YIJOM-3423; No of Pages 10

Int. J. Oral Maxillofac. Surg. 2016; xxx: xxxxxx

http://dx.doi.org/10.1016/j.ijom.2016.05.005, available online at http://www.sciencedirect.com

Systematic Review
Oral Surgery

Palatal injection for removal of E. K. Badenoch-Jones1, T. Lincoln2

1
School of Medicine, The University of
Queensland, Brisbane, Queensland,
Australia; 2Maxillofacial Department, Princess

maxillary teeth: is it required? A Alexandra Hospital, Brisbane, Queensland,

Australia

systematic review
E.K. Badenoch-Jones, T. Lincoln: Palatal injection for removal of maxillary teeth: is
it required? A systematic review. Int. J. Oral Maxillofac. Surg. 2016; xxx: xxxxxx. #
2016 International Association of Oral and Maxillofacial Surgeons. Published by
Elsevier Ltd. All rights reserved.

Abstract. There is a growing body of work examining whether a palatal injection is

necessary for the extraction of maxillary teeth with contemporary local
anaesthetics. The available literature was reviewed systematically by conducting a
search of the PubMed, EMBASE, and Cochrane CENTRAL databases for trials
examining outcomes of maxillary tooth extraction where buccal injection of local
anaesthetic only was used for one or more test groups. The selected studies were
reviewed for study type, sample size, quality, participant characteristics and
methodology, outcome variables, and findings. Fifteen studies met the inclusion
criteria. Six of the studies were randomized controlled trials. Four studies were
controlled clinical trials that did not report randomization. Five were clinical trials
that were not controlled and examined outcomes of one or more test groups. The
pain of local anaesthetic injection(s) in the test group (buccal injection only) versus
control group (buccal and palatal injection), number of cases requiring
supplemental buccal or palatal injection in cases of unsuccessful local anaesthesia,
and pain during the procedure were designated as primary outcomes. Pain on Key words: maxillary; extraction; anaesthesia;
probing of the mucosa was designated as a secondary outcome. All nine controlled palatal; oral surgery.
studies that assessed pain during the procedure found no statistically significant
difference between the test and control groups. Accepted for publication 9 May 2016

Palatal injection (infiltration and/or block)
is widely practiced for the removal of
maxillary teeth under local anaesthesia,
although it is poorly tolerated by patients
due to the rich nerve supply of the palatal
tissues and firm attachment of palatal mu-
cosa to bone.1,2 A number of techniques
are used in clinical practice to reduce the
discomfort of palatal injection, including
pressure applied to the area of needle
penetration, a fine gauge needle, conven-
tional topical anaesthetics, eutectic mix-
ture of local anaesthetic (EMLA) cream,
topical cooling of the palate (e.g. topical
ice), computerized delivery systems, and
transcutaneous electronic nerve stimula-
tion (TENS). However, the necessity of
palatal injection for maxillary tooth
extractions has been questioned by a num-
ber of authors. The purpose of this study
was to systematically review all available
trials examining outcomes of maxillary
tooth extractions using buccal injection
of local anaesthetic only.
Methods
Trials that examined any outcome of the
extraction of maxillary teeth (anterior and/
or premolar and/or molar), where one or

0901-5027/000001+010 # 2016 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Badenoch-Jones EK, Lincoln T. Palatal injection for removal of maxillary teeth: is it required? A
systematic review, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.05.005
YIJOM-3423; No of Pages 10

2 Badenoch-Jones and Lincoln

more test groups used buccal injection of

local anaesthetic only, were reviewed. In
selecting the studies for review, no restric-
tions were imposed on study participants,
e.g. health status and age. A test group was
defined as a group of participants initially
given a buccal injection of local anaes-
thetic only. A control group was defined as
a group of participants initially given both
a buccal and palatal injection of local
anaesthetic. This was regardless of the
protocol that the trial used for cases of
unsuccessful anaesthesia; some trials gave
a supplemental palatal injection in the test
and/or control group if there was unsuc-
cessful anaesthesia.
The search (Fig. 1) was designed by
the first author. The PubMed (from 1951
through June 2015), EMBASE (from
1966 through June 2015), and Cochrane
Central Register of Controlled Trials
(CENTRAL; from 1996 through June
2015) databases were used. The medical
subject headings and key words used Fig. 1. Flow chart of the article selection process.
in the search are presented in the Ap-
pendix. There were no language restric-
tions and non-English articles were Results clinical trials that were not controlled,
translated. of which four examined outcomes of
The search identified 416 studies. Thirty-
All studies generated by the search were two or more test groups with different
five studies were potentially eligible on
reviewed independently in an un-blinded protocols. All 10 controlled trials com-
the basis of title and abstract. Finally, 15
manner by both researchers (EBJ, TL). pared the test group (buccal injection of
studies met the inclusion criteria; these
The titles and abstracts were reviewed, local anaesthetic only) with a positive
were published from 2006 through 2015
followed by the full-text articles of those control (standard practice, buccal and pal-
(Fig. 1).115 One study was not in English
deemed potentially relevant, to assess the atal injection of local anaesthetic). One
and it was translated.13
eligibility of the study for inclusion study included a placebo (saline) palatal
according to the pre-defined criteria. A injection in the test group, while the others
manual search of the reference lists of administered a buccal injection of local
studies identified as potentially relevant Characteristics of studies included anaesthetic only in the test group.
in the database search was conducted. The sample size of the studies ranged from
Full-text articles were available for all 30 to 200 participants. Six studies utilized
studies included. Disagreements between Risk of bias
a parallel design, six studies utilized a
the two reviewers were resolved by dis- split-mouth design, two studies utilized Figs. 2 and 3 display the risk of bias within
cussion. a combination of split-mouth and parallel each study and across the studies, accord-
The same reviewers independently designs, and one study utilized a single test ing to each of the Cochrane Handbook
assessed the risk of bias of included stud- group only. Six of the studies were ran- criteria. Because important information
ies according to the Cochrane Handbook domized controlled trials. Four studies was often missing from the methods sec-
for Systematic Reviews of Interventions were controlled clinical trials that did tions of the studies, the risk of bias was
criteria, and disagreements were again not report randomization. Five were frequently unclear. Sequence generation,
resolved by discussion. As per the
Cochrane Handbook, a study was desig-
nated as a randomized controlled trial only
if the methods of random sequence gener-
ation were clearly described and were
considered to be adequate.
The first author independently extracted
data from those studies meeting the inclu-
sion criteria, using a standardized data
extraction form. The selected studies were
reviewed for study type, sample size, qual-
ity, participant characteristics and meth-
odology, outcome variables, and findings.
When required, investigators were con-
tacted for clarification of information or Fig. 2. Risk of bias: review authors judgements about each risk of bias item across the studies
if data were missing. included (i.e. across-study risk of bias).

