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Effectiveness of different anesthetic methods for mandibular posterior teeth with symptomatic irreversible pulpitis: a systematic review and meta-analysis

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Abstract

Objective

This systematic review aimed to assess the effectiveness of anesthetic methods for mandibular posterior teeth with symptomatic irreversible pulpitis, comparing to the inferior alveolar nerve block (IANB) by meta-analysis.

Materials and methods

Studies were identified from Cochrane Library, Embase, Lilacs, PubMed, Scopus, and Web of Science databases up to May 2021. Randomized clinical trials comparing the anesthetic success rate of IANB and any other alternative anesthetic method were included. The quality of the selected studies was assessed by the Cochrane Risk of Bias 2.0 tool. Meta-analyses using Mantel–Haenszel method and random-effect models were performed to find the pooled estimates of risk ratio (RR) with 95% confidence interval (CI). The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation approach.

Results

Twenty-two studies were selected, which included fourteen anesthetic methods. Two studies were classified as high risk of bias, five as uncertain risk and fifteen as low risk. Vazirani-Akinosi nerve block (VANB) [RR = 1.27; p = 0.007; 95% CI, 1.07–1.52; I2 = 0%] and intraosseous injection (IOI) [RR = 1.48; p = 0.04; 95% CI, 1.02–2.15; I2 = 46%] had superior effectiveness compared to IANB, with low certainty of evidence, as well as buccal infiltrations associated with IANB (BI + IANB) [RR = 1.84; p = 0.004; 95% CI, 1.22–2.79; I2 = 52%], with very low certainty.

Conclusion

Evidence suggests that buccal infiltrations associated with IANB, VANB, and IOI are more effective than IANB at anesthetizing posterior mandibular teeth with symptomatic irreversible pulpitis.

Clinical significance

Alternative primary methods of anesthesia might be indicated for mandibular posterior teeth presenting symptomatic irreversible pulpitis.

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Authors and Affiliations

  1. Department of Dentistry, Federal University of Santa Catarina (UFSC), Campus Reitor João David Ferreira Lima, Florianópolis, SC, 88040-900, Brazil

    Luiz Carlos de Lima Dias-Junior, Adriana Pinto Bezerra, Daniela Peressoni Vieira Schuldt, Morgane Marion Kuntze, Graziela de Luca Canto, Lucas da Fonseca Roberti Garcia, Cleonice da Silveira Teixeira & Eduardo Antunes Bortoluzzi

  2. Brazilian Centre for Evidence Based Research, Department of Dentistry, Federal University of Santa Catarina, Florianópolis, Brazil

    Graziela de Luca Canto

Authors
  1. Luiz Carlos de Lima Dias-Junior
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  2. Adriana Pinto Bezerra
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  3. Daniela Peressoni Vieira Schuldt
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  4. Morgane Marion Kuntze
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  5. Graziela de Luca Canto
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  6. Lucas da Fonseca Roberti Garcia
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  7. Cleonice da Silveira Teixeira
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  8. Eduardo Antunes Bortoluzzi
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Corresponding author

Correspondence to Lucas da Fonseca Roberti Garcia.

