Pain Reduction of Ibuprofen Sodium Dihydrate Alone and in Combination with Acetaminophen in an Untreated Endodontic Pain Model: A Randomized, Double-blind Investigation.

INTRODUCTION: Most pain studies have been based on a post-surgical, third molar model using ibuprofen (IBU)/acetaminophen (APAP). Studies have found quicker onset of pain relief with a newer formulation of IBU - ibuprofen sodium dihydrate (ISD). The purpose of this study was to compare pain reduction of ISD/APAP to ISD in an acute endodontic pain model of untreated patients experiencing moderate to severe pain with symptomatic apical periodontitis. METHODS AND MATERIALS: In this double-blind randomized study, 64 adult emergency patients in acute moderate to severe pain, a pulpal diagnosis of symptomatic irreversible pulpitis or necrosis, and symptomatic apical periodontitis participated. Each patient randomly received either one dose of 768 mg ISD/1000 mg APAP or one dose 768 mg ISD. Pain intensity scores were recorded every 15 minutes over 240 minutes using the Heft-Parker VAS along with time to first sign of pain relief, time to meaningful pain relief, and time to 50% pain relief also recorded. The data were analyzed statistically. RESULTS: Both ISD and ISD/APAP groups showed a progressive decrease in pain from baseline to 120 minutes after medication administration. Afterwards, a relative plateau was seen in the patients' pain. There was no difference in the VAS scores between the ISD and ISD/APAP at any given time point, time to first sign of pain relief, time to meaningful pain relief, and time to 50% pain relief. CONCLUSIONS: The addition of APAP to ISD for pain control in an untreated endodontic pain model did not differ significantly from ISD alone.

Efficacy of the TuttleNumbNow Intraosseous Method for Pulpal Anesthesia in the Mandibular First Molar: A Prospective, Randomized, Crossover Study.

INTRODUCTION: Previous studies on intraosseous (IO) anesthesia as a primary injection have shown high success rates. The TuttleNumbNow (TNN; Orem, UT) is a new primary IO injection technique that has not been scientifically evaluated. Therefore, the purpose of this prospective randomized, crossover study was to evaluate the anesthetic efficacy of the TNN IO technique using the Septoject Evolution needle (Septodont, Saint-Maur-des-Fosses, France) compared with buccal infiltration for pulpal anesthesia in mandibular first molars. METHODS: One hundred four healthy subjects were randomly assigned to 2 treatment groups separated by at least 2 weeks. One set of injections consisted of buccal infiltration of the mandibular first molar using 1.8 mL 4% articaine with 1:100,000 epinephrine followed by a mock TNN injection distal to the mandibular first molar. The other set of injections was a mock buccal infiltration of the mandibular first molar followed by a TNN injection of 1.8 mL 4% articaine with 1:100,000 epinephrine distal to the mandibular first molar. Statistical analyses were performed. RESULTS: For the mandibular first molar, which had a 42% anesthetic success rate (highest 80 reading) with buccal infiltration compared with 49% with the TNN, no statistically significant difference in success was observed (P = .2115). CONCLUSIONS: The TNN technique has been advocated as an IO injection. However, the inability to deliver anesthetic solution to the cancellous bone resulted in an anesthetic success rate of 49%. The success was statistically similar to a buccal infiltration (42%) and would not provide adequate pulpal anesthesia as a primary injection.

Success of Pulpal Anesthesia Following Buccal Infiltration of the Maxillary First Molar With 1.8 mL and 3.6 mL of 4% Articaine With 1:100,000 Epinephrine: A Prospective, Randomized Crossover Study.

