A Comparison between Inferior Alveolar Nerve Block and Crestal Anesthesia in Children Undergoing Dental Extraction Procedure

ABSTRACT Objective: To evaluate the efficacy of crestal anesthesia compared to the inferior alveolar nerve block (IANB) in 6-9-year-old children undergoing tooth extraction. Material and Methods: This case-control study was conducted on 70 children who needed bilateral mandibular primary molar extractions. The Faces Pain Scale was used to determine the efficacy of the anesthetic technique. Demographic data, onset time of anesthesia, duration of anesthesia, and blood pressure were also recorded. The data were analyzed using SPSS 25 and analytical tests: t-test, chi-squared test, and one-way ANOVA. The level of significance was set at p<0.05. Results: The efficacy of the IANB was significantly higher than the crestal anesthesia (p<0.05). The duration of IANB anesthesia was significantly more than the crestal anesthesia (p<0.05). The two anesthetic techniques showed no significant differences in pediatric blood pressure as a determinant of the pain evoked in children during the injection (p>0.05). Conclusion: Crestal anesthesia proved an effective method to extract primary molars. However, further studies are necessary to confirm this.

A propósito de la crioanestesia dental / Apropos dental cryoanesthesia

RESUMEN Introducción: La crioanestesia es una forma de anestesia tópica utilizada en procedimientos médicos menores aprovechando el descenso o inhibición del umbral doloroso causado por el estímulo térmico. Es posible emplearla en procedimientos sobre tejidos dentales para complementar la anestesia con fármacos y combatir el fracaso anestésico. Objetivo: Describir los hallazgos sobre el uso y aplicación de la crioanestesia dental en odontología. Métodos: Revisión exploratoria de la literatura científica y gris, donde se evaluó la disminución de la sensación dolorosa empleando frío sin alcanzar congelación del tejido dental. Fueron consultadas las bases de datos Pubmed, Embase, Scopus, SciELO, Elsevier y Science Direct. La búsqueda en Google Académico se realizó eliminando las entradas repetidas y limitada a los 100 primeros resultados. La investigación cubrió el periodo de 1941 hasta diciembre de 2018 y se utilizó la lista de comprobación PRISMA para ejecutar la revisión. Resultados: Cuatro artículos fueron seleccionados. Todos emplearon diferentes dispositivos, refrigerantes y escalas para valoración del dolor; sin embargo, todos reportaron ausencia de dolor en algunas de sus muestras. Conclusión: Se identificó evidencia escasa y antigua con desigualdad en las escalas de valoración, protocolos clínicos, sustancias refrigerantes y dispositivos utilizados(AU)

ABSTRACT Introduction: Cryoanesthesia is a type of topical anesthesia used in minor medical procedures. It is based on the descent or inhibition of the pain threshold caused by the thermal stimulus. Cryoanesthesia may be used in procedures performed on dental tissues to complement anesthetic drugs and combat anesthetic failure. Objective: Describe the findings about the use and application of cryoanesthesia in dental practice. Methods: An exploratory review was conducted of scientific and grey literature to evaluate pain reduction using cold temperatures without freezing the dental tissue. The databases consulted were Pubmed, Embase, Scopus, SciELO, Elsevier and Science Direct. The search in Google Scholar removed repeated entries and was limited to the first 100 results. The study covered the period extending from 1941 to December 2018, and used the PRISMA checklist to carry out the review. Results: Four papers were selected. All four used different devices, refrigerants and pain assessment scales. However, they all reported an absence of pain in some of their samples. Conclusion: Scant, outdated evidence was identified which contained discrepancies in the assessment scales, clinical protocols, refrigerant substances and devices used(AU)

Liposomal anesthetic gel for pain control during periodontal therapy in adults: a placebo-controlled RCT

Abstract Periodontal therapy usually requires local anesthesia. If effective, a non-invasive, liposomal anesthetic gel could increase the levels of acceptance of patients in relation to periodontal therapy. Objective: This study investigated the efficacy of liposomal anesthetic gel for pain control during periodontal therapy. Methodology: Forty volunteers with moderate to severe chronic periodontitis were recruited, of which at least three sextants required periodontal therapy. At least one of the selected teeth had one site with a probing depth of ≥4 mm. The volunteers received the following three gels: a placebo, lidocaine/prilocaine (Oraqix®), or a liposomal lidocaine/prilocaine, which were applied to different sextants. Pain frequency was registered during treatment and the volunteers received a digital counter to register any painful or uncomfortable experiences. At the end of each session, the volunteers indicated their pain intensity using rating scales (NRS-101 and VRS-4). The volunteers had their hemodynamic parameters measured by a non-invasive digital monitor. Results: Pain frequency/intensity did not show statistical difference between intervention groups. The tested gels did not interfere with the hemodynamic indices. Dental anxiety, suppuration and probing depth could influence pain during periodontal therapy. Conclusion: Our results suggest limited indications for the use of non-invasive anesthesia when used for scaling and root planing. Intra-pocket anesthetic gel could be a good option for anxious patients, or those who have a fear of needles.

Pharmacological Synergism: A Multimodal Analgesia Approach to Treat Dental Pain / Sinergismo Farmacológico: Un enfoque de analgesia multimodal para el manejo de dolor dental

Abstract Dental pain is usually managed by clinical interventions and pharmacological coadjuvants such as NSAIDs. However, its perception and modulation is mediated by different nociceptive mechanisms and these strategies can be insufficient. The multimodal analgesia refers to the use of 2 or more analgesic drugs that attenuate or blockade different mechanisms of pain, obtaining a greater clinical effect. Within this concept, pharmacological synergism plays a leading role, combining different molecules in lower doses to diminish also side effects. Since there are no standard prescriptions to be use in all the patients, multimodal approaches allow the clinician to make responsible effective combinations, individualizing analgesia as the pathway to success.

