Evaluating the effect of using anti-stress balls as a distraction technique in reducing pain during inferior alveolar nerve block injection: a randomized clinical trial.

OBJECTIVE: The aim of this study is to evaluate the effect of using anti-stress balls in reducing patients' pain during injection of the inferior alveolar nerve block (IANB). MATERIALS AND METHODS: In this randomized clinical trial, 32 individuals were divided into two groups. The conventional method of anesthesia injection was performed using IANB conventional injection technique. During the injection, individuals in the anti-stress ball group were asked to use the anti-stress ball as a distraction technique. For the control group, no supersede methods were used for pain control. Finally, both groups were asked to record their pain utilizing the numerical rating scale (NRS). The participants' vital signs were monitored before and after injection. Kolmogorov-Smirnov test, independent T-test, and Fisher's exact chi-square test were performed for statistical analysis (α = 0.05). RESULTS: Sixteen females and 16 males in the age range of 40 to 20 years old participated in this study. The mean pain score in the anti-stress ball group was significantly lower (p < 0.001). In both sexes, the pain score in the anti-stress ball group was significantly lower (males p < 0.001 and females p = 0.001). In addition, in all age ranges, the pain score in the control group was higher except for the above 35 years old participants (p = 0.078). Moreover, there were no significant differences in individuals' vital signs (p > 0.05). CONCLUSION AND CLINICAL RELEVANCE: Utilizing an anti-stress ball reduces patients' pain significantly during IANB in both sexes and individuals who are below 35 years without changing vital signs. CLINICAL REGISTRATION NUMBER: IRCT20220815055704N1.

A Randomized Controlled Clinical Trial of Pulpotomy versus Root Canal Therapy in Mature Teeth with Irreversible Pulpitis: Outcome, Quality of Life, and Patients' Satisfaction.

INTRODUCTION: Vital pulp therapy is increasingly practiced as an alternative treatment to root canal therapy (RCT) in teeth with carious pulp exposure. The aim of this study was to compare the outcome, quality of life (QOL), and patients' satisfaction after full pulpotomy and RCT in mature teeth with irreversible pulpitis. METHODS: Sixty mature permanent molar teeth with carious pulp exposure and a diagnosis of irreversible pulpitis were randomly divided into 2 groups (n = 30). The first group was treated with full pulpotomy using Biodentine (Septodont, Saint Maur des Fosses, France), and the second group was treated with RCT. The pain level was recorded preoperatively and at 1, 2, 3, 5, and 7 days. Clinical and radiographic assessments were performed at the 6- and 12-month follow-ups; 1 case in each group did not attend. Based on the Oral Health Impact Profile questionnaire and 7 semantic differential scales, QOL, and patients' satisfaction were evaluated and compared statistically. RESULTS: Pulpotomy and RCT had comparable success rates (27/29, 93%). Pain levels at day 1 after pulpotomy were significantly lower than after RCT (P = .037), less patients required analgesics (P = .028), and pulpotomy provided pain relief in a shorter time compared with RCT. Both treatments improved the Oral Health Impact Profile QOL of patients without significant differences (60.29, 64.1% at 1 year). Patients' satisfaction with pulpotomy was higher than RCT in terms of the time involved, intraoperative pain, pleasantness, and cost (P < .05). CONCLUSIONS: Full pulpotomy could be an alternative treatment to RCT in mature teeth with carious pulp exposure and symptomatic irreversible pulpitis based on the clinical and radiographic success rates and patients' satisfaction.

A pilot study of local anesthesia training using a mixed-reality haptic fidelity model.

PURPOSE/OBJECTIVES: One of the most difficult local anesthetic blocks to master in dentistry is the inferior alveolar nerve block (IANB). Historically, dental students have practiced local anesthesia on one another. At the University of Colorado, these practice sessions have been limited to one required laboratory session. The predictability and confidence of student IANB success have not been high in the past. Therefore, the objective of this study was to investigate the impact of a novel IANB simulator, built on a three dimensional (3D)-printed mixed-reality haptic model, for second-year dental students to practice on prior to their laboratory session. METHODS: Thirty-nine student participants volunteered to practice with the IANB simulator. Participants were divided into two groups, Group A and Group B. Self-reported confidence and injection-specific accuracy were measured during IANB simulator practice and the laboratory session. During lab, partner numbness was assessed as a measure of IANB success. Groups A (n = 20) and B (n = 19) practiced with the simulator before and after laboratory, respectively. Injection domains were not assessed during Group B's practice with the IANB simulator. RESULTS: Self-reported confidence increased for both groups (p < 0.001). However, for anesthetic success, Group A exhibited significantly greater success (52.6%) than Group B (17.6%) (p = 0.029). CONCLUSION: Self-reported confidence in performing an IANB improved and higher anesthetic success was achieved for Group A. Further investigation is necessary to determine the long-term impact of using the IANB simulator in dental education.

