Retrospective comparison of local anesthesia for mandibular molars: articaine buccal infiltration vs. lidocaine intraosseous anesthesia

Retrospective comparison of local anesthesia for mandibular molars: articaine buccal infiltration vs. lidocaine intraosseous anesthesia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Retrospective comparison of local anesthesia for mandibular molars: articaine buccal infiltration vs. lidocaine intraosseous anesthesia Ji-Young Yoon, Damin Park, Jeong-Kui Ku This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4213775/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objectives It is vital to identify more efficient anesthesia techniques for restorative or endodontic treatments of mandibular molars. Both articaine buccal infiltration anesthesia (ABI) and lidocaine inferior alveolar nerve block anesthesia (LIANB) may not provide profound anesthesia, necessitating supplementary anesthesia. This study aims to investigate whether lidocaine intraosseous (LIO) injection, compared to ABI, is suitable for primary anesthesia for caries treatments of mandibular molars. Materials and Methods This study retrospectively analyzed on patients for the treatment of advanced caries corresponding to the International Caries Detection and Assessment System (ICDAS) 5 and 6. The study involved 48 patients, split evenly between those receiving ABI and LIO, examining anesthesia success rate, pain during anesthesia, onset time, duration, and lower lip numbness, with data analyzed using Chi-square and Independent T-tests. Results In the ABI group, 17 individuals (70.8%) did not require additional anesthesia, whereas all 24 individuals (100%) in the LIO group did not require additional anesthesia ( P <.001). ABI showed significantly higher pain during anesthesia, slower onset time, and longer duration of anesthesia compared to LIO. There was no significant difference in lower lip numbness between the two anesthesia methods. Conclusions For treating severe caries in mandibular molars, intraosseous anesthesia using lidocaine is more effective for its higher success rate, decreased pain during anesthesia, faster onset, and shorter recovery time. Clinical Relevance The findings of this study suggest that LIO may be considered as a primary anesthesia method for mandibular molar caries treatments in clinical practice, providing beneficial effects for patients. Articaine Dental Caries Lidocaine Local Anesthesia Figures Figure 1 Figure 2 Introduction Mandibular molars have dense alveolar bone surrounding them, which poses challenges for achieving complete anesthesia [1]. This difficulty is particularly pronounced in cases of advanced caries corresponding to International Caries Detection and Assessment System (ICDAS) 5 and 6, where decay extends into the inner 1/3 of dentin close to the pulp [1-3]. Achieving profound anesthesia with lidocaine buccal and lingual infiltration alone during conservative or endodontic treatment is difficult. Inappropriate level of anesthesia may lead to treatment interruptions, repeated anesthesia, prolonged treatment times, and patient dissatisfaction. Therefore, efficient anesthesia for mandibular molars during caries treatment remains a concern [4, 5]. Despite its technical challenges and longer anesthesia times compared to infiltration anesthesia, many practitioners often prefer inferior alveolar nerve block (IANB) for deep anesthesia in mandibular molars [6, 7]. Studies comparing articaine buccal infiltration (ABI) to lidocaine IANB (LIANB) have shown varying success rates. While Monteiro et al. found ABI success rates of 40% surpassing LIANB's 10% for irreversible pulpitis, Ali et al. and Jung et al. reported similar success rates (53.8% and 54% for ABI vs. 61.5% and 43% for LIANB) [8-10]. Regardless of which anesthesia method is deemed more effective, it is crucial to consider supplemental anesthesia for both approaches to ensure sufficient anesthesia effect [11]. Intraosseous anesthesia (IO) is valued for its rapid and profound anesthesia effects [12]. However, its invasive nature, involving cortical bone drilling, limits its primary use in routine dental practice [13]. Consequently, intraosseous injection is often considered as a supplemental method to enhance pulpal anesthesia [11]. Recently, a computer-controlled intraosseous anesthesia device, the Quicksleeper5 ® system (DHT, Cholet, France), has been introduced. It employs a 30-gauge short Aiguilles ® needle (DHT, Cholet, France) to penetrate through the alveolar bone in the attached gingiva of the interdental area, enabling direct injection into the bone marrow [14-16]. This leads to a less technique-sensitive process, with controlled constant injection associated with a high success rate and reduced pain. However, intraosseous anesthesia is known for its shorter duration when used as a primary injection, so its suitability for restorative treatment needs assessment [13]. There have been no studies on comparing ABI and lidocaine IO (LIO) in mandibular molars. This study aims to compare the success rate, pain levels during anesthesia, onset, lasting time, and lower lip numbness between ABI and LIO for caries treatment (resin restoration, inlay restoration, root canal treatment) of mandibular first and second molars. Materials And Methods This study was conducted under Seoul National University Bundang Hospital (SNUBH) IRB approval. (IRB No.: B-2403-891-103) From May 1, 2021, to February 29, 2024, patients who visited the Department of Conservative Dentistry for the treatment of caries in mandibular first and second molars were included in the study. The inclusion/exclusion criteria are shown in Table 1. Based on the extent of caries, direct/indirect restoration, or root canal treatment was performed, and the anesthesia method used during these procedures (ABI or LIO) was compared through retrospective review of medical records. The anesthesia methods were performed as follows: For ABI anesthesia (Fig. 1a), 1 cartridge (1.8mL) of 4% articaine with 1:100,000 epinephrine(epi.) (Huons, Pangyo, Korea) was injected using a dental syringe into the buccal mucosa adjacent to the tooth for 4 minutes. The 30-gauge needles (J.MORITA CORP., Osaka, Japan) were inserted at the point bisecting the line connecting the apices of the mesial and distal roots. For LIO anesthesia (Fig. 1b), 1 cartridge (1.8mL) of 2% lidocaine with 1:100,000 epi. (Huons, Pangyo, Korea) was injected into the mesial or distal interdental alveolar bone using a device called Quicksleeper5® with a 30-gauge Aiguilles® needle for 4 minutes. The decision to inject into the mesial or distal roots was based on the area with a wider interproximal bone space observed on periapical radiographs. Data collection included the following information: 1) Gender, Age, Tooth position, ICDAS classification 2) Vitality status of the tooth before anesthesia: assessed for vital teeth only 3) Anesthesia method: ABI or LIO 4) Pain level during anesthesia [Heft-Parker Visual Analogue Scale (VAS)] (Fig. 2) 5) Onset: time taken for 64 readings on the pulp tester at 1, 3, 5, 7, and 9 minutes after anesthesia 6) Need for additional anesthesia: periodontal anesthesia with a 2% lidocaine containing 1:100,000 epi. was administered if the tooth remained positive on the EPT after 9 minutes. 7) Occurrence of pain requiring additional anesthesia during treatment, even after starting with EPT-negative teeth 8) Post-anesthesia lower lip numbness 9) Time until complete anesthesia resolution: time taken for sensation to return to normal after post-anesthesia numbness 10) Whether there were complaints of increased heart rate Statistical Analysis The data were analyzed using SPSS 27.0 (IBM Corp., Armonk, NY). Chi-square tests (or Fisher's exact test) and t-tests assessed homogeneity in general characteristics and tooth-related features. Differences in success rates, pain during anesthesia, onset time, total duration, and soft tissue numbness by anesthesia methods were also analyzed using chi-square tests (or Fisher's exact test) and t-tests. Statistical significance was set at P < 0.05. Results General and teeth-related characteristics The study included 48 patients and teeth, evenly divided into ABI and LIO groups, with mean ages of 46.07 years (ABI) and 49.71 years (LIO), respectively. Both groups had similar gender distributions, with most participants in each group classified as having ICDAS5 caries classification. The left mandibular first molar was the most common in both groups. Overall, there were no significant differences in demographics or dental-related characteristics between the two groups, indicating homogeneity (Table 2). The local anesthesia success rates for LIO and ABI The success rate of anesthesia methods, which resulted to unpainful treatment without supplemental anesthesia, was compared. As shown in Table 3, 17 individuals (70.8%) in the ABI group did not require additional anesthesia, while all of 24 individuals in the LIO group (100%) did not require additional anesthesia, which was a significant difference (χ²=8.20, P <0.01). The seven cases requiring additional anesthesia consisted of six patients with a