IntrapulpalAnesthesia.pdf

See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/382817230 Intrapulpal anesthesia in endodontics: an updated literature review Article in Journal of Dental Anesthesia and Pain Medicine · August 2024 DOI: 10.17245/jdapm.2024.24.4.265 CIT...

See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/382817230 Intrapulpal anesthesia in endodontics: an updated literature review Article in Journal of Dental Anesthesia and Pain Medicine · August 2024 DOI: 10.17245/jdapm.2024.24.4.265 CITATIONS READS 0 83 5 authors, including: Raghavendra Penukonda Amil Sharma Mahsa University College Modern Dental College 16 PUBLICATIONS 68 CITATIONS 18 PUBLICATIONS 6 CITATIONS SEE PROFILE SEE PROFILE Harshada Pattar Mahsa University College 7 PUBLICATIONS 10 CITATIONS SEE PROFILE All content following this page was uploaded by Amil Sharma on 05 August 2024. The user has requested enhancement of the downloaded file.  pISSN 2383-9309❚eISSN 2383-9317 Review Article J Dent Anesth Pain Med 2024;24(4):227-000❚https://doi.org/10.17245/jdapm.2024.24.4.227 Intrapulpal anesthesia in endodontics: an updated literature review Raghavendra Penukonda1, Saloni Choudhary2, Kapilesh Singh3, Amil Sharma4, Harshada Pattar5 1 Dental Research Unit, Center for Global Health Research, Saveetha Medical College and Hospital, Saveetha Institute of Medical and Technical Sciences, Chennai, Tamil Nadu, India 2 Department of Conservative Dentistry and Endodontics, Krishnadevaraya College of Dental Sciences and Hospital, Bangalore, India 3 Department of Conservative Dentistry and Endodontics, SMBT Dental College and Hospital, Mumbai, India 4 Department of Conservative Dentistry and Endodontics. Modern Dental College and Hospital, Indore, Madhya Pradesh, India 5 Department of Oral Pathology, Pandit Deendayal Upadhyay Dental College, Solapur, Maharashtra, India Effective pain management is crucial for the successful performance of various endodontic procedures. Painless treatments are made possible by anesthetizing the tooth to be treated using various nerve-block techniques. However, certain circumstances necessitate supplemental anesthetic techniques to achieve profound anesthesia, especially in situations involving a “hot tooth” in which intrapulpal anesthesia (IPA) is employed. IPA is a technique that involves the injection of an anesthetic solution directly into the pulp tissue and is often utilized as the last resort when all other anesthetic techniques have been unsuccessful in achieving complete pulpal anesthesia. This review focuses on the IPA procedure and the factors that influence its success. Additionally, the advantages, limitations, disadvantages, and future directions of IPA are discussed. Keywords: Hot Tooth; Intrapulpal Anesthesia; Local Anesthesia; Pain Management; Supplemental Anesthetic Technique. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. INTRODUCTION Local anesthetics continue to be the most widely employed drugs during endodontic procedures. Various local anesthetic techniques are employed to Effective pain management is crucial when performing anesthetize the tooth, enabling the clinician to perform endodontic therapy, since it decreases the patient's anxiety endodontic therapy. However, achieving profound and improves comfort, thereby allowing the clinician to anesthesia depends on the dental arch to be anesthetized, focus on treatment without interruptions. Delivering the tooth's pulpal status, the chosen anesthetic technique, painless treatments to patients increases their satisfaction the type and amount of anesthetic solution used, and the and the probability of obtaining referrals, thus enhancing patient's anxiety levels [4,5]. Previous research indicates clinical practice overall. Pharmacological agents, such that it is more challenging to anesthetize the mandibular as local anesthetics and analgesic drugs, are used to teeth than the maxillary teeth due to anatomical alleviate pain during and after endodontic procedures. variability, increased bone density of the mandible, and Received: March 20, 2024 Revised: April 26, 2024 Accepted: July 8, 2024 Corresponding Author: Raghavendra Penukonda, Adjunct Faculty, Dental Research Unit, Center for Global Health Research, Saveetha Medical College and Hospital, Saveetha Institute of Medical and Technical Sciences, Chennai 600077, Tamil Nadu, India E-mail: [email protected] Copyrightⓒ 2024 Journal of Dental Anesthesia and Pain Medicine http://www.jdapm.org 227 Raghavendra Penukonda, et al additional nerve innervations. in endodontics, highlighting its benefits, drawbacks, and The inferior alveolar nerve block (IANB) is