1. Newcastle University, UK
Efficacy Of Dental Local Anaesthesia In Mandibular Teeth: Current Views
DDS, MPhil, PhD
Specialty Doctor OMFS: Kettering General Hospital
PhD Clinical Research Project
Newcastle University, UK
Dr Mohammad Dib Kanaa
O M I C S
Dubai 2015
Support and Sponsorship:
Kettering General Hospital
SAS
OMICS

2. Introduction (Healy and Pollard, 1999)
“Anaesthesia is the art or science of removing sensation of and reaction to a surgical procedure. Anaesthesia means loss of all forms of sensation whether it is the sense of pain, touch, temperature or position sense”
(Healy and Pollard, 1999)
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3. Introduction
Local anaesthesia is the method of choice for pain control during operative dental treatment;
It was reported that half of the local anaesthetic injections in the United States each year were IANB injections;
IANB is reported to be successful in 85-95% of cases (100, ,000 of injections were failure);
The success rate of mandibular anaesthesia with IANB extremely varied in the literature, it ranged between 30% to 97%.
IANB injection alone does not secure satisfactory pain free treatment.
(Montagnese et al., 1984; Donkor et al., 1990; Nist et al., 1992; Wong & Jacobsen 1992; McLean et al., 1993; Bou Dagher et al., 1997; Yared and Bou Dagher, 1997; Hannan et al., 1999; Yonchak et al., 2001; 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)
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4. Introduction Relevant variables of IANB failure: O M I C S
Obese; those with large and laterally flaring mandibles;
Very anxious;
Edentulous patients;
(Wong and Jacobsen, 1992)
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5. Causes of LA failure Anatomical Pathological Pharmaceutical
Pharmacological
Psychological
Technical
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(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)

6. Introduction Injection speed
There are conflicting views on the influence of rate of injection on the distribution of local anaesthetic drugs and its likely effect on securing anaesthesia.
(Rucci et al., 1995; Kaiser & Hargreaves, 2002; Oliveira et al., 2004)
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7. Introduction Summary
Therefore an investigation to establish if there is an association between speed injection (slow & rapid) and IANB, is required.
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8. Materials and Methods Study design
A double blind randomized crossover study design was employed using healthy volunteers aged over 18 years at the presentation of this research.
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9. Official clearances
NHS Trust
MHRA
LREC
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10. Materials and Methods Power calculation
Using 38 volunteers the study would have 80% power to detect an effect size of 0.9 (a shift of 0.9 standard deviations) in a continuous outcome measure assuming a significance level of 5% and a correlation of 0.5 between responses from the same subject.
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11. Materials and Methods Sampling randomised procedure
The 38 volunteers were randomly allocated for their first injection using web-based program (1) to receive slow or rapid injection at the first visit. At the second visit, the other IANB was provided.
(1) (
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12. Materials and Methods Inclusion criteria
Healthy 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.
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13. Materials and Methods Application techniques
The local anaesthetic needle was inserted midway between the internal oblique ridge and the pterygomandibular raphe and advanced until an adequate bony contact was achieved (direct or Halstead approach). Blinded and randomised application with 2mL of 2% lidocaine with 1:80,000 epinephrine for each volunteer was employed on two occasions after an adequate aspiration:
Rapid IANB delivery over 15s, the needle remained in place for a further 45s;
Slow IANB delivery over 60s.
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14. Materials and Methods Objective measurement of anaesthetic efficacy
Standard electronic pulp tester (1st molar, 1st or 2nd premolar & lateral incisor pulps);
(Analytic Technology, Washington, USA)
Unanaesthetised tooth on the other side of the lower jaw had been had pulp sensitivity readings performed twice at base lines and once at 10 and 45 minutes post injection;
An absence of pulp sensation when stimulated at the maximum output (80 reading) was the criterion for pulpal anaesthesia.
