PEDIATRIC DENTISTRY V 40 / NO 7 NOV / DEC 18 O COHORT STUDY How Effective are Inferior Alveolar Nerve Block and Supplemental Intraligamentary Injections in Pediatric Patients with Deep Carious Permanent Mandibular Molars? Papimon Chompu-inwai, DDS, MS1 • Thitida Sutharaphan, DDS, MS2 • Areerat Nirunsittirat, DDS, MMEd, PhD3 • Patchanee Chuveera, DDS, MIPH4 • Thanida Srisuwan, DDS, MS, PhD5 • Thanapat Sastraruji, PhD6 Abstract: Purpose: The purpose of this study was to assess, within the deep carious permanent mandibular molars of pediatric patients: (1) pre- operative pulpal anesthesia following an inferior alveolar nerve block (IANB); (2) preoperative pulpal anesthesia following a supplemental in- traligamentary injection (SII); and (3) intraoperative pulpal anesthesia. Methods: Vital permanent mandibular molars with deep caries were first anesthetized with IANB. Preoperative pulpal anesthesia was assessed, and success was defined when the tooth had no response to the sensi- bility tests. In cases with failed preoperative pulpal anesthesia, an SII was administered and pulpal anesthesia was reassessed. A maximum of three SIIs was allowed. Intraoperatively, pulpal anesthesia was determined when the Wong-Baker FACES Pain Rating Scale reported by the patients was no more than four. Results: Sixty molars of patients aged 10.9±2.9 years old were included. The success of preoperative pulpal anesthesia following IANB was 26.7 percent. In cases with failed IANB, SIIs were administered. The overall cumulative success rate of preopera- tive pulpal anesthesia was 80 percent. Intraoperatively, the success of pulpal anesthesia was 72.9 percent. Conclusions: The success of pulpal anesthesia by inferior alveolar nerve block in young permanent teeth with deep caries was low. A supplemental intraligamentary injection can greatly enhance preoperative pulpal anesthesia; however, 27.1 percent of patients still experienced pain during treatment. (Pediatr Dent 2018;40(7):437-42) Received June 7, 2018 | Last Revision October 7, 2018 | Accepted October 7, 2018 KEYWORDS: PULPAL ANESTHESIA, INFERIOR ALVEOLAR NERVE BLOCK, SUPPLEMENTAL INTRALIGAMENTARY INJECTION, PEDIATRIC PATIENTS Soft tissue anesthesia does not always guarantee pulpal anes- SII can effectively increase the success of pulpal anesthesia; thesia,1 and inadequate pulpal anesthesia can result in a painful, success rates of 48 to 70 percent have been reported in adult traumatic experience. This can lead to a negative attitude toward teeth with irreversible pulpitis.10,14 Moreover, an SII can be future dental treatment, especially in young patients.2 Inferior administered under rubber dam isolation, making it convenient, alveolar nerve block (IANB) has been the most common tech- especially during pulp treatment.15 nique used for anesthetizing mandibular teeth; however, The purpose of this study was to assess, within the deep evidence of its pulpal anesthetic success in deep carious perma- carious permanent mandibular molars of pediatric patients: (1) nent mandibular molars of pediatric patients is currently lacking. preoperative pulpal anesthesia following an inferior alveolar Most previous studies regarding pulpal anesthesia by IANB nerve block; (2) preoperative pulpal anesthesia following a have been performed in teeth with irreversible pulpitis in adults supplemental intraligamentary injection; and (3) intraoperative older than 18 years, with success rates reported between 10 pulpal anesthesia. and 75 percent.3,4 However, differences between young and mature permanent teeth may affect pulpal anesthetic success. Methods Young permanent teeth seem to have a greater pulpal response This study was approved by the Human Experimentation to the inflammatory process than do mature teeth because of Committee of the Faculty of Dentistry, Chiang Mai Univer- the former’s larger dentinal tubules.5 Moreover, the young pulp sity, Chiang Mai, Thailand. The study details were explained with greater innervation can be extremely sensitive, and only to both pediatric patients and their legal guardians. If they minor injury and inflammation can affect its responses.6 agreed to participate, the patients and legal guardians signed Researchers have previously reported attempts to increase assent and informed consent forms, respectively. pulpal anesthetic success by changing the local anesthetic agents,7 Sample size. The sample size calculation was based on a increasing the volume of the solution,8 using adjunct drugs,9 study by Kanaa et al.10 in teeth diagnosed with irreversible and using supplemental injections.10 The supplemental intra- pulpitis; they reported 32 to 84 percent success rates using ligamentary injection (SII) has been one of the most studied pulpal anesthesia with different