frequently limitations. It intends to enhance our understanding of used to anesthetize the mandibular teeth, with success IPA and the factors influencing its success when rates varying considerably, often between 80% and 85%, performing endodontic therapy. and decreasing further to 25–48% in cases where the tooth is diagnosed with symptomatic irreversible pulpitis [7,8]. METHODS Employing supplemental anesthetic techniques, such as intraligamentary, intraosseous, and interseptal anesthesia, in conjunction with IANB, is beneficial in attaining The two principal authors performed an extensive adequate anesthesia. However, achieving complete literature search using the PubMed and Medline databases anesthesia becomes exceptionally challenging in "hot as the primary sources for identifying relevant tooth" situations [9,10]. The potential causes for the publications. The search was performed using MEsH inability to induce anesthesia in hot tooth situations are terms related to IPA, encompassing "Intrapulpal as follows. Anaesthesia," "Intrapulpal Injections," "Pulpal a) Decreased pH levels: Inflamed tissues often exhibit Anaesthesia," "Supplemental Anaesthetic Techniques," decreased pH levels as postulated in the “pH theory”. and "Local Anesthesia." The search terms were combined Low pH reduces the ability of the anesthetic's base form using the Boolean operators "OR" and "AND." The to penetrate nerve sheaths and membranes, typically search was restricted to articles published between 1966 leading to insufficient anesthesia. and February 2024 to ensure a broad selection of b) Altered nerve properties: Inflamed nerves usually publications containing the most up-to-date information exhibit altered resting potential and reduced excitability, on the current topic. The search yielded 235 articles. making anesthetics less effective at blocking nerve The inclusion criteria encompassed studies published impulses. exclusively in English that examined i) the employed c) Reduced neural sensitivity: A reduction in neural technique; ii) the factors influencing success, such as the sensitivity may result from the existence of size of the pulpal exposure, the gauge of the needle anesthetic-resistant tetrodotoxin sodium channel receptors employed, the type and volume of anesthetic solution and sodium channel upregulation, which occur in cases used, and the pressure employed to perform IPA; and iii) of irreversible pulpitis, leading to increased expression the advantages, disadvantages, and limitations of IPA in levels of sodium channels within the dental pulp and the context of endodontic treatment. Case reports and eventually, reducing nerve sensitivity to anesthetics. abstracts were omitted from the analysis. Intrapulpal anesthesia (IPA) is considered a last resort The primary and secondary authors meticulously for achieving adequate anesthesia in an affected tooth that examined the articles that met the inclusion criteria. After has failed to respond to conventional and other acquiring the full texts of the selected papers, a careful supplemental anesthetic techniques. IPA requires the examination of the reference lists therein was performed direct injection of the anesthetic solution into the exposed using Google Scholar to incorporate additional relevant pulp under adequate pressure and it has been found to research papers that the initial search might have missed. be extremely useful for managing "hot tooth" conditions. Any discrepancies or conflicts regarding the technique, It is necessary for approximately 5 to 10% of patients advantages, disadvantages, and factors affecting the to attain complete anesthesia, allowing clinicians to success described in the chosen publications were handled extirpate the pulp and proceed comfortably with the through author discussions until a unanimous consensus treatment. This review examines the IPA procedure was reached. Thirty-four articles were included in the 228 J Dent Anesth Pain Med 2024 August; 24(4): 000-000  Intrapulpal Anesthesia in Endodontics present literature review. mechanisms through which IPA achieves profound anesthesia. IPA PROCEDURE a) Direct nerve inhibition: Since the anesthetic solution is directly injected into the pulp, it functions by obstructing nerve impulses. The local anesthetic agent IPA is performed as follows: binds to sodium channels within the membranes of nerve a) The patient is first educated about and prepared for cells, thereby inhibiting the entry of sodium ions crucial the potential discomfort associated with the IPA for transmitting nerve signals. Consequently, this direct technique, emphasizing that the discomfort will only be