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REVIEW ARTICLE
Year : 2016 | Volume
: 10
| Issue : 1 | Page : 81-86
Role of intraseptal anesthesia for pain-free dental treatment
G Gazal1, WM Fareed1, MS Zafar2
1 Department of Oral Surgery, College of Dentistry, Taibah University, Al Madinah Al Munawwarah, Saudi Arabia
2 Department of Restorative Dentistry, College of Dentistry, Taibah University, Al Madinah Al Munawwarah, Saudi Arabia
Correspondence Address:
M S Zafar
College of Dentistry, Taibah University, P.O. Box 2898, Al Madinah Al Munawwarah
Saudi Arabia
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/1658-354X.169482
| Date of Web Publication | 12-Nov-2015 |
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Pain control during the dental procedure is essentials and challenging. A complete efficacious pulp anesthesia has not been attained yet. The regional anesthesia such as inferior alveolar nerve block (IANB) only does not guarantee the effective anesthesia with patients suffering from irreversible pulpitis. This main aim of this review was to discuss various aspects of intraseptal dental anesthesia and its role significance in pain-free treatment in the dental office. In addition, reasons of failure and limitations of this technique have been highlighted. Literature search was conducted for peer-reviewed articles published in English language in last 30 years. Search words such as dental anesthesia, pain control, intraseptal, and nerve block were entered using a web of knowledge and Google scholar databases. Various dental local anesthesia techniques were reviewed. A combination of block anesthesia, buccal infiltration and intraligamentary injection resulted in deep anesthesia (P = 0.003), and higher success rate compared to IANB. For pain-free management of conditions such as irreversible pulpitis, buccal infiltration (4% articaine), and intraosseous injection (2% lidocaine) are better than intraligamentary and IANB injections. Similarly, nerve block is not always effective for pain-free root canal treatment hence, needing supplemental anesthesia. Intraseptal anesthesia is an efficient and effective technique that can be used in maxillary and mandibular adult dentition. This technique is also beneficial when used in conjunction to the regional block or local dental anesthesia. Keywords: Dental anesthesia; intraseptal injection; medullary diffusion
How to cite this article:
Gazal G, Fareed W M, Zafar M S. Role of intraseptal anesthesia for pain-free dental treatment. Saudi J Anaesth 2016;10:81-6 |
| Introduction | |  |
In order to be a successful dentist, you have to implement a pain-free dental treatment. This can be merely achieved by effective local anesthetic techniques. [1],[2],[3],[4] Considering the complex nature of oral and dental tissues, attaining effective dental local anesthesia may be challenging in certain circumstances. For example, the failure of local anesthetic injections in irreversible pulpitis can be 8 times higher than health teeth. Such issues cannot be ignored as a good number of patients with endodontic complaints attend the dental clinics on a daily basis. Failure of the local anesthetic injections using inferior alveolar nerve block (IANB) for lower dentition and buccal infiltration for upper teeth in asymptomatic and symptomatic patients requires additional buck-up strategies to achieve pain-free dental treatment. [5],[6] Otherwise, the patient complains of severe pain and hindering the clinician to proceed to the dental treatment. [7]
In the light of these facts and dilemma, supplemental injection techniques are the solution that can help the dentist to carry out the pain-free dental treatment. On the basis of anatomical site of injection, commonly used supplemental local anesthetic techniques are termed as intraligamentary (periodontal ligament), interosseous (alveolar bone), intrapulpal (pulp), and intraseptal (bony septum) injections. [8] Intraligamentary injections are used for cavity preparation and caused no complications regarding the hemorrhage and hematoma formation in hemophiliac patients. [8],[9] However, intraligamentary anesthesia is not recommended for treating deciduous teeth because it may damage un-erupted teeth. [10] The pressure used during intraligamentary injections causes the anesthetic solution to spread into underlying tooth germs. [11] A defective enamel formation has been reported in monkeys following intraligamentary injections. [12] However, in humans, there are no studies reporting cases of defective enamel formation. [10] Intrapulpal anesthesia technique has limited applications as it can only be used if the pulp is exposed. Intrapulpal anesthesia used for pulpotomy did not interfere with the healing process of pulpotomized teeth. [13] The method of intraosseous anesthesia is technically more difficult than infiltration, and intraseptal anesthesia (ISA), and specialized equipment may be required. Intraosseous technique can lead to rapid absorption of local anesthetic and vasoconstrictor in the circulation. Hence, cardiovascular changes are attributable to adrenaline entry into the circulation that may occur immediately after intraosseous injection. [14]
