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Enhancing Efficacy of Dental Local Anaesthesia in Mandibular Teeth: Investigating Injection Speed

Explore the impact of injection speed on anaesthesia success in dental procedures, aiming to improve local anaesthesia efficacy for mandibular teeth. The study employs a double-blind randomized crossover design with healthy volunteers to analyze the association between injection speed (slow vs. rapid) and inferior alveolar nerve block (IANB) outcomes. By investigating variables such as anatomical, pathological, pharmaceutical, pharmacological, psychological, and technical factors influencing local anaesthesia, this research seeks to enhance pain control during operative dental treatments. The study involves measuring anaesthetic efficacy using a standard electronic pulp tester, aiming to establish criteria for successful pulpal anaesthesia based on sensation readings post-injection. Join us in advancing current views on dental anaesthesia for better patient care and treatment outcomes.

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Enhancing Efficacy of Dental Local Anaesthesia in Mandibular Teeth: Investigating Injection Speed

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  1. Efficacy Of Dental Local Anaesthesia In Mandibular Teeth: Current Views Dr Mohammad Dib Kanaa DDS, MPhil, PhD Specialty Doctor OMFS: Kettering General Hospital PhD Clinical Research Project Newcastle University, UK O M I C S Dubai 2015 • Support and Sponsorship: • Kettering General Hospital • SAS • OMICS

  2. “Anaesthesia is the art or science of removing sensation of and reaction to a surgical procedure. Anaesthesia means loss of all forms of sensation whether it is the sense of pain, touch, temperature or position sense” (Healy and Pollard, 1999) Introduction O M I C S Dubai 2015

  3. Introduction • Local anaesthesia is the method of choice for pain control during operative dental treatment; • It was reported that half of the local anaesthetic injections in the United States each year were IANB injections; • IANB is reported to be successful in 85-95% of cases(100,000 -300,000 of injections were failure); • The success rate of mandibular anaesthesia with IANB extremely varied in the literature, it ranged between 30% to 97%. • IANB injection alone does not secure satisfactory pain free treatment. (Montagneseet al., 1984; Donkoret al., 1990; Nistet al., 1992; Wong & Jacobsen 1992; McLean et al., 1993; BouDagheret al., 1997; Yared and BouDagher, 1997; Hannanet al., 1999; Yonchaket al., 2001; Kaiser & Hargreaves, 2002; Kanaa et al., 2006; Whitworth et al., 2007; Corbett et al., 2008; Kanaa et al., 2009; Kanaa et al., 2012., Gazalet al., 2015) O M I C S Dubai 2015

  4. Introduction Relevant variables of IANB failure: • Obese; those with large and laterally flaring mandibles; • Very anxious; • Edentulous patients; (Wong and Jacobsen, 1992) O M I C S Dubai 2015

  5. Causes of LA failure • Anatomical • Pathological • Pharmaceutical • Pharmacological • Psychological • Technical O M I C S Dubai 2015 (Haas et al., 1990; Reisman et al., Wong & Jacobsen 1992; 1997; Nusstein et al., 1998; Yonchak et al., 2001; Meechan & Ledvinka, 2002; Kaiser & Hargreaves, 2002 ;Kanaa et al., 2006; Kanaa et al, 2009, Kanaa 2011)

  6. IntroductionInjection speed There are conflicting views on the influence of rate of injection on the distribution of local anaesthetic drugs and its likely effect on securing anaesthesia. (Rucci et al., 1995; Kaiser & Hargreaves, 2002; Oliveira et al., 2004) O M I C S Dubai 2015

  7. IntroductionSummary Therefore an investigation to establish if there is an association between speed injection (slow & rapid) and IANB, is required. O M I C S Dubai 2015

  8. Materials and MethodsStudy design A double blind randomized crossover study design was employed using healthy volunteers aged over 18 years at the presentation of this research. O M I C S Dubai 2015

  9. Official clearances • NHS Trust • MHRA • LREC O M I C S Dubai 2015

  10. Materials and MethodsPower calculation Using 38 volunteers the study would have 80% power to detect an effect size of 0.9 (a shift of 0.9 standard deviations) in a continuous outcome measure assuming a significance level of 5% and a correlation of 0.5 between responses from the same subject. O M I C S Dubai 2015