OBJECTIVE: The purpose of this prospective, randomized crossover study was to compare the peak incidence of success, onset, and incidence over time of pulpal anesthesia in maxillary first molars following a buccal infiltration of 1.8 mL or 3.6 mL of 4% articaine with 1:100 000 epinephrine. METHODS: A total of 118 adults received 1.8 mL or 3.6 mL of 4% articaine with 1:100 000 epinephrine via buccal infiltration of the maxillary first molar at 2 separate appointments. Electric pulp testing (EPT) of the maxillary first molar was performed over 68 minutes. RESULTS: There was no significant difference in the peak incidence of anesthetic success (85% and 92%, respectively) in the maxillary first molar between 1.8 mL and 3.6 mL. The difference in onset times (4.5 min for 1.8 mL vs 4.4 min for 3.6 mL) was not statistically significant. However, the 3.6-mL volume did produce a significantly higher incidence of pulpal anesthesia from minutes 48 to 68 compared with the 1.8-mL volume. CONCLUSION: There was no significant difference in peak incidence or onset of pulpal anesthesia in the maxillary first molar between 1.8 mL and 3.6 mL of articaine with epinephrine. The incidence of pulpal anesthesia was significantly higher with 3.6 mL of articaine at 48 minutes and beyond, but neither volume provided complete pulpal anesthesia for all subjects that lasted at least 60 minutes.

Articaine Infiltrations of the Mandibular Lateral Incisor-Is It Volume or Location of the Infiltrations That Affect Success? A Prospective, Randomized Crossover Study.

INTRODUCTION: A combination labial infiltration (1.8 mL) plus lingual infiltration (1.8 mL) of 4% articaine with 1:100,000 epinephrine in the mandibular lateral incisor was found superior to a labial infiltration of 1.8 mL of the same solution. However, it is not known whether the volume or the location had the greatest effect. Therefore, the purpose of this prospective, randomized crossover study was to determine the anesthetic efficacy of a labial infiltration of a 3.6 mL volume of 4% articaine with 1:100,000 epinephrine compared with labial infiltration (1.8 mL) plus lingual infiltration (1.8 mL) of 4% articaine with 1:100,000 epinephrine in the mandibular lateral incisor. METHODS: One hundred subjects randomly received 2 sets of injections, using 4% articaine with 1:100,000 epinephrine, consisting of labial and lingual infiltrations of 1.8 mL (3.6 mL total) and 2 labial infiltrations of 1.8 mL (3.6 mL total) of the mandibular lateral incisor in 2 separate appointments. Electric pulp testing was used to determine anesthetic success (highest 80/80 reading). The data were analyzed statistically. RESULTS: The labial and lingual combination exhibited a significantly higher anesthetic success rate (97%) when compared with the 2 labial infiltrations (74%) and had significantly higher 80/80s readings from 1 minute to 58 minutes. CONCLUSIONS: Within the limitations of this clinical study, a combination labial plus lingual infiltration using a 3.6-mL volume of 4% articaine with 1:100,000 epinephrine significantly increased pulpal anesthetic success for the mandibular lateral incisor when compared with a labial infiltration using a 3.6-mL volume of articaine. Therefore, location of the infiltrations was more important than volume.

Comparison of Maxillary Lateral Incisor Infiltration Pain Using the Dentapen and a Traditional Syringe: A Prospective Randomized Study.

INTRODUCTION: The anterior maxillary infiltration is one of the more painful dental injections. The Dentapen is an electronic syringe that uses computer-controlled delivery technology to administer dental local anesthesia at a slow controlled rate. The purpose of this prospective, randomized, single-blind study was to evaluate solution deposition pain of a maxillary lateral incisor infiltration using the Dentapen with the slow flow rate (1.8 mL/162 sec) and ramp-up setting compared with a traditional syringe infiltration at a flow rate of 1.8 mL/60 sec. METHODS: One hundred thirty adults were administered a maxillary lateral incisor infiltration with the Dentapen and a traditional syringe at 2 separate appointments in a single-blind manner. The infiltrations of 2% lidocaine with 1:100,000 epinephrine were given at a rate of 1.8 mL/162 sec with the ramp-up feature for the Dentapen and 1.8 mL/60 sec for the traditional infiltration. The pain of solution deposition was recorded on a visual analogue scale. At the conclusion of the study, subjects selected their preferred injection technique. The data were analyzed statistically using paired t tests, a mixed-effect model, and odds ratio. RESULTS: The pain of solution deposition was significantly less for the Dentapen injection than the traditional injection (P < .001). With the Dentapen device, 16% experienced moderate pain, and for the traditional syringe, 39% experienced moderate pain. Overall, 75% of subjects preferred the Dentapen injection over the traditional injection. CONCLUSIONS: The Dentapen, using the slow flow rate and ramp-up mode, significantly reduced the pain of solution deposition for maxillary lateral incisor infiltrations.