Intraseptal injection has been reported to be more effective for controlling postoperative pain compared to intraosseous and intraligamentary injections. [15] The efficacy of ISA is similar to intraosseous injection, and they are both more successful than the intraligamentary injection because a greater amount of anesthetic solution can be delivered during the injection. [16] Supplementary techniques might have a negative effect on the cardiovascular system, for example, increased heart rate for a couple of minutes after intraosseous injection. [17] Brkovic et al. [15] indicated that the use of both intraseptal and periodontal ligament techniques is beneficial and appropriate for the routine tooth/teeth removal. Intraseptal technique provides local anesthesia of one tooth including the soft-tissues. Intraseptal technique anesthetizes surrounding nerve endings in the tissues of a particular tooth. [18] There are a few contraindications such as acute inflammation or infection at injection cite. However, ISA remains a convenient local anesthesia practice for a general dental surgeon. [19]
The protocol used for the administration of ISA has been described briefly. Patient ought to be placed in the supine position. Considering the thick of soft-tissues, a short injection needle is usually proffered. The target region is located 2-3 mm apical to the apex of the papillary triangle [Figure 1]a and b. | Figure 1: Intraseptal injection technique; (a) marking for the administration of anesthesia (b) positioning of the needle 3 mm apical to the apex of the papillary triangle (c) ischemia of the soft-tissue surrounding the injection site
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The needle is introduced into the soft-tissue and advanced until contact with bone is made. Pressure must be applied to the syringe and drive the barb slightly deeper (1-2 mm) into the interdental septum. Afterward, anesthetic solution (0.2-0.4 ml) is deposited in a minimum of 20 s time. Prevailing resistance to the flow/movement of the anesthetic solution and ischemic discoloration of the neighboring soft-tissues are main signs of success of this technique. [20],[21] This is illustrated in [Figure 1]c. This main aim of this review was to discuss various aspects of intraseptal dental anesthesia and its role significance in pain-free treatment in the dental office. In addition, reasons of failure and limitations of this technique have been highlighted.
| Failure of Conventional Local Anesthetic Techniques | | |
The pain is considered an important defense mechanism of the body, [22] however, pain control can be challenging in certain clinical conditions. For example, failure of local anesthetic injections is deemed the most severe task especially for mandibular teeth with reversible pulpitis. Attainment of IANB is indicated by numbness of soft-tissue and lip. [5],[23],[24] However, failure blocks associated to the lack of lip numbness happens in approximately 5% of cases and requiring another injection before commencing the treatment. [25] In light of this fact, few options regarding injection techniques or anesthetic solutions are available in order to achieve anesthetic success. Anesthetic success for mandibular anesthesia is determined by the percentage of subjects who achieve 2 consecutive electrical pulp tester readings of 80 or 64 within 15 min and continue these readings for 60 min/1 h. [26],[27],[28] Clinically, anesthetic success is considered if a dentist can work on the patient no later than 15 min after giving the IANB and having pulpal anesthesia for 1 h. [29],[30] Success rates of maxillary infiltration anesthetic injection techniques are about 95% or higher. However, the success rates for IANBs generally are 80-85%. [31],[32] Lower success rates in the mandible could be as the results of the greater density of the buccal alveolar plate (which prevents supraperiosteal infiltration), limited access to the inferior alveolar nerve and a wide variation in neuroanatomy. [33]
There were no positive effects for increasing both the volume of the local anesthetic and the concentration of epinephrine delivered during the administration of IANB on the incidence of pulpal anesthesia. [23],[29],[34],[35] Occasionally, patients with asymptomatic teeth may have difficulties in achieving successful anesthesia for mandibular anterior teeth. One possible theory that is considered the best explanation stated that the nerve trunk of the inferior alveolar nerve is consisted of superficial and deep fibers. The outer nerves supply the molar teeth, while the anterior teeth nerves lie deeper. If the anesthetic solutions cannot diffuse the nerve stalk to approach all the nerves, they will not be able to provide an adequate block in the mandibular anterior teeth. [25],[36] Patients diagnosed with irreversible pulpitis may encounter extra difficulties to obtain pulpal anesthesia. The anesthetic failure can be due to pulpitis that results in hyperalgesia in enclosed pulp tissues. [37] Inflamed tissues may alter the nerves' resting membrane potentials and decrease excitability thresholds. Therefore, routine local anesthetic techniques may not prevent nerve transmission adequately because of the lowered excitability thresholds.