Efficacy of four local anaesthesia protocols for mandibular first molars with symptomatic irreversible pulpitis: A randomized clinical trial.

AIM: To examine the efficacy rate of four anaesthetic protocols in mandibular first molars with symptomatic irreversible pulpitis (SIP). METHODOLOGY: One hundred and sixty patients with a diagnosis of SIP were included in this randomized clinical trial. Patients were randomly allocated into four treatment groups (N = 40) according to the administered technique: Group 1 (IANB): standard inferior alveolar nerve block (IANB) injection; Group 2 (IANB + IO): standard IANB followed by a supplemental intraosseous infusion (IO) injection; Group 3 (IANB + PDL): standard IANB followed by a supplemental periodontal ligament (PDL) injection; Group 4 (IANB + BI): standard IANB followed by a supplemental buccal infiltration. Patients rated pain intensity using a verbal rating scale when the root canal treatment procedure was initiated, that is, during caries removal, access preparation and pulpectomy. Heart rate changes were recorded before, during and after each injection. The anaesthetic efficacy rates were analysed using chi-square tests, age differences using one-way anova, gender differences using Fischer Exact tests whilst heart rate changes were analysed using Kruskal-Wallis tests. Statistical significances were set at p < .05 level. RESULTS: All the included patients were analysed. No differences in the efficacy rate were found in relation to the age or gender of the participants amongst the study groups (p > .05). IANB + IO injections had a significantly higher efficacy rate (92.5%) when compared to other techniques (p < .05), followed by IANB + PDL injections (72.5%), IANB + BI injections (65.0%), with no significant differences between the IANB + PDL or IANB + BI injections (p > .05). IANB injection alone had a significantly lower rate (40%) compared to the other techniques (p < .05). A transient but significant rise in the heart rate was recorded in 60% (24/40) of patients who received the IANB + IO injection compared to other groups (p < .05). CONCLUSIONS: Inferior alveolar nerve block injection alone did not reliably permit pain-free treatment for mandibular molars with SIP. The use of an additional IO supplemental injection provided the most effective anaesthesia for patients requiring emergency root canal treatment for SIP in mandibular posterior teeth.

Can buccal infiltration of articaine replace traditional inferior alveolar nerve block for the treatment of mandibular molars in pediatric patients?: A systematic review and meta-analysis.

BACKGROUND: It is unclear if buccal articaine infiltration can be used as an alternative to standard inferior alveolar nerve block (IANB) for treating mandibular molars in pediatric patients. Therefore, this study aimed to pool evidence to compare the efficacy of buccal infiltration of articaine vs IANB with lignocaine for pediatric dental procedures. MATERIAL AND METHODS: We searched the PubMed, Embase, ScienceDirect, CENTRAL, and Google Scholar databases for randomized controlled trials (RCTs) comparing the two techniques in pediatric patients and reporting the success of anesthesia and/or pain during treatment. PRISMA guidelines were followed. RESULTS: Seven RCTs were included. Pooled analysis of five studies indicated no statistically significant difference in the success rates of the two anesthetic techniques (OR: 1.02; 95% CI: 0.13, 7.96; I2=69%, p=0.98). Meta-analysis of data from the four studies demonstrated no statistically significant difference in pain during the procedure with buccal infiltration of articaine or IANB with lignocaine (SMD: 0.62; 95% CI: -1.37, 0.12; I2=88%, p=0.10). CONCLUSIONS: Evidence suggests that buccal infiltration of articaine is a viable alternative to IANB with lignocaine in pediatric patients for treating mandibular molars. Based on the confidence intervals, there may be a tendency of higher success rates with buccal infiltration of articaine.

The effect of low-level laser therapy on the success rate of inferior alveolar nerve blocks in mandibular molars with symptomatic irreversible pulpitis: A randomized clinical trial.

