CLINICAL RESEARCH

Dustin Weitz, DDS, MS,*

Preoperative Factors Ronald Ordinola-Zapata, DDS,
MS, PhD,*
Associated with Anesthesia Scott B. McClanahan, DDS,
MS,* Michael Shyne, MS,†
Failure for Patients Undergoing Alan S. Law, DDS, MS, PhD,*‡
and Donald R. Nixdorf, DDS,
Nonsurgical Root Canal MS§ The National Dental
Practice-Based Research
Therapy: A National Dental Network Collaborative Groupk1

Practice-Based Research
Network Study

ABSTRACT
SIGNIFICANCE
Introduction: The aim of this study was to identify preoperative factors associated with local
anesthesia failure. Methods: The National Dental Practice-Based Research Network (www. A range of 5%–30% of
NationalDentalPBRN.org) data from 534 patients who received a nonsurgical root canal anesthesia failures was
treatment completed in a single appointment were included in this analysis. Three methods for identified. Numerous variables
defining anesthesia failure were used: definition 1, patient-reported level of numbness; defi- are associated with local
nition 2, provider-reported quality of anesthesia; and definition 3, provider-reported use of anesthesia failure including
supplemental anesthesia. Fifty-one preoperative factors were investigated and analyzed provider type and experience.
individually against the overall failure rate for each method, and multivariate generalized Greater severity of various
estimating equation logistic models were fit with predictors chosen using stepwise model tooth-related pain
selection to evaluate factors that may interact with each other. Results: The overall characteristics, as a group but
anesthesia failure rates were 5%, 15%, and 30% for definitions 1, 2, and 3, respectively. not individually, accounted for
Provider experience, diabetes, absence of sharp or aching pain, absence of smoking, and a more anesthesia failures.
fair expected outcome were associated with anesthesia failure (definition 1). Provider level of
From the Divisions of *Endodontics and
training, absence of a sinus tract, bite sensitivity, and stress making the pain worse were §
TMD and Orofacial Pain, School of
associated with anesthesia failure (definition 2). Provider level of training, pain provoked by Dentistry and †Biostatistical Design and
stimulus, mandibular teeth, teeth with vital pulps, and pain interfering with daily activities were Analysis Center, Clinical and Translational
Science Institute, University of Minnesota,
associated with the use of supplemental anesthesia (definition 3). Conclusions: With the Minneapolis, Minnesota; ‡Private
range of 5%–30% of anesthesia failures, a few common factors across the models assessed Practice, The Dental Specialists, Lake
were elucidated. Providers with higher levels of training had significantly fewer anesthesia Elmo, Minnesota; and kSchool of
Dentistry, University of Alabama at
failures. Patient self-reported history of diabetes and preoperative pain-related interference Birmingham, Birmingham, Alabama
with daily activities were associated with more anesthesia failures. Greater severity of various 1
The National Dental Practice-Based
tooth-related pain characteristics, as a group but not individually, accounted for more Research Network Collaborative Group
anesthesia failures. (J Endod 2021;47:1875–1882.) includes practitioner, faculty, and staff
investigators who contributed to this
activity. A complete list is available at
KEY WORDS http://nationaldentalpbrn.org/.

Dental anesthesia; local anesthesia; persistent pain; practice-based research Address requests for reprints to Dr Ronald
Ordinola-Zapata, Division of Endodontics,
University of Minnesota, School of
Dentistry, 8-166 Moos Tower, 515
The ability to provide safe and effective local anesthesia is perhaps the most important skill a dentist can Delaware Street SE, Minneapolis, MN
develop. Barclay1 perfectly summarized the importance of local anesthesia by stating, “The cornerstone 5545
E-mail address: rordinol@umn.edu
to anxiety and pain control in dentistry is a sympathetic, understanding and caring clinician, and one 0099-2399/$ - see front matter
skilled in the use of local anesthesia.” Despite our best efforts, root canal therapy often has a
Copyright © 2021 American Association
compromised reputation because of a perceived association with extreme pain causing many patients to of Endodontists.
be anxious before and during the procedure. Most often pain is well managed; however, there are a https://doi.org/10.1016/
number of patients who do not experience adequate anesthesia2,3. j.joen.2021.09.005

