Chewing causes rapid changes in immunoreactive nerve patterns in rat molar teeth: Implications for dental proprioception and pain.

OBJECTIVE: This study tests the hypothesis that normal use of teeth (chewing) causes changes in immunoreactive-(IR) patterns for endings of large Aß and CGRP axons in rat molar cusps. DESIGN: First, a new paradigm to test chewing in adult male rats was developed. Then IR patterns for large dental axons were analysed for a calcium-binding protein, parvalbumin (PV), heavy neurofilament protein-200 (NFP), and vesicle-release molecule synaptophysin (SYN) that all typify large dental axons and proprioceptors for comparison with endings of CGRP-IR neuropeptide axons. The behavior groups were: (1) daytime sleeping/fasting (Group:SF); (2) brief feeding after 8-11 h of daytime sleeping/fasting (Group:SF-C); (3) normal nocturnal feeding (Group:N); (4) nocturnal fasting (Group:NF); (5) brief feeding/chewing after nocturnal fasting (Group:NF-C). RESULTS: Nerve endings with NFP-, PV-, or SYN-IR were lost or altered in pulp and dentin in all chewing groups. Other endings with CGRP-IR were near those with PV-, NFP- and SYN-IR at the pulp-dentin border and in dentin, and they also lost immunoreactivity in all chewing groups. The special beaded regions along the crown pulp/dentin borders lost neural labeling in all chewing groups. Nerves of molar roots and periodontal ligament were not changed. CONCLUSIONS: Rapid neural reactions to chewing show extensive, reversible, non-nociceptive depletions of crown innervation. Those changes were rapid enough to occur during normal feeding followed by recovery during rest. The new dental paradigm related to chewing and fasting allows dissection of intradental proprioceptive-like mechanisms during normal tooth functions for comparison with nociceptive and mechanosensitive reactions after injury or inflammation.

Trigeminal Nerve Transection-Induced Neuroplastic Changes in the Somatosensory and Insular Cortices in a Rat Ectopic Pain Model.

The primary sensory cortex processes competitive sensory inputs. Ablation of these competitive inputs induces neuroplastic changes in local cortical circuits. However, information concerning cortical plasticity induced by a disturbance of competitive nociceptive inputs is limited. Nociceptive information from the maxillary and mandibular molar pulps converges at the border between the ventral secondary somatosensory cortex (S2) and insular oral region (IOR); therefore, S2/IOR is a suitable target for examining the cortical changes induced by a disturbance of noxious inputs, which often causes neuropathic pain and allodynia. We focused on the plastic changes in S2/IOR excitation in a model of rats subjected to inferior alveolar nerve transection (IANX). Our optical imaging using a voltage-sensitive dye (VSD) revealed that the maxillary molar pulp stimulation-induced excitatory propagation was expanded one to two weeks after IANX at the macroscopic level. At the cellular level, based on Ca2+ imaging using two-photon microscopy, the amplitude of the Ca2+ responses and the number of responding neurons in S2/IOR increased in both excitatory and inhibitory neurons. The in vitro laser scanning photostimulation (LSPS) revealed that Layer II/III pyramidal and GABAergic fast-spiking neurons in S2/IOR received larger excitatory inputs from Layer IV in the IANX models, which supports the findings obtained by the macroscopic and microscopic optical imaging. Furthermore, the inhibitory postsynaptic inputs to the pyramidal neurons were decreased in the IANX models, suggesting suppression of inhibitory synaptic transmission onto excitatory neurons. These results suggest that IANX induces plastic changes in S2/IOR by changing the local excitatory and inhibitory circuits.

Buccal infiltration versus inferior alveolar nerve block in mandibular 2nd premolars with irreversible pulpitis.

