Effect of Premedication on the Success of Inferior Alveolar Nerve Block in Patients with Irreversible Pulpitis: A Systematic Review of the Literature
Table 2
Studies on the success of IANB using premedication by classification with drug type.
Author year
Study design
Power analysis
Corah dental anxiety
Initial pain
Anesthetic
Supplementary injection
No. of patients evaluated teeth-success rate
M/F
Age
Medications used
Success criteria
Results
Risk of bias
IBUPROFEN
Oleson et al. 2010
Prospective Double-blind Randomized (no explanation) Placebo-controlled
no
yes
Heft-parker vas
2% lidocaine with 1:100,000 epinephrine (0.9 mL for the long buccal injection)
100 Mandibular posterior teeth (molar or premolar); No subjects were eliminated as a result of lack of lip numbness after 15 min
45 M/ 55 F
32±8;33±12
Ibuprofen (800 mg) Placebo
Success=no or mild pain (heft-parker VAS) on pulpal access or instrumentation
No statistical significance
medium
Noguera-Gonzales et al. 2013
Double-blind Randomized (The patients were assigned sequential numbers in the order of their enrolment and received their allocated treatment according to a randomization schedule designed previously.) Placebo-controlled
yes
no
Heft-parker vas
2% mepivacaine with 1:100 000 epinephrine.
50
18 M/ 32 F
18-68
Ibuprofen (600 mg) Placebo
Failure=no lip numbness after 15 min or painful response to cold or painful response to endodontic access; heft-parker Vas only at the beginning
Significant improvement in the efficacy of IANB with preoperative administration of Ibuprofen.
medium
IBUPROFEN AND ACETAMINOPHEN
Modaresi et al 2006
Randomized (no explanation) Placebo-controlled Double-blind
no
no
Ept
2% lidocaine with 1:80 000 epinephrine (If no subjective signs of anesthesia, consisting of lower lip and tongue tip numbness, appeared within the time interval, readministration)
Success=no or mild pain (heft-parker VAS) on access, clean and shape
No significant difference
medium
IBUPROFEN, OTHER NON-STEROIDAL ANTI-INFLAMMATORY DRUGS AND CORTICOSTEROIDS
Parirokh et al. 2010
prospective Randomized (patient chooses an opaque envelope) Placebo-controlled Double-blind
yes
no
Heft-parker vas Significantly higher preoperative vas scores for indomethacin
2% lidocaine with 1:80000 epinephrine
150
71 M/ 79 F
18-64
Ibuprofen (600 mg) Indomethacin (75 mg) Placebo
Success=no or mild pain (heft-parker VAS) on pulpal access (within dentin, entering the chamber, file inserted into canal); failure=sensitivity to cold anytime after ianb
Significant improvement in IANB with preoperative administration of both Ibuprofen and Indomethacin.
medium
Aggarwal et al. 2010
Prospective Double-blind Randomized (with a linear congruential generator) Placebo-controlled
yes
no
Heft-parker vas with no mm
2% lidocaine with 1:200,000 epinephrine
69 (3 patients excluded unsuccessful anesthesia)
36 M/33 F
21-38
Ibuprofen (300 mg) Ketorolac (10 mg) Placebo
Heft-parker Vas in case of pain during endodontic treatment (success=no pain or weak/mild pain during Access preparation and instrumentation; The millimeter marks were removed from the VAS
No significant difference
medium
Aggarwal et al. 2011
Prospective Randomized (simple random generator) Double-blind Control (no supplemental injection)
yes
no
Heft-parker vas with no mm
2% lidocaine with 1:200,000 epinephrine
94 (2 patients excluded unsuccessful anesthesia 2 patients excluded for severe transient injection pain- ketorolac tromethamine)
45 M/ 49 F
24-36
supplemental buccal infiltration of 4% articaine with 1:100,000 ephinephrine; supplemental buccal infiltration of 1 mL/4 mg of dexamethasone; supplemental buccal infiltration of 1 mL/30 mg of ketorolac tromethamine preceeded by 0.9 mL of 4% articaine infiltration-10 min.