positive EPT response after 9 minutes and one patient who experienced discomfort despite a negative response on the pulp tester. Differences in pain, onset time, and duration of anesthesia between LIO and ABI To compare the effectiveness of each anesthesia method, pain levels during anesthesia as well as the onset and duration of anesthesia were evaluated. Using the Heft-Parker VAS, the pain experienced during anesthesia in the ABI group was 32.0 (±18.6), whereas in the LIO group, it was 17.3 (±17.3) (Table 4). ABI showed significantly higher pain during anesthesia compared to LIO (t=2.9, P <0.01). In terms of onset time (Table 5), in the ABI group, anesthesia onset occurred with 8 individuals (33.3%) at 5 minutes, 6 individuals (25.0%) at 3 minutes or failed, 3 individuals (12.5%) at 1 minute, and 1 individual (4.2%) at 7 minutes. Conversely, in the LIO group, the majority (91.7%) experienced anesthesia onset at 1 minute, showing a significant difference in these proportions (χ²=33.3, P <0.001). Lastly, for comparing anesthesia duration (Table 6), the ABI method lasted for 231.3 minutes (±79.7 minutes), whereas the LIO method lasted for 118.6 minutes (±52.2 minutes), which was significantly shorter (t=5.8, P <0.001). Comparison of lower lip numbness between LIO and ABI Lower lip numbness, a common discomfort resulting from mandibular teeth anesthesia, was reported by all individuals (100%) in the ABI group and by 83.3% in the LIO group. Despite LIO injections being administered into the bone marrow, a notable percentage of participants experienced lower lip numbness, with no statistically significant differences observed. Effects of LIO and ABI on heart rate In the LIO group, 8.33% (2 out of 24 individuals) reported increased heart rate, whereas no complaints were observed in the ABI group. The elevated heart rate returned to baseline within minutes. Discussion Here, through comparing the two anesthesia methods, ABI and LIO, we aimed to propose a more effective and reliable anesthesia technique for the caries treatment of mandibular molars. LIO guarantees a higher anesthesia success rate compared to ABI. As describe in Table 2, in comparison to ABI, LIO achieved comprehensive anesthesia, eliminating the necessity for supplementary anesthesia. A study evaluating the efficacy of intraosseous injection using 2% lidocaine (1:100,000 epinephrine) as the primary anesthesia method for mandibular molars with irreversible pulpitis found a higher success rate of 87%, surpassing the reported 60% success rate of the inferior alveolar nerve block (IANB) [12]. Similarly, another study demonstrated 74% success rate of intraosseous injection [17]. Many intraosseous anesthesia studies have reported high success rates [18, 19]. and this was confirmed in our study as well. Our study achieved 100% success with enhanced control and precision in intraosseous anesthesia using the QuickSleeper5 ® anesthesia device. In contrast, ABI showed lower success requiring additional anesthesia compared to LIO. The success rate of ABI was 70.8%, which was similar to previous studies reporting about 65% [20]. Recent studies have compared the success rates of ABI and LIANB in treating irreversible pulpitis in mandibular molars. According to a study, ABI has been reported to have a success rate ranging from 64.5% to 70.4%, which is not significantly different from the success rate of lidocaine IANB, which ranges from 55.6% to 69.2% [20, 21]. While ABI shows success rates comparable to IANB, it still proves to be less efficient than intraosseous anesthesia, necessitating adjunctive anesthesia [22]. Nevertheless, buccal infiltration anesthesia is considered less invasive and simpler compared to techniques like intraosseous, as it does not involve cortical bone perforation, making it a less invasive option. Therefore, in the absence of a specialized anesthetic device for bone penetration, ABI can be considered for mandibular molar treatment instead of IANB. Pain during needle insertion and local anesthetic deposition were significantly lower in LIO compared to ABI. The primary cause of pain during anesthesia is attributed to the speed of injection [23, 24]. In the case of LIO, a slower and more controlled speed of deposition using Quicksleeper5 ® is possible, which can result in a reduced level of pain experienced by the patient. Furthermore, patients did not report any specific discomfort during drilling for intraosseous anesthesia. This can be attributed to the technique of applying infiltration anesthesia to the drilling site with approximately 1/4 of an ampoule before drilling, rather than immediately proceeding with drilling. Additionally, the use of thin needles rotating at high speed (15,000 rpm) for anesthesia further contributed to the absence of discomfort after the numbness wore off [14, 15]. This study revealed no instances of discomfort at the injection site in cases of LIO. However, although ABI resulted in significantly higher pain compared to LIO, it was still manageable, especially considering the slow injection rate of 0.45ml/min. The efficacy of each method was evaluated based on onset and duration. Traditional intraosseous anesthesia is known for its rapid onset and short duration [11]. Vongsavan et al. reported a mean onset of intraosseous anesthesia (IO) of 2.4 minutes and a mean duration of 38 minutes [25]. In our study, 91.7% of cases with intraosseous anesthesia showed no response to the electric pulp tester after just 1 minute of anesthesia. Conversely, there were only three instances where anesthesia was achieved within one minute with ABI. According to a study investigating the buccal infiltration of 4% articaine or 2% lidocaine into the mandibular first molar, the time to achieve negative readings on the EPT was significantly faster with articaine, at 4.2 minutes, compared to lidocaine, which took 7.7 minutes [22]. The author speculated that articaine's higher lipid solubility, attributed to its benzene ring rather than a thiophene ring, allows it to penetrate nerve cell lipid membranes more effectively. In our study, although 70.8% achieved a negative reading on the EPT within 5 minutes, this was significantly slower than intraosseous injection using lidocaine, which involves a direct injection into the bone marrow. Consequently, the choice of anesthetic method plays a more crucial role in achieving faster anesthesia than the specific anesthetics used. When measuring the time taken for anesthesia to wear off, articaine took 231.25 minutes, while lidocaine took 118.63 minutes, with lidocaine significantly shorter. According to a study, both articaine and lidocaine buccal infiltration anesthesia demonstrated the recovery from pulpal anesthesia starting around 25 to 30 minutes [21, 26]. Here, we retrospectively analyzed the anesthesia methods utilized in the treatment of mandibular molars based on medical record data. Unlike conventional randomized clinical trials, regular EPT was not conducted during anesthesia at post-injection intervals to record the time necessary for the recovery of pulpal sensory function, indicated by the return of a positive response. Instead, the total duration of anesthesia was calculated based on patients' recollection of the time when sensation in their lips returned to normal, which they reported during their subsequent follow-up visits. Therefore, our results indicate that the mean total duration until patients' subjective numbness wore off was 231.25 minutes, which was longer compared to LIO. There was no significant difference in soft tissue anesthesia between the two anesthesia methods. In the case of ABI, 100% of participants exhibited subjective lower lip numbness, which was consistent with findings from previous studies. According to these studies, it is known that when buccal infiltration is performed, the anesthetic solution spreads through the mental foramen, leading to numbness in the lower region [21, 27]. In a study about the efficacy of the primary intraosseous injection using lidocaine in the mandibular first molar, 58% of patients reported experiencing subjective numbness in the lower lip [19]. In our study, LIO showed 83.3% lower lip numbness. We did infiltration anesthesia 0.45mL (1/4 of an ampoule) before intraosseous injection. We can speculate that 0.45mL was related high accidence of lower lip numbness. However, the observation of a trend toward soft tissue anesthesia even in cases where only intraosseous anesthesia was administered is noteworthy and deserves attention. In this study, only two individuals (8.33%) complained of an increased heart rate during LIO, which differs from findings in other previous studies. According to Replogle et al., when LIO containing 1:100,000 epi. was administered for 2 minutes, an increase in heart rate was observed in 67% of cases [28]. Another study reported that during a fast LIO injection (45 seconds), there was an increase in heart rate ranging from an average of 21 to 28 beats /min, while during a slow injection (4 minutes and 45 seconds), there was an increase ranging from 10 to 12 beats/min. It was suggested that approximately a 10 beats/min increase would be necessary