JOE  Volume 47, Number 12, December 2021 Preoperative Factors Associated with Anesthesia Failure 1875

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 Kaufman et al4 found anesthesia failure
to vary by the type of injection administered
and found an overall failure rate of 13.7%. A
follow-up study regarding patient perception of
anesthesia found patient-reported anesthesia
success to be 69.7%; 13.7% of patients
reported being not numb enough, 14.3%
reported pain but it was manageable, and
2.2% reported not being able to complete
treatment due to inadequate anesthesia5.
Despite advances in techniques, the
achievement of profound local anesthesia
does not occur in every case. The reasons for
failure can generally be placed into 4
categories:
(1) poor technique,
(2) anatomic variability,
(3) inflammation and infection, and
(4) psychological factors3,6. Regardless
of the exact mechanism for failure, the ability to
identify preoperative factors that contribute to
anesthesia failure is invaluable. The main
objective of this study was to analyze data
previously collected by the National Dental
Practice-Based Research Network (DPBRN)7
to identify preoperative factors that are
associated with failure of local anesthesia
when performing endodontic therapy. This is
the first study using a large practice-based
research network to examine preoperative
factors related to anesthesia failure during
endodontic therapy.
MATERIALS AND METHODS
This investigation examined preoperative
factors associated with local anesthesia failure
through the secondary analysis of existing data
collected by the DPBRN for the purpose of
studying pain and quality of life burden
associated with nonsurgical root canal
therapy. Details of the studied methods have
been previously reported7,8. Forty-six general
dentists and 16 endodontists from 5
geographic areas in the United States and
Europe were recruited and calibrated for the
data collection; patient enrollment and patient
characteristics were collected over 6 months
with questionnaires completed by the
providers and patients before and immediately
after treatment. The inclusion criteria were
patients who were 19–70 years of age and had
a tooth requiring nonsurgical root canal
treatment. The exclusion criteria were previous
nonsurgical root canal treatment; iatrogenic
pulp exposure; the patient was previously
enrolled in the study (only 1 tooth per patient
contributed to the study); obvious cognitive
impairments; and the inability to read,
understand, and complete the baseline
questionnaire7,8. For standardization
purposes, the investigation was limited to teeth
1876 Weitz et al.
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in which the root canal therapy was completed supplement.php). Provider-related
in a single appointment. An additional 29 characteristics were provider experience,
patients were excluded because of the use of defined as 10 years or more in practice.
general anesthesia, intravenous sedation, or Provider type was either general dentist or
oral conscious sedation. Five cases were endodontist. The patient characteristics
excluded because of conflicting reporting, and studied were age, sex, ethnicity, race, level of
140 cases were not obturated at the first education, annual income, dental insurance
appointment. Of the total 708 patients who coverage, self-reported history of diabetes,
completed the study, 534 were included in the current smoker, lifetime smoking of at least
final analysis. 100 cigarettes, preoperative fear level (high or
low), patient-expected outcome (favorable or
unfavorable), and if the patient suffered from
Defining Anesthesia Failure
chronic body pain or body pain present for at
Three methods for defining anesthesia failure
least 4 days a week for the last 3 months.
were used: definition 1, patient-reported level
Preoperative fear level and expected
of numbness during the procedure; definition
outcomes responses were converted to
2, provider-reported quality of anesthesia; and
binary. Patient-reported quality of life
definition 3, provider-reported use of
characteristics studied were how much tooth
supplemental anesthesia administered after
pain interfered with daily activities, recreation,
the initial injections.
social, or family activities in the week before
For definition 1, patient-reported level of
treatment and how much tooth pain interfered
numbness immediately after the completion of
with work, including housework.
the treatment was obtained by the following
Subjective reported characteristics
