Aust Endod J 2018; 44: 14–25

ORIGINAL RESEARCH

Supplementary techniques for pain control during root canal

treatment of lower posterior teeth with irreversible pulpitis: A
systematic review and meta-analysis
Pinpana Tupyota, DDS, MSc1; Pattama Chailertvanitkul, DDS, PhD1,* ; Malinee Laopaiboon, PhD2;
Chetta Ngamjarus, PhD2; Paul V. Abbott, BDSc, MDS, FRACDS(Endo), FPFA, FADI, FICD, FACD3 ; and
Suttichai Krisanaprakornkit, DDS, MSD, PhD4
1 Department of Restorative Dentistry, Faculty of Dentistry, Khon Kaen University, Khon Kaen, Thailand
2 Department of Biostatistics and Demography, Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand
3 School of Dentistry, University of Western Australia, Nedlands, Western Australia, Australia
4 Department of Oral Biology and Diagnostic Sciences, Faculty of Dentistry Center of Excellence in Oral and Maxillofacial Biology, Chiang Mai
University, Chiang Mai, Thailand

Keywords
inferior alveolar nerve block, irreversible
pulpitis, meta-analysis, systematic review.
Correspondence
Pattama Chailertvanitkul, Department of
Restorative Dentistry, Khon Kaen University,
Khon Kaen 40002, Thailand.
Email: patchai@kku.ac.th
doi: 10.1111/aej.12212
Abstract
The purpose of this systematic review and meta-analysis was to evaluate utili-
sation of supplementary techniques for pain control during root canal treat-
ment of lower molars with irreversible pulpitis. The literature was searched
using electronic databases up to year 2012. Seventeen studies with 1504 par-
ticipants were included and each study compared experimental interventions
with a standard treatment, i.e. the inferior alveolar nerve block. Changing the
injection techniques or supplemental injection had no significant effect on
pulp anaesthesia compared to the standard treatment (P = 1.00 or P = 0.14),
whereas changing anaesthetic features and increasing anaesthetic volumes
resulted in significantly higher rates of anaesthesia than those of the standard
treatment (P = 0.03 and P = 0.007, respectively). Premedication with non-
steroidal anti-inflammatory drugs (NSAIDs) also significantly increased the
success rate of anaesthesia (P = 0.001). Taken together, increased anaesthetic
volumes and premedication with NSAIDs provide predictable anaesthesia and
more pain control during endodontic treatment of lower molars with irre-
versible pulpitis.

Introduction Materials and Methods

The inferior alveolar nerve block (IANB) is the most
commonly used local anaesthetic technique for root
canal treatment of mandibular teeth. In healthy teeth,
the failure rate of IANB is 15%, whereas this rate
increases dramatically to be as high as 44–81% in teeth
with acute irreversible pulpitis (1). Numerous studies
have evaluated the efficacy of different pain manage-
ment strategies as well as the influences of various sup-
plemental anaesthetic techniques and pre-operative
medications with distinct methods and results. The pur-
pose of this systematic review was, therefore, to assess
the effectiveness of various interventions for pain relief
during root canal treatment in lower molars with irre-
versible pulpitis.
Inclusion criteria for eligible studies
Type of studies
Randomised control trials (RCTs) that compared various
interventions with a standard intervention (IANB) for
pain relief during root canal treatment in lower molars
with irreversible pulpitis.
Type of participants
Adults aged 18 years and above who were experiencing
pain in mandibular molars as a result of irreversible pul-
pitis. Radiographs showed no periapical radiolucency
other than a widened periodontal ligament space. The