Heft-parker Vas in case of pain during endodontic treatment (success=no pain or weak/mild pain during Access preparation and instrumentation; The millimeter marks were removed from the VAS
Articaine and articaine+ketorolac significantly increased success rate
medium
Jena &Shashirekha 2013
Prospective Randomized (no explanation) Double-blind Placebo-controlled
Heft-parker Vas 15 min after iabn and in case of pain during treatment; success=no or mild pain at any stage during the endodontic procedure; failure=no lip numbness 15 min after injection)
Significant improvement with both Ibuprofen and Dexamethasone Significantly more effective (successful) than placebo
medium
Shantiaee et al. 2017
Double-blind Randomized (patient chooses an envelope) Parallel (Placebo and control groups)
no
no
Heft-parker vas EPT
2% lidocaine with 1:100,000 epinephrine
92
44 M/ 48 F
Means 29.26, 32.78, 31.7,32.22
Meloxicam (7.5 g.) Ibuprofen (600 mg) Placebo no medication
Success= no, or only mild, pain (VAS recordings) while preparing the access cavity or during initial instrumentation and no response to the EPT
Significant improvement with meloxicam and ibuprofen
high
OTHER NON-STEROIDAL ANTI-INFLAMMATORY DRUGS
Prassana et al. 2011
Randomized (with a linear congruential generator) Double-blind Placebo-controlled
yes
no
Heft-parker vas
2% lidocaine with 1:200,000 epinephrine
114
55 M/ 59 F
21-40
Larnoxicam (8 mg) Diclofenac (50 mg) Placebo.
Failure=pain or sensitivity to cold and pain during access; Heft-parker Vas but The millimeter marks were removed from the VAS
Significant improvement with Larnoxicam; Significantly high post-injection vas scores in placebo
medium
Paul et al. 2011
Prospective Double-blind (no explanation) Randomized (no explanation) Placebo-controlled
no
yes
Heft-parker vas
2% lidocaine with 1:100000 epinephrine (0.9 mL for the long buccal injection)
40
23 M/ 17 F
Means 30.4 and 31.7 not younger than 18
Acclofenac (100 mg) Placebo
Heft-parker vas;success=no pain or weak/mild pain during Access preparation and instrumentation
Piroxicam (20 mg) Diclofenavc potassium (50 mg) Naproxen sodium (550 mg) Placebo (drug becefol?) 1 h before
No pain during endodontic treatment
Significantly greater success with piroxicam compared to naproxen sodium and placebo; No difference between piroxicam and diclofenac potassium
high
Yadav et al. 2015
Prospective Double-blind Randomized (no explanationr) controlled
no
no
Heft-parker vas with no mm
4% articaine with 1:100,000 epinephrine 2% lidocaine with 1:80,000 epinephrine
150
78 M/ 72 F
20-35
(1) 0.9 mL BI and 0.9 mL LI with either articaine or lidocaine (2) Ketorolac (10 mg) (3) Ketorolac (10 mg) followed by BI and LI (0.9 mL each) with either articaine or lidocaine
Success= no, or only mild, pain (VAS recordings) while preparing the access cavity or during initial instrumentation
Significant improvement with Articaine + oral ketorolac premedication Significant improvement with Articaine +infiltration+ketorolac; Articaine+infiltrations better than lidocaine+infiltrations
high
Saha et al. 2016
Prospective Double-blind Randomized (with a linear congruential generator) Placebo-controlled
success=no pain during Access preparation and instrumentation
Significant improvement with Ketorolac; both for vas and success significant differences among three groups:ketrolac-diclofenac-placebo
medium
Akhlaghi et al. 2016
Prospective Double-blind (++) Randomized (random number table) Placebo-controlled
yes
no
Heft-parker vas with no mm, pain (visual analog scale >54) with prolonged response to cold testing (lingering pain for more than 45 seconds)
1.8 mL 4% articaine with 1:100,000 epinephrine (buccal infiltration of 0.9mL articaine immediately after the block injection)
Whenever an extra injection was applied because of severe pain at any stage, the patient’s pain score was recorded, and that patient was excluded from the remainder of the study.-failure
40 11 %40 %15
16 M/ 24 F
18-65
After 5 minutes buccal infiltration of 30 mg/mL ketorolac tromethamine buccal infiltration of normal saline (Placebo)
Heft-parker vas; Success=absence of pain or only mild pain present during any of the stages of treatment (caries and dentin removal (CDR), access cavity preparation (ACP), and canal length measurements (CLM) stages)
ketorolac significantly increased the success rate
medium
OPIOID ANALGESICS
Fullmer et al. 2014
Prospective Double-blind Randomized (random numbers identified the medications) Placebo-controlled
yes
yes
Heft-parker vas
2% lidocaine with 1:100,000 epinephrine (0.9 mL for the long buccal injection)
100 Mandibular posterior teeth (molar or premolar)
Success=no or mild pain (heft-parker VAS) on pulpal access or instrumentation; second cartridge if nı lip numbness after 15 min-4in premedication and 5 in placebo group out of 100 patients)
1.3 mL of 2% mepivacaine with epinephrine 1 : 100 000 plus 0.5 mL of tramadol 50 mg mL 1 (experimental group) or 1.8 mL of 2% mepivacaine with epinephrine 1 : 100 000 (control group).
