Painless palatal anesthesia

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.

Anesthetic efficacies of buccal with palatal injection versus buccal with intra-septal injection in permanent maxillary first molars of pediatric patients

The high success rate of dental treatment is dependent on the cooperation of pediatric patients during procedures. Dental treatment often causes pain, particularly in children. The factors in providing treatment to pediatric patients include the characteristics and location of the tooth, profoundness of the anesthesia including the type of local anesthetic, and cooperation of the patient. Previous studies have examined several techniques to successfully achieve profound pulpal anesthesia in maxillary permanent teeth. The dentist should select the injection technique to be used based on patient needs. In children, either buccal with palatal injections or buccal with intra-septal injections may be used to anesthetize the permanent maxillary first molar. Buccal with palatal injections are commonly used prior to routine maxillary dental procedures. Currently, there are only a few studies on the employment of buccal with intra-septal injections to anesthetize permanent maxillary first molars in pediatric patients. This review will focus on efficacy of buccal with palatal versus buccal with intra-septal pulpal anesthesia of the permanent maxillary first molars in pediatric patients and aim to determine which technique should be used during routine dental procedures.

Comparison of the efficacy of 4% articaine with epinephrine 1:100,000 and 2% lidocaine with epinephrine 1:100,000 buccal infiltration for single maxillary molar extraction: a double-blind, randomised, clinical trial

The present study was designed to compare the efficiency of 4% articaine with epinephrine 1:100,000 and 2% lidocaine with epinephrine 1:100,000 in providing adequate anaesthesia for maxillary molar extraction with buccal infiltration only. In this randomised, double-blind clinical trial, 139 patients who needed maxillary molars extracting were enrolled. Individuals were randomly divided into two groups of 2% lidocaine with epinephrine 1:100,000 treated by buccal infiltration without palatal injection and 4% articaine with epinephrine 1:100,000 treated with the same method. Then, teeth were extracted and the pain assessed. During the extraction of teeth, 90.63% of patients in the lidocaine-treated group and 36% of patients in the articaine-treated group experienced pain (p<0.0001). In other words, the rates of successful anaesthesia with lidocaine and articaine buccal infiltration were 9.38% and 64%, respectively. Despite the better performance of articaine, it seems that some factors such as bone thickness and anatomical variations among individuals, besides the condition of the tooth, affects articaine's level of efficiency in each case.

Buccal infiltration injection without a 4% articaine palatal injection for maxillary impacted third molar surgery

Objectives

Palatal infiltration is the most painful and uncomfortable anesthesia technique for maxillary impacted third molar surgery (MITMS). This approach could cause patients distress and aversion to dental treatment. The aim of this study was to evaluate the anesthetic efficacy of a buccal infiltration injection without a palatal injection in MITMS.

Materials and Methods

This prospective research study was a crossover split mouth-randomized controlled trial. Twenty-eight healthy symmetrical bilateral MITMS patients (mean age, 23 years) were randomly assigned to two groups. Buccal infiltration injections without palatal injections were designated as the study group and the buccal with palatal infiltration cases were the control group, using 4% articaine and 1:100,000 epinephrine. The operation started after 10 minutes of infiltration. Pain assessment was done using a visual analogue scale and a numeric rating scale after each injection and extraction procedure. Similarly, the success rate, hemodynamic parameters, and additional requested local anesthetic were assessed.

Results

The results showed that the pain associated with local anesthetic injections between both groups were significantly different. However, the success rates between the groups were not significantly different. Postoperative pain was not significant between both groups and a few patients requested an additional local anesthetic, but the results were not statistically significant. For hemodynamic parameters, there was a significant difference in systolic pressure during incision, bone removal, and tooth elevation. In comparison, during the incision stage there was a significant difference in diastolic pressure; however, other steps in the intervention were not significantly different between groups.

Conclusion

We concluded that buccal infiltration injection without palatal injection can be an alternative technique instead of the conventional injection for MITMS.