question: How numb your tooth felt during the
related to tooth pain were the number of days
root canal treatment? (mark one): a. the tooth
in the week before treatment with tooth pain,
was not numb enough, b. the tooth was numb
was the tooth pain chronic (8 hours a day for
enough, or c. the tooth was too numb. For the
15 days or more than a month for the past
purposes of this study, answer “a” was
3 months), was pain medication taken, pain
considered a failure.
quality in the 7 days before treatment (reported
For definition 2, provider-reported
as none, dull, sharp, aching, throbbing,
quality of anesthesia was used to determine
burning, shooting, or electric), spontaneous
failure. The following question was answered
pain in the 7 days before treatment, pain
by the provider: What was your impression
provoked by using the tooth or an irritant in the
about the quality of the local anesthesia? (mark
7 days before treatment, factors that make the
one) a. Excellent, patient felt “nothing”; b.
pain worse (including nothing, never gets
Adequate, patient experienced nonpainful
worse, nothing, gets worse all by itself, biting or
sensations; c. Marginal, patient experienced
chewing, cold or hot food or drink, or stress),
some pain; and d. Less than marginal, patient
and pain levels (including pain level
experienced a lot of pain.” For the purposes of
immediately before treatment, worst level pain
this study, answers of “c” or “d” were
in the week before treatment, and average pain
considered a failure.
level in the week before treatment). Pain levels
For definition 3, provider-reported use of
were reported on a scale of 1 to 10, with
supplemental anesthesia was used to
0 being “no pain” and 10 being “pain as bad as
determine failure. The question was as follows:
could be.” The pain level data were converted
Were any of the following necessary to obtain
to binary with pain levels 7–10 being severe
adequate anesthesia to perform treatment?
pain and 0–6 being not severe.
(mark all that apply) a. Second injection of the
Objective reported characteristics were
same type into the same location, b. Second
tooth type, presence of a periapical radiolucent
injection of the same type into a slightly
lesion, percussion and biting sensitivity,
different location, c. Block anesthesia
responsive to cold, lingering pain with cold,
technique different from the previously
periodontal health determined by the deepest
provided, d. Periodontal ligament injection, e.
pocket depth, pulp vitality confirmed by
Intraosseous injection other than periodontal
bleeding upon access, presence of a sinus
ligament injection, and f. Intrapulpal injection.
tract, and presence of swelling. Tooth type
When entered into the database, all results
was reported by tooth number from 1–32; the
were entered as either “1” (yes) or “0” (no).
data were converted to binary in 2 ways,
maxillary or mandibular and molar or nonmolar
Preoperative Factors Studied based on the universal tooth number. The
Fifty-one preoperative factors were deepest periodontal pocket depth was
investigated and analyzed individually against reported in millimeters, and 1–3 mm was
the overall failure rate for each definition considered healthy, and .4 mm was
(DPBRN Study 17, https://www.dpbrn.org/ considered diseased, which is consistent with
JOE  Volume 47, Number 12, December 2021
the most recent staging criteria for periodontal
disease.
Statistical Procedures
Descriptive statistics were generated for all
survey variables. Participant characteristics
were summarized using counts and rates or
means and standard deviations. The
relationships between potential risk factors
and anesthesia failure were examined for each
of the 3 anesthesia failure outcomes using
logistic regression models estimated using the
generalized estimating equation method with
an exchangeable correlation structure to
account for within-provider clustering.
Multivariate generalized estimating equation
logistic models were also fit, with predictors
chosen using stepwise model selection based
on the quasi-likelihood under independence
model criterion, starting with the intercept-only
model and allowing both forward and
backward selection until the quasi-likelihood
under independence model criterion was
minimized. Analyses were conducted using R
version 4.1.1 (https://www.R-project.org/)
including the packages geepack version 1.3-2,
pstools version 0.1.1, and table one version
0.13.0.
RESULTS
Patient demographics are presented in
Table 1. The overall anesthesia failure rates
