REFEREED PAPER
Is it essential to perform an inferior alveolar nerve block
to anaesthetise posterior mandibular teeth?
A.Koner *1
'BDS Student, University of Manchester, Higher Cambridge St, Manchester M15 6FH
*Correspondence to: Amarith Koner
Email: amarith.koner@manchester.student.ac.uk
Abstract
This article explores the possibility of utilising a combination of
simple injection techniques, instead of an inferior alveolar nerve
block, to achieve adequate anaesthesia of posterior mandibular
teeth.The conventional inferior alveolar nerve block is regarded as
the gold standard, but the technique has a high failure rate and is
associated with many complications.To improve anaesthesia
supplemental injections are used alongside the inferior alveolar
nerve block. As a result, recent studies have compared the
effectiveness of the inferior alveolar nerve block against alternative
techniques such as infiltration, intraligamental, and intraosseous
when anaesthetising mandibular posterior teeth. In general, these
alternative injection techniques performed similarly to the inferior
alveolar nerve block in terms of adequate anaesthesia.This implies
that the use of direct and simple injection techniques to achieve
satisfactory anaesthesia of posterior mandibular teeth may be a
more suitable approach than the inferior alveolar nerve block.
Short and non-complex dental procedures can benefit from this
new strategy of using a combination of simple injection
techniques as it provides localised, predictable, brief, and safe
anaesthesia. As well as that, these simple injection techniques are
not linked to severe complications unlike the inferior alveolar
nerve block.
Introduction
Pain management is a principle all dentists should uphold to
ensure their patients are treated with dignity and respect.1
Administering local anaesthetic is a common practice used by
dentists to alleviate pain for patients receiving dental treatment.
When performing invasive treatment on mandibular posterior
teeth, dentists adopt the inferior alveolar nerve block (IANB)
technique to anaesthetise these teeth, surrounding gingiva,
tongue, and associated structures unilaterally.2 Utilising this
indirect injection technique overcomes the barrier set by the
dense mandibularcortical bone.3 Unlikethe maxilla the mandible
is not as porous, so the anaesthetic fluid is unable to effectively
diffuse into the bone and reach the tooth's apex. However, recent
studies have suggested that 4% articaine is a suitable anaesthetic
agent which can penetrate thick cortical bone and successfully
anaesthetise mandibular teeth. Researchers from the Ohio State
University have investigated the analgesic effect upon the first
mandibular molar's pulp when 4% articaine is administered via
buccal infiltration (Bl).When compared to 2% lidocaine Bl, 4%
articaine performed significantly better with successful pulpal
anaesthesia ranging from 75 to 92%.4 Many other studies share the
same findings.56 This breakthrough means infiltrations (IFA) can
SAAD DIGEST I VOL.3812022
help to anaesthetise mandibular teeth and with the support of
other direct injection techniques, such as intraligamentary (ILA)
and intraosseous (10), has the potential to replace the IANB.These
direct techniques do not share the same limitations as the IANB
and may be a more suitable method of anaesthesia as a result. Due
tothis,the IANBmay no longer be the gold standard and
potentially be referred as a rescue method.
2% lidocaine vs 4% articaine - which anaesthetic agent is best?
First synthesised in 1943, lidocaine has been the first choice of
anaesthetic for many United Kingdom (UK) dentists. In 2008 over
20 million lidocaine cartridges were sold in the UK.7 The use of
articaine, however, as a modern local anaesthetic agent, has
gradually increased in popularity due to its superioranalgesic
effects. Articaine was first introduced into dental practices in 1998
and sold approximately 10 million cartridges in 2008 in the UK.'
