less than 60 min with vasoconstrictor and approximately 15-30 min without vasoconstrictor. [19]

The risks factors associated with intraosseous injections include separation of the perforator needle from the plastic shank and localized infection that can occur at the site of perforation and may require use of oral antibiotics. The most significant concern with this route is increased heart rate that occurs when using epinephrine and levonordefrin-containing solutions. [19]


   Conclusions Top


The intraosseous delivery of local anesthetic has been shown to be an effective method of achieving pulpal anesthesia in mandibular posterior teeth of patients where routine inferior alveolar nerve block has failed. Intraosseous injection can be a useful adjunct to the dentist's local anesthetic armamentarium when a supplemental anesthetic is desired, especially in patients with irreversible pulpitis.

 
   References Top

1.Meechan JG. Supplementary routes to local anaesthesia. Int Endod J 2002;35:885-96.  Back to cited text no. 1
    
2.Ingle JI, Bakland LK. Preparation for Endodontic Treatment. In: Endodontics. 5 th ed Hamilton: BC Decker; 2002. p. 385.  Back to cited text no. 2
    
3.Matthews R, Drum M, Reader A, Nusstein J, Beck M. Articaine for supplemental buccal mandibular infiltration anesthesia in patients with irreversible pulpitis when the inferior alveolar nerve block fails. J Endod 2009;35:343-6.  Back to cited text no. 3
    
4.Khan AA, Owatz CB, Schindler WG, Schwartz SA, Keiser K, Hargreaves KM. Measurement of mechanical allodynia and local anesthetic efficacy in patients with irreversible pulpitis and acute periradicular periodontitis. J Endod 2007;33:796-9.  Back to cited text no. 4
    
5.Heft MW, Parker SR. An experimental basis for revising the graphic rating scale for pain. Pain 1984;19:153-61.  Back to cited text no. 5
    
6.Verma PK, Srivastava R, Kumar MR. Anesthetic efficacy of X-tip intraosseous injection using 2% lidocaine with 1:80,000 epinephrine in patients with irreversible pulpitis after inferior alveolar nerve block: A clinical study. J Conserv Dent 2013;16:162-6.  Back to cited text no. 6
[PUBMED]  Medknow Journal  
7.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.  Back to cited text no. 7
    
8.Malamed SF, Gagnon S, LeBlanc D. Articaine hydrochloride: A study of the safety of anew amide local anesthetic. J Am Dent Assoc 2001;132:177-85.  Back to cited text no. 8
    
9.Schertzer ER, Malamed SF. Articaine vs. lidocaine. J Am Dent Assoc 2000;131:1248-50.  Back to cited text no. 9
    
10.Dunbar D, Reader A, Nist R, Beck M, Meyers WJ. Anesthetic efficacy of the intraosseous injection after an inferior alveolar nerve block. J Endod 1996;22:481-6.  Back to cited text no. 10
    
11.Bigby J, Reader A, Nusstein J, Beck M. Anesthetic efficacy of lidocaine/meperidine for inferior alveolar nerve blocks in patients with irreversible pulpitis. J Endod 2007;33:7-10.  Back to cited text no. 11
    
12.Cohen HP, Cha BY, Spangberg LS. Endodontic anesthesia in mandibular molars: A clinical study. J Endod 1993;19:370-3.  Back to cited text no. 12
    
13.Kanaa 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.  Back to cited text no. 13
    
14.Makade CS, Shenoi PR, Gunwal MK. Comparison of acceptance, preference and efficacy between pressure anesthesia and classical needle infiltration anesthesia for dental restorative procedures in adult patients. J Conserv Dent 2014;17:169-74.  Back to cited text no. 14
[PUBMED]  Medknow Journal  
15.Jena A, Shashirekha G. Effect of preoperative medications on the efficacy of inferior alveolar nerve block in patients with irreversible pulpitis: A placebo-controlled clinical study. J Conserv Dent 2013;16:171-4.  Back to cited text no. 15
[PUBMED]  Medknow Journal  
16.Ramachandran A, Khan SI, Mohanavelu D, Senthil kumar K. The efficacy of pre-operative oral medication of paracetamol, ibuprofen, and aceclofenac on the success of maxillary infiltration anesthesia in patients with irreversible pulpitis: A double-blind, randomized controlled clinical trial. J Conserv Dent 2012;15:310-4.  Back to cited text no. 16
[PUBMED]  Medknow Journal  
17.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;48:299-302.  Back to cited text no. 17
    
18.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.  Back to cited text no. 18
    
19.Blanton PL, Jeske AH. Dental local anesthetics: Alternative delivery methods. J Am Dent Assoc 2003;134:228-34.  Back to cited text no. 19
    

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Correspondence Address:
Nasil Sakkir
Tc 2/453(22), Aisha Cottage, P.T Chacko Nagar, Medical College P.O. Thiruvananthapuram - 695 011, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-0707.139828

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