Reversal of soft-tissue local anesthesia with phentolamine mesylate in adolescents and adults

BACKGROUND: The authors conducted two multicenter, randomized, double-blinded, controlled Phase III clinical trials to study the efficacy and safety of phentolamine mesylate (PM) in shortening the duration and burden of soft-tissue anesthesia. The study involved 484 subjects who received one of four commercially available local anesthetic solutions containing vasoconstrictors for restorative or scaling procedures. METHODS: On completion of the dental procedure, subjects randomly received a PM or a sham injection (an injection in which a needle does not penetrate the soft tissue) in the same site as the local anesthetic injection. The investigators measured the duration of soft-tissue anesthesia by using standardized lip- and tongue-tapping procedures every five minutes for five hours. They also evaluated functional measures and subject-perceived altered function, sensation, appearance and safety. RESULTS: Median recovery times in the lower lip and tongue for subjects in the PM group were 70 minutes and 60 minutes, respectively. Median recovery times in the lower lip and tongue for subjects in the sham group were 155 minutes and 125 minutes, respectively. Upper lip median recovery times were 50 minutes for subjects in the PM group and 133 minutes for subjects in the sham group. These differences were significant (P < .0001). Recovery from actual functional deficits and subject-perceived altered function, sensation and appearance also showed significant differences between the PM and the sham groups. CONCLUSIONS: PM was efficacious and safe in reducing the duration of local anesthetic- induced soft-tissue numbness and its associated functional deficits. CLINICAL IMPLICATIONS: Clinicians can use PM to accelerate reversal of soft-tissue anesthesia and the associated functional deficits.     

Reversal of soft-tissue local anesthesia with phentolamine mesylate in pediatric patients

BACKGROUND: The authors evaluated the safety and efficacy of a formulation of phentolamine mesylate (PM) as a local anesthesia reversal agent for pediatric patients. METHODS: A total of 152 pediatric subjects received injections of local anesthetic with 2 percent lidocaine and 1:100,000 epinephrine before undergoing dental procedures. The authors then randomized subjects to receive a PM injection or a control injection (sham injection in which a needle does not penetrate the tissue) in the same sites as the local anesthetic was administered in a 1:1 cartridge ratio after the procedure was completed. Over a two- to-four-hour period, they measured the duration of soft-tissue anesthesia and evaluated vital signs, pain and adverse events. RESULTS: The median recovery time to normal lip sensation was 60 minutes for the subjects in the PM group versus 135 minutes for subjects in the control group. The authors noted no differences in adverse events, pain, analgesic use or vital signs, and no subjects failed to complete the study. CONCLUSIONS: PM was well-tolerated and safe in children 4 to 11 years of age, and it accelerated the reversal of soft-tissue local anesthesia after a dental procedure in children 6 to 11 years of age. CLINICAL IMPLICATIONS: PM can help dental clinicians shorten the post-treatment duration of soft-tissue anesthesia and can reduce the number of posttreatment lip and tongue injuries in children.     

A prospective, randomized single-blind study of the anesthetic efficacy of frequency-dependent conduction blockade of the inferior alveolar nerve

Introduction

The purpose of this prospective, randomized single-blind study was to evaluate the degree of pulpal anesthesia obtained with frequency-dependent conduction blockade of the inferior alveolar nerve (IAN).

Methods

Eighty adult volunteers randomly received two IAN blocks: an IAN block followed by continuous electrical stimulation for 3 minutes of the first molar or lateral incisor for six cycles over a time period of 64 minutes; an IAN block followed by mock electrical stimulation using the same cycles. The IAN blocks were administered at two separate appointments spaced at least 1 week apart in a crossover design. An electric pulp tester was used to test for anesthesia of the first molar and lateral incisor. Anesthesia was considered successful when two consecutive 80 readings were obtained within 15 minutes, and the 80 reading was recorded through the 60th minute.

Results

The anesthetic success rate for the stimulated IAN block was 35% and 48% for the lateral incisor and first molar, respectively. For the mock stimulated IAN, success was 18% for the lateral incisor and 62% for the first molar. There was no significant difference between the two IAN block techniques.

