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Original Article

Buccal Infiltration versus Inferior Alveolar Nerve Block in Mandibular

2nd Premolars with Irreversible Pulpitis
K Yılmaz, U Tunga1, T Özyürek1

Çorum Oral and Dental
Health Center, Çorum,
1
Department of Endodontics,
acult of entistr ,
Ondokuz Mayis University,
Samsun, Turkey
Purpose: The purpose of this study is to compare the success rates of inferior
Abstract
alveolar nerve block B an buccal infiltration anest esia of man ibular
second premolar with irreversible pulpitis and to evaluate the level of patient
iscomfort it t ese met o s. Matherials and Methods: ort atients, o
had irreversible pulpitis in the mandibular 2nd premolar teeth, were included in
t e stu . atients ere ran oml istribute in t o rou s. n one rou B,
in t e ot er rou buccal infiltration anest esia ere erforme . e efficac of
t ese t o ifferent anest esia tec ni ues on t e relate teet as investi ate it
t e eft arker visual analo scale. n a ition, it a ulse o imetr evice,
t e c an es in t e atients eart rates ere com are bet een t e rou s. e
obtaine ata ere evaluate statisticall . Results: Bot anest esia tec ni ues
re uce t e ain si nificantl in atients before t e a ministration P . , but
t ere as no si nificant ifference amon t e rou s re ar in t e ain control
and success rates of anesthesia (P . . Bot of t e anest esia tec ni ues
increased the heart rate (P . . e increase in t e eart rate of t e atients
as si nificantl i er in t e buccal infiltration anest esia rou t an t e ot er
anesthesia group (P . . Conclusion: it in t e limitation of t is in vivo
stu , t ere as no ifference bet een t e efficacies of t e buccal infiltration
anesthesia and IANB anesthesia in the mandibular 2nd premolar teeth with
irreversible ul itis. Buccal infiltration anest esia cause more iscomfort in t e
atients com are it t e B urin t e a ministration.

Date of Acceptance: Keywords: Efficacy of the anesthesia, Heft–Parker visual analog scale,
12-Jul-2017 infiltration anesthesia, pulse oximetry

Introduction in dentistry for >20 years, and it is considered a good

S uccessful anesthesia is one of the most important
com onents of en o ontic treatment. ffective
pain control decreases the possible fear and anxiety of
atients ue to en o ontic treatment.[1] n ammation
in teeth with irreversible pulpitis leads to hyperalgesia
in patients and negatively affects the success of local
anesthesia performed during emergency endodontic
treatment.[2] s a result of in ammation, t e so ium
channels of nociceptors are four times more resistant to
local anest esia t an ealt nerve fibrils.[3]
or anest esia of teet it irreversible ul itis, various
anest esia tec ni ues an anest etic solutions ave been
utilize .[4] Articaine has been used as a local anesthetic
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alternative to lidocaine for healthy teeth and for patients
it s m tomatic ul itis.[5] A previous study reported
that in healthy mandibular teeth, a 4% articaine solution
containin : . e ine rine as better in ensurin
pulpal anesthesia than a 2% lidocaine solution containing
: . e ine rine.[6]
Anesthesia of the second mandibular premolar and
molar teeth is generally performed through inferior
alveolar nerve block B anest esia. o ever, B
Address for correspondence: Dr. K Yılmaz,
Çorum Oral and Dental Health Center, Çorum, Turkey.
E-mail: koray1903@hotmail.com
This is an open access article distributed under the terms of the Creative Commons
Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak,
and build upon the work non-commercially, as long as the author is credited and the new
creations are licensed under the identical terms.

For reprints contact: reprints@medknow.com

DOI: 10.4103/njcp.njcp_135_17

How to cite this article: Yilmaz K, Tunga U, Özyürek T. Buccal infiltration

PMID: ******* versus inferior alveolar nerve block in mandibular 2nd premolars with
irreversible pulpitis. Niger J Clin Pract 2018;21:473-7.