14 © 2017 Australian Society of Endodontology Inc


P. Tupyota et al.
participants were able to understand and use a visual
pain scale. The participants were in good health and not
taking any medications that would alter their pain per-
ception, and females were neither pregnant nor breast-
feeding.
Type of interventions
Any supplementary interventions, such as changing the
injection techniques, supplemental injection, changing
the characteristics of local anaesthetic agents, or using
pre-operative medications with analgesic drugs, were
considered. The standard intervention was defined as use
of local anaesthetic injection by IANB.
Type of outcome measures
The primary outcome was clinical success of pulp anaes-
thesia such that the participants felt only mild or no pain
during root canal treatment.
Search methods for identification of studies and data
collection
The following databases were searched for relevant trials
from the inception of each electronic database to April
2013: Cochrane Central Register of Controlled Trials
(CENTRAL) http://www.thecochranelibrary.com/view/
0/index.htmll, MEDLINE (Pubmed) http://www.ncbi.
nlm.nih.gov/pubmed?holding=ithkkumlib, SCOPUS
http://www.scopus.com/home.url, and MEDLINE (Ovid)
http://ovidsp.tx.ovid.com/sp3.8.0a/ovidweb.cgi. The fol-
lowing keywords were used: ‘inferior alveolar nerve
block’, ‘irreversible pulpitis’, and ‘randomised or ran-
domised control trials’.
Hand searching was performed in relevant journals
from 2003 to 2012 plus Journal of the Endodontic Soci-
ety of Thailand, Khon Kaen University Dental Journal,
Mahidol Dental Journal, Chiang Mai Dental Journal,
Journal of the Dental Association of Thailand, Srinakhar-
inwirot University Dental Journal, Chulalongkorn
University Dental Journal, North-Eastern Thai Journal of
Neuroscience, Thai Journal of Oral and Maxillofacial Sur-
gery, Journal of Orofacial Pain and Songklanagarind
Medical Journal.
Two reviewers (PT and PC) independently screened
abstracts of the potential articles obtained from all the
electronic and hand searching to decide whether the
studies met the inclusion criteria. Any disagreements
were resolved by discussion. A third reviewer (ML) was
consulted if there was any unresolved disagreement. Full
texts of the eligible articles were then separately
reviewed by the first two reviewers.
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Pain Control During Root Canal Treatment
Assessment for the methodological quality of
included studies
The risk of bias for all included studies was assessed using
seven domains as described in the Cochrane Handbook
for Systematic Reviews of Interventions (2), including
sequence generation, allocation concealment, blinding of
participants, personnel and outcome assessors, incom-
plete outcome data, selective outcome reporting and
other potential sources of bias. The judgment for each
item was ‘Yes’ indicating low risk of bias, ‘No’ indicating
high risk of bias, or ‘Questionable’ indicating the lack of
information. If the sequence generation and allocation
concealment of each study were judged to have a low risk
of bias, its quality was assumed to have a low risk of bias.
Data analysis
Data analysis was carried out using Revman 5.2 software
(Cochrane Collaboration, Oxford, UK) (2). The rate of
successful pulp anaesthesia was expressed as relative risk
(RR) with 95% confidence interval (CI). The RR and
95% CI for pain relief improvement of individual studies
were presented using forest plots. The heterogeneity of
results from included studies was investigated by I square
(I2). The statistical heterogeneity was presented as signifi-
cant when I2 was over 50% or P < 0.10. Sub-group anal-
ysis was conducted to investigate whether there was a
statistically significant difference between interventions.
The random effect meta-analysis was used to combine
success rates of anaesthesia. A funnel plot of successful
pulp anaesthesia was conducted to identify a publication
bias.
Results
A total of 113 articles were retrieved from PubMed
(n = 34), CENTRAL (n = 17), SCOPUS (n = 33) and Ovid
(n = 29), while there was no additional article found
through other sources by hand searching (Fig. 1). All
articles were evaluated by reading their titles and
abstracts. Seventy-seven articles were rejected as being
from the same journals and fourteen articles were
rejected because they did not meet the inclusion criteria.
Twenty-two full texts were evaluated independently by
two reviewers (PT and PC), from which five studies were
rejected as not meeting the inclusion criteria. Thus, 17
studies were assessed for quality and their data were
analysed (Fig. 1).
There were 1504 participants involved in these 17
studies (Table 1), and each study compared the experi-
mental (supplemental) techniques with the standard
intervention of IANB. The 17 studies were divided into
15