Conclusions

We concluded that the stimulation of nerves in the presence of local anesthesia (frequency-dependent nerve block) did not statistically increase the success rate of pulpal anesthesia for an IAN block.     

A prospective, randomized, single-blind comparative evaluation of anesthetic efficacy of posterior superior alveolar nerve blocks, buccal infiltrations, and buccal plus palatal infiltrations in patients with irreversible pulpitis

Introduction

The purpose of this study was to evaluate and compare the anesthetic efficacy of posterior superior alveolar (PSA) nerve blocks, buccal infiltrations, and buccal plus palatal infiltrations with 2% lidocaine with 1:200,000 epinephrine in maxillary first molars with irreversible pulpitis.

Methods

Ninety-four adult patients participated in this prospective, randomized, single-blinded study. The patients were divided into 3 treatment groups on a random basis. Twenty-eight patients received a PSA nerve block, 33 patients received buccal infiltrations, and 33 patients received buccal plus palatal infiltrations with 2% lidocaine with 1:200,000 epinephrine. Endodontic access preparation was initiated 15 minutes after injection. Pain during treatment was recorded using a Heft-Parker visual analog scale. Success was recorded as “none” or “mild” pain.

Results

Statistical analysis using nonparametric chi-square tests revealed that there was no statistical difference between the anesthetic success of PSA nerve blocks (64%), buccal infiltrations (54%), and buccal plus palatal infiltrations (70%).

Conclusions

None of the tested methods gave 100% anesthetic success rates in maxillary first molars with irreversible pulpitis.     

Postoperative endodontic pain of three different instrumentation techniques in asymptomatic necrotic mandibular molars with periapical lesion: a prospective,randomized, double-blind clinical trial

Objectives

The purpose of this prospective, randomized, double-blind study was to compare postoperative pain of root canal treatment in patients with asymptomatic mandibular molar teeth with necrotic pulp and periapical lesion using three different instrumentation techniques: hand, multi-file rotary (ProTaper Universal), and reciprocating single-file (Wave-One) instrumentation techniques.

Materials and methods

Ninety-six patients who fulfilled specific inclusion criteria were assigned to three groups according to the root canal instrumentation technique used: Hand (G1), ProTaper Universal (G2), and Wave-One (G3). One-visit root canal treatment was carried out, and the severity of the postoperative pain was assessed by the Heft-Parker visual analogue scale 6, 12, 18, 24, 48, and 72 h after treatment. Data were analyzed by Kruskal-Wallis, χ ², Cochrane Q, one-way ANOVA, and Spearman’s correlation analyses (α = 0.05).

Results

The patients in group 3 reported significantly lower postoperative pain levels at 6, 12, and 18 h compared with the patients in the two other groups (P < .05). In addition, the patients in group 2 reported significantly lower postoperative pain levels at 6 and 12 h compared with the patients in group 1 (P < .05). There were no significant differences in postoperative pain between the three groups at other time intervals (P > .05). The analgesic consumption was significantly higher in group 1 (P < .05), but no difference was seen between the two other groups (P > .05).

Clinical relevance

Postoperative pain was significantly lower in patients undergoing root canal instrumentation with the Wave-One file compared with the ProTaper Universal and hand files.

     

Pulpal anaesthesia for mandibular permanent first molar teeth: a double-blind randomized cross-over trial comparing buccal and buccal plus lingual infiltration injections in volunteers