Comparison of the buccal injection versus buccal and palatal injection for extraction of permanent maxillary posterior teeth using 4% articaine: a split mouth study

In spite of the development of modern injection techniques, palatal injection is still a painful experience for patients. A plethora of techniques has been tested to reduce this. One such technique that has been claimed to work is administering articaine on the buccal side alone for the extraction of maxillary teeth due to its ability to diffuse through soft and hard tissues more reliably than other local anaesthetics. This split mouth study evaluated the efficacy of 4% articaine with 1:100000 adrenaline to avoid the painful palatal injection for bilateral permanent maxillary tooth extraction in 50 patients. The 100mm 10 point Visual Analog Scale/Wong Baker Facial Pain Scale was used to rate the amount of pain felt on injection, on probing the tissues prior to, or during, extraction, and one hour postoperatively. Although the buccal injection alone resulted in lower pain while injecting the anaesthetic, it did not result in the absence of pain before tooth extraction as has been suggested by various studies. A total of 74% patients required a palatal injection on the study side. We conclude that in most cases, when using a buccal injection alone, one cannot rely on the diffusion of articaine for effective palatal anaesthesia. Despite this, we suggest that as an initial option in young patients, the operator can consider avoiding the painful palatal injection by the use of articaine to prevent aversion to dental treatment. Postoperatively, the difference in pain levels was not statistically significant and no patient showed signs of lesions at the injection sites.

Palatal needle-free anesthesia for upper molars extraction. A randomized clinical trial

BACKGROUND

The aim of this study was to compare the ability of liposomal and non-liposomal lidocaine and prilocaine in hydrogel formulations to promote topical anesthesia in palatal mucosa during upper molar extractions.

METHODS

In this randomized, cross over, triple-blinded clinical trial, a liposomal and a non-liposomal formulation of the eutectic mixture of local anesthetics, 2.5% lidocaine and 2.5% prilocaine, were used to promote palatal anesthesia without the local anesthetic infiltration during bilateral upper molars extractions.

RESULTS

From the total of 40 patients included in this study, the non-liposomal eutectic lidocaine-prilocaine formulation failed in 40% of cases, unlike the liposomal formulation, which was effective for all patients (Fisher's exact test, p < 0.0001). Furthermore, the liposomal formulation (26.75 ± 7,47 min) induced longer anesthesia duration (t-test, p < 0.0001) than the non-liposomal formulation (16.78 ± 4.75 min). No mucosal ulceration or discomfort was reported for both formulations.

CONCLUSION

The liposomal formulation was able to induce adequate anesthesia in palatal mucosa during dental extraction, avoiding the local anesthetic infiltration. For the first time, a topical formulation allowed upper molars surgical removal without injection of any local anesthetic agent into palatal mucosa in adults.

"Sodium bicarbonate": an adjunct to painless palatal anesthesia

PURPOSE

It is believed that whenever we inject local anesthesia into the palate it is a painful experience for the patients. The aim of this study was to make palatal anesthesia painless by adding 7.4% sodium bicarbonate as an adjunct in local anesthesia.

METHODS

Fifty subjects requiring extraction of maxillary bilateral premolar teeth for orthodontic purpose free from periapical infections. These extractions were divided in such a way that all right-sided extractions were done under 2% lignocaine with 1:80,000 adrenaline; and all left-sided extractions were done under 2% lignocaine with 1:80,000 adrenaline with 7.4% sodium bicarbonate added. All extractions were performed using a consistent intra-alveolar technique by a single operator. Both the patient and the operator were blinded to the contents of the local anesthetic solution. Data records of these patients were procured on the basis of VAS and VRS, requirement of repeated injection, and onset and duration of anesthesia.

RESULTS

Clinical and statistical data confirmed that the addition of sodium bicarbonate in local anesthetics reduces pain and decreased the onset and increased duration of local anesthesia in the palatal site, as compared to injection of local anesthetic without sodium bicarbonate.

CONCLUSION

Effect of sodium bicarbonate on reducing pain while injecting into the palatal aspect was noted in this study.