56
16 M/40 F
18-50
1.3 mL of 2% mepivacaine with 1 : 100 000 epinephrine + 0.5 mL tramadol 50 mg mL(experimental group) 1.8 mL of 2% mepivacaine with epinephrine 1 : 100 000 (control group).
Success= zero value on heft-parker vas (100 mm?) on all following steps: numbness of the lip, positive or negative cold test, asymptomatic management of dental hard tissues and access to dental pulp
No significant difference
medium
De-Pedro Munoz & Mena-Alvarez 2017
Randomized (nonprobabilistic sampling of consecutive cases, randomization software) Double-blind Placebo-controlled
Pilot study
no
vas
4% articaine with 1 : 100 000.epinephrine
42
equal
Mean 40.35 and 37.7
Tramadol (50 mg) mandibular infiltration and a placebo group
Success=2 consecutive negative response out of 3 to electric pulp tester at maximum and negative response to cold and no pain during access cavity preparation/instrumentation
Significant improvement with Tramadol; Tramadol significantly higher success during access cavity
high
Mahajan et al. 2017
Randomized (patient picks one of the slips with medication name on it from a box) Double-blind Placebo-controlled
Failure=No Lip numbness after 15 min;success=Heft-parker vas no ormild pain during procedure
Significant improvement with Tradamol Success rate significantly higher compared to placebo
high
BENZODIAZEPINES
Lindemann 2008
Prospective Double-blind Randomized (no explanation) Placebo-controlled
no
yes
Heft-parker vas
2% lidocaine with 1:100,000 epinephrine
58 Mandibular posterior teeth (molar or premolar)
34 M/ 24 F
18-62
Triazolam ( 0.25 MG) Placebo
success=Heft-parker vas no or mild on access or initial instrumentation
No significant difference
medium
Khademi et al. 2012
Prospective Double-blind Randomized (random number generator Placebo-controlled
no
yes
Heft-parker vas
2% lidocaine with 1:100,000 epinephrine
60
30 M/ 30 F
18-50
Alprazolam (0.5 mg) Placebo
success=Heft-parker vas no or mild on access cavity preparation and initial instrumentation
No significant difference
medium
Shetkar et al. 2016
Randomized (no explanation) Double-blind Placebo-controlled
yes
yes
Heft-parker vas
inferior alveolar, Vazirani-Akinosi, and Gow-Gates techniques 2% lidocaine with 1:100,000 epinephrine
180 (60 patients for each technique) 14 patients excluded unsuccessful anesthesia, 4 patients excluded for statistics
96M/84 F
18-50
Placebo and Alprazolam (0.5 mg.)+ Diclofenac potassium (50 mg.) for all 3 types of anesthesia.