application enables prompt and precise administration of momentary, lasting only a few seconds. The majority of anesthesia to the afflicted tooth, resulting in instant pain patients are willing to tolerate a brief period of pain when alleviation during endodontic operations by affecting the they are informed that profound anesthesia is to follow nerve fibers temporarily to convey pain signals [18,20].. b) Direct neural damage: IPA works by applying b) The tooth is isolated, and the existing restoration pressure to introduce an anesthetic solution into the pulp is removed. After visually locating the pulp chamber, before pulpal extirpation. The anesthesia is significantly access is gained using a high-speed, small round bur at influenced by the pressure exerted on the pulp by the the highest pulp horn in the area with thinner dentin. The solution. The anesthesia is profound and rapid when patient is reassured as they will feel a sharp, momentary administering the injections and achieving significant pain. Any bleeding is managed by applying a cotton pellet resistance. The exact method by which pressure might soaked in a local anesthetic solution. This small portion induce anesthesia is not fully understood. Nevertheless, of the exposed pulp chamber is the target area and it is hypothesized that continuous pressure may result in provides sufficient space to insert a 27-, 30-, or 31-gauge the degeneration of nerve fibers in numerous cases, needle [8,15]. resulting in adequate anesthesia. Further research should c) A topical anesthetic gel is applied to the exposed investigate the mechanism by which IPA works to gain pulp and rubbed for approximately 1 min to let the gel a more comprehensive understanding [19,21,22]. penetrate, which may assist in reducing the pain when the needle is inserted into the exposed pulp. FACTORS AFFECTING THE SUCCESS OF IPA d) The patient is always informed before insertion of the needle into the exposed pulp tissue. A 90-degree bend 1. Size of the pulpal exposure is placed on the needle to facilitate insertion. For the greatest effectiveness, pressure is applied with the The pulpal exposure should be as small as possible, opposite index finger or thumb to the area until resistance allowing the insertion of the needle deep into the pulp, is felt. Subsequently, approximately 0.2–0.3 mL of thereby enhancing the chances of attaining high pressure anesthetic solution is administered with sufficient within the chamber, resulting in direct pulpal damage and pressure to achieve pulpal anesthesia [17,18,19]. complete anesthesia. Hence, anesthetic success is influenced by the size of the exposed pulp, with smaller MECHANISM OF ACTION exposures increasing the likelihood of achieving profound anesthesia [8,19]. In case of significant exposure to the pulp chamber, The precise mechanism by which IPA acts continues the clinician should consider flooding the pulp chamber to be discussed. Nevertheless, there are two proposed with an adequate anesthetic solution for 1 min before http://www.jdapm.org 229 Raghavendra Penukonda, et al inserting the needle. Pulpal anesthesia can then be situations, such as highly anxious patients, thereby achieved by one of the following techniques. increasing the patient's comfort during IPA [8,18]. i) The "stoppering technique" refers to a procedure 3. Type and volume of anesthetic solution adopted to ensure that adequate pressure develops during the delivery of IPA. The approach involves using a stopper, Different anesthetic drugs have been employed in such as a cotton pellet or a gutta-percha point, to generate dentistry to anesthetize the teeth and ensure painless backpressure and ensure efficient deposition of the treatments. Commonly used local anesthetics in anesthetic solution into the pulp chamber. Suresh N endodontic treatments include lidocaine with 1:100,000 et al., in a study conducted to evaluate pain perception adrenaline, articaine, mepivacaine, bupivacaine, and following various needle gauges during IPA, used the prilocaine. Two percent lidocaine with 1:100,000 is still stoppering technique, wherein the cotton pellet was placed widely used as an anesthetic agent for nerve blocks and over the exposed pulp chamber after the needle was inserted IPA in both adults and pediatric patients [9,24]. Articaine into the pulp chamber. This backpressure, which is essential is a recently developed anesthetic that has enhanced for facilitating the distribution of the anesthetic solution efficacy for pulpal anesthesia due to its unique chemical within the pulp chamber, contributes to the efficacy of structure, allowing it to penetrate more effectively