Please cite this article in press as: Badenoch-Jones EK, Lincoln T. Palatal injection for removal of maxillary teeth: is it required? A
systematic review, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.05.005
YIJOM-3423; No of Pages 10
Fig. 3. Risk of bias: review authors judge-
ments about each risk of bias item for each
study included (i.e. within-study risk of bias).
allocation concealment, and blinding (par-
ticularly who was blinded) were frequent-
ly unreported. Requests for clarification of
methods and results were sent to 14 inves-
tigators and seven provided an informative
response. None of the studies reported
whether the investigators had any conflicts
of interest. Sample sizes were often small,
which is a risk for bias.
Methodology and participant
characteristics
There was substantial variation in trial
protocols, particularly with regard to the
local anaesthetic (and volume) used, how
the study design accommodated for
patients whose initial anaesthesia was un-
successful (i.e. did not accommodate, use
of supplemental buccal injection and/or
supplemental palatal injection), and the
time interval between administering local
anaesthetic, supplemental anaesthetic, and
the initiation of the procedure, as well as
the teeth extracted (region of the maxilla:
Please cite this article in press as: Badenoch-Jones EK, Lincoln T. Palatal injection for removal of maxillary teeth: is it required? A
systematic review, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.05.005
Palatal injection for removal of maxillary teeth
anterior and/or premolar and/or molar). For
this reason, the results for each outcome
variable could not be subjected to meta-
analysis. Table 1 summarizes major char-
acteristics of the studies and the patient
populations. The populations were similar
with respect to age and health status.
Tooth number(s) and impaction status
Five studies included erupted maxillary
teeth and did not report any exclusions.
Two studies excluded the third molar tooth
only. One study involved only the incisor
teeth. Two studies included premolar teeth
only and one study included premolar and
molar teeth only. Four studies included
only the third molar tooth.
Local anaesthetic
Five studies used lignocaine for buccal
injection in the test and control groups.
Three used articaine in the test and control
groups. Two studies (Luqman et al.3 and
Somuri et al.8) compared articaine in the
test group with lignocaine in the control
group. The remaining studies were not
controlled.
In all controlled trials except the ones
by Badcock et al.14 and Peng et al.,13 the
local anaesthetic used for palatal injection
in the control group was the same as the
local anaesthetic used for buccal injection
in that group. In all trials that utilized a
jection required supplemental palatal
supplemental palatal injection for test and/
or control groups in cases of unsuccessful
anaesthesia, the local anaesthetic used for
supplemental palatal injection was the
same as the local anaesthetic used for
buccal injection in that group.
Extraction technique
Eight studies utilized a non-surgical extrac-
tion technique (forceps and/or elevators).
Four studies did not report the extraction
technique; it was assumed to be non-surgi-
cal in these studies. Two studies utilized a
surgical technique with a mucoperiosteal
flap, extraction, and sutures. One study
included both surgical and non-surgical
procedures, although it did not utilize
sutures for the surgical procedures. Those
studies involving surgical procedures were
for the extraction of third molars.
Primary outcome variables
Requirement for supplemental buccal or
palatal injection
Badcock et al.14 and Fan et al.10 utilized a
similar protocol and were the only studies
3
to employ a supplemental buccal injection
to accommodate for patients in whom
initial anaesthesia was ineffective (Table
2). In both trials, if the patient experienced
unacceptable pain/discomfort during the
procedure (which began 5 min after initial
local anaesthetic), a supplemental buccal
injection was administered. If the pain/
discomfort persisted after an additional
5 min, a supplemental palatal injection
was given. Badcock et al. found that more
patients in the test group compared to the
control group required supplemental buc-
cal injection (P = 0.06). Fan et al. found no
evidence for an effect (P = 0.683).
Ten studies, including those by Bad-
cock et al.14 and Fan et al.,10 examined
the requirement for supplemental palatal
injection (Table 3). None of these studies
reported a P-value comparing test and
control groups, although two studies
reported a P-value comparing different
test groups.
Lima et al.,7 Lima-Junior et al.,11 and
Isik et al.9 utilized similar protocols. In the
studies by Lima et al. and Lima-Junior
et al., a supplemental palatal injection was
offered at each surgical phase (flap, ex-
traction, suture) if the patient experienced
pain during the procedure. In both studies,
some patients with mild pain during the
suturing phase declined supplemental pal-
atal injection. Lima et al. found that
patients who received 4% articaine hydro-
chloride + 1:100,000 adrenaline buccal in-
injection less often than patients who re-
ceived 4% articaine hydrochlo-
ride + 1:200,000 adrenaline (P = 0.01).
Lima-Junior et al. found that patients
who received 4% articaine hydrochlo-
ride + 1:100,000 adrenaline buccal injec-
tion and had extraction 10 min after initial
local anaesthetic required supplemental
palatal injection less often than patients
who received the same local anaesthetic
and had extraction after 5 min (P < 0.01),
and less often than patients who received
4% articaine hydrochloride + 1:200,000
adrenaline buccal injection and had ex-
traction after 5 min (P < 0.01) or 10 min
(P < 0.01). The protocol of Isik et al. was
to utilize a supplemental palatal injection
if there was unacceptable pain during the
procedure (defined as greater than mild
pain); the study examined outcomes of a
single test group and found that none of
the patients required a supplemental pala-
tal injection.
Five studies administered a supplemen-
tal palatal injection if there was pain on
probing of the palatal, or buccal and pala-
tal, mucosa. Probing of the tissues was
performed at different time intervals after
 4