for patients to subjectively perceive an increase in heart rate [29]. In our study, LIO anesthesia was administered over a period of 4 minutes, with a slow and controlled injection speed. Therefore, it is assumed that the frequency of subjective perception by patients regarding increased heart rate would have been reported less frequently. Further research should be conducted using electrocardiogram monitoring for more objective assessment. It is believed that intraosseous anesthesia is superior to articaine infiltration anesthesia in terms of no supplemental anesthesia, rapid onset and return to normal sensation. The invasiveness typically associated with traditional intraosseous anesthesia can be mitigated to some extent by the development of new intraosseous anesthesia devices. However, in situations where there are barriers such as the purchase of anesthesia equipment, ABI anesthesia may be considered as an alternative. In such cases, it is necessary to wait patiently for the anesthesia to take full effect, and additional anesthesia methods such as supraperiosteal anesthesia should be considered if anesthesia is not achieved. Conclusion Within the limitation of this study, lidocaine intraosseous anesthesia (LIO) significantly outperforms articaine buccal infiltration anesthesia (ABI) in mandibular molars, marked by a higher success rate without the need for additional anesthesia, less pain during administration, quicker onset, and shorter duration. While ABI may still serve as an alternative when LIO is not feasible, it requires careful consideration of the potential need for supplementary anesthesia and patient management for effective outcomes. Declarations Author Contribution J.Y. was the primary investigator for this study. J.Y. and D.P. collected the data and evaluated the findings. J.Y. analyzed the data. J.Y., D.P., and J.K. performed the literature review and revised the manuscript. All authors have read and approved the final version submitted for publication. Ethics Approval and Consent to Participate Ethics Approval This study was conducted under Seoul National University Bundang Hospital (SNUBH) IRB approval. (IRB No.: B-2403-891-103) Informed consent Not applicable Funding No funding was obtained for this study. Conflict of interests The authors have no conflicts of interest to declare that are relevant to the content of this article. Acknowledgments None. References Palti DG, Almeida CM, Rodrigues Ade C, Andreo JC, Lima JE (2011) Anesthetic technique for inferior alveolar nerve block: a new approach. J Appl Oral Sci 19:11-15. https://doi.org/10.1590/s1678-77572011000100004 Ismail AI, Sohn W, Tellez M, Amaya A, Sen A, Hasson H, Pitts NB (2007) The International Caries Detection and Assessment System (ICDAS): an integrated system for measuring dental caries. 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Anesth Prog 55:9-15. https://doi.org/10.2344/0003-3006(2008)55[9:HREOII]2.0.CO;2 Tables Table 1 The inclusion/exclusion criteria Inclusion criteria Exclusion criteria 1) Teeth exhibiting extensive caries corresponding to ICDAS 5 and 6 2) Showing positive responses in two Electric Pulp Testing (EPT) sessions 3) Administration of local anesthesia by ABI or LIO 4) Age>19 years 1) Teeth with EPT negative 2) Presence of periapical lesions or tumors 3) Those who had taken analgesics for tooth pain 4) Patients requiring treatment for more than one tooth 5) Those who received block anesthesia 6) Individuals with any neurologic syndrome or symptoms. Note: ABI, Articaine Buccal Infiltration. EPT, Electric Pulp Testing. LIO, Lidocaine Intraosseous. ICDAS, International Caries Detection and Assessment System. Table 2 General and teeth-related characteristics according to the anesthesia method Variable ABI M(SD)/N(%) LIO M(SD)/N(%) χ 2 /t P Age 46.07(17.79) 49.71(18.10) Gender Male 8(33.3) 11(45.8) Female 16(66.7) 13(54.2) ICDAS classification 5 14(58.3) 18(75.0) 1.50 .221 6 10(41.7) 6(25.0) Tooth number (FDI system) #36 8(33.3) 10(41.7) 2.31 † .678 #37 7(29.2) 5(20.8) #38 1(4.2) 0(0) #46 2(8.3) 4(16.7) #47 6(25.0) 5(20.8) † Fisher’s exact test Note: ABI, Articaine Buccal Infiltration. FDI, Fédération Dentaire Internationale. ICDAS, International Caries Detection and Assessment System. LIO, Lidocaine Intraosseous. M, Median. P , P -value. SD, Standard Deivation. Table3 The differences in success rate according to the anesthesia method Variable ABI LIO χ 2 P N(%) N(%) Additional anesthesia No 17(70.8) 24(100) 8.20 † .009* Yes 7(29.2) 0(0) † Fisher’s exact test ∗ Significant P value at 0.05 level Note: ABI, Articaine Buccal Infiltration. LIO, Lidocaine Intraosseous. Table 4 The difference in pain during anesthesia Group N Pain during anesthesia M±SD t( P ) ABI 24 32.0±18.6 2.9(.006)* LIO 24 17.3±17.3 ∗ Significant P value at 0.05 level Note: ABI, Articaine Buccal Infiltration. LIO, Lidocaine Intraosseous. M, Median. P , P -value. SD, Standard Deivation. Table 5 The differences in anesthesia onset time according to the anesthesia method Variable ABI N(%) LIO N(%) χ 2 P Onset time 1 min. 3(12.5) 22(91.7) 33.3 <.001* 3min. 6(25.0) 0(0) 5min. 8(33.3) 1(4.2) 7min. 1(4.2) 1(4.2) failure 6(25.0) 0(0) ∗ Significant P value at 0.05 level Note: ABI, Articaine Buccal Infiltration. LIO, Lidocaine Intraosseous. P , P -value. Table 6 The difference in the duration of anesthesia according to the anesthesia method Group N Duration of anesthesia M±SD t( P ) ABI 24 231.3±79.7 5.8(<.001)* LIO 24 118.6±52.2 ∗ Significant P value at 0.05 level Note: ABI, Articaine Buccal Infiltration. LIO, Lidocaine Intraosseous. P , P -value. Table 7 The differences in the occurrence of soft tissue anesthesia according to the anesthesia method Variable ABI N(%) LIO N(%) χ 2 P Lower lip numbness No 0() 4(16.7) 4.36 † .109 Yes 24(100) 20(83.3) † Fisher’s exact test Note: ABI, Articaine Buccal Infiltration. LIO, Lidocaine Intraosseous. P , P -value. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4213775","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":290296956,"identity":"1c6d0116-4e4a-4b36-b691-97adbceb1ab3","order_by":0,"name":"Ji-Young Yoon","email":"","orcid":"","institution":"Seoul National University Bundang Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ji-Young","middleName":"","lastName":"Yoon","suffix":""},{"id":290296957,"identity":"bc47354c-114a-4938-87a6-5157b9b0bf63","order_by":1,"name":"Damin Park","email":"","orcid":"","institution":"Seoul National University Bundang Hospital","correspondingAuthor":false,"prefix":"","firstName":"Damin","middleName":"","lastName":"Park","suffix":""},{"id":290296958,"identity":"7641f7a2-18f3-4a85-9c1b-0e6876ec8194","order_by":2,"name":"Jeong-Kui Ku","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAr0lEQVRIiWNgGAWjYBACCQaGZIYPQIaBBClaGGeQqoWZmYckLZIzEh4b2/y5k7hduoHxccUvIrRISyQkJ+e2PUvcOecAs+HZPiK0yAG1HM5tOJy44UYCm2RjD7FaLP6QogXsMAY2qJaGH0Rokex5kGzY23bYeOeMxGbDxgYitEgcz0mW+PHnsOx2ieSDDxv+EKGFgYEnAcpgbGBgbCNKC/sBJA5xtoyCUTAKRsEIAwDEBjqydKkmGgAAAABJRU5ErkJggg==","orcid":"","institution":"Seoul National University Bundang Hospital","correspondingAuthor":true,"prefix":"","firstName":"Jeong-Kui","middleName":"","lastName":"Ku","suffix":""}],"badges":[],"createdAt":"2024-04-03 15:35:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4213775/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4213775/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":54931105,"identity":"bad8761d-4ea1-4807-afc6-ae55db96bd6a","added_by":"auto","created_at":"2024-04-18 18:35:01","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":348212,"visible":true,"origin":"","legend":"\u003cp\u003eAnesthesia methods: (a) Articaine buccal infiltration. With a dental syringe, the 30-gauge needles were inserted at the point bisecting the line connecting the apices of the mesial and distal roots. (b) Lidocaine Intraosseous injection. A short needle (16mm, 30-gague) was injected into the mesial or distal interdental alveolar bone using a device called Quicksleeper5\u003csup\u003e®\u003c/sup\u003e\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4213775/v1/51eaba43b8e3fa350f0335b9.jpg"},{"id":54931106,"identity":"cc203e37-9efe-49f0-9d33-2a369ed53594","added_by":"auto","created_at":"2024-04-18 18:35:01","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":119373,"visible":true,"origin":"","legend":"\u003cp\u003eHeft-Parker Visual Analogue Scale (VAS): Patients were asked to assess their pain levels using the Heft-Parker VAS specifically to evaluate the discomfort experienced from both needle insertion and anesthesia injection.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4213775/v1/f215bac655c562ba89bdc93a.jpg"},{"id":55953410,"identity":"03460bbf-0a4c-4ac1-b53f-9254e9802378","added_by":"auto","created_at":"2024-05-06 19:08:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":613196,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4213775/v1/9979b1f7-6f9b-4457-bddb-90fe0aee5086.