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Appendices

Appendix 1. Database search strategy

Database

Search

PubMed

May 12, 2021

((((("dentition, permanent"[MeSH Terms] OR "Permanent Dentition" OR "Permanent Dentitions" OR "Secondary Dentition" OR "Adult Dentition" OR "Secondary Dentitions" OR "Adult Dentitions" OR "molar"[MeSH Terms] OR "molar" OR "molars" OR "bicuspid"[MeSH Terms] OR "bicuspid" OR "bicuspids" OR "premolar" OR "premolars" OR "mandible"[MeSH Terms] OR "mandible" OR "mandibular teeth" OR "mandibular tooth" OR "mandibular dentition" OR "mandibular dentitions" OR "posterior teeth" OR "posterior tooth")) AND ("Endodontics"[MeSH Terms] OR "Endodontics"[Title/Abstract] OR "endodontic"[Title/Abstract] OR "pulpitis"[MeSH Terms] OR "pulpitis" OR "pulpitides" OR "pulp inflammation" OR "pulp inflammations" OR "inflamed pulp" OR "inflamed pulps"))) AND ("anesthesia"[MeSH Terms] OR "Anesthesia, Dental"[MeSH Terms] OR "anesthetics, local"[MeSH Terms] OR "anesthesia, local"[MeSH Terms] OR "anesthesia" OR "anesthesias" OR "anaesthesia" OR "anaesthesias" OR "anesthetic" OR "anesthetics" OR "anaesthetic" OR "anaesthetics" OR "aesthesia" OR "Gow-gates" OR "gow gates" OR "ggnb" OR "vazirani-akinosi" OR "vazirani akinosi" OR "Halsted" OR "Halstead" OR "Nerve Block"[MeSH Terms] OR "nerve block" OR "Nerve Blocks" OR "Nerve Blockade" OR "Nerve Blockades" OR "X-tip" OR Stabident OR "intraflow" OR "Endo-Ice" OR (("buccal-plus-lingual" OR "intraosseous" OR "pdl" OR "buccal" OR "lingual" OR "intraligamentary" OR "intraseptal" OR "supplementary" OR "supplemental" OR "ice application") AND ("injections"[MeSH Terms] OR "injections" OR "injection" OR "infiltration" OR "infiltrations" OR anesthe*)))) AND ("mandibular nerve"[MeSH Terms] OR "mandibular nerve" OR "mandibular nerves" OR "inferior alveolar nerve" OR "inferior alveolar nerves" OR "IANB" OR "IAN block" OR "Inferior Alveolar block" OR "IA block" OR "conventional technique")

Embase

May 12, 2021

(("Permanent Dentition" OR "Permanent Dentitions" OR "Secondary Dentition" OR "Adult Dentition" OR "Secondary Dentitions" OR "Adult Dentitions" OR molar* OR bicuspid* OR premolar* OR mandibul* OR "posterior teeth" OR "posterior tooth") AND (Endodontic* OR "pulpitis" OR "pulpitides" OR "pulp inflammation" OR "pulp inflammations" OR "inflamed pulp" OR "inflamed pulps")) AND (Anesthesia* OR anaesthesia* OR anesthetic* OR anaesthetic* OR "aesthesia" OR "Gow-gates" OR "gow gates" OR "ggnb" OR "vazirani-akinosi" OR "vazirani akinosi" OR "Halsted" OR "Halstead" OR "nerve block" OR "Nerve Blocks" OR "Nerve Blockade" OR "Nerve Blockades" OR "X-tip" OR Stabident OR "intraflow" OR "Endo-Ice" OR (("buccal-plus-lingual" OR "intraosseous" OR "pdl" OR "buccal" OR "lingual" OR "intraligamentary" OR "intraseptal" OR "supplementary" OR "supplemental" OR "ice application") AND (injection* OR infiltration* OR anesthe*))) AND ("mandibular nerve" OR "mandibular nerves" OR "inferior alveolar nerve" OR "inferior alveolar nerves" OR "IANB" OR "IAN block" OR "Inferior Alveolar block" OR "IA block" OR "conventional technique")

Scopus

May 12, 2021

TITLE-ABS-KEY(("Permanent Dentition" OR "Permanent Dentitions" OR "Secondary Dentition" OR "Adult Dentition" OR "Secondary Dentitions" OR "Adult Dentitions" OR molar* OR bicuspid* OR premolar* OR mandibul* OR "posterior teeth" OR "posterior tooth") AND (Endodontic* OR "pulpitis" OR "pulpitides" OR "pulp inflammation" OR "pulp inflammations" OR "inflamed pulp" OR "inflamed pulps")) AND TITLE-ABS-KEY(Anesthesia* OR anaesthesia* OR anesthetic* OR anaesthetic* OR "aesthesia" OR "Gow-gates" OR "gow gates" OR "ggnb" OR "vazirani-akinosi" OR "vazirani akinosi" OR "Halsted" OR "Halstead" OR "nerve block" OR "Nerve Blocks" OR "Nerve Blockade" OR "Nerve Blockades" OR "X-tip" OR Stabident OR "intraflow" OR "Endo-Ice" OR (("buccal-plus-lingual" OR "intraosseous" OR "pdl" OR "buccal" OR "lingual" OR "intraligamentary" OR "intraseptal" OR "supplementary" OR "supplemental" OR "ice application") AND (injection* OR infiltration* OR anesthe*))) AND TITLE-ABS-KEY("mandibular nerve" OR "mandibular nerves" OR "inferior alveolar nerve" OR "inferior alveolar nerves" OR "IANB" OR "IAN block" OR "Inferior Alveolar block" OR "IA block" OR "conventional technique")