YIJOM-3423; No of Pages 10
Table 1. Characteristics of the studies included.
systematic review, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.05.005
Please cite this article in press as: Badenoch-Jones EK, Lincoln T. Palatal injection for removal of maxillary teeth: is it required? A

Extraction Age

Badenoch-Jones and Lincoln

Participants technique/time (mean (SD)
Participants (health between LA and Age range or median) Impaction
Study Year Country Design (n) Sex (n) status) Protocol extraction (years) (years) status/teetha
Luqman 2015 Pakistan Parallel 194 F: 113 Healthy Test: 1.7 ml of 4% Elevators or forceps/ 2060 Mean: 41.1 Erupted/Mx
et al.3 M: 81 AH + 1:200,000 AD via BI; depending on time (13.6)
if required, SPI 0.20.4 ml of to anaesthesia on
same LA repeated until probing of palatal
anaesthesia mucosa
Control: 1.0 ml of 2%
LH + 1:100,000 AD via BI
and 0.20.4 ml via PI; if
required, SPI 0.20.4 ml of
same LA repeated until
anaesthesia
Kumaresan 2015 Malaysia Parallel 150 F: 83 Healthy Test: 1.5 ml 2% Non-surgical/ 1550 Median: Erupted/A,
et al.4 M: 67 LH + 1:80,000 AD via BI; if depending on time 35.9 P, M1, M2
required, SPI 0.3 ml of same to anaesthesia on
LA probing of palatal
Control: 1.5 ml 2% mucosa
LH + 1:80,000 AD via
BI + 0.3 ml via PI
Darawade 2014 India Split-mouth 50 NR Healthy Test 1: 0.51.0 ml of 4% Forceps/time NR 1525 NR Erupted/P
et al.5 AH + 1:100,000 AD via BI;
if required, SPI 0.5 ml of
same LA
Test 2: 0.81.0 ml of 2%
LH + 1:100,000 AD via BI; if
required, SPI 0.5 ml of same
LA
Sharma 2014 India Split-mouth 80 F: 43 Healthy Test 1: 1.8 ml 2% NR/6 min (TG1/ 1867 Mean: Erupted P/M
et al.6 M: 37 LH + 1:100,000 AD via BI; if TG2) 38.7 (12.7)
required, SPI (volume NR) of
same LA
Test 2: 0.9 ml 4%
AH + 1:100,000 AD via BI;
if required, SPI (volume NR)
of same LA
Lima 2013 Brazil Parallel 30 NR NR Test 1: 1.8 ml 4% Surgical 1546 NR Partially
et al.7 AH + 1:100,000 AD via BI (mucoperiosteal impacted/M3
Test 2: 1.8 ml 4% flap, tooth elevation,
AH + 1:200,000 AD via BI sutures)/5 min
(TG1/TG2)
Somuri 2013 India Split-mouth 30 F: 19 No severe Test: 1.7 ml 4% Forceps/time NR 1030 Mean: Erupted/P
et al.8 M: 11 systemic AH + 1:100,000 AD via BI 17.73 (4.30)
disease Control: 1.75 ml 2%
LH + 1:100,000 AD via
BI + 0.25 ml via PI
 YIJOM-3423; No of Pages 10
Yadav 2013 India Parallel 200 F: 79 No severe Test: 2.0 ml 2% Elevation + forceps/ NR Mean Erupted/M3
systematic review, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.05.005
Please cite this article in press as: Badenoch-Jones EK, Lincoln T. Palatal injection for removal of maxillary teeth: is it required? A

et al.2 M: 121 systemic LH + 1:200,000 AD via BI 5 min (TG/CG) Test:

disease Control: 1.75 ml 2% 35.2 (NR)
LH + 1:200,000 AD via BI Control
and 0.25 ml via PI NR (NR)
Isik 2011 Turkey NA 45 NR NR Test: 1.7 ml 4% Non-surgical/6 min 1576 NR Erupted/A,
et al.9 AH + 1:100,000 AD via BI; P, M1, M2
if required, SPI 0.3 ml of
same LA
Sekhar 2011 India Parallel 100 F: 63 No severe Test: 2.0 ml 2% Elevation + forceps/ NR Mean Erupted/Mx
et al.1 M: 37 systemic LH + 1:80,000 AD via BI 8 min (TG/CG) Test: 40.21
disease Control: 1.75 ml 2% (13.86)
LH + 1:80,000 AD via Control:
BI + 0.25 ml via PI 36.40 (11.86)
Fan 2009 China Split-mouth 71 F: 33 No severe Test: 1.7 ml of 4% Elevator or forceps/ 1867 Mean: Erupted/Mx
et al.10 M: 38 systemic AH + 1:100,000 AD via BI; 5 min (TG/CG) 25.37 (NR)
disease if required, SBI 1.7 ml of
same LA; if required, SPI
0.4 ml of same LA
Control: 1.7 ml of 4%
AH + 1:100,000 AD via
BI + 0.4 ml via PI; if
required, SBI 1.7 ml of same
LA; if required, SPI 0.4 ml of
same LA
Lima-Junior 2009 Brazil Split-mouth 100 NR NR Test 1A: 1.8 ml 4% Surgical (incision, 1546 NR Impacted/M3
et al.11 AH + 1:100,000 AD via BI; extraction, suture)/
if required, SPI 0.6 ml of 5 min (TG1A,
same LA TG2A), 10 min
Test 1B: 1.8 ml 4% (TG1B, TG2B)

Palatal injection for removal of maxillary teeth

AH + 1:100,000 AD via BI;
if required, SPI 0.6 ml of
same LA
Test 2A: 1.8 ml 4%
AH + 1:200,000 AD via BI;
if required, SPI 0.6 ml of
same LA
Test 2B: 1.8 ml 4%
AH + 1:200,000 AD via BI;
if required, SPI 0.6 ml of
same LA
Lassemi 2008 Iran Parallel 60 Test: F: 16 NR Test: 1.8 ml of NR/time NR NR Mean Test: Erupted/I
et al.12 M: 14 LH + 1:80,000 AD via BI; if 44.2 (NR)
Control: (NR) required, SPI (volume NR) Control:
Control: LH + 1:80,000 AD (NR)
via BI (volume NR) + via PI
(volume NR)

5
YIJOM-3423; No of Pages 10

6 Badenoch-Jones and Lincoln

AD, adrenaline; AH, articaine hydrochloride; BI, buccal injection; CG, control group (buccal and palatal injection); F, female; LA, local anaesthetic; LH, lignocaine hydrochloride; M, male; NA, not
M3 (erupted,
status/teetha

erupted, and
Erupted/Mx

Erupted/Mx
initial local anaesthetic in the different
Impaction

unerupted)
trials (Luqman et al.3: 5 min (test group),

partially
2 min (control group); Kumaresan et al.4:
10 min (test group and control group);
Sharma et al.6: 5 min (test group 1 and

Mean (adult):

Mean (child):
test group 2); Lassemi et al.12: time inter-
(mean (SD)
or median)

Median: 24
val not reported; Darawade et al.5: time
(years)

42.4 (NR)

10.5 (NR)
Age

interval not reported). In the trial by

Mean:

41.54
(NR)
Sharma et al., a supplemental palatal in-
jection was only administered if the pain

applicable; NR, not reported; PI, palatal injection; SBI, supplemental buccal injection; SPI, supplemental palatal injection; TG, test group (buccal injection only).
on probing was greater than 54 on a 170-
Age range

1848 + 4
(years)

children
unit visual analogue scale (VAS). In the

Mx: all maxillary teeth; A: anterior teeth (incisors and canines); P: premolars; M: molars (M1 first molar, M2 second molar, M3 third molar); I: incisors.
1856

1864

three controlled studies, patients in the test

group required a supplemental palatal in-
jection more frequently than patients in
removal, no suture)/

NR/5 min (TG/CG)

the control group, although P-values were
between LA and

surgical + surgical
technique/time

(mucoperiosteal

not reported. For the non-controlled trials,

5 min (TG/CG)
Extraction

extraction

Sharma et al. found that patients who

flap  bone
NR/5 min

received 2% lignocaine hydrochlo-

ride + 1:100,000 adrenaline buccal injec-
Non-

tion required a supplemental palatal

injection much more frequently than
patients who received 4% articaine hydro-
BI + 0.2 ml normal saline via
PI; if required, SBI 2.2 ml of

required, SBI 2.2 ml of same

BI + 0.2 ml 2% LH (without
(vasoconstrictor NR) via PI
AH + 1:100,000 AD via BI

AH + 1:100,000 AD via BI
LA as BI; if required, SPI
same LA; if required, SPI

chloride + 1:100,000 adrenaline buccal in-

vasoconstrictor) via PI; if

0.2 ml of same LA as BI
AH + 1:100,000 AD via

AH + 1:100,000 AD via
BI + 0.25 ml of 2% LH

Control: 1.75 ml of 4%
jection (P-value not reported). Similarly
LH + 1:80,000 AD via

