Clinical Oral Investigations

https://doi.org/10.1007/s00784-021-03855-2

ORIGINAL ARTICLE

Retromolar canal infiltration as a supplement to the inferior alveolar

nerve block injection: an uncontrolled clinical trial
Kasra Karamifar 1,2 & Dorna Shirali 3 & Mohammad Ali Saghiri 4,5 & Paul V. Abbott 6

Received: 1 January 2021 / Accepted: 22 February 2021

# The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2021

Abstract
Objectives This study aimed to determine the success rate of retromolar canal (RMC) infiltration following the failure of inferior
alveolar nerve block (IANB) injections for the anesthesia of mandibular first molars with acute irreversible pulpitis.
Materials and methods An IANB injection was administered for 50 patients with acute irreversible pulpitis. Lip numbness was
set as the sign of anesthesia and further evaluated and confirmed with pulp sensibility tests after 10–15 min. Access cavity
preparation was commenced unless the patient felt any pain; in this case, an RMC infiltration injection was given. The success
rate was determined through the patients’ recording of the presence, absence, or reduction of pain severity during access cavity
preparation using the Heft-Parker visual analog scale.
Results Seven patients (14%) did not experience any pain by pulp sensibility tests and during access cavity preparation after IANB
injection. Twenty-five (58.1%) of the remaining 43 patients who had the RMC infiltration injection had reduced pain, and four
patients (9.3%) experienced no pain after the RMC infiltration. Fourteen patients (32.5%) experienced no change in pain. Chi-
squared test results revealed that the percentage of patients with reduced pain was higher than that of other patients (P < 0.001).
Conclusions RMC infiltration, along with IANB, significantly reduced the pain felt by patients and increased the success of the
anesthetic technique for root canal treatment of mandibular first molars with acute irreversible pulpitis.
Clinical relevance The administration of RMC infiltration can enhance the success of the IANB technique for anesthetizing
mandibular first molars exhibiting acute irreversible pulpitis.

Keywords Acute irreversible pulpitis . Anesthesia success . Inferior alveolar nerve block . Retromolar canal infiltration

Highlights
• Retromolar canal infiltration, along with inferior alveolar nerve block, Introduction
can reduce the severity of pain felt by patients with mandibular first
molars with acute irreversible pulpitis.
Achieving adequate anesthesia for root canal treatment is a
* Kasra Karamifar
challenge for dental practitioners in most cases. Although
kasra.karamifar@gmail.com the inferior alveolar nerve block (IANB) injection is the most
widely used technique to anesthetize mandibular molars for
1 endodontic treatment [1], the success rate (19–56%) is not
Oral and Dental Disease Research Center, School of Dentistry,
Shiraz University of Medical Sciences, Ghasrodasht st, Shiraz, Iran always adequate, particularly in patients with acute irrevers-
2 ible pulpitis [2–5]. Therefore, using supplementary injections
Sector of Angiogenesis Regenerative Medicine, Dr. Hajar Afsar
Lajevardi Research Cluster (DHAL), Hackensack, NJ, USA and techniques is necessary when the pain is too severe for the
3 clinician to proceed [6].
Department of Endodontics, Dental School, Shiraz Azad University,
Shiraz, Iran Some reasons have been proposed for the failure of
4 IANB—these include needle placement [7], level of anxiety,
Biomaterial and Prosthodontics Laboratory, Department of
Restorative Dentistry, Rutgers School of Dental Medicine, psychological factors (personality, expectations, and anticipa-
Newark, NJ, USA tion) [8], potential variations in innervation and accessory in-
5
Department of Endodontics, University of the Pacific, Arthur A. nervation [9, 10], a double or bifid inferior alveolar nerve [11],
Dugoni School of Dentistry, San Francisco, CA, USA accessory innervation from the sensory component of the
6
Clinical Dentistry, UWA Dental School, University of Western mylohyoid nerve [12], innervation corresponding to the first
Australia, Perth, Australia cervical branches, and inflammation and infection [13].