Web of Science

May 12, 2021

(("Permanent Dentition" OR "Permanent Dentitions" OR "Secondary Dentition" OR "Adult Dentition" OR "Secondary Dentitions" OR "Adult Dentitions" OR molar* OR bicuspid* OR premolar* OR mandibul* OR "posterior teeth" OR "posterior tooth") AND (Endodontic* OR "pulpitis" OR "pulpitides" OR "pulp inflammation" OR "pulp inflammations" OR "inflamed pulp" OR "inflamed pulps")) AND (Anesthesia* OR anaesthesia* OR anesthetic* OR anaesthetic* OR "aesthesia" OR "Gow-gates" OR "gow gates" OR "ggnb" OR "vazirani-akinosi" OR "vazirani akinosi" OR "Halsted" OR "Halstead" OR "nerve block" OR "Nerve Blocks" OR "Nerve Blockade" OR "Nerve Blockades" OR "X-tip" OR Stabident OR "intraflow" OR "Endo-Ice" OR (("buccal-plus-lingual" OR "intraosseous" OR "pdl" OR "buccal" OR "lingual" OR "intraligamentary" OR "intraseptal" OR "supplementary" OR "supplemental" OR "ice application") AND (injection* OR infiltration* OR anesthe*))) AND ("mandibular nerve" OR "mandibular nerves" OR "inferior alveolar nerve" OR "inferior alveolar nerves" OR "IANB" OR "IAN block" OR "Inferior Alveolar block" OR "IA block" OR "conventional technique")

Cochrane Library

May 12, 2021

(("Permanent Dentition" OR "Permanent Dentitions" OR "Secondary Dentition" OR "Adult Dentition" OR "Secondary Dentitions" OR "Adult Dentitions" OR molar* OR bicuspid* OR premolar* OR mandibul* OR "posterior teeth" OR "posterior tooth") AND (Endodontic* OR "pulpitis" OR "pulpitides" OR "pulp inflammation" OR "pulp inflammations" OR "inflamed pulp" OR "inflamed pulps")) AND (Anesthesia* OR anaesthesia* OR anesthetic* OR anaesthetic* OR "aesthesia" OR "Gow-gates" OR "gow gates" OR "ggnb" OR "vazirani-akinosi" OR "vazirani akinosi" OR "Halsted" OR "Halstead" OR "nerve block" OR "Nerve Blocks" OR "Nerve Blockade" OR "Nerve Blockades" OR "X-tip" OR Stabident OR "intraflow" OR "Endo-Ice" OR (("buccal-plus-lingual" OR "intraosseous" OR "pdl" OR "buccal" OR "lingual" OR "intraligamentary" OR "intraseptal" OR "supplementary" OR "supplemental" OR "ice application") AND (injection* OR infiltration* OR anesthe*))) AND ("mandibular nerve" OR "mandibular nerves" OR "inferior alveolar nerve" OR "inferior alveolar nerves" OR "IANB" OR "IAN block" OR "Inferior Alveolar block" OR "IA block" OR "conventional technique")