Prospective Study on PDL Anesthesia as an Aide to Decrease Palatal Infiltration Pain.

OBJECTIVE: The purpose of this prospective randomized study was to assess using a periodontal ligament (PDL) injection as an aide to decrease palatal infiltration pain. METHODS: A total of 133 subjects randomly received a PDL injection and alternative palatal infiltration or a mock PDL injection and conventional palatal infiltration at 2 separate appointments. PDL injection was given in the mid-palatal sulcus of the maxillary first molar. Mock PDL injection consisted of only needle insertion. All subjects then received a palatal infiltration administered into the blanched gingival tissue 3 mm (alternative palatal infiltration) or 7 mm (conventional palatal infiltration) from the gingival collar. Subjects recorded needle insertion and solution deposition pain using a Heft-Parker visual analog scale (VAS). RESULTS: The combined PDL injection and alternative palatal infiltration had significantly decreased mean VAS ratings for needle insertion and solution deposition pain (P < .0001). Incidence of moderate/severe pain for needle insertion and solution deposition was reduced from 65% to 1% and from 65% to 2%, respectively. CONCLUSION: Providing PDL anesthesia into the mid-palatal sulcus of the maxillary first molar and then administering an alternative palatal infiltration into the blanched collar around the PDL molar site led to significant reductions in needle insertion and solution deposition pain compared with a mock PDL and conventional palatal infiltration.

Effect of a Combination of Nitrous Oxide and Intraligamentary Injection on the Success of the Inferior Alveolar Nerve Block in Patients with Symptomatic Irreversible Pulpitis.

INTRODUCTION: The purpose of this prospective study was to determine the effect of a combination of nitrous oxide/oxygen and 1 set of supplemental intraligamentary/periodontal ligament (PDL) injections followed by a second set of PDL injections on anesthetic success in patients with symptomatic irreversible pulpitis (SIP). METHODS: Ninety-four patients with a mandibular posterior tooth diagnosed with SIP received nitrous oxide/oxygen and an inferior alveolar nerve block (IANB) with 2% lidocaine with 1:100,000 epinephrine. Patients rated the pain of PDL injections and endodontic access on a visual analog scale. If moderate to severe pain was felt during treatment, the operator administered 1 set of supplemental PDL injections with 4% articaine with 1:100,000 epinephrine. If moderate to severe pain was felt again during treatment, the operator administered a second set of supplemental PDL injections. Anesthetic success was defined as having no to mild pain during endodontic treatment. RESULTS: The success of the IANB with nitrous oxide was 44% (95% confidence interval [CI], 34%-54%). The overall anesthetic success rate (IANB with PDL injections) was increased from 69% (95% CI, 60%-78%) with 1 set of PDL injections to 80% (95% CI, 72%-88%) with a second set of PDL injections. CONCLUSIONS: Although the second set of PDL injections increased anesthetic success, it was not sufficient to ensure complete pulpal anesthesia.

Nitrous Oxide/Oxygen Effect on IANB Injection Pain and Mandibular Pulpal Anesthesia in Asymptomatic Subjects.

The inferior alveolar nerve block (IANB) does not always result in successful pulpal anesthesia. Nitrous oxide may increase the success of the IANB. The purpose of this investigation was to study the effect of nitrous oxide/oxygen (N2O/O2) on IANB injection pain and mandibular pulpal anesthesia in asymptomatic subjects. One hundred five asymptomatic subjects received an IANB after the administration of N2O/O2 or room air/oxygen (air/O2) at 2 separate appointments. After the IANB, subjects rated their level of pain for each phase of the injection (needle insertion, needle placement, and solution deposition) using a Heft Parker visual analog scale. Pulpal anesthesia was evaluated with an electric pulp tester for 60 minutes. The mean pain rating for all 3 injection phases showed a statistically significant reduction in pain when N2O/O2 was used compared with Air/O2 (P < .05). Odds ratios demonstrated a statistically significant increase in IANB success for the N2O/O2 group compared with the air/O2 group. N2O/O2 administration statistically decreased pain for all 3 injection phases of the IANB. In addition, nitrous oxide statistically increased the likelihood of pulpal anesthesia for posterior mandibular teeth. However, the incidence of pulpal anesthesia was not 100%.

