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View………………………………………………………………………5 Mechanism of Action of Local Anesthetics……………………………………....5 Pharmacology of Local Anesthetics ANESTHETIC EFFICACY OF 3.6 ML OF 4% ARTICAINE WITH 1:100,000 EPINEPHRINE COMPARED TO 1.8 ML OF 4% ARTICAINE WITH 1:100,000 EPINEPHRINE AS PRIMARY BUCCAL INFILTRATIONS IN MANDIBULAR POSTERIOR TEETH A Thesis Presented in Partial Fulfillment of the Requirements for The Degree of Master of Science in the Graduate School of The Ohio State University By Matthew Joshua Martin, D.D.S. Graduate Program in Dentistry The Ohio State University 2010 Master’s Examination Committee Dr. John M. Nusstein, Advisor Dr. Al Reader Dr. Melissa Drum Dr. F. Michael Beck Copyright by Matthew J. Martin 2010 ABSTRACT The purpose of this prospective, randomized, single-blind study was to compare the anesthetic efficacy of 3.6 mL of 4% articaine with 1:100,000 epinephrine to 1.8 mL of 4% articaine with 1:100,000 epinephrine in mandibular buccal infiltration injections given next to the first molar. Using a cross-over design, 86 adult subjects (43 males and 43 females) randomly received two primary buccal mandibular infiltration injections given next to the first molar of 3.6 mL of 4% articaine with 1:100,000 epinephrine and 1.8 ml of 4% articaine with 1:100,000 epinephrine, in two separate appointments, spaced at least one week apart. The second molar through the first premolar were tested with an electric pulp tester every 3 minutes for a total of 90 minutes. The pain of injection and any postoperative discomfort over the next three days was rated by the subjects on a Heft-Parker visual analogue scale. Each test tooth had a higher percentage of 80/80 readings for each test time when the 3.6 mL volume was injected but not all differences reached statistical significance. Anesthetic success was defined as two consecutive 80/80 readings at any point during the testing time. The incidence of anesthetic success was 65.1% and 48.8% of second molars, 75.6% and 52.3% of first molars, 92.9% and 87.1% of second premolars, and 91.9% and 81.4% of first premolars for Group 1 (3.6 mL volume) and Group 2 (1.8 mL volume), respectively: There was no statistically significant difference in anesthetic success ii between Groups 1 and 2 for the second premolar (p=0.1797), but the second molar, first molar, and first premolar were significantly different (p=0.0129, <0.0001, and =0.0234, respectively). The incidence of anesthetic failure was 34.9% and 51.2% in the second molars, 24.4% and 47.7% in the first molars, 7.1% and 12.9% in the second premolars, and 8.1% and 18.6% in the first premolars for Group 1 and Group 2, respectively. There was no statistically significant difference between Groups 1 and 2 for the second premolar (p=0.1797), but the second molar, first molar, and first premolar were significantly different (p=0.0129, <0.0001, and =0.0234, respectively). The percentages of short duration of anesthesia was significantly higher for second molar, first molar, second premolar, and first premolar in Group 2 (1.8 mL volume) compared to Group 1 (3.6 mL volume) (p=0.0215, 0.0068, <0.0001, and =0.0001, respectively). There were no significant differences between Groups 1 and 2 for any of the four teeth tested for slow onset of anesthesia or for incidences of non- continuous anesthesia. There were no significant differences in pain ratings between the two volumes for needle insertion, needle placement, or anesthetic deposition. The 3.6 mL volume had significantly higher pain ratings at each post-operative period, but the average pain ratings were still in the mild category. In conclusion, the anesthetic efficacy of 3.6 mL of 4% articaine with 1:100,000 iii epinephrine was superior to 1.8 mL of 4% articaine with 1:100,000 epinephrine in a single primary mandibular buccal infiltration injection given next to the first molar. iv Dedicated to my parents Michael and Julie Martin. Your love and inspiration allowed me to chase my dreams. Without your support and sacrifice none of this would have been possible for me. I love you more than you could ever know and continue to miss you more with every passing day, Dad. v ACKNOWLEDGMENTS I wish to specially thank my advisor, Dr. John Nusstein. Thank you for your hard work, dedication to teaching, and your guidance over the last two years. You are an incredible teacher and mentor, and your passion for endodontics, Ohio State, and your residents shows through in all of your teaching efforts. I will miss the slow afternoons that enabled us to talk about sports and life. I thank Dr. Al Reader for your great humor and love of teaching. Your experience and dedication to our program is an integral part to the success of all who are fortunate enough to attend Ohio State. Thank you for teaching me about how to hire staff people (the elbow test), and for all of your