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REVIEW ARTICLE
Year : 2021  |  Volume : 11  |  Issue : 3  |  Page : 277-282

Most effective local anesthetic technique for mandibular posterior teeth with irreversible pulpitis: A systematic review and meta-analysis


1 Department of Operative Dentistry, Baharia University Medical and Dental College, Karachi, Pakistan
2 Department of Surgery, Section of Operative Dentistry, Aga Khan University Hospital, Karachi, Pakistan
3 Department of Surgery, Section of Orthodontics, Aga Khan University Hospital, Karachi, Pakistan

Date of Submission20-Nov-2020
Date of Decision28-Dec-2020
Date of Acceptance06-Jan-2021
Date of Web Publication3-Sep-2021

Correspondence Address:
Dr. Kamil Zafar
Department of Surgery, Section of Operative Dentistry, Aga Khan University Hospital, Stadium Road, Karachi 74800,
Pakistan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sej.sej_259_20

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  Abstract 

Introduction: Achieving profound pulpal anesthesia is considered as a keystone in endodontic practice as it benefits both the patient and the dentist for smooth delivery of care. A tooth that has irreversible pulpitis causes severe pain and poses an additional challenge. The aim of the present systematic review is to compare the standard inferior alveolar nerve block with other local anesthesia techniques for effectively anesthetizing the mandibular posterior teeth that present with irreversible pulpitis. Materials and Methods: A systematic review protocol was registered at Prospero. The following databases were searched: PubMed, CINAHL, Cochrane, EBSCO Oral and Dentistry Database, and Trip Database using strict inclusion and exclusion criteria. All randomized control trials on the topic published in the English language only were included. Results: The first search yielded 1213 articles, and after going through extensive screening and eligibility process, only 8 articles were finally selected for the review. There were six articaine infiltration technique groups; two were based on intraosseous technique and one each on Gow-Gates and Vazirani–Akinosi methods. The standard inferior alveolar nerve block was compared with other mandibular anesthesia techniques pooled together. A meta-analysis was carried out to compare inferior alveolar nerve block with the articaine infiltration. The difference among two sets of techniques was found to be nonsignificant (P = 0.07). However, the overall results of the meta-analysis favor articaine infiltration. The study is first of its kind comparing multiple anesthetic techniques in mandibular posterior teeth with irreversible pulpitis. Studies with the highest level of evidence, i.e., randomized controlled trials, were included only. No conclusive inference regarding Gow-Gates block and Vazirani–Akinosi techniques could be drawn on account of limited data. Conclusions: Infiltration and intraosseous appeared to be viable alternative to standard inferior alveolar nerve block in the posterior teeth with irreversible pulpitis.

Keywords: Gow-Gates technique, inferior alveolar nerve block technique, intraosseous technique, irreversible pulpitis, Vazirani–Akinosi technique


How to cite this article:
Nazeer MR, Zafar K, Khan FR, Ghafoor R, Sukhia RH. Most effective local anesthetic technique for mandibular posterior teeth with irreversible pulpitis: A systematic review and meta-analysis. Saudi Endod J 2021;11:277-82

How to cite this URL:
Nazeer MR, Zafar K, Khan FR, Ghafoor R, Sukhia RH. Most effective local anesthetic technique for mandibular posterior teeth with irreversible pulpitis: A systematic review and meta-analysis. Saudi Endod J [serial online] 2021 [cited 2021 Dec 7];11:277-82. Available from: https://www.saudiendodj.com/text.asp?2021/11/3/277/325403


  Introduction Top


Toothache is a public health problem that affects 28% of adult population and can be the worst pain that a human can feel.[1] Effective control of pain is necessary to reduce the fear and anxiety associated with an endodontic procedure.[2] Attaining profound pulpal anesthesia is considered as a keystone in endodontic practice as it benefits both the patient and the dentist for smooth delivery of care.[2],[3]