supplementary local anesthetic supplemental methods in adults after failure of IANB because techniques after failure of IANB in healthy patients aged 18 of its several advantages. First, an SII has immediate to rapid years or older. With a 10 percent error limit and a significance onset,11 which generally is within 30 seconds.12,13 Second, an level of 0.05, 52 to 96 teeth were required. Sixty teeth were included in this study. Participants. The study recruited American Society of 1 Dr. Chompu-inwai is an assistant professor, Department of Orthodontics and Pediatric Anesthesiologists (ASA) 1 or 2 patients who attended the 2 3 Dentistry, Dr. Sutharaphan is a post-graduate student, Dr. Nirunsittirat is an instruc- Pediatric Dentistry Clinic, Faculty of Dentistry, Chiang Mai tor and 4Dr. Chuveera is an assistant professor, Department of Family and Commu- nity Dentistry, 5Dr. Srisuwan is assistant professor, Department of Restorative Dentistry University, Chiang Mai, Thailand, between June 2014 and and Periodontology, and 6Dr. Sastraruji is a researcher, Dental Research Center, all in June 2015. The inclusion criteria included patients who: (1) the Faculty of Dentistry, Chiang Mai University, Chiang Mai, Thailand. were six to 18 years old; (2) had no hypersensitivities to articaine Correspond with Dr. Chompu-inwai at [email protected] PULPAL ANESTHESIA IN PEDIATRIC PATIENTS 437 PEDIATRIC DENTISTRY V 40 / NO 7 NOV / DEC 18 or any components of the anesthetic agent; (3) did not take was initially deposited. After a 15-minute waiting period, lip any analgesic drugs on the day of treatment; (4) were cooper- and tongue anesthesia was confirmed. If there was no lip and ative and able to communicate well (scoring three or four tongue anesthesia, IANB could be readministered to a maxi- on the Frankl Behavior Rating Scale); (5) had a permanent mum of two injections. If there was soft tissue anesthesia, the mandibular molar with a deep carious lesion penetrating into tooth was further tested for preoperative pulpal anesthesia using three fourths or more of the entire dentin thickness, as presented both the Green Endo-Ice cold test and the electric pulp test on a posterior bitewing radiograph; and (6) had a tooth with (EPT; Kerr Vitality Scanner; SybronEndo, Glendora, Calif., a positive response to cold testing with Green Endo-Ice USA). The success of preoperative pulpal anesthesia was defined (Coltene Whaledent, Cuyahoga Falls, Ohio, USA). Each tooth as two consecutive negative responses to both tests. was diagnosed with normal pulp or reversible or irreversible In cases where preoperative pulpal anesthesia was achieved pulpitis, based on the clinical diagnosis criteria of the American with IANB, a one-quarter cartridge of anesthetic solution was Association of Endodontists.16 deposited using a long buccal nerve block to anesthetize the Study protocol. One postgraduate student in pediatric buccal soft tissue in order to facilitate the placement of a rubber dentistry explained the scales used in this study to the partici- dam clamp, and treatment was then initiated. However, if pre- pants in age-appropriate terms. The same dentist also performed operative pulpal anesthesia failed to occur following an IANB, all clinical procedures under supervision of one experienced demonstrated by a positive response to pulp testing, SIIs were instructor. The parent was present during the explanations and administered using 0.4 ml of anesthetic solution and 0.2 ml treatment. at the mesial and distal aspects via a pressure syringe (Ergoject Before treatment, the fear and anxiety level of each parti- Intralig Syringe; Anthogyr, Sallanches, France). Preoperative cipant was measured using the Facial Image Scale (FIS).17 The pulpal anesthesia was then retested. Up to three SIIs could be FIS consists of five figures of faces, ranging from a very happy administered. After preoperative pulpal anesthesia was success- to a very unhappy face. The children were asked to point at ful, a one-fourth cartridge of anesthetic solution was deposited the face that matched their feelings. using a long buccal nerve block to anesthetize the buccal soft Preoperative phase. The anesthetic agent used in all steps tissue. Next, a rubber dam clamp was placed and treatment of this study was four percent articaine with epinephrine one was begun. Teeth with preoperative pulpal anesthesia failure in 100,000 (Septanest SP; Septodont, Saint-Maur-des-Fossés, following three SIIs were excluded. France). The Figure shows the flow chart for this study. The Intraoperative phase. During treatment, the success of carious tooth was anesthetized with IANB using a 27-gauge pulpal anesthesia was determined using the Wong-Baker FACES short needle (Terumo Dental Needle; Terumo Corporation, Pain