Clinical Research
Effect of Sodium Bicarbonate–buffered Lidocaine on the
Success of Inferior Alveolar Nerve Block for Teeth with
Symptomatic Irreversible Pulpitis: A Prospective,
Randomized Double-blind Study
Masoud Saatchi, DDS, MS,* Abbasali Khademi, DDS, MS,* Badri Baghaei, DDS, MS,†
and Hamid Noormohammadi, DDS, MS‡
Abstract
Introduction: The purpose of this prospective, random-
ized, double-blind study was to compare the anesthetic
efficacy of buffered with nonbuffered 2% lidocaine with
1:80,000 epinephrine solution for inferior alveolar nerve
(IAN) block in patients with mandibular posterior
teeth experiencing symptomatic irreversible pulpitis.
Methods: Eighty adult patients diagnosed with symp-
tomatic irreversible pulpitis of a mandibular posterior
tooth were selected. The patients received 2 cartridges
of either 2% lidocaine with 1:80,000 epinephrine buff-
ered with 0.18 mL 8.4% sodium bicarbonate or 2% lido-
caine with 1:80,000 epinephrine with 0.18 mL sterile
distilled water using conventional IAN block injections.
Endodontic access preparation was initiated 15 minutes
after injection. Lip numbness was required for all the pa-
tients. Success was determined as no or mild pain on the
basis of Heft-Parker visual analog scale recordings upon
access cavity preparation or initial instrumentation. Data
were analyzed by the t, Mann-Whitney, and chi-square
tests. Results: The success rates were 62.5% and
47.5% for buffered and nonbuffered groups, respec-
tively, with no significant differences between the two
groups (P = .381). Conclusions: Buffering the 2% lido-
caine with 1:80,000 epinephrine with 8.4% sodium bi-
carbonate did not improve the success of the IAN
block in mandibular molars in patients with symptom-
atic irreversible pulpitis. (J Endod 2015;41:33–35)
Key Words
Buffered, inferior alveolar nerve block, irreversible pulpi-
tis, local anesthesia, sodium bicarbonate
From the *Torabinejad Dental Research Center, Depart-
ment of Endodontics, School of Dentistry, Isfahan University
of Medical Sciences, Isfahan; †Department of Endodontics,
School of Dentistry, Rafsanjan University of Medical Sciences,
Rafsanjan; and ‡Isfahan University of Medical Sciences, Isfa-
han, Iran.
Address requests for reprints to Dr Abbasali Khademi,
Department of Endodontics, School of Dentistry, Isfahan Uni-
versity of Medical Sciences, Isfahan, Iran 81746-73461.
E-mail address: a_khademi@dnt.mui.ac.ir
0099-2399/$ - see front matter
Copyright ª 2015 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2014.09.011
JOE — Volume 41, Number 1, January 2015
I nferior alveolar nerve (IAN) block is the most routinely used injection technique for
achieving local anesthesia for endodontic treatment of mandibular teeth (1). Clinical
studies have reported 44%–81% failure rates for IAN block in mandibular posterior
teeth with irreversible pulpitis (2–4). Therefore, it can be advantageous to improve
the success rate of the IAN block.
Lidocaine is the most frequently used local anesthetic (LA), which contains a vaso-
constrictor and antioxidant (5). Commercially available lidocaine solutions with
epinephrine have a low pH range between 2.9 and 4.4 (6). Decreasing the pH extends
the shelf life of the solution and prevents its early oxidation (7, 8). However, a low pH
may produce a burning sensation on the injection site, a slower onset of anesthesia, and
a decrease in its clinical efficacy (8).
Buffering of LAs (alkalinization) has been suggested to achieve pain control (9).
Alkalinization will increase the dissociation rate of the LA molecule and then increase
the uncharged base form that crosses the nerve membrane to the intraneuronal site
where it exerts its action (10, 11). The most common method for buffering of LAs is
with the addition of sodium bicarbonate. It is an alkalinizing agent, which is most
commonly used for the treatment of metabolic acidosis. The addition of sodium
bicarbonate to LAs not only will increase the pH of the solution but will also result in
the production of carbon dioxide and water (12). Carbon dioxide potentiates local
anesthesia by 3 mechanisms (13, 14):
1. A direct depressant effect of carbon dioxide on the axon
2. Concentrating LA inside the nerve trunk (diffusion trapping)
3. Converting LA to the active cation through its effect on pH at the site of action inside
the nerve
Some studies have shown that buffering of LAs reduces the pain of injection (6, 9,
15, 16), hastens the onset of anesthesia (6, 9, 16), and improves the success rate of
anesthesia (9, 17, 18). Others have reported that buffering of LAs cannot reduce the
pain of injection (19–21), hasten the onset of anesthesia (19, 20), or improve the
success rate of anesthesia (19, 22).