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Yılmaz, et al.: Buccal infiltration versus inferior alveolar nerve block

anest esia fre uentl fails, es eciall in t e man ibular ic o erates for mont s in a ear. is recruitment
teet it in ammation. or e am le, in a stu of t e lasted one and half a years with an estimated 645 patients
effectiveness of IANB anesthesia in teeth with irreversible un er oin an roce ure. it in t ese atients, ere
ul itis, t e failure rate of t is tec ni ue as re orte to selecte to take art in t is clinical trial. ac atient as
var bet een an .[6] In such cases of IANB experiencing spontaneous moderate-to-severe pain at the
failure, infiltration, intraosseous, intrali amentar , an emer enc a ointment. atients it no or mil ain,
intra ul al anest esia are use as au iliar anest esia.[7] periradicular pathosis, or no vital coronal pulpal tissue on
According to our literature review, a number of studies access ere e clu e from t e stu . etaile me ical
reported that when IANB anesthesia failed in mandibular istor as obtaine from eac atient. ll t e atients
molar teeth with irreversible pulpitis, a supplemental ere ealt an ol er t an ears. atients oun er
buccal infiltration anest esia as successful.[8] However, than 18 years, allergic to local anesthesia, pregnant
few studies have evaluated the effectiveness of buccal women, patients using medications affecting the sense of
infiltration anest esia in t e man ibular secon remolar pain (narcotics, analgesics, antidepressants, and sedative
teet en use as rimar anest esia. arious stu ies medications), and patients having active pathology at the
t at com are t e effectiveness of buccal infiltration in ection site ere e clu e .
anesthesia of molar teeth with that of IANB anesthesia
Before the treatment, the patients were asked to mark the
re orte t at infiltration anest esia mi t be a useful
level of pain they felt on the Heft–Parker visual analog
alternative to B anest esia.[9-11]
scale , an t ese values ere recor e . e
The aim of the present study was to compare the success 170-mm long l HPVAS is divided into four categories,
rates of B an buccal infiltration anest esia of namel , no ain mm , mil ain mm , mo erate
mandibular second teeth with irreversible pulpitis and ain mm , an severe ain mm .
to evaluate the level of patient discomfort with these
fter restin for min, eac atient s ri t in e fin er
met o s. e null ot esis as t at t ere oul be
as connecte to a ulse o imeter evice ,
no difference between the success rates of IANB and
, urke . e eart rates of t e atients ere
buccal infiltration anest esia or t e levels of atient
measured for 5 min at 1 min intervals, and the results
iscomfort cause b t ese anest esia tec ni ues urin
ere recor e .
t e in ection.
atients ere blin e to t e t e of anest etic solution.
Matherials and Methods o ical anest etic as not a lie before t e in ection.
This study was designed as a randomized clinical ent atients ere iven . ml buccal infiltration
trial comparing the anesthetic effectiveness of 4% anest esia, it articaine containin : .
articaine it : . e ine rine in B e ine rine ltracain orte oec st , ainz,
an buccal infiltration anest esia. is stu as Germany), and the other 20 patients received IANB
approved by the Ethical Committee of Ondokuz Mayis anest esia, it articaine containin : .
niversit roval o. . fter a o er e ine rine. urin t e s of t e in ection, t e eart
analysis, 40 patients (20 patients in each group) were rates of the patients were measured and recorded at
selected through simple random sampling, with a 99% s intervals. ll local anest etic in ections ere iven
confi ence level an sensitivit . by a single operator who was not a part of the study
rocess. is o erator a no involvement it t e stu
The 40 patients involved in this study were randomly
outcome.
ivi e into t o rou s. an om numbers ere create
in cel icrosoft ffice cel icrosoft After 10 min of resting after the local anesthesia, root
or oration, e mon , , . o stan ar , t e canal treatment was initiated in the relevant teeth, after
present study, 10 male and 10 female patients who had ensurin t e insensitivit of t e li s in t e B rou .
inclusion criteria ere selecte for eac rou . If the patient had no lip insensitivity after administering
the IANB anesthesia, the patient was excluded from
All the patients who participated in the study were given
t e stu an anot er atient as inclu e . fter t e
detailed information about the treatment procedures
re aration of an en o ontic entrance cavit , a
and potential complications that could occur during the
file as use to etermine t e orkin len t usin
treatment and written and signed informed consent was
an a e locatar oot ini orita, saka, a an .
obtaine .
Each patient was advised to alert the physician to any
Approximately 100 patients attend monthly at the ain t e felt b raisin t eir an . n cases ere t e
emergency center of the department of endodontics, patient felt pain, the process was stopped when the