Pain Control During Root Canal Treatment
Figure 1 PRISMA flow diagram of the meta-analysis.
five categories for comparison, and some studies were
used for more than one comparison. Of the 17 studies, 15
studies showed comparable baseline characteristics of the
participants, such as gender, age, initial pain and distribu-
tion of teeth. The quality of included articles was good
since most of them had low risk (Fig. 2). As summarised
in Table 1, the indicators used to determine clinically
successful IANB in 17 studies varied as ten studies used
lip numbness, while five studies used lip numbness plus a
cold pulp test and two studies used electric pulp testing.
Thirteen studies used the Heft-Parker visual analogue
scale, two studies used a verbal analogue scale, one study
16
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P. Tupyota et al.
used a visual analogue scale and one study used verbal
description of pain whilst having root canal treatment. A
funnel plot of primary outcome from eight included stud-
ies relating to changing the features of local anaesthetic is
shown in Figure 3, and the symmetry of eight plots,
which means no publication bias, was demonstrated.
Effects of interventions
1. Changing the techniques of local anaesthetic injection
versus standard intervention. Buccal infiltration with 4%
articaine and 1:100 000 epinephrine was compared in
© 2017 Australian Society of Endodontology Inc
 Table 1 Characteristics of 17 included studies

Study Methods Participants Interventions Outcome

Poorni et al. (3) 156 volunteers Healthy, aged 18–30 years with active pain of at least Group I: IANB with 4% articaine with Success was the ability to access
54 mm. HP-VAS in mandibular molars, prolonged 1:100 000 adrenaline (n = 52) and instrument the tooth
P. Tupyota et al.

response to cold testing with ice stick and EPT, Group II: Buccal infiltration with 4% articaine without pain (VAS score 0) or
absence of any periapical radiolucency on radiograph with 1:100 000 adrenaline (n = 52) mild pain (VAS ≤ 54)
except widening PDL space, vital coronal pulp on Group III (control): IANB using 2% lidocaine
access opening with 1:100 000 adrenaline (n = 52)
Aggarwal et al. (4) 87 patients with actively Good health, not taking any medication that would alter Group I: Supplemental with buccal and Success rate to pulpal
experiencing pain pain perception, actively experiencing pain in a lingual infiltration with 2% articaine with anaesthesia: no pain or weak/
mandibular molar, prolonged response to cold testing 1:200 000 epinephrine two min after IANB mild pain during access
with an ice stick and EPT, absence of any periapical with 1.8 mL of 2% lidocaine with 1:200 000 preparation and

© 2017 Australian Society of Endodontology Inc

Parirokh et al. (5) 84 patients Older than 18 years, healthy, having a first mandibular
Aggarwal et al. (6) 55 volunteers selected Good health, none were taking any medication that
from dental emergency
department
radiolucency on radiographs, except for a widened epinephrine (n = 31) instrumentation
PDL and vital coronal pulp on access opening Group II: Supplemental with buccal and
lingual infiltration with 2% lidocaine with
1:200 000 epinephrine two min after IANB
with 1.8 mL of 2% lidocaine with 1:200 000
epinephrine (n = 31)
Group III (control): IANB with 1.8 mL of 2%
lidocaine with 1:200 000 epinephrine
(n = 25)
Group I (control): IANB using 1.8 mL 2% Success was no pain or weak/mild
molar with irreversible pulpitis and normal periapical lidocaine with 1:80 000 epinephrine pain during endodontic access
radiographic appearance (clinical diagnosis of (n = 28) preparation and
irreversible pulpitis was confirmed by a positive Group II: IANB using 3.6 mL 2% lidocaine with instrumentation
response to an EPT and a prolonged response with 1:80 000 epinephrine (n = 28)
moderate to severe pain to a cold test using Roeko Group III: IANB using 1.8 mL 2% lidocaine
Endo-Frost) with 1:80 000 epinephrine plus buccal
infiltration using 1.8 mL 2% lidocaine with
1:80 000 epinephrine (n = 28)
Group I (control): IANB using 1.8 mL of 2% Success was no pain or weak/mild
would alter pain perception, as determined by oral lidocaine with 1:200 000 epinephrine pain during endodontic access
questioning and written questionnaire, actively (n = 27) preparation and
experiencing pain in a mandibular molar (>54 mm on Group II: IANB using 3.6 mL of 2% lidocaine instrumentation
Heft-Parker visual analogue scale: HP-VAS), prolonged with 1:200,000 epinephrine (n = 28)
response to cold testing with an ice stick and EPT,
absence of any periapical radiolucency on
radiographs, except for a widened PDL and vital
coronal pulp on access opening, American Society of
Anesthesiologists class I or II medical history and
ability to understand the use of pain scale