  11. Materials and MethodsSampling randomisedprocedure The 38 volunteers were randomly allocated for their first injection using web-based program (1) to receive slow or rapid injection at the first visit. At the second visit, the other IANB was provided. (1) (http://department.obg.cuhk.edu.hk/researchsupport/Random_integer.asp) O M I C S Dubai 2015

  12. Materials and MethodsInclusion criteria • Healthy volunteers; • Over 18 years; • Standing vital 1st molar, premolar (1st or 2nd) and lateral incisor in at least one side of the mandible; • Volunteers who accept to participate in the trial after reading the information sheet and signed the consent. O M I C S Dubai 2015

  13. Materials and MethodsApplication techniques The local anaesthetic needle was inserted midway between the internal oblique ridge and the pterygomandibular raphe and advanced until an adequate bony contact was achieved (direct or Halstead approach).Blinded and randomised application with 2mL of 2% lidocaine with 1:80,000 epinephrinefor each volunteer was employed on two occasions after an adequate aspiration: Rapid IANB delivery over 15s, the needle remained in place for a further 45s; Slow IANB delivery over 60s. O M I C S Dubai 2015

  14. Materials and MethodsObjective measurement of anaesthetic efficacy • Standard electronic pulp tester (1st molar, 1st or 2nd premolar & lateral incisor pulps); (Analytic Technology, Washington, USA) • Unanaesthetised tooth on the other side of the lower jaw had been had pulp sensitivity readings performed twice at base lines and once at 10 and 45 minutes post injection; • An absence of pulp sensation when stimulated at the maximum output (80 reading) was the criterion for pulpal anaesthesia. Baseline (twice) Then at intervals of 5 mins for 45 mins At intervals of 2 mins for first 10 mins O M I C S Dubai 2015

  15. Criterion for success An absence of pulp sensation when stimulated at the maximum output (80reading) of tooth pulp testing O M I C S Dubai 2015

  16. Materials and MethodsThe statistical analysis of the study • Frequencies; • Descriptions; • Crosstabulation; • Pearson Chi-Square; • Fisher’s Exact Test; • McNemar Test; • Paired T test. O M I C S Dubai 2015

  17. Objective assessment of pulpal anaesthesia after slow & rapidIANB injection Results O M I C S Dubai 2015

  18. Results Slow vs. Rapid IANB in 1st molar teeth • Percentage of frequency of 80 reading of 1st molar pulp anaesthesia (without sensation) at time intervals after Slow and rapid IANB O M I C S Dubai 2015

  19. Results Slow vs. Rapid IANB in premolar teeth • Percentage of frequency of 80 reading of premolar pulp anaesthesia (without sensation) at time intervals after Slow and rapid IANB O M I C S Dubai 2015

  20. Results Slow vs. Rapid IANB in lateral incisors • Percentage of frequency of 80 reading of lateral incisor pulp anaesthesia (without sensation) at time intervals after Slow and rapid IANB O M I C S Dubai 2015

  21. Results 1stmolar vs. premolar vs. lateral incisor after Slow IANB • Percentage of frequency of 80 reading of 1st molar, premolar and lateral incisor pulp anaesthesia (without sensation) at time intervals after Slow IANB O M I C S Dubai 2015

  22. Results 1stmolar vs. premolar vs. lateral incisor after Rapid IANB • Percentage of frequency of 80 reading of 1st molar, premolar and lateral incisor pulp anaesthesia (without sensation) at time intervals after Rapid IANB O M I C S Dubai 2015

  23. Conclusion • Slow IANB produced more episodes of no sensation on maximal electronic pulp stimulation in first molars, premolars and lateral incisors than rapid IANB injection. • Premolars were more likely to have successful pulpal anaesthesia than first molars and lateral incisors following IANB (either slowly or rapidly). O M I C S Dubai 2015

  24. The outcome This study will help to inform: what and how best practice in everyday dental procedure should be. O M I C S Dubai 2015