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Yılmaz, et al.: Buccal infiltration versus inferior alveolar nerve block

patient raised his/her hand, and the pain level of the Table 1: Demographic and clinical features of the
atient as marke on t e b t e atient. ases, patients
where the patients indicated that the pain level was IANB Buccal infiltration P
moderate or severe during the endodontic treatment, were (n=20) (%) (n=20) (%)
considered “unsuccessful,” and the treatment procedure Gender
was continued using auxiliary anesthesia (intrapulpal emale 10 (50) 10 (50) .
or intrali amentar . or atients at felt no ain or Male 10 (50) 10 (50) .
mild pain, the local anesthesia process was considered Age (years)a . . .
“successful,” and the procedure was continued without HPVAS
usin an au iliar anest esia.[12] Before treatment . . . . .
During treatment . . . . .
Statistical analysis Heart rate
The Anderson–Darling test was used to test the normal Before injection . . . . .
distribution of the HPVAS and heart rate data, and the During injection . . . . .
Levene test was used to test the homogeneity of group a
ean . eft arker visual analo scales
variances. n t e com arisons of t e rou s, t e tu ent s tan ar eviation B nferior alveolar nerve block
t test as use for t o in e en ent rou s. n all t e
calculations an inter retations, t e level of si nificance Table 2: Success and failure rates according to
as set at . ll t e calculations ere erforme techniques
it t e B nc., ica o, , IANB Buccal infiltration Total
statistical acka e soft are. (n=20) (%) (n=20) (%)
ailure 6 (30) 8 (40) 14 (35)
Results Success 14 (70) 12 (60) 26 (65)
Total 20 (100) 20 100) 40 (100)
Comparison of Heft–Parker visual analog scale
ere as no statisticall si nificant ifference bet een rou s
values (P . . B nferior alveolar nerve block
The comparisons of the age and gender distribution of
the participating patients, their HPVAS scores before Discussion
the process, and their pain scores during the root canal
Local anesthesia is one of the most reliable methods for
treatment operation are presented in Table .
painless endodontic treatment, and it is the preferred
According to the results of the present study, the pain scores met o of most clinicians. ase of a ministration,
of t e atients in bot rou s si nificantl ecrease after comfort for the patient and clinicians, no tongue
the anesthesia injection (P . . e ifference bet een insensitivity, and a very low possibility of nerve damage
the pain scores of the patients in the two groups during or intravenous injection of anesthetic solution make
t e o eration as not statisticall si nificant P . . buccal infiltration anest esia more a vanta eous t an
e success rates of t e anest esia tec ni ues use in t e B. arious stu ies ave com are t e success rate of
present study are presented in Table . buccal infiltration anest esia an B.[13,14] The failure
rate of t e B anest esia tec ni ue in man ibular
According to the results, there was no statistically
molar teet it ul itis as re orte to be .[5,15]
si nificant ifference bet een t e success failure rates
Anesthesia failure was reported to be eight times more
of B anest esia an buccal infiltration anest esia in
common in irreversible pulpitis cases when compared to
terms of the pain scores during the root canal treatment
as m tomatic cases.[16] Only one study comparing the
of the patients (P . .
anesthesia levels in mandibular second premolar teeth
Comparison of heart rate values rovi e b buccal infiltration, an an B anest esia
The heart rates of the participating patients, which were tec ni ue as foun in t e literature, ar al et al.[17]
measured through a pulse oximeter device before and foun no statisticall si nificant ifference bet een t e
during the administration of the two different anesthesia success rate of anest esia tec ni ues. o revious
methods, are presented in Table . urin bot B studies evaluated the pain that patients felt during the
an buccal infiltration anest esia, t e eart rates of t e a ministration of t ese t o anest esia tec ni ues.
atients si nificantl increase in ro ortion to t e values
mon local anest etics, articaine is uni ue in t at it
measured before the anesthesia (P . .
contains a t io ene an an ester rin . tu ies s o e
oreover, buccal infiltration anest esia le to a that articaine was as effective as lidocaine, mepivacaine,
si nificantl i er increase in eart rates, en com are an rilocaine in block anest esia an buccal infiltration
to those recorded using IANB anesthesia (P . . anest esia. urt ermore, articaine can enetrate t e