AIM: To evaluate the effect of low-level laser therapy (LLLT) on the success rate of inferior alveolar nerve blocks (IANB) in mandibular molar teeth with symptomatic irreversible pulpitis (SIP). METHODOLOGY: Eighty-eight patients who were diagnosed with SIP were randomly divided into two groups: the group in which only IANB was applied and the group in which IANB + LLLT was applied. IANB was applied to patients in the control group with 4% articaine. LLLT was applied to the patients in the experimental group in addition to IANB. The pain experienced during the operation was evaluated using a visual analog scale. If the patients reported moderate or severe pain during the treatment, the IANB was defined as unsuccessful. Pearson's chi-square test was used to analyse anaesthetic success rates. RESULTS: Whilst the anaesthesia success rate was 34% in the group where only IANB was applied, it was 57% in the group in which LLLT was applied in addition to IANB. There was a significant difference between the groups (p = .032). CONCLUSIONS: The application of LLLT to support IANB in mandibular molar teeth with SIP increased the success of anaesthesia. However, it was insufficient for a complete pulpal anaesthesia.

Evaluation of aromatherapy on success rate of inferior alveolar nerve block in teeth with irreversible pulpitis: a prospective randomized clinical trial.

OBJECTIVE: This prospective, block randomized clinical trial was conducted to evaluate the effect of aromatherapy on the success rate of inferior alveolar nerve block (IANB) in teeth with irreversible pulpitis. METHOD AND MATERIALS: In this clinical trial, 46 patients fulfilling the inclusion criteria were randomly divided into two equal groups: group I (n = 22) received IANB in a closed operatory without any fragrance, whereas group II (n = 24) received IANB in a separate closed operatory saturated with lavender fragrance using a candle warmer. The modified dental anxiety scale (MDAS) for anxiety and visual analog scale (VAS) for pain were recorded preoperatively as well as during access cavity preparation. For MDAS, a total score of more than 18 was considered as tremendously anxious or dental phobic. No or mild pain on VAS was considered as success. Data were analyzed using paired t test and independent sample t test. P < .05 was considered as statistically significant. RESULTS: Difference in mean VAS (P = .749) and MDAS (P = 1.000) between both the groups was statistically nonsignificant. However there was a statistically significant difference in mean VAS (P = .000) and MDAS (P = .001) during access opening. CONCLUSION: Lavender aromatherapy can be used successfully to alleviate dental anxiety as well as to increase the anesthetic success rate of IANB in teeth with irreversible pulpitis.

Local anaesthesia for surgical extraction of mandibular third molars: a systematic review and network meta-analysis.

OBJECTIVES: Pain management for the extraction of the mandibular third molar is a challenge as compelling evidence in comparative anaesthetics is currently lacking. MATERIALS AND METHODS: Thorough literature searches took place in PubMed, ScienceDirect, CENTRAL, Embase, Web of Science, CBM, and CNKI. Thirty-three trials were meta-analysed using a Bayesian statistical approach within the random-effects model. Grading of Recommendations Assessment, Development, and Evaluation was performed to determine the overall quality of evidence across all comparisons. RESULTS: In terms of success rate, an inferior alveolar nerve block (IANB) injection of 2% lidocaine with epinephrine was less effective than a combined injection of buccal infiltration (BI) and lingual infiltration (LI) with a 4% articaine (RR = 0.85 [0.75, 0.96], P = 0.611). According to visual analogue scale (VAS), 2% lidocaine-IANB with epinephrine caused higher VAS scores than 4% articaine-IANB with epinephrine (MD = 0.84 [0.28, 1.40], P = 0.057), whereas 0.5% levobupivacaine-IANB showed lower scores than 2% lidocaine-IANB (MD = - 1.62 [- 2.97, - 0.28], P = 0.045). Also, 2% lidocaine-IANB with epinephrine presented longer latency than both 4% articaine-IANB with epinephrine (MD = 39.44 [16.97, 61.90], P < 0.001) and 4% articaine-BI + LI with epinephrine (MD = 164.41 [16.23, 312.58], P < 0.001); 4% articaine-IANB with epinephrine produced shorter latency than 0.5% bupivacaine-IANB with epinephrine (MD = - 42.92 [- 70.28, - 15.56], P = 0.106); 0.75% ropivacaine-IANB caused shorter onset of action compared with 2% lidocaine-IANB (MD = - 40.88 [- 65.50, - 16.26], P < 0.001). In addition, 2% lidocaine-IANB with epinephrine produced significantly shorter duration than both 4% articaine-IANB with epinephrine (MD = - 47.33 [- 57.88, - 36.77], P = 0.265) and 2% mepivacaine-IANB with epinephrine (MD = - 10.01 [- 19.59, - 0.44], P = 0.769). The duration of action triggered by 4% articaine-IANB with epinephrine was shorter compared with 0.5% bupivacaine-IANB with epinephrine (MD = - 64.17 [- 74.65, - 53.69], P = 0.926). Both 0.5% levobupivacaine-IANB and 0.75% ropivacaine-IANB produced longer duration of action than 2% lidocaine-IANB (MD = 333.70 [267.33, 400.07], P < 0.001) and (MD = 288.01 [287.67, 288.34], P = 0.634, respectively). CONCLUSIONS: The network meta-analysis demonstrated that the intraosseous injection of 4% articaine with epinephrine had the most noteworthy success rate. However, the combination of BI and LI of 4% articaine with epinephrine, and IANB of 0.5% bupivacaine were, according to a VAS, the most effective. It should be noted that a rapid onset of action was produced by BI combined with LI of 4% articaine with epinephrine and IANB of 2% mepivacaine with epinephrine, while the most prolonged duration of action was generated by IANB of 0.5% levobupivacaine or 0.5% bupivacaine. CLINICAL RELEVANCE: For a better understanding of local anaesthesia for the extraction of the third molar, our study was aimed to provide evidence to guide better dental practices in pain management for clinicians.

