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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 3  |  Issue : 2  |  Page : 49-52

Local anesthetic methods used by UK NHS general dental practitioner's for mandibular central incisor anesthesia: A study


1 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Sebha University, Sebha, Libya
2 Department of Oral Pathology and Microbiology, Faculty of Dentistry, Sebha University, Sebha, Libya
3 Department of Oral Surgery, School of Dental Sciences, Newcastle University, United Kingdom

Date of Web Publication22-Jun-2015

Correspondence Address:
Aesa Alzaroug Jaber
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Sebha University, Sebha
Libya
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2348-1471.159185

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  Abstract 

Objective: To determine the methods of dental local anesthesia employed by UK general dental practice to anesthetize mandibular central incisor teeth and to evaluate any variations with the technique with an increase in experience. Materials and Methods: A total of 233 general dental practitioners attending postgraduate courses in dental local anesthesia and British Endodontic Society meeting completed a written questionnaire. Respondents were requested to provide information on their year and university of qualification, their location of practice and the primary local anesthetic technique employed for pulp extirpation of an inflamed vital mandibular permanent incisor. Analysis was undertaken to determine whether dentists qualified for <5 years, between 5 and 10 years and >10 years adopted different strategies. Data were analyzed by Chi-square test. Results: Buccal infiltration was employed by 110 (49.1%) practitioners. There were significant differences in choice of anesthetic method among practitioners of differing seniority. Conclusions: Buccal infiltration is the most commonly used the local anesthetic method to anesthetize the permanent mandibular central incisor teeth. More experienced practitioners, qualified >10 years, were more likely to employ a combination of methods from the outset.

Keywords: Anesthetic technique, general dental practitioners, local anesthesia, mandibular central incisor


How to cite this article:
Jaber AA, Ramalingam K, Martin WJ, Ian C, John M. Local anesthetic methods used by UK NHS general dental practitioner's for mandibular central incisor anesthesia: A study. Dent Med Res 2015;3:49-52

How to cite this URL:
Jaber AA, Ramalingam K, Martin WJ, Ian C, John M. Local anesthetic methods used by UK NHS general dental practitioner's for mandibular central incisor anesthesia: A study. Dent Med Res [serial online] 2015 [cited 2019 Jun 15];3:49-52. Available from: http://www.dmrjournal.org/text.asp?2015/3/2/49/159185


  Introduction Top


Adequate pain control is crucial to the practice of clinical dentistry. Unfortunately, the administration of local anesthesia may not produce satisfactory anesthesia, particularly in the case of irreversible pulpitis. Mandibular central incisor teeth are more susceptible to fail anesthesia than the maxillary anterior teeth due to difficulties in blocking the inferior alveolar nerve, collateral, and accessory innervations. [1],[2],[3],[4],[5]

In a recent systematic review, Dou et al. have reported that additional lingual infiltration following buccal infiltration can enhance the anesthetic efficacy compared with buccal infiltration alone in the mandibular incisor area. [6]

The aim of this questionnaire-based study was to identify the primary local anesthetic methods used most commonly by general dentists of differing seniority working within the UK National Health Service to anesthetize the pulp of a single mandibular central incisor tooth for the purpose of pulp extirpation. The study also aimed to determine any variations in technique between recent graduates and more experienced practitioners.


  Materials and Methods Top


The UK general dentists attending postgraduate courses in local anesthesia or attending the Spring Scientific Meeting of British Endodontic Society 2009 were invited to complete a simple questionnaire requesting information on their year and place of qualification, primary location of practice and primary method of anesthetizing a single mandibular central incisor for pulp extirpation. The following choices were offered: Buccal infiltration, lingual infiltration, inferior alveolar nerve block (IANB), incisive/mental nerve block (IMNB), periodontal ligament (PDL), intraosseous injection, other (describe).

Two hundred and fifty-nine questionnaires were distributed among the group of practitioners (general dental practitioners [GDPs], community, specialist or mixed practice). Respondents were stratified according to number of years in practice: <5 years (group 1), 5-10 years (group 2), >10 years (group 3). Differences in the methods employed by the 3 cohorts of dentists were analyzed in SPSS (SPSS 15.0, SPSS Inc., Chicago, IL, USA) by Chi-square test.