TABLE 1 - Patient Characteristics (N 5 534)
Characteristic
N 534
Patient-related characteristics
Age, mean (SD)
Number missing (%)
Male sex, n (%)
Number missing (%)
Ethnicity, n (%)
Hispanic
Non-Hispanic
Number missing (%)
Race, n (%)
White
Black
Other
Number missing (%)
Highest level of education, n (%)
Less than high school
High school
Some college
College
Advanced or graduate degree
Number missing (%)
Income
Greater than $50,000 per year
Number missing (%)
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were 5% (26/531), 15% (78/534), and 30%
(160/534) for definitions 1, 2, and 3,
respectively (Tables 2–4). In group 1, 3 patients
did not report the level of numbness. A
multivariate analysis was not conducted in the
patient-reported level of numbness because of
the low number of failures (5%).
Definition 1: Patient-Reported
Numbness
When evaluating anesthesia failure by patient-
reported numbness, the univariate test
revealed that provider experience, history of
diabetes, absence of tobacco smoking, and a
fair expected outcome had statistical
significance. The presence of sharp and
aching pain was negatively correlated to
anesthesia failure (Table 2).
Definition 2: Provider-Reported
Quality of Anesthesia
When evaluating anesthesia failure by
provider-reported numbness, provider level of
training, “stress makes the pain worse,” and
bite sensitivity were common factors identified
by the multivariate analysis. The presence of a
sinus tract was negatively correlated with
anesthesia failure (protective factor) (Table 3).
Definition 3: Use of Supplemental
Anesthesia
Using this definition, provider level of training,
pain provoked by stimulus, mandibular teeth,
Overall
47.17 (13.02)
1.9
211 (40)
1.3
24 (4.6)
510 (95.4)
2.2
481 (91.3)
21 (4.0)
16 (4.7)
1.3
4 (0.8)
80 (15.2)
159 (30.2)
205 (39.0)
78 (14.4)
1.5
320 (63.5)
5.6
Preoperative Factors Associated with Anesthesia Failure
pain interfering with daily activities, and teeth
with vital pulps present higher failure rates (use
of supplemental anesthesia) (Table 4).
Table 5 summarizes the success and
failure percentages (cross-tabulation).
According to the 3 definitions used in this
study, successful anesthesia was found in
66.9% of the cases. Failures that were
common in the 3 scenarios were found in 2.1%
of the cases.
DISCUSSION
Patient-reported numbness (definition 1) was
chosen as the patient-centered method for
defining anesthesia failure. The most plausible
explanation for the low percentages of failures
is that intraoperative pain is short and
momentary and did not leave the patient
feeling the anesthesia was inadequate. In
addition, supplemental anesthesia could be
provided for these patients, both increasing
the time for the initial injection to act and
increasing the volume of anesthetic available in
the area. Provider-reported quality of
anesthesia (definition 2) could be skewed in
that there could have been an initial failure after
which the dentist may have used multiple types
of supplementary anesthesia and eventually
made the patient quite comfortable, causing
the patient to report the quality of anesthesia
as excellent in definition 1. Many providers
consider anesthesia a strategy and not a single
technique for all situations and may treat for
symptomatic “hot” teeth differently by giving
supplemental anesthesia (definition 3) before a
failure occurs9,10.
General dentists were more likely to
have failures, with an odds ratio pointing to
approximately double the chance for a failure
compared with endodontists. Operator
experience was found to be significant when
analyzed individually in the final model.
Dower11 published the results of a survey
pertaining to local anesthesia training in dental
schools. He found that in 85% of schools the
oral and maxillofacial surgery departments
were solely responsible for the training. The
survey also found a general lack of protocol for
dealing with failed anesthesia11. Arguably, oral
and maxillofacial surgeons have the most
training on anatomy and the placement of
anesthesia blocks; however, achieving pulpal
anesthesia is much more difficult than
achieving soft tissue anesthesia. For example,
when studying the periodontal ligament
injection, Malamed12 found anesthesia to
always be successful for extractions but only
60% successful for endodontics. Most
endodontists routinely use a cold test before
initiating treatment because soft tissue lip
numbness is not reliable for determining pulpal
1877
TABLE 2 - Definition 1: Significant Factors Associated with Anesthesia Failure