PURPOSE: The purpose of this study is to compare the success rates of inferior alveolar nerve block (IANB) and buccal infiltration anesthesia of mandibular second premolar with irreversible pulpitis and to evaluate the level of patient discomfort with these methods. MATHERIALS AND METHODS: Forty patients, who had irreversible pulpitis in the mandibular 2nd premolar teeth, were included in the study. Patients were randomly distributed in two groups. In one group IANB, in the other group buccal infiltration anesthesia were performed. The efficacy of these two different anesthesia techniques on the related teeth was investigated with the Heft-Parker visual analog scale. In addition, with a pulse oximetry device, the changes in the patients' heart rates were compared between the groups. The obtained data were evaluated statistically. RESULTS: Both anesthesia techniques reduced the pain significantly in patients before the administration (P < 0.05), but there was no significant difference among the groups regarding the pain control and success rates of anesthesia (P > 0.05). Both of the anesthesia techniques increased the heart rate (P < 0.05). The increase in the heart rate of the patients was significantly higher in the buccal infiltration anesthesia group than the other anesthesia group (P < 0.05). CONCLUSION: Within the limitation of this in vivo study, there was no difference between the efficacies of the buccal infiltration anesthesia and IANB anesthesia in the mandibular 2nd premolar teeth with irreversible pulpitis. Buccal infiltration anesthesia caused more discomfort in the patients compared with the IANB during the administration.

Semaphorin 3A receptor inhibitor as a novel therapeutic to promote innervation of bioengineered teeth.

The sensory innervation of the dental pulp is essential for tooth function and protection. It is mediated by axons originating from the trigeminal ganglia and is spatio-temporally regulated. We have previously shown that the innervation of bioengineered teeth can be achieved only under immunosuppressive conditions. The aim of this study was to develop a model to determine the role of Semaphorin 3A (Sema3A) in the innervation of bioengineered teeth. We first analysed innervation of the dental pulp of mandibular first molars in newborn (postnatal day 0: PN0) mice deficient for Sema3A (Sema3A-/- ), a strong inhibitor of axon growth. While at PN0, axons detected by immunostaining for peripherin and NF200 were restricted to the peridental mesenchyme in Sema3A+/+ mice, they entered the dental pulp in Sema3A-/- mice. Then, we have implanted cultured teeth obtained from embryonic day-14 (E14) molar germs of Sema3A-/- mice together with trigeminal ganglia. The dental pulps of E14 cultured and implanted Sema3A-/- teeth were innervated, whereas the axons did not enter the pulp of E14 Sema3A+/+ cultured and implanted teeth. A "Membrane Targeting Peptide NRP1," suppressing the inhibitory effect of Sema3A, has been previously identified. The injection of this peptide at the site of implantation allowed the innervation of the dental pulp of bioengineered teeth obtained from E14 dental dissociated mesenchymal and epithelial cells reassociations of ICR mice. In conclusion, these data show that inhibition of only one axon repellent molecule, Sema3A, allows for pulp innervation of bioengineered teeth.

Multiple complex somatosensory systems in mature rat molars defined by immunohistochemistry.

OBJECTIVE: Intradental sensory receptors trigger painful sensations and unperceived mechanosensitivity, but the receptor bases for those functions are only partly defined. We present new evidence here concerning complex endings of myelinated axons in rat molars. DESIGN: We sectioned mature rat jaws in sagittal and transverse planes to analyze neural immunoreactivity (IR) for parvalbumin, peripherin, neurofilament protein, neurotrophin receptors, synaptophysin, calcitonin gene-related peptide (CGRP), or mas-related g-protein-receptor-d (Mrgprd). RESULTS: We found two complex sensory systems in mature rat molar dentin that labeled with neurofilament protein-IR, plus either parvalbumin-IR or peripherin-IR. The parvalbumin-IR system made extensively branched, beaded endings focused into dentin throughout each pulp horn. The peripherin-IR system primarily made unbeaded, fork-shaped dentinal endings scattered throughout crown including cervical regions. Both of these systems differed from neuropeptide CGRP-IR. In molar pulp we found peripherin- and parvalbumin-IR layered endings, either near special horizontal plexus arrays or in small coiled endings near tangled plexus, each with specific foci for specific pulp horns. Parvalbumin-IR nerve fibers had Aß axons (5-7µm diameter), while peripherin-IR axons were thinner Aδ size (2-5µm). Mechano-nociceptive Mrgprd-IR was only found in peripherin-IR axons. CONCLUSIONS: Complex somatosensory receptors in rat molars include two types of dentinal endings that both differ from CGRP-IR endings, and at least two newly defined types of pulpal endings. The PV-IR neurons with their widely branched, synaptophysin-rich, intradentinal beaded endings are good candidates for endodontic non-nociceptive, low threshold, unperceived mechanoreceptors. The complex molar dentinal and pulpal sensory systems were not found in rat incisors.