Anesthetizing symptomatic teeth can be more challenging
than that of asymptomatic teeth [14] with acute inflammation
having been suggested as the reason for this difference [15].
A handful of methods have been proposed to overcome
such failures. Supplementary injections are the first means that
can be used. Intraosseous and intraligamentary anesthesia [3,
16] plus buccal infiltration of sodium bicarbonate [17] are
among the proposed methods.
The retromolar fossa is a triangular area posterior to the
mandibular third molar tooth, where the retromolar canal
(RMC) and foramen (RMF) may be present as a variation in
the anatomy of the retromolar area. These may accommodate
and deliver neurovascular elements, which may possibly in-
nervate the mandibular third molars and surrounding tissues.
They might play a role in the anesthetic failure, sensory loss in
the area innervated by the buccal nerve, and local hemorrhage
during surgery [18, 19]. In the case of anesthetic failure, a few
drops of anesthetic solution in the anomalous retromolar re-
gion, or adoption of the same approach as in patients with a
bifid canal (high mandibular block) [19], can overcome this
failure. Furthermore, the infiltrative anesthetic technique to
the inferior alveolar nerve via the retromolar triangle has been
proposed as a technique for patients with blood dyscrasias
[20] which shows the connection between these two anatom-
ical structures.
The supplemental retromolar foramen injection has not
been thoroughly studied in endodontics. Therefore, the aim
of this study was to clarify the clinical anesthetic effectiveness
of the supplementary retromolar foramen injection technique
for mandibular first molars with acute irreversible pulpitis
when the routine IANB injection has failed.
Materials and methods
The Ethics Committee of the University approved the protocol
of the study (no. IR. IAU. SHIRAZ. REC.1397.001; IRCT.ir
code, IRCT20161031030608N2). All the patients signed and
submitted informed consent forms. The inclusion criteria
consisted of having a mandibular first molar with moderate-
to-severe pain, with prolonged response to a cold spray (Endo-
Frost; Coltene-Whaledent, Langenau, Germany) test. Patients
exhibiting no response to cold testing, no bleeding of the cor-
onal pulp tissue on access, or a periapical radiolucency (other
than a widening of the periodontal ligament space) were not
included. All the patients included had a mandibular first mo-
lar tooth with acute irreversible pulpitis.
The exclusion criteria were:
& Patients < 18 years of age
& A history of a major medical condition, pregnancy, aller-
gic reactions to local anesthetics or sulfites
& Use of medications affecting the anesthetic assessment
Clin Oral Invest
& Active pathological conditions in the area of injection
& Inability to submit an informed consent form
Fifty healthy patients participated in this uncontrolled clin-
ical trial. The subjects were selected randomly (simple ran-
domization) from emergency patients referred to the
Department of Endodontics, in the Dental School, Shiraz
Azad University, Shiraz, Iran.
The pulp sensibility of each included tooth was recorded at
baseline with an electric pulp tester (Analytic Technology,
Redmond, WA) and cold test (Endo-Ice, Coltene/Whaledent
Inc., Cuyahoga, OH) before the first injection which was an
IANB. The validity of the readings provided by the pulp tester
was assessed at baseline with a control tooth on the contralat-
eral side (the corresponding contralateral tooth was used if
present) once prior to the IANB injection, which also made