Overall (N 5 531) Failure (n 5 26) Success (n 5 505) Failure rate (%) Univariate P value OR (95% CI)
Provider characteristics
More experienced* 431 17 414 3.9 .0145 0.3 (0.2–0.6)
Less experienced 77 8 69 10.4
Number missing 4.7
Patient characteristics
Diabetes history 58 9 49 15.5 .003 4.8 (1.7–13.6)
No diabetes history 460 17 443 3.7
Number missing 3
Current smoker 82 0 82 0 .02 0 (0–0.8)
Current nonsmoker 445 26 419 5.8
Number missing 1.3
Expected outcome favorable 520 23 497 4.4
Expected outcome fair 11 3 8 27.2 .02 7.9 (1.4–43.8)
Number missing 0.6
Tooth characteristics
Sharp pain 148 2 146 1.3
No sharp pain 377 24 353 6.3 .04 0.2 (0.1–0.9)
Number missing 1.7
Aching pain 210 6 204 2.8
No aching pain 315 20 295 6.3 .5 0.5 (0.2–0.9)
Number missing 1.7

CI, confidence interval; OR, odds ratio.

The event rate for patient-reported failure was too low to support a multivariate logistic model. In the univariate results for patient-reported failure, the Fisher exact test was used instead of
generalized estimating equation logistic regression for the following predictors due to complete separation: smoker, opioid preoperatively, pain burn, and a sinus tract.
*Provider experience, defined as 10 years or more in practice.

anesthesia; a negative cold test can predict
profound pulpal anesthesia 88%–92% of the
time13,14.
It was also found that patients with a
self-reported history of diabetes had 4.8 higher
chances of anesthesia failure. There is a dearth
of literature in dentistry relating diabetes to
local anesthesia success and failure. From the
medical literature, different authors found
diabetes mellitus was not significantly
correlated to spinal anesthesia failure15 or
peripheral nerve blockade16. It was speculated
that nerve fibers in diabetics may be more
sensitive to local anesthesia potentially caused
by microvascular damage seen with diabetes
or that diabetic neuropathy leads to decreased
sensation, making it appear that the anesthetic
is more successful17. The findings of these
studies appear to contrast with the findings of
this study; however, these were studies that
dealt with confirmed diabetics rather than self-
reported. The pulp has a unique microvascular
structure and relation of neurons to the smooth
muscle of the microvasculature18–20. It is
possible that microvascular changes in the
pulp and other diabetic changes that could
affect neurons may be different compared with
the large fiber neuropathy demonstrated in the
peripheral nerves in these medical studies.
Based on the findings of this study, dental
providers should expect higher rates of
anesthesia failure in endodontic procedures in
diabetic patients. More research specifically
designed to investigate diabetes and dental
local anesthesia is needed.
Some variables related to apical
periodontitis had statistical significance (biting
sensitivity and sinus tract). Teeth with apical
periodontitis may be associated with teeth with
pulpitis, necrotic pulps, or occlusal trauma21.
The presence of a sinus tract will always be
associated with necrotic pulp in teeth that are
not previously treated. In definition 2, the
presence of a sinus tract was inversely
associated with anesthesia failure with
statistical significance. A potential exception
exists with bite sensitivity, which was found to
be higher in the early stages of apical
periodontitis in vital teeth by Owatz et al22,
possibly explaining the higher failure rates
found in definition 2 with biting sensitivity.
Tooth pain with a greater impact on
quality of life factors was found to be significant
in this study. In the final regression model for
definition 3, the greater interference with daily
activities caused patients to have a 1.1 times
chance of anesthesia failure for each higher
level of interference reported on a scale of 1 to
10; a person reporting a level of 10 would have
an 11 times higher chance of failure compared
with a person reporting 1. Similarly, patients in
which the stress makes the pain worse were
2.1 times more likely to experience anesthesia
failure (definition 2). These factors showed that
more disruptive pain, whether by intensity,
duration, or some other manner, was
associated with anesthesia failure. These
results would be in agreement with the well-
established concept of symptomatic teeth
being more difficult to anesthetize3,9,10,14,23.
The definition 3 results are also in line with the
well-established view that teeth with pulp
vitality confirmed with the presence of bleeding
upon access and teeth with pain provoked by
stimulus are more difficult to
anesthetize3,9,10,14,23. Other tooth-related
characteristics significantly associated with
anesthesia failure were mandibular teeth when
analyzed individually in definition 3. Mandibular
teeth are often associated with anesthesia
difficulties9, which is consistent with our
finding.
Patient fear levels did not show
statistical significance in any model when
evaluated individually. Studies looking
specifically at dental anesthesia failure or
success related to anxiety levels are lacking
despite the fact that many studies on
anesthesia success incorporated a Corah
Anxiety Scale24. Typically, studies found that
anxiety is attributed to the symptomatic
irreversible pulpitis diagnosis and the
emergency treatment needed25. The current

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TABLE 3 - Definition 2: Significant Factors Associated with Anesthesia Failure*

