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The Inferior Alveolar Nerve Block Is the Most Frequently Used for Achieving Anesthetic Efficacy of a Labial plus Lingual Infiltration Compared to a Labial Infiltration using Articaine in Mandibular Anterior 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 Frederick Micah Nuzum, D.D.S. Graduate Program in Dentistry The Ohio State University 2009 Master’s Examination Committee Dr. Melissa Drum, Advisor Dr. John M. Nusstein Dr. Al Reader Dr. F. Michael Beck Copyright by Frederick Micah Nuzum, D.D.S. 2009 ABSTRACT The purpose of this prospective, randomized, single-blinded study was to determine the anesthetic efficacy of a combination labial plus lingual infiltration compared to a labial infiltration using 4% articaine with 1:100,000 epinephrine in mandibular anterior teeth. Eighty-two subjects randomly received mandibular lateral incisor infiltrations, either a combination of labial and lingual (totaling 3.6 mL) or labial and mock (totaling 1.8 mL), utilizing cartridges of 4% articaine with 1:100,000 epinephrine at two separate appointments spaced at least 1 week apart. In mandibular lateral incisors, the labial and lingual combination exhibited a significantly higher anesthetic success rate of 98% success when compared with a 76% success rate with the single labial infiltration. Similarly, the central incisor and canine adjacent to the infiltrations exhibited significantly higher anesthetic success rates when compared with the single infiltration. In conclusion, a mandibular infiltration combining a labial and lingual cartridge of 4% articaine with 1:100,000 epinephrine statistically improved anesthetic success when compared with a single labial infiltration with 4% articaine with 1:100,000 epinephrine. ii Dedicated to my wife- Your unconditional love and encouragement, and your eternal perspective and support for me have been a benchmark through all of this educational journey. You are the rarest treasure and a lifelong gift. Philippians 1:3 I love you. iii ACKNOWLEDGMENTS I wish to specially thank my advisor, Dr. Melissa Drum. Thank you for your encouragement, positive attitude and reinforcement. You are a great teacher and listener and your quest for knowledge, excellence, and fun shows through in all of your teaching efforts. I thank Dr. Al Reader for your experience and practical knowledge. Your humor and wisdom is an integral part to the success and sustenance of this excellent program. Thank you for letting me be a part of your “endo” family. I promise to put a few more hours into refining my golf skills in the following years! I thank Dr. John Nusstein for giving me the opportunity to learn and achieve skills that I would not have found in any other program. For keeping the fires hot – to learn faster and more predictable endodontic skills to get the job done. I thank Dr. William Meyers for your absolute devotion and willingness to make others succeed. Thanks for your wisdom, kindness, and legacy. May your sharp mind continue to guide and support this program. I thank Dr. Michael Beck for your commitment and support. Thank you for making statistics, though almost in all regards a foreign language to me, understandable, purposeful, and useful. Your search for the truth and accuracy comes through with clarity. I thank my co-residents Aaron Aue, Mayes McEntire, and Mark Oleson. May your lives be rich with blessing and success in all that you pursue. iv VITA 2002………………………………………B.A. The Ohio State University 2006………………………………………D.D.S. The Ohio State University 2009……….……………………………..Specialization in Endodontics Post-Doctoral Certificate, The Ohio State University FIELDS OF STUDY Major Field: Dentistry Specialization: Endodontics v TABLE OF CONTENTS Page Abstract…………………………………………………………………………………...ii Dedication………………………………………………………………………………...iii Acknowledgments………………………………………………………………………..iv Vita………………………………………………………………………………………..v List of Tables……………………………………………………………………………viii List of Figures……………………………………………………………………………..x Chapters: 1. Introduction……………………………………………………………………………..1 2. Literature Review………………………………………………………………………5 Mechanism of Action of Local Anesthetics……………………………………....5 Pharmacology of Local Anesthetics........................................................................8 Vasoconstrictors in Local Anesthetics......……………………………………….11 Articaine.................................................................................................................14 Safety…………....…....………………………………………………….18 Efficacy, Onset Time, and Duration of Articaine for Mandibular Infiltration injections……………………………………………..30 Mandibular Anesthesia: Articaine for Inferior Alveolar Nerve Block….