Heft-parker Vas following access cavity preparation or initial file placement
Significant improvement with Alprazolam combined with diclofenac potassium. for all 3 types of anesthesia.
low
NITROUS OXIDE AND OTHER SEDATIVES
Kaviani et al. 2011
Randomized (on the day of treatment randomly assigned) Double-blind Placebo-controlled
no
no
no
2% lidocaine with 1/100000 epinephrine
36
15-45
Ketamine ( 10 mg) Placebo
Vas following treatment (positive response to pulp tester after 5-10 min-another cartridge injected IANB and the total number of cartridges recorded;during treatment in case of pain supplemental injections;questionnire for ibuprofen taken for the first 24 hours following treatment)
Significant improvement with ketamine
high
Stentz et al. 2018 +nitrous oxide
Prospective Double-blind (++) Randomized (6-digit random numbers) Placebo-controlled
no
no
Heft-parker vas, Spontaneous and greater than 54 mm-moderate or severe
3.6 mL 2% lidocaine with 1:100,000 epinephrine
topical anesthetic gel; molar teeth were given a buccal nerve block using 0.4 mL 2% lidocaine with 1:100,000 epinephrine for rubber dam clamp anesthesia. Failure-If the pain rating was moderate or greater during treatment, supplemental anesthesia was administered (buccal infiltration of articaine and/or intraosseous injections).
102 Mandibular posterior teeth (molar or premolar) 51 %54 %46
36 M/ 66 F
18-64, less than 110 lb weight
Intranasal ketorolac (31.5 mg ketorolac tromethamine) + nitrous oxide/oxygen (10 min before IANB and 20 min after intranasal ketorolac) Placebo (31.5 mg intranasal bacteriostatic 0.9% sodium chloride(saline) + nitrous oxide/oxygen (10 min before IANB and 20 min after intranasal saline)
Heft-parker vas; success=no pain or weak/mild pain ability to access and instrument
No significant difference
high
Sakhaeimanesh et al. 2017
Prospective Double-blind (++) Randomized (no explanation) Placebo-controlled
no
no
Heft-parker vas (96±30.2 and 101±30)
1.6 mL 4% articaine with 1:200000 Epinephrine + 0.2 mL ketamine hydrochloride (50 mg/mL) 1.6 mL 4% articaine with 1:200000 Epinephrine + 0.2 mL normal saline (Placebo)
Failure-If the pain rating was moderate or greater during treatment
42 Mandibular posterior teeth (molar or premolar) %55 %42.9
24 M/ 18 F
19-56
1.6 mL 4% articaine with 1:200000 Epinephrine + 0.2 mL ketamine hydrochloride (50 mg/mL) 1.6 mL 4% articaine with 1:200000 Epinephrine + 0.2 mL normal saline (Placebo)
success=Heft-parker vas no or mild on access cavity preparation and initial instrument placement
No significant difference
medium
Stanley et al. 2012
Prospective Double-blind (++) Randomized (6-digit random number) Placebo-controlled
yes
yes
Heft-parker vas, moderate or severe
3.6 mL of 2% lidocaine with 1:100,000 epinephrine
Topical anesthetic gel The patients who reported moderate or severe pain (VAS rating >54 mm) during access into dentin or when entering the pulp chamber -failure
100 Mandibular posterior teeth (molar or premolar) 39 %50 %28
43 M/ 57 F
Means 33±11 and 35±13 not younger than 18
inhalation regimen of nitrous oxide/oxygen mix 5 min before the IANB inhalation regimen of room air/ oxygen mix (placebo) 5 min before the IANB
success = ability to access and clean and shape the canals without pain (VAS score of 0) or mild pain (VAS rating ≤54 mm).
administration of 30%–50% nitrous oxide resulted in a statistically significant increase in the success
Bigby et al. 2007
Prospective Single-blind (patient? +) Randomized (5-digit random number) Controlled ???
no
no
Heft-parker vas, (104±36 and 103±31)
1.8 ml of 36 mg of lidocaine with 18 μg of epinephrine 3.6 ml of 36 mg of lidocaine with 18 μg of epinephrine plus 36 mg meperidine with 18 μg of epinephrine
Topical anesthetic gel long buccal nerve injection using a quarter of a cartridge of 2% lidocaine with 1:100,000 epinephrine The patients who reported moderate or severe pain (VAS rating >54 mm) within dentin, entering the pulp chamber, or initial file placement-failure
50 Mandibular posterior teeth (molar or premolar) 8 %26 %12
20 M/ 28 F
20-53
1.8 ml of 36 mg of lidocaine with 18 μg of epinephrine 3.6 ml of 36 mg of lidocaine with 18 μg of epinephrine plus 36 mg meperidine with 18 μg of epinephrine
success = ability to access and instrument the tooth without pain (VAS score of 0) or mild pain (VAS rating ≤54 mm).
