The effect of intraosseous local anesthesia of 4% articaine with 1:100,000 epinephrine on pulpal blood flow and pulpal anesthesia of mandibular molars and canines
Authors: Praphasri Rirattanapong
Kanittha Kijsamanmith
Noppakun Vongsavan
Kadkao Vongsavan
Tshering Samdrup
Journal: Clinical Oral Investigations (2019)
Discipline: CLINICAL MEDICINE
Keywords: 4% articaine; Intraosseous anesthesia; Laser-Doppler flowmetry; Mandibular molars; Pulpal anesthesia
Affiliations: Department of Pediatric Dentistry, Faculty of Dentistry, Mahidol University, Bangkok, Thailand., Department of Oral Biology, Faculty of Dentistry, Mahidol University, Yothi Road, Bangkok, 10400, Thailand. ., Department of Oral Biology, Faculty of Dentistry, Mahidol University, Yothi Road, Bangkok, 10400, Thailand.

Abstract:  Objectives: The aim of this study was to determine the effect of intraosseous (IO) anesthesia with 4% articaine and 1:100,000 epinephrine on pulpal blood flow (PBF) and pulpal anesthesia of mandibular first molars and canines in human subjects. Materials and methods: Ten healthy volunteers with intact mandibular first molar and canine were given an osteocentral technique of IO injection using the Quick Sleeper 5 system and 4% articaine with 1:100,000 epinephrine at distal site of mandibular first molar. The PBF was monitored by a laser Doppler flowmeter (LDF). Pulpal anesthesia was assessed with an electric pulp tester (EPT). Results: IO injection caused a decrease in PBF in molars from 6.31 ± 3.85 perfusion units (P.U.) before injection to 2.51 ± 2.53 P.U. 1 min after injection (P &lt; 0.001). The percentage reduction in PBF was 60% after 1 min and PBF returned back to the baseline after 45 min. No significant reduction in PBF was observed in the canines (P = 0.212). For pulpal anesthesia in the molars, the mean onset was 2.40 ± 0.84 min and the mean duration was 38 ± 16.19 min. In the canines, there was a decrease in the sensitivity to EPT but complete pulpal anesthesia was not achieved. Conclusions: IO injection distal to mandibular first molar caused a decrease in PBF and successful pulpal anesthesia in first molar, but not in canine. Both PBF and EPT readings returned to normal, suggesting that pulpal ischemia may not occur. Clinical relevance: IO anesthesia is safe to use as a primary technique in teeth with normal pulp. 