Resumen El dolor dental generalmente se trata con intervenciones clínicas y coadyuvantes farmacológicos como los AINEs. Sin embargo, su percepción y modulación está mediada por diferentes mecanismos nociceptivos y estas estrategias pueden ser insuficientes. La analgesia multimodal se refiere al uso de 2 o más fármacos analgésicos que atenúan o bloquean diferentes mecanismos de dolor, obteniendo un mayor efecto clínico. Dentro de este concepto, el sinergismo farmacológico juega un papel importante, combinando diferentes moléculas en dosis más bajas para disminuir también los efectos secundarios. Dado que no hay prescripciones estándar para ser usadas en todos los pacientes, los enfoques multimodales permiten al clínico realizar combinaciones responsables y eficaces, individualizando la analgesia como el camino hacia el éxito.

Assessment of anesthetic properties and pain during needleless jet injection anesthesia: a randomized clinical trial

Abstract Pain due to administration of local anesthetics is the primary reason for patients' fear and anxiety, and various methods are used to minimize it. This study aimed to measure the degree of pain during administration of anesthesia and determine the latency time and duration of pulpal anesthesia using two anesthetic methods in the maxilla. Materials and Methods: A randomized, single-blind, split-mouth clinical trial was conducted with 41 volunteers who required class I restorations in the maxillary first molars. Local anesthesia was administered with a needleless jet injection system (experimental group) or with a carpule syringe (control) using a 30-gauge short needle. The method of anesthesia and laterality of the maxilla were randomized. A pulp electric tester measured the latency time and duration of anesthesia in the second molar. Visual analogue scale (VAS) was used to measure the degree of pain during the anesthetic method. Data were tabulated and then analyzed by a statistician. The t-test was used to analyze the differences between the groups for basal electrical stimulation. Duration of anesthesia and degree of pain were compared using the Mann-Whitney test. A 5% significance level was considered. Results: There was no statistical difference in the basal electrical stimulation threshold (mA) and degree of pain between the two methods of anesthesia (p>0.05). Latency time was 2 minutes for all subjects. The duration of pulpal anesthesia showed no statistical difference (minutes) between the two methods (p<0.001), with a longer duration for the traditional method of anesthesia (median of 40 minutes). Conclusions: The two anesthetics methods did not differ concerning the pain experienced during anesthesia. Latency lasted 2 minutes for all subjects; the traditional infiltration anesthesia resulted in a longer anesthetic duration compared with the needleless jet injection.

Predicting intraoperative pain in emergency endodontic patients: clinical study

Abstract This prospective observational study sought to investigate the incidence of intraoperative pain (IOP) among emergency endodontic patients and to construct an IOP prediction model that includes preoperative pain level (PPL). All patients who underwent emergency endodontic treatment at Gazi University, Ankara, Turkey, during the spring term of 2016 were considered for inclusion in the study. Demographic and clinical variables and PPL were recorded. Local anesthesia was provided to all patients before beginning routine endodontic treatment. IOP was defined as the condition of requiring supplementary anesthesia before the working length was established and exhibiting persistent moderate or severe pain despite supplementary anesthesia. Data from 85% and 15% of 435 patients (178 men, 257 women; mean age: 35 years) were used to develop predictive models by multiple logistic regression analysis and to test external validity of the models, respectively. Two multiple logistic regression models achieved good model fits. Model 1 included age, pulpal diagnosis, and arc (p < 0.05). In addition to these variables, Model 2 included periapical diagnosis and PPL (p < 0.15). Models 1 and 2 showed accuracies of 0.76 and 0.75, sensitivities of 0.74 and 0.77, and specificities of 0.76 and 0.74, respectively for the modeling data (internal validity), and accuracies of 0.82 and 0.80, sensitivities of 0.83 and 0.67, and specificities of 0.81 and 0.81, respectively for the control data (external validity). The IOP incidence was 10.3%. IOP in patients undergoing emergency endodontic treatment can be successfully predicted by using models that account for demographic and clinical variables, including PPL.

Virtual Reality simulator for dental anesthesia training in the inferior alveolar nerve block

Abstract Objectives This study shows the development and validation of a dental anesthesia-training simulator, specifically for the inferior alveolar nerve block (IANB). The system developed provides the tactile sensation of inserting a real needle in a human patient, using Virtual Reality (VR) techniques and a haptic device that can provide a perceived force feedback in the needle insertion task during the anesthesia procedure. Material and Methods To simulate a realistic anesthesia procedure, a Carpule syringe was coupled to a haptic device. The Volere method was used to elicit requirements from users in the Dentistry area; Repeated Measures Two-Way ANOVA (Analysis of Variance), Tukey post-hoc test and averages for the results' analysis. A questionnaire-based subjective evaluation method was applied to collect information about the simulator, and 26 people participated in the experiments (12 beginners, 12 at intermediate level, and 2 experts). The questionnaire included profile, preferences (number of viewpoints, texture of the objects, and haptic device handler), as well as visual (appearance, scale, and position of objects) and haptic aspects (motion space, tactile sensation, and motion reproduction). Results The visual aspect was considered appropriate and the haptic feedback must be improved, which the users can do by calibrating the virtual tissues' resistance. The evaluation of visual aspects was influenced by the participants' experience, according to ANOVA test (F=15.6, p=0.0002, with p<0.01). The user preferences were the simulator with two viewpoints, objects with texture based on images and the device with a syringe coupled to it. Conclusion The simulation was considered thoroughly satisfactory for the anesthesia training, considering the needle insertion task, which includes the correct insertion point and depth, as well as the perception of tissues resistances during the insertion.

Influencia de los vasoconstrictores añadidos a la anestesia dental en la frecuencia cardiaca y la tensión arterial / Influence of vasoconstrictors added to dental anesthetics on blood pressure and heart rate

Introduction: vasoconstrictors are substances added to local anesthetics to lengthen their time of action, reduce their toxicity and enhance their local hemostatic effect. There is controversy about whether the use of vasoconstrictors in dental anesthetics has a negative effect on blood pressure and heart rate. Objective: determine the influence of vasoconstrictors added to dental anesthetics on blood pressure and heart rate. Methods: an experimental study was conducted with 120 patients divided in two groups of 60. These patients attended clinics in the Dental Academic Unit of the Autonomous University of Guerrero from July to December 2015. Group A was given just 3 percent mepivacaine, whereas Group B was given mepivacaine with epinephrine at a concentration of 1:100 000. Measurements were taken of the patients' heart rate, systolic blood pressure and diastolic blood pressure at two moments: at baseline before infiltration and 5 minutes after infiltration. Statistical analysis was based on Student's t-test for independent samples. Results: heart rate and systolic blood pressure did not yield any statistically significant value. Diastolic blood pressure was the only hemodynamic parameter showing a statistically significant difference (t= 2.3; p= 0.02). Conclusions: the results obtained coincide with those reported by similar studies. At the doses recommended, epinephrine is safe for healthy patients as well as for those with controlled cardiovascular conditions(AU)