Multivariate
Overall Failure Success Failure Univariate P value P value
(N 5 534) (n 5 78) (n 5 456) rate (%) OR (CI) OR (CI)
Provider characteristics
General dentist 194 38 156 19.6
Endodontist 340 40 300 11.8 .03 .07
0.5 (0.2–0.9) 0.5 (0.3–1)
Number missing 0
Tooth characteristics
Pain provoked by stimulus 266 48 218 18.0 .008 —
1.7 (1.1–2.5)
Pain not provoked by stimulus 255 29 226 11.4
Number missing 2.4
Sharp pain 148 27 121 18.2 .02 —
1.5 (1–2.2)
No sharp pain 377 50 327 13.3
Number missing 1.7
Stress makes pain worse 34 9 25 26.5 .04 .08
2.2 (1–4.1) 2.1 (0.9–4.8)
Stress does not worsen pain 490 68 422 13.9
Number missing 1.9
Cold lingering 191 35 156 18.3 .04 —
1.65 (1–2.6)
No cold lingering 339 43 296 12.7
Number missing 0.7
Sinus tract present 46 2 44 4.3 .04 .15
0.3 (0.1–0.9) 0.4 (0.1–1.4)
Sinus tract absent 474 73 401 15.4
Number missing 2.6
Bite sensitivity 296 54 242 18.2 .0003 .007
No bite sensitivity 237 24 213 10.1 2 (1.4–3) 2 (1.2–3.2)
Number missing 0.2
Quality of life characteristics (reported on a
scale of 1–10)
How much has tooth pain interfered with 2.14 (62.9) 1.34 (62.4) .002 —
recreational 1.1 (1–1.2)
activities from 1–10?

CI, confidence interval; OR, odds ratio; PARL, periapical radiolucency.

Data include the preliminary (univariate) and final model (multivariate).
*Predictors for the multivariate models were chosen using stepwise selection based on the quasi-likelihood under independence model criterion.

study also revealed that patients with a “fair”
expected outcome for the treatment
compared with “excellent” or “good” had a
statistically higher chance of anesthesia failure
(27.27% vs 4.42%) when analyzed individually
in the first definition of failure. Another
significant predictor was “stress makes the
pain worse.” It is interesting that these
psychological-related variables had statistical
significance. Catastrophizing patients were
relatively rare in this study; there were only 11
of 531 (data not shown). Highly fearful patients
were more common, representing 89 of 531
patients. Even though these variables did not
present significance in the other models and
are relatively rare, clinicians should take care to
question patients regarding preoperative fear,
level of stress, and expected outcome and
understand that fearful patients and those who
tend to catastrophize are more likely to be
dissatisfied with the level of numbness during
root canal therapy.
The failure rate according to the
patient-centered outcome (definition 1) was
only 5%. It is important to note that a
multivariate analysis was not conducted in the
patient-reported outcome because of the low
number of failures (26/531). Thus, the results
obtained in the univariate model need to be
taken with caution. Two subjective reported
characteristics related to tooth pain (sharp
and aching pain) and 1 patient-related
characteristic (smoking) were found to be
protective factors against anesthesia failure.
Patients reporting sharp and aching pain had
statistical significance when analyzed
individually in the first definition of failure and
were negatively correlated with anesthesia
failure (odds ratio 5 0.2 and 0.5, respectively).
These results are conflicting, making it difficult
to interpret and making this clinical relevance
questionable. A clearer interpretation could be
made in the final multivariate model. Failures
were associated with pain that increases with
stress, bite sensitivity, pain provoked by
stimulus, pain interfering with daily activities,
mandibular teeth, and pulp vitality confirmed
by bleeding upon access. Two protective
factors were identified: the level of training and
the presence of a sinus tract. Studies
specifically relating to diabetes or smoking
and local anesthesia failure are lacking,
providing an opportunity for future
investigation.