Retracted: No

PubPeer comments:
 In the introduction, the authors claim that intraosseous (IO) anesthesia u201cis restricted to the tooth, the surrounding soft tissue should remain largely unaffectedu201d. In IO technique, the anesthesia is not limited to the tooth. It involves the area close to the teeth, namely: alveolar bone, periodontal ligament, attached gingiva surrounding the tooth, and, of course, the teeth themselves (pulpal anesthesia). This is demonstrated by the possibility to perform non-surgical periodontal treatments [1], extractions [2,3], simple implant surgery [4,5], even more extensive oral surgery with IO anesthesia [6]. Furthermore, it is my personal experience that 2 to 8 teeth can be anesthetized, depending on the location (maxilla mandible, anterior posterior teeth) and the amount injected. The authors affirm: u201cWhen the injection point gets as close as possible to the apex of tooth concerned, it leads to increase the quantity injected, to increase the vasoconstrictor concentration, and to reduce the distance between the apex and the injection point, which are the strategies to anesthetize the tooth with pulpitisu201d. Injecting as close as possible to the tooth apex does not in itself increase the quantity injected or the vasoconstrictor concentration. The quantity injected, and the vasoconstrictor dilution result of the practitioneru2019s choice and action. In fact, reducing the distance between the injection point and the target (the tooth apex) allows a maximum concentration of the anesthetic solution at the required location, as the dilution gradient varies with the cube of the distance [7,8]. Adding a vasoconstrictor to the anesthetic formulation allows the anesthetic solution not to fade too rapidly. Collier et al. hypothesized the strategies for anesthetizing teeth with pulpitis with IO anesthesia [9] As stated in the article, u201can IO injection alone successfully anesthetizes patients with irreversible pulpitisu201d. Other studies can confirm this: Villette et al. showed a global success rate of 77.3% (100% after reinjection] with Quicksleeper [10]; Terrer et al. compared intraosseous anesthesia with Quicksleeper and a block of the inferior alveolar nerve with a success rate of 86% (100% after re-injection) for IO anaesthesia [11]. About articaine, the authors write: u201cas it contains a thiophene ring instead of a benzene ring which increases its lipid solubility [u2026] articaine is the local anesthetic that best diffuses within soft and hard tissues . Skjevik et al., which are cited in the article, explain: u201cthiophene itself is actually less hydrophobic than benzene. [u2026] It may very well be that it is instead the intramolecular hydrogen bond that contributes to giving articaine its favorable properties.u201d [12] The allegation by the authors that u201cno study has evaluated the effect of IO anesthesia on pulpal circulation and pulpal anesthesiau201d is inaccurate. In 2015, Kulyhina and Muntian [13] conducted a comparative evaluation of capillary blood flow using Laser Doppler flowmetry (LDF) in 109 patients during infiltrative, nerve-block and intraosseous local anesthesia techniques. They observed an initial decrease, then the activation of pulpal blood flow and its regulation for the viability of the pulp); the initial level of microcirculation was recovered in the 30th minute following the anesthesia. They concluded that the most effective technique was primary intraosseous anesthesia delivered with the QuickSleeper Computer-Controlled Local Anesthesia Device (CCLAD). In the materials and methods section The osteocentral IO technique used in this research was first described by Gru00e9aud et al. [14] The present study demonstrates the versatility of the Quicksleeper CCLAD, the only device allowing an easy IO anesthesia u2018transcortical and osteocentral), as well as any other oral anesthetic technique (block of the IAN, periodontal, intraseptal, supraperiosteal). In the results section The current study demonstrates a very limited soft tissue (lip and tongue) anesthesia (STA). STA is a major drawback in children. This lack of STA with IO anesthesia, along with its excellent efficacy, supports the use of IO anesthesia in children, as shown by Sixou et al. [15-17], Trentesaux et al. [18], Noirrit et al. [19], Amu00e9du00e9e [20]. In the discussion section Some remarks by the authors are quite stimulating: - u201cthe anesthetic effect of IO anesthesia depends on the distribution and spread of solution within cancellous boneu201d; u201coptimal injection site for IO anesthesia is a site distal to the tooth to be anesthetizedu201d and u201cthe effect of the IO anesthesia was significantly greater, with longer duration in the mandibular molars than in the caninesu201d. These three observations fully corroborate the recommendations by the manufacturer of the Quicksleeper, Dental Hi Tec (Cholet, France). In the mandible, the orientation of the vascular supply is disto-mesial from the mandibular foramen. Hence, the diffusion of the local anesthetic injected with an IO anesthesia technique will tend to flow mesially: it is my clinical experience that for mandibular molars, the anesthetic will generally diffuse distally to the next tooth only and mesially to the two proximal teeth, depending on the amount injected and the location [21]. This clinical finding is now supported by the experimental evidence provided. This explains why, a study evaluating the success rate of IO anesthesia for third molar surgery returned relatively poor results: ignoring the basic but essential recommendation that, in the mandibu, IO anesthesia injection should be made in the distal aspect of the tooth teeth to be treated, the researchers injected distal to the first mandibular molar, so that the anesthetic solution could not consistently reach the third molar. [22] - u201cthe IO anesthesia is unlikely to cause ischemic conditions within the dental pulpu201d: this shows that IO anesthesia should be considered not only as a very efficient supplemental technique in endodontics (as usually stated) but too as a technique perfectly suited for all conservative treatments, as previously shown. [23-26] The idea that u201ca dense layer of bone covers the IANu201d remains highly questionable. Denio et al. who are cited in the article, actually write:u201d The periphery of the mandibular canal was not a solid body channel throughout its entire course. Instead, it was more like a coalescence of trabecular bone, which in some cases ranged from quite dense to very delicate structure. The canal wall was less identifiable in the region of the second premolar and first molar.u201d [27]. The French anatomist and oral surgeon Gaudy, based on dissections, considers that there is no truly individualized cortical bone lining the mandibular canal; the densification observed radiologically on the periphery of the mandibular canal is related to the specific orientation of the trabeculae of spongy bone close to the inferior alveolar nerve. [28] The assertion that the needle used in this research has an u201casymmetric triple bevelu201d is probably incorrect, provided that the needles sold in Thailand are the same as those sold in Europe: the u201cscalpelu201d design needle marketed by Dental Hi Tec (Cholet, France) for intraosseous anesthesia with Quicksleeper, has been invented by a French dental surgeon, Dr. Alain Villette. This needle has two bevels: one main bevel which is cut by one secondary bevel on the opposite side, creating the asymmetrical aspect of the needle tip. 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