Baseline (twice)
At intervals of 2 mins
for first 10 mins
Then at intervals of
5 mins for 45 mins
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15. Criterion for success
An absence of pulp sensation when stimulated at the maximum output (80 reading) of tooth pulp testing
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16. Materials and Methods The statistical analysis of the study
Frequencies;
Descriptions;
Crosstabulation;
Pearson Chi-Square;
Fisher’s Exact Test;
McNemar Test;
Paired T test.
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17. Results
Objective assessment of pulpal anaesthesia after slow & rapid IANB injection
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18. Slow vs. Rapid IANB in 1st molar teeth
Results
Slow vs. Rapid IANB in 1st molar teeth
Percentage of frequency of 80 reading of 1st molar pulp anaesthesia (without sensation) at time intervals after Slow and rapid IANB
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19. Slow vs. Rapid IANB in premolar teeth
Results
Slow vs. Rapid IANB in premolar teeth
Percentage of frequency of 80 reading of premolar pulp anaesthesia (without sensation) at time intervals after Slow and rapid IANB
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20. Slow vs. Rapid IANB in lateral incisors
Results
Slow vs. Rapid IANB in lateral incisors
Percentage of frequency of 80 reading of lateral incisor pulp anaesthesia (without sensation) at time intervals after Slow and rapid IANB
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21. 1st molar vs. premolar vs. lateral incisor after Slow IANB
Results
1st molar vs. premolar vs. lateral incisor after Slow IANB
Percentage of frequency of 80 reading of 1st molar, premolar and lateral incisor pulp anaesthesia (without sensation) at time intervals after Slow IANB
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22. 1st molar vs. premolar vs. lateral incisor after Rapid IANB
Results
1st molar vs. premolar vs. lateral incisor after Rapid IANB
Percentage of frequency of 80 reading of 1st molar, premolar and lateral incisor pulp anaesthesia (without sensation) at time intervals after Rapid IANB
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23. Conclusion
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).
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24. The outcome
This study will help to inform: what and how best practice in everyday dental procedure should be.
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25. Articaine vs. Lidocaine In Mandibular buccal plus lingual infiltration4% 2%
1.8ml
(Haas et al., 1990; Yonchak et al., 2001; Meechan & Ledvinka, 2002; Kanaa et al., 2006)
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26. Aim
To evaluate the efficacy of articaine and lidocaine buccal plus lingual infiltrations in securing pulp anesthesia in vital mandibular first molars
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27. Research question (H0) O M I C S Dubai 2015 Articaine Lidocaine B & L
Infiltrations
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28. Materials and Methods
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29. Study design Randomized Double blind Crossover Prospective O M I C S
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30. Power calculation
Using 31 subjects would have 90% power to detect an effect size of 0.83 (a change of 0.83 standard deviations) in a continuous outcome measure assuming a significance level of 5%
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31. Official clearances
NHS Trust
MHRA
LREC
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32. Inclusion criteria Healthy adult volunteers 18 years old and over
Vital mandibular 1st molar
Signed the consent form
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33. Anesthetic Delivery Buccal & lingual infiltration
4% Articaine with
1:100,000 epinephrine
2% Lidocaine with
1:100,000 epinephrine
One week
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34. Buccal infiltration 0.9 mL Lingual infiltration 0.9 mL O M I C S
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35. Objective measurement
Mandibular first molar
Unanesthetised tooth
Base-line (twice)
At intervals of 2
mins until 30 mins
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36. Criterion for success
An absence of pulp sensation when stimulated at the maximum output (80 reading) on two or more consecutive episodes of testing
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37. Statistical analysis of the study
McNemar Test
Paired T test
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38. Results
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39. Changes from baseline pulp tester reading at first sensation (reading) in lower first molars
Paired T test, t=14, P < 0.001
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40. Episodes of no response to maximal (80 reading) stimulation at time intervals using articaine and lidocaine
Articaine vs. Lidocaine: 242, 114 respectively, McNemar Test, P < 0.001
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41. Anesthetic success 68% 32% O M I C S (10/31) (21/31) Dubai 2015
Articaine
Lidocaine