Efficacy of orally administered prednisolone versus partial endodontic treatment on pain reduction in emergency care of acute irreversible pulpitis of mandibular molars: study protocol for a randomized controlled trial.

BACKGROUND: Irreversible pulpitis is a highly painful inflammatory condition of the dental pulp which represents a common dental emergency. Recommended care is partial endodontic treatment. The dental literature reports major difficulties in achieving adequate analgesia to perform this emergency treatment, especially in the case of mandibular molars. In current practice, short-course, orally administered corticotherapy is used for the management of oral pain of inflammatory origin. The efficacy of intraosseous local steroid injections for irreversible pulpitis in mandibular molars has already been demonstrated but resulted in local comorbidities. Oral administration of short-course prednisolone is simple and safe but its efficacy to manage pain caused by irreversible pulpitis has not yet been demonstrated. This trial aims to evaluate the noninferiority of short-course, orally administered corticotherapy versus partial endodontic treatment for the emergency care of irreversible pulpitis in mandibular molars. METHODS/DESIGN: This study is a noninferiority, open-label, randomized controlled clinical trial conducted at the Bordeaux University Hospital. One hundred and twenty subjects will be randomized in two 1:1 parallel arms: the intervention arm will receive one oral dose of prednisolone (1 mg/kg) during the emergency visit, followed by one morning dose each day for 3 days and the reference arm will receive partial endodontic treatment. Both groups will receive planned complete endodontic treatment 72 h after enrollment. The primary outcome is the proportion of patients with pain intensity below 5 on a Numeric Scale 24 h after the emergency visit. Secondary outcomes include comfort during care, the number of injected anesthetic cartridges when performing complete endodontic treatment, the number of antalgic drugs and the number of patients coming back for consultation after 72 h. DISCUSSION: This randomized trial will assess the ability of short-term corticotherapy to reduce pain in irreversible pulpitis as a simple and rapid alternative to partial endodontic treatment and to enable planning of endodontic treatment in optimal analgesic conditions. TRIAL REGISTRATION: ClinicalTrials.gov, identifier: NCT02629042 . Registered on 7 December 2015. (Version n°1.1 28 July 2015).

Immunohistochemical localization of SNARE core proteins in intrapulpal and intradentinal nerve fibers of rat molar teeth.

OBJECTIVE: The present study was designed to elucidate whether three soluble N-ethylmaleimide-sensitive fusion protein attachment protein receptor (SNARE) core proteins, syntaxin-1, synaptosomal-associated protein of 25kDa (SNAP-25), and vesicle-associated membrane protein-2 (VAMP-2), are present in the dental pulp of the rat molar at both the light and electron microscopic levels. DESIGN: Immunohistochemistry for protein gene product 9.5 (PGP 9.5), a pan-neuronal marker, syntaxin-1, SNAP-25, and VAMP-2 was performed on decalcified rat molars for light and electron microscopic analyses. Double-immunolabeling of PGP 9.5 and the SNARE core proteins, as well as combinations of the SNARE core proteins, was also carried out. RESULTS: PGP 9.5-immunoreactive nerve fibers ran toward the coronal region, ramified at the subodontoblast layer, and formed the subodontoblastic nerve plexus. Most nerve fibers penetrated the predentin and dentin along the dentinal tubules. Most, if not all, nerve fibers displayed immunoreactivity for syntaxin-1, SNAP-25, and VAMP-2. Immunoelectron microscopic analyses confirmed the presence of immunoreactivity for the SNARE core proteins within the intradental axonal elements. CONCLUSIONS: The present findings suggest that, since SNARE core proteins participate in the docking and exocytosis of synaptic vesicles in the central nervous system, they may contribute to vesicle exocytosis from the dental nerve fibers even though there are no apparent synapses.