Extraction of maxillary teeth by dental students without palatal infiltration of local anaesthesia: a randomised controlled trial

OBJECTIVE

Palatal infiltration of local anaesthesia (LA) for maxillary tooth extractions is painful. One of the techniques for reducing the discomfort of this injection is to avoid it altogether. Given enough time, LA administered only as buccal infiltration diffuses to reach and anaesthetise the palatal tissues. The aim of this double-blind randomised controlled trial was to test the hypothesis that buccal infiltration alone of LA by dental students should be adequate for maxillary tooth extractions.

PATIENTS AND METHODS

Fifty adult patients presenting for single-tooth maxillary extractions were randomly allocated between two groups. The control group received palatal injections of 0.1 ml 2% lidocaine with 1:100,000 adrenaline, whilst the experimental group received a similar amount of saline (placebo). Extractions performed without further administration of LA were categorised as successful.

RESULTS

Palatal infiltration of lidocaine with adrenaline was significantly more effective than saline (P = 0.002). Overall buccal infiltration alone was successful in 28% patients, with a 40% success rate in the posterior maxilla.

CONCLUSION

Results suggest that dental students should, as a matter of routine, extract maxillary teeth with both buccal and palatal infiltration of LA, whilst buccal infiltration alone may be considered in the posterior maxilla.

The Effectiveness of Articaine and Lidocaine Single Buccal Infiltration versus Conventional Buccal and Palatal Injection Using Lidocaine during Primary Maxillary Molar Extraction: A Randomized Control Trial

Background:

Despite the advent of modern injection techniques, palatal injection continues to be a painful experience for children.

Aims:

To compare the pain experienced during extraction of maxillary primary molars with conventional lignocaine anesthesia versus lignocaine and articaine buccal infiltration in children aged 6–14 years.

Materials and Methods:

A prospective randomized triple blinded study was conducted with ninety children (n = 90), randomly allocated to receive lignocaine conventional anesthesia (Group I [control group]), and buccal infiltration using articaine (Group II [articaine group]) or lignocaine (Group III [lignocaine group]). A composite score of self-report (faces pain scale-revised), behavioral measure (face legs activity cry consolability scale), and a physiological response (pulse rate) was measured following maxillary primary molar extraction.

Statistical Analysis Used:

To test the mean difference between two groups, Students’ t-test was used and among the three groups, one-way ANOVA with post hoc test was used.

Results:

Articaine group had significantly lower pain scores for self-report (P < 000.1) and behavioral measures (P < 000.1) while there was no significant difference (P > 0.05) between articaine and control groups during primary maxillary molar extraction.

Conclusion:

Maxillary primary molar extraction procedure can be successfully accomplished by bypassing the palatal injection. Articaine buccal infiltration can be considered as an alternative to conventional local anesthesia for the extraction of maxillary primary molars.

Local Anaesthetic Drug Administration in Dentistry Using Computer Assisted Anaesthetic Delivery System: A Systematic Review

Background:

Local anaesthetics play a key role in reducing pain and anxiety during dental treatment. However the disadvantage of using syringe and needle technique in the maxilla, proximal to the apices of the teeth is that it is painful and also leads to collateral anaesthesia. Hence this systematic review aims to identify whether computer assisted local anaesthetic delivery system could produce predictable results similar to conventional syringe needle technique and also eliminate the disadvantages.

Method:

Electronic databases were searched for eligible studies. A pre-tested data extraction form was created and following data were extracted from each eligible study: trial site, year, trial methods, participants, interventions and outcomes. A significant heterogeneity was seen in between the eligible studies.

Results:

Six studies met the inclusion criteria and were included in the present review. One was cross-over and one split mouth, while others were parallel. Only one was open label and the rest were single blinded. Three studies were conducted in children while the rest in adults. The outcome measurement was directed to measure psychological attributes using visual analog scale, electric pulp testing and pain behaviour code.

Conclusion:

Unfortunately because of the clinical heterogeneity, meta-analysis could not be performed. Hence it is difficult to conclude that the computer assisted delivery is better than the conventional method, although it was found to perform better. Many high quality studies assessing the efficacy and cost-efficiency of various modes of administration are required to confirm the utility of computer assisted delivery systems.