The efficacy of supplemental intraseptal and buccal infiltration anesthesia in mandibular molars of patients with symptomatic irreversible pulpitis.

OBJECTIVE: The aim of this randomized clinical trial was to compare the success rate of three different anesthetic techniques in mandibular molars with symptomatic irreversible pulpitis. MATERIALS AND METHODS: Ninety patients with symptomatic irreversible pulpitis in mandibular molars randomly received three anesthetic techniques. Group I: an inferior alveolar nerve block (IANB) of 2% lidocaine. Group II: IANB and buccal infiltration (BI) of 4% articaine. Group III: IANB + BI and intraseptal injection of articaine in each mesial and distal papilla. The pain (Heft-Parker visual analog scale (VAS)) and electric pulp tester (EPT) scores were recorded prior to (VAS1, EPT1) and after the injection and during access preparation (VAS2, EPT2). The success of anesthesia was defined as the ability to access the tooth with no or mild pain (VAS ≤ 54). RESULTS: The mean value for VAS2 was significantly less and the mean value for EPT2 was significantly more in groups II and III compared with group I. The success rates for groups I, II, and III were 30.33%, 66.66%, and 80.00% respectively. Also, differences of EPT2, VAS2, and success rates were statistically significant between groups II and III. CONCLUSION: Administration of articaine as a supplemental intraseptal and BI following IANB can be considered a more successful anesthetic technique in mandibular molars with symptomatic irreversible pulpitis compared with the conventional IANB and supplemental BI. CLINICAL RELEVANCE: The addition of an articaine intraseptal injection to IANB+BI technique may result in a significantly higher success rate of pulpal anesthesia in mandibular molars with symptomatic irreversible pulpitis.

The Effect of Acupuncture on the Success of Inferior Alveolar Nerve Block for Teeth with Symptomatic Irreversible Pulpitis: A Triple-blind Randomized Clinical Trial.

INTRODUCTION: An inferior alveolar nerve block (IANB) does not always provide satisfactory anesthesia for patients with irreversible pulpitis. The aim of this study was to assess the effect of preoperative acupuncture on the success rate of IANBs for teeth with symptomatic irreversible pulpitis. METHODS: In a randomized triple-blinded clinical trial, 40 patients with symptomatic irreversible pulpitis were divided into 2 groups: the acupuncture and control groups. In the acupuncture group, a disposable needle was inserted at LI4 (Hegu) acupoint, and after 15 minutes, for patients who had reported the De qi sensation, an IANB was administered. In the control group, 15 minutes before the administration of an IANB, the practitioner simply imitated the acupuncture procedure but did not actually insert the needle. Endodontic treatments were conducted for the patients who reported lip numbness 15 minutes after the injection of the IANB. If the patients felt intolerable pain (>20 mm on a visual analog scale of 100 mm) during the procedure, a supplementary injection was administered. In those situations, the IANB was considered an unsuccessful injection. Data were evaluated by the chi-square, Wilcoxon, Mann-Whitney, and t tests. The level of significance was set at 0.05. RESULTS: The overall success rates of IANB for the acupuncture and control groups were 60% and 20%, respectively (P < .05). CONCLUSIONS: The application of acupuncture before the endodontic treatment increased the effectiveness of IANBs for mandibular molars with symptomatic irreversible pulpitis.