Introducción: los vasoconstrictores son substancias que han sido añadidas a los anestésicos locales con la finalidad de aumentar su tiempo de acción, disminuir su toxicidad y aprovechar su efecto hemostático local. Existe controversia sobre si el uso de vasoconstrictores en los anestésicos dentales produce efectos negativos en la tensión arterial y la frecuencia cardiaca. Objetivo: determinar la influencia de los vasoconstrictores añadidos a la anestesia dental en la frecuencia cardiaca y la tensión arterial. Métodos: se realizó un estudio experimental en 120 pacientes divididos en dos grupos de 60, que acudieron a las clínicas de la Unidad Académica de Odontología de la Universidad Autónoma de Guerrero en el periodo julio-diciembre de 2015. Al grupo A se le administró mepivacaína simple al 3 por ciento, y al grupo B se le administró mepivacaína con epinefrina a una concentración de 1:100 000. Se realizaron tomas de frecuencia cardiaca, tensión arterial sistólica y tensión arterial diastólica en dos momentos. Se realizó una toma basal de frecuencia cardiaca, tensión arterial sistólica y diastólica antes de la infiltración, y una segunda toma 5 min posteriores a la infiltración. Se realizó la prueba estadística t de Student para grupos independientes. Resultados: la frecuencia cardiaca y la tensión arterial sistólica no obtuvieron significancia estadística. El único parámetro hemodinámico que tuvo una diferencia estadísticamente significativa fue la tensión arterial diastólica (t= 2,3; p= 0,02). Conclusiones : los resultados obtenidos en esta investigación, coinciden con los reportados en otros estudios similares. La epinefrina puede ser utilizada de manera segura a las dosis recomendadas tanto en pacientes sin enfermedad cardiovascular, como en pacientes con compromiso cardiovascular en control(AU)

Dor em urgência odontológica: uso de anti-inflamatórios, corticoides e analgésicos em casos de pulpite aguda irreversível / Pain in dental emergency: anti inflammatory use, steroids and painkillers in cases of irreversible acute pulpitis

O objetivo deste estudo foi avaliar o uso do cetorolaco de trometamina 10mg sublingual 30 minutos antes do procedimento de biopulpectomia em pacientes com pulpite irreversível com relação à dor antes do procedimento e nas 48 horas subsequentes, a quantidade de medicação consumida no pós-operatório e tempo esperado para sua utilização. Também foi avaliada a influência da anestesia intrapulpar, o uso da automedicação analgésica antes da procura pelo atendimento e diferença entre gêneros sobre os níveis de dor pré e pós-operatória. Propôs-se avaliar também a necessidade da presença do antibiótico na medicação intracanal, comparando o Otosporin® com hidrocortisona. Participaram da pesquisa 608 pacientes que procuraram o Setor de Urgência Odontológica da Faculdade de Odontologia de Bauru ou o Setor Odontológico do Pronto Socorro Central da Prefeitura Municipal de Bauru, sendo que 34 completaram de forma adequada o protocolo previsto. Foram divididos em 4 grupos que receberam cetorolaco ou placebo como medicação pré-operatória e Otosporin® ou hidrocortisona como medicação intracanal. Foram anotados os valores de intensidade de dor, em uma escala visual analógica, antes da medicação pré-operatória, antes do atendimento, após o atendimento, 1, 2, 4, 12, 24, 48 horas após e quando houve necessidade de medicação pós-operatória para alívio da dor. Também foi anotado se o paciente havia se automedicado e qual a droga utilizada, se houve necessidade de anestesia intrapulpar, a quantidade de medicação consumida pelo paciente no pós-operatório e o tempo esperado para seu consumo. Dos resultados observou-se que os pacientes que receberam cetorolaco como medicação pré-operatória tiveram uma redução significativa da dor em 30 minutos, quando comparado ao placebo. Foi observado que o tempo necessário para a ingestão de medicamentos pós-operatórios não demonstrou diferença significativa entre os grupos, assim como na quantidade de medicação ingerida. O tempo decorrido entre a primeira e a última dose de medicação pós-operatória também não demonstrou diferença estatística. Com relação a anestesia intrapulpar, 78% dos pacientes necessitaram desta técnica, mas devido ao pequeno tamanho da amostra obtida, não foi possível correlacionar o seu uso com a utilização da medicação pós-operatória. Para os pacientes que se automedicaram previamente, não houve diferença significativa em relação à dor inicial. Quando os gêneros foram comparados, não foi possível observar uma diferença estatística significante entre eles com relação aos parâmetros estudados. Também foram descritos no trabalho os motivos de não inclusão dos 574 pacientes que foram abordados durante a realização deste estudo. Com base nos resultados, conclui-se que o cetorolaco diminuiu expressivamente o nível de dor durante a espera pelo atendimento, porém com relação ao tempo esperado pelo paciente para tomar a primeira dose de medicação pós-operatória, a última dose, a quantidade de comprimidos e a frequência de ingestão não demonstrou a mesma diferença. Também não houve diferença no nível de dor inicial entre os pacientes que se automedicaram e os que não fizeram uso dessa prática. Devido ao pequeno número da amostra, não foi possível encontrar uma correlação entre o uso da técnica anestésica intrapulpar e medicação pós-operatória, sugerindo mais estudos futuros.(AU)