Anesthetic Success Using Nitrous Oxide and a Combination of Lidocaine/Clonidine for the Inferior Alveolar Nerve Block and the Effects on Blood Pressure and Pulse in Patients with Symptomatic Irreversible Pulpitis: A Prospective, Randomized, Double-blind Study.

INTRODUCTION: The pulpal anesthetic success rates for an inferior alveolar nerve block (IANB) alone in patients presenting with symptomatic irreversible pulpitis are less than adequate. Nitrous oxide and clonidine have shown increases in IANB success when administered individually, but their success has not been evaluated when used together. The purpose of this prospective, randomized, double-blind study was to determine the effect of nitrous oxide/oxygen plus an IANB using lidocaine/clonidine on the success of the IANB in patients with symptomatic irreversible pulpitis and to evaluate the effect of clonidine on blood pressure and pulse. METHODS: Sixty-two emergency patients experiencing moderate to severe pain and a diagnosis of symptomatic irreversible pulpitis were enrolled. Subjects were randomly divided into 2 groups and received nitrous oxide/oxygen and an IANB using 2% lidocaine with either 27 µg clonidine or 18 µg epinephrine as vasoconstrictors. Blood pressure and pulse were recorded before and during the emergency endodontic treatment. Anesthetic success was defined as no or mild pain upon access and instrumentation of the canals. RESULTS: The pulpal anesthetic success rate in both treatments was 58%, with no significant difference between the groups. There was no statistically significant difference in pulse or systolic blood pressure with the use of clonidine compared with epinephrine. Diastolic blood pressure was significant. CONCLUSIONS: The use of nitrous/oxide plus the addition of lidocaine/clonidine for the IANB in teeth with symptomatic irreversible pulpitis resulted in no statistically significant difference in anesthetic success of the IANB. There were no statistically significant differences in pulse or systolic blood pressure with the use of clonidine compared with epinephrine; diastolic blood pressure was significant.

Pulpal Anesthesia of Adjacent Teeth Following Infiltration of 2% Lidocaine With 1:100,000 Epinephrine in the Maxillary Lateral Incisor and First Molar.

The purpose of this study was to determine anesthetic success in adjacent teeth following a primary infiltration of the maxillary lateral incisor and first molar using 1.8 mL of 2% lidocaine with 1:100,000 epinephrine. Three hundred eight asymptomatic subjects received an infiltration of a cartridge of 2% lidocaine with 1:100,000 epinephrine over the maxillary lateral incisor (163 subjects) or first molar (145 subjects). Pulpal anesthesia of the injected tooth and adjacent mesial and distal teeth was monitored with the electric pulp tester in 2-minute cycles for a total of 60 minutes. No response from the subject at the maximum output (80 reading) of the pulp tester was used as the criterion for pulpal anesthesia. Comparisons of the odds of pulpal anesthesia (defined as an 80/80 response to electric pulp testing over 60 minutes) between the experimentally injected tooth and adjacent teeth were analyzed using mixed-models, repeated-measures logistic regression. When compared with the lateral incisor infiltration, the adjacent mesial tooth (central incisor) and distal tooth (canine) achieved statistically lower anesthetic success. When compared with the first molar, the mesial tooth (second premolar) did not differ statistically. However, significant differences were shown between the first molar and the second molar, with the distal tooth (second molar) achieving a statistically higher rate of pulpal anesthesia, which was related to a better duration of anesthesia. For asymptomatic patients, local anesthesia of the adjacent mesial (central incisor) and distal (canine) teeth to the infiltrated lateral incisor had lower pulpal anesthetic success. Because standard infiltration anesthesia of the lateral incisor is of short duration, repeating the infiltration at 30 minutes will result in a high incidence of pulpal anesthesia for 60 minutes. Local anesthesia of the adjacent distal tooth to the first molar (second molar) had a statistically higher rate of total pulpal anesthesia than the infiltrated first molar due to the longer duration of pulpal anesthesia. However, if pulpal anesthesia is required for 60 minutes in the first and second molars, the clinician may need to add an additional infiltration to ensure anesthesia.

