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Comparative Evaluation of Effect of Preoperative Oral Medication of Ibuprofen and Ketorolac on Anesthetic Efcacy of Inferior Alveolar Nerve Block with Lidocaine in Patients with Irreversible Pulpitis: A Prospective, Double-blind, Randomized Clinical Trial
Vivek Aggarwal, MDS,* Mamta Singla, MDS, and Debipada Kabi, MDS*
Abstract
Introduction: Anesthetic efcacy of inferior alveolar nerve block decreases in patients with irreversible pulpitis. It was hypothesized that premedication with nonsteroidal anti-inammatory drugs might improve the success rates in patients with inamed pulps. Methods: Sixty-nine adult volunteers who were actively experiencing pain participated in this prospective, randomized, double-blind study. The patients were divided into 3 groups on a random basis and were randomly given 1 of the 3 drugs including ibuprofen, ketorolac, and placebo 1 hour before anesthesia. All patients received standard inferior alveolar nerve block of 2% lidocaine with 1:200,000 epinephrine. Endodontic access preparation was initiated after 15 minutes of initial inferior alveolar nerve block. Pain during treatment was recorded by using a Heft Parker visual analog scale. Success was recorded as none or mild pain. Results: Statistical analysis with nonparametric c2 tests showed that placebo gave 29% success rate. Premedication with ibuprofen gave 27%, and premedication with ketorolac gave 39% success rate. There was no signicant difference between the 3 groups. Conclusions: Preoperative administration of ibuprofen or ketorolac has no signicant effect on success rate of inferior alveolar nerve block in patients with irreversible pulpitis. (J Endod 2010;36:375378)
Key Words
Ibuprofen, inferior alveolar nerve block, irreversible pulpitis, ketorolac, NSAIDs
From the *Department of Dental Surgery, Safdarjung Hospital, New Delhi; and Department of Conservative Dentistry and Endodontics, Institute of Dental Sciences and Technology, Modinagar, India. Address requests for reprints to Dr Vivek Aggarwal, Department of Dental Surgery, Safdarjung Hospital, New Delhi, India. E-mail address: drvivekaggarwal@gmail.com. 0099-2399/$0 - see front matter Copyright 2010 American Association of Endodontists. doi:10.1016/j.joen.2009.11.010
ocal anesthesia is an integral part of management of painful endodontic emergencies by inhibiting the nociceptive signals (14). The inferior alveolar nerve block (IANB) is the standard and most commonly used technique for achieving pulpal anesthesia for mandibular endodontic procedures. IANB has a high failure rate, ranging from 7% 77% (2, 3, 510). The success rates get even worse in patients with inamed pulpal tissues (2, 3, 10, 11). Various mechanisms have been hypothesized to explain the failure of local anesthetics including anatomic variations like cross innervations and accessory innervations (1114), decreased local pH (2, 14), tachyphylaxis of anesthetic solutions (14), and activation of nociceptors including tetrodotoxin (TTX) and capsaicin-sensitive transient receptor potential vanilloid type 1 (TRPV1) (1416). The most plausible explanation for decrease in success rate in inamed pulp can be the activation of nociceptors by inammation (1517). Inammatory mediators reduce the threshold for activation of nociceptor neurons to a point that a minor stimulus now might re these neurons (17, 18). This inammatory process is mediated via prostaglandins (PGs), which are end products of arachidonic acid (AA) metabolism, produced via cyclooxygenase (COX) pathway (19, 20). PGs act by sensitizing nerve endings to bradykinins and histamines and hence enhance the pain and tenderness of inammation (1520). COX is available in body in 2 isoforms, COX-1 and COX-2 (21, 22). COX-1 regulates normal cell activities in the stomach, kidneys, and platelets by synthesizing prostanoids that have cytoprotective functions (21, 22). The COX-2 is normally not present in tissue (except kidneys) and is present only in areas of tissue injury and inammation (22, 23). Traditional nonsteroidal anti-inammatory drugs (NSAIDs) act by nonselective inhibition of COX activity, resulting in some gastrointestinal side effects (23). Specic COX-2 inhibitors were developed to deliver equivalent pain relief to that of the nonselective NSAIDs, but without the accompanying risk of gastrointestinal complications. Recently a number of large clinical trials have revealed that the COX-2specic inhibitors are associated with an increased risk of cardiovascular toxicity, which led to withdrawal of Rofecoxib from the market in 2004 (2427). Among the nonselective NSAIDs, ibuprofen and ketorolac have been shown to provide signicantly improved pain control over placebo (2830). Ibuprofen is a propionic acid derivative and an effective analgesic and anti-inammatory agent. Ketorolac, a pyrrolo-pyrrole derivative, is as effective as morphine or meperidine for pain relief (2831). Many researchers have identied inammation as an important component of the pathogenesis of hyperalgesia and failure of local anesthesia (1520). Because NSAIDs reduce nociceptor activation by decreasing the levels of inammatory mediators, it is hypothesized that premedication with NSAIDs will affect the success rate of local anesthesia in patients with irreversible pulpitis. In 2007 Modaresi et al (32) studied the role of premedication with ibuprofen and acetaminophen-codeine for achieving deep anesthesia in patients with irreversible pulpitis. Efcacy in achieving deep anesthesia was evaluated with the help of electric pulp tester. The authors did not evaluate the success or failure rate on basis of pain during root canal treatment. Therefore the present study
375
IBUP
30 8; range, 2338 10 males, 12 females 106 38 10 4
KETA
29 8; range, 2437 12 males, 11 females 101 45 93
was planned to evaluate the effect of premedication with various NSAIDs on anesthetic success rate in terms of pain during endodontic procedure. The purpose of this prospective, randomized, double-blind study was to compare the effect of oral premedication of ibuprofen, ketorolac, and a placebo medication on anesthetic efcacy of IANB with lidocaine with 1:200,000 epinephrine in patients with irreversible pulpitis.