There are no studies evaluating the use of a sodium bicarbonate–buffered lido-
caine formulation for IAN block for teeth with irreversible pulpitis. The purpose of
this prospective, randomized, double-blind study was to compare the success rate of
IAN block obtained with 2 cartridges of 2% lidocaine with 1:80,000 epinephrine buff-
ered with 0.18 mL 8.4% sodium bicarbonate versus 2 cartridges of 2% lidocaine with
1:80,000 epinephrine with 0.18 mL sterile distilled water for endodontic treatment of
mandibular molars with symptomatic irreversible pulpitis.
Materials and Methods
Eighty adult patients participated in this prospective, randomized, double-blind
study. All were emergency patients of the Dental Clinic of Isfahan University of Medical
Sciences, Isfahan, Iran, and were in good health as determined by oral questioning
and a health history. Patients who were under 18 years of age, had a history of significant
Buffered Lidocaine for the IAN Block 33
Clinical Research
medical conditions, were allergic to LAs or sulfites, were pregnant, were
taking any medications that might influence anesthetic assessment, had
active sites of pathosis in the area of injection, or were unable to give
informed consent were excluded. The Ethics Committee of Isfahan Uni-
versity of Medical Sciences approved the protocol of the study (no.
393396), and written informed consent was obtained from each patient.
To qualify for the study, each patient had a vital mandibular pos-
terior tooth with active pain and a long response to cold testing with
Endo-Frost cold spray (Roeko; Coltene Whaledent, Langenau,
Germany). Patients with no response to cold testing or with a periapical
lesion (other than a widened periodontal ligament) were not included
in the study. Therefore, each patient had a vital mandibular molar tooth
with a clinical diagnosis of symptomatic irreversible pulpitis.
Each patient rated his or her initial pain on a Heft-Parker visual
analog scale (HP-VAS) (23). This scale is a 170-mm horizontal line
divided into 4 categories. No pain corresponded to 0 mm; mild pain
was defined as >0 mm and #54 mm. Mild pain category included faint,
weak, and mild pain. A score >54 mm and <114 mm indicated moderate
pain and included the descriptor of moderate pain. A score >54 mm and
<114 mm indicated moderate pain and included the descriptor of mod-
erate pain. Severe pain was defined as $114 mm. Severe pain was
defined as strong, intense, and maximum possible. Patients presenting
with moderate to severe initial pain were included in the study.
Buffered LA solution was prepared as follows: under sterile condi-
tions, 0.18 mL from a 1.8-mL cartridge of 2% lidocaine with 1:80,000
epinephrine (Lignospan; Septodont, Saint Maur des Fosses, France) was
drawn and replaced with 0.18 mL 8.4% sodium bicarbonate (8.4%
weight/volume, 50 mEq/50 mL; Samen Pharmaceutical Co, Mashhad,
Iran) using a glass microliter syringe (Hamilton, Bonaduz, Switzerland).
The cartridge was inverted 5 times to mix the solution, and no precip-
itation was present. For nonbuffered LA solution, 0.18 mL from a 1.8-mL
cartridge of 2% lidocaine with 1:80,000 epinephrine was drawn and re-
placed with 0.18 mL of sterile distilled water. A trained dental assistant
prepared the 2 formulations and coded them in a random manner. A
single operator administered 2 IAN blocks of either buffered or nonbuf-
fered LA solution for each patient in a double-blind trial. All the injec-
tions were performed using a 27-G, 1.5-inch needle (Septoject;
Septodont, Saint-Maur-des-fosses Cedex, France) attached to a standard
aspirating dental injection syringe. Lip numbness was set as a criterion to
IAN block achievement; it was considered profound for 15 minutes after
the injection. If lip numbness was not profound, the IAN block was indi-
cated as missed, and the patient was excluded from the study. Fifteen mi-
nutes after the injection, the teeth were isolated with a rubber dam, and
access cavities were prepared. All the teeth had vital coronal pulp tissue
on access cavity preparation.
The patients were instructed to rate any pain felt during access cav-
ity preparation or initial file placement. If the patient felt pain, the treat-
ment was immediately ceased, and the patient rated the discomfort by
using the HP-VAS. The success of the IAN block was defined as the tooth
without pain (HP-VAS score equal to 0 mm) or with mild pain (HP-VAS
rating #54 mm).
Statistical Analysis
Of 80 adult patients, 46 were women and 34 were men. The age
range was 20–55 years, with a mean  standard deviation of 35  9
and 36  8 years in the buffered and nonbuffered groups, respectively.