  Results Top


Out of 259 questionnaires distributed, 233 were completed (90%) by GDPs and the remaining 26 (10%) were completed by dentists in the community, hospital, specialist or mixed practice. Only the fully completed questionnaires (224) completed by GDPs were included in the data analysis.

The range of experience in practice was from 1 to 43 years (mean 13.1 years, standard deviation, 12.4 years). The number of respondents stratified by time from graduation is shown in [Figure 1]. Gender distribution was not considered in this survey.
Figure 1: Number of respondent practitioners within group 1 = less than 5 years, group 2 = 5 to 10 years and group 3 = more than 10 years

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Buccal infiltration was the most commonly employed local anesthetic method in anesthetizing permanent mandibular central incisor teeth within the study population, with 110 (49.1%) practitioners [Figure 2]. The second most widely used method was a combination of buccal and lingual infiltrations, 50 (22.3%) practitioners. 21 (9.4%) practitioners employed IMNB plus buccal infiltration. 18 (8%) practitioners employed IMNB alone, 12 (5.4%) practitioners employed IANB plus buccal infiltration. Only 7 (3.1%) practitioners employed IANB and IMNB and 6 (2.7%) IANB alone.
Figure 2: Percentages of respondent practitioners with local anesthetic methods

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There were significant differences in choice of anesthetic method among UK National Health Service general dentists: Buccal infiltration alone was more commonly employed than the IANB alone (49.1% vs. 2.7% respectively, χ2 = 125, P < 0.001). Similarly, use of buccal infiltration alone was more significant than the IMNB alone (49.1% vs. 8% respectively, χ2 = 92, P < 0.001). Again, buccal infiltration alone (49.1%) was more significantly employed than the combination of buccal and lingual infiltrations (22.3%), (χ2 = 35, P < 0.001) [Figure 2]. IMNB alone more significantly employed than the IANB alone (8% vs. 2.7% respectively, χ2 = 6.3, P < 0.012).

Buccal infiltration alone was employed most commonly by practitioners with less than 5 years' experience. However, both the IANB and IMNB were the most commonly employed by practitioners with over 10 years' experience. Practitioners with more than 10 years' experience were more likely to use combination methods such as buccal plus lingual infiltrations, IANB plus buccal infiltration, IMNB plus buccal infiltration, and IANB plus the IMNB.

With regard to combined techniques, a combination of buccal and lingual infiltrations was more commonly employed than the IANB plus buccal infiltration (22.3% vs. 5.4% respectively, χ2 = 27, P < 0.001). Again, buccal plus lingual infiltrations employed more significantly than the incisive mental nerve block plus buccal infiltration (22.3% vs. 9.4% respectively, χ2 = 14, P < 0.001). There was no significant difference when the IANB plus buccal infiltration was compared to IMNB plus buccal infiltration (5.4% vs. 9.4% respectively, χ2 = 2.6, P < 0.104).

For buccal infiltration alone, group 1 employed this method significantly more than group 2 [58 (53.7%) versus 9 (8.3%) respectively, χ2 = 42.3, P ≤ 0.001] [Table 1]. Group 3 employed buccal infiltration more significantly than group 2 (41 [38%] vs. 9 [8.3%] respectively, χ2 = 23.1, P ≤ 0.001).
Table 1: Local anesthetic methods and years of experience of respondent practitioners in groups

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For combined buccal and lingual infiltrations, no significant difference was noted between group 1 and group 2 (17 [34%] vs. 9 [18%] respectively [χ2 = 2.61, P = 0.106]). Again, the difference was not significant when group 3 compared to group 1 (24 [48%] vs. 17 [34%] respectively, χ2 = 1.31, P = 0.251). None of the respondents in groups 1 and 2, compared with 6 (100%) in group 3 employed IANB alone. This difference was significant (χ2 = 12.11, P = 0.002).