The aim of this study was to evaluate the use of ketorolac tromethamine (10mg sublingual taken 30 minutes before pulpectomy in patients with irreversible pulpitis) in pain reduction immediately before the procedure and the 48 subsequent hours, postoperative consumption of analgesic drugs and time for its use. The influence of intrapulpal anesthesia, the use of analgesic self-medication prior to the demand for care and gender difference on the levels of pre- and postoperative pain was also evaluated. It was also proposed assess the need for antibiotic presence in the intracanal medicament, comparing Otosporin® with hydrocortisone. A total of 608 patients who presented to Dental Urgency Sector from Dental School of Bauru (USP) or Emergency Dental Sector from Bauru City Hall were invited to participate, and 34 completed properly planned protocol. They were distributed in 4 groups that received either ketorolac or placebo as preoperative medication and Otosporin® or hydrocortisone as intracanal medication. The rates of pain intensity were recorded by means of a visual analogue scale before pretreatment medication, immediately before the appointment, 1, 2, 4, 12, 24, 48 hours after the appointment, and when there was taken post medication for postoperative pain relief. It was also recorded if the patient had self medicated and which the drug used and, if there was need intrapulpal anesthesia, amount of ketorolac and rescue medication (paracetamol 750mg) consumed by the patient postoperative time and the waitng time for consumption. The results showed that patients receiving Ketorolac as preoperative medication had a significant reduction of pain in 30 minutes compared to placebo. It was observed that the time required for the intake of postoperative drug showed no significant difference between groups, as well as the amount of medication intake. The time elapsed between the first and last dose of postoperative medication also showed no statistical difference. Concerning intrapulpal anesthesia, 78% of patients required for this technique, but because of the small sample size obtained it was impossible to correlate their use with the use of postoperative medication. For patients who practiced self medication previously, there was no significant difference with respect to initial pain. When genders were compared, it was not possible to observe a statistically significant difference between them regarding the parameters studied. Were also described in the study the reasons of non-inclusion of 574 patients that were addressed during this study. Based on the results, it is concluded that ketorolac significantly decreased the level of pain during the waiting time, but with respect to the time length for the patient to take the first dose of postoperative medication, the last dose, the number of tablets and taken frequency did not show the same difference. There was no difference in the initial level of pain among patients who practiced self medication and those who did not use this practice. Due to the small sample size, it was not possible to find a correlation between the use of the anesthetic technique intrapulpal and postoperative medication, suggesting more future studies.(AU)

Perception of discomfort during injection and the need for supplemental anesthesia in the intraosseous technique using 4 per cent articaine / Percepción de incomodidad durante la inyección y necesidad de anestesia suplementaria en anestesia intraósea usando articaína al 4

The authors conducted an experimental study to determine patient perception of discomfort during injection and the need for supplemental anesthesia using the intraosseous technique with 4% articaine with 1:100,000 epinephrine in patients with symptomatic pulpitis in mandibular molars. At different clinical sessions, researchers used 4% articaine with 1:100,000 epinephrine to apply intraosseous injection (Group 1) or inferior alveolar nerve block (Group 2). Each technique was applied in 35 patients. In each group, the need for additional anesthesia was determined and patient discomfort during injection was assessed with a Visual Analogue Scale (VAS) test. In the intraosseous group, no supplemental technique was needed in 22 patients (62.85 %), and results were similar for the inferior alveolar technique (n: 23 65.71%). The intraosseous technique proved to be more comfortable than the mandibular technique (18 patients - 25.7%). This study found that the use of intraosseous technique with 4% articaine shows promising results regarding patient comfort and reducing the need for additional anesthesia.

Los autores condujeron un estudio experimental para deter minar la eficacia de la técnica anestésica intraósea usando articaína al 4% con epinefrina 1:100.000, en pacientes con pulpitis aguda en molares mandibulares. En diferentes sesiones clínicas, los miembros del equipo de investigadores usaron articaína al 4% con epinefrina 1:100.000 para inducir anestesia mandibular con la técnica intraósea (Grupo 1) o con el bloqueo del nervio alveolar inferior (Grupo 2), se aplicó cada técnica en 35 pacientes con diagnóstico de pulpitis aguda en molares inferiores. En cada grupo, se determinó la necesidad de hacer anestesia complementaria y la comodidad del paciente con un test Escala Visual Analoga. Un total de 70 pacientes fueron enrolados en este estudio (35 sujetos por grupo). En el grupo de intraósea no fue necesaria la aplicación de técnicas complementarias en 22 pacientes (31.4%), resultados similares en la técnica alveolar inferior (n: 23 32.8%). La técnica intraósea demostró ser más cómoda al compararla con técnica mandibular (18 pacientes 25.7%). Este estudio demostró que el uso de la técnica intraósea conarticaína al 4%, arrojó resultados prometedores en lo que a comodidad y reducción en la anestesia complementaria hace referencia.

Effect of warming anaesthetic solutions on pain during dental injection: a randomized clinical trial / Efecto del calentamiento del anestésico sobre el dolor durante la inyección dental: ensayo clínico aleatorio

To determine the effectiveness of warming anesthetic solutions on pain produced during the administration of anesthesia in maxillary dental infiltration technique. Material and Methods: A double-blind cross-over clinical study was designed. Fifty-six volunteer students (mean age 23.1+/-2.71 years) of the Dental School at Universidad Austral de Chile (Valdivia, Chile) participated in the study. Subjects were given 0.9ml of 2 percent lidocaine with 1:100.000 epinephrine (Alphacaine®; Nova DFL - Brazil) by two punctions at buccal vestibule of lateral incisor. Warm anesthesia at 42°C(107.6°F) was administered in a hemi-arch; and after one week anesthesia at room temperature (21°C; 69.8°F) and at a standardized speed was administered at the contralateral side. The intensity of pain felt during injection was registered and compared using visual analog scale (VAS) of 100mm (Wilcoxon test p<0.05). Results: The use of anesthesia at room temperature caused a VAS-pain intensity of 34.2+/-16.6mm, and anesthesia at 42°C a VAS-pain intensity of 15.7+/-17.4mm (p<0.0001). Conclusion: The use of anesthesia at42°C resulted in a significantly lower pain intensity perception during injection compared with the use of anesthesia at room temperature during maxillary infiltration technique...