LH + 1:80,000 AD via
Control: 1.7 ml of 4%

Darawade et al. found that all patients who

Control: 2.2 ml 2%

BI + 0.25 ml via PI
0.2 ml of same LA
Test: 1.7 ml of 4%

Test: 2.0 ml of 4%
Protocol

received 2% lignocaine hydrochlo-

Test: 2.2 ml 2%

ride + 1:100,000 adrenaline buccal injec-

tion required a supplemental palatal
injection, whereas none of the patients
who received 4% articaine hydrochlo-
ride + 1:100,000 adrenaline buccal injec-
tion required a supplemental palatal
Participants

No severe

injection.
(health
status)

systemic
Healthy

disease
NR

Pain during the procedure

Seven studies reported pain during the
procedure as a continuous variable (Table
4), although the study by Luqman et al.
Sex (n)

M: 55

M: 17

M: 28

included in their results the patients in the

F: 49

F: 34

F: 25

test group who had received a supplemen-

tal palatal injection and therefore the
Participants

results for this study should be interpreted

with caution.3 It did not find evidence for
(n)

an effect of palatal injection for the ex-

104

51

53

traction of teeth in the anterior, premolar,

or molar maxillary regions. For the other
Split mouth +

Split mouth +

six studies, the data did not include

Split-mouth
Design

patients given a supplemental palatal in-

parallel

parallel

jection. None of the six controlled trials

found strong evidence for an effect of
palatal injection, while the non-controlled
trial examined outcomes of a single test
Australia
Country

Turkey

group and found a very low mean pain

China

level.
Five studies reported pain during the
Table 1 (Continued )

2008

2007

2006

procedure as a dichotomous variable and

Year

did not include patients given a supple-

mental palatal injection prior to recording
of the outcome (Table 4). Three were
et al.13

et al.14

et al.15
Badcock

controlled studies. Although the precise

Uckan
Study
Peng

P-values were not reported, all three stud-

a

ies found that the difference between the

Please cite this article in press as: Badenoch-Jones EK, Lincoln T. Palatal injection for removal of maxillary teeth: is it required? A
systematic review, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.05.005
YIJOM-3423; No of Pages 10

Palatal injection for removal of maxillary teeth 7

Table 2. Patients requiring supplemental buccal anaesthesia. of the palatal mucosa (as a dichotomous
Study Test (incidence) Control (incidence) P-value (test vs. control) outcome) to determine the need for a
supplemental palatal injection. These
Badcock et al.14 7/51 2/51 0.06
Fan et al.10 3/71 2/71 0.683 results are discussed in the text above
relating to Table 3; the time interval be-
tween initial anaesthesia and probing of
Table 3. Patients requiring supplemental palatal anaesthesia. the mucosa is also reported in this text. In
P-value addition to reporting this pain as a dichot-
Control (test vs. omous outcome, as per Table 3, the study
Study Test (incidence) (incidence) control) by Sharma et al., which compared two test
SPI according to pain of procedure (non-surgical) groups, also reported the outcome as a
Fan et al.10 0/71 0/71 NA continuous variable on a 170-mm VAS.6
Isik et al.9 0/45 No control groupa NA Very strong evidence was found that there
is less pain on probing of the mucosa
SPI according to pain of procedure (surgical and non-surgical cases)
Badcock et al.14 0/51 0/51 NA following the administration of 4% arti-
caine hydrochloride + 1:100,000 adrena-
SPI according to pain of procedure (surgical) line buccal injection (33.0/170 (21.1))
Lima et al.7 Test 1: 0/15 No control groupa NA compared to 2% lignocaine hydrochlo-
Test 2: 3/15
ride + 1:100,000 adrenaline buccal injec-
(P = 0.01)
Lima-Junior et al.11
Test 1A: 7/50 No control groupa NA tion (128.9/170 (19.2)) (P < 0.001).
Test 1B: 1/50 Somuri et al. (probing 6 min after initial
(P < 0.01 compared to all other TGs) local anaesthetic) assessed pain on prob-
Test 2A: 11/50 ing of the mucosa without reporting that it
Test 2B: 9/50 was used to assess the necessity for sup-
SPI according to pain on probing of mucosa (non-surgical) plemental palatal injection.8 They
Kumaresan et al.4 14/75 0/75 NR reported that all patients in the test group
Luqman et al.3 16/100 0/94 NR and control group had no pain on probing
Sharma et al.6 Test 1: 80/80 No control groupa NA of the mucosa (test group 0/30, control
Test 2: 5/80 group 0/30).
Lassemi et al.12 7/30 5/30 NR
Darawade et al.5 Test 1: 0/50 No control groupa NA
Test 2: 50/50 Other
NA, not applicable; NR, not reported; SPI, supplemental palatal injection; TG, test group. Two studies reported the time taken to
a
No control group: the study included test group(s) with different protocols only and did not achieve anaesthesia (according to probing
include a control group. of the mucosa), the results of which
depended heavily on the study protocol
(particularly time to administration of sup-
test and control groups was non-significant. An operator judged the pain level accord- plemental palatal injection). In the trial by
Two studies were not controlled and com- ing to the facial expressions of the patient. Kumaresan et al., supplemental palatal in-
pared test groups with different protocols. All found no evidence for an effect of jection (if required) was administered at
Lima et al. found that patients who received palatal injection (Table 5). 10 min.4 Time to achieve palatal anaesthe-
4% articaine hydrochloride + 1:100,000 sia (in min) was considerably greater for the
adrenaline via buccal injection had no pain test group than the control group, although
during the procedure, whereas a third of Pain of injection(s) a P-value was not reported (anterior region:
those who received 4% articaine hydro- Four studies examined the difference in test group 7.10 (1.4), control group 1.72
chloride + 1:200,000 adrenaline via buccal pain of local anaesthetic injections between (0.7); premolar region: test group 7.80
injection had pain during the procedure (P- test and control groups, although only two (1.2), control group 1.68 (0.7); molar re-
value not reported).7 Lima-Junior et al. studies reported the results. Of the latter two gion: test group 8.8 (0.9), control group
found that patients who received 4% arti- studies, neither included in their results 1.40 (0.5)). In the study by Darawade
caine hydrochloride + 1:100,000 adrena- those patients who had a supplemental pal- et al., the protocol was not expounded
line via buccal injection and had atal injection. Not surprisingly, given that sufficiently (including time to administra-
extraction after 10 min experienced pain palatal injection is known to be particularly tion of supplemental palatal injection not
during the procedure less often than painful, both studies found strong evidence reported) to interpret the results.5
patients who received the same local anaes- for an effect of palatal injection on pain of Other outcome variables reported in the
thetic and had extraction after 5 min (P- local anaesthetic injection(s) between the studies included were volume of local
value not reported), and less often than test and control groups (Table 6). anaesthetic required to achieve anaesthesia
patients who received 4% articaine hydro- (one study), duration of anaesthesia (one
chloride + 1:200,000 adrenaline via buccal study), and vital signs and electrocardio-
injection and had extraction after 5 min (P- Secondary outcome variables gram before and after local anaesthetic (one
value not reported) or 10 min (P-value not study). For the former two outcomes, the
Pain on probing of mucosa
reported).11 protocols were not expounded sufficiently
Three controlled studies reported pain Six studies assessed pain on probing of the to interpret the results; the latter outcomes
during the procedure using a faces pain palatal, or buccal and palatal, mucosa. were not considered relevant to the research
scale (continuous) in addition to a VAS. Five of these studies used pain on probing question in this review.