  25. Articaine vs. Lidocaine In Mandibular buccal plus lingual infiltration 2% 4% 1.8ml (Haas et al., 1990; Yonchak et al., 2001; Meechan & Ledvinka, 2002; Kanaa et al., 2006) O M I C S Dubai 2015

  26. Aim To evaluate the efficacy of articaine and lidocaine buccal plus lingual infiltrations in securing pulp anesthesia in vital mandibular first molars O M I C S Dubai 2015

  27. Research question (H0) Articaine Lidocaine B & L Infiltrations O M I C S Dubai 2015

  28. Materials and Methods O M I C S Dubai 2015

  29. Study design Prospective Randomized Double blind Crossover O M I C S Dubai 2015

  30. Power calculation Using 31 subjects would have 90% power to detect an effect size of 0.83 (a change of 0.83 standard deviations) in a continuous outcome measure assuming a significance level of 5% O M I C S Dubai 2015

  31. Official clearances • NHS Trust • MHRA • LREC O M I C S Dubai 2015

  32. Inclusion criteria Healthy adult volunteers 18 years old and over Vital mandibular 1st molar Signed the consent form O M I C S Dubai 2015

  33. Anesthetic DeliveryBuccal & lingual infiltration 4% Articaine with 1:100,000 epinephrine 2% Lidocaine with 1:100,000 epinephrine One week O M I C S Dubai 2015

  34. Buccal infiltration 0.9 mL Lingual infiltration 0.9 mL O M I C S Dubai 2015

  35. Objective measurement Mandibular first molar Unanesthetised tooth Base-line (twice) At intervals of 2 mins until 30 mins O M I C S Dubai 2015

  36. Criterion for success An absence of pulp sensation when stimulated at the maximum output (80reading) on two or more consecutive episodes of testing O M I C S Dubai 2015

  37. Statistical analysis of the study • McNemar Test • Paired T test O M I C S Dubai 2015

  38. Results O M I C S Dubai 2015

  39. Changes from baseline pulp tester reading at first sensation(reading) in lower first molars Paired T test, t=14, P < 0.001 O M I C S Dubai 2015

  40. Episodes of no response to maximal (80 reading) stimulation at time intervals using articaine and lidocaine Articaine vs. Lidocaine: 242, 114 respectively, McNemar Test,P < 0.001 O M I C S Dubai 2015

  41. Anesthetic success (10/31) (21/31) 68% 32% Lidocaine Articaine B & L Infiltrations (P = 0.001) O M I C S Dubai 2015

  42. Conclusions O M I C S Dubai 2015

  43. Articaine produced more episodes of no response to maximal (80 reading) stimulation at time intervalspost injectionthan lidocaine • Articaine was more successful than lidocaine in producing anaesthesia in lower first molars after buccal plus lingual infiltrations O M I C S Dubai 2015

  44. Irreversible Pulpitis in Mandibular Permanent Teeth O M I C S Dubai 2015

  45. Objectives To compare the efficacy of supplementary repeat lidocaine IANB, ABI, lidocaine PDL and lidocaine IO following failed lidocaine IANB for securing pain free treatment in patients experiencing irreversible pulpitis in mandibular permanent teeth O M I C S Dubai 2015

  46. Research question (HO) IO ABI PDL rIANB Supplemented IANB Supplemented IANB IANB Supplemented O M I C S Dubai 2015

  47. Materials and MethodsStudy design A prospective randomized clinical trial design was employed O M I C S Dubai 2015

  48. Power calculation Based on outcome data for intraosseous anaesthesia, a study with at least 21 subjects in each supplementary technique group was reported to have 90% power to detect a difference in success rate of 82% (8% vs. 90%, Nusstein et al., 1998) assuming a significance level of 5% and a correlation of 0.5 between subjects O M I C S Dubai 2015

  49. Official clearances • NHS Trust • MHRA • LREC O M I C S Dubai 2015

  50. Inclusion criteria 182 healthy adult patients 18 years old and over Irreversible pulpitis mandibular tooth Signed the consent form O M I C S Dubai 2015

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