Effects of Two Different Anesthetic Solutions on Injection Pain, Efficacy, and Duration of Soft-Tissue Anesthesia with Inferior Alveolar Nerve Block for Primary Molars.

OBJECTIVES: The purpose of the study was to compare the efficacy, injection pain, duration of soft tissue anesthesia, and postoperative complications of two different anesthetics (2% lidocaine with 1:80,000 epinephrine and 3% plain mepivacaine) in pediatric patients in inferior alveolar nerve block (IANB) administered by a computer-controlled delivery system (CCDS). STUDY DESIGN: The study was conducted as a randomized, controlled-crossover, double-blind clinical trial with 60 children requiring bilateral pulpotomy or extraction of primary mandibular molars. A CCDS was used to deliver 3% mepivacaine to 1 primary tooth and 2% lidocaine to the contralateral tooth with an IANB technique. Severity of pain and efficacy of anesthesia were evaluated using the Face, Legs, Activity, Cry, Consolability Scale, and comfort and side effects were assessed using a questionnaire. Data were analyzed using the Mann-Whitney U, Wilcoxon t, and Fisher exact tests. RESULTS: Patients receiving 2% lidocaine experienced significantly less pain during injection than those receiving 3% mepivacaine, and no significant differences were found in the pain scores during treatments or in postoperative complications between the two anesthetics. The mean durations of anesthesia for 3% mepivacaine and 2% lidocaine were 139.68 minutes and 149.10 minutes, respectively. CONCLUSIONS: Plain mepivacaine and 2% lidocaine were similarly effective in pulpotomy and the extraction of primary mandibular molars. Although the use of 3% mepivacaine provided a shorter duration of anesthesia than 2% lidocaine, both solutions showed similar results in terms of postoperative complications.

Efficacy of Ketorolac Buccal Infiltrations and Inferior Alveolar Nerve Blocks in Patients with Irreversible Pulpitis: A Prospective, Double-blind, Randomized Clinical Trial.

INTRODUCTION: The purpose of this prospective, randomized, double-blind, placebo-controlled study was to determine whether ketorolac buccal infiltrations (BIs) helped to improve the success of inferior alveolar nerve blocks (IANBs) in patients with acute irreversible pulpitis (AIP). METHODS: Forty adult volunteers with AIP in a mandibular molar were included in this study. Patients were instructed to evaluate their pain by using a Heft-Parker visual analog scale. They were randomly divided into 2 groups (n = 20). All patients received standard IANB injection and after that a BI of 4% articaine with 1:100,000 epinephrine. After 5 minutes, 20 patients received a BI of 30 mg/mL ketorolac, and the other received a BI of normal saline (control group). Endodontic access cavity preparation (ACP) was initiated 15 minutes after the IANB when the patient reported lip numbness and had 2 electric pulp tests with no responses. The patient's pain during caries and dentin removal, ACP, and canal length measurements (CLM) was recorded by using Heft-Parker visual analog scale. Successful anesthesia was defined as no or mild pain during any of these steps, without the need for additional injection. Data were statistically analyzed by using Mann-Whitney U and χ(2) tests. RESULTS: Successful anesthesia after an IANB plus BI of articaine was obtained in 15% of patients in the control group at the end of CLM. Adding BI of ketorolac significantly increased the success rate to 40% (P < .05). Patient's pain during ACP and CLM was significantly lower in the ketorolac group (P < .05). CONCLUSIONS: Ketorolac BI can increase the success rate of anesthesia after IANB and BI with articaine in patients with AIP.

Anesthetic Success of an Inferior Alveolar Nerve Block and Supplemental Articaine Buccal Infiltration for Molars and Premolars in Patients with Symptomatic Irreversible Pulpitis.