the patients familiar with the pulp tester function and sensa-
tion. Each patient was administered an IANB injection with a
direct or Halstead approach. After aspiration, 1.8 mL of 2%
lidocaine HCl with 1:80,000 concentration of epinephrine
(Persocaine-E, Darou Pakhsh Pharmaceutical Co., Iran) was
deposited slowly (2 mL/min).
After the initial IANB injection, the pulp testing procedure
was undertaken again every 2 min for approximately 10 to
15 min or until a maximum reading of 80 was achieved with-
out sensation. Lip numbness was considered as a further cri-
terion for the IANB success and the patient was questioned for
lip numbness 10 to 15 min after the injection. If lip numbness
was not achieved, the IANB was considered to be unsuccess-
ful, and the retromolar pad injection was administered (Fig. 1).
Those patients exhibiting pulp anesthesia (a pulp test reading
of 80 without sensation) after the initial IANB injection
underwent the root canal treatment after consulting with the
clinician in charge. A note was made when the treatment was
rendered with no pain. Those patients who did not have pulp
anesthesia by 10 min after the initial IANB injection or those
exhibiting pain during the endodontic procedure underwent
the retromolar pad infiltration injection. Treatment was then
instituted immediately once there was no response to the pulp
sensibility test (Fig. 2).
The patients were asked to categorize their treatment expe-
rience as pain-free or painful. The presence of moderate or
severe pain during treatment was deemed a failure of anesthe-
sia. The sensibility of the pulp was registered 2 min after each
supplementary injection, followed by the repetition of the pro-
cedure at 5 min if pulp anesthesia (no response at a reading of
80) was not confirmed at the 2-min interval. If a reading of 80
was not achieved with the pulp tester without sensation after 5
min, the patient was excluded from the study, and their end-
odontic treatment was completed using further supplementary
anesthetic measures.
Each patient rated his or her pain on a Heft-Parker VAS
(HP-VAS) [21], which consists of a 170-mm marked line
Clin Oral Invest
Fig. 1 a and b Location for injection of the retromolar canal infiltration
divided into four categories with different terms describing the
severity of pain: no pain, mild pain, moderate pain, and severe
pain at 0-mm, 1–54-mm, 55–113-mm, and 114–170-mm in-
tervals, respectively.
Seven patients reported lip numbness and had no response
to EPT and cold test after the IANB—therefore, their treat-
ment was initiated without any supplemental injections.
Fifteen minutes after each injection, the relevant tooth
Fig. 2 Consort flowchart: Flow diagram of the progress through the
phases of the study
underwent isolation with a dental dam and the access cavities
were prepared. The same operator instructed the patients to
rate any pain felt during access cavity preparation or initial file
placement. When the patient felt any pain, the treatment pro-
cedure was interrupted immediately, so that the patient could
rate the pain severity on the HP-VAS. No pain or mild pain
(an HP-VAS score of up to 54) indicated success of the IANB
injection. A single operator performed all the injections, pulp
testing procedures, and the endodontic treatments (D. Sh). All
injections were administered using a standard aspirating den-
tal syringe and a 27-G, 31-mm needle (CK ject; CK Dental,
Kor-Kyungji-do, Korea).
In this study, the presence or absence of anesthesia after
10–15 min following injection was considered as primary