AIM: To compare the efficacy of buccal and buccal plus lingual infiltration anaesthesia for permanent mandibular first molars. METHODOLOGY: Thirty one healthy adult volunteers received each of the following methods of anaesthesia for a mandibular first molar tooth in a randomised order, 1) Buccal infiltration of 1.8 mL and needle penetration lingually. 2) Buccal infiltration of 0.9 mL, plus lingual infiltration of 0.9 mL. Two percent lidocaine with 1:100,000 epinephrine was used. Electrical pulp testing was performed before, and every 2 minutes for 30 minutes after injection. A successful outcome was recorded as the absence of pulp sensation on two or more consecutive maximal pulp tester stimulations (80 microA). Injection discomfort was assessed using visual analogue scales. Data were compared with McNemar and Wilcoxon Signed Ranks tests. RESULTS: Buccal infiltration was successful in 38.7% of cases compared to 32.3% after combined infiltrations; the difference was not significant (P = 0.63). Buccal infiltration produced more episodes of no response to maximum stimulation than buccal and lingual infiltrations (129 and 114 respectively), this difference was not significant (P = 0.11). Peak anaesthetic effect occurred around 10-14 minutes after injection. There was no difference in injection discomfort between buccal injections of 0.9 mL and 1.8 mL of solution (P = 0.90). Lingual injection was more uncomfortable than lingual penetration (P = O.O02). CONCLUSIONS: Buccal and buccal plus lingual infiltrations did not differ in their efficacy in producing anaesthesia of permanent first molar teeth.     

The role of preoperative prophylactic antibiotic administration in periapical endodontic surgery: a randomized, prospective double-blind placebo-controlled study

AIM: To determine the value of clindamycin prophylaxis in the prevention of postoperative wound infections in patients undergoing endodontic surgery. METHODOLOGY: This study included 256 patients undergoing endodontic surgery in a prospective double-blind placebo-controlled trial comparing oral administration of an oral placebo versus a preoperative 600 mg dose of clindamycin. After randomization the study medication was administered orally 1 h before surgery in a double-blind fashion. For a period of 4 weeks the postoperative course was observed according to clinical parameters of infection. Primary end-point was infection at the surgical site. RESULTS: The mean age of the study population was 44.4 years (SD 11.4, range 18-82 years) with a sex distribution of 147 females (47.4%) and 109 males (42.6%). Mean age of the patients in the clindamycin group was 44.7 years (SD 12.0), and the mean age in the placebo group was 44.1 years (SD 10.8) (P = 0.49). In the clindamycin group, the mean duration of surgery was 32.3 min (SD 8.8) and in the placebo group the mean duration of surgery was 32.5 min (SD 8.4) (P = 0.89). Two infections [1.6%; 95 confidence interval (CI): 0.48-4.72] were identified in the clindamycin group and four (3.2%; 95 CI: 0.42-1.33) in the placebo group (P = 0.448). CONCLUSIONS: No statistically significant difference was found between clindamycin prophylaxis and placebo with regard to the prevention of postoperative infection in endodontic surgical procedures.     

Outcomes of endodontic micro-resurgery: a prospective clinical study

Introduction

This study examined the outcomes of endodontic resurgery by using current microsurgery techniques on failed teeth with previous endodontic surgery. Another goal was to determine any significant outcome predictors of endodontic surgery by determining the causes of failure in the first endodontic surgery.

Methods

The data were collected from patients in the Department of Conservative Dentistry at the Dental College, Yonsei University in Seoul, Korea between March 2001 and May 2009. All 54 teeth that required surgical retreatment were included in this study. All surgical procedures were performed by using an operating microscope and biocompatible root-end filling materials such as mineral trioxide aggregate (MTA) or Super EBA. The patients were recalled every 6 months for 2 years and every year thereafter to assess the clinical and radiographic signs of healing.

Results

The recall rate was 77.8% (42 of 54 patients). Of the 42 cases recalled, 39 cases were included in the success category, giving an overall success rate of 92.9%. The most common possible causes of failure were no root-end filling and incorrect root-end preparation.

Conclusions

The use of microsurgical techniques and biocompatible materials such as MTA and Super-EBA resulted in a high clinical success rate, even in endodontic resurgery.     