Determinar la efectividad del calentamiento de anestesia en la reducción del dolor producidodurante la administración de anestesia dental en técnica infiltrativa maxilar. Material y método: Se diseñó un estudio clínico doble ciego de brazos cruzados.Participaron cincuenta y seis estudiantes voluntarios (23.1+/-2.71 años) de la Escuela de Odontología de la Universidad Austral de Chile (Valdivia, Chile). Se les administró 0.9ml de lidocaína 2 por ciento con epinefrina 1:100.000 (Alphacaine®; Nova DFL - Brasil) mediante 2 punciones en el fondo de vestíbulo a nivel del incisivo lateral superior. En una hemi-arcada se administró anestesia a 42ºC (107.6°F) y luego de una semana se les administró anestesia en el lado contralateral a temperatura ambiente (21ºC; 69.8°F) con una velocidad estandarizada. Se comparó laintensidad de dolor percibida durante la inyección mediante escala visual análoga (EVA) de 100mm (pruebade Wilcoxon p<0.05). Resultados: El uso de anestesia a temperatura ambiente provocó un dolor promedio EVAde 34.2+/-16.6mm y la anestesia a 42°C un dolor promedio EVA 15.7+/-17.4mm (p<0.0001). Conclusión: El uso de anestesia a 42ºC generó una percepción de dolor significativamente menor durante la inyección del anestésico en comparación a su uso con temperatura ambiente en la técnica infiltrativa maxilar...

Influencia de la temperatura de la lidocaína 2 por ciento con epinefrina 1: 80.000 sobre el dolor por inyección e inicio de acción en el bloqueo del nervio dentario inferior / Effect of themperature of lidocaine 2 per cent with epinephrine 1: 80.000 on pain from injection and onset of action in inferior alveolar nerve block

La colocación de anestesia local genera un dolor manifestado por los pacientes, pues antes de que el anestésico inicie su efecto, ingresa a la mucosa a una temperatura inferior a la corporal y produce un estímulo doloroso. El objetivo de este estudio fue determinar la influencia de la temperatura de la lidocaína al 2 por ciento con epinefrina 1:80,000 sobre el dolor por inyección e inicio de acción. Material y métodos: Se realizó un estudio ciego en 38 pacientes sometidos a dos aplicaciones de lidocaína 2 por ciento con epinefrina 1:80,000 a temperatura de 37o C y temperatura ambiente. Resultados: Según la escala visual análoga, se obtuvieron para la administración de anestesia a 37o C valores de 6.63 ± 5.037 mm, y para la administración a temperatura ambiental, valores de 12.870 ± 12.001 mm (p < 0.05). Según la escala de respuesta verbal, se encontró que para la administración de anestesia a 37o C, el 100 por ciento manifestó un dolor menor a lo esperado¼, mientras que en la administración a temperatura ambiente, sólo 61 por ciento manifestó olor menor de lo esperado¼ (p < 0.05). En relación con el tiempo de inicio de acción, se encontró que la administración de anestesia a 37o C presentó un valor de 201.66 ± 85.336 segundos, mientras que para la administración a temperatura ambiente, se presentó un valor de 286.66 ± 84.292 segundos (p < 0.05). Conclusión: La administración del anestésico local a 37o C produce menor intensidad de dolor y menor tiempo de inicio de acción en compa-ración con la administración de anestésico local a temperatura ambiente.

The placement of local anesthesia causes pain in patients due to the fact that before the anesthetic takes effect, it fi rst enters the mucosa at a temperature that is below body temperature, which results in a pain stimulus. The aim of this study was to determine the extent to which the temperature of lidocaine 2% with epinephrine 1:80,000 affects the pain caused by an injection and the onset of action. Material and methods:We performed a blind study involving 38 patients who received two applications of lidocaine 2% with epinephrine 1:80,000, one at 37 oC and the other at room temperature. Results: Based on the visual analog scale, administering anesthesia at 37 oC produced values of 6.63 ± 5.037 mm, and at room temperature, values of 12.870 ± 12.001 mm (p < 0.05). On the verbal response scale, administering anesthesia at 37 oC resulted in 100% expressing ®less than expected¼ pain, while the administration at room temperature resulted in only 61% expressing ®less than expected¼ pain (p < 0.05). In terms of time to onset of action, it was found that administering anesthesia at 37 oC produced a value of 201.66 ± 85.336 seconds, whereas at room temperature, the value was 286.66 ± 84.292 seconds (p < 0.05). Conclusion: Administering the local anesthetic at 37 oC produces a lower pain intensity and shorter onset of action compared to doing so at room temperature.

Stress and Anxiety in Children After the Use of Computerized Dental Anesthesia

The aim of this study was to evaluate the transitory stress levels and the anxiety state in children submitted to conventional and computerized dental anesthesia. Twenty children (7 to 12 years) were randomly assigned to receive conventional and computerized dental anesthesia. To investigate the hypothesis that transitory stress could be lower after using computerized anesthesia compared to conventional anesthesia, cortisol levels in saliva were measured before and after each technique. Anxiety was also evaluated individually by answering the State-Trait Anxiety Inventory for Children (STAIC). Numerical data were analyzed statistically by the Mann-Whitney non-parametric test (5% significance level). Salivary cortisol levels increased in 8 (40%) patients after conventional anesthesia and in 9 (45%) patients after computerized anesthesia, with no statistically significant difference between the two types (p=0.34). In the same way, no statistically significant difference was found between the techniques (p=0.39) related to the psychological analysis based on the STAIC scores. Local anesthesia using either conventional anesthesia or a computerized delivery system produced similar level of stress/anxiety in pediatric patients, using both quantitative and qualitative analyses.

O objetivo deste estudo foi avaliar os níveis de estresse transitório e o estado de ansiedade em crianças submetidas à anestesia dental convencional e computadorizada. Vinte crianças (7 a 12 anos de idade) foram randomicamente designadas para receber anestesia dental convencional e computadorizada. Para investigar a hipótese que o estresse transitório poderia ser menor após a anestesia computadorizada, comparada à anestesia convencional, os níveis de cortisol na saliva foram medidos antes e depois de cada técnica. A ansiedade também foi avaliada individualmente por meio do State-Trait Anxiety Inventory for Children (STAIC). Os dados numéricos foram analisados estatisticamente pelo teste não paramétrico de Mann-Whitney (nível de significância de 5%). Os níveis salivares de cortisol aumentaram em 8 (40%) pacientes após anestesia convencional e em 9 (45%) pacientes após anestesia computadorizada, sem diferença estatisticamente significante entre os dois tipos (p=0,34). Da mesma maneira, não foi encontrada diferença estatisticamente significante entre as técnicas (p=0,39) com relação à análise psicológica baseada nos escores STAIC. Anestesia local usando tanto a anestesia convencional quanto o sistema de aplicação computadorizado produziu nível similar de estresse/ansiedade em pacientes infantis, utilizando análises quantitativa e qualitativa. .