(continued)

17
Pain Control During Root Canal Treatment

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 Table 1 (continued)

18
Study Methods Participants Interventions Outcome

Bigby et al. (7) 50 patients diagnosed A vital mandibular posterior tooth (molar or premolar), Group I (control): IANB using 1.8 mL of Success was the ability to access
with irreversible pulpitis actively experiencing pain, had a prolonged response 36 mg of lidocaine with 18 µg of and instrument the tooth
of a mandibular to cold testing with Endo-ice epinephrine (n = 24) without pain (VAS score 0) or
posterior tooth Group II: IANB using 3.6 mL of 36 mg of mild pain (VAS ≤ 54)
lidocaine with 18 µg of epinephrine plus
36 mg of meperidine with 18 µg of
epinephrine (n = 26)
Kreimer et al. (8) 106 patients participated Adults with a vital mandibular posterior tooth (molar or Group I (control): IANB using 3.18 mL Success was the ability to access
in the studies: 55 premolar), actively experiencing pain and had a formulation containing 63.6 mg of and instrument the tooth
patients enrolled in prolonged response to cold testing with Endo-ice lidocaine with 31.8 µg epinephrine without pain (VAS score 0) or
Pain Control During Root Canal Treatment

study I and 51 patients (n = 27) mild pain (VAS ≤ 54)

enrolled in study II. Group II: IANB using 5 mL formulation
Study II was excluded containing 63.6 mg of lidocaine with
from data analysis due 31.8 µg epinephrine (3.18 mL) plus
to an inability to 1.82 mL of 0.5 mol L 1 mannitol (n = 28)
compare with standard
treatment (IANB 2%
lidocaine)
Claffey et al. (9) 72 patients diagnosed Good health, had a vital mandibular posterior tooth Group I: IANB using 2.2 mL of 4% articaine Success was the ability to access
with irreversible pulpitis (molar or premolar), actively experiencing pain and with 1:100 000 epinephrine (n = 37) and instrument the tooth
of a mandibular had a prolonged response to cold testing with Group II (control): IANB using 2.2 mL of 2% without pain (VAS score 0) or
posterior tooth Endo-ice lidocaine with 1:100 000 epinephrine mild pain (VAS ≤ 54)
(n = 35)
Sampaio et al. (10) 70 patients 18–50 years old, good health according to a health Group I (control): IANB using 3.6 mL of 2% Success was defined as no pain
history questionnaire, had at least one molar adjacent lidocaine with 1:100 000 epinephrine (pain score 0 or 1) during
to a molar presenting irreversible pulpitis and a (n = 35) endodontic access preparation
healthy contralateral canine with no deep carious Group II: IANB using 3.6 mL of 0.5% and root canal instrumentation
lesions, extensive restoration, advanced periodontal bupivacaine with 1:200 000 epinephrine
disease, a history of trauma, or sensitivity, had a (n = 35)
moderate to severe spontaneous pain, positive
response to the electric pulp test and a prolonged
response to cold testing with Endo-Frost
Tortamano et al. (11) 40 patients with actively 18–50 years old, good health as determined by a health Group I (control): IANB using 3.6 mL of 2% Success was no pain (pain score 0
experiencing pain history questionnaire. Moderate severe spontaneous lidocaine with 1:100 000 epinephrine or 1) during access preparation
pain and exhibited a positive response to EPT and a (n = 20) and root canal instrumentation
prolonged response to cold testing with Endo-Frost. Group II: IANB using 3.6 mL of 4% articaine
Had at least one adjacent tooth plus a healthy with 1:100 000 epinephrine (n = 20)
contralateral canine or a contralateral canine without
deep carious lesions, extensive restoration, advanced
periodontal disease, history of trauma or sensitivity

(continued)
P. Tupyota et al.