Comparative evaluation of 2.0-mm locking plate system vs 2.0-mm nonlocking plate system for mandibular fracture: a prospective randomized study

This study evaluated the efficacy of a 2.0-mm locking plate/screw system compared with a 2.0-mm non-locking plate/screw system in mandibular fractures. A prospective randomized clinical trial was conducted. Patients were randomly assigned to receive 2.0-mm locking plates (group A) or 2.0-mm nonlocking plates (group B). All patients were followed up for 12 weeks postoperatively. Complications were analysed according to the type of plate used and the site of fracture. Fifty patients with 76 fractures met the inclusion criteria. Thirty-six fracture sites were treated with 2.0-mm locking plates and 40 with 2.0-mm nonlocking plates. The number of patients requiring postoperative maxillomandibular fixation was significantly higher in group B (p < 0.01); seven complications occurred representing 9% of the total. Two complications occurred in the locking group and five in the nonlocking group with complication rates equalling 6% and 13%, respectively. When comparing the overall complication rates according to plates used, the χ² test showed no statistically significant difference between the locking and nonlocking plates (p > 0.05). In conclusion, mandible fractures treated with 2.0-mm locking plates and 2.0-mm nonlocking plates present similar short-term complication rates.     

A comparison of pre-emptive analgesic efficacy of diflunisal and lornoxicam for postoperative pain management: a prospective, randomized, single-blind, crossover study

Diflunisal and lornoxicam are currently available non-steroidal anti-inflammatory drugs (NSAIDs) that have been shown to be effective to various degrees in pain relief when administered either pre-emptively or postoperatively. The pre-emptive analgesic efficacy of diflunisal 1000 mg was compared with that of lornoxicam 16 mg in 40 ASA I patients undergoing surgical removal of bilateral impacted third molars. The impacted third molar teeth on one side were removed at the first surgical appointment using one of the two drug regimens being assessed and the teeth on the contralateral side were removed at a second appointment using the alternate drug regimen; all operations were performed by the same surgeon. Acetaminophen up to 2000 mg daily was provided as rescue medication. The postoperative rescue analgesic consumption was recorded and pain scores were evaluated with a visual analogue scale at 2, 4, 6, 12 and 24h postoperatively. No statistically significant differences were found between groups with respect to rescue analgesic consumption and postoperative pain scores. Pre-emptive administration of both NSAIDs proved to be effective in the management of pain following the surgical removal of impacted third molar teeth.     

Fate of monocortical bone blocks grafted in the human maxilla: a histological and histomorphometric study

Local bone defects in the anterior maxilla are commonly grafted with monocortical blocks of autologous bone in order to restore the defect site prior to the placement of dental implants. Increasing evidence suggests that osteocytes are involved in the control of bone remodelling and thus may be important for optimalisation of bone structure around implants, and thus for implant osseointegration. However, it is not well known whether osteocytes will survive when bone blocks are grafted into defects. We grafted 19 patients with monocortical bone blocks derived from the symphysis, to the defect site in the maxillary alveolar process. The bone grafts were left to heal for times varying from 2.5 to 7 months. During implant installation, bone biopsies were removed using a trephine burr, and processed for hard tissue histology. Bone histology and histomorphometry were then carried out in order to gain insight into the density, viability and remodelling of the graft. Clinically, all the bone grafts were successful, with no implant failures, and little resorption was seen. Histologically, bone volume expressed as percentage of tissue volume at the implant site varied from 27% to 57% with an overall average of 41%. Bone fields with empty osteocyte lacunae were observed and measured. The amount of this so-called nonvital bone (NVB) varied between 1% and 34% of the total tissue volume. The amount of NVB decreased significantly with the time of healing. The data suggest that the majority of the osteocytes of the monocortical bone do not survive grafting. The results indicate that the NVB is progressively remodelled into new vital bone 7 months after grafting.     

Superior border versus inferior border fixation in displaced mandibular angle fractures: prospective randomized comparative study

A prospective randomized comparative study was conducted to compare open reduction and internal fixation of displaced fractures (>2 mm) via intraoral approach with application of a single monocortical miniplate according to Champy's ideal line of osteosynthesis (group A) versus an extraoral approach with application of an inferior border plate with at least two holes (bicortical screws) on either side of the fracture line (group B). Clinical and radiographic assessment was done preoperatively, immediately postoperative, and at 1, 4, and 12 weeks of follow-up. Parametric and non-parametric data were evaluated by independent samples t-test and χ² analysis, respectively; P < 0.05 was considered statistically significant. There was no significant difference between the two groups with regard to complication rates, although functional outcomes including pain (visual analogue scale score) at the 1-week follow-up and inter-incisal mouth opening at the 12-week follow-up were found to be better in group B. On radiographic assessment, the inferior border was better aligned in group B than in group A, with no superior border distraction in group B. The duration of surgery was shorter in group B, and this was considered to be the easier approach for fixation of the device as assessed by the surgeons.     