Although articaine is an amide, its chemical structure differs to
lidocaine. Articaine like lidocaine, derives from thiophene rather
than benzene.This is advantageous as it makes the anaesthetic
more lipid soluble and potent so a greater amount of anaesthetic
agent can diffuse into the neuron.8 In addition, articaine contains
an ester group which allows hydrolysation by unspecific blood
esterase.9 90% of articaine is metabolised in the blood and is
excreted by the kidney as articainic acid glucuronide.1° Lidocaine is
also excreted by the kidney but is predominately metabolised by
the liver, so the use of lidocaine is not recommended for patients
with ineffective liver function. Although articaine and lidocaine
have a relatively low and similar pKa value, articaine has a slightly
shorter onset time of 7.4 minutes which is 1.3 minutes quicker than
lidocaine.7 The fear of neurotoxicity has prevented the use of 4%
articaine IANB, however, many studies have proven 4% articaine to
be as equally as effective and safe as lidocaine when administered
13.14
via IANB. 1 1.12 This finding is also seen in paediatric patients.
The injection techniques
Inferior alveolar nerve block
~ ,
--
-61/<*%
.'. 10/Ir
9 .... 4 -* I
-In,4.10.
*0¥~~
Fig. 1 Inferior alveolar nerve block
25
REFEREED PAPER
Conventional IANB is the gold standard when anaesthetising
posterior mandibularteeth. Ideally,the dentist should aim to
deposit the anaesthetic agent around the lingula,as this is where
the inferior alveolar nerve enters the mandibular foramen.
Approaching from the contralateral premolars, a long needle is
advanced through the pterygomandibular space, 1 mm above the
occlusal plane until contact with the mandible has been made
(Fig. 1). After a slight retraction of the needle and a negative
aspiration,the dentist can administer the anaesthetic.
Due to the complexity of the procedure, the technique is prone to
failure of anaesthesia and complications.The rate of inadequate
anaesthesia ranges from 31% to 81% and poor technique can lead
to the following complications:2
Facial palsy - The facial nerve gives rise to five terminal
branches within the parotid gland,a structure that surrounds
the mandible, and injecting too deep or superiorthrough the
coronoid process can cause trauma to the nerve,5
Nerve injury - Permanent nerve injury rarely occurs (1 in 52 -
57,000) and approximately 75% of injuries may resolve.'° It is
associated with numbness, paraesthesia, and neuropathic pain
Haematoma - It is recommended to avoid an IANB in patients
who have coagulopathies or platelet malfunction
Trismus - Development of a haematoma in the medial
pterygoid muscle or swelling in the pharyngeal arch area can
lead to trismus.Two-weeks of daily mouth exercises can resolve
the trismusls
Increased risk of burn and/or bite injury - Due to the prolonged
loss of sensation to the soft tissues, patients are unaware of the
trauma caused to the area.16
It must be noted, alternative methods have been developed to
overcome the limitations associated with the IANB.The Gow-Gates
technique was introduced in 1973 and has a success rate of 75%,17
It uses extra-oral landmarks to locate the neck of the condyle,
where it is able to anaesthetise the entire distribution of the
mandibulartrigeminal division.This technique requires the patient
to have a wide mouth opening and no swelling of the extraoral
landmarks. In 1960,Vazirani designed a closed-mouth techniqueto
accommodate patients with a limited mouth opening, or where
the dentist is unable to palpate the intraoral landmarks needed to
perform an IANB. Anaesthesia of the inferior alveolar nerve, lingual
nerve and long buccal nerve is simultaneously achieved by filling
the pterygomandibular space with local anaesthetic.The Vazirani
technique has the same success rateas Gow-Gates.17
Supraperiosteal (Infiltration)
Fig. 2 Infiltration injection
26
The aim of an IFA is to saturate small terminal nerve endings within
a limited area with local anaesthetic. It is commonly used for pulpal
anaesthesia in maxillaryteeth. Using a short needle, the needle is
advanced into the mucobuccal fold above the apex of the tooth
being anaesthetised (Fig. 2). Unlike the IANB, it is a simple procedure
and has a high success rate of>9596.2 Nonetheless, this technique is
not ideal if a large area needs anaesthetising as multiple needle
insertions will be necessary thus inflicting more pain.