For combined IMNB and buccal infiltration, group 1 employed this method significantly more than group 2 (8 [44.4%] vs. none (0%) respectively, χ2 = 8.1, P = 0.004). Similarly, group 3 employed that method significantly more than group 2 (10 [55.6%] vs. none [0%] respectively, χ2 = 10.23, P = 0.001).

For IMNB alone, group 1 employed this injection method more significantly than group 2 [5 (27.8%) vs. none (0%) respectively, χ2 = 5.0, P = 0.025) [Table 1]. Group 3 employed IMNB alone more significantly than group 2 [13 (72.2%) vs. 5 (27.8%) respectively, (χ2 = 13.39, P = 0.001) [Table 1].

For IMNB plus IANB, there were no significant differences between group 1, 2, and 3, except between group 3 and 2 (0% vs. 71.4% respectively P = 0.025).

For IMNB plus IANB, there were no significant differences between group 1, 2, and 3, except between group 3 and 2 (0% vs. 71.4% respectively P = 0.025).

For IANB plus buccal infiltration, no significant difference between group 1 and group 2 (1 [8.3%] vs. 2 [16.7%] respectively, χ2 = 0.33, P = 0.562). Group 3 employed the IANB plus buccal infiltration more significantly than group 2 (9 [75%] vs. 2 [16.7%], respectively, χ2 = 4.56, P = 0.033). Similarly, there was significant difference between group 3 and group 1 (9 [75%] vs. 1 [8.3%] respectively, [χ2 = 6.55, P = 0.010]).


  Discussion Top


A number of alternative and supplementary techniques have been described to overcome the failure of the conventional IANB injection, including infiltration anesthesia, intraligamentary anesthesia, intraosseous anesthesia, and mental and incisive nerve block (MINB). [7],[8],[9],[10],[11] The current survey found that the buccal infiltration alone and combined buccal and lingual infiltrations were the most common primary methods employed by the current sample of UK NHS GDPs to anesthetize lower incisor teeth for pulp extirpation.

With regard to IANB and PDL techniques, very small numbers of practitioners within the surveyed sample employed these techniques. This is probably because these techniques possess many disadvantages such as the potential for nerve damage, the incidence of intravascular injection (IANB), and damage to periodontal tissues and bacteremia (PDL) when compared to infiltration techniques. Furthermore, might very poor anesthetic success rates following PDL in the anterior mandible and high failure rates following IANB in the anterior mandible restricted their use among GDPs within the surveyed sample. [1],[7]

The use of these techniques has been supported by a number of recently published volunteer clinical studies. Yonchak et al. reported successful pulpal anesthesia (63%) after buccal infiltration in the mandibular anterior teeth. [12] Meechan and Ledvinka demonstrated that although infiltration anesthesia can be successful in securing pulpal anesthesia in mandibular central incisor teeth, a split buccal and lingual dose of was more effective than buccal infiltration alone, (92%) versus (50%) respectively. [1] Donohue, Sharaf reported that mandibular infiltration was as effective as mandibular block anesthesia in young children. [13],[14] Jaber et al. have reported that digital soft tissue massage after MINB did not have a significant influence on the occurrence or duration of pulp anesthesia in mandibular teeth. [15] Whitworth et al. noted no difference in success between rapid and slow injection on the efficacy of MINB for pulpal anesthesia on mandibular teeth. [16]

Parirokh and Abbott have reported that a combination of buccal and lingual infiltrations provides significantly higher rates of successful anesthesia compared to either labial or lingual infiltration. They recommended that dentists should employ techniques that have a higher success rate with less pain and discomfort to the patient during and postinjection. They advocated the use of supplementary or alternative techniques when the first injection was not successful in providing profound anesthesia. [17] It can be noted from our study that, intentionally or not, the majority of practitioners are employing evidence-based practice, by the use of buccal infiltration and combined buccal plus lingual infiltrations for anesthetizing lower central incisor teeth.


  Conclusion Top


Buccal infiltration and buccal plus lingual infiltrations anesthesia found to be the most widely employed primary local anesthetic methods for anesthetizing the mandibular central incisor teeth prior to pulp extirpation in this sample of NHS GDPs.