Temporomandibular disorders in patients with mandibular fractures: a preliminary comparative case-control study between South Australia and Oman

The status of temporomandibular disorders (TMD) in subjects with previously treated mandibular fracture was evaluated in two centres: South Australia (SA) and Oman (O). TMD status was evaluated using Mandibular Function Impairment Questionnaire (MFIQ), Helkimo index for clinical dysfunction (HI), RDC/TMD and Wilkes’ classification. Data were retrieved for adult patients treated for mandibular fracture over 3 years from January 2004 to December 2006. Thirty-six subjects participated from SA and 23 from O. Their results were compared with matched controls. The incidence of TMD symptoms in SA injured and control groups was higher compared with the O groups. There was statistically significant difference on all evaluation indices for SA injured subjects compared with controls (MFIQ/P 0.04, HI/P 0.0015, RDC/TMD/P 0.05, Wilkes classification/P 0.03). These TMD symptoms were clinically insignificant for most subjects and all were internal derangement of the temporomandibular joint (TMJ). There was no significant difference in all evaluation indices for O injured subjects compared with controls. For SA injured subjects who reported clinically significant TMD symptoms, assault and bilateral mandibular fractures were predominant features. The study shows that most mandibular injuries fully recover and the associated TMJ trauma usually has low clinical significance in the long term.     

Effect of treatment of temporomandibular disorders (TMD) in patients with cervicogenic headache: a single-blind, randomized controlled study

The present study was comprised of 43 patients (16 men) with cervicogenic headaches for over three months, diagnosed according to the International Classification of Diagnostic Criteria of Headaches (ICDH-II). The patients were randomly assigned to receive either manual therapy for the cervical region (usual care group) or additional manual therapy techniques to the temporomandibular region to additionally influence temporomandibular disorders (TMD). All patients were assessed prior to treatment, after six sessions of treatment, and at a six-month follow-up. The outcome criteria were: intensity of headaches measured on a colored analog scale, the Neck Disability Index (Dutch version), the Conti Anamnestic Questionnaire, noise registration at the mandibular joint using a stethoscope, the Graded Chronic Pain Status (Dutch version), mandibular deviation, range of mouth opening, and pressure/pain threshold of the masticatory muscles. The results indicate in the studied sample of cervicogenic headache patients, 44.1% had TMD. The group that received additional temporomandibular manual therapy techniques showed significantly decreased headache intensities and increased neck function after the treatment period. These improvements persisted during the treatment-free period (follow-up) and were not observed in the usual care group. This trend was also reflected on the questionnaires and the clinical temporomandibular signs. Based on these observations, we strongly believe that treatment of the temporomandibular region has beneficial effects for patients with cervicogenic headaches, even in the long-term.     

Power chains as an alternative to steel-wire ligatures in temporary maxillomandibular fixation: a pilot study

The aim of this study was to compare two techniques for temporary intraoperative maxillomandibular fixation (TIO-MMF) during orthognathic surgery: steel-wire ligatures versus power chains. Patients undergoing orthognathic surgery between October 2019 and March 2020 were included in a prospective cross-sectional study conducted in three participating hospitals. Data were collected using a standardized measurement form. A total of 44 patients were included, in whom TIO-MMF was applied 79 times. A statistically significant difference in intraoperative loss of stability of the segment relationship was found between steel-wire ligatures (11.4%) and power chains (0%). The mean application time of TIO-MMF differed significantly between steel-wire ligatures (99 seconds) and power chains (157 seconds) (P < 0.001). There was no statistical difference in occurrence of adverse events between the two techniques. This study found that the application of TIO-MMF with power chains is more stable compared to steel-wire ligatures. Steel-wire ligatures were significantly faster to apply, although the absolute difference (less than 1 minute) was small. Other possible advantages of the proposed technique are discussed. The results of this study suggest that power chains for the application of TIO-MMF in orthognathic surgery are a valuable alternative to steel-wire ligatures.     