Er:YAG 2,940-nm laser fiber in endodontic treatment: a help in removing smear layer.

Cleaning and disinfection of the root canal system are some of the most important goals in endodontic therapy. The aim of this preliminary study is to assess the effectiveness of Er:YAG laser fiber in removing the smear layer produced during root canal walls instrumentation. Forty-eight single-rooted teeth were prepared with manual and rotary Ni-Ti instruments, in addition to 2.5% NaOCl irrigation. Samples were randomly subdivided into groups and treated with: three irradiations of 5 s each, with 300-µm Er:YAG endodontic fiber, 1 W and 2.5% NaOCl solution (A Group); two laser irradiations with 17% EDTA solution and 2.5% NaOCl solution (B Group); laser irradiation plus 17% EDTA solution and 2.5% NaOCl (C Group); only in the final wash of 17% EDTA (control group D). During laser treatment, temperature variations were analyzed by using thermocouple and thermal camera devices in order to test both deep and superficial temperatures. Each sample was finally observed by scanning electron microscope (SEM) at the coronal, medium, and apical thirds at ×500 magnification and blindly scored depending on the amount of smear layer. Statistical analysis of the results was conducted using the Kruskal-Wallis and Mann-Whitney test to determine the eventual significant differences between the quantity of smear layer in each group and between the groups at coronal, medium, and apical third: a p value <0.05 was considered significant. The thermal analysis realized by thermocouple with the used parameters demonstrated that laser endodontic fiber produces an average deep temperature increase of 3.5 ± 0.4 °C; analysis performed with a thermal camera showed an average superficial temperature increase of 1.3 ± 0.2 °C produced by laser endodontic fiber use. Deep and superficial temperatures fall immediately after irradiation possibly without causing structural damage or anatomical alteration inside the root canal and neither on periodontal tissues. SEM analysis showed that specimens of group B had the highest level of cleaning in every third, with a significant difference with groups D and A; group C samples showed a good percentage of cleaned tubules in apical and middle thirds, while group D teeth showed open dentinal tubules in coronal third, with a statistical difference with group A samples which were the worst cleaned. The Er:YAG fiber double irradiation with EDTA 17% and NaOCl 2.5% has been demonstrated to be effective in removing smear layer, even in the apical third which is described as the hardest area to clean during endodontic treatment.

Revisión de una fractura radicular con tratamiento atípico durante 23 años / Review of root fracture with atypical treatment for 23 years

Presentamos el caso de un incisivo central superior derecho, con fractura del tercio medio radicular, que fue tratado de forma atípica y se revisó durante 23 años de evolución. La fractura del tercio medio, conminuta en su área central, se produjo por un traumatismo contuso, acudiendo el paciente de urgencia por dolor agudo y movilidad del cliente. Con el diagnóstico de pulpitis aguda y fractura radicular media con subluxación, se decidió tratarlo en toda su longitud después de su ferulización. Practicado el tratamiento se dejó hidróxido de calcio en el conducto y a las dos semanas, con un diente asintomático desde el primer día, se selló definitivamente con hidróxido de calcio en suero fisiológico y gutapercha en condensación lateral. Tres meses después se retiró la ferulización y el diente esta asintomático, funcional y con una movilidad semejante a la de los incisivos vecinos. Radiológicamente, el área de fractura presento distintos aspectos diagnósticos a lo largo de 23 años de seguimiento. Actualmente, el incisivo sigue asintomático, firme, funcional y con un remodelado de su contorno bien definido (AU)

We are herewith presenting a case based on a maxillary right superior central incisor, which suffered a middle third fracture of the root. This fracture has been atypically treated and has been checked up throughout 23 years. The middle third fracture, which is comminuted in its central area, was caused by a contusion trauma. The patient came with urgency due to tooth mobility as well as an acute pain. After being diagnosed acute pulpitis and mid radicular fracture with subluxation, it was agreed to treat it throughout the whole process after its ferulization. Once treated, calcium hydroxide was left in the canal and two weeks after, with an asymptomatic tooth since the first day, it was sealed with calcium hydroxide with physiological saline solution and lateral condensation with gutta-percha. Three months after, ferulization was removed and the incisor was asymptomatic, functional and with mobility similar to the neighboring incisive. Radiograph examinations proved that the fracture presented different diagnosis throughout its 23 years. Nowadays, this incisor keeps being asymptomatic, firm and functional with a well done reshape (AU)

Efficacy of combining a buccal infiltration with an inferior alveolar nerve block for mandibular molars with irreversible pulpitis.