170-mm line marked with various terms describing the levels of pain was used for this purpose (33). The millimeter marks were removed from the scale, and the scale was divided into 4 categories: no pain corresponded to 0 mm; faint, weak, or mild pain corresponded to 054 mm; moderate pain corresponded to 55114 mm; and strong, intense, and maximum possible pain corresponded to more than 114 mm (3). A trained dental hygienist divided 144 empty capsules of same color and size into 3 bottles: ibuprofen (IBUP), ketorolac (KETA), and placebo (PLAC) group. IBUP capsules were lled with 300 mg of ibuprofen, KETA capsules were lled with 10 mg of ketorolac, and PLAC capsules were lled with starch. The bottles were masked with an opaque label and were randomly assigned a 3-digit alphanumeric value. Another trained dental hygienist randomly divided all the patients into 3 groups of 24 patients each and gave 2 capsules 1 hour before the procedure. Only the alphanumeric values were recorded on the data sheets to blind the experiment. After 1 hour of oral administration of the capsules, all patients received standard IANB injections by using 1.8 mL of 2% lidocaine with 1:200,000 epinephrine (Xylocaine; AstraZeneca Pharmaceutical Products, Wilmington, DE). The solution was injected by the same clinician (rst author) by using self-aspirating syringes (Septodont, SaintMaur-des-Fosses Cedex, France) and 27-gauge long needles (Septoject; Septodont). After reaching the target area, aspiration was performed, and 1.7 mL of solution was deposited at a rate of 1 mL/min. After 15 minutes of the initial IANB, each patient was asked if his or her lip was numb. If profound lip numbness was not recorded within 15 minutes, the block was considered unsuccessful, and the patients were excluded from the study. The patients were again asked to rate their pain on Heft Parker VAS. The involved teeth were isolated with a rubber dam, and a conventional access opening was initiated. Patients were instructed to raise their hand if any pain was felt during the procedure. In case of pain during the treatment, the procedure was stopped, and patients were asked to rate the pain on Heft Parker VAS. The extent of access preparation and/or instrumentation was recorded as within dentin, within pulpal space, and instrumentation of canals. Success was dened as no pain or weak/mild pain during endodontic access preparation and instrumentation (3). The ndings were recorded on a Microsoft Excel sheet (Microsoft Ofce Excel 2003; Microsoft Corp, Redmond, WA) for statistical evaluation by using the program BioEstat, version 4.0 (Mamiraua Institute, Belem, Brazil). Age and initial and postinjection pains of the subjects
TABLE 3. Comparison of Percentage of Successful Anesthesia in Control and Test Groups Control PLAC
Successful anesthesia 7 of 24 patients (29%)
IBUP
6 of 22 patients (27%)
KETA
9 of 23 patients (39%)
Control PLAC
12/24 (50%) 12/24 (50%)
IBUP
10/22 (45%) 12/22 (55%)
KETA
11/23 (48%) 12/23 (52%)
PLAC, placebo; IBUP, ibuprofen; KETA, ketorolac. There was no signicant difference (P > .05) between the groups.
PLAC, placebo; IBUP, ibuprofen; KETA, ketorolac. There was no signicant difference (P > .05) between the groups.
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Aggarwal et al.
Results
Seventy-two adult volunteer subjects, 38 men and 34 women, with an average age of 31 years, range 2138 years, participated in this prospective, randomized, double-blind study. Of the original 72 patients, 3 patients, 2 from IBUP group and 1 from KETA group, did not have profound lip numbness at 15 minutes and were excluded from the study. The age, gender, and initial and 15-minute postinjection pain of all the patients are presented in Table 1. Distribution of teeth for PLAC (control), IBUP, and KETA groups is presented in Table 2. There was no statistical difference between the age (P = .72), gender (P = .94), initial pain (P > .05), and distribution of teeth. All patients included in the study had profound lip anesthesia after 15 minutes. All patients reported a signicant decrease in active pain after local anesthesia (P < .05). The postinjection pain Heft Parker VAS scores of different groups were insignicant (P = .94). The comparison of percentage of patients with successful anesthesia (no pain or weak/mild pain during endodontic access preparation and instrumentation) is presented in Table 3. Control PLAC gave 29% success rate (7 of 24 patients). Premedication with ibuprofen (IBUP) gave 27% (6 of 22 patients), and premedication with ketorolac (KETA) gave 39% (9 of 23 patients) success rate. There was no significant difference between the 3 groups. None of the techniques gave 100% success rate. The pain and discomfort ratings of the patients with unsuccessful anesthesia (Heft Parker VAS score >54) with relation to extent of access preparation and/or instrumentation are presented in Table 4.
Discussion
IANB is an effective tool in management of mandibular endodontic procedures by reversibly interrupting the propagation of inferior alveolar nerve impulses. IANB might provide successful anesthesia in 70% of uninamed pulp, but the success rate drastically decreases to 30% or even less in patients with irreversible pulpitis (2, 3, 510). The literature suggests activation of nociceptors by inammatory mediators such as PGs as a major cause of increased incidence of failure of IANB in patients with irreversible pulpitis (1520).
TABLE 4. Comparison of Number of Unsuccessful Anesthesia in Control and Test Groups Heft Parker VAS score 54114
Within dentin Within pulpal space Instrumentation of canals Control PLAC IBUP KETA Control PLAC IBUP KETA Control PLAC IBUP KETA 5 of 17 4 of 16 4 of 14 2 of 17 2 of 16 3 of 14 2 of 17 2 of 16 2 of 14
Supplementary data
Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.joen.2009.11.010
References
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