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TABLE 4 - Definition 3: The Use of Supplemental Anesthesia

Univariate Multivariate
Overall Failure Success Failure P value P value
(N 5 534) (n 5 160) (n 5 374) rate (%) OR (CI) OR (CI)
Provider characteristics
General dentist 194 75 119 38.7
Endodontist 340 85 255 25.0 .03 .05
0.5 (0.3–0.9) 0.5 (0.3–1)
Number missing
Patient characteristics
Age (years, SD) 45 6 12 48 6 13 .0003 —
0.98 (0.9–0.9)
Number missing 1.9
Tooth characteristics
Sharp pain 148 57 91 38.5 .0007 —
1.8 (1.3–2.6)
No sharp pain 377 102 275 27.0
Number missing 1.7
Pain provoked by stimulus 266 90 176 33.8 .005 .06
1.6 (1.1–2.2) 1.4 (1–2)
Pain not provoked by stimulus 255 66 189 25.9
Number missing 2.4
Maxillary 321 83 238 25.8 .005 .04
0.7 (0.4–0.9) 0.7 (0.4–0.9)
Mandibular 213 77 136 36.1
Number missing 0
PARL present* 218 54 164 24.8 .008 —
0.6 (0.4–0.9)
PARL absent 312 105 207 33.6
Number missing 0.7
Responsive to cold 282 65 217 23.0 .0001 —
2.4 (1.5–3.8)
Not responsive to cold 249 94 155 37.7
Number missing 0.6
Lingering cold response 191 75 116 39.3 .0009 —
2.1 (1.4-3.3)
No lingering cold response 339 83 256 24.5
Number missing 0.7
Vital pulp 278 103 175 37.0 .0002 .002
2.4(1.5–3.7) 2.2 (1.3–3.6)
Nonvital pulp 256 57 199 22.3
Number missing 0
Temperature changes make pain worse 239 79 160 33.0 0.02 —
1.6 (1.1–2.2)
Temperature does not make pain worse 285 80 205 28.1
Number missing 1.9
Sinus tract present 46 8 38 17.4 .02 —
0.4 (0.2–0.9)
Sinus tract absent 474 146 328 30.8
Number missing 2.6
Quality of life characteristics (reported on a scale of 1–10)
How much has tooth pain interfered with daily activities? 2.2 (62.8) 1.6 (62.4) .02 .04
1.1 (1–1.1) 1.1 (1–1.2)
How many days in the last week have you had tooth pain? 3.9 (62.8) 3.6 (62.8) .04 —
1.1 (1–1.1)

CI, confidence interval; OR, odds ratio; PARL, periapical radiolucency.

Data include the preliminary (univariate) and final model (multivariate).
*Predictors for the multivariate models were chosen using stepwise selection based on the quasi-likelihood under independence model criterion.

1880 Weitz et al. JOE  Volume 47, Number 12, December 2021

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TABLE 5 - Cross-tabulation of Results Comparing Success and Failure for the 3 Definitions related interference with daily activities led
to more anesthesia failures. Greater severity
Definition 1 Definition 2 Definition 3 n (%) of various tooth-related pain characteristics,
Success Success Success 355 (66.9) as a group but not individually across
Success Success Failure 86 (16.2) models, accounted for more anesthesia
Success Failure Failure 56 (10.5) failures.
Success Failure Success 8 (1.5)
Failure Success Success 6 (1.1)
Failure Success Failure 6 (1.1) ACKNOWLEDGMENTS
Failure Failure Success 3 (0.6)
Failure Failure Failure 11 (2.1) The authors thank Michael Evans, MS, BDAC,
531 (100) for statistical advice.
Supported by National Institutes of
Health (grant numbers K12-RR023247, U01-
CONCLUSIONS more experienced providers and those with DE016746, U01-DE016747, U19-DE-28717,
higher levels of training had significantly and UL1TR002494).
A range of 5%–30% of anesthesia failures
fewer anesthesia failures. Patient self- The authors deny any conflicts of
was identified. Multiple models found that
reported history of diabetes and pain- interest related to this study.

REFERENCES
1. Barclay JK. Current status of education in anesthesia and sedation in New Zealand, 1988. Anesth
Prog 1989;36:214–5.
2. Walton RE, Torabinejad M. Managing local anesthesia problems in the endodontic patient. J Am
Dent Assoc 1992;123:97–102.
3. Hargreaves KM, Keiser K. Local anesthetic failure in endodontics. Endod Topics 2002;1:26–39.

4. Kaufman E, Weinstein P, Milgrom P. Difficulties in achieving local anesthesia. J Am Dent Assoc

1984;108:205–8.
5. Weinstein P, Milgrom P, Kaufman E, et al. Patient perceptions of failure to achieve optimal local
anesthesia. Gen Dent 1985;33:218–20.