A tooth that has irreversible pulpitis is also called a “hot tooth.” It causes a severe type of dental pain.[4] The presence of irreversible pulpitis in posterior mandible teeth poses an additional challenge. Anatomically, achieving adequate pulpal anesthesia is difficult mainly because of the thick cortical bone present on the buccal aspect of teeth that prevent local anesthetic solution to reach to the tooth pulp.[5],[6] Therefore, mandibular posterior teeth are usually anesthetized by regional blockade of the inferior alveolar nerve. This technique is highly unpredictable specifically in teeth diagnosed with irreversible pulpitis with or without acute apical periodontitis.[7],[8],[9] The clinical failure rate of standard inferior alveolar nerve block in teeth with irreversible pulpitis has been stated to be 44%–81%.[7],[8],[9],[10],[11] Some studies have reported eight times higher failure of local anesthesia in such cases.[3],[12] There are many reasons attributed to it such as the presence of preexisting hyperalgesia, allodynia, altered resting nerve potentials, decreased excitability, upgradation of tetrodotoxin-resistant sodium channels, the presence of thick cortical bone, and accessory nerve supply, i.e., nerve to mylohyoid.[12] However, there are ways to manage and attain profound local anesthesia in teeth with irreversible pulpitis. These include selecting a different chemistry of local anesthetic agent, altering the volume of local anesthesia and concentration of epinephrine, changing the technique of delivery of local anesthesia (e.g., Gow-Gates, Vazirani–Akinosi, or closed-mouth method) or infiltration techniques (articaine infiltration and intraosseous anesthesia).[3]

Gow-Gates block is an alternate method that is recommended when standard inferior alveolar nerve block fails. The Gow-Gates block has been reported to have higher success rate than standard inferior alveolar nerve block, but clinical trials failed to prove its superiority.[12],[13],[14],[15],[16] Vazirani–Akinosi is another technique recommended for patients with limited mouth opening or, when anatomical landmarks are difficult to locate, has also not been shown to be superior to standard inferior alveolar nerve block.[17],[18] In contrast to this, Zain et al.[19] found 77% success of articaine infiltration as a primary technique when compared to standard inferior alveolar nerve block in symptomatic irreversible pulpitis.[19] Another study compared standard inferior alveolar nerve block with intraosseous infiltration as a primary technique and reported 85% success of intraosseous technique.[20] Hence, to address this ambiguity it was decided to carry a systematic review. The review question was: Which is the most effective local anesthesia technique for mandibular posterior teeth diagnosed with irreversible pulpitis?

Rationale

The aim of this review was to compare the standard inferior alveolar nerve block with other local anesthesia techniques for effectively anesthetizing the mandibular posterior teeth in patients diagnosed with irreversible pulpitis.

Objective

The following PICOS model was used:

  • Population: Mandibular posterior teeth presenting with irreversible pulpitis
  • Intervention: Local anesthesia achieved with the following techniques: Gow-Gates technique, Vazirani–Akinosi technique, intraosseous technique, and articaine infiltration
  • Control: Anesthesia achieved with the abovementioned techniques was compared with the standard inferior alveolar nerve block
  • Outcome: Attainment of adequate anesthesia that allowed root canal therapy to be initiated without any additional need of anesthesia
  • Study design: Randomized clinical trials comparing standard inferior alveolar nerve block with other techniques.



  Materials and Methods Top


Data search

The protocol was registered with PROSPERO, an international database at the University of York, UK. This database prospectively registers systematic reviews to avoid repetition. For selection of studies, literature search was conducted exploring four major health science database (PubMed, CINAHL Plus, Cochrane, and EBSCO Oral and Dentistry Database along with the hand search), with various key terms in different combinations (“Mandibular Nerve” [Mesh: noexp]) OR (“mandibular molar”) OR (“irreversible pulpitis”) OR (“inferior alveolar nerve block”) OR (“hot tooth”)) AND ((“Gow-Gates Technique”) OR (“mandibular block technique”) OR (“Vazirani Akinosi technique”) OR (“intraosseous technique”) OR (“open mouth local anesthesia technique”) OR (“closed mouth local anesthesia technique”) OR (“dental anesthesia”) OR (“local anesthesia”) OR (“mandibular nerve anesthesia”) OR (“mandibular anesthesia”) OR (articaine))) AND (Randomized Controlled Trial [ptyp] AND Humans [Mesh]).

Inclusion criteria

Randomized clinical trials in which comparison of standard inferior alveolar nerve block with various local anesthetics techniques as a primary injection in mandibular posterior teeth with irreversible pulpitis requiring endodontic treatment were included in this review.

Exclusion criteria

Case reports/series, reviews, case control, cohort, single-arm clinical trials, and languages other than English were excluded from the study.