Intraligamentary
~
.ligigitdillillilill
-Als - 7 -7./
Fig. 3 Intraligamentary injection
Usually, following an unsuccessful IANB, dentists use an ILA to
achieve adequate supplemental anaesthesia especially when
treating teeth with symptomatic irreversible pulpitis.18 It is
recommended to use a short needle to access the periodontal
ligament (PDL) via the base of the periodontal crevice (Fig. 3).The
anaesthetic agent is deposited into the coronal PDL segment and
distributed into the surrounding soft and hard tissues by the
vascular dental socket. Moderate to strong pressure leads to a
greater widespread of the local anaesthetic.1, Success rates range
from 60% for endodontic therapies to 100% for periodontal
therapies and extractions.20 This technique is ideal for patients with
bleeding disorders as it avoids the deep needle insertion required
foran IANB.21 However, this technique is not suitable if the
periodontal site is inflamed or infected as it can induce
bacteraemia.22 The dentist may consider antibiotic prophylaxis or
completely avoiding the ILA if they believe the patient is at risk of
bacterial endocarditis.23 Furthermore, cases of enamel hypoplasia
and hypomineralisation in permanent teeth have been
documented when anaesthetising primary teeth via ILA, therefore
this technique is not recommended for paediatric patients.24
Intraosseous Injection
Similar to the ILA, IO is considered a supplemental injection
technique and is used when the IANB has failed.The technique
requires the dentist to perforate the cortical bone, approximately
5mm apical to the buccal papilla, using the handpiece with a light
pecking motion.25 Once the bone has been perforated, the dental
needle is introduced and 1/4 to 1/~ of the cartridge is administered.
10 is contraindicated when gross periodontal disease and acute
periapical infection is present.21 This technique also carries more
complications than an ILA. As well as pain and tenderness, reports
of fistula formation have been documented and the risk of a
perforating fracture increases when the cortical plate is thick.25 In
addition, the mandibularcancellous bone is well vascularised
therefore the adrenaline is readily adsorbed and carried within the
bloodstream. Many studies have seen a strong correlation between
10 and an increased heart rate when participants are injected with
2% lidocaine with 1:100000 adrenaline. 26,27 Because of this, a slow
SAAD DIGEST I VOL.3812022
delivery of local anaesthetic without a vasoconstrictor is
recommended for patients with moderate to severe cardiovascular
disease and/or those taking tricyclic antidepressants or
nonselective 13-adrenergic blocking agents.21
Is the IANB the only way to anaesthetise mandibular posterior
teeth?
Jung et a |.R undertook a crossover design study to evaluate the
performance of Bl and IANB in pulpal anaesthesia in healthy
mandibular teeth when using 1.7 mi of 4% articaine with 1:100000
adrenaline. Bl had a higher anaesthetic success rate (54%) than
IANB (43%).28 This implies that 4% articaine Bl is more effective
than IANB and can be considered a suitable alternative, however,
the difference was not significant. Also, the results cannot be
applied to teeth with a compromised pulp. Rate of failure of local
anaesthetic injections in teeth with irreversible pulpitis is eight
times higherthan in a healthy pulp.29 Therefore, it is unlikelythe
same results can be achieved when anaesthetising teeth without a
healthy pulp. It is also important to note response bias is high as
all participates had a dental education.
Similarly, Corbett3° and Poornin assessed the performance of 4%
articaine Bl when compared with 2% lidocaine IANB, for pulpal
anaesthesia of permanent mandibularteeth in adult patients.
Unlike Poorni31 where both techniques achieved the same success
rate (69.2%), Corbett" reported 4% articaine Bl to be 14.8% more
successful at achieving pulpal anaesthesia than 2% lidocaine IANB.
Both sets of results were not statistically significant and both study
designs contained flaws that could question the validity of their
results.