Maxillary posterior teeth removal without palatal injection -truth or myth: a dilemma for oral surgeons

BACKGROUND

Pain control is one of the most important factors for successful treatment. Each new measure to control pain has been looked as miraculous act at the initial stages. The improvements in agents and techniques for local anaesthesia are probably the most important advances in dental science to have occurred in the past years.

AIM

To evaluate 4% articaine hydrochloride against 2% lignocaine hydrochloride anaesthesia in providing adequate palatal anaesthesia in maxillary posterior regions, without the need for a palatal block.

SETTINGS AND DESIGN

Healthy patients above 15 y of age and requiring bilateral extraction of their maxillary posterior teeth were included in this crossover study. The exclusion criteria included medical history of cardiovascular and kidney diseases, gastrointestinal bleeding or ulceration, allergic reactions to local anaesthetic, pregnancy or current lactation.

MATERIALS AND METHODS

Eighty patients, requiring bilateral extraction of their teeth due to various reasons were enrolled for this study. Each patient received both lignocaine and articaine anaesthetic in equivalent dose at two different appointments. Maxillary infiltration technique was used for extraction of maxillary posterior teeth at both the appointments. A 170-mm Heft Parker visual analogue scale was used to assess the pain on the palatal mucosa after buccal infiltration of either anaesthetic agent. Blood pressure, Pulse rate and electrocardiographic monitoring were done during the procedure. Adverse effects during the study period were also monitored.

STATISTICAL ANALYSIS

Data was analysed by Z-test and student's t-test.

RESULTS

Pain scores on probing palatal mucosa after buccal infiltration of the anaesthetic were more for lignocaine as compare to articaine and it was statistically significant (p <.001). However, for hemodynamic parameters and electrocardiographic monitoring, there was no statistically significant difference in blood pressure, pulse rate and electrocardiograph before and after the completion of extraction (p > 0.05).

CONCLUSION

Four percent articaine offers better clinical performance than 2% Lignocaine, particularly in terms of providing adequate palatal anaesthesia with only buccal infiltration.

Comparison of the effectiveness of lidocaine in permanent maxillary teeth removal performed with single buccal infiltration versus routine buccal and palatal injection

PURPOSE

For many dental patients, palatal injection proves to be a very traumatic experience. Diverse methods have been suggested to reduce the discomfort of palatal injection. Nevertheless, the reliability of these methods is not obviously evident and they are not found to be universally effective. The desirable method to evade pain during palatal injection is just not to have one. Hence, the present study aims at investigating if lidocaine hydrochloride could provide palatal anesthesia in maxilla when only a buccal infiltration anesthesia is done for teeth extraction.

PATIENTS AND METHODS

One hundred and fifty patients requiring extraction of maxillary teeth were included in the study. Patients were randomly allotted to two groups, study and control. Patients in study group received a single buccal infiltration of 1.5 mL of lidocaine with epinephrine for extraction of maxillary teeth. Patients in control group received 1.5 mL of buccal and 0.3 mL of palatal infiltration of lidocaine with epinephrine for the extraction. After achieving adequate palatal anesthesia the tooth was extracted with consistent technique. Pain level experienced by the patients during injection procedure and during tooth extraction was rated in an 11-point pain rating scale. Time taken to achieve palatal anesthesia following a single buccal infiltration of anesthetic solution was evaluated by regular pin-prick evaluation of palatal tissues.

RESULTS

The overall success rate of palatal anesthesia achieved with a single buccal infiltration is 81.3 %. The success rate reduced as we proceed from anterior to posterior maxilla. Time taken to achieve successful palatal anesthesia by single buccal infiltration is 7-9 min.

CONCLUSION

The extraction of permanent maxillary anterior teeth and premolars is possible by depositing local anesthesia to the buccal vestibule of the tooth without palatal supplementation. However, the extraction of permanent maxillary posterior teeth with similar technique would result in fewer success rates suggesting its avoidance.