B & L
Infiltrations
(P = 0.001)
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42. Conclusions
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43. Articaine produced more episodes of no
response to maximal (80 reading) stimulation
at time intervals post injection than lidocaine
Articaine was more successful than lidocaine
in producing anaesthesia in lower first
molars after buccal plus lingual infiltrations
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44. Irreversible Pulpitis
in Mandibular Permanent Teeth
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45. Objectives
To compare the efficacy of supplementary repeat lidocaine IANB, ABI, lidocaine PDL and lidocaine IO following failed lidocaine IANB for securing pain free treatment in patients experiencing irreversible pulpitis in mandibular permanent teeth
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46. Research question (HO)
ABI IO
PDL
rIANB
Supplemented
IANB
Supplemented
IANB
IANB
Supplemented
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47. Materials and Methods Study design
A prospective randomized clinical trial design was employed
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48. Power calculation O M I C S
Based on outcome data for intraosseous anaesthesia, a study with at least 21 subjects in each supplementary technique group was reported to have 90% power to detect a difference in success rate of 82% (8% vs. 90%, Nusstein et al., 1998) assuming a significance level of 5% and a correlation of 0.5 between subjects
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49. Official clearances
NHS Trust
MHRA
LREC
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50. Inclusion criteria 182 healthy adult patients 18 years old and over
Irreversible pulpitis mandibular tooth
Signed the consent form
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51. Anaesthetic Delivery
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52. Objective measurement
Unanaesthetised tooth
Tooth with irreversible pulpitis
IANB injection
At intervals of 2
mins until 10 mins
or till 80 reading
on pulp test secured
Base-line (twice)
Supplementary Techniques
At intervals of 2 mins if no
80 reading then at 5 mins
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53. Criterion for LA success
An absence of pulp sensation when stimulated at the maximum output (80 reading) of testing
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54. Criterion treatment success
An absence of any sensation of pain during the treatment; even mild pain
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55. Statistical analysis of the study
SPSS software 17.0, SPSS Inc., Chicago, USA
Pearson Chi-Square
Fisher’s Exact Test
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56. Results
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57. General distribution
182 patients with mandibular irreversible pulpitis teeth
133 males: 73.1%
49 females: 26.9%
Age range: years old (mean 31.9, SD 10.0).
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58. O M I C S
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59. Premolars vs. Molars Treatment outcomes Success N % Failure Total N 6
Molars 71 77
Relationship between treatment outcomes in premolars and molars in 77 patients with a negative response to pulp testing after supplementary injections. (Chi-Square p = 0.14, Fisher’s Exact Test p = 0.33)
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60. Molar tooth & supplementary techniques
Treatment
outcomes
molars
r IANB
N %
ABI
N %
PDL IO
Total
Success
Failure 14 23 15 19 71
Experience of treatment success in 71 mandibular molar teeth after repeat IANB injection (r IANB), articaine buccal infiltration (ABI), intraligamentary (PDL) and intraosseous injection (IO): Pearson Chi-Square p = 0.025, Likelihood Ratio p = 0.021
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61. Anesthetic success O M I C S Dubai 2015 ABI 92% IO 84% PDL 72% 60%
rIANB
60%
Supplemented
IANB
Supplemented
IANB
IANB
Supplemented
(P = 0.04)
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62. Treatment success O M I C S Dubai 2015 PDL 67% 53% ABI IO 91% 81% IANB
rIANB
53%
ABI
91% IO
81%
Supplemented
IANB
Supplemented
IANB
IANB
Supplemented
(P = 0.04)
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63. Conclusions
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64. IANB injection alone does not secure satisfactory pain free treatment (45%)
Articaine buccal infiltration and intraosseous injections are better supplementary techniques than intraligamentary and repeat IANB injections for patients experiencing irreversible pulpitis in the mandibular permanent teeth
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65. Thank you O M I C S M.D. Kanaa J.M. Whitworth J.G. Meechan
Special Thanks:
Kettering General Hospital
SAS Support and Sponsorship
OMICS
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66. The first alphabet and first written musical note were discovered in Ugarit, Syria
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67. Thank You
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Syria: 5000 years of civilization