Interventions for anesthetic success in symptomatic irreversible pulpitis: A network meta-analysis of randomized controlled trials

BACKGROUND: Local anesthetics alone or in combination with adjuncts, such as oral medications, have routinely been used for pain control during endodontic treatment. The best clinical choice amongst the vast numbers of agents and techniques available for pain control for irreversible pulpitis is unclear. This network meta-analysis combined the available evidence on agents and techniques for pulpal anesthesia in the maxilla and mandible, in order to identify the best amongst these approaches statistically, as a basis for future clinical trials.METHODS: Randomized trials in MEDLINE, DARE, and COCHRANE databases were screened based on inclusion criteria and data were extracted. Heterogeneity was assessed and odds ratios were used to estimate effects. Inconsistencies between direct and indirect pooled estimates were evaluated by H-statistics. The Grading of Recommendation, Assessment, Development, and Evaluation working group approach was used to assess evidence quality.RESULTS: Sixty-two studies (nine studies in the maxilla and 53 studies in the mandible) were included in the meta-analysis. Increased mandibular pulpal anesthesia success was observed on premedication with aceclofenac + paracetamol or supplemental 4% articaine buccal infiltration or ibuprofen+paracetamol premedication, all the above mentioned with 2% lignocaine inferior alveolar nerve block (IANB). No significant difference was noted for any of the agents investigated in terms of the success rate of maxillary pulpal anesthesia.CONCLUSION: Direct and indirect comparisons indicated that some combinations of IANB with premedication and/or supplemental infiltration had a greater chance of producing successful mandibular pulpal anesthesia. No ideal technique for maxillary anesthesia emerged. Randomized clinical trials with increased sample size may be needed to provide more conclusive data. Our findings suggest that further high-quality studies are required in order to provide definitive direction to clinicians regarding the best agents and techniques to use for mandibular and maxillary anesthesia for irreversible pulpitis.

Anxiolytic, sedative, and hypnotic activities of aqueous extract of Morinda citrifolia fruit.

Morinda citrifolia (Indian mulberry or noni) fruit has been long used as a folk medicine for a wide range of health purposes as it is claimed to have analgesic, antiinfl ammatory, antioxidant, detoxifi er, and cell-rejuvenator properties. A recent study has revealed central nervous system suppressant nature of its extract. Hence, the present study has evaluated the anxiolytic, sedative, and hypnotic effects of the aqueous extracts of Morinda citrifolia in rodents in comparison to diazepam. Anxiety was assessed by ‘Isolation-induced aggression’ model, sedation by ‘Spontaneous locomotor activity using actophotometer’ and hypnotic activity by ‘Prolongation of ketamine-induced sleeping time’. Six male mice were used for each of the groups and postdose, all the six that received diazepam had shown an inhibition of aggression, whereas in the test group, fi ve of six mice and none in the control group had shown an inhibition of aggression (P = 0.0007). Similarly, for the sedative activity, the total number of spontaneous locomotor activity at 30 min following drug administration was found to be 364.67±10.74, 123.16±8.33, and 196.67±3.7, while at 60 min it was found to be 209±12.98, 49±5.78, and 92±2.5 (mean±SD) for the control, standard, and test groups of mice respectively (P < 0.001). Hypnotic activity was measured by prolongation of ketamine-induced sleeping time wherein the onset and duration of loss of righting refl ex were compared among each group of mice. The time in minutes for the onset in control, standard, and test groups was 4.01±0.22, 1.23±0.05, and 2.23±0.07, respectively. The duration of loss of righting refl ex was 44.23±0.59, 56.03±1.34, and 50.57±0.36, respectively. Both these were statistically signifi cant (P < 0.001). However, more clinical studies are needed to assess the long-term effects of the extract in humans.