Effects of preemptive analgesia with intravenous acetaminophen on postoperative pain relief in patients undergoing third molar surgery: a prospective,single-blind,randomized controlled trial

Background The efficacy of preemptive analgesia in managing postoperative pain remains controversial. The aim of this study was to compare the efficacy of intravenous (IV) acetaminophen administered before or immediately after the surgical extraction of an impacted mandibular third molar. Material and Methods This prospective randomized clinical trial included 120 patients. The patients were assigned to one of three groups: the preoperative-treatment group (pre-group), which received 1000 mg of IV acetaminophen 20 min before surgery; the postoperative-treatment group (post-group), which received 1000 mg of IV acetaminophen after surgery; the no-treatment group (control-group), which did not receive any analgesic. Rescue analgesic (60 mg loxoprofen) was issued to each patient, with instructions on self-administration if needed. For the rescue medication usage, the time of first loxoprofen usage and the total amount of loxoprofen consumption were obtained for a 17-hour period after surgery. We measured pain using the visual analogue scale at 1 hour and at 2, 3, 4, 5, and 15 hours after surgery. Results There was no significant difference in pain level among the three groups at any time interval. However, the pre-group demonstrated significantly lower rescue analgesic consumption and longer time until initial administration. Conclusions Administration of IV acetaminophen before third molar surgery provides more effective pain control than postoperative administration and no treatment. Key words:Preemptive analgesia, acetaminophen, impacted third molar, pain relief, randomized controlled trial.     

Sleep quality in patients with xerostomia: a prospective and randomized case-control study

Objectives To investigate sleep quality, anxiety/depression and quality-of-life in patients with xerostomia. Materials and methods This prospective, observational, cross-sectional study was conducted among a group of xerostomia patients (n?=?30) compared with 30 matched control subjects. The following evaluation scales were used to assess the psychological profile of each patient: the Hospital Anxiety and Depression Scale, the Oral Health Impact Profile-14 (OHIP-14), the Xerostomia Inventory, the Pittsburgh Sleep Quality Index (PSQI) and the Epworth Sleepiness Scale (ESS). Results The PSQI obtained 5.3 3?±?1.78 for patients with xerostomia compared with 4.26?±?1.01 for control subjects (p?=?0.006); ESS obtained 5.7?±?2.1 for test patients vs 4.4 0?±?1 for control subjects (p?=?0.010). Statistical regression analysis showed that xerostomia was significantly associated with depression (p?=?0.027). Conclusions Patients with xerostomia exhibited significant decreases in sleep quality compared with control subjects.     

Calvarial graft resorption index in the reconstruction of the maxillary sinus in patients with atrophic maxillas: a prospective clinical study

The objective of this study was to assess the resorption index of particulate calvarial grafts in maxillary sinuses of patients undergoing total reconstruction of an atrophic maxilla with residual alveolar bone that was less than, or equal to, 3 mm thick. Twenty-one maxillary sinus floor elevations were carried out using particulate calvarial grafts in 11 individuals with totally edentulous maxillas. All patients had computed tomography (CT) before (T0), and 48 hours (T1) and six months after surgery (T2). For each CT scan, linear measurements were taken of sections of the anterior, medial, and posterior regions of the maxillary sinus. There was a significant increase in the height of the maxillary sinus floor when T0 was compared with T1 (p = 0.001). There was a statistically significant reduction in all maxillary sinus measurements when T1 was compared with T2; the mean height reduction being 2.36 mm (16.87%) in the anterior region, 3.53 mm (22.47%) in the medial region, and 2.21 mm (22.78%) in the posterior region (p = 0.001). Mean resorption was 20.7%. Autogenous calvarial bone used alone is an option for graft material in pneumatised maxillary sinuses and in cases where there is limited alveolar bone.