Comparison of depth of anesthesia in different parts of maxilla when only buccal anesthesia was done for maxillary teeth extraction

Objective. Recently, some authors reported that maxillary teeth could be extracted without using palatal anesthesia, but they did not clearly specify the extracted teeth. This is important, because apparently the local anesthetic solution infiltrates the maxilla and achieves a sufficient anesthesia in the palatal side. Thus, thickness of the bone may affect the depth of anesthesia. The aim of this study was to compare the depth of anesthesia in different parts of the maxilla when only a buccal infiltration anesthesia was done. Patients and Method. The maxilla was divided into anterior, premolar, and molar regions. In each region, 15 teeth were extracted with a single buccal infiltration. The patient marked the pain level on a numerical rating scale. Results. Anesthesia depth was sufficient and was not significantly different (P > 0.05) among three maxillary regions. Conclusion. Except for surgical interventions, all maxillary teeth can be extracted using only a buccal infiltration anesthesia.

Liposomal delivery system for topical anaesthesia of the palatal mucosa

An effective topical agent to reduce pain during local anaesthesia of the palate is not yet available. The aim of the present study was to evaluate the efficiency of liposome-encapsulated ropivacaine in different concentrations for topical anaesthesia of the palatal mucosa. In this single-blinded, placebo-controlled, crossover study 40 (20 male) healthy volunteers were randomised to be given: liposome-encapsulated 2% ropivacaine, liposome-encapsulated 1% ropivacaine, a eutectic mixture of 2.5% lidocaine and 2.5% prilocaine (EMLA), and liposomal placebo gel, topically on to the palatal mucosa of the right canine region for 5 min each, at four different sessions. Pain associated with insertion of a 30G needle, and with injection of a local anaesthetic, was rated on a visual analogue scale (VAS). The effect of liposomal ropivacaine 1% and 2% did not differ from that of placebo (p=0.3 and p=0.1, respectively) in reducing pain during insertion of the needle. Lower VAS were obtained with EMLA. In this group VAS were lower in women than men (p=0.007). There was no difference in VAS among groups (p=0.3) as far as injection of the local anaesthetic was concerned. In conclusion, liposomal-encapsulated ropivacaine formulations did not reduce the pain of insertion of a needle into the palatal mucosa. None of the anaesthetic formulations tested, including the positive control (EMLA), were effective in reducing the pain of an injection of local anaesthetic compared with placebo.

Is permanent maxillary tooth removal without palatal injection possible?

OBJECTIVE

The aim of the present study was to demonstrate if articaine HCl could provide palatal anesthesia in maxillary tooth removal without the need for a second palatal injection.

STUDY DESIGN

Of 53 patients, 23 had bilateral and 30 had unilateral extractions. In the study group 2 mL of 4% articaine/HCl with 1:100,000 epinephrine was injected into the buccal vestibule of the tooth. After 5 min the extraction was performed. 27 subjects were controls and subjected to the same protocol with palatal injection. All patients completed a Faces Pain Scale (FPS) and a 100-mm Visual Analogue Scale (VAS) after extraction.

RESULTS

According to VAS and FPS scores, when permanent maxillary tooth removal with palatal injection (97.5%) and without palatal injection (96.8%) were compared the difference was not statistically significant (P > .05) [corrected].

CONCLUSION

Permanent removal of maxillary teeth without palatal injection is possible by depositing 2 mL articaine/HCl to the buccal vestibule of the tooth.

P-ASA block injection: a new palatal technique to anesthetize maxillary anterior teeth

This technique article presents a new local anesthetic injection that is reported to produce anesthesia of the six maxillary anterior teeth, the anterior third of the palate, and the facial gingiva from a single-site injection. The injection is referred to as the palatal approach anterior superior alveolar (P-ASA) nerve block. The 0.9 to 1.4 mL dosage recommendation for this block injection is significantly less than for a traditional supraperiosteal approach. The primary advantage of this injection is that it allows the dentist to anesthetize the teeth and gingiva without collateral anesthesia to the lips, face, or muscles of facial expression. Therefore, the smile line is not distorted during the operative phase of an appointment, and the patient is more comfortable postoperatively.

CLINICAL SIGNIFICANCE

The P-ASA is a new block injection technique that provides anesthesia of the maxillary anterior teeth from a single injection without numbness of the face, lips, and muscles of facial expression. This injection technique prevents distortion of the smile line and enhances restorative procedures that use the lip line as an esthetic reference element.