support over the years. You are a huge part of the reason Ohio State Endo has the excellent, and well deserved, reputation it does. I thank Dr. Melissa Drum for helping to teach me everything Endo. Your great personality and love of what you do made residency fun. I hope I’ve made Yoda proud with my endodontic knowledge and clinical skills. We need more people like you in education. I am relieved to know that you will continue the great tradition of OSU Endo for the decades to come. I thank Dr. William Meyers for your amazing stories of every historical person in endodontics. Your wisdom, kindness, and dedication to teaching young dental students and residents is inspiring. I hope you continue to shape the minds of students for many more years to come. I thank Dr. Michael Beck for your commitment and support. Thank you for making my life easier and taking the time to explain stats to me. Your continued dedication to the College of Dentistry and specifically the Division of Endodontics is appreciated more than you could ever know. I thank my co-residents Sara Fowler, Kevin Wells, and Mike Simpson. You have become like a dysfunctional family to me over the last two years. I will cherish the time I spent with you for the rest of my life. I hope life continues to bring each of you everything you are searching for. I thank all of the dental students who helped me complete my research including Jonathan Mason, Spencer Fullmer, Matt Balasco, Vivian Kaufman, and Josh Melton. Without your help I would still be pulp testing teeth. vi VITA February 28, 1982……………………….....Born – Peoria, Illinois 2004………………………………………..B.A. Psychology, University of Michigan 2008………………………………………..D.D.S., University of Michigan 2010……….……………………………….Specialization in Endodontics Post-Doctoral Certificate, The Ohio State University FIELDS OF STUDY Major Field: Dentistry Specialization: Endodontics vii TABLE OF CONTENTS Page Abstract…………………………………………………………………………………....ii Dedication………………………………………………………………………………....v Acknowledgments………………………………………………………………………..vi Vita………………………………………………………………………………………vii List of Tables……………………………………………………………………………...x List of Figures……………………………………………………………………………xii Chapters: 1. Introduction……………………………………………………………………………..1 2. Literature Review………………………………………………………………………5 Mechanism of Action of Local Anesthetics……………………………………....5 Pharmacology of Local Anesthetics........................................................................8 Articaine.................................................................................................................11 Safety of Articaine………………………………….....................………17 Efficacy of Articaine……………………………………………………..32 Onset and Duration of Articaine…………………………………............49 Vasoconstrictors………………………………………………………………….53 Mandibular Buccal Infiltration Injection………………………………………..57 Effect of Volume on Anesthesia…………………………………………………65 The Electric Pulp Tester………………………………………………………….68 The Visual Analogue Scale………………………………………………………71 3. Materials and Methods………………………………………………………………...73 4. Results…………………………………………………………………………………80 5. Discussion of Materials and Methods............................................................................92 6. Discussion of Results...................................................................................................114 Subject Biographical Information………………………………………114 Sex Differences in Pain…………………………………………………115 Pain of Injection.......................................................................................118 Pain during needle insertion…………………………………….118 Pain during needle placement…………………………………...122 viii Pain during solution deposition…………………………………124 Anesthetic Efficacy…………………………..........................................130 Frequency of Pulpal Anesthesia………………………………………...131 Anesthetic Success……………………………………………………...137 Anesthetic Failure……………………………………………………….149 Onset of Pulpal Anesthesia……………………………………………...152 Duration of Pulpal Anesthesia…..……………………………………...154 Slow Onset of Anesthesia, Short Duration of Anesthesia, and Non-continuous Anesthesia………………………………..157 Postoperative Pain………………………………………………………162 7. Summary and Conclusions…………………………………………………………..174 Appendices A. Tables…………………………………………………………...178 B. Figures…………………………………………………………..204 C. Biographical Data………………………………………………211 D. Medical History Form……..……………………………………213 E. Consent…………………………………………………………216 F. HIPAA………………………………………………………….223 G. Random code list………………………………………………..227 H. VAS form and raw VAS pain score data……………………….232 I. Electric pulp testing form and raw EPT data…………………...234 References…………………………………………………….………….……...…...…240 ix LIST OF TABLES Table Page 1. Biographical data for all subjects…………………………………....………….179 2. Mean VAS values (mm) for infiltration injection………………………………180 3 Mean VAS values (mm) for
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