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 Table 1 (continued)
Study Methods
Aggarwal et al. (12) 72 patients actively
experiencing pain
© 2017 Australian Society of Endodontology Inc
Oleson et al. (13) 100 patients diagnosed
with irreversible pulpitis
of a mandibular
posterior tooth
Parirokh et al. (14) 150 patients with
irreversible pulpitis
Prasanna et al. (15) 114 patients with
irreversible pulpitis of a
mandibular posterior
tooth
19
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Participants Interventions Outcome
Good health, not taking any medication that would alter Group I: Premedication with ibuprofen 600 mg Success was no pain or weak/mild
pain perception, actively experiencing pain in a one h before IANB with 2% pain during endodontic access
P. Tupyota et al.
mandibular molar, a prolonged response to cold lidocaine with 1:200 000 epinephrine preparation and
testing with an ice stick and EPT, absence of any (n = 24) instrumentation
periapical radiolucency on radiographs, except for Group II: Premedication with ketorolac 20 mg
widened PDL and vital coronal pulp on access opening one h before IANB with 2% lidocaine with
and ability to understand the use of pain scale 1:200 000 epinephrine (n = 24)
Group III (control): Premedication with starch
(placebo) one h before IANB with 2%
lidocaine with 1:200 000 epinephrine (n = 24)
Not taken any analgesics for at least eight hours before Group I: Premedication with ibuprofen Success was the ability to access
enrolment, a vital mandibular posterior tooth, actively 800 mg 45 min before IANB with 2% and instrument the tooth
experiencing pain, a prolonged response to cold test, lidocaine with 1:100 000 epinephrine (n = 49) without pain (VAS score 0) or
had no periradicular pathosis (other than widened Group II (control): Premedication with mild pain (VAS ≤ 54)
PDL), vital coronal pulp tissue on access placebo 45 min before IANB with 2%
lidocaine with 1:100 000 epinephrine (n = 51)
Over 18 years of age, healthy, having a first or second Group I: Premedication with 600 mg Success was no pain or weak/mild
mandibular molar with irreversible pulpitis and normal ibuprofen one h before IANB with 2% pain during endodontic access
periapical radiographic appearance (clinical diagnosis lidocaine with 1:80 000 epinephrine (n = 50) preparation and
of irreversible pulpitis was confirmed by a response to Group II: Premedication with 75 mg instrumentation
an electric pulp test and a prolonged and exaggerated indomethacin one h before IANB with 2%
response with moderate to severe pain to cold test lidocaine with 1:80 000 epinephrine (n = 50)
using Roeko Endo-Frost) Group III (control): Premedication with
placebo one h before IANB with 2%
lidocaine with 1:80 000 epinephrine (n = 50)
Age range of 21–40 years who reported to the dental Group I: Premedication with 8 mg lornoxicam Success was no pain during
emergency department, healthy (ASA I or II), one h before IANB with 1.8 mL 2% endodontic access preparation
experiencing pain in a mandibular molar with a lidocaine containing 1:200 000 and root canal instrumentation
prolonged response to cold testing (lingering pain epinephrine (n = 38)
more than 45 s) and EPT, vital pulp, absence of Group II: Premedication with 50 mg
periapical radiolucency on radiograph except for diclofenac potassium 1 h before IANB with
widened PDL space, ability to understand the use of 1.8 mL 2% lidocaine containing 1:200 000
pain scales epinephrine (n = 38)
Group III (control): Premedication with
placebo 1 h before IANB with 1.8 mL 2%
lidocaine containing 1:200 000
epinephrine (n = 38)
(continued)
Pain Control During Root Canal Treatment
 Table 1 (continued)
20
Study Methods
Shahi et al. (16) 165 patients