On the other hand, significant differences between 4% articaine Bl
and 2% lidocaine IANB were recorded by Monteiro et al n Patients
who required emergency endodontic treatment were recruited and
the success of anaesthesia was determined ten minutes after 1.8 mi
of anaesthetic agent was administered. Bl achieved anaesthesia in
40% of cases whereas IANB achieved 10%.32 These low success rates
were dramatically improved following a supplemental injection.The
Bl was supplemented by a 4% articaine ILA which led to successful
anaesthesia in 70% of cases.32 For the IANB, successful anaesthesia
was achieved in 80% of cases after a 4% articaine Bl.32
In 2017, researchers at King's College Hospital conducted a
prospective study to investigate whether 4% articaine Bl is
appropriate for mandibular molar extraction. In total, 112 teeth
were extracted and 57% of those extractions were completed
using a single dose (<2.2 mi) of 4% articaine delivered via Bl.33 Only
16% required a 2% lidocaine IANB rescue injection.33 The remaining
extractions required additional 4% articaine to be administered via
Bl either after the primary injection or during the procedure.33
Conversely, a randomised clinical trial of 133 participants requiring
a mandibular molar extraction concluded that a single articaine
(1.8 mi) Bl was not a suitable alternative to 2% lidocaine (1.8 mi)
IANB due to its limited success rate.34 Furthermore, a prospective
randomised study set in Germany deemed 4% articaine Bl with a
pressure syringe system not suitable for anaesthesia of posterior
mandibularteeth needing extraction, as only 35% of cases
achieved anaesthesia unlike IAN13 which achieved 100%.35
A recent prospective study involving simple, single tooth
extractions compared the use of ILA to IANB. Both techniques
SAAD DIGEST I VOL.3812022
achieved similar success rates, 76,19% via ILAand 77.86% via IANB,
even though the mean amount of anaesthetic fluid administer via
ILA (0.35 mi) was considerably less than IANB (2.08 mi).36 This
indicates ILA is as effective as IANB.Teeth displaying grade 1
mobility and acute apical infection, or drainage of pus were
excluded from the research since the results will differ when
anaesthetising an infected pulp. A meta-analysis of English and
German literature published from 1979- 2012 comparing ILA and
IANB techniques explained all the data analysed was supported by
flawed methodology and reporting.37 Therefore, it would be
inappropriate to declare ILA as a suitable alternative to IANB.
Promising success rates have been documented for IO when
compared to IANB.One study produced results that showed 1.8 mi
of 2% lidocaine 10 to be 27% more successful at anaesthetising
posterior mandibular molars diagnosed with irreversible pulpitis,
than 1.8 mi of 2% lidocaine IANB.30 However, the difference was not
statistically significant38. Farhad et a/.39 published similar findings
that were statistically significant. A higher success rate was seen
with 1.8 mi of 3% mepivacaine 10 (56.7%) than 1.8 ml of 3%
mepivacaine IANB (23.3%) when treating teeth with symptomatic
irreversible pulpitis.39 Nonetheless, neither technique provided
profound anaesthesia which suggests supplemental anaesthesia
would be required. Moreover, a prospective, randomised, double-
blind study reported over 90% of successful mandibular molar
pulpal anaesthesia was achieved by 0.9 mi of 4% articaine 10 with
either 1:100,000 or 1:200,000 and minimal cardiovascular
complications were observed.40
Discussion
Unfortunately, the data available does not indicate a clear
techniquethat hasthe ability to completely replace the IANB.