INTRODUCTION: The purpose of this retrospective study was to determine the anesthetic success of the inferior alveolar nerve (IAN) block, and supplemental articaine buccal infiltration after a failed IAN block, in first and second molars and premolars in patients presenting with symptomatic irreversible pulpitis. METHODS: As part of 6 studies, 375 emergency patients presenting with symptomatic irreversible pulpitis received 2% lidocaine with 1:100,000 epinephrine via an IAN block. After profound lip numbness, endodontic access and instrumentation were initiated. If the patient felt moderate to severe pain, a supplemental buccal infiltration of a cartridge of 4% articaine with 1:100,000 epinephrine was administered (204 patients), and endodontic treatment continued. Success was defined as the ability to access and instrument the tooth without pain (visual analogue scale rating of 0) or mild pain (visual analogue scale rating less than or equal to 54 mm). RESULTS: IAN block success was 28% for the first molars, 25% for the second molars, and 39% for the premolars. There were no significant differences when comparing molars with premolars. For the supplemental articaine buccal infiltration, success was 42% for the first molars, 48% for the second molars, and 73% for the premolars. There were no significant differences when comparing the molars, but there was a significant difference when comparing the premolars with the molars. CONCLUSIONS: For patients presenting with symptomatic irreversible pulpitis, the success rates for the IAN block and supplemental buccal infiltration of articaine of the molars and premolars would not be high enough to ensure profound pulpal anesthesia.

Comparison of Anaesthetic Efficacy of 4% Articaine Primary Buccal Infiltration Versus 2% Lidocaine Inferior Alveolar Nerve Block in Symptomatic Mandibular First Molar Teeth.

OBJECTIVE: To evaluate success of pulpal anaesthesia of mandibular 1st molar by using 4% articaine in buccal infiltration versus 2% lidocaine in inferior alveolar nerve block. STUDY DESIGN: Randomized control trial. PLACE AND DURATION OF STUDY: Department of Operative Dentistry, Sardar Begum Dental College, Gandhara University, Peshawar, from March to August 2014. METHODOLOGY: One hundred and fifty-six emergency patients, who had 1st molar diagnosed with irreversible pulpitis, participated in the study. Subjects were divided into two groups by random allocation. One group received 4% articaine buccal infiltration and the other group received inferior alveolar nerve block of 2% lidocaine. Subjects’self-reported pain response was recorded on Heft Parker Visual Analogue Scale after local anaesthetic administration during access cavity preparation and pulp extirpation. RESULTS: Mean age of subjects was 31.46 ±10.994 years. The success rate of 4% buccal infiltration was 76.9%; whereas the success rate of 2% lidocaine inferior alveolar nerve block was 62.8%. There was no statistically significant difference between the two groups. CONCLUSION: 4% articaine buccal infiltration can be considered a viable alternative to 2% lidocaine inferior alveolar nerve block in securing successful pulpal anaesthesia for endodontic therapy.

Distinct Excitation to Pulpal Stimuli between Somatosensory and Insular Cortices.

Somatosensory information from the dental pulp is processed in the primary (S1) and secondary somatosensory cortex (S2) and in the insular oral region (IOR). Stimulation of maxillary incisor and molar initially induces excitation in S2/IOR, rostrodorsal to the mandibular incisor and molar pulp-responding regions. Although S1 and S2/IOR play their own roles in nociceptive information processing, the anatomical and physiological differences in the temporal activation kinetics, dependency on stimulation intensity, and additive or summative effects of simultaneous pulpal stimulation are still unknown. This information contributes not only to understanding topographical organization but also to speculating about the roles of S1 and S2/IOR in clinical aspects of pain regulation. In vivo optical imaging enables investigation of the spatiotemporal profiles of cortical excitation with high resolution. We determined the distinct features of optical responses to nociceptive stimulation of dental pulps between S1 and S2/IOR. In comparison to S1, optical signals in S2/IOR showed a larger amplitude with a shorter rise time and a longer decay time responding to maxillary molar pulp stimulation. The latency of excitation in S2/IOR was shorter than in S1. S2/IOR exhibited a lower threshold to evoke optical responses than S1, and the peak amplitude was larger in S2/IOR than in S1. Unexpectedly, the topography of S1 that responded to maxillary and mandibular incisor and molar pulps overlapped with the most ventral sites in S1 that was densely stained with cytochrome oxidase. An additive effect was observed in both S1 and S2/IOR after simultaneous stimulation of bilateral maxillary molar pulps but not after contralateral maxillary and mandibular molar pulp stimulation. These findings suggest that S2/IOR is more sensitive for detecting dental pulp sensation and codes stimulation intensity more precisely than S1. In addition, contra- and ipsilateral dental pulp nociception converges onto spatially closed sites in S1 and S2/IOR.