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Retrospective comparison of local anesthesia for mandibular molars: articaine buccal infiltration vs. lidocaine intraosseous anesthesia","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMandibular molars have dense alveolar bone surrounding them, which poses challenges for achieving complete anesthesia [1]. This difficulty is particularly pronounced in cases of advanced caries corresponding to International Caries Detection and Assessment System (ICDAS) 5 and 6, where decay extends into the inner 1/3 of dentin close to the pulp\u0026nbsp;[1-3].\u0026nbsp;Achieving profound anesthesia with lidocaine buccal and lingual infiltration alone during conservative or endodontic treatment is difficult. Inappropriate level of anesthesia may lead to treatment interruptions, repeated anesthesia, prolonged treatment times, and patient dissatisfaction. Therefore, efficient anesthesia for mandibular molars during caries treatment remains a concern\u0026nbsp;[4, 5].\u003c/p\u003e\n\u003cp\u003eDespite its technical challenges and longer anesthesia times compared to infiltration anesthesia, many practitioners often prefer inferior alveolar nerve block (IANB) for deep anesthesia in mandibular molars\u0026nbsp;[6, 7]. Studies comparing articaine buccal infiltration (ABI) to lidocaine IANB (LIANB) have shown varying success rates. While Monteiro et al. found ABI success rates of 40% surpassing LIANB\u0026apos;s 10% for irreversible pulpitis, Ali et al. and Jung et al. reported similar success rates (53.8% and 54% for ABI vs. 61.5% and 43% for LIANB)\u0026nbsp;[8-10].\u0026nbsp;Regardless of which anesthesia method is deemed more effective, it is crucial to consider supplemental anesthesia for both approaches to ensure sufficient anesthesia effect\u0026nbsp;[11].\u003c/p\u003e\n\u003cp\u003eIntraosseous anesthesia (IO) is valued for its rapid and profound anesthesia effects\u0026nbsp;[12].\u0026nbsp;However, its invasive nature, involving cortical bone drilling, limits its primary use in routine dental practice\u0026nbsp;[13].\u0026nbsp;Consequently, intraosseous injection is often considered as a supplemental method to enhance pulpal anesthesia\u0026nbsp;[11]. Recently, a computer-controlled intraosseous anesthesia device, the Quicksleeper5\u003csup\u003e\u0026reg;\u0026nbsp;\u003c/sup\u003esystem (DHT, Cholet, France), has been introduced. It employs a 30-gauge short Aiguilles\u003csup\u003e\u0026reg;\u0026nbsp;\u003c/sup\u003eneedle (DHT, Cholet, France) to penetrate through the alveolar bone in the attached gingiva of the interdental area, enabling direct injection into the bone marrow\u0026nbsp;[14-16].\u0026nbsp;This leads to a less technique-sensitive process, with controlled constant injection associated with a high success rate and reduced pain. However, intraosseous anesthesia is known for its shorter duration when used as a primary injection, so its suitability for restorative treatment needs assessment\u0026nbsp;[13].\u003c/p\u003e\n\u003cp\u003eThere have been no studies on comparing ABI and lidocaine IO (LIO) in mandibular molars. This study aims to compare the success rate, pain levels during anesthesia, onset, lasting time, and lower lip numbness between ABI and LIO for caries treatment (resin restoration, inlay restoration, root canal treatment) of mandibular first and second molars.\u003c/p\u003e"},{"header":"Materials And Methods","content":"\u003cp\u003eThis study was conducted under Seoul National University Bundang Hospital (SNUBH) IRB approval. (IRB No.: B-2403-891-103) From May 1, 2021, to February 29, 2024, patients who visited the Department of Conservative Dentistry for the treatment of caries in mandibular first and second molars were included in the study. The inclusion/exclusion criteria are shown in Table 1. Based on the extent of caries, direct/indirect restoration, or root canal treatment was performed, and the anesthesia method used during these procedures (ABI or LIO) was compared through retrospective review of medical records.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe anesthesia methods were performed as follows:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor ABI anesthesia (Fig. 1a), 1 cartridge (1.8mL) of 4% articaine with 1:100,000 epinephrine(epi.) (Huons, Pangyo, Korea) was injected using a dental syringe into the buccal mucosa adjacent to the tooth for 4 minutes. The 30-gauge needles (J.MORITA CORP., Osaka, Japan) were inserted at the point bisecting the line connecting the apices of the mesial and distal roots.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor LIO anesthesia (Fig. 1b), 1 cartridge (1.8mL) of 2% lidocaine with 1:100,000 epi. (Huons, Pangyo, Korea) was injected into the mesial or distal interdental alveolar bone using a device called Quicksleeper5\u0026reg; with a 30-gauge Aiguilles\u0026reg; needle for 4 minutes. The decision to inject into the mesial or distal roots was based on the area with a wider interproximal bone space observed on periapical radiographs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection included the following information:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1) Gender, Age, Tooth position, ICDAS classification\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2) Vitality status of the tooth before anesthesia: assessed for vital teeth only\u003c/p\u003e\n\u003cp\u003e3) Anesthesia method: ABI or LIO\u003c/p\u003e\n\u003cp\u003e4) Pain level during anesthesia [Heft-Parker Visual Analogue Scale (VAS)] (Fig. 2)\u003c/p\u003e\n\u003cp\u003e5) Onset: time taken for 64 readings on the pulp tester at 1, 3, 5, 7, and 9 minutes after anesthesia\u003c/p\u003e\n\u003cp\u003e6) Need for additional anesthesia: periodontal anesthesia with a 2% lidocaine containing 1:100,000 epi. was administered if the tooth remained positive on the EPT after 9 minutes.\u003c/p\u003e\n\u003cp\u003e7) Occurrence of pain requiring additional anesthesia during treatment, even after starting with EPT-negative teeth\u003c/p\u003e\n\u003cp\u003e8) Post-anesthesia lower lip numbness\u003c/p\u003e\n\u003cp\u003e9) Time until complete anesthesia resolution: time taken for sensation to return to normal after post-anesthesia numbness\u003c/p\u003e\n\u003cp\u003e10) Whether there were complaints of increased heart rate\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data were analyzed using SPSS 27.0 (IBM Corp., Armonk, NY). Chi-square tests (or Fisher\u0026apos;s exact test) and t-tests assessed homogeneity in general characteristics and tooth-related features. Differences in success rates, pain during anesthesia, onset time, total duration, and soft tissue numbness by anesthesia methods were also analyzed using chi-square tests (or Fisher\u0026apos;s exact test) and t-tests. Statistical significance was set at \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eGeneral and teeth-related characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study included 48 patients and teeth, evenly divided into ABI and LIO groups, with mean ages of 46.07 years (ABI) and 49.71 years (LIO), respectively. Both groups had similar gender distributions, with most participants in each group classified as having ICDAS5 caries classification. The left mandibular first molar was the most common in both groups. Overall, there were no significant differences in demographics or dental-related characteristics between the two groups, indicating homogeneity (Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe local anesthesia success rates for LIO and ABI\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe success rate of anesthesia methods, which resulted to unpainful treatment without supplemental anesthesia, was compared. As shown in Table 3, 17 individuals (70.8%) in the ABI group did not require additional anesthesia, while all of 24 individuals in the LIO group (100%) did not require additional anesthesia, which was a significant difference (\u0026chi;\u0026sup2;=8.20, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.01). The seven cases requiring additional anesthesia consisted of six patients with a positive EPT response after 9 minutes and one patient who experienced discomfort despite a negative response on the pulp tester.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDifferences in pain, onset time, and duration of anesthesia between LIO and ABI\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo compare the effectiveness of each anesthesia method, pain levels during anesthesia as well as the onset and duration of anesthesia were evaluated. Using the Heft-Parker VAS, the pain experienced during anesthesia in the ABI group was 32.0 (\u0026plusmn;18.6), whereas in the LIO group, it was 17.3 (\u0026plusmn;17.3) (Table 4). ABI showed significantly higher pain during anesthesia compared to LIO (t=2.9, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.01). In terms of onset time (Table 5), in the ABI group, anesthesia onset occurred with 8 individuals (33.3%) at 5 minutes, 6 individuals (25.0%) at 3 minutes or failed, 3 individuals (12.5%) at 1 minute, and 1 individual (4.2%) at 7 minutes. Conversely, in the LIO group, the majority (91.7%) experienced anesthesia onset at 1 minute, showing a significant difference in these proportions (\u0026chi;\u0026sup2;=33.3, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001). Lastly, for comparing anesthesia duration (Table 6), the ABI method lasted for 231.3 minutes (\u0026plusmn;79.7 minutes), whereas the LIO method lasted for 118.6 minutes (\u0026plusmn;52.2 minutes), which was significantly shorter (t=5.8, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparison of lower lip numbness between LIO and ABI\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLower lip numbness, a common discomfort resulting from mandibular teeth anesthesia, was reported by all individuals (100%) in the ABI group and by 83.3% in the LIO group. Despite LIO injections being administered into the bone marrow, a notable percentage of participants experienced lower lip numbness, with no statistically significant differences observed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEffects of LIO and ABI on heart rate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the LIO group, 8.33% (2 out of 24 individuals) reported increased heart rate, whereas no complaints were observed in the ABI group. The elevated heart rate returned to baseline within minutes.