Ianiro et al. (17) 40 patients diagnosed
with irreversible pulpitis
of a posterior
mandibular tooth
Simpson et al. (18) 100 patients with a clinical
diagnosis of
symptomatic
irreversible pulpitis
Aggarwal et al. (19) 98 volunteers selected
from dental emergency
department
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Participants Interventions Outcome
Adults had not taken any analgesics for at least 12 hours Group I (control): Premedication with Success was no pain or mild
before enrolment in the study and had a first or placebo + IANB using 1.8 mL 2% lidocaine pain (VAS < 20) during
second mandibular molar with asymptomatic with 1:80 000 epinephrine (n = 55) endodontic access
irreversible pulpitis and a normal periapical Group II: Premedication with 0.5 preparation and
radiographic appearance. The clinical diagnosis of dexamethasone + IANB using 1.8 mL 2% instrumentation
irreversible pulpitis was verified by a prolonged lidocaine with 1:80 000 epinephrine (n = 55)
response to cold testing with Green Endo-Ice Group III: Premedication with 400 mg
ibuprofen + IANB using 1.8 mL 2% lidocaine
with 1:80 000 epinephrine (n = 55)
Nine years or older, diagnosis of irreversible pulpitis in a Group I: (n = 14): Premedication with 1000 mg If access and subsequent
Pain Control During Root Canal Treatment
posterior mandibular tooth, good health, had no acetaminophen + IANB with 3.6 mL of 2% treatment were rendered
contra-indication to taking acetaminophen, ibuprofen lidocaine with 1:100 000 epinephrine without pain, the IANB was
or sugar placebo Group II (n = 13): Premedication with recorded as a success
1000 mg acetaminophen + 600 mg
ibuprofen + IANB with 3.6 mL of 2%
lidocaine with 1:100 000 epinephrine
Group III (control; n = 13): Premedication
with placebo + IANB with 3.6 mL of 2%
lidocaine with 1:100 000 epinephrine
Adult patients had not taken any analgesics for at least Group I: Premedication with a combination of Success was the ability to
eight hours before enrolment in the study, had a vital 800 mg ibuprofen USP powder and access, clean, and shape the
mandibular posterior tooth (molar or premolar), 1000 mg acetaminophen USP tooth without pain (VAS score
actively experiencing moderate to severe pain and powder + IANB using 1.8 mL 2% lidocaine 0) or mild pain (VAS ≤ 54)
had a prolonged response to cold testing with Green with 1:100 000 epinephrine (n = 50)
Endo-Ice Group II: Premedication with placebo + IANB
using 1.8 mL 2% lidocaine with 1:100 000
epinephrine (n = 50)
Actively experiencing pain, good health, not taking any Group I: IANB using 1.8 mL of 2% lidocaine Success was no pain or
medication that would alter pain perception, as with 1:200 000 epinephrine + buccal weak/mild pain during
determined by oral questioning and written infiltration of 4% articaine with 1:100 000 endodontic access
questionnaire, actively experiencing pain in a epinephrine (n = 24) preparation and
mandibular molar (>54 mm on Heft-Parker visual Group II: IANB using 1.8 mL of 2% lidocaine instrumentation
analogue scale: HP-VAS), a prolonged response to with 1:200 000 epinephrine + buccal
cold testing with an ice stick and EPT, absence of any infiltration of 30 mg mL 1 of ketorolac
periapical radiolucency on radiographs, except for tromethamine (n = 26)
widened PDL and vital coronal pulp on access Group III: IANB using 1.8 mL of 2% lidocaine
opening, American Society of Anesthesiologists class I with 1:200 000 epinephrine + buccal
or II medical history and ability to understand the use infiltration of 4 mg mL 1 of
of pain scale dexamethasone (n = 24)
Group IV (control): IANB using 1.8 mL of 2%
lidocaine with 1:200 000 epinephrine + did
not receive buccal infiltration (n = 24)
P. Tupyota et al.