……….40 Mandibular Infiltration Injection………………………………………………...44 Posterior Infiltration……………………………………………………..44 Anterior Infiltration………………………………………………………52 The Electric Pulp Tester………………………………………………………….56 The Visual Analogue Scale………………………………………………………59 Topical Anesthetic……………………………………………………………….60 3. Materials and Methods………………………………………………………………...64 4. Results…………………………………………………………………………………72 5. Discussion …………………………………………………………………………….78 Discussion of Materials and Methods……………………………………………78 Discussion of Results..........................................................................................102 Discussion of Age......…………..………………………………………103 Discussion of Weight Related to Dosage of Articaine……….….……..103 vi Discussion of Gender Related to Pain and Anesthesia…………………104 Pain of Injection………………………………………………………...109 Pain on Needle Insertion….…………………………………….109 Pain on Needle Placeement……………………………………..115 Pain on Solution Deposition…………………………………….117 Anesthetic Efficacy…………………………...........................................131 Frequency of Pulpal Anesthesia……………………....………...132 Anesthetic Success………………………………………...........141 Anesthetic Failure……………………………………………….155 Onset of Pulpal Anesthesia……………………………………...159 Slow Onset of Anesthesia, Short Duration of Anesthesia, and Noncontinuous Anesthesia…………………………163 Duration of pulpal anesthesia…………………………………………...168 Postoperative Pain………………………………………………………172 Postoperative Complications…………………………………...177 6. Summary and Conclusions…………………………………………………………..182 Appendices A. Tables…………………………………………………………...187 B. Figures………………………………………………………….208 C. Biographical Data………………………………………………212 D. Health history questionnaire……………………………………214 E. Consent…………………………………………………………217 F. HIPAA………………………………………………………….226 G. VAS form and raw VAS pain score data……………………….230 H. Electric pulp testing form and raw EPT data…………………...242 References…………………………………………………….………….……...…...….237 vii LIST OF TABLES Table Page 1. Biographical Data for All Subjects……………..…………………....………….188 2. Mean VAS Values (mm) of Procedural Discomfort Ratings for Groups by Location of Injection, Step of Injection, and Gender...........................................189 3. Summary of Pain Ratings for Needle Insertion Utilizing Numerical Scale...................................................................................................190 4. Summary of Pain Ratings for Needle Placement Utilizing Numerical Scale...................................................................................................191 5. Summary of Pain Ratings for Anesthetic Deposition Utilizing a Numerical Scale...................................................................................................192 6. Between-Group Comparisons of Percent 80/80 for the Lateral Incisor..............193 7. Between-Group Comparisons of Percent 80/80 for the Central Incisor.....…….194 8. Between-Group Comparisons of Percent 80/80 for the Canine…………..…....195 9. Anesthetic Success by Group and Definition of Success………………………196 10. Anesthetic Failure by Tooth and Group …..........................................................197 11. Mean Onset (minutes) of Pulpal Anesthesia ………………………………..….198 12. Short Duration Anesthesia, Non-Continuous Anesthesia, and Slow-Onset by Group and Tooth………………………………………….……199 13. Mean VAS Values (mm) of Postoperative Discomfort Ratings for Groups by Gender…………………………………………………………………………..200 14. Summary of Pain Ratings for Post-op Day 0 Utilizing a Numerical Scale…….201 viii 15. Summary of Pain Ratings for Post-op Day 1 Utilizing a Numerical Scale.........202 16. Summary of Pain Ratings for Post-op Day 2 Utilizing a Numerical Scale….....203 17. Summary of Pain Ratings for Post-op Day 3 Utilizing a Numerical Scale….....204 18-1. Frequency of Subject-Reported Postoperative Complications by Day......... ......205 18-2. Frequency of Subject-Reported Postoperative Complications by Day…...…….206 19. Postoperative Complications Associated with Articaine Infiltration Injection for Groups by Location…………………….………….……………...207 ix LIST OF FIGURES Figure Page 1. Percentage of 80 Readings for the Lateral Incisor by Group and Time………..209 2. Percentage of 80 Readings for the Central Incisor by Group and Time….…….210 3. Percentage of 80 Readings for the Canine by Group and Time………..………211 x CHAPTER 1 INTRODUCTION The inferior alveolar nerve block is the most frequent injection used for achieving local anesthesia for both restorative and surgical procedures in the mandible. Yet, the inferior alveolar nerve (IAN) block does not always result in successful pulpal anesthesia (1-12). Anesthetic failure rates in anterior teeth have ranged from 10-90% (1-12). Recently, infiltration anesthesia has been advocated to supplement regional blocks, due to failure of inferior alveolar nerve blocks to achieve pulpal anesthesia in
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