Pain Perception during Intrapulpal Anesthesia: A Systematic Literature Review
Corresponding Author: Krithika Arumbakkam Chakravarthy, Department of Dental, Primary Health Care Corporation, Doha, Qatar, Phone: +00974 33689275, e-mail: firstname.lastname@example.org
How to cite this article: Chakravarthy KA, Jagannathan S, Lalitha VM. Pain Perception during Intrapulpal Anesthesia: A Systematic Literature Review. J Oral Health Comm Dent 2023;17(2):57–61.
Source of support: Nil
Conflict of interest: None
Received on: 19 May 2023; Accepted on: 05 July 2023; Published on: 29 August 2023
Intrapulpal injections are a blessing in disguise to endodontists. Every endodontist would have successfully achieved pain relief in cases by administering intrapulpal injections. The satisfaction of painless pulp extirpation to the dentist and comfortable endodontic treatment experienced by the patient following intrapulpal anesthesia cannot be emphasized more. At the same time, intrapulpal injections are themselves extremely painful. The objective of this systematic review is to determine the pain associated with the administration of intrapulpal injections through a systematic review.
Keywords: Intrapulpal anesthesia, Irreversible pulpitis, PRISMA 2020, Pain perception.
Pulpitis is one of the few dental conditions that need emergency care. By the rule of thumb, any inflammation causes edema. In a pulpitis scenario, there is no effective drainage of the edema fluid as the pulp chamber is a closed cavity. This increases the intrapulpal pressure. The management of acute pulpal inflammation is to relieve the intrapulpal pressure by draining the fluid and extirpate the inflamed pulp. Draining fluid can be achieved by opening the coronal access and with anti-inflammatory medications. Extirpation of the inflamed pulp is important as this prevents further accumulation of edema fluid. In addition to the intrapulpal pressure, the pain in pulpitis is attributed to the nerve terminals in the chamber. A delta and C fibers get stimulated because of the inflammatory process leading to a specific type of pain.1
Emergency access opening and pulp extirpation is the one-step pain relieving procedure that helps manage both conditions. Access opening can be an extremely painful procedure by itself if not anesthetized properly. Thus, achieving adequate pulpal anesthesia is important for a painless endodontic treatment. In most cases, the common anesthetic techniques of buccal infiltration and inferior alveolar nerve block are adequate to achieve profound anesthesia.
When the primary anesthetic technique fails, supplementary techniques like intraligamentary, intraosseous, and intrapulpal anesthesia are administered.2–4 Intrapulpal injections are indicated when pulpal anesthesia is not achieved even after adequate soft tissue anesthesia and the patient feels pain when the pulp chamber is entered. The effect of the intrapulpal injection is immediate but extremely painful with a shorter duration of effective anesthesia. Thus, it is important to assess pain perception during intrapulpal anesthesia. Extol literature review done in this regard has brought forth the necessity to consolidate the body of knowledge about pain perception during intrapulpal anesthesia. So, a literature review was commissioned to throw much light on the intricacies involved in the study concept. Systematic review articles give a detailed evidence-based insight of the topic.5–7
This article consolidates the available literature that helps to determine the pain associated with the administration of intrapulpal injections. The PRISMA 20208 is adopted as a guide for executing the systematic review.
Intrapulpal injections are a blessing in disguise to endodontists. Every endodontist would have successfully achieved pain relief in pulp extirpations by administering intrapulpal injections. The satisfaction of painless pulp extirpation to the dentist and comfortable endodontic treatment experienced by the patient following intrapulpal anesthesia cannot be emphasized more. At the same time, intrapulpal injections are themselves extremely painful.9 Various research articles were published related to supplementary anesthetic techniques.10,11 Although the literature is scanty in this area, available literature was reviewed to assess the pain during intrapulpal injections. The gathered research is consolidated for steering the research aspirants in the field. Accordingly, the following research questions were framed.
What was the pain response among patients during the administration of intrapulpal injections?
What are the procedures which could alter the pain scale during administration of intrapulpal injections?
The methodology of the systematic literature review was executed by identifying the keywords. These keywords were finalized by reviewing the significance of the topic and the allied topics related to the study.
SELECTION OF KEYWORDS
The keywords used to search the database are tabulated in Table 1.
|Keyword 1||Pain perception during intrapulpal anesthesia|
|Keyword 2||Intrapulpal anesthesia as supplementary anesthetic technique|
After deciding the list of keywords to use for collecting the literature, eligibility criteria were decided to proceed for further collection of literature. Decision about the eligibility criteria not only consolidates the relevant literature but also guides for further systematic literature review.
The eligibility criteria for selecting the articles to answer the research questions were decided by the following criteria.
English language published articles
Published between 2001 and 2023
Studies on human, adult patients
Clinical studies/published clinical trials related to pain in irreversible pulpitis and intrapulpal injections
Articles in languages other than English
Clinical trials that are not yet published
Articles with clinical studies on children, nonhuman subjects
Articles published related to pain management for other dental treatments
By adhering to these norms of eligibility following data repositories were verified.
The following databases were reviewed between April 1 and May 3, 2023 to identify the relevant studies using the specified keywords.
Taylor and Francis
Cochrane and Embase database
Cochrane and Embase searches resulted in documents repeated in PubMed. So, they were excluded. The results were supplemented with hand search and citation mining.
The above-mentioned databases were searched for with two different keywords for each database. Year of publication (2001–2023) and only original research papers were added in the filter to make the search specific. As there was not much work done in the area related to pain perception during intrapulpal anesthesia, a long span of studies was considered (2001–2023). The details about the database, initial set of articles, and final set of selected articles are listed in Table 2.
|Database||Searched articles||Reviewed after exclusions||Relevant articles to the research questions|
|Taylor and Francis
|Taylor and Francis
|3||2||2 (Research question 2)|
|Cochrane and Embase||2||2||2 (Duplicated articles)|
A total of 65 articles were collected using the two keywords from the five databases. All the articles went through the process of critical review for the selection of a final list of articles and data collection. Data items were listed and a synthesis of the information from the selected articles was made. The results were listed as follows.
A detailed review of the relevant 27 articles that were considered out of 37 originally selected articles from the ScienceDirect library was done. About 13 articles with keyword 1 search10–22 and 14 articles with keyword 2 search11,13–16,18,23–30 were extracted. Following the suit, a detailed review of the relevant 8 articles out of 11 articles from keyword 131–36 and keyword 2 search31,37,38 from the SpringerLink database was done. Also, a review of the five relevant articles out of nine articles from Taylor and Francis searches was done, and three articles39–41 meeting keyword 1 search as well as three articles satisfying keyword 239,42,43 search were extracted. Finally, three relevant articles44–46 were retrieved from PubMed. Articles from Cochrane and Embase search engines were duplicated in PubMed, thus they were excluded.
Extracted articles were finally reviewed with research questions 1 and 2. As mentioned initially, there was a dearth of literature related to the study topic. Only two articles were finally selected depending on their suitability to the research questions.
It was found that most of the articles from Science Direct were on irreversible pulpitis and they either have tested various chemical agents or techniques for achieving local anesthesia other than intrapulpal anesthesia. None of them answered our research questions. It was found that from the SpringerLink articles, one article studied the effect of endoice on anesthetizing the tooth, while the other article discussed the effect of