Anesthetic Efficacy of Intranasal 3% Tetracaine plus 0.05% Oxymetazoline (Kovanaze) in Maxillary Teeth.

INTRODUCTION: Needle-free anesthetic delivery is a promising alternative to traditional anesthetic routes of administration. The purpose of this study was to determine the patient preference for and pulpal anesthetic efficacy of a 3% tetracaine plus 0.05% oxymetazoline (Kovanaze) nasal spray in maxillary lateral incisors and first premolars. METHODS: Fifty adult subjects randomly received a 3% tetracaine plus 0.05% oxymetazoline (Kovanaze) nasal spray and mock infiltration or a mock nasal spray and 2% lidocaine with 1:100,000 epinephrine infiltration at the maxillary lateral incisor or first premolar in 2 appointments spaced at least 1 week apart in a single-blind cross-over design. Pulpal anesthesia was evaluated with an electric pulp tester. Side effects and subject preferences were also recorded. RESULTS: Anesthetic success was significantly lower for the Kovanaze nasal spray and mock infiltration (22%-37%) than for the mock nasal spray and lidocaine infiltration (89%-91%). Subjects reported more unwanted effects (nasal drainage and congestion, burning, pressure, and sinus congestion) after the Kovanaze nasal spray and mock infiltration than the mock spray and maxillary infiltration. Before participating in the study, more subjects (56%) preferred the nasal spray route versus a standard infiltration (44%). After experiencing both routes of administration, 100% of subjects preferred the standard infiltration. CONCLUSIONS: The 3% tetracaine plus 0.05% oxymetazoline (Kovanaze) nasal spray provided significantly less successful pulpal anesthesia than the lidocaine infiltration, was less preferable, and caused more unwanted effects.

Ibuprofen and Acetaminophen Versus Intranasal Ketorolac (Sprix) in an Untreated Endodontic Pain Model: A Randomized, Double-blind Investigation.

INTRODUCTION: Previously, ketorolac was available for primary use only via intravenous and intramuscular routes. Its availability in intranasal form offers an alternative route of administration that patients can self-administer. The purpose of this study was to compare the efficacy of intranasal ketorolac (Sprix; Egalet US Inc, Wayne, PA) with a combination of ibuprofen/acetaminophen in an acute pain model of untreated endodontic patients experiencing moderate to severe pain and symptomatic apical periodontitis. METHODS: Seventy patients experiencing moderate to severe pain, a pulpal diagnosis of symptomatic irreversible pulpitis or necrosis, and a periapical diagnosis of symptomatic apical periodontitis participated. Patients were randomly divided into 2 groups and received either 31.5 mg intranasal ketorolac and placebo capsules or 1000 mg acetaminophen/600 mg ibuprofen capsules and a mock nasal spray. Patients recorded perceived pain scores on a visual analog scale every 15 minutes from drug administration up to 240 minutes. The time to 50% pain relief, the first sign of pain relief, and meaningful pain relief were recorded, and the data were analyzed. RESULTS: A decline in reported pain was observed until 120 minutes after dosing, after which reported pain remained relatively constant. There was no significant difference between the 2 groups for the time to 50% pain relief, the first sign of pain relief, or meaningful pain relief. CONCLUSIONS: The effectiveness of intranasal ketorolac was not significantly different from that of a 1000 mg acetaminophen/600 mg ibuprofen combination. Intranasal ketorolac provides a nonnarcotic alternative and an additional route of medication administration to practicing clinicians.

An Evaluation of Ibuprofen Versus Ibuprofen/Acetaminophen for Postoperative Endodontic Pain in Patients With Symptomatic Irreversible Pulpitis and Symptomatic Apical Periodontitis.