OBJECTIVE: The aim of this study was to assess the efficacy of inferior alveolar nerve (IAN) block combined with buccal infiltration for mandibular molars with irreversible pulpitis. METHODOLOGY: Eighty-four patients were randomly assigned to 3 groups of 28 patients each. Lidocaine 2% with 1:80,000 epinephrine was used for all injections. Group I patients received an IAN block with 1.8 mL of anesthetic. Group II patients received an IAN block using 3.6 mL. Group III patients received 1.8 mL as an IAN block and 1.8 mL as a buccal infiltration. A visual analogue scale was used to rate pain before anesthesia and discomfort experienced before and during access cavity preparation. Data were analyzed by chi-square, ANOVA, Kruskal-Wallis, and Mann-Whitney tests. RESULTS: The success rates for groups I to III were 14.8%, 39.3%, and 65.4%, respectively. Group III had significantly better anesthesia compared with group I (P < .05). CONCLUSION: Combining an IAN block and a buccal infiltration injection provided more effective anesthesia in mandibular molars with irreversible pulpitis. However, some cases may still require further anesthesia to prevent pain during endodontic treatment.

Topical anesthetic as an adjunct to local anesthesia during pulpectomies.

A technique is described using topical anesthetic to supplement local anesthesia. It is the author's opinion that it enhances patient comfort during pulpectomies on teeth with irreversible pulpitis.

Endodontic anesthesia in mandibular molars: a clinical study.

Sixty-one mandibular molar teeth with clinically manifest pulpitis, which required endodontic therapy, were studied. Twenty-seven subjects received standard inferior alveolar nerve block (IANB) with 2% lidocaine HCI with 1:100,000 epinephrine and 34 subjects received IANB with 3% mepivacaine with no vasoconstrictor. Pulpal anesthesia was assessed with dichlorodifluormethane (DDM). Subjects who gave a positive response to DDM were given a periodontal ligament injection with 2% lidocaine with 1:100,000 epinephrine. This study showed that 3% mepivacaine HCI is as effective as 2% lidocaine HCI in achieving pulpal anesthesia in mandibular molars with IANB. Of a total 61 IANB with lip anesthesia, 23 subjects required periodontal ligament injection to achieve a negative response to DDM. It was concluded that lip anesthesia is not a reliable indicator of pulpal anesthesia. The use of DDM is a reliable method of determining true pulpal anesthesia.

[The use of tricalcium phosphate in the vital subtotal extirpation of the pulp]. / Primenenie trikal'tsiifosfata pri vital'noi subtotal'noi ékstirpatsii pul'py.

The authors have proved the desirability of vital subtotal extirpation of the pulp in experiments and clinically. Exposure to tricalcium phosphate transformed the terminal portion of the root pulp into osseocement biologic filling, obturated the apical opening and thus prevented the inflammation in the periodontium and protected it from pathologic exposures.

Managing local anesthesia problems in the endodontic patient.

Root canal therapy has a poor public image related to occasional and sometimes severe pain, and to dentists' inability to obtain profound anesthesia. Patients' apprehension, in combination with tissue inflammation, significantly lowers the pain threshold, which decreases the anesthetic's effectiveness. The best and also the first approach to achieving anesthesia is to administer a conventional block or infiltration. If profound anesthesia does not occur after this attempt, use a supplemental technique such as lingual infiltrations, PDL or intrapulpal injections. Because infiltrations are generally not effective, PDL and intrapulpal injections are preferred. The PDL is better than the intrapulpal injection because it is non-painful, safe and usually effective. The intrapulpal injection is limited and may be uncomfortable. Administer both the PDL and intrapulpal injections under back-pressure to achieve effective, but short-lived anesthesia. Special injection devices (for example, pressure syringes for the PDL) are not required for either technique. Two anesthetic types are useful. Administer 2 percent lidocaine with epinephrine for conventional and supplemental injections. For emergencies and long procedures, administer 0.5 percent bupivacaine with epinephrine to provide effective, long-lasting anesthesia and analgesia.

Local anesthesia failure in endodontic therapy: the acute inflammation factor.

The attainment of clinically acceptable local anesthesia is often problematic in the treatment of symptomatic pulpitis and symptomatic apical periodontitis. This article reviews the literature to identify the extent of this problem and to understand the organic components involved with this condition. Inflammation, infection, pH changes, alteration in nerve cell membranes, and anatomic variations are all possible causes for failure of local anesthesia during emergency endodontic therapy.