However, there is a strong argument in support of using a
combination of direct injection techniques to achieve the same
quality of anaesthesia as the IANB.The majority of the studies
analysed displayed results that suggested IANB and the
comparative injection technique to be similar in effectiveness and
success rate. As a result, dentists should expect the direct injection
techniqueto require supplemental anaesthesia, like the IANB, to
increase the likelihood of achieving adequate anaesthesia.When
considering these alternative injections, the choice and amount of
anaesthetic agent used is key to improve the chances of successful
anaesthesia. It is essential to use 4% articaine when performing a Bl
as it is the chemical structure that enables the anaesthetic agent to
reach the apices thus anaesthetise the mandibular teeth, unlike
lidocaine. Furthermore, the success of anaesthesia is influenced by
the apical and periodontal status of the tooth. Presence of pus and
periodontal disease is a contraindication for the use of ILA and 10,
hence it may be more suitable to employ an IANB. For patients who
require multiple treatments in the posterior mandibular region, the
generalised anaesthesia achieved by an IANB is desirable. IFA, ILA,
and 10 injections would require the patient to endure multiple
insertions of the needle which istime consuming and
uncomfortable for the patient.The dentist should also considerthe
duration of the treatment to ensure anaesthesia is maintained
throughout. Every injection technique has a different anaesthesia
duration. It is estimated ILA can maintain sufficient pulpal
anaesthesia for up to 15 minutes which is half the anaesthesia time
of IO.41 Simple dental procedures such as cavity preparation,
pulpectomy, and simple extraction can be performed within
27
15 minutes.42 More advanced dental procedures may require the
longer anaesthesia that can be achieved via Bl or IANB. Pulpal
anaesthesia achieved via Bl steadily declines over 60 minutes,
whereas an IANB maintainsthe analgesic effect for an average of
2 hours and 24 minutes.43 However, unnecessarily prolonged
anaesthesia increases the risk of trauma to the soft tissues; this is
mostly seen in paediatric patients.44 Regarding paediatric patients,
Arrow45 produced statistically significant results that stated IANB
is more successful at achieving anaesthesia for mandibular
posterior teeth than Bl.45 More recently, Arali eta/.446 concluded that
Bl with 4% articaine was a safe and effective alternative to IANB.42
Conclusion
So, is it essential to perform an IANB to anesthetise posterior
mandibularteeth? It can be argued that the employment of direct
injection techniques can be more predictable and successful at
anaesthetising posterior mandibular teeth in comparison to IANB
alone. Dentists should consider the dental treatment, duration,
apical and periodontal status of the tooth as well as the patient
when deciding the injection method. From the results explored,
simple restorations, extractions, and endodontic treatment can be
performed under anaesthesia without using an IANB, for both
adult and paediatric patients.This implies thatthe use of an IANB is
not essential to anaesthetise posterior mandibularteeth. Although
it is extremely unlikely for the practice of IANB to be discontinued,
there may be a shift towards utilising direct injection techniques to
achieve adequate anaesthesia of posterior mandibular teeth and
considering IANB as a rescue method.
References
1. General Dental Council. Standards for the Dental Team.2001.Online information
available at https://standards.gdc-uk.org/pages/principlel/principlel.aspx
(accessed Dec 2020)
2. Malamed S F. Handbook of local anaesthesia, Sixth ed. St Louis: Mosby, 2012.
3. Blanton P LIeske A H.Thekeyto profound local anesthesia: neuroanatomy. JADA
2003; 134:753-60.
4. Robertson D, Nusstein J, Reader A, Beck M, McCartney M.The anesthetic efficacy
of articaine in buccal infiltration of mandibular posterior teeth. JADA 2007;
138:1104-12.
5. Kanaa M D, Whitworth J M, Corbett I R Meechan J G. Articaine and lidocaine
mandibular buccal infiltration anesthesia: a prospective randomized double-blind
crossover study. J Endont 2006; 32: 296-8
6. Abdulwahab M, Boynes S, Moore R Seifikar S, Al-Jazzaf A, Alshuraidah A, Zovko J,
Close J.The efficacy of six local anesthetic formulations used for posterior
mandibular buccal infiltration anesthesia. JADA 2009; 140: 1018-1024.
7. Bartlett G, Mansoor J. Articaine buccal infiltration vs lidocaine inferior dental
block-a review of the literature. Br Dent J 2016; 220: 117-20.
8. Becker D E, Reed K L. Essentials of local anesthetic pharmacology. Anesthesia
Progress 2006; 53: 98-109.
9. Oertel R, Rahn R, Kirch W.Clinical pharmacokinetics of articaine. Clin
Pharmacokinetics 1997,33: 417-25.