P. Tupyota et al.
Figure 2 Quality of 17 included studies: (+) indicates adequate quality;
(?) indicates questionable quality.
one study (n = 104) with a standard intervention, i.e.
IANB with 2% lidocaine (3). There was no statistically
significant difference in terms of pulp anaesthesia
between these two techniques (RR = 1.00; 95%
CI = 0.76–1.32; Fig. 4).
2. Supplemental injection plus standard intervention
versus standard intervention. Two studies (n = 107)
reported a comparison of different methods of supple-
mental injection. The standard intervention, i.e. IANB
using 2% lidocaine, was followed by the buccal and lin-
gual infiltration as the supplemental injection in one
study (4), whereas only the buccal infiltration was per-
formed for the supplemental injection in the other study
(5). Although there was a statistically significant
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Pain Control During Root Canal Treatment
difference in pulp anaesthesia (P = 0.002; RR = 4.41;
95% CI = 1.71–11.37), favouring IANB plus supplemen-
tal buccal infiltration (5), there was no statistically signifi-
cant difference in pulp anaesthesia between IANB and
IANB plus supplemental injection for pooled data from
these two studies (P = 0.14; pooled RR = 2.37; 95%
CI = 0.75–7.46; Fig. 5).
3. Changing the features of local anaesthetic versus stan-
dard intervention. A meta-analysis of eight studies (3, 5–
11), including a total of 492 participants, is reported in
Figure 6. The overall success rate of pulp anaesthesia
with supplemental interventions was statistically signifi-
cantly higher than that of the standard intervention
(P = 0.03; pooled RR = 1.26; 95% CI = 1.02–1.56).
However, the results among these eight studies were low
in consistency with overlapped CIs and I2 = 20%. Thus,
the source of heterogeneity was conducted by sub-group
analysis: (i) increasing volumes of local anaesthetic (ii)
increasing volumes and changing components of local
anaesthetic and (iii) changing types of local anaesthetic.
Among the three sub-groups, a statistically significant
higher success rate of pulp anaesthesia was found only in
the sub-group where there was an increase in anaesthetic
volumes (P = 0.007; RR = 2.25; 95% CI = 1.25–4.05;
Fig. 6).
4. Premedication with non-steroidal anti-inflammatory
drugs (NSAIDs), acetaminophen, or a combination of
acetaminophen and ibuprofen versus standard interven-
tion. Seven studies (n = 696; 12–18) were included for
this comparison. The supplemental interventions were
divided into three sub-groups: (I) premedication with
NSAIDs (II) premedication with acetaminophen and (III)
premedication with a combination of acetaminophen
and ibuprofen. The results derived from these seven stud-
ies could not be pooled due to two comparisons being
reported in one study (17). However, five studies (12–16)
using premedication with NSAIDs as the supplemental
intervention showed a statistically significantly higher
rate of successful pulp anaesthesia than that of the stan-
dard intervention (P = 0.001; random pooled RR = 1.75,
95% CI = 1.24–2.48; Fig. 7).
5. Supplemental infiltration with other local anaesthetic
agents, including 2% articaine with 1:200 000 epinephr-
ine, 4% articaine with 1:100 000 epinephrine,
30 mg mL 1 of ketorolac tromethamine, and 4 mg mL 1
of dexamethasone, versus standard intervention. Two
studies (n = 194) (4, 19) provided four comparisons of
the supplemental infiltration with different local anaes-
thetic agents versus the standard intervention, i.e. IANB
using 2% lidocaine with 1:200 000 epinephrine. Of four
different interventions, only supplemental buccal and
lingual infiltration with 2% articaine and 1:200 000 epi-
nephrine yielded a statistically significant higher rate
21
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Pain Control During Root Canal Treatment P. Tupyota et al.