| Mechanism of Action for Intraseptal Injection | | |
The route of diffusion and distribution of the anesthetic solution in the intraseptal technique is most likely through the medullary bone [Figure 1]b. It offers anesthesia to the bone, delicate/soft-tissues, and root structure in the region of infusion. It is best when both pain control and hemostasis are wanted for delicate/soft-tissue and bony periodontal treatment. [10],[28],[34],[38]
Advantages of intraseptal injection
In contrast to IANB and local infiltration, the intraseptal technique prevents the anesthesia of tissues such as lips and tongue hence, decreases the chances of cheek or lip biting (self-trauma). It necessitates minimum or least dosage of local anesthetic and minimizes bleeding during the surgical procedure. This technique being less traumatic has immediate or instantaneous (<30 s) onset of action and comparatively less number of postsurgical complications. [10],[16],[39] Intravascular injection is extremely unlikely to occur [31] compared to IANB or infiltration. Assertions that ISA is immediate are properly consistent with previous clinical results. Their findings reported that the onset of action for anesthesia was within 1 min after injection. Hence, the onset time can be considered rapid if not immediate. [40],[41],[42],[43]
Disadvantages of intraseptal injection
Clinical experience and multiple tissue punctures may be necessary to perform this technique. During the anesthetic procedure, the anesthetic solution may leak into the oral cavity resulting discomfort and an unpleasant or bitter taste. The effective period anesthesia for pulpal and soft-tissues is very limited [10],[16],[44] hence multiple repeats may be required for longer surgical procedures.
| Results and Discussion | | |
Different supplementary local anesthetic techniques for patients have been compared [Table 1]. Parirokh et al. [45] evaluated the depth of anesthesia for lower molars for irreversible pulpitis using IANB injection supplemented with or without intraligamentary injection and buccal infiltration. Patients who received IANB, buccal infiltration, and intraligamentary injection in a combination had more deep anesthesia (P = 0.003) and higher success rate than those who received only IANB. [45] The effectiveness of additional lingual infiltration on the depth of anesthesia for mandibular teeth has been reviewed recently. [49] Previous clinical studies were searched, and the information regarding the advantages of using supplemental lingual infiltration on the pulpal anesthesia of lower teeth was extracted by two investigators using a designed extraction form. This systematic review reported that there were no advantages in adding lingual injection to buccal infiltration for mandibular canines, premolars, and molars in terms of onset and period of pulpal anesthesia. However, the depth of pulpal anesthesia for the mandibular incisors improved by giving an additional lingual infiltration following buccal infiltration. [49] According to Kanaa et al. [28] and Shabazfar et al., [50] IANB is not always enough for achieving free pain root canal treatment for irreversible pulpitis in the lower molars teeth. In order to achieve pain-free management irreversible pulpitis, buccal infiltration (4% articaine), and intraosseous injection (2% lidocaine) are better than intraligamentary and IANB injections. [28] On the other hand, intraosseous injections have been reported to raise the heart rate transitory (Stabident and X-Tip systems). The escalation in heart rate increased from 12 to 32 beats/min using local anesthesia (2% lidocaine; 1:100,000 epinephrine). [42],[51],[52],[53],[54] However, the use of 3% mepivacaine did not cause any significant rise in the heart rate [53],[55] and can be considered the choice of anesthetic for medically compromised patients. Cardiovascular changes associated with supplementary dental injections have been discussed [Table 2].