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eHere, through comparing the two anesthesia methods, ABI and LIO, we aimed to propose a more effective and reliable anesthesia technique for the caries treatment of mandibular molars.\u003c/p\u003e\n\u003cp\u003eLIO guarantees a higher anesthesia success rate compared to ABI. As describe in Table 2, in comparison to ABI, LIO achieved comprehensive anesthesia, eliminating the necessity for supplementary anesthesia. A study evaluating the efficacy of intraosseous injection using 2% lidocaine (1:100,000 epinephrine) as the primary anesthesia method for mandibular molars with irreversible pulpitis found a higher success rate of 87%, surpassing the reported 60% success rate of the inferior alveolar nerve block (IANB)\u0026nbsp;[12]. Similarly, another study demonstrated 74% success rate of intraosseous injection\u0026nbsp;[17]. Many intraosseous anesthesia studies have reported high success rates\u0026nbsp;[18, 19]. and this was confirmed in our study as well. Our study achieved 100% success with enhanced control and precision in intraosseous anesthesia using the QuickSleeper5\u003csup\u003e\u0026reg;\u003c/sup\u003e anesthesia device.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;In contrast, ABI showed lower success requiring additional anesthesia compared to LIO. The success rate of ABI was 70.8%, which was similar to previous studies reporting about 65%\u0026nbsp;[20]. Recent studies have compared the success rates of ABI and LIANB in treating irreversible pulpitis in mandibular molars. According to a study, ABI has been reported to have a success rate ranging from 64.5% to 70.4%, which is not significantly different from the success rate of lidocaine IANB, which ranges from 55.6% to 69.2%\u0026nbsp;[20, 21].\u0026nbsp;While ABI shows success rates comparable to IANB, it still proves to be less efficient than intraosseous anesthesia, necessitating adjunctive anesthesia\u0026nbsp;[22]. Nevertheless, buccal infiltration anesthesia is considered less invasive and simpler compared to techniques like intraosseous, as it does not involve cortical bone perforation, making it a less invasive option. Therefore, in the absence of a specialized anesthetic device for bone penetration, ABI can be considered for mandibular molar treatment instead of IANB.\u003c/p\u003e\n\u003cp\u003ePain during needle insertion and local anesthetic deposition were significantly lower in LIO compared to ABI. The primary cause of pain during anesthesia is attributed to the speed of injection\u0026nbsp;[23, 24]. In the case of LIO, a slower and more controlled speed of deposition using Quicksleeper5\u003csup\u003e\u0026reg;\u003c/sup\u003e is possible, which can result in a reduced level of pain experienced by the patient. Furthermore, patients did not report any specific discomfort during drilling for intraosseous anesthesia. This can be attributed to the technique of applying infiltration anesthesia to the drilling site with approximately 1/4 of an ampoule before drilling, rather than immediately proceeding with drilling. Additionally, the use of thin needles rotating at high speed (15,000 rpm) for anesthesia further contributed to the absence of discomfort after the numbness wore off\u0026nbsp;[14, 15].\u0026nbsp;This study revealed no instances of discomfort at the injection site in cases of LIO. However, although ABI resulted in significantly higher pain compared to LIO, it was still manageable, especially considering the slow injection rate of 0.45ml/min.\u003c/p\u003e\n\u003cp\u003eThe efficacy of each method was evaluated based on onset and duration. Traditional intraosseous anesthesia is known for its rapid onset and short duration\u0026nbsp;[11]. Vongsavan et al. reported a mean onset of intraosseous anesthesia (IO) of 2.4 minutes and a mean duration of 38 minutes\u0026nbsp;[25].\u0026nbsp;In our study, 91.7% of cases with intraosseous anesthesia showed no response to the electric pulp tester after just 1 minute of anesthesia. Conversely, there were only three instances where anesthesia was achieved within one minute with ABI. According to a study investigating the buccal infiltration of 4% articaine or 2% lidocaine into the mandibular first molar, the time to achieve negative readings on the EPT was significantly faster with articaine, at 4.2 minutes, compared to lidocaine, which took 7.7 minutes\u0026nbsp;[22]. The author speculated that articaine\u0026apos;s higher lipid solubility, attributed to its benzene ring rather than a thiophene ring, allows it to penetrate nerve cell lipid membranes more effectively.\u0026nbsp;In our study, although 70.8% achieved a negative reading on the EPT within 5 minutes, this was significantly slower than intraosseous injection using lidocaine, which involves a direct injection into the bone marrow. Consequently, the choice of anesthetic method plays a more crucial role in achieving faster anesthesia than the specific anesthetics used.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhen measuring the time taken for anesthesia to wear off, articaine took 231.25 minutes, while lidocaine took 118.63 minutes, with lidocaine significantly shorter. According to a study, both articaine and lidocaine buccal infiltration anesthesia demonstrated the recovery from pulpal anesthesia starting around 25 to 30 minutes\u0026nbsp;[21, 26].\u0026nbsp;Here, we retrospectively analyzed the anesthesia methods utilized in the treatment of mandibular molars based on medical record data. Unlike conventional randomized clinical trials, regular EPT was not conducted during anesthesia at post-injection intervals to record the time necessary for the recovery of pulpal sensory function, indicated by the return of a positive response. Instead, the total duration of anesthesia was calculated based on patients\u0026apos; recollection of the time when sensation in their lips returned to normal, which they reported during their subsequent follow-up visits. Therefore, our results indicate that the mean total duration until patients\u0026apos; subjective numbness wore off was 231.25 minutes, which was longer compared to LIO.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere was no significant difference in soft tissue anesthesia between the two anesthesia methods. In the case of ABI, 100% of participants exhibited subjective lower lip numbness, which was consistent with findings from previous studies.\u0026nbsp;According to these studies, it is known that when buccal infiltration is performed, the anesthetic solution spreads through the mental foramen, leading to numbness in the lower region\u0026nbsp;[21, 27].\u0026nbsp;In a study about the efficacy of the primary intraosseous injection using lidocaine in the mandibular first molar, 58% of patients reported experiencing subjective numbness in the lower lip\u0026nbsp;[19].\u0026nbsp;In our study, LIO showed 83.3% lower lip numbness. We did infiltration anesthesia 0.45mL (1/4 of an ampoule) before intraosseous injection. We can speculate that 0.45mL was related high accidence of lower lip numbness. However, the observation of a trend toward soft tissue anesthesia even in cases where only intraosseous anesthesia was administered is noteworthy and deserves attention.\u003c/p\u003e\n\u003cp\u003eIn this study, only two individuals (8.33%) complained of an increased heart rate during LIO, which differs from findings in other previous studies. According to Replogle et al., when LIO containing 1:100,000 epi. was administered for 2 minutes, an increase in heart rate was observed in 67% of cases\u0026nbsp;[28]. Another study reported that during a fast LIO injection (45 seconds), there was an increase in heart rate ranging from an average of 21 to 28 beats /min, while during a slow injection (4 minutes and 45 seconds), there was an increase ranging from 10 to 12 beats/min. It was suggested that approximately a 10 beats/min increase would be necessary for patients to subjectively perceive an increase in heart rate\u0026nbsp;[29]. In our study, LIO anesthesia was administered over a period of 4 minutes, with a slow and controlled injection speed. Therefore, it is assumed that the frequency of subjective perception by patients regarding increased heart rate would have been reported less frequently. Further research should be conducted using electrocardiogram monitoring for more objective assessment.