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Yılmaz, et al.: Buccal infiltration versus inferior alveolar nerve block

cortical bone, and it could be used in the mandibular B an buccal infiltration anest esia met o s ere
molar re ion.[4,8,17-26] or t ese reasons, ltracain used together (66%) and in cases where IANB was used
orte oec st , ainz, erman anest etic solution alone ere not statisticall si nificantl ifferent.
containin articaine an e ine rine : . as In a study of 27 healthy volunteers, Corbett et al.[11]
use in t e resent stu . re orte t at B rovi e a . success rate in
man ibular first molar teet an t at buccal infiltration
In a study on the use of topical anesthetic material before
anest esia rovi e a success rate of . , but t e
the administration of local anesthesia, the application
ifference as not statisticall si nificant.
of topical anesthetics to the relevant region before
the injection did not change the patient’s level of pain In the present study, the heart rates of the patients were
erce tion.[27] or t is reason, no to ical anest etic as i er it t e buccal infiltration anest esia met o
a lie before t e in ection in t e current stu . t an t e B met o , an buccal infiltration anest esia
cause a reater sense of atient iscomfort t an B.
anaa et al.[28] reported that slow administration of IANB
Based on an extensive literature review, there are a
anest esia . ml s as more acce table to atients
limite number of similar stu ies ere foun .[34] The heart
t an fast a ministration . ml s. stu on t e
rates recorded in the present study were higher than those
success of computer-controlled slow injection systems reported in Monteiro et al.[10] an anaa et al.[34] stu ies.
reported that they did not decrease the injection pain e iscor in t e fin in s mi t be ue to atients
level of atients.[29] Thus, we administered the anesthetic erce tions t at buccal infiltration anest esia oul be
slo l . ml s in t e resent stu . more painful than other methods and to differences in
Although some studies considered the absence of pain clinicians ractices.
as success, ot ers classifie cases it a mo erate
level of pain as successful[11,21,30-33] and should not be Conclusion
classifie as success in en o ontics. or t is reason, Buccal infiltration anest esia a lie it a articaine
onl t e absence of ain an mil ain solution before root canal treatment of mandibular
value mm ere consi ere as success in second premolar teeth with irreversible pulpitis may be a
our stu .[12] oo alternative to B anest esia.
According to the results of the present study, using Acknowledgments
bot t e anest esia tec ni ues, t e ain scores of t e e aut ors en an con icts of interest relate to t is
atients urin t e roce ure B . . , stu .
infiltration . . ere statisticall si nificantl Financial support and sponsorship
lo er t an t ose before t e roce ure B . ,
il.
infiltration . P . . ese ata are in
agreement with those obtained by other studies of Conflicts of interest
patients with irreversible pulpitis of mandibular molar ere are no con icts of interest.
teet .[10,12]
References
In the present study, the success rate of the IANB
. liveira , ol ato , amacciato , anali . rticaine
tec ni ue as , ereas t at of t e buccal an li nocaine efficienc in infiltration anaest esia: ilot stu .
infiltration anest esia tec ni ue as . o ever, Br ent : .
en e com are t e anest esia tec ni ues accor in . usstein , ea er , rum . ocal anest esia strate ies
to the accepted criteria for success, there were no for t e atient it a ot toot . ent lin ort m
: .
statisticall si nificant ifferences in t e success of t e
. o , ara as i . ifferential ro erties of
two methods (P . . n common it t e results tetrodotoxin-sensitive and tetrodotoxin-resistant sodium channels
of the present study, Aggarwal et al.[17] found no in rat orsal root an lion neurons. eurosci : .
statisticall si nificant ifference bet een t e success . ortamano , iviero , osta , Buscariolo , rmonia .
rate of mental incisive nerve (%555) block and the IANB com arison of t e anest etic efficac of articaine an li ocaine
in atients it irreversible ul itis. n o : .
tec ni ue in man ibular remolars.
. ikesell , usstein , ea er , Beck , eaver .
e success failure values of t e anest esia tec ni ues A comparison of articaine and lidocaine for inferior alveolar
in the present study are in accordance with those in nerve blocks. n o : .
. osenber , min , ibari Y, in . om arison of
literature, with most reported studies failing to achieve a 4% articaine with 1:100,000 epinephrine and 2% lidocaine with
success rate.[10,12,33,34] imilar to our results, oster : , e ine rine en use as a su lemental anest etic.
et al. reported that the success rates in cases where
[35]
n o : .