Data on age, sex, initial pain, and the success of IAN block ratings were
collected and statistically analyzed using SPSS software (Version 15;
SPSS Inc, Chicago, IL). Comparisons between the buffered and nonbuf-
fered lidocaine groups for the success of the IAN block and sex differ-
ences were analyzed by the chi-square test; age was analyzed using the
TABLE 1. Preoperative Values for the Buffered and Nonbuffered Groups
Value Buffered Nonbuffered P value*
Total subjects 40 40
Age (y) 20–55 22–52 .298
Sex 22 women 24 women .835
18 men 16 men
Initial pain† 102 (18.6) 105 (26.5) .164
*There were no significant differences between the 2 groups (P > .05).
†
Mean (standard deviation).
t test, and initial pain was analyzed using the Mann-Whitney test. With a
2-sided alpha risk of 0.05, a sample size of 40 subjects per group was
required to detect a difference of 30 percentage points in anesthetic
success with a power of more than 0.80. Statistical significance was
defined at P < .05.
Results
The age, sex, and initial pain ratings for the buffered and nonbuf-
fered groups are presented in Table 1. The distribution of teeth for buff-
ered and nonbuffered groups is presented in Table 2. There were no
differences in age, sex, or initial pain between the 2 groups
(P > .05). The IAN block success rate was 62.5% for the buffered group
and 47.5% for nonbuffered group. There was no statistically significant
difference in success rates between the 2 groups (P = .381).
Discussion
There were no statistically significant differences in the effects of
sex, age, and initial pain between the buffered and nonbuffered groups.
Therefore, the effects of these variables were minimal between the
2 groups. Moreover, all the teeth had a long response to cold testing,
vital coronal pulp tissue on access cavity preparation, and moderate
to severe pain on the HP-VAS (Table 1), which indicated that the teeth
had symptomatic irreversible pulpitis. In both groups, 3.24 mL 2% lido-
caine with 1:80,000 epinephrine was administered to each patient.
Therefore, the volume of LA was the same in the 2 groups. Although buff-
ered lidocaine remains effective for as long as 1 week after preparation
(24), the buffered lidocaine formulations were prepared immediately
before the injections.
The success of the IAN block was evaluated by measuring the pain
level during endodontic access and initial instrumentation using the HP-
VAS, and further tests with an electric pulp tester were eliminated in this
study. This was based on the findings of Nusstein et al (3) on teeth with
irreversible pulpitis in which an electric pulp tester was used for
measuring the pain level. They showed that 42% of patients with a nega-
tive response to an electric pulp tester after receiving anesthesia still re-
ported pain during treatment and needed supplemental injections.
In this study, the success rate of the IAN block was higher than
those reported in previous studies by Matthews et al (25), Oleson
et al (26), Simpson et al (27), and Kreimer et al (28). Differences in
patient populations or operators might justify the diverse success rates
among the studies.
Because of the notable failure of the IAN block for mandibular mo-
lars with irreversible pulpitis, many studies have been performed to
evaluate factors that might enhance the success rate of the IAN block,
TABLE 2. Distribution of Teeth in the Buffered and Nonbuffered Groups
Tooth Buffered, n (%) Nonbuffered, n (%)
First molar 21 (52) 23 (57)
Second molar 15 (37) 12 (30)
Third molar 4 (10) 5 (12)

34 Saatchi et al. JOE — Volume 41, Number 1, January 2015


such as anesthetic techniques (29), anesthetic solutions (4), and pre-
medications (30, 31). Moreover, the addition of different compounds
such as hyaluronidase (32), clonidine (33), meperidine (2), and
mannitol (28) to the lidocaine anesthetic solution has been evaluated.
Most of them have failed to improve the success rate of the IAN block.
Some studies have shown that buffered lidocaine improves the ef-
ficacy of LA (9, 17, 18). This was based on a theory that when sodium
bicarbonate is added, it is also available in the tissues as bicarbonate
ion, which alkalinizes the extracellular pH. Extracellular pH is
increased by the addition of bicarbonate. Subsequently, the
decreased intracellular pH (via the diffusion of carbon dioxide
produced from hydrogen and hydrogen carbonate interaction in the
extracellular fluid) may also play a role in increasing the effect of the
LA block through protonation of intracellular freebase LA (ion
trapping) and increasing the concentration gradient for the freebase
LA across the plasma membrane (34). However, in this study, although
the buffered group had a higher success rate than the nonbuffered
group, this improvement was not statistically significant, and the success
rate was not adequate to provide profound pulpal anesthesia. There-
fore, clinicians should consider supplemental techniques.
In conclusion, buffering the 2% lidocaine containing 1:80,000
epinephrine with 8.4% sodium bicarbonate did not improve the success
of the IAN block in mandibular molars in patients with symptomatic
irreversible pulpitis.
Acknowledgments
Supported by Isfahan University of Medical Sciences Research
(grant no. 393396).
The authors deny any conflicts of interest related to this study.
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Buffered Lidocaine for the IAN Block 35