Decreased face primary motor cortex (face-M1) excitability induced by noxious stimulation of the rat molar tooth pulp is dependent on the functional integrity of medullary astrocytes.

We have recently shown that application of the small-fiber excitant and inflammatory irritant mustard oil (MO) to the rat molar tooth pulp can decrease face-M1 excitability, but increase the excitability of trigeminal medullary dorsal horn (MDH) nociceptive neurons and that application of the astrocytic inhibitor methionine sulfoximine (MSO) to the face-M1 or MDH can attenuate the MO-induced changes. The present study aimed to determine whether medullary MSO application could modulate the MO-induced decreased face-M1 excitability. Under ketamine general anesthesia, electromyographic (EMG) electrodes were implanted into the right anterior digastric (RAD, jaw-opening muscle) of adult male Sprague-Dawley rats. A microelectrode was positioned at a low-threshold (≤30 µA) site in the left face-M1. Then MO (n = 16) or control-solution (n = 16) was applied to the previously exposed molar tooth pulp, and intracortical microstimulation threshold intensities for evoking RAD EMG activities were monitored for 15 min. MSO (0.1 mM, n = 8) or phosphate-buffered saline (PBS, n = 8) was then applied to the MDH and RAD thresholds monitored every 15 min for 120 min. Statistics used ANOVA followed by post hoc Bonferroni as appropriate (p < 0.05). As compared to baseline, RAD thresholds significantly increased (i.e., decreased excitability) within 1 min (26.3 ± 7.9%, p = 0.007) and peaked at 15 min following pulpal MO application (49.9 ± 5.7%, p < 0.001) but not following control-solution. Following MSO (but not PBS) application to the medulla, RAD thresholds significantly decreased within 15 min (26.5 ± 3.0%, p = 0.05) and at 60 min approached 6.3 ± 2.4%, of baseline values (p = 0.1). These novel findings suggest that clinically related motor disturbances arising from dental pain may involve decreased face-M1 excitability that is modulated by medullary astrocytes.

Frequency and anatomy of the retromolar canal - implications for the dental practice.

The retromolar canal (RMC) is an anatomical variant of the mandibular canal. Apart from blood vessels it also contains accessory nerve fibers and is clinically important, because its presence can account for failures of mandibular block anesthesias and in rare cases, injuries of its neurovascular bundle can lead to complications such as hemorrhages and dysesthesias. The aim of this retrospective case study was to analyze the frequency and anatomy of the RMC using cone beam computed tomography (CBCT) in order to draw conclusions for the dental practice. A total of 680 CBCT scans comprising 1,340 mandibular sides were evaluated. A total of 216 RMCs (16.12%) were found. The most common appearance of the canal (39.82%) corresponded to type Al (vertical course), whereas type C (horizontal course) occurred least often (6.02%). Mean measured values were 1.03 mm (SD=0.27mm) regarding the RMC diameter, 10.19 mm (SD=2.64mm) regarding the RMC height and 15.10 mm (SD=2.83 mm) regarding the distance of the RMC to the second molar. Neither demographic factors nor the spatial resolution of the CBCT had a statistically significant impact on the frequency of the RMC. Since the present study revealed a frequency of RMCs amounting to 16.12% (corresponding approximately to every sixth retromolar area), we recommend to spare it during surgery or to consider an additional locoregional anesthesia in the retromolar region. For preoperative diagnosis the CBCT has proved suitable, offering the possibility to select the spatial resolution depending on the indication, so that radiation exposure is reduced without a decrease in validity.

Description and evaluation of an intraoral cervical plexus anesthetic technique.