Buccal infiltration alone was employed most commonly by practitioners with <5 years experience. However, both the inferior alveolar nerve and incisive mental nerve blocks were the most commonly employed by experienced practitioners over 10 years. Experienced practitioners were more likely to use combination methods for anesthesia.

 
  References Top

1.
Meechan JG, Ledvinka JI. Pulpal anaesthesia for mandibular central incisor teeth: A comparison of infiltration and intraligamentary injections. Int Endod J 2002;35:629-34.  Back to cited text no. 1
    
2.
DeSantis JL, Liebow C. Four common mandibular nerve anomalies that lead to local anesthesia failures. J Am Dent Assoc 1996;127:1081-6.  Back to cited text no. 2
    
3.
Wilson S, Johns P, Fuller PM. The inferior alveolar and mylohyoid nerves: An anatomic study and relationship to local anesthesia of the anterior mandibular teeth. J Am Dent Assoc 1984;108:350-2.  Back to cited text no. 3
[PUBMED]    
4.
Stein P, Brueckner J, Milliner M. Sensory innervation of mandibular teeth by the nerve to the mylohyoid: Implications in local anesthesia. Clin Anat 2007;20:591-5.  Back to cited text no. 4
    
5.
Carter RB, Keen EN. The intramandibular course of the inferior alveolar nerve. J Anat 1971;108:433-40.  Back to cited text no. 5
[PUBMED]    
6.
Dou L, Luo J, Yang D, Wang Y. The effectiveness of an additional lingual infiltration in the pulpal anesthesia of mandibular teeth: A systematic review. Quintessence Int 2013;44:457-64.  Back to cited text no. 6
    
7.
Nist RA, Reader A, Beck M, Meyers WJ. An evaluation of the incisive nerve block and combination inferior alveolar and incisive nerve blocks in mandibular anesthesia. J Endod 1992;18:455-9.  Back to cited text no. 7
    
8.
Nusstein J, Claffey E, Reader A, Beck M, Weaver J. Anesthetic effectiveness of the supplemental intraligamentary injection, administered with a computer-controlled local anesthetic delivery system, in patients with irreversible pulpitis. J Endod 2005;31:354-8.  Back to cited text no. 8
    
9.
Kanaa MD, Whitworth JM, Corbett IP, Meechan JG. Articaine buccal infiltration enhances the effectiveness of lidocaine inferior alveolar nerve block. Int Endod J 2009;42:238-46.  Back to cited text no. 9
    
10.
Bigby J, Reader A, Nusstein J, Beck M, Weaver J. Articaine for supplemental intraosseous anesthesia in patients with irreversible pulpitis. J Endod 2006;32:1044-7.  Back to cited text no. 10
    
11.
Meechan JG. Supplementary routes to local anaesthesia. Int Endod J 2002;35:885-96.  Back to cited text no. 11
    
12.
Yonchak T, Reader A, Beck M, Clark K, Meyers WJ. Anesthetic efficacy of infiltrations in mandibular anterior teeth. Anesth Prog 2001;48:55-60.  Back to cited text no. 12
    
13.
Oulis CJ, Vadiakas GP, Vasilopoulou A. The effectiveness of mandibular infiltration compared to mandibular block anesthesia in treating primary molars in children. Pediatr Dent 1996;18:301-5.  Back to cited text no. 13
    
14.
Sharaf AA. Evaluation of mandibular infiltration versus block anesthesia in pediatric dentistry. ASDC J Dent Child 1997;64:276-81.  Back to cited text no. 14
    
15.
Jaber A, Whitworth JM, Corbett IP, Al-Baqshi B, Jauhar S, Meechan JG. Effect of massage on the efficacy of the mental and incisive nerve block. Anesth Prog 2013;60:15-20.  Back to cited text no. 15
    
16.
Whitworth JM, Kanaa MD, Corbett IP, Meechan JG. Influence of injection speed on the effectiveness of incisive/mental nerve block: A randomized, controlled, double-blind study in adult volunteers. J Endod 2007;33:1149-54.  Back to cited text no. 16
    
17.
Parirokh M, Abbott PV. Various strategies for pain-free root canal treatment. Iran Endod J 2014;9:1-14.  Back to cited text no. 17
    


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