The purpose of this investigation was to compare ibuprofen versus an ibuprofen/acetaminophen combination for postoperative pain control in a patient model specific to teeth diagnosed with symptomatic irreversible pulpitis and symptomatic apical periodontitis. One hundred and two patients presenting with moderate to severe pain from a maxillary or mandibular posterior tooth diagnosed with symptomatic irreversible pulpitis and symptomatic apical periodontitis were included. Following local anesthetic administration, complete endodontic cleaning and shaping was performed. Patients were randomly assigned to receive identically appearing tablets of ibuprofen 200 mg or a combination of ibuprofen 200 mg/acetaminophen 216.7 mg with instructions to take 3 tablets every 6 hours as needed for pain. Patients were also given a prescription for an escape medication to take if the study medications did not adequately control their pain. A 4-day diary was used to record pain ratings and medication use. Moderate to severe pain was experienced by 59-61% of the patients on postoperative day 1 and 50-57% of the patients on day 2, with the pain ratings decreasing over the next 2 days. There were no statistically significant differences between the 2 groups in postoperative pain, percussion pain, or medication use. There was no difference between ibuprofen and the combination of ibuprofen/acetaminophen in the reduction of postoperative pain following endodontic debridement in patients with symptomatic irreversible pulpitis and symptomatic apical periodontitis.

Postoperative Pain Management with Oral Methylprednisolone in Symptomatic Patients with a Pulpal Diagnosis of Necrosis: A Prospective Randomized, Double-blind Study.

INTRODUCTION: The purpose of this prospective randomized, double-blind, placebo-controlled study was to evaluate postoperative pain by using an oral dose regimen of methylprednisolone in symptomatic patients with pulpal necrosis and symptomatic apical periodontitis, a periapical radiolucency, and experiencing preoperative moderate to severe pain. METHODS: One hundred twenty-five adult symptomatic patients presenting for emergency endodontic treatment with a pulpal diagnosis of necrosis and symptomatic apical periodontitis, a periapical radiolucency, and experiencing moderate to severe pain participated. All patients received complete endodontic debridement and were randomly divided into 2 groups. In a double-blind manner, the groups received either an oral regimen of methylprednisolone (96 mg immediately after treatment followed by 48 mg each day for 5 consecutive days) or a lactose placebo. All patients received 600 mg ibuprofen and an opioid-containing escape medication to take if needed. Patients completed a 7-day diary to record pain and number of analgesic medications taken each day. RESULTS: Moderate to severe pain was experienced by 40%-50% of the patients on day 1 and 31% of the patients on day 2, with the pain ratings decreasing during the next 7 days. There were no statistically significant differences in pain ratings between the methylprednisolone and placebo groups. CONCLUSIONS: When compared with a placebo, the current regimen of oral methylprednisolone did not significantly reduce postoperative pain after complete debridement of symptomatic patients presenting for emergency endodontic treatment with a pulpal diagnosis of necrosis and symptomatic apical periodontitis, periapical radiolucency, and experiencing moderate to severe pain.

Is Eye Color Related to Dental Injection Pain? A Prospective, Randomized, Single-blind Study.

INTRODUCTION: Recent studies have investigated the relationship between pain perception and specific phenotypes such as red hair color and various eye colors. Further investigations into biomarkers as they relate to pain could be useful in understanding underlying genetic components involved in these pathways. Additionally, it would be clinically useful to determine if a patient would be more likely to experience pain during dental treatment based on eye color. The purpose of this study was to investigate a link between eye color and perceived injection pain in healthy, asymptomatic white women. METHODS: Three hundred healthy, adult, white female patients were included, 133 with dark eyes and 167 with light eyes. Dental anxiety was assessed with the Corah Dental Anxiety Scale. Subjects with their eye color masked by dark glasses received a right maxillary lateral incisor infiltration of 1 cartridge of 2% lidocaine with 1:100,000 epinephrine. Patients rated their injection pain on a 170-mm Heft-Parker visual analog scale. Photographs of the subjects' eyes were taken after the infiltrations and categorized into dark- and light-eyed groups by 3 independent observers. Comparisons for injection pain were analyzed using analysis of variance and the Tukey-Kramer test. RESULTS: No significant differences were found for pain of injection between dark- or light-eyed subjects. CONCLUSIONS: Eye color was not shown to be a predictor for injection pain in white women. Therefore, eye color would not be clinically useful in determining if a patient would be more likely to experience pain during dental treatment.

Anesthetic Efficacy of a Combination of 4% Prilocaine/2% Lidocaine with Epinephrine for the Inferior Alveolar Nerve Block: A Prospective, Randomized, Double-blind Study.