Topical Intrapocket Anesthesia During Scaling and Root Planing: a Randomized Clinical Trial

Although the use of injectable anesthesia prior to subgingival scaling and root planing (SRP) reduces pain, many patients report fear and prolonged numbness of adjacent tissues. The aim of the present study was to compare the effects of a eutectic mixture containing 25 mg/g of lidocaine and 25 mg/g of prilocaine, injectable 2% lidocaine, topical 2% benzocaine and a placebo substance on reducing pain during SRP. In this randomized, split-mouth, masked clinical trial, thirty-two patients presenting more than two teeth with probing depth and clinical attachment level ≥5 mm in at least 4 sextants were randomly allocated to four groups: EMLA(r); injectable 2% lidocaine; topical 2% benzocaine and placebo. Pain and discomfort were measured using a visual analogue scale (VAS) and verbal scale (VS). Repeated-measures analysis of variance and Poisson regression were used for analysis. Patient satisfaction with the anesthesia was determined at the end of each treatment session. VAS and VS scores did not differ between injectable 2% lidocaine and EMLA (p>0.05) and both substances showed significantly better pain control compared to 2% benzocaine and placebo (p<0.05). 93.7% and 81.2% of the individuals were satisfied with the injectable anesthetic and EMLA, respectively (p=0.158). Dissatisfaction with benzocaine and placebo was approximately 10 times greater than injectable anesthesia (p=0.001). In conclusion, EMLA showed an equivalent effect on pain control when compared to the injectable anesthesia and performed better than 2% benzocaine in SRP. Thus, EMLA is a viable anesthetic option during scaling and root planning, despite the frequent need for second application.

Embora a anestesia injetável previamente a raspagem e alisamento subgengival (RASUB) reduza a dor, muitos pacientes relatam medo e amortecimento prolongado dos tecidos adjacentes. O objetivo deste estudo foi comparar o efeito de uma mistura eutética contendo 25mg/g de lidocaína e 25 mg/g de prilocaína, lidocaína 2% injetável, benzocaína 2% tópica e um placebo na redução da dor durante a RASUB. Neste ensaio clínico randomizado, cego de boca dividida, trinta e dois pacientes que apresentavam mais que dois dentes com profundidade de sondagem e nível de inserção clínica ≥ 5 mm, em no mínimo 4 sextantes, foram randomicamente alocados em 4 grupos: EMLA(r), lidocaína 2% injetável, benzocaína 2% tópica ou placebo. Dor e desconforto foram mensurados usando uma Escala Visual Analógica (EVA) e Escala Verbal (EV). A satisfação dos pacientes com a anestesia foi determinada ao final de cada consulta. Análise de variância de medidas repetidas e regressão de Poisson foram usadas para análise. Os escores da EVA e EV não demonstraram diferenças estatisticamente significantes entre lidocaína injetável e EMLA(r) (p > 0,05) e ambas as substâncias demonstraram significativamente melhor controle da dor comparadas a benzocaína 2% e placebo (p<0,05). 93,7% e 81,2% dos indivíduos ficaram satisfeitos com o anestésico injetável e EMLA(r), respectivamente (p=0,158). A insatisfação com a benzocaína e placebo foi aproximadamente 10 vezes maior do que com a anestesia injetável (p=0,001). Em conclusão, o EMLA(r) demonstrou um efeito equivalente no controle da dor quando comparado com a anestesia injetável e melhor do que a benzocaína 2% em RASUB. Assim, o EMLA(r) é uma opção anestésica viável durante a raspagem e alisamento radicular, apesar da necessidade frequente de segunda aplicação.

Eficácia da articaína, da bupivacaína e da lidocaína associadas à epinefrina em pacientes com pulpite irreversível em molares inferiores / Effectiveness of articaine, bupivacaine and lidocaine with epinephrine in patients with irreversible pulpitis in molars

O objetivo deste estudo foi comparar a eficácia anestésica da articaína 4%, da lidocaína 2%, ambas associadas à epinefrina 1:100.000, e da bupivacaína 0.5%, associada à epinefrina 1:200.000, durante pulpectomia em pacientes com pulpite irreversível em molares inferiores. Cento e cinco voluntários do Setor de Urgência da Faculdade de Odontologia da Universidade de São Paulo receberam, aleatoriamente, 3,6mL de um dos anestésicos locais para o convencional bloqueio do nervo alveolar inferior (BNAI). No caso de falha do BNAI, foram administrados 3,6mL da mesma solução como injeção complementar no ligamento periodontal. O sinal subjetivo de anestesia do lábio, a presença de anestesia pulpar e ausência de dor durante a pulpectomia foram avaliados, respectivamente, por indagação ao paciente, por meio do aparelho estimulador pulpar elétrico (pulp tester) e por uma escala analógica verbal. A análise estatística foi realizada por meio dos testes Qui-quadrado, Kruskal Wallis e Razão de Verossimilhanças. Foi adotado nível de significância de 0,05 (P <= 0,05). Todos os pacientes reportaram anestesia no lábio após o BNAI. A lidocaína apresentou valores superiores (42,9%) para a anestesia pulpar após o BNAI e após a injeção no ligamento periodontal (61,5%). A bupivacaína apresentou valores superiores para a analgesia (80%) após o BNAI e a lidocaína (92,3%) após a injeção no ligamento periodontal. Após a falha do BNAI, a dor na câmara pulpar foi a mais frequente para articaína e lidocaína e na dentina para a bupivacaína e após a falha da injeção no ligamento periodontal, a dor foi similar para articaína nas diferentes regiões; câmara, canal e dentina; para a bupivacaína foi mais frequente na dentina e para a lidocaína no canal. No entanto, essas diferenças não foram estatisticamente significantes. Portanto as três soluções anestésicas locais se comportam de forma semelhante e não apresentam efetivo controle da dor no tratamento da pulpite irreversível em molares inferiores.