outcome. If reduced pain after injection occurred in 50% of
the samples, considering the maximum error type 1 (0.05) and
power of 80, 45 samples were required. In order to enhance
the validity of the study, the number of the samples was in-
creased to 50.
Statistical analysis
Data on initial pain and success of the IANB and retromolar
canal injections are presented as mean ± SD and N (%). The
chi-square test was used with SPSS (Software version 20,
IBM Corporation, Armonk, NY) to compare the proportions
of pain severities. The level of significance was set at 0.05 (P
< 0.05).
Results
Seven patients (14%) did not experience any pain after the
IANB injection, and the root canal treatment was performed.
The remaining 43 patients had an RMC injection. Of these, 25
(58.1%) patients experienced reduced pain and four patients
(9.3%) had no pain after the RMC injection. Fourteen patients
(32.5%) experienced no change in their level of pain after the
RMC injection. The chi-squared tests revealed that the per-
centage of patients with reduced pain was higher than the
other patients with no change in pain (P < 0.001).
Discussion
Anesthetic failure can be confirmed if symptoms of anes-
thesia are not evident after 10–15 min following the ad-
ministration of the anesthetic solution [19]. The underlying
cause should be identified to overcome this failure and
other methods need to be considered to improve the level
of anesthesia for the patient.
The retromolar fossa is a triangular area posterior to the
mandibular third molar tooth. The RMF is present in this area,
and it can contain nerve fibers that innervate the mandibular
molars [22, 23] with the prevalence ranging from 1.7 to 72%
[23–25]. Furthermore, it can extend into the mandibular body
with the branches of the IAN innervating the molar area with
the chance of evading the effects of anesthetic solutions [19,
26, 27], thus increasing the chance of lowering the success
rate of IANB injections [19, 28].
As the IANB injection technique is not very efficient (23–
41% success rate) in providing adequate anesthesia in patients
with mandibular molars and premolars that have acute irre-
versible pulpitis, various techniques and solutions, such as the
Gow-Gates and Vazirani-Akinosi block injection techniques,
increasing the volume and changing the type of the anesthetic
Clin Oral Invest
solution, or pre-treatment with ibuprofen, have been proposed
[4, 29, 30]. Repeating the injection is the first option in case of
initial injection failure [31]. Other means are intraligamentary
injections with a reported success rate of around 63–93% after
the first injection [32, 33] and 92% after the second injection
[32]. An intraosseous injection is another method with an
approximate 90% success rate [34].
In order to eliminate the effect of age, gender, and initial
pain variables on the results, these variables were matched
between the two groups. All patients had acute irreversible
pulpitis, which was confirmed by the response to cold testing
and the presence of bleeding coronal pulp tissue during access
cavity preparation with moderate to severe preoperative pain.
Pulp sensibility testing with Endo Ice and EPT was used in
this study to evaluate the status of the pulp anesthesia. These
tests are said to be accurate and reliable methods of determin-
ing the pulp status [35]. However, more than 40% of the
patients with irreversible pulpitis that had no response to the
electric pulp test and Endo-Ice required supplemental injec-
tions [2] which is reported to be mainly due to accessory
innervation and anatomical variations in the innervation of
mandibular molars [2, 36]. It is noteworthy to mention that
lip numbness as an initial test is a common method used by
dentists to assess whether an IANB injection is working prior
to commencing any treatment, the absence of which indicates
the failure of IANB. However, it was not the definitive test in
this study since the pulp of the involved teeth was also tested
with cold and electric pulp tests prior to starting treatment.
In the current study, 14% of the patients did not experience
any pain after the IANB injection, which was confirmed by
the EPT and cold test, and the root canal treatment procedure
continued without any further injections. This is reasonably
consistent with some previous studies [2, 5, 37].
The RMC infiltration significantly increased (9.3%) the
success of anesthesia, and more cases showed the real efficacy
of this technique. Furthermore, RMC infiltration resulted in a
significant decrease in pain severity in 58.1% of cases, which
makes this infiltration a candidate to be considered as a sup-
plementary injection technique. However, some patients
(32.6%) did not experience a change in the level of pain after
retromolar pad infiltration. This is likely to be related to the
variable presence of the nerves in the RMC that innervate the
molar teeth, as discussed above.
In many dental researches, HP-VAS has been used to eval-
uate the level of pain as this method is more common, more
reliable, valid, sensitive, and appropriate in comparison with
some other methods [38]; therefore, this method was used in
this study.
One of the limitations of this study was that it was not
possible to have a control group as it would be unethical to
use a sham or mock injection when treating human patients
who require pain relief. This study was not designed to com-
pare this injection technique with other supplementary
Clin Oral Invest
injections. It was designed to determine whether this injection
technique could be used as a supplementary injection when an
IANB has not been successful. Furthermore, it should be not-
ed that in about 8% of cases receiving IANB, the onset of
anesthesia can take up to 30 min which can affect the result
of the study [39].
Further studies should focus on the prevalence of RMC in
different races and ethnicities. Other variables that should be
addressed in further studies include the sample size, the effect
of this infiltration for second molars, and the type of the anes-
thetic solution used. The efficacy of this technique should also
be compared with other supplementary anesthetic techniques
in future controlled and blinded studies.
Conclusion
The administration of RMC infiltration injections after an
IANB injection significantly reduced the amount of pain felt
by patients and increased the success rate of anesthesia for
root canal treatment of mandibular first molars with acute
irreversible pulpitis.
Acknowledgements MAS is a recipient of New Jersey Health
Foundation Award. The views expressed in this paper are those of the
authors and do not necessarily reflect the views or policies of the affiliated
organizations. The authors hereby announced that they have active coop-
eration in this scientific study and preparation of present manuscript. The
authors confirm that they have no financial involvement with any com-
mercial company or organization with direct financial interest regarding
the materials used in this study.
Authors’ contributions Designed the experiment: KK, DS, MAS, PVA.
Conducted the experiment: KK and DS. Analyzed/interpreted data: KK,
DS, MAS, PVA. Wrote the article: KK, DS, MAS, PVA. Proofed/revised
article: KK, DS, MAS, PVA.
Funding The work was self-funded.
Declarations
Ethics approval and consent to participate All procedures performed in
the study were in accordance with the ethical standards of the institutional
and/or national research committee and with the 1964 Helsinki declara-
tion and its later amendments or comparable ethical standards. Informed
consent was obtained from all individual participants included in the
study.
Conflict of interest The authors declare no conflict of interest.
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