INTRODUCTION: Prilocaine plain has a high pH and concentration (4%), which could decrease the pain of injection and increase success. The purpose of this study was to compare pain associated with anesthetic solution deposition and the degree of pulpal anesthesia obtained with the combination of prilocaine and lidocaine versus a lidocaine and lidocaine combination when used for inferior alveolar nerve blocks (IANBs). METHODS: One hundred eighteen asymptomatic subjects were randomly given a combination of 1 cartridge of 4% prilocaine plain plus 1 cartridge of 2% lidocaine with 1:100,000 epinephrine or a combination of 2 cartridges of 2% lidocaine with 1:100,000 epinephrine for the IANB at 2 separate appointments. Subjects rated the pain associated with anesthetic solution deposition of injection. Mandibular teeth were tested with an electric pulp tester every 4 minutes for 57 minutes. Anesthesia was considered successful when 2 consecutive 80 readings were obtained within 17 minutes and the 80 reading was continuously sustained for 57 minutes. Comparisons for anesthetic success were analyzed using the exact McNemar test, and pain ratings associated with anesthetic solution deposition were analyzed using multiple Wilcoxon matched pairs signed rank tests; both were adjusted using the step-down Bonferroni method of Holm. RESULTS: Four percent prilocaine plain was significantly less painful upon anesthetic solution deposition. Pulpal anesthetic success was not significantly different between the 2 combinations. CONCLUSIONS: The combination of 4% prilocaine plain plus 2% lidocaine with 1:100,000 epinephrine did not increase pulpal anesthetic success for IANBs compared with a combination of 2 cartridges of 2% lidocaine with 1:100,000 epinephrine. Pain associated with anesthetic solution deposition from the first cartridge of 4% prilocaine plain was significantly less when compared with the first cartridge of 2% lidocaine with 1:100,000 epinephrine.

What Is the Outcome of an Incision and Drainage Procedure in Endodontic Patients? A Prospective, Randomized, Single-blind Study.

INTRODUCTION: There are no prospective endodontic studies to determine the outcome of an incision and drainage (I&D) procedure for swelling in healthy, endodontic patients. The purpose of this prospective, randomized, single-blind study was to compare the postoperative course of I&D with drain placement versus a mock I&D procedure with mock drain placement after endodontic debridement in swollen emergency patients with symptomatic teeth and a pulpal diagnosis of necrosis. METHODS: Eighty-one adult emergency patients presenting with clinical swelling received either penicillin or, if allergic, clindamycin and complete endodontic debridement, and then were randomly divided into 2 treatment groups: I&D with drain placement or a mock I&D procedure with mock drain placement. At the end of the appointment, all patients received a combination of ibuprofen/acetaminophen and, if needed, an opioid-containing escape medication. Patients recorded their pain and medication use for 4 days postoperatively. Success was defined as no or mild postoperative pain and no use of an opioid-containing escape medication. Success was evaluated using repeated measure mixed model logistic regression. RESULTS: Both groups had a decrease in postoperative pain and medication use over the 4 days. The mock I&D group had significantly higher success than the I&D group (odds ratio = 2.00; 95% confidence interval, 1.16-3.41). The success rate was 45% with the mock I&D and 33% with the I&D. CONCLUSIONS: After endodontic debridement, patients who received a mock I&D procedure with mock drain placement had more success than patients who received I&D with drain placement. Both groups clinically improved over 4 days.

Effect of a Combination of Intranasal Ketorolac and Nitrous Oxide on the Success of the Inferior Alveolar Nerve Block in Patients with Symptomatic Irreversible Pulpitis: A Prospective, Randomized, Double-blind Study.