Please cite this article in press as: Badenoch-Jones EK, Lincoln T. Palatal injection for removal of maxillary teeth: is it required? A
systematic review, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.05.005
YIJOM-3423; No of Pages 10

8 Badenoch-Jones and Lincoln

Table 4. Pain during the procedure.

Reported as a continuous variable
Study Units Test, mean (SD) Control, mean (SD) P-value (test vs. control)
Data include patients with SPI
Luqman et al.3 VAS, 10 cm Anterior: 3.77 (1.79) Anterior: 4.28 (1.49) Anterior: 0.2
Premolars: 3.54 (1.75) Premolars: 4.14 (1.57) Premolars: 0.2
Molars: 3.83 (1.67) Molars: 3.82 (1.44) Molars: 0.9
Data do not include patients with SPI
Sekhar et al.1 VAS, 100 mm 6.41 (3.37) 6.00 (2.90) 0.584
Kumaresan et al.4 VAS, 11 units (faces pain scale) 0.61 (NR) 0.39 (NR) 0.071
Yadav et al.2 VAS, 100 mm 5.30 (11.71) 4.82 (9.72) 0.75
Badcock et al.14 VAS, 135 mm 14.6 (17.7) 12.1 (20.8) 0.18
9
Isik et al. VAS, 10 units 0.18 (0.44) No control groupa NA
Anterior: 0.13 (0.35)
Premolars: 0.13 (0.35)
Molars: 0.27 (0.59)
Fan et al.10 VAS, 100 mm 14.68 (6.72) 12.82 (5.16) 0.066
Reported as a dichotomous variable (data do not include patients with SPI prior to recording of the outcome)
Study Definition Test Control P-value (test vs. control)
Lima et al.7 Number with pain Test 1: 0/15 No control groupa NA
Test 2: 5/15
Lima-Junior et al.11 Number with pain Test 1A: 11/50 No control groupa NA
Test 1B: 3/50
Test 2A: 16/50
Test 2B: 14/50
Somuri et al.8 Number with pain 3/30 0/30 NS (value NR)

Peng et al.13 Number with pain 4/104 3/104 >0.05

defined as VAS
410/10 (no pain
defined as 03/10)
Uckan et al.15,b Percentage with pain 6.4% 4.6% >0.05
NA, not applicable; NR, not reported; NS, not significant; SD, standard deviation; SPI, supplemental palatal injection; VAS, visual analogue scale.
a
No control group: the study included test group(s) with different protocols only and did not include a control group.
b
The success rate reported by Uckan et al. was interpreted by the authors of this review as the percentage of participants in the test group and
control group with no pain. This was converted to the percentage of patients in the test group and control group with pain (as the number of
participants with pain could not be determined).

Table 5. Pain during the procedure: faces pain scale.

Study Units Test, mean (SD) Control, mean (SD) P-value (test vs. control)
Data include patients with supplemental palatal anaesthesia
Luqman et al.3 6 units 0.43 (0.82) 0.54 (1.01) 0.864
Data do not include patients with supplemental palatal anaesthesia
Sekhar et al.1 11 units 0.31 (0.46) 0.28 (0.46) 0.803
Yadav et al.2 11 units 0.98 (1.79) 0.80 (1.50) 0.44
SD, standard deviation.

Table 6. Pain of injection.

Study Units Test, mean (SD) Control, mean (SD) P-value (test vs. control)
Kumaresan et al.4 11-unit FPS 0.91 (NR) 3.03 (NR) <0.05
Fan et al.10 100-mm VAS 25.73 (7.84) 37.70 (6.43) <0.01
FPS, faces pain scale; NR, not reported; SD, standard deviation; VAS, visual analogue scale.