Figure 3 Funnel plot of primary outcome from eight included studies. RR, relative risk; SE, standard error.

Figure 4 Changing the techniques of local anaesthetic injection versus standard intervention. CI, confidence interval; IANB, inferior alveolar nerve
block.

Figure 5 Supplemental injection plus standard intervention versus standard intervention. CI, confidence interval; IANB, inferior alveolar nerve block.

of pulp anaesthesia than the standard intervention

(P = 0.03; RR = 2.00, 95% CI = 1.08–3.72; Fig. 8),
whereas the differences between supplemental infiltra-
tion and the standard intervention for the remaining
three comparisons did not reach the significance level
(Fig. 8).
Discussion
The current review included 17 studies with a total of
1504 participants. The results demonstrate that more
effective local anaesthesia and pain control occurs
when supplemental interventions are used in addition

22 © 2017 Australian Society of Endodontology Inc

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P. Tupyota et al. Pain Control During Root Canal Treatment

Figure 6 Changing the features of local anaesthetic versus standard intervention. CI, confidence interval.

Figure 7 Premedication with non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, or a combination of acetaminophen and ibuprofen ver-
sus standard intervention. CI, confidence interval; IANB, inferior alveolar nerve block.

© 2017 Australian Society of Endodontology Inc 23


Pain Control During Root Canal Treatment
Figure 8 Supplemental infiltration with other local anaesthetic agents, including 2% articaine with 1:200 000 epinephrine, 4% articaine with 1:100 000
epinephrine, 30 mg mL 1 of ketorolac tromethamine, and 4 mg mL 1 of dexamethasone, versus standard intervention. CI, confidence interval; IANB,
inferior alveolar nerve block.
to the standard inferior alveolar nerve block whilst
performing root canal treatment on lower molars with
irreversible pulpitis. These supplemental interventions
that improved the success of pulp anaesthesia were
increasing the anaesthetic volumes and premedication
with NSAIDs. This result is similar to a study by Li
et al. in 2012 (20) who used similar criteria and a sim-
ilar methodology.
The review process of the current study was done inde-
pendently by two reviewers for the selection of eligible
studies, for assessment of the quality of each study, and
for data extraction. Discussion with the third reviewer
was only required when disagreement occurred. Eleven
of the 17 included studies (65%) were judged to have a
low risk of bias and none of the 17 included studies was
judged as having a high risk of bias in any domains of
methodological quality (Fig. 2). Baseline characteristics
were balanced between the intervention groups. Hence,
this review provides evidence that should be reliable and
of benefit to clinical practice.
Most studies reviewed have used lip numbness as the
criteria for successful anaesthesia but some used this
along with a cold pulp test or electric pulp testing. Most
studies used the Heft-Parker visual analogue scale,
although some used a verbal analogue scale or verbal
description of pain during root canal treatment.
The risk ratio was used in this review because prospec-
tive studies were selected. The random effect model was
used due to heterogeneity of the selected studies in
which a very low possibility of no difference among those
studies was expected. Even though no heterogeneity was
24
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P. Tupyota et al.
observed, the results of random and fix models are still
the same.
Although some results of this study were statistically
significant, the 1.75–2.25 times of difference may not
be considered by some as being of clinical significance.
However, clinical significance is very subjective and it
can be affected by many individual patient and opera-
tor factors. The most important consideration when
treating patients is to try and minimise the pain they
feel and ideally this should be done in a proactive or
anticipatory manner. That is, it is better for the patient
not to experience any pain at all than to experience
pain and then have to have further anaesthetic admin-
istered. This can result in the patient losing confidence
in the procedure and/or the operator in addition to
possibly increasing the amount of post-operative pain
experienced. Hence, this systematic review provides
readers with beneficial information that can be
adapted for the clinical situation to minimise pain for
the patient. For example, operators should consider
using pre-operative medications with NSAIDs where
appropriate and supplemental injection to increase the
volume of anaesthetic solution used prior to commenc-
ing root canal treatment.
Conclusions
Increasing the volume of anaesthetic and premedication
with NSAIDs provided more predictable pulp anaesthesia
and pain control during root canal treatment of lower
molars with irreversible pulpitis.
© 2017 Australian Society of Endodontology Inc

P. Tupyota et al.
Acknowledgements
Financial support from KhonKaen University to P.C. and
the Thailand Research Fund (#BRG6080001) to S.K. is
gratefully acknowledged.
Conflict of Interests
None declared. All authors have read, edited and
approved this manuscript.
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