INTRODUCTION: Previous studies in patients with irreversible pulpitis have reported increased success of the inferior alveolar nerve block (IANB) using premedication with ketorolac. Preemptive nitrous oxide administration has also shown an increase in the success of the IANB. Recently, ketorolac has been made available for intranasal delivery. Perhaps combining ketorolac and nitrous oxide would increase success. Therefore, the purpose of this prospective, randomized, double-blind study was to determine the effect of a combination of intranasal ketorolac and nitrous oxide/oxygen on the anesthetic success of the IANB in patients presenting with symptomatic irreversible pulpitis. METHODS: One hundred two patients experiencing spontaneous moderate to severe pain with symptomatic irreversible pulpitis in a mandibular posterior tooth participated. Patients were randomly divided into 2 groups and received either 31.5 mg intranasal ketorolac or intranasal saline placebo 20 minutes before the administration of nitrous oxide/oxygen. Ten minutes after the administration of nitrous oxide/oxygen, the IANB was given. After profound lip numbness, endodontic treatment was performed. Success was defined as the ability to perform endodontic access and instrumentation with no pain or mild pain. RESULTS: The odds of success for the IANB was 1.631 in the intranasal saline/nitrous oxide group versus the intranasal ketorolac/nitrous oxide group with no significant difference between the groups (P = .2523). CONCLUSIONS: Premedication with intranasal ketorolac did not significantly increase the odds of success for the IANB over the use of nitrous oxide/oxygen alone. Supplemental anesthesia will still be needed to achieve adequate anesthesia.

Anesthetic Efficacy of Supine and Upright Positions for the Inferior Alveolar Nerve Block: A Prospective, Randomized Study.

INTRODUCTION: It has been recommended to place patients in an upright position after administration of an inferior alveolar nerve block (IANB), theoretically allowing the anesthetic to diffuse in an inferior direction and resulting in better pulpal anesthesia. The purpose of this study was to compare an upright versus a supine position on the success of pulpal anesthesia when an IANB was administered in asymptomatic teeth. METHODS: One hundred ten asymptomatic subjects were randomly given IANBs by using 2% lidocaine with 1:100,000 epinephrine while they were in an upright position and supine position at 2 different appointments spaced at least 2 weeks apart. Pulpal anesthesia was measured in the molars, premolars, and incisors with an electric pulp tester in 4-minute cycles for 60 minutes. Anesthetic success was defined as the subject achieving 2 consecutive 80 readings within 15 minutes of the injection and sustaining the 80 reading for 60 minutes. Success was analyzed by using a mixed model logistic regression. RESULTS: Pulpal anesthesia for the supine position was not statistically more successful than the upright position in the second molars (73% vs 65%), first molars (59% vs 54%), lateral incisors (28% vs 23%), and central incisors (11% vs 8%), respectively. The supine position significantly improved success in the second premolars (63% vs 53%) and first premolars (75% vs 64%). CONCLUSIONS: The supine and upright positions were equally successful in the molars and anterior teeth. The supine position was more successful in the premolars. However, clinically, neither position for the IANB administration would provide complete pulpal anesthesia.

Inferior Alveolar Nerve Block Injection Pain Using a Computer-Controlled Local Anesthetic Device (CCLAD): A Prospective, Randomized Study.

There is evidence that the Computer-Controlled Local Anesthetic Device (CCLAD) decreases the pain of oral injections. The purpose of this study was to evaluate injection pain of the inferior alveolar nerve block (IANB) using the CCLAD in an upright position versus a supine position. Additionally, we evaluated solution deposition pain with the CCLAD when compared to previous studies using a traditional syringe. One hundred ten asymptomatic subjects were randomly given IANBs using 2% lidocaine with 1:100,000 epinephrine while in an upright sitting position and supine position, at 2 different appointments, spaced at least 2 weeks apart. Each subject rated the pain for needle insertion, needle placement, and solution deposition on a Heft-Parker visual analogue scale. Pain ratings were compared between the upright and supine positions using a repeated-measures analysis of variance with post hoc testing using the Tukey-Kramer procedure. Moderate to severe pain was reported by 10% to 13% of the patients for needle insertion, 74% to 75% for full needle placement, and 8% to 10% for solution deposition. There was no significant difference between groups for phases of the injection. When comparing the injection phases within the groups, the needle placement phase of the injection was statistically more painful than both the needle insertion phase and solution deposition phase ( p = .0001). Using the CCLAD, IANB injection pain of the supine and upright positions was not statistically different. Needle placement was the most painful phase of the injection. Solution deposition pain was less with the CCLAD when compared to other studies of the IANB using a traditional syringe.