Please cite this article in press as: Badenoch-Jones EK, Lincoln T. Palatal injection for removal of maxillary teeth: is it required? A
systematic review, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.05.005
YIJOM-3423; No of Pages 10
Outcome variables according to region of
maxilla (anterior to posterior)
The success of anaesthetizing the palatal
tissues with buccal injection depends only
on the diffusion of local anaesthetic across
the buccalpalatal cortical bone distance,
which increases going anteriorly to poste-
riorly in the mouth.4 Kumaresan et al.
found that supplemental palatal injection
(according to pain on probing of the mu-
cosa) was more often required in the test
group for posterior teeth than anterior
teeth (anterior teeth: 0/12; premolars: 2/
25; molars: 12/25; P-value not reported).4
Sharma et al. compared the requirement
for supplemental palatal injection (accord-
ing to pain on probing of the mucosa)
between premolar and molar teeth in the
test group and the difference was less than
that reported by Kumaresan et al. (pre-
molars: 0/29; molars: 5/51; P-value not
reported).6
Luqman et al.3 and Isik et al.9 reported
pain during the procedure for anterior,
premolar, and molar groups (Table 4; P-
values between regions not reported).
Compared to the results found for pain
on probing of the mucosa, there was little
difference found for pain during the pro-
cedure according to the region of the
maxilla in the test group. Readers should
note the pre-mentioned caveat in interpret-
ing the results of Luqman et al.
Discussion
In clinical practice, the relevant question is
the cost versus benefit of the intervention,
i.e. the pain of palatal injection (cost)
versus the pain that it eliminates during
the procedure (benefit). Most studies con-
sidered only whether there was a benefit
from the intervention. Two studies
reported the cost and benefit of the inter-
vention separately (as per outcomes of
pain of local anaesthetic injection(s) and
pain during the procedure as above).
The trial by Badcock et al. considered
the net benefit, which was defined as the
difference (on a VAS) in the pain of the
procedure between the test and control
groups (i.e. the benefit or additional pain
in the test group), less the pain (on a VAS)
of the palatal injection (i.e. the cost).14
They reported a mean VAS net benefit of
45.45 (30.38) mm with a 95% confi-
dence interval of 58.5 to 32.3 mm
on a 135-mm VAS (i.e. palatal injection
is more painful than the relief from the
injection). The validity of this measure-
ment depends on the relative weight that
patients place on the cost and benefit.
Generally, palatal injection lasts for a brief
Please cite this article in press as: Badenoch-Jones EK, Lincoln T. Palatal injection for removal of maxillary teeth: is it required? A
systematic review, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.05.005
Palatal injection for removal of maxillary teeth 9
period compared to the time required for and articaine hydrochloride using the
extraction and therefore the elimination of same protocol, as this would allow for
pain for the latter may be more important direct comparison between these two
to the patient. This is not accounted for by agents.
the net benefit calculation of Badcock
et al. However, of interest in that study,
Funding
which was limited to third molars, 85/102
extractions were completed in less than No funding.
1 min. Thus, their net benefit measure-
ment may be valid for their trial, while the
Conflict of interest
weight given to cost versus benefit may
need to be adjusted for a trial where the No conflicts of interest.
average time for extraction is much lon-
ger.
Ethical approval
Fan et al. did not calculate the differ-
ence in cost and benefit, although the pain Not required.
of palatal injection can be calculated from
their report as 11.57 mm (on a 100-mm
Patient consent
VAS) and the benefit from palatal injec-
tion calculated as 1.86 mm (also on a 100- Not required.
mm VAS).10 Thus palatal injection was
found to be more painful than relief from
Acknowledgement. Wenxin Cai for trans-
the injection. This is consistent with the
lation of a non-English article.
results reported by Badcock et al., al-
though the mean extraction time (affecting
weight of cost versus benefit) was not
reported. Appendix. Search strategyPubMed
This review has summarized the grow- (1951 through June 2015)
ing body of objective evidence addressing
the research question of whether a palatal
injection is necessary for the extraction of Palate [Mesh]
maxillary teeth with contemporary local palat*
anaesthetics. The variation in study meth- #1 OR #2
ods meant that the results could only be Anaesthesia [Mesh] OR Injections [Mesh]
interpreted within the framework of the anaesthe* OR anesthe* OR injection* OR
protocol of the particular study; thus, the infiltration
#4 OR #5
results for each outcome variable could
not be used to perform a meta-analysis. Tooth [Mesh]
molar* OR tooth OR teeth
However, it was found that all nine con-
#7 OR #8
trolled studies examining pain during the #3 AND #6 AND #9
procedure found no statistically significant