Study selection

The first search hits were reviewed by two authors to exclude any duplications or studies not relevant to the research question. Titles of all the remaining probable studies were reviewed by the investigators independently, and any argument was decided through discussion with the third author. The reasons for excluding studies were also noted. [Figure 1] shows the selection flowchart.
Figure 1: Flowchart of the systematic review

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  Results Top


A total eight studies were included for the final analysis. All included studies were randomized controlled trials as per the strict inclusion criteria and were published within the last 10 years. In all clinical trials, the control group was standard inferior alveolar nerve block and the comparison group was at least one of the following local anesthesia techniques, i.e., Vazirani–Akinosi technique, Gow-Gates block, articaine infiltration, and intraosseous technique. There were eight control and ten comparison groups in all the included studies. Out of all comparison groups, articaine infiltration was present in the six studies, intraosseous technique was in two, while Vazirani–Akinosi technique and Gow-Gates block were reported in one study each. There were a total of 282 teeth in the control group and 325 teeth in the comparison group. The difference among teeth in both the groups was attributed to one clinical trial in which three comparison groups were present.[21] The lowest sample size among all the included trials was 15; it was reported by Remmers et al.[22] comparing standard inferior alveolar nerve block with intraosseous technique. However, the largest sample size reported was 78 in the trial conducted by Zain et al.[19] comparing articaine infiltration with standard inferior alveolar nerve block technique.

In six out of eight trials, the assessment method was Visual Analog Scale (VAS).[19],[21],[23],[24],[25],[26] In the remaining studies, it was an electric pulp tester.[20],[22] In the trial conducted by Aggarwal et al.,[21] the success rate was highest for Gow-Gates block, i.e., 52%, which was better than that of the control standard inferior alveolar nerve block. However, the authors concluded that no technique provided acceptable clinical success. In four out of six articaine infiltration groups, articaine infiltration turned out to be superior to standard inferior alveolar nerve block technique. However, the difference was not statistically significant. The authors did conclude that articaine was better alternative.

A meta-analysis was carried out to compare inferior alveolar nerve block with the articaine infiltration. The difference among two sets of techniques was found to be nonsignificant (P = 0.07). However, the overall result of the meta-analysis favors articaine infiltration [Figure 2].
Figure 2: Forest plot showing the comparison and success of local anesthesia in control versus comparison groups

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The two studies that compared intraosseous technique with standard inferior alveolar nerve block,[20],[22] reported that intraosseous technique is better than the standard technique, but one study further concluded that the intraosseous is a difficult technique as it requires special armamentarium. Hence, intraosseous technique cannot be considered as a suitable alternative to standard inferior alveolar nerve block.[20]


  Discussion Top


To the best of our knowledge, the present study is the first systematic review to compare multiple anesthetic techniques in mandibular posterior teeth with irreversible pulpitis. There are multiple systematic reviews reported in the literature that evaluated the effectiveness of local anesthesia techniques on the basis of chemistry, volume, effects of supplemental infiltration, and effects of preoperative analgesics.[27],[28],[29],[30],[31],[32],[33] However, those studies were confined to comparing not more than two techniques at a time. The review was unique as multiple local anesthetic techniques were evaluated and included randomized controlled trials only. The control group was the standard inferior alveolar nerve block, and comparators were other techniques such as Vazirani–Akinosi technique, Gow-Gates block, articaine infiltration, and intraosseous technique. It is important to note that only those trials were included where the previously mentioned techniques were employed as the primary technique for anesthetizing mandibular posterior teeth.

There were two assessment tools that were used for assessing the pain (the lack of which constituted the success of intervention). Those were VAS followed by the use of electric pulp test. The total time from the administration of local anesthesia and start of endodontic procedure mentioned in three trials were in the range of 10–20 mins.[21],[23],[24] Zain et al.[19],[26] did not mention the injection to access opening time interval in their two trials. Rajput et al.[25] failed to mention the initial and final VAS score. VAS has limited value for evaluating pain because of its subjectivity. The primary limitation of VAS is the problem associated with the perception and understanding, i.e., some patients are unable to estimate the worsening pain. González-Fernández et al.[34] compared VAS with general Labeled Magnitude Scale (gMLS) and concluded that gMLS is clinically more feasible. The assessment method in clinical trials with intraosseous comparative groups[20],[22] was an electric pulp tester. The onset of anesthesia in both trials for intraosseous technique was in the range of 4–9.5 min which was significantly shorter than that reported for the standard inferior alveolar nerve block.[20],[22]

The cumulative success rate of Gow-Gates block was 52%, Vazirani–Akinosi technique was 41%, and standard inferior alveolar nerve block 36%. The authors could not found any systematic review or other randomized controlled trials to compare achieved results. However, a recent book published on the topic of successful local anesthesia in endodontics[35] reported that neither the Gow-Gates block nor Vazirani–Akinosi technique is better than the standard inferior alveolar nerve block technique.