A single-blinded study [47] was conducted to assess the effectiveness and safety of intraseptal and periodontal ligament anesthesia (PLA) using computer-regulated articaine and adrenaline dispersals in human mandibular premolars. One hundred and eighty volunteers were included in this study. Success rate, depth of anesthesia, and time of pulpal and soft-tissue anesthesia were considerably improved in case of ISA compared to the PLA. Moreover, there were no noteworthy cardiovascular variations seen in any groups.
Zarei et al. [44] reported a temporary rise in heart rate while using intraosseous injections (X-Tip) for lower molar irreversible pulpitis patients. A total of 40 patients with failure of IANB were recruited in and randomly allocated to two groups. First group received an intraosseous injection (X-Tip system) and the second group received periodontal injections. Visual analog scale was used to assess the discomfort of needle prick at each step of injection, and a pulse oximeter was attached to monitor the heart rate. The findings of this study stated that the anesthetic success was 100% in the intraosseous group and 70% in intraligamentary. [44] In a similar study, [57] the uneasiness of injection or infusion, heart rate changes, and postoperative pain of the intraligamentary injection (4% articaine and 2% lidocaine with epinephrine, 1:100,000) administered using a computer-controlled local anesthetic delivery system were evaluated. In terms of anesthetic solutions, there were no remarkable variations for both articaine and lidocaine solutions. Both solutions did not affect to increase in heart rate over baseline evaluations. [57]
Gallatin et al. [55] compared the relationship of anesthetic effectiveness and heart rate for subjects receiving an intraosseous injection (3% mepivacaine), supplemented to IANB augmented with the mock intraosseous injection. For 3% mepivacaine intraosseous injection group, there was a significant increase in anesthetic success for half an hour in the 1 st molar and participants described a minimal rise in heart rate. Borodina and Petrkas [56] administrated dental local anesthetic using intraseptal injection technique in dental carries patients. Complete pain relief was observed in 135 (out of 154) patients. Intraseptal injection did not affect in seven cases only. The success rate of intraseptal injections was similar for upper and lower teeth. Brkovic et al. [15] conducted a study to compare the effectiveness of intraseptal technique with PLA for extraction of maxillary teeth. Postoperative pain was reduced in ISA group than in the PLA group, but variations were insignificant. Clinically, the heart rate increased in either groups; however, insignificant alterations in the hemodynamic response for ISA and PLA. Both systems considered valuable and have been recommended for the usual dental extractions. [15]
Likewise, Idris et al. [16] used intraosseous infusion/injection as a subordinate to conventional local anesthetic techniques for treatment of lower molars with irreversible pulpitis. Their findings uncovered that the intraosseous injection method was effective in 87.5% of patients. However, Doman [48] carried out a study to evaluate the effectiveness of 4% articaine intraseptal local anesthetic injection for cavity preparation in mandibular molar and premolar (113 patients). Pain-free dental treatment was completed in 71% patients whereas 16% experienced a very minor pain during treatment. In addition, no side-effects were reported. [16] The first author has been using the intraseptal injection technique as standard injection techniques for last two decades for treating upper and lower teeth regardless of the type of dental procedure. Clinically, he found this technique was 100% successful for dental extractions of upper and lower teeth with no complications. It is the author's belief that is consistence with previous studies showing the superiority and safety of this technique. [15],[47],[55],[56],[58]
| Conclusion | | |
Dental techniques demanding significant pulpal, bone, and soft-tissue anesthesia can be adequately and securely acquired using ISA. It can be a first choice anesthesia for teeth extractions and restorative dental procedures. Intraseptal injection is likewise helpful for giving hemostasis for surgical flap procedures and periodontal curettage.