into the IPA procedure. the nerves that need to be anesthetized. Mepivacaine ii) A 31-gauge needle is inserted deeply into the canal and bupivacaine are categorized as long-acting until resistance is felt, after which approximately 0.2 to anesthetics ; however, their efficacy and durability 0.3 mL of anesthesia is injected into each canal [8,19]. when employed for IPA requires further evaluation. Overall, using different anesthetic drugs in dentistry 2. Gauge of the needle enables effective treatment without discomfort. Among The extent of pain experienced during IPA is these options, lidocaine is most commonly used for IPA influenced by factors such as the design of the needle, owing to its established efficiency, with minimal side the gauge of the needle used to administer the solution effects [18,24]. into the pulp tissue, the depth at which the needle is VanGheluwe conducted a comparative study to assess inserted, and the characteristics of the tissue into which the efficacy of 2% lidocaine with 1:100,000 epinephrine the anesthetic solution is injected. Of these factors, the and sterile saline solution at inducing anesthesia. The gauge of the needle used for IPA significantly influences results indicated that the effective induction of IPA is the perception of pain during the injection procedure. A independent of the solution used, suggesting similar 31-gauge needle produces substantially less pain levels of efficacy across both solutions. Additionally, perception and discomfort during IP injection in Birchfield and Rosenburg found no substantial disparity comparison to a 27-gauge needle, since the outer and in the induced local anesthesia between a sterile normal inner diameter of a 31-gauge needle is smaller than that saline solution and 2% lidocaine with 1:50,000 of a 27-gauge needle, resulting in contact with a smaller epinephrine. Therefore, when choosing a solution for area of pulp tissue and fewer type A nerve fibers being inducing IPA, both local anesthetic and sterile saline triggered during insertion. In addition, the flow rate of solutions can be considered equally effective. the solution deposited using a 31-gauge needle is The volume of local anesthetic solution utilized for IPA comparatively less because of the smaller bore diameter, is critical in guaranteeing adequate anesthesia, managing which creates less interstitial pressure during the pressure build-up, and enhancing patient comfort during deposition of the anesthetic solution. Therefore, using endodontic treatments. The amount of anesthetic solution thinner needles can help manage difficult clinical is proportional to the level of anesthesia achieved and 230 J Dent Anesth Pain Med 2024 August; 24(4): 000-000  Intrapulpal Anesthesia in Endodontics plays a significant role in sufficiently saturating the pulp considered to be the most painful injection. Introducing tissue with the anesthetic solution by promoting better the needle into the pulp tissue activates type A nerve penetration and generating suitable pressure to enhance fibers, producing an initial sharp sensation. Additionally, the efficacy of pulpal anesthesia. However, the factor that injecting a local anesthetic solution increases the ultimately decides the effectiveness of IPA is the pressure interstitial tissue pressure by expanding type A and C exerted during IPA administration [7,8,15,18,19]. fibers. Hence, the cumulative effect of increased interstitial pressure and direct nerve damage directly 4. Pressure triggers the nerve fibers, causing intense pain and Pressure plays a pivotal role in the successful execution significant patient discomfort [8,28]. However, one of of IPA. An average pressure of approximately 170 psi two techniques can be employed to reduce the pain. First, is typically required. The delivery of the anesthetic a small amount of 20% topical benzocaine gel, combined solution with substantial backpressure induces profound with hyaluronidase, can be applied before IP injection and rapid anesthesia. The requisite pressure varies into the exposed pulp. Hyaluronidase is an enzyme that depending on the dimensions and layout of the pulp hydrolyses hyaluronic acid, the main component of chamber and the canal being injected. In essence, connective tissue. It promotes drug diffusion into the the precise pressure needed for each injection may vary pulpal connective tissue, resulting in mild-to-moderate depending on specific circumstances and requires anesthesia of the exposed superficial pulpal tissue. clinicians to rely on their expertise. Second, a 31-gauge needle with a short length of approximately 6 mm can be employed. A 31-gauge