6. Sherman MG, Flax M, Namerow K, Murray PE. Anesthetic efficacy of the Gow-Gates injection and
maxillary infiltration with articaine and lidocaine for irreversible pulpitis. J Endod 2008;34:656–9.

7. Nixdorf DR, Law AS, Look JO, et al. Large-scale clinical endodontic research in the National
Dental Practice-Based Research Network: study overview and methods. J Endod
2012;38:1470–8.
8. Law AS, Nixdorf DR, Rabinowitz I, et al. Root canal therapy reduces multiple dimensions of pain: a
national dental practice-based research network study. J Endod 2014;40:1738–45.
9. Nusstein JM, Reader A, Drum M. Local anesthesia strategies for the patient with a “hot” tooth.
Dent Clin North Am 2010;54:237–47.

10. Drum M, Reader A, Nusstein J, Fowler S. Successful pulpal anesthesia for symptomatic
irreversible pulpitis. J Am Dent Assoc 2017;148:267–71.

11. Dower JS. A survey of local anesthesia course directors. Anesth Prog 1998;45:91.

12. Malamed SF. The periodontal ligament (PDL) injection: an alternative to inferior alveolar nerve
block. Oral Surg Oral Med Oral Pathol 1982;53:117–21.

13. Cohen HP, Cha BY, Sp

angberg LS. Endodontic anesthesia in mandibular molars: a clinical study.
J Endod 1993;19:370–3.
14. Hsiao-Wu GW, Susarla SM, White RR. Use of the cold test as a measure of pulpal anesthesia
during endodontic therapy: a randomized, blinded, placebo-controlled clinical trial. J Endod
2007;33:406–10.
15. Ozturk I, Kilic B, Demiroglu M, et al. Effect of diabetes mellitus on spinal anesthesia failure. Acta
Med Mediterr 2017;33:417–21.

JOE  Volume 47, Number 12, December 2021 Preoperative Factors Associated with Anesthesia Failure 1881

Downloaded for Anonymous User (n/a) at University of Guadalajara from ClinicalKey.com by Elsevier on March 07,
2022. For personal use only. No other uses without permission. Copyright ©2022. Elsevier Inc. All rights reserved.
16.  P, Kirkham KR, et al. Comparison of peripheral nerve blockade characteristics
Baeriswyl M, Taffe
between non-diabetic patients and patients suffering from diabetic neuropathy: a prospective
cohort study. Anaesthesia 2018;73:1110–7.

17. Gebhard ER, Nielsen CK, Pietrobon AR, et al. Diabetes mellitus, independent of body mass
index, is associated with a “higher success” rate for supraclavicular brachial plexus blocks. Reg
Anesth Pain Med 2009;34:404–7.

18. Okamura K, Kobayashi I, Matsuo K, et al. An immunohistochemical and ultrastructural study of

vasomotor nerves in the microvasculature of human dental pulp. Arch Oral Biol 1995;40:47–53.

19. Takahashi K, Kishi Y, Kim S. A scanning electron microscope study of the blood vessels of dog
pulp using corrosion resin casts. J Endod 1982;8:131–5.
20. Kim S. Microcirculation of the dental pulp in health and disease. J Endod 1985;11:465–71.

21. Abbott PV. Classification, diagnosis and clinical manifestations of apical periodontitis. Endod
Topics 2004;8:36–54.
22. Owatz CB, Khan AA, Schindler WG, et al. The incidence of mechanical allodynia in patients with
irreversible pulpitis. J Endod 2007;33:552–6.

23. Dreven LJ, Reader A, Beck FM, et al. An evaluation of an electric pulp tester as a measure of
analgesia in human vital teeth. J Endod 1987;13:233–8.

24. Corah NL. Development of a dental anxiety scale. J Dent Res 1969;48:596.
25. Stanley W, Drum M, Nusstein J, et al. Effect of nitrous oxide on the efficacy of the inferior alveolar
nerve block in patients with symptomatic irreversible pulpitis. J Endod 2012;38:565–9.

1882 Weitz et al. JOE  Volume 47, Number 12, December 2021

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