Articaine infiltration was compared with standard inferior alveolar nerve block in six out of eight studies. Aggarwal et al.[21] reported that success of articaine infiltration was lower than that of standard inferior alveolar nerve block. However, Poorni et al.[24] inferred that the effectiveness of both techniques was similar. In four clinical trials, the clinical success of articaine infiltration was superior to the standard inferior alveolar nerve block, however, the differences were not statistically significant. The authors suggested articaine infiltration as a viable alternative to the standard inferior alveolar nerve block. Articaine infiltration technique is simple, patient experience less injection pain, is more comfortable to the patient, avoids numbness of tongue and lower morbidity or chances of injury to the nerve as compare to standard inferior alveolar nerve block.[36]

The two trials based on intraosseous technique methods[20],[22] reported that intraosseous technique was better than the standard inferior alveolar nerve block, but the difference was not statistically significant. The intraosseous technique injection is usually associated with more discomfort, requires special armamentarium, causes transient tachycardia, and may be associated with root damage. For these reasons, Razavian et al.[20] concluded that is should not be used as a primary technique. However, Remmers et al.[22] reported it to be more predictable. The authors could not found any comparative systematic reviews comparing these two techniques as a head-on comparison.

When compared results of the current review with the other systematic reviews done on the topic,[27],[32] somewhat similar results were observed. However, other reviews have employed articaine infiltration as a supplemental anesthesia where lidocaine was compared with articaine; therefore, the difference among the groups was on the basis of chemistry or supplementation. In the present review, only those trials where articaine infiltration was employed as the primary anesthetic technique were considered, hence eliminating the difference on the basis of the chemistry of a local anesthetic agent.

Risk of bias assessment of all included studies was done using EPOC criteria[37] [Figure 3]. The highest risk of bias was reported in two studies[20],[25] and low risk of bias was reported in one study.[23] Among all studies, none of the authors mentioned any conflicts of interests or sponsorship statement; therefore, conflict of interests and other biases were remained unclear. In a study by Monteiro et al.,[23] the high risk was only reported for blinding, while in the studies done by Rajput et al.[25] and Razavian et al.[20] along with blinding, a high risk was also reported for incomplete outcome data and selective reporting. The quality of methodology in all the included studies was not excellent, so the need of high-quality clinical trials on this topic is warranted. [Figure 4] shows the overall risk of bias of the present systematic review. The highest risk of bias was regarding lack of blinding, followed by incomplete reporting of outcome data and selective reporting. The conflicts of interest and other biases remained uncleared.
Figure 3: Risk of bias assessment of individual studies included in the present systematic review

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Figure 4: Overall risk bias in the present systematic review

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The strengths of the present systematic review were that it is first of its kind comparing multiple anesthetic techniques in mandibular posterior teeth with irreversible pulpitis. Studies with the highest level of evidence, i.e., randomized controlled trials, were included only. Quality assessment of all the included studies was performed. The research question was more focused and commensurate with a problem routinely encountered in clinical practice that is achieving predictable anesthesia in mandibular posterior teeth with irreversible pulpitis. There were some limitations in the present review, such as the measure of heterogeneity was not explored and no conclusive inference regarding Gow-Gates block and Vazirani–Akinosi techniques could be drawn on account of limited data (one study only). It is recommended that high-quality randomized controlled trials evaluating different local anesthesia techniques, especially Gow-Gates block and Vazirani–Akinosi techniques, should be carried.


  Conclusions Top


Within the limitations, conclusions are following:

  1. No mandibular anesthetic technique provided 100% success
  2. The standard inferior alveolar nerve block was not significantly better than articaine infiltration technique in patients with irreversible pulpitis, P = 0.07. However, the overall result of the meta-analysis favors articaine infiltration
  3. Intraosseous technique appeared to be viable alternative to the standard inferior alveolar nerve block in posterior teeth with irreversible pulpitis
  4. The effectiveness of Gow-Gates block and Vazirani–Akinosi techniques cannot be determined on account of insufficient data.


Acknowledgments

We would like to thank Khawaja Mustafa (Librarian).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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