ADVANTAGES OF IPA needle is preferred over thicker needles for the injection technique, because its small diameter enables deeper penetration into the pulp chamber [8,29]. a) The onset of IPA is immediate, and it is highly c) Clinicians are required to be mindful of interactions successful in achieving profound anesthesia when the between endodontic irrigants and anesthetic solutions. operator employs the appropriate technique. Sodium hypochlorite, a commonly employed irrigation b) IPA requires no special armamentarium, unlike the solution for dissolving pulp tissue in endodontics, other supplemental anesthetic techniques, such as interacts with local anesthetic solutions, such as lidocaine intraligamentary and intraosseous anesthesia. hydrochloride (with or without adrenaline), and may c) Systemic effects are non-existent or negligible, since contribute to the formation of the toxic precipitate, the volume of the anesthetic solution employed is 2,6-xylidine, which is a known carcinogen. However, minimal. clinicians neglect this crucial interaction because only a small volume of local anesthetic solution is required. LIMITATIONS AND DISADVANTAGES OF IPA d) IPA has challenges in some instances. While IPA is recommended for teeth with vital pulps, it is contraindicated for cases with partial pulp necrosis. In a) IP anesthesia has a relatively brief duration of effect, such cases, the apical extrusions of the anesthetic often lasting approximately 15–20 min. The clinician solution, necrotic debris, and pulp tissue may evoke an must work quickly and efficiently to complete the inflammatory reaction in the periapical area. required treatment within this short period to guarantee Additionally, in cases of teeth with significant canal the patient's comfort [11,23]. calcification or severe uncontrollable bleeding, the b) IPA cannot be used as a primary injection and is clinician may fail to achieve profound pulpal anesthesia, http://www.jdapm.org 231 Raghavendra Penukonda, et al even after administering IPA. to recognize its limitations and drawbacks to ensure its careful and safe application. Investigating new research FUTURE DIRECTIONS fields, such as the development of innovative anesthetic agents and fine needles, can enhance precision and reduce pain perception during administration, thereby enhancing IPA is a sophisticated technique that can achieve the predictability of IPA. In summary, IPA represents a complete anesthesia. However, additional research is cornerstone in endodontics, enabling pain management, necessary to compare the effectiveness of IPA with other particularly in situations involving hot teeth, and supplemental anesthesia techniques commonly used in facilitating efficient pain control. endodontics by utilizing different anesthetic solutions and modern instruments used for administering anesthesia. AUTHOR ORCIDs Comparative studies with significant sample numbers and Raghavendra Penukonda: https://orcid.org/0009-0009-6541-5526 rigorous procedures may yield robust information Saloni Choudhary: https://orcid.org/0009-0008-4675-7558 concerning the efficacy, pain control, and patient Kapilesh Singh: https://orcid.org/0000-0001-6893-7623 Amil Sharma: https://orcid.org/0000-0002-3408-0307 satisfaction achieved when using IPA. Harshada Pattar: https://orcid.org/0009-0001-8315-2119 IPA, being one of the most painful methods of anesthesia, necessitates future research to focus on topical AUTHOR CONTRIBUTIONS anesthetic gels or sprays with advanced formulations and Raghavendra Penukonda: Conceptualization, Data curation, Formal the invention and adaption of fine needles to minimize analysis, Investigation, Methodology, Supervision, Writing – original the discomfort experienced during its administration draft, Writing – review & editing [8,33]. Saloni Choudhary: Data curation, Formal analysis, Investigation, Writing – review & editing In brief, the future of IPA in endodontics shows Kapilesh Singh: Data curation, Methodology, Visualization, Writing excellent prospects. By employing inventive methods, – review & editing customized strategies, enhanced anesthetic solutions, and Amil Sharma: Data curation, Investigation, Project administration, cutting-edge needles, and with collaborative efforts across Supervision Harshada Pattar: Conceptualization, Data curation, Formal analysis, multiple disciplines, IPA can continue to advance, Investigation, Methodology, Writing – original draft, Writing – review offering patients better comfort, with reduced anxiety, and & editing offering dental professionals superior treatment outcomes. 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