The aim of this study was to compare the anesthetic efficacy of 4% articaine and 2% lidocaine both associated with 1:100,000 epinephrine and 0.5% bupivacaine associated with 1:200,000 epinephrine in patients with irreversible pulpitis of the mandibular molars during a pulpectomy procedure. One hundred and five volunteers from the Emergency Center of the School of Dentistry at University of São Paulo randomly received 3.6 mL of local anesthetic as a conventional inferior alveolar nerve block (IANB). The subjective signal of lip numbness, pulpal anesthesia and the absence of pain during the pulpectomy procedure were, respectively, evaluated by questioning the patient, stimulation using an electric pulp tester and a verbal analogue scale. Statistical analysis was performed using the chi-square test, Kruskal Wallis and likelihood rations. The level for significance of differences was P <= .05. All patients reported the subjective signal of lip numbness after the application of either IANB. Lidocaine showed higher values for pulpal anesthesia after the IANB (42.9%) and after injection in the periodontal ligament (61.5%). Bupivacaine presented higher values for analgesia after the IANB (80,0%) and lidocaine after injection in the periodontal ligament (92,3%). After the failure of the IANB, the pain in the pulp chamber was the most frequent to articaine and lidocaine and bupivacaine for dentin and after the failure of the periodontal ligament injection, the pain was equal to articaine in different regions, chamber, canal and dentin; for bupivacaine was greater in dentin and lidocaine was higher in the channel. However, these differences were not statistically significant. So the three local anesthetic solutions behave similarly and not present any effective pain control in the treatment of irreversible pulpitis in mandibular molars.

Vertiginous syndrome associated with incorrect anesthesia technique to block the maxillary nerve via the greater palatine canal: case report and anatomic correlation with cadaveric parts / Síndrome vertiginoso asociado a técnica anestésica incorrecta para bloquear el nervio maxilar vía canal palatino mayor: reporte de caso y correlación anatómica en piezas cadavéricas

The anesthetic technique through the greater palatine canal seeks to block the maxillary nerve in the pterygopalatine fossa and anesthetize a large area, including the pulp and periodontium of the arch in question. After applying this technique in a patient, it failed to obtain the expected result. The patient began to experience dizziness, nausea, vomiting and the sensation of fluid in the ear. She was evaluated in both the emergency room of the Hospital Parroquial de San Bernardo and at a private clinic without accurate diagnosis. Only symptomatic treatment was provided. The next day she was discharged with reduced symptoms, which disappeared completely during the day. We propose the hypothesis of a diffusion of the anesthetic solution into the middle and inner ear through the auditory tube. This diffusion would explain the vestibular symptoms and the absence of anesthesia in the expected areas. We carried out an anatomic correlation in cadavers, following the path of a needle from the palatal mucosa to the pharyngeal opening of auditory tube. We conclude that the vertiginous syndrome could be due to an incorrect application of the technique, with the needle entering the auditory tube and spreading the anesthetic solution into the middle ear.

La técnica anestésica vía canal palatino mayor tiene como objetivo abordar al nervio maxilar en la fosa pterigopalatina, anestesiando un gran territorio, incluyendo la pulpa y periodonto de la hemiarcada correspondiente. Después de haber aplicado esta técnica en una paciente y no obteniendo el resultado esperado, esta comenzó a experimentar vértigo, náuseas, sensación de líquido en el oído y vómitos. Fue evaluada en el servicio de urgencias del Hospital Parroquial de San Bernardo y en una Clínica Privada, sin lograr un diagnóstico preciso y realizando solo un tratamiento sintomático. Al día siguiente fue dada de alta con baja sintomatología, la cual desapareció totalmente durante el día. Se propone la hipótesis de una difusión del anestésico hacia el oído medio e interno mediante el tubo auditivo. Esto explicaría por un lado la sintomatología vestibular y por otro la ausencia de anestesia en los dientes y territorios esperados. Además se realizó una correlación anatómica en cadáveres, utilizando 8 hemicabezas conservadas y siguiendo el posible trayecto de la aguja desde la mucosa palatina hasta el orificio faríngeo de la tuba auditiva. Se concluyó que el síndrome vertiginoso experimentado por la paciente se pudo deber a una técnica fallida al nervio maxilar vía canal palatino mayor con ingreso de la aguja al tubo auditivo, difundiendo el anestésico hacia el oído medio.

Puede el paciente advertir cercanía al nervio dentario inferior bajo anestesia infiltrativa?: presentación de un caso clínico / Can the patient notice the proximity to mental nerve under local anesthesia?: report of a clinical case

Cuando se colocan implantes dentales en el sector posterior de la mandíbula, el profesional debe decidir si utilizar la técnica troncular o la infiltrativa. Algunos estudios afirmaron que bajo anestesia infiltrativa el paciente podría advertir al profesional a través de su dolor, la cercanía del fresado o la colocación del implante al nervio dentario inferior. En contra posición, el objetivo de esta presentación de un caso clínico es evidenciar a través de tomografías pre y post quirúrgicas,que bajo anestesia infiltrativa la paciente no refirió dolor a pesar que el implante fue colocado íntimamente en relación al conducto dentario inferior.