10. Renton T. Inferior dental blocks versus infiltration dentistry: is it time for change?.
Dent Update 2019;46: 204-18.
11. Katyal V.The efficacy and safety of articaine versus lignocaine in dental
treatments: a meta-analysis.J Dent 2010;38:307-17.
12. Hopman A J, Baart J A, Brand H S. Articaine and neurotoxicity-a review. Br Dent J
2017;223:501.
13. Malamed S EGagnon S, Leblanc D.A comparison between articaine HCI and
lidocaine HCI in pediatric dental patients. Ped Dent 2000; 22: 307-311.
14. Ram D, Amir E.Comparison of articaine 4% and lidocaine 2% in paediatric dental
patients. Int J Paed Dent 2006,16:252-6.
15. Tzermpos F H,Cocos A, Kleftogiannis M, Zarakas M, latrou 1.Transient delayed
facial nerve palsy after inferior alveolar nerve block anesthesia. Anesthesia
Progress 2012; 59: 22-7.
16, Baart J A, Brand H S, Local anaesthesia in dentistry. 2nd ed. Oxford: Wiley-
Blackwell, 2017.
17. Haas D A. Alternative mandibular nerve block techniques:a review of the Gow-
Gates and Akinosi-Vazirani closed-mouth mandibular nerve block techniques.
JADA 2011; 142: 85-125.
28
18. Bangerter C, Mines R Sweet M.The use of intraosseous anesthesia among
endodontists: results of a questionnaire. J Endod 2009; 35: 15-8.
19. Smith G N, Walton R E. Periodontal ligament injection: distribution of injected
solutions. Oral Surg, Oral Med Oral Path 1983; 55:232-8.
20. Malamed S F.The periodontal ligament (PDL) injection: an alternative to inferior
alveolarnerve block. Oral Surg Oral Med Oral Path 1982;53:117-121.
21. Moore P A, Cuddy M A, Cooke M R, Sokolowski C J. Periodontal ligament and
intraosseous anesthetic injection techniques: alternatives to mandibular nerve
blocks. JADA 2011; 142: 13S-8S.
22. Roberts G J, Simmons N B, Longhurst R Hewitt P B. Bacteraemia following local
anaesthetic injections in children. Br Dent J 1998; 185: 295-8.
23. Thornhill M H, Dayer M, Lockhart P B, McGurk M, Shanson D, Prendergast B,
Chambers J B. A change in the NICEguidelines on antibiotic prophylaxis. Br Dent
J 2016;221:112-4.
24. Brannstrom M, Lindskog S, Nordenvall ICI. Enamel hypoplasia in permanent teeth
induced by periodontal ligament anesthesia of primary teeth. JADA 1984; 10: 735-6
25. Malamed S F. Supplemental injection techniques. In: Handbook of Local
Anesthesia. 5th ed. St. Louis: Mosby 2004: 256-275.
26. Replogle K, Reader A, Nist R, Beck M, Weaver J, Meyers W J. Cardiovascular effects
of intraosseous injections of 2 percent lidocaine with 1:100,000 epinephrine and
3 percent mepivacaine.JADA 1999,130:649-57.
27. Coggins R, Reader A, Nist R, Beck M, Meyers W J. Anesthetic efficacy of the
intraosseous injection in maxillary and mandibular teeth Oral Surg Oral Med Oral
Path Oral Radiol Endod 1996; 81:634-41.
28. Jung l Y, Kim J H,Kim E S,Lee CY, Lee S J.An evaluation of buccal infiltrations and
inferior alveolar nerve blocks in pulpal anesthesia for mandibular first molars.
J Endod. 2008,34: 11-3.
29. Hargreaves K M, Keiser K. Local anesthetic failure in endodontics: mechanisms
and management. Endod Topics 2002;1: 26 -39.
30. Corbett I R Kanaa M D, Whitworth J M, Meechan J G. Articaine infiltration for
anaesthesia of mandibular first molars. J Endod 2008; 34: 514-8.