Unsuccessful anesthesia of the inferior alveolar nerve (IAN) may be due to supplementary innervations of mandibular molars from other branches, namely the cervical plexus (CP). The purpose of this prospective, randomized, double-blind, controlled trial was to determine the effectiveness of an intraoral cervical plexus anesthetic technique (ICPAT) in mandibular molars with symptomatic irreversible pulpitis (SIR) when the IAN and lingual nerve (LN) blocks failed, and to provide a description of the technique. Forty patients diagnosed with SIR received IAN and LN block anesthesia prior to treatment. After clinical signs of anesthesia, patients were subjected to an electrical pulp test (EPT) at 2-min cycles for 10 min post-injection. The anesthesia was considered unsuccessful if there was a positive EPT response ten minutes following profound lip numbness. The experimental group (n = 20) were administered 2% Lidocaine with 1:100,000 epinephrine using the ICPAT. The control group (n = 20) were administered 0.9% sterile saline using the ICPAT. Success was defined as no response on two consecutive readings from an EPT. In the experimental group, 60% of subjects showed successful anesthesia, whereas none of the subjects in the control group had successful anesthesia. A multiple logistic regression analysis showed that the anesthesia success rate using the ICPAT method was significantly higher (P < 0.05) than in the control group, irrespective of molar tooth type. The ICPAT method may be useful as a supplementary anesthetic technique for mandibular molars with SIR in subjects whom the IAN and LN blocks do not provide adequate anesthesia.

Does the combination of 3% mepivacaine plain plus 2% lidocaine with epinephrine improve anesthesia and reduce the pain of anesthetic injection for the inferior alveolar nerve block? A prospective, randomized, double-blind study.

INTRODUCTION: In theory, using 3% mepivacaine initially for an inferior alveolar nerve (IAN) block would decrease the pain of injection, provide faster onset, and increase anesthetic success. The purpose of this prospective, randomized, double-blind study was to compare the degree of pulpal anesthesia obtained with a combination of 3% mepivacaine/2% lidocaine (1:100,000 epinephrine) versus a combination of 2% lidocaine (1:100,000 epinephrine)/2% lidocaine (1:100,000 epinephrine) in IAN blocks. Injection pain was also studied. METHODS: One hundred asymptomatic subjects were randomly given a combination of a 1-cartridge volume of 3% mepivacaine plus a 1-cartridge volume of 2% lidocaine with 1:100,000 epinephrine and a combination of a 1-cartridge volume of 2% lidocaine with 1:100,000 epinephrine plus a 1-cartridge volume of 2% lidocaine with 1:100,000 epinephrine for the IAN block at 2 separate appointments. Subjects rated the pain of injection. The molars, premolars, and incisors were tested 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 after completion of the IAN blocks and sustaining the 80 reading for 60 minutes. RESULTS: Success was not significantly different (P > .05) between the 2 combinations. No statistical differences in injection pain or onset times were found. CONCLUSIONS: The combination of 3% mepivacaine plus 2% lidocaine with 1:100,000 epinephrine was equivalent to the combination of 2 cartridges of 2% lidocaine with 1:100,000 epinephrine in terms of injection pain, onset time, and pulpal anesthetic success for the IAN block.

Anaesthetic efficacy of bupivacaine 2-hydroxypropyl-ß-cyclodextrin for dental anaesthesia after inferior alveolar nerve block in rats.