Lilacs

May 12, 2021

(tw:(("Permanent Dentition" OR "Permanent Dentitions" OR "Secondary Dentition" OR "Adult Dentition" OR "Secondary Dentitions" OR "Adult Dentitions" OR molar* OR bicuspid* OR premolar* OR mandibul* OR "posterior teeth" OR "posterior tooth" OR "Dentição Permanente" OR "dentição secundária" OR "dentição adulta" OR "dente pré-molar" OR "dentes pré-molares" OR "dentes posteriores" OR "dente posterior" OR "Dentición Permanente" OR "dentición secundaria" OR "dentición adulta" OR "dientes posteriors" OR "diente posterior") AND (endodonti* OR "pulpitis" OR "pulpitides" OR "pulp inflammation" OR "pulp inflammations" OR "inflamed pulp" OR "inflamed pulps" OR "pulpite" OR "inflamação pulpar" OR "inflamações pulpares" OR "polpa inflamada" OR "polpas inflamadas" OR "Endodoncia" OR "inflamacion pulpar" OR " inflamaciones pulpares" OR "pulpa inflamada" OR "pulpas inflamadas"))) AND (tw:(anesthesia* OR anaesthesia* OR anesthetic* OR anaesthetic* OR "aesthesia" OR "Gow-gates" OR "gow gates" OR "ggnb" OR "vazirani-akinosi" OR "vazirani akinosi" OR "Halsted" OR "Halstead" OR "nerve block" OR "Nerve Blocks" OR "Nerve Blockade" OR "Nerve Blockades" OR "X-tip" OR stabident OR "intraflow" OR "Endo-Ice" OR anestesi* OR "Bloqueio nervoso" OR "Bloqueio de nervo" OR "Bloqueio do nervo" OR "Bloqueo nervioso" OR "Bloqueo de nervio" OR "Bloqueo del nervio" OR (("buccal-plus-lingual" OR "intraosseous" OR "pdl" OR "buccal" OR "lingual" OR "intraligamentary" OR "intraseptal" OR "supplementary" OR "supplemental" OR "ice application" OR "intraosseo" OR "bucal" OR intraligamenta* OR suplementar* OR "aplicação de gelo" OR "intraoseo" OR "bucal" OR "aplicacion de hielo") AND (injection* OR infiltration* OR anesthe* OR "injeções" OR "injeção" OR infiltrac* OR "inyecciones" OR "inyeccion" OR infiltracion*)))) AND (tw:("mandibular nerve" OR "mandibular nerves" OR "inferior alveolar nerve" OR "inferior alveolar nerves" OR "IANB" OR "IAN block" OR "Inferior Alveolar block" OR "IA block" OR "conventional technique" OR "nervo mandibular" OR "nervos mandibulares" OR "nervo alveolar inferior" OR "nervos alveolares inferiores" OR "BNAI" OR "técnica convencional" OR "nervio mandibular" OR "nervios mandibulares" OR "nervio alveolar inferior" OR "nervios alveolares inferiores")) AND (instance:"regional") AND ( db:("LILACS"))

ProQuest dissertations and theses

May 12, 2021

noft((("Permanent Dentition" OR "Permanent Dentitions" OR "Secondary Dentition" OR "Adult Dentition" OR "Secondary Dentitions" OR "Adult Dentitions" OR molar* OR bicuspid* OR premolar* OR mandibul* OR "posterior teeth" OR "posterior tooth") AND (Endodontic* OR "pulpitis" OR "pulpitides" OR "pulp inflammation" OR "pulp inflammations" OR "inflamed pulp" OR "inflamed pulps")) AND (Anesthesia* OR anaesthesia* OR anesthetic* OR anaesthetic* OR "aesthesia" OR "Gow-gates" OR "gow gates" OR "ggnb" OR "vazirani-akinosi" OR "vazirani akinosi" OR "Halsted" OR "Halstead" OR "nerve block" OR "Nerve Blocks" OR "Nerve Blockade" OR "Nerve Blockades" OR "X-tip" OR Stabident OR "intraflow" OR "Endo-Ice" OR (("buccal-plus-lingual" OR "intraosseous" OR "pdl" OR "buccal" OR "lingual" OR "intraligamentary" OR "intraseptal" OR "supplementary" OR "supplemental" OR "ice application") AND (injection* OR infiltration* OR anesthe*))) AND ("mandibular nerve" OR "mandibular nerves" OR "inferior alveolar nerve" OR "inferior alveolar nerves" OR "IANB" OR "IAN block" OR "Inferior Alveolar block" OR "IA block" OR "conventional technique"))