Análise funcional do bloqueio ciático em ratos com lidocaína associada à hialuronidase em complexação com hidroxipropil - ß-ciclodextrina e citotoxicidade / Functional analysis of rat sciatic block with lidocaine associated to hyaluronidase in complexation with hydroxypropyl- ß-cyclodextrin and cytotoxicity

O uso da enzima hialuronidase como adjuvante do anestésico local está consagrado em oftalmologia, por melhorar a eficácia anestésica devido ao seu efeito difusor de fármacos, ocasionado pela quebra temporária do hialuronan (ácido hialurônico) que é o principal constituinte de tecidos conectivos. Em odontologia, a utilização da enzima como adjuvante no bloqueio do nervo alveolar inferior não apresentou vantagens quando injetada concomitante ao anestésico local, resultando em dor e trismo. Entretanto, com a utilização de um novo protocolo onde a aplicação da hialuronidase ocorria aos 30 min do início da anestesia, prolongou o efeito anestésico e sem ocorrência de efeitos adversos. Este protocolo oferecia a vantagem de evitar complementação anestésica reduzindo os riscos de toxicidade local e sistêmica, porém ainda havia a desvantagem da necessidade de uma nova puntura para aplicação da enzima. Surgiu a hipótese de se manter os benefícios desse protocolo com o uso da hialuronidase, de prolongar a duração da ação anestésica, injetando-a concomitantemente ao anestésico local, porém estando a enzima em um sistema de liberação lenta. Deste modo, a hialuronidase (75 UTR/ml) foi incorporada a uma nanopartícula, a hidroxipropil- ß-ciclodextrina, que atrasaria sua biodisponibilidade e simularia o protocolo da injeção antes do término da ação anestésica. Assim, este trabalho teve como objetivo verificar a eficácia do complexo de inclusão hialuronidase: hidroxipropil- ß-ciclodextrina injetado concomitantemente ao anestésico local, em prolongar a duração de ação do bloqueio nervoso funcional, a fim de oferecer uma alternativa futura de solução anestésica em procedimentos clínicos demorados ou para o alívio de dor, principalmente, em pacientes com comprometimento sistêmico cuja utilização de vasoconstritor adrenérgico ou anestésico de ação prolongada esteja contraindicada.

Também foi avaliada a citotoxicidade do novo sistema carreador, o complexo de inclusão hialuronidase: hidroxipropil- ß-ciclodextrina. O bloqueio funcional sensitivo, motor e proprioceptivo do nervo ciático de ratos foi avaliado através de reflexo de retirada da pata e pinçamento, reflexo extensor tibiotarsal e claudicação, e resposta de salto. A citotoxicidade foi avaliada através do teste contagem por Azul de Tripan em fibroblastos e de hemólise em eritrócitos, ambos de rato. Os grupos onde o complexo de inclusão hialuronidase: hidroxipropil- ß-ciclodextrina foi injetado concomitantemente ao anestésico local apresentaram aumento significativo em comparação a todos os demais. O complexo de inclusão não se apresentou citotóxico, mas quando associado à lidocaína, manteve a citotoxicidade desta. Nenhum efeito hemolítico foi observado nas concentrações utilizadas para enzima, o complexo de inclusão e para a lidocaína.

The use of hyaluronidase as an adjuvant to local anesthetic is established in ophthalmology anesthesia to improve the effect of the drugs due to its spreading effect caused by a temporary break of hyaluronan (hyaluronic acid), which is the main component of connective tissue. In dentistry, the use of the enzyme as adjuvant in inferior alveolar nerve blockade was not advantageous when injected concomitantly with local anesthetic, resulting in pain and trismus. However, when the enzyme was injected before the end of nervous block, the anesthetic effect was extended and had no adverse effects. This protocol offered the advantage of avoiding anesthetic supplementation and reduces the risk of local and systemic toxicity, but there was still the disadvantage of receiving a new puncture to inject the enzyme. It has been hypothesized to maintain the benefits of this protocol with the use of hyaluronidase, to extend the duration of anesthetic action, injecting the hyaluronidase concomitantly with the local anesthetic, but the enzyme should be in a slow release system. Thus, hyaluronidase (75 TRU/ml) was incorporated into a nanoparticle, hydroxypropyl- ß-cyclodextrin, which would delay its bioavailability and simulate the protocol of the injection before the end of anesthetic action. This study aimed to determine the efficacy of inclusion complex hyaluronidase: hydroxypropyl- ß- cyclodextrin injected concomitantly with the local anesthetic to extend the duration of action of functional nervous block, to offer a future alternative of anesthetics to the clinical prolonged procedures or to relieve the pain, mainly in patients with systemic compromising whose the use of adrenergic vasoconstrictor or long-acting anesthetic are contraindicated.

The cytotoxicity of the inclusion complex hyaluronidase: hydroxypropyl- -cyclodextrin was also evaluated. The nociceptive, motor and proprioceptive functional blockade of the sciatic nerve in rats was assessed by paw withdrawal reflex and clamping (pinprick), tibiotarsal extensor reflex response and claudication, and jumping response, respectively. The cytotoxicity was assessed through cell viability test by Trypan blue counts of fibroblasts and hemolysis test, both in rat cells. Groups where the inclusion complex hyaluronidase : hydroxypropyl- ß-cyclodextrin was injected concomitantly to the local anesthetic showed a significant increase of duration of anesthetic action compared to the others. The plain inclusion complex showed no cytotoxicity, but when associated with lidocaine, the cytotoxicity of this was maintained. None haemolytic effect was observed for the concentration used to the groups hyaluronidase, inclusion complex and lidocaine.

Modeling of Recovery Profiles in Mentally Disabled and Intact Patients after Sevoflurane Anesthesia; A Pharmacodynamic Analysis

PURPOSE: Mentally disabled patients show different recovery profiles compared to normal patients after general anesthesia. However, the relationship of dose-recovery profiles of mentally disabled patients has never been compared to that of normal patients. MATERIALS AND METHODS: Twenty patients (10 mentally disabled patients and 10 mentally intact patients) scheduled to dental surgery under general anesthesia was recruited. Sevoflurane was administered to maintain anesthesia during dental treatment. At the end of the surgery, sevoflurane was discontinued. End-tidal sevoflurane and recovery of consciousness (ROC) were recorded after sevoflurane discontinuation. The pharmacodynamic relation between the probability of ROC and end-tidal sevoflurane concentration was analyzed using NONMEM software (version VII). RESULTS: End-tidal sevoflurane concentration associated with 50% probability of ROC (C50) and gamma value were lower in the mentally disabled patients (C50=0.37 vol %, gamma=16.5 in mentally intact patients, C50=0.19 vol %, gamma=4.58 in mentally disabled patients). Mentality was a significant covariate of C50 for ROC and gamma value to pharmacodynamic model. CONCLUSION: A sigmoid Emanx model explains the pharmacodynamic relationship between end-tidal sevoflurane concentration and ROC. Mentally disabled patients may recover slower from anesthesia at lower sevoflurane concentration at ROC an compared to normal patients.