title: A prospective randomized trial of different supplementary local anesthetic techniques after failure of inferior alveolar nerve block in patients with irreversible pulpitis in mandibular teeth.
abstract: OBJECTIVE
  The objective of this study was to compare the efficacy of supplementary repeat inferior alveolar nerve block with 2% lidocaine and epinephrine, buccal infiltration with 4% articaine with epinephrine, intraligamentary injection, or intraosseous injection (both with 2% lidocaine with epinephrine) after failed inferior alveolar nerve block (IANB) for securing pain-free treatment in patients experiencing irreversible pulpitis in mandibular permanent teeth.
  
  
  METHODS
  This randomized clinical trial included 182 patients diagnosed with irreversible pulpitis in mandibular teeth. Patients received 2.0 mL of 2% lidocaine with 1:80,000 epinephrine as an IANB injection. Patients who did not experience pain-free treatment received randomly 1 of 4 supplementary techniques, namely repeat lidocaine IANB (rIANB), articaine buccal infiltration (ABI), lidocaine intraligamentary injection (PDL), or lidocaine intraosseous injection (IO). Successful pulp anesthesia was considered to have occurred when no response was obtained to the maximum stimulation (80 reading) of the pulp tester, at which time treatment commenced. Treatment was regarded as being successfully completed when it was associated with no pain. Data were analyzed by χ(2) and Fisher exact tests.
  
  
  RESULTS
  Of the 182 patients, 122 achieved successful pulpal anesthesia within 10 minutes after initial IANB injection; 82 experienced pain-free treatment. ABI and IO allowed more successful (pain-free) treatment (84% and 68%, respectively) than rIANB or PDL supplementary techniques (32% and 48%, respectively); this was statistically significant (P = .001).
  
  
  CONCLUSIONS
  IANB injection alone does not always allow pain-free treatment for mandibular teeth with irreversible pulpitis. Supplementary buccal infiltration with 4% articaine with epinephrine and intraosseous injection with 2% lidocaine with epinephrine are more likely to allow pain-free treatment than intraligamentary and repeat IANB injections with 2% lidocaine with epinephrine for patients experiencing irreversible pulpitis in mandibular permanent teeth.
authors.affiliation: Centre for Oral Health Research, Newcastle University, Newcastle upon Tyne, England.
authors.forename: Mohammad D
authors.initials: MD
authors.lastname: Kanaa
authors.forename: John M
authors.initials: JM
authors.lastname: Whitworth
authors.forename: John Gerard
authors.initials: JG
authors.lastname: Meechan
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000766:Anesthesia, Dental / Q000379:methods*; D000772:Anesthesia, Local / Q000379:methods*; D000779:Anesthetics, Local / Q000008:administration & dosage; D002355:Carticaine / Q000008:administration & dosage; D003782:Dental Pulp / Q000187:drug effects; D004837:Epinephrine / Q000008:administration & dosage; D005260:Female; D006801:Humans; D007267:Injections; D008012:Lidocaine / Q000008:administration & dosage; D008297:Male; D008334:Mandible; D008340:Mandibular Nerve; D008875:Middle Aged; D009061:Mouth Mucosa; D009407:Nerve Block; D010513:Periodontal Ligament; D011446:Prospective Studies; D011671:Pulpitis / Q000628:therapy*; D012390:Root Canal Therapy; D012677:Sensation / Q000187:drug effects; D013997:Time Factors; D014081:Tooth Extraction; D016896:Treatment Outcome; D014662:Vasoconstrictor Agents / Q000008:administration & dosage; D055815:Young Adult
chemical_list: D000779:Anesthetics, Local; D014662:Vasoconstrictor Agents; D008012:Lidocaine; D002355:Carticaine; D004837:Epinephrine