OpenGrey

May 12, 2021

(("Permanent Dentition" OR "Permanent Dentitions" OR "Secondary Dentition" OR "Adult Dentition" OR "Secondary Dentitions" OR "Adult Dentitions" OR molar* OR bicuspid* OR premolar* OR mandibul* OR "posterior teeth" OR "posterior tooth") AND (Endodontic* OR "pulpitis" OR "pulpitides" OR "pulp inflammation" OR "pulp inflammations" OR "inflamed pulp" OR "inflamed pulps")) AND (Anesthesia* OR anaesthesia* OR anesthetic* OR anaesthetic* OR "aesthesia" OR "Gow-gates" OR "gow gates" OR "ggnb" OR "vazirani-akinosi" OR "vazirani akinosi" OR "Halsted" OR "Halstead" OR "nerve block" OR "Nerve Blocks" OR "Nerve Blockade" OR "Nerve Blockades" OR "X-tip" OR Stabident OR "intraflow" OR "Endo-Ice" OR (("buccal-plus-lingual" OR "intraosseous" OR "pdl" OR "buccal" OR "lingual" OR "intraligamentary" OR "intraseptal" OR "supplementary" OR "supplemental" OR "ice application") AND (injection* OR infiltration* OR anesthe*))) AND ("mandibular nerve" OR "mandibular nerves" OR "inferior alveolar nerve" OR "inferior alveolar nerves" OR "IANB" OR "IAN block" OR "Inferior Alveolar block" OR "IA block" OR "conventional technique")

Google Scholar

May 12, 2021

(mandibular OR "posterior teeth" OR "posterior tooth") AND ("pulpitis") AND (Anesthesia OR "Gow-gates" OR "gow gates" OR "ggnb" OR "vazirani-akinosi" OR "vazirani akinosi" OR "Halsted") AND ("inferior alveolar nerve" OR "Inferior Alveolar block")

Appendix 2. Excluded articles and reasons for exclusion

Author, year

Reason for exclusion

Bigby et al., 2006 [62]

5

Brignardello-Petersen, 2018 [63]

1

Brignardello-Petersen, 2019 [64]

1

Click et al., 2015 [17]

5

Collier, 2018 [65]

1

Corbett et al., 2008 [66]

2

Dou et al., 2013 [67]

5

Eriksen et al., 1986 [68]

2

Esnaashari et al., 2018 [69]

2

Fan et al., 2009 [70]

5

Farhad, 2018 [71]

1

Gallatin et al., 2000 [72]

2

Kennedy et al., 2003 [6]

2

Marjanović et al., 2017 [73]

2

Montagnese et al., 1984 [74]

2

Peñarrocha-Oltra et al., 2012 [75]

2

Rakusin et al., 1986 [76]

2

Sherman et al., 2008 [15]

5

Shetkar et al., 2016 [77]

4

Yadav et al., 2015 [78]

5

1, observational studies, reviews, letters, case reports, case series, and studies with full text not available (n = 4); 2, studies in which sample includes patients with primary or maxillary teeth, teeth with incomplete root formation, and patients without symptomatic irreversible pulpitis (n = 9); 3, studies that included patients submitted to supplemental or complementary anesthetic methods after the failure of the primary method (n = 0); 4, articles that reported inclusion of patients on use of any medications such as analgesics, anti-inflammatories, sedatives, antidepressants, or anxiolytics, which may influence pain assessment (n = 1); 5, articles that did not use the standard inferior alveolar nerve block as control (n = 6).

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Dias-Junior, L.C.d., Bezerra, A.P., Schuldt, D.P.V. et al. Effectiveness of different anesthetic methods for mandibular posterior teeth with symptomatic irreversible pulpitis: a systematic review and meta-analysis. Clin Oral Invest 25, 6477–6500 (2021). https://doi.org/10.1007/s00784-021-04145-7

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