Bupivacaine is a long-acting local anaesthetic that is widely used in medicine and dentistry. The duration and intensity of its sensory blockade in animal models is increased by its inclusion in complexes with cyclodextrins. The aim of the present study was to evaluate the anaesthetic efficacy of bupivacaine 2-hydroxypropyl-ß-cyclodextrin (HPßCD) inclusion complex for dental anaesthesia after inferior alveolar nerve block in rats. Thirty rats were each given an injection close to the mandibular foramen of 0.2ml of one of the following formulations: 0.5% bupivacaine alone; 0.5% bupivacaine with 1:200,000 epinephrine; and 0.5% bupivacaine-HPßCD inclusion complex (bupivacaine-HPßCD). The other sides were used as controls, with either 0.9% saline or anaesthetic-free HPßCD solution being injected. The onset, success, and duration of pulpal anaesthesia were assessed by electrical stimulation ("pulp tester") on inferior molars. Results were analysed using ANOVA (Tukey), log rank, and chi square tests (α=5%). There were no differences among the formulations in onset of anaesthesia (p=0.59) or between the bupivacaine plus epinephrine and bupivacaine plus HPßCD in duration of anaesthesia, but bupivacaine plus epinephrine gave significantly higher values than bupivacaine alone (p=0.007). Bupivacaine plus epinephrine was a better anaesthetic than bupivacaine alone (p=0.02), while Bupi-HPßCD gave intermediate results, and therefore did not differ significantly from the other 2 groups (p=0.18 with bupivacaine alone; and p=0.44 with bupivacaine plus epinephrine). The bupivacaine-HPßCD complex showed similar anaesthetic properties to those of bupivacaine with epinephrine.

Risk assessment of inferior alveolar nerve injury for immediate implant placement in the posterior mandible: a virtual implant placement study.

OBJECTIVES: To investigate the prevalence and morphological parameters of lingual concavity, and whether these factors are related to a higher risk of inferior alveolar nerve (IAN) injury when performing an immediate implant surgery in posterior mandible region. METHODS: The CBCT images from 237 subjects (1008 teeth) were analysed the shape of the mandibles (C, P, U type), dimensional parameters of lingual concavity (angle, height, depth), and its relation to inferior alveolar canal (IAC) (A, B, C zone), RAC (distance from root apex to IAC) and probability of IAN injury. Multiple logistic regression modelling to determine the odds ratio of variables that made an important contribution to the probability of IAN injury and to adjust for confounding variables. RESULTS: The U type ridge (46.7%) and the most concave point located at C zone (48.8%) are most prevalent in this region. The mandibular second molar presents highest risk for IAN injury than other tooth type (p<0.001), which were 3.82 times to occur IAN injury than the mandibular second premolar. The concave point located at A zone and B zone were 7.82 and 3.52 times than C zone to have IAN damage, respectively. The probability of IAN injury will reduce 26% for every 1mm increase in RAC (p<0.001). CONCLUSIONS: The tooth type, morphological features of lingual concavities, and RAC are associated with risks of IAN injury during immediate implant placement. CLINICAL SIGNIFICANCE: Pre-surgical mapping of the IAC and identification of its proximity relative to the lingual concavity in the posterior mandible regions may avoid unpleasant complications, specifically when performing immediate implant procedures.

Immunomodulation stimulates the innervation of engineered tooth organ.

The sensory innervation of the dental mesenchyme is essential for tooth function and protection. Sensory innervation of the dental pulp is mediated by axons originating from the trigeminal ganglia and is strictly regulated in time. Teeth can develop from cultured re-associations between dissociated dental epithelial and mesenchymal cells from Embryonic Day 14 mouse molars, after implantation under the skin of adult ICR mice. In these conditions however, the innervation of the dental mesenchyme did not occur spontaneously. In order to go further with this question, complementary experimental approaches were designed. Cultured cell re-associations were implanted together with trigeminal ganglia for one or two weeks. Although axonal growth was regularly observed extending from the trigeminal ganglia to all around the forming teeth, the presence of axons in the dental mesenchyme was detected in less than 2.5% of samples after two weeks, demonstrating a specific impairment of their entering the dental mesenchyme. In clinical context, immunosuppressive therapy using cyclosporin A was found to accelerate the innervation of transplanted tissues. Indeed, when cultured cell re-associations and trigeminal ganglia were co-implanted in cyclosporin A-treated ICR mice, nerve fibers were detected in the dental pulp, even reaching odontoblasts after one week. However, cyclosporin A shows multiple effects, including direct ones on nerve growth. To test whether there may be a direct functional relationship between immunomodulation and innervation, cell re-associations and trigeminal ganglia were co-implanted in immunocompromised Nude mice. In these conditions as well, the innervation of the dental mesenchyme was observed already after one week of implantation, but axons reached the odontoblast layer after two weeks only. This study demonstrated that immunodepression per se does stimulate the innervation of the dental mesenchyme.