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Yılmaz, et al.: Buccal infiltration versus inferior alveolar nerve block

. eec an . u lementar routes to local anaest esia. nt a re eate buccal infiltration of articaine in rolon in uration
n o : . of ul al anest esia in t e man ibular first molar. nest ro
. att e s , rum , ea er , usstein , Beck . rticaine : .
for su lemental buccal man ibular infiltration anest esia in . Batista a ilva , Berto , ol ato , amacciato ,
patients with irreversible pulpitis when the inferior alveolar Motta RH, Ranali J, et al. nest etic efficac of articaine
nerve block fails. n o : . an li ocaine for incisive mental nerve block. n o
. rinivasan , avit a , o anat an , a mini . : .
om arison of anest etic efficac of articaine an . uzum , rum , usstein , ea er , Beck . nest etic
li ocaine for ma illar buccal infiltration in atients it efficac of articaine for combination labial lus lin ual
irreversible ul itis. ral ur ral e ral at ol ral a iol infiltrations versus labial infiltration in t e man ibular lateral
n o : . incisor. n o : .
. onteiro , ro o , aiter eto , ol ato , . att e , usstein , rum , ea er, Beck . nest etic
lmei a . articaine buccal infiltration versus li ocaine efficac of . m versus . m of articaine it : .
inferior alveolar nerve block for emergency root canal treatment e ine rine as a rimar buccal infiltration of t e man ibuler
in mandibular molars with irreversible pulpits: A randomized first molar. en o : : .
clinical stu . nt n o : . . c ntire , usstein , rum , ea er , Beck . nest etic
. orbett , anaa , it ort , eec an . rticaine efficac of articaine it : , e ine rine versus
infiltration for anest esia of man ibular first molars. n o 4% articaine with 1:200,000 epinephrine as a primary buccal
: . infiltration in t e man ibular first molar. n o : .
. oorni , enias ok B, ent ilkumar , n ira , . rum , ea er , Beck . on buccal nerve block in ection
amac an ran . nest etic efficac of four ercent articaine ain in atients it irreversible ul itis. ral ur ral e
for pulpal anesthesia by using inferior alveolar nerve block ral at ol ral a iol n o :e .
an buccal infiltration tec ni ues in atients it irreversible . anaa , it ort , orbett , eec an . rticaine
ul itis: ros ective ran omize ouble blin clinical trial. an li ocaine man ibular buccal infiltration anest esia:
n o : . ros ective ran omize ouble blin cross over stu .
. aas , ennon . ear retros ective stu of re orts of n o : .
arest esia follo in local anest etic a ministration. an ent . oc man , iarello , oc man B, o atkin , er ola .
ssoc : , , . om uterize local anest etic eliver vs. ra itional
. eec an . nfiltration anest esia in t e m an ible. ent lin s rin e tec ni ue. ub ective ain res onse. Y tate ent
ort m : . : .
. c ean , ea er , Beck , er ers . n evaluation . eisman , ea er , ist , Beck , eaver . nest etic
of 4% prilocaine and 3% mepivacaine compared with 2% efficac of t e su lemental intraosseous in ection of
lidocaine (1:100,000 epinephrine) for inferior alveolar nerve me ivacaine in irreversible ul itis. ral ur ral e ral
block. n o : . at ol ral a iol n o : .
. ar reaves , eiser . ocal anest etic failure in . Berlin , usstein , ea er , Beck , eaver . fficac of
en o ontics. n o o : . articaine and lidocaine in a primary intraligamentary injection
. ar al , in la , i lani , o li . om arative administered with a computer-controlled local anesthetic delivery
evaluation of mental incisal nerve block, inferior alveolar nerve s stem. ral ur ral e ral at ol ral a iol n o
block, and their combination on the anesthetic success rate in : .
symptomatic mandibular premolars: A Randomized double-blind . obertson , usstein , ea er , Beck , c artne .
clinical trial. n o : . e anest etic efficac of articaine in buccal infiltration of
. aas , ar er , aso , Youn . om arison of man ibular osterior teet . m ent ssoc : .
articaine an rilocaine anest esia b infiltration in ma illar . un Y, im , im , ee Y, ee . n evaluation of
an man ibular arc es. nest ro : . buccal infiltrations an inferior alveolar nerve blocks in ul al
. ri t , einber er , arti , lotzke . e effectiveness anest esia for man ibular first molars. n o : .
of infiltration anest esia in t e man ibular rimar molar re ion. . anaa , it ort , orbett , eec an . rticaine
e iatr ent : . buccal infiltration en ances t e effectiveness of li ocaine inferior
. talo , ntila , e tinen . rticaine an li ocaine for alveolar nerve block. nt n o : .
ma illar infiltration anest esia. nest ro : . . oster , rum , ea er , Beck . nest etic efficac of
. alame , a non , eblanc . fficac of articaine: ne buccal an lin ual infiltrations of li ocaine follo in an inferior
ami e local anest etic. m ent ssoc : . alveolar nerve block in man ibular osterior teet . nest ro
. abst , usstein , rum , ea er , Beck . e efficac of : .

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