No significant difference
high
HYPEROSMOLAR SOLUTIONS
Kreimer et al. 2012 Study 1 Mannitol: natural diuretic
Prospective Single-blind (patient?+) Randomized (4-digit computer random number) Controlled
yes
no
Heft-parker vas (89±43 and 92±53)
3.18 mL of lidocaine (63.6 mg) with 31.8 μg Epinephrine 3.18 mL of lidocaine (63.6 mg) with 31.8 μg epinephrine plus 1.82 mL of 0.5 mol/L mannitol (5 mL)
If the patient felt pain, Heft–Parker VAS moderate or severe-failure
55 Mandibular posterior teeth (molar or premolar)
25 M/ 30 F
19-60
3.18 mL of lidocaine (63.6 mg) with 31.8 μg Epinephrine 3.18 mL of lidocaine (63.6 mg) with 31.8 μg epinephrine plus 1.82 mL of 0.5 mol/L mannitol (5 mL)
Heft-parker vas; success=no pain or weak/mild pain ability to access and instrument
No significant difference
medium
Kreimer et al. 2012 Study 2 Mannitol: natural diuretic
Prospective Single-blind (patient?+) Randomized (4-digit computer random number) Controlled
yes
no
Heft-parker vas (73±36 and 71±41)
1.9 mL of lidocaine (76.4 mg) with 36 μg Epinephrine 1.9 mL of idocaine (76.4 mg) with 36 μg epinephrine plus 1.1 mL of 0.5 mol/L mannitol (3mL)
If the patient felt pain, Heft–Parker VAS moderate or severe-failure
51 Mandibular posterior teeth (molar or premolar)
15 M/ 36 F
18-59
1.9 mL of lidocaine (76.4 mg) with 36 μg Epinephrine 1.9 mL of idocaine (76.4 mg) with 36 μg epinephrine plus 1.1 mL of 0.5 mol/L mannitol (3mL)
Heft-parker vas; success=no pain or weak/mild pain ability to access and instrument
addition of 0.5 mol/L mannitol to 1.9 mL of lidocaine (76.4 mg) with epinephrine resulted in a statistically higher success rate
medium
ANTIHYPERTENSIVE MEDICATIONS AND MAGNESIUM SULPHATE
Hemodynamic parameters were continuously monitored by an electrocardiogram monitor
Heft-parker vas (103±19 and 102±17)
1.8 mL of 2% lidocaine with clonidine (15 lg mL−1) 1.8 mL of 2% lidocaine with epinephrine (12.5 lg mL-1) (Control group)
topical anesthetic gel At each step, when patients reported moderate to severe pain (>54 mm), the IANB was considered to have failed.
100 (98) 43 %59 %29
49 M/ 51 F
18-56
1.8 mL of 2% lidocaine with clonidine (15 lg mL−1) 1.8 mL of 2% lidocaine with epinephrine (12.5 lg mL-1) (Control group)
Heft-parker vas; Success=absence of pain or only mild pain in all of the following steps (penetrate dentine, enter the pulp and advance instruments into the coronal part of the canal pulp)
clonidine group exhibited a significantly higher success rate
medium
Shetty et al. 2015
Prospective Double-blind (++) Randomized (6-digit random number) Placebo-controlled
no
no
Heft-parker vas (135.6±10.2 and 136.96±9.5)
1.8 mL 2% lidocaine with 1:100,000 epinephrine
moderate or severe pain (heft- parker VAS score, >54 mm) during access cavity preparation or initial file placement received supplemental anesthetic injection-failure
100 mandibular posterior tooth (premolar or molar) %58 %32
42 M/ 58 F
Means 33.48±3.8 and 31.8±4.4 not younger than 18
injection of 1 mL magnesium sulfate USP 50% -60 min before IABN Injection of 1 mL distilled water (placebo) -60 min before IABN
Heft-parker vas, Success= access cavity preparation or initial file Placement without pain (VAS score, 0 mm) or with mild pain (VAS score, ≤54 mm).
preoperative administration of 1 mL magnesium sulfate USP 50% resulted in statistically significant increase in success of IAN block compared with placebo.