difference between the test and control Search strategyEMBASE (1966
groups. through June 2015)
palate/exp AND [embase]/lim
More randomized controlled trials, par- palat*
ticularly with larger sample sizes and sim- #1 OR #2
ilar protocols, are necessary to further dental anaesthesia/exp AND [embase]/lim
examine this question, which is relevant injection/exp AND [embase]/lim
to the everyday practice of oral surgery anaesthe* OR anesthe* OR injection* OR
procedures, both by general dentists and infiltration
oral and maxillofacial surgeons. The #4 OR #5 OR #6
authors of this paper support trials that tooth/exp AND [embase]/lim
employ the methodology used by Badcock molar* OR tooth OR teeth
#8 OR #9
et al.,14 particularly on the following
#3 AND #7 AND #10 AND [humans]/lim
points: the use of saline palatal injection
as the control, determining unsuccessful Search strategyCochrane CEN-
anaesthesia by pain during the procedure TRAL (1996 through June 2015)
MeSH descriptor: [Palate] explode all trees
rather than by probing of the mucosa (the palat*
former directly addresses the research #1 OR #2
question), and the protocol utilized for MeSH descriptor: [Anaesthesia, Dental] ex-
cases of failed initial anaesthesia (supple- plode all trees
mental buccal injection and if unsuccess- MeSH descriptor: [Injections] explode all
ful after 5 min, supplemental palatal trees
injection). Further, it is suggested that anaesthe* OR anesthe* OR injection* OR
trials compare lignocaine hydrochloride infiltration
YIJOM-3423; No of Pages 10
10 Badenoch-Jones and Lincoln
#4 OR #5 OR #6
MeSH descriptor: [Tooth] explode all trees
molar* or tooth or teeth
#8 OR #9
#3 AND #7 AND #10
trials
References
1. Sekhar GR, Nagaraju T, KolliGiri. Nanda-
gopal V, Sudheer R, Sravan. Is palatal injec-
tion mandatory to extraction of permanent
maxillary tooth: a preliminary study. Indian
J Dent Res 2011;22:1002.
2. Yadav S, Verma A, Sachdeva A. Buccal
injection of 2% lidocaine with epinephrine
for the removal of maxillary third molars.
Anesth Prog 2013;60:958.
3. Luqman U, Janjua OS, Ashfaq M, Irfan H,
Mushtag S, Bilal A. Comparison of articaine
and lignocaine for uncomplicated maxillary
exodontia. J Coll Phys Surg Pak
2015;25:1814.
4. Kumaresan R, Srinivasan B, Pendayala S.
Comparison of the effectiveness of lidocaine
in permanent maxillary teeth removal per-
formed with single buccal infiltration versus
routine buccal and palatal injection. J Max-
illofac Oral Surg 2015;14:2527.
5. Darawade DA, Kumar S, Budhiraja S, Mittal
M, Mehta TN. A clinical study of efficacy of
4% articaine hydrochloride versus 2% lig-
nocaine hydrochloride in dentistry. J Int Oral
Health 2014;6:813.
Please cite this article in press as: Badenoch-Jones EK, Lincoln T. Palatal injection for removal of maxillary teeth: is it required? A
systematic review, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.05.005
6. Sharma K, Sharma A, Aseri M, Batta A,
Singh V, Pilania D, Kumar Sharma Y. Max-
illary posterior teeth removal without palatal
injectiontruth or myth: a dilemma for oral
surgeons. J Clin Diagn Res 2014;8:ZC014.
7. Lima Jr JL, Dias-Ribeiro E, Ferreira-Rocha
J, Soares R, Costa FW, Fan S, Santana E.
Comparison of buccal infiltration of 4%
articaine with 1:100,000 and 1:200,000 epi-
nephrine for extraction of maxillary third
molars with pericoronitis: a pilot study.
Anesth Prog 2013;60:425.
8. Somuri AV, Rai AB, Pillai M. Extraction of
permanent maxillary teeth by only buccal
infiltration of articaine. J Maxillofac Oral
Surg 2013;12:1302.
9. Isik K, Kalayci A, Durmus E. Comparison of
depth of anesthesia in different parts of
maxilla when only buccal anesthesia was
done for maxillary teeth extraction. Int J
Dent 2011;2011:575874.
10. Fan S, Chen WL, Yang ZH, Huang ZQ.
Comparison of the efficiencies of permanent
maxillary tooth removal performed with sin-
gle buccal infiltration versus routine buccal
and palatal injection. Oral Surg Oral Med
Oral Pathol Oral Radiol Endodontol
2009;107:35963.
11. Lima-Junior JL, Dias-Ribeiro E, de Araujo
TN, Ferreira-Rocha J, Honfi-Junior ES, Sar-
mento CF, Seabra FR, de Sousa Mdo S.
Evaluation of the buccal vestibulepalatal
diffusion of 4% articaine hydrochloride in
impacted maxillary third molar extractions.
Med Oral Patol Oral Cir Bucal
2009;14:E12932.
12. Lassemi E, Motamedi MH, Jafari SM,
Talesh KT, Navi F. Anaesthetic efficacy of
a labial infiltration method on the nasopala-
tine nerve. Br Dent J 2008;205:E21.
13. Peng M, Zhu ZM, Yang XM. Feasibility of
permanent maxillary tooth removal using
articaine anesthesia without palatal injec-
tion. Hua Xi Kou Qiang Yi Xue Za Zhi
2008;26:4168.
14. Badcock ME, Gordon I, McCullough MJ. A
blinded randomized controlled trial compar-
ing lignocaine and placebo administration to
the palate for removal of maxillary third
molars. Int J Oral Maxillofac Surg
2007;36:117782.
15. Uckan S, Dayangac E, Araz K. Is permanent
maxillary tooth removal without palatal in-
jection possible. Oral Surg Oral Med Oral
Pathol Oral Radiol Endodontol
2006;102:7335.
Address:
Emma Kate Badenoch-Jones
School of Medicine
The University of Queensland
Brisbane
Queensland
Australia
Tel: +61 4 14 907 869
E-mail:
emma.badenochjones@uqconnect.edu.au