\u003c/p\u003e\n\u003cp\u003eIt is believed that intraosseous anesthesia is superior to articaine infiltration anesthesia in terms of no supplemental anesthesia, rapid onset and return to normal sensation. The invasiveness typically associated with traditional intraosseous anesthesia can be mitigated to some extent by the development of new intraosseous anesthesia devices. However, in situations where there are barriers such as the purchase of anesthesia equipment, ABI anesthesia may be considered as an alternative. In such cases, it is necessary to wait patiently for the anesthesia to take full effect, and additional anesthesia methods such as supraperiosteal anesthesia should be considered if anesthesia is not achieved.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWithin the limitation of this study, lidocaine intraosseous anesthesia (LIO) significantly outperforms articaine buccal infiltration anesthesia (ABI) in mandibular molars, marked by a higher success rate without the need for additional anesthesia, less pain during administration, quicker onset, and shorter duration. While ABI may still serve as an alternative when LIO is not feasible, it requires careful consideration of the potential need for supplementary anesthesia and patient management for effective outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJ.Y. was the primary investigator for this study. J.Y. and D.P. collected the data and evaluated the findings. J.Y. analyzed the data. J.Y., D.P., and J.K. performed the literature review and revised the manuscript. All authors have read and approved the final version submitted for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted under Seoul National University Bundang Hospital (SNUBH) IRB approval. (IRB No.: B-2403-891-103)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was obtained for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest to declare that are relevant to the content of this article.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePalti DG, Almeida CM, Rodrigues Ade C, Andreo JC, Lima JE (2011) Anesthetic technique for inferior alveolar nerve block: a new approach. J Appl Oral Sci 19:11-15. https://doi.org/10.1590/s1678-77572011000100004\u003c/li\u003e\n\u003cli\u003eIsmail AI, Sohn W, Tellez M, Amaya A, Sen A, Hasson H, Pitts NB (2007) The International Caries Detection and Assessment System (ICDAS): an integrated system for measuring dental caries. Community Dent Oral Epidemiol 35:170-178. https://doi.org/10.1111/j.1600-0528.2007.00347.x\u003c/li\u003e\n\u003cli\u003eGugnani N, Pandit IK, Srivastava N, Gupta M, Sharma M (2011) International Caries Detection and Assessment System (ICDAS): A New Concept. Int J Clin Pediatr Dent 4:93-100. https://doi.org/10.5005/jp-journals-10005-1089\u003c/li\u003e\n\u003cli\u003eHuh YK, Montagnese TA, Harding J, Aminoshariae A, Mickel A (2015) Assessment of patients' awareness and factors influencing patients' demands for sedation in endodontics. J Endod 41:182-189. https://doi.org/10.1016/j.joen.2014.10.009\u003c/li\u003e\n\u003cli\u003eParirokh M, Abbott PV (2022) Present status and future directions-Mechanisms and management of local anaesthetic failures. Int Endod J 55 Suppl 4:951-994. https://doi.org/10.1111/iej.13697\u003c/li\u003e\n\u003cli\u003eCohen HP, Cha BY, Spangberg LS (1993) Endodontic anesthesia in mandibular molars: a clinical study. J Endod 19:370-373. https://doi.org/10.1016/S0099-2399(06)81366-X\u003c/li\u003e\n\u003cli\u003eDrum M, Reader A, Nusstein J, Fowler S (2017) Successful pulpal anesthesia for symptomatic irreversible pulpitis. J Am Dent Assoc 148:267-271. https://doi.org/10.1016/j.adaj.2017.01.002\u003c/li\u003e\n\u003cli\u003eMonteiro MR, Groppo FC, Haiter-Neto F, Volpato MC, Almeida JF (2015) 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 48:145-152. https://doi.org/10.1111/iej.12293\u003c/li\u003e\n\u003cli\u003eAli MA, Akter K, Molla MTIH, Kabir R (2023) 4% Articaine Buccal Infiltration Versus 2% Lignocaine Inferior Alveolar Nerve Block for Pulpal Anaesthesia in Mandibular First Molars. European Journal of Dental and Oral Health 4:1-5\u003c/li\u003e\n\u003cli\u003eJung IY, Kim JH, Kim ES, Lee CY, Lee SJ (2008) An evaluation of buccal infiltrations and inferior alveolar nerve blocks in pulpal anesthesia for mandibular first molars. J Endod 34:11-13. https://doi.org/10.1016/j.joen.2007.09.006\u003c/li\u003e\n\u003cli\u003eMeechan JG (2002) Supplementary routes to local anaesthesia. Int Endod J 35:885-896. https://doi.org/10.1046/j.1365-2591.2002.00592.x\u003c/li\u003e\n\u003cli\u003eRemmers T, Glickman G, Spears R, He J (2008) The efficacy of IntraFlow intraosseous injection as a primary anesthesia technique. J Endod 34:280-283. https://doi.org/10.1016/j.joen.2007.12.005\u003c/li\u003e\n\u003cli\u003eNilius M, Mueller C, Nilius MH, Haim D, Leonhardt H, Lauer G (2020) Intraosseous anesthesia in symptomatic irreversible pulpitis: Impact of bone thickness on perception and duration of pain. J Dent Anesth Pain Med 20:367-375. https://doi.org/10.17245/jdapm.2020.20.6.367\u003c/li\u003e\n\u003cli\u003eSmail-Faugeron V, Muller-Bolla M, Sixou JL, Courson F (2019) Evaluation of intraosseous computerized injection system (QuickSleeper) vs conventional infiltration anaesthesia in paediatric oral health care: A multicentre, single-blind, combined split-mouth and parallel-arm randomized controlled trial. Int J Paediatr Dent 29:573-584. https://doi.org/10.1111/ipd.12494\u003c/li\u003e\n\u003cli\u003eSovatdy S, Vorakulpipat C, Kiattavorncharoen S, Saengsirinavin C, Wongsirichat N (2018) Inferior alveolar nerve block by intraosseous injection with Quicksleeper(R) at the retromolar area in mandibular third molar surgery. J Dent Anesth Pain Med 18:339-347. https://doi.org/10.17245/jdapm.2018.18.6.339\u003c/li\u003e\n\u003cli\u003eSmail-Faugeron V, Muller-Bolla M, Sixou JL, Courson F (2015) Split-mouth and parallel-arm trials to compare pain with intraosseous anaesthesia delivered by the computerised Quicksleeper system and conventional infiltration anaesthesia in paediatric oral healthcare: protocol for a randomised controlled trial. BMJ Open 5:e007724. https://doi.org/10.1136/bmjopen-2015-007724\u003c/li\u003e\n\u003cli\u003eReplogle K, Reader A, Nist R, Beck M, Weaver J, Meyers WJ (1997) Anesthetic efficacy of the intraosseous injection of 2% lidocaine (1:100,000 epinephrine) and 3% mepivacaine in mandibular first molars. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 83:30-37. https://doi.org/10.1016/s1079-2104(97)90087-1\u003c/li\u003e\n\u003cli\u003eNusstein J, Reader A, Nist R, Beck M, Meyers WJ (1998) Anesthetic efficacy of the supplemental intraosseous injection of 2% lidocaine with 1:100,000 epinephrine in irreversible pulpitis. J Endod 24:487-491. https://doi.org/10.1016/S0099-2399(98)80053-8\u003c/li\u003e\n\u003cli\u003eCoggins R, Reader A, Nist R, Beck M, Meyers WJ (1996) Anesthetic efficacy of the intraosseous injection in maxillary and mandibular teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 81:634-641. https://doi.org/10.1016/s1079-2104(96)80067-9\u003c/li\u003e\n\u003cli\u003eCorbett IP, Kanaa MD, Whitworth JM, Meechan JG (2008) Articaine infiltration for anesthesia of mandibular first molars. J Endod 34:514-518. https://doi.org/10.1016/j.joen.2008.02.042\u003c/li\u003e\n\u003cli\u003eKanaa MD, Whitworth JM, Corbett IP, Meechan JG (2006) Articaine and lidocaine mandibular buccal infiltration anesthesia: a prospective randomized double-blind cross-over study. J Endod 32:296-298. https://doi.org/10.1016/j.joen.2005.09.016\u003c/li\u003e\n\u003cli\u003eRobertson D, Nusstein J, Reader A, Beck M, McCartney M (2007) The anesthetic efficacy of articaine in buccal infiltration of mandibular posterior teeth. J Am Dent Assoc 138:1104-1112. https://doi.org/10.14219/jada.archive.2007.0324\u003c/li\u003e\n\u003cli\u003eAggarwal V, Singla M, Miglani S, Kohli S, Irfan M (2012) A prospective, randomized single-blind evaluation of effect of injection speed on anesthetic efficacy of inferior alveolar nerve block in patients with symptomatic irreversible pulpitis. J Endod 38:1578-1580. https://doi.org/10.1016/j.joen.2012.08.006\u003c/li\u003e\n\u003cli\u003eWhitworth JM, Kanaa MD, Corbett IP, Meechan JG (2007) Influence of injection speed on the effectiveness of incisive/mental nerve block: a randomized, controlled, double-blind study in adult volunteers. J Endod 33:1149-1154. https://doi.org/10.1016/j.joen.2007.07.016\u003c/li\u003e\n\u003cli\u003eVongsavan K, Samdrup T, Kijsamanmith K, Rirattanapong P, Vongsavan N (2019) The effect of intraosseous local anesthesia of 4% articaine with 1:100,000 epinephrine on pulpal blood flow and pulpal anesthesia of mandibular molars and canines. Clin Oral Investig 23:673-680. https://doi.org/10.1007/s00784-018-2481-3\u003c/li\u003e\n\u003cli\u003eNydegger B, Nusstein J, Reader A, Drum M, Beck M (2014) Anesthetic comparisons of 