Acknowledgments
Authors would like to thank all the anesthetists, dental practitioners, medical caretakers, and pediatric staff at the Manchester University Dental Hospital, UK.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Gazal G, Fareed WM, Zafar MS, Al-Samadani KH. Pain and anxiety management for pediatric dental procedures using various combinations of sedative drugs: A review. Saudi Pharm J 2014. E-published ahead of print. Doi:10.1016/j.jsps.2014.04.004.  |
| 2. | Gazal G, Fareed WM, Zafar MS. Effectiveness of gaseous and intravenous inductions on children's anxiety and distress during extraction of teeth under general anesthesia. Saudi J Anaesth 2015;9:33-6. [ PUBMED]  |
| 3. | Bansal N, Saha S, Jaiswal J, Samadi F. Pain Elimination during Injection with Newer Electronic Devices: A Comparative Evaluation in Children. Int J Clin Pediatr Dent 2014;7:71-6. |
| 4. | Verma PK, Srivastava R, Ramesh KM. Anesthetic efficacy of X-tip intraosseous injection using 2% lidocaine with 1:80,000 epinephrine in patients with irreversible pulpitis after inferior alveolar nerve block: A clinical study. J Conserv Dent 2013;16:162-6. [ PUBMED] |
| 5. | Nusstein JM, Reader A, Drum M. Local anesthesia strategies for the patient with a "hot" tooth. Dent Clin North Am 2010;54:237-47. |
| 6. | Claffey E, Reader A, Nusstein J, Beck M, Weaver J. Anesthetic efficacy of articaine for inferior alveolar nerve blocks in patients with irreversible pulpitis. J Endod 2004;30:568-71. |
| 7. | Mikesell P, Nusstein J, Reader A, Beck M, Weaver J. A comparison of articaine and lidocaine for inferior alveolar nerve blocks. J Endod 2005;31:265-70. |
| 8. | Ah Pin PJ. The use of intraligamental injections in haemophiliacs. Br Dent J 1987;162:151-2. [ PUBMED] |
| 9. | Spuller RL. Use of the periodontal ligament injection in dental care of the patient with hemophilia - A clinical evaluation. Spec Care Dentist 1988;8:28-9. [ PUBMED] |
| 10. | Meechan JG. Supplementary routes to local Anesthesia. Int Endod J 2002;35:885-96. |
| 11. | Brännström M, Nordenvall KJ, Hedström KG. Periodontal tissue changes after intraligamentary anesthesia. ASDC J Dent Child 1982;49:417-23. |
| 12. | Brannstrom M, Lindskog S, Nordenvall KJ. Enamel hypoplasia in permanent teeth induced by periodontal ligament anesthesia of primary teeth. J Am Dent Assoc 1984;109:735-6. [ PUBMED] |
| 13. | Teixeira L, Demarco F, Coppola M, Bonow M. Clinical and radiographic evaluation of pulpotomies performed with intrapulpal injection of anesthetic solution. J Dent Res 1999;78:385. |
| 14. | Coggins R, Reader A, Nist R, Beck M, Meyers WJ. Anesthetic efficacy of the intraosseous injection in maxillary and mandibular teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;81:634-41. |
| 15. | Brkovic BM, Savic M, Andric M, Jurisic M, Todorovic L. Intraseptal vs. periodontal ligament Anesthesia for maxillary tooth extraction: Quality of local Anesthesia and haemodynamic response. Clin Oral Investig 2010;14:675-81. |
| 16. | Idris M, Sakkir N, Naik KG, Jayaram NK. Intraosseous injection as an adjunct to conventional local anesthetic techniques: A clinical study. J Conserv Dent 2014;17:432-5. [ PUBMED] |
| 17. | Wood M, Reader A, Nusstein J, Beck M, Padgett D, Weaver J. Comparison of intraosseous and infiltration injections for venous lidocaine blood concentrations and heart rate changes after injection of 2% lidocaine with 1:100,000 epinephrine. J Endod 2005;31:435-8. |
| 18. | Malamed SF, Trieger N. Intraoral maxillary nerve block: An anatomical and clinical study. Anesth Prog 1983;30:44-8. [ PUBMED] |
| 19. | Woodmansey K. Intraseptal anesthesia: A review of a relevant injection technique. Gen Dent 2005;53:418-20. |
| 20. | Malamed SF. Local anesthesia. J Calif Dent Assoc 1998;26:657, 660. |
| 21. | Kanaa MD, Whitworth JM, Corbett IP, Meechan JG. Articaine buccal infiltration enhances the effectiveness of lidocaine inferior alveolar nerve block. Int Endod J 2009;42:238-46. |
| 22. | Verma V, Sheikh Z, Ahmed AS. Nociception and role of immune system in pain. Acta Neurol Belg 2014. E-Published ahead of prints. Doi: 10.1007/s13760-014-0411-y. |
| 23. | Vreeland DL, Reader A, Beck M, Meyers W, Weaver J. An evaluation of volumes and concentrations of lidocaine in human inferior alveolar nerve block. J Endod 1989;15:6-12. [ PUBMED] |
| 24. | Hinkley SA, Reader A, Beck M, Meyers WJ. An evaluation of 4% prilocaine with 1:200,000 epinephrine and 2% mepivacaine with 1:20,000 levonordefrin compared with 2% lidocaine with:100,000 epinephrine for inferior alveolar nerve block. Anesth Prog 1991;38:84-9. |
| 25. | Hannan L, Reader A, Nist R, Beck M, Meyers WJ. The use of ultrasound for guiding needle placement for inferior alveolar nerve blocks. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:658-65. |
| 26. | Simon F, Reader A, Meyers W, Beck F, Nist R. Evaluation of a peripheral-nerve stimulator in human mandibular Anesthesia. J Dent Res 1990;69:278. |
| 27. | Fernandez C, Reader A, Beck M, Nusstein J. A prospective, randomized, double-blind comparison of bupivacaine and lidocaine for inferior alveolar nerve blocks. J Endod 2005;31:499-503. |
| 28. | Kanaa MD, Whitworth JM, Meechan JG. A prospective randomized trial of different supplementary local anesthetic techniques after failure of inferior alveolar nerve block in patients with irreversible pulpitis in mandibular teeth. J Endod 2012;38:421-5. |
| 29. | Nusstein J, Reader A, Beck FM. Anesthetic efficacy of different volumes of lidocaine with epinephrine for inferior alveolar nerve blocks. Gen Dent 2002;50:372-5. |
| 30. | Lindemann M, Reader A, Nusstein J, Drum M, Beck M. Effect of sublingual triazolam on the success of inferior alveolar nerve block in patients with irreversible pulpitis. J Endod 2008;34:1167-70. |
| 31. | Malamed SF. Handbook of Local Anesthesia . St. Louis Missouri, USA: Elsevier Health Sciences; 2004. |
| 32. | Kaufman E, Weinstein P, Milgrom P. Difficulties in achieving local anesthesia. J Am Dent Assoc 1984;108:205-8. [ PUBMED] |
| 33. | Moore PA, Cuddy MA, Cooke MR, Sokolowski CJ. Periodontal ligament and intraosseous anesthetic injection techniques: alternatives to mandibular nerve blocks. J Am Dent Assoc 2011;142 Suppl 3:13S-8. |
| 34. | Clark TM, Yagiela JA. Advanced techniques and armamentarium for dental local anesthesia. Dent Clin North Am 2010;54:757-68. |
| 35. | Yonchak T, Reader A, Beck M, Meyers WJ. Anesthetic efficacy of unilateral and bilateral inferior alveolar nerve blocks to determine cross innervation in anterior teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;92:132-5. |
| 36. | Agren E, Danielsson K. Conduction block analgesia in the mandible. A comparative investigation of the techniques of Fischer and Gow-Gates. Swed Dent J 1981;5:81-9. [ PUBMED] |
| 37. | Torabinejad M, Walton RE. Principles and Practice of Endodontics . Philadelphia: Saunders; 2002. |
| 38. | Nusstein J, Kennedy S, Reader A, Beck M, Weaver J. Anesthetic efficacy of the supplemental X-tip intraosseous injection in patients with irreversible pulpitis. J Endod 2003;29:724-8. |
| 39. | Malamed SF, Gagnon S, Leblanc D. Articaine hydrochloride: A study of the safety of a new amide local anesthetic. J Am Dent Assoc 2001;132:177-85. |
| 40. | Dunbar D, Reader A, Nist R, Beck M, Meyers WJ. Anesthetic efficacy of the intraosseous injection after an inferior alveolar nerve block. J Endod 1996;22:481-6. |
| 41. | Reitz J, Reader A, Nist R, Beck M, Meyers WJ. Anesthetic efficacy of the intraosseous injection of 0.9 mL of 2% lidocaine (1:100,000 epinephrine) to augment an inferior alveolar nerve block. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86:516-23. |
| 42. | Guglielmo A, Reader A, Nist R, Beck M, Weaver J. Anesthetic efficacy and heart rate effects of the supplemental intraosseous injection of 2% mepivacaine with 1:20,000 levonordefrin. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:284-93. |
| 43. | Wong JK. Adjuncts to local anesthesia: separating fact from fiction. J Can Dent Assoc 2001;67:391-7. |
| 44. | Zarei M, Ghoddusi J, Sharifi E, Forghani M, Afkhami F, Marouzi P. Comparison of the anaesthetic efficacy of and heart rate changes after periodontal ligament or intraosseous X-Tip injection in mandibular molars: a randomized controlled clinical trial. Int Endod J 2012;45:921-6. |
| 45. | Parirokh M, Sadr S, Nakhaee N, Abbott PV, Askarifard S. Efficacy of supplementary buccal infiltrations and intraligamentary injections to inferior alveolar nerve blocks in mandibular first molars with asymptomatic irreversible pulpitis: A randomized controlled trial. Int Endod J 2014;47:926-33. |
| 46. | Dou L, Luo J, Yang D. Anaesthetic efficacy of supplemental lingual infiltration of mandibular molars after inferior alveolar nerve block plus buccal infiltration in patients with irreversible pulpitis. Int Endod J 2013;46:660-5. |
| 47. | Biocanin V, Brkovic B, Milicic B, Stojic D Efficacy and safety of intraseptal and periodontal ligament anesthesia achieved by computer-controlled articaine epinephrine delivery: A dose-finding study. Clin Oral Investig 2013;17:525-33. |
| 48. | Doman SM. An audit of the use of intra-septal local Anesthesia in a dental practice in the South of England. Prim Dent Care 2011;18:67-71. |
| 49. | Dou L, Luo J, Yang D, Wang Y. The effectiveness of an additional lingual infiltration in the pulpal anesthesia of mandibular teeth: a systematic review. Quintessence Int 2013;44:457-64. |
| 50. | Shabazfar N, Daubländer M, Al-Nawas B, Kämmerer PW. Periodontal intraligament injection as alternative to inferior alveolar nerve block - Meta-analysis of the literature from 1979 to 2012. Clin Oral Investig 2014;18:351-8. |
| 51. | Stabile P, Reader A, Gallatin E, Beck M, Weaver J. Anesthetic efficacy and heart rate effects of the intraosseous injection of 1.5% etidocaine (1:200,000 epinephrine) after an inferior alveolar nerve block. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:407-11. |
| 52. | Bigby J, Reader A, Nusstein J, Beck M. Anesthetic efficacy of lidocaine/meperidine for inferior alveolar nerve blocks in patients with irreversible pulpitis. J Endod 2007;33:7-10. |
| 53. | Replogle K, Reader A, Nist R, Beck M, Weaver J, Meyers WJ. Cardiovascular effects of intraosseous injections of 2 percent lidocaine with 1:100,000 epinephrine and 3 percent mepivacaine. J Am Dent Assoc 1999;130:649-57. |
| 54. | Chamberlain TM, Davis RD, Murchison DF, Hansen SR, Richardson BW Systemic effects of an intraosseous injection of 2% lidocaine with 1:100,000 epinephrine. Gen Dent 2000;48:299-302. |
| 55. | Gallatin E, Stabile P, Reader A, Nist R, Beck M. Anesthetic efficacy and heart rate effects of the intraosseous injection of 3% mepivacaine after an inferior alveolar nerve block. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:83-7. |
| 56. | Borodina OE, Petrkas AZh. Intraceptal anesthesia of lower and upper teeth. Stomatologiia (Mosk) 2009;88:19-20. |
| 57. | Nusstein J, Berlin J, Reader A, Beck M, Weaver JM. Comparison of injection pain, heart rate increase, and postinjection pain of articaine and lidocaine in a primary intraligamentary injection administered with a computer-controlled local anesthetic delivery system. Anesth Prog 2004;51:126-33. |
| 58. | Lönnqvist PA. Adjuncts should always be used in pediatric regional anesthesia. Paediatr Anaesth 2015;25:100-6. |
[Figure 1]
[Table 1], [Table 2]
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