31. Poorni S,Veniashok B, Senthilkumar A D, Indira R, Ramachadran S.Anaesthetic
efficacy of four percent articaine for pulpal anaesthesia by using inferior alveolar
nerve block and buccal infiltration techniques in patients with irreversible
pulpitis: A prospective randomized double-blind clinical trial. J Endod 2011;37:
1603-7.
32. Monteiro M R, Groppo F C, Haiter-Neto F,Volpato M C, Almeida J R 4% articaine
buccal infiltration versus 2% lidocaine inferior alveolar nerve block for emergency
root canal treatment in mandibular molars with irreversible pulpits: a randomized
clinical study. Int Endod J 2015,48: 145-52.
33. Awal D H, Yilmaz Z, Osailan S, Renton T. Articaine-only buccal infiltrations for
mandibular molar extractions: an alternative to inferior dental nerve blocks. Dent
Update 2017;44:838-45.
34. Rayati E Noruziha A, Jabbarian R. Efficacy of buccal infiltration anaesthesia with
articaine for extraction of mandibular molars: a clinical trial. Br J Oral Max Surg
2018,56:607-10.
35. Thiem D G,Schnaith EVan Aken CM,etc/. Extraction of mandibular prernolars
and molars: comparison between local infiltration via pressure syringe and
inferior alveolar nerve block anesthesia. Clinical Oral Invest 2018,22:1523-30.
36. Kammerer P W, Adubae A, Buttchereit 1, Thiem D G, Daublander M, Frerich B.
Prospective clinical study comparing intraligamentary anesthesia and inferior
alveolar nerve block for extraction of posterior mandibular teeth. Clin Oral Invest
2018,22: 1469-75.
37. Shabazfar N, Daublander M, Al-Nawas B, Kammerer P W. Periodontal intraligament
injection as alternative to inferior alveolar nerve block-meta-analysis of the
literature from 1979 to 2012. Clin Oral Invest 2014;18:351-8.
38. Remmers T, Glickman G, Spears R, He J.The efficacy of IntraFlow intraosseous
injection as a primary anesthesia technique. J Endod 2008; 34: 280-3.
39. Farhad A, Razavian H, Shafiee M. Effectofintraosseous injection versus inferior
alveolar nerve block as primary pulpal anaesthesia of mandibular posterior teeth
with symptomatic irreversible pulpitis: a prospective randomized clinical trial.
Acta Odont Scand 2018; 76:442-7.
40. Pereira L A, Groppo F C, de Cassia Bergamaschi C, eta/. Articalne (496) with
epinephrine (1:100,000 or 1:200,000) in intraosseous injections in symptomatic
irreversible pulpitis of mandibular molars: anaesthetic efficacy and cardiovascular
effects. Oral Surg Oral Med Oral Path Oral Radiol Endod 2013,116: e85-e91.
41. Meechan J G. Supplementary routes to local anaesthesia. Int Endod J 2002; 35:
885-96.
42. Kaufman E,Galili D, Garfunkel A A. Intraligamentary anesthesia: a clinical study,
J Prosth Dent 1983;49:337-9.
43. Fernandez C, Reader A, Beck M, Nusstein J. A prospective, randomized, double-
blind comparison of bupivacaine and lidocaine for inferior alveolar nerve blocks.
J Endod 2005; 31:499-503.
44. Welbury R, Duggal M S, Hosey M T Paed Dent. 5th ed. Oxford:Oxford University
press, 2018.
45. Arrow R A comparison of articaine 4% and lignocaine 2% in block and infiltration
analgesia in children. Austral Dent J 2012;57:325-33.
46. Arali V, Mytri R Anaesthetic efficacy of 4% articaine mandibular buccal infiltration
compared to 2% lignocaine inferior alveolar nerve block in children with
irreversible pulpitis. JCDRes 2015;9: ZC65.
SAAD DIGEST I VOL.3812022
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