4% concentrations of articaine, lidocaine, and prilocaine as primary buccal infiltrations of the mandibular first molar: a prospective randomized, double-blind study. J Endod 40:1912-1916. https://doi.org/10.1016/j.joen.2014.08.001\u003c/li\u003e\n\u003cli\u003eMeechan JG, Kanaa MD, Corbett IP, Steen IN, Whitworth JM (2006) Pulpal anaesthesia for mandibular permanent first molar teeth: a double-blind randomized cross-over trial comparing buccal and buccal plus lingual infiltration injections in volunteers. Int Endod J 39:764-769. https://doi.org/10.1111/j.1365-2591.2006.01144.x\u003c/li\u003e\n\u003cli\u003eReplogle K, Reader A, Nist R, Beck M, Weaver J, Meyers WJ (1999) Cardiovascular effects of intraosseous injections of 2 percent lidocaine with 1:100,000 epinephrine and 3 percent mepivacaine. J Am Dent Assoc 130:649-657. https://doi.org/10.14219/jada.archive.1999.0274\u003c/li\u003e\n\u003cli\u003eSusi L, Reader A, Nusstein J, Beck M, Weaver J, Drum M (2008) Heart rate effects of intraosseous injections using slow and fast rates of anesthetic solution deposition. Anesth Prog 55:9-15. https://doi.org/10.2344/0003-3006(2008)55[9:HREOII]2.0.CO;2\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e1\u003c/strong\u003e The inclusion/exclusion criteria\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eInclusion criteria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eExclusion criteria\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e1) Teeth exhibiting extensive caries corresponding to ICDAS 5 and 6\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2) Showing positive responses in two Electric Pulp Testing (EPT) sessions\u003c/p\u003e\n \u003cp\u003e3) Administration of local anesthesia by ABI or LIO\u003c/p\u003e\n \u003cp\u003e4) Age\u0026gt;19 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e1) Teeth with EPT negative\u003c/p\u003e\n \u003cp\u003e2) Presence of periapical lesions or tumors\u003c/p\u003e\n \u003cp\u003e3) Those who had taken analgesics for tooth pain\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4) Patients requiring treatment for more than one tooth\u003c/p\u003e\n \u003cp\u003e5) Those who received block anesthesia\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6) Individuals with any neurologic syndrome or symptoms.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: ABI, Articaine Buccal Infiltration. EPT, Electric Pulp Testing. LIO, Lidocaine Intraosseous. ICDAS, International Caries Detection and Assessment System.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e General and teeth-related characteristics according to the anesthesia method\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.22314049586777%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.694214876033058%\" valign=\"top\"\u003e\n \u003cp\u003eABI\u003c/p\u003e\n \u003cp\u003eM(SD)/N(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.694214876033058%\" valign=\"top\"\u003e\n \u003cp\u003eLIO\u003c/p\u003e\n \u003cp\u003eM(SD)/N(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.694214876033058%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026chi;\u003csup\u003e2\u003c/sup\u003e/t\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.694214876033058%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.22314049586777%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.694214876033058%\"\u003e\n \u003cp\u003e46.07(17.79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.694214876033058%\"\u003e\n \u003cp\u003e49.71(18.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.694214876033058%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.694214876033058%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.677685950413224%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.545454545454545%\" valign=\"top\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.694214876033058%\"\u003e\n \u003cp\u003e8(33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.694214876033058%\"\u003e\n \u003cp\u003e11(45.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.694214876033058%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.694214876033058%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.88617886178862%\" valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.528455284552845%\"\u003e\n \u003cp\u003e16(66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.528455284552845%\"\u003e\n \u003cp\u003e13(54.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.528455284552845%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.528455284552845%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.677685950413224%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eICDAS\u003c/p\u003e\n \u003cp\u003eclassification\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.545454545454545%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.694214876033058%\"\u003e\n \u003cp\u003e14(58.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.694214876033058%\"\u003e\n \u003cp\u003e18(75.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.694214876033058%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e1.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.694214876033058%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e.221\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.344827586206897%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.827586206896555%\"\u003e\n \u003cp\u003e10(41.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.827586206896555%\"\u003e\n \u003cp\u003e6(25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.677685950413224%\" rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003eTooth number\u003c/p\u003e\n \u003cp\u003e(FDI system)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.545454545454545%\" valign=\"top\"\u003e\n \u003cp\u003e#36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.694214876033058%\"\u003e\n \u003cp\u003e8(33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.694214876033058%\"\u003e\n \u003cp\u003e10(41.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.694214876033058%\" rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e2.31\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.694214876033058%\" rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e.678\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.344827586206897%\" valign=\"top\"\u003e\n \u003cp\u003e#37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.827586206896555%\"\u003e\n \u003cp\u003e7(29.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.827586206896555%\"\u003e\n \u003cp\u003e5(20.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.344827586206897%\" valign=\"top\"\u003e\n \u003cp\u003e#38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.827586206896555%\"\u003e\n \u003cp\u003e1(4.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.827586206896555%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.344827586206897%\" valign=\"top\"\u003e\n \u003cp\u003e#46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.827586206896555%\"\u003e\n \u003cp\u003e2(8.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.827586206896555%\"\u003e\n \u003cp\u003e4(16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.344827586206897%\" valign=\"top\"\u003e\n \u003cp\u003e#47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.827586206896555%\"\u003e\n \u003cp\u003e6(25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.827586206896555%\"\u003e\n \u003cp\u003e5(20.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003e\u0026dagger;\u003c/sup\u003eFisher\u0026rsquo;s exact test\u003c/p\u003e\n\u003cp\u003eNote: ABI, Articaine Buccal Infiltration. FDI, F\u0026eacute;d\u0026eacute;ration Dentaire Internationale. ICDAS, International Caries Detection and Assessment System. LIO, Lidocaine Intraosseous. M, Median. \u003cem\u003eP\u003c/em\u003e, \u003cem\u003eP\u003c/em\u003e-value. SD, Standard Deivation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable3\u003c/strong\u003e The differences in success rate according to the anesthesia method\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.22314049586777%\" colspan=\"2\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.694214876033058%\" valign=\"top\"\u003e\n \u003cp\u003eABI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.694214876033058%\" valign=\"top\"\u003e\n \u003cp\u003eLIO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.694214876033058%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026chi;\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.694214876033058%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eN(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eN(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.666666666666668%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eAdditional anesthesia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e17(70.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e24(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e8.20\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e.009*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e7(29.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003e\u0026dagger;\u003c/sup\u003eFisher\u0026rsquo;s exact test\u003c/p\u003e\n\u003cp\u003e\u0026lowast; Significant \u003cem\u003eP\u003c/em\u003e value at 0.05 level\u003c/p\u003e\n\u003cp\u003eNote: ABI, Articaine Buccal Infiltration. LIO, Lidocaine Intraosseous.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4\u003c/strong\u003e The difference in pain during anesthesia\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eGroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003ePain during anesthesia\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eM\u0026plusmn;SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003et(\u003cem\u003eP\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eABI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e32.0\u0026plusmn;18.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2.9(.006)*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eLIO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e17.3\u0026plusmn;17.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026lowast; Significant \u003cem\u003eP\u0026nbsp;\u003c/em\u003evalue at 0.05 level\u003c/p\u003e\n\u003cp\u003eNote: ABI, Articaine Buccal Infiltration. LIO, Lidocaine Intraosseous. M, Median. \u003cem\u003eP\u003c/em\u003e, \u003cem\u003eP\u003c/em\u003e-value. SD, Standard Deivation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5\u003c/strong\u003e The differences in anesthesia onset time according to the anesthesia method\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.22314049586777%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.694214876033058%\" valign=\"top\"\u003e\n \u003cp\u003eABI\u003c/p\u003e\n \u003cp\u003eN(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.694214876033058%\" valign=\"top\"\u003e\n \u003cp\u003eLIO\u003c/p\u003e\n \u003cp\u003eN(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.694214876033058%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026chi;\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.694214876033058%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.666666666666668%\" rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003eOnset time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e1 min.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e3(12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e22(91.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\" rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e33.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\" rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt;.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\"\u003e\n \u003cp\u003e3min.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e6(25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\"\u003e\n \u003cp\u003e5min.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e8(33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e1(4.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e7min.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e1(4.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e1(4.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003efailure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e6(25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026lowast; Significant \u003cem\u003eP\u0026nbsp;\u003c/em\u003evalue at 0.05 level\u003c/p\u003e\n\u003cp\u003eNote: ABI, Articaine Buccal Infiltration. LIO, Lidocaine Intraosseous. \u003cem\u003eP\u003c/em\u003e, \u003cem\u003eP\u003c/em\u003e-value.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6\u003c/strong\u003e The difference in the duration of anesthesia according to the anesthesia method\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eGroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eDuration of anesthesia\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eM\u0026plusmn;SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003et(\u003cem\u003eP\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eABI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e231.3\u0026plusmn;79.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e5.8(\u0026lt;.001)*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eLIO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e118.6\u0026plusmn;52.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026lowast; Significant \u003cem\u003eP\u003c/em\u003e value at 0.05 level\u003c/p\u003e\n\u003cp\u003eNote: ABI, Articaine Buccal Infiltration. LIO, Lidocaine Intraosseous. \u003cem\u003eP\u003c/em\u003e, \u003cem\u003eP\u003c/em\u003e-value.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 7\u003c/strong\u003e The differences in the occurrence of soft tissue anesthesia according to the anesthesia method\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.22314049586777%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.694214876033058%\" valign=\"top\"\u003e\n \u003cp\u003eABI\u003c/p\u003e\n \u003cp\u003eN(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.694214876033058%\" valign=\"top\"\u003e\n \u003cp\u003eLIO\u003c/p\u003e\n \u003cp\u003eN(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.694214876033058%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026chi;\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.694214876033058%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.666666666666668%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eLower lip numbness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e0()\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e4(16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e4.36\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e.109\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e24(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e20(83.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003e\u0026dagger;\u003c/sup\u003eFisher\u0026rsquo;s exact test\u003c/p\u003e\n\u003cp\u003eNote: ABI, Articaine Buccal Infiltration. LIO, Lidocaine Intraosseous. \u003cem\u003eP\u003c/em\u003e, \u003cem\u003eP\u003c/em\u003e-value.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Articaine, Dental Caries, Lidocaine, Local Anesthesia","lastPublishedDoi":"10.21203/rs.3.rs-4213775/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4213775/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjectives\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIt is vital to identify more efficient anesthesia techniques for restorative or endodontic treatments of mandibular molars. Both articaine buccal infiltration anesthesia (ABI) and lidocaine inferior alveolar nerve block anesthesia (LIANB) may not provide profound anesthesia, necessitating supplementary anesthesia. This study aims to investigate whether lidocaine intraosseous (LIO) injection, compared to ABI, is suitable for primary anesthesia for caries treatments of mandibular molars.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials and Methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study retrospectively analyzed on patients for the treatment of advanced caries corresponding to the International Caries Detection and Assessment System (ICDAS) 5 and 6. The study involved 48 patients, split evenly between those receiving ABI and LIO, examining anesthesia success rate, pain during anesthesia, onset time, duration, and lower lip numbness, with data analyzed using Chi-square and Independent T-tests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the ABI group, 17 individuals (70.8%) did not require additional anesthesia, whereas all 24 individuals (100%) in the LIO group did not require additional anesthesia (\u003cem\u003eP\u003c/em\u003e\u0026lt;.001). ABI showed significantly higher pain during anesthesia, slower onset time, and longer duration of anesthesia compared to LIO. There was no significant difference in lower lip numbness between the two anesthesia methods.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor treating severe caries in mandibular molars, intraosseous anesthesia using lidocaine is more effective for its higher success rate, decreased pain during anesthesia, faster onset, and shorter recovery time.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Relevance\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe findings of this study suggest that LIO may be considered as a primary anesthesia method for mandibular molar caries treatments in clinical practice, providing beneficial effects for patients.\u003c/p\u003e","manuscriptTitle":"Retrospective comparison of local anesthesia for mandibular molars: articaine buccal infiltration vs. lidocaine intraosseous anesthesia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-18 18:34:56","doi":"10.21203/rs.3.rs-4213775/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"affca48a-c7ce-4aeb-8711-fd72a9fb0886","owner":[],"postedDate":"April 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-05-11T06:08:44+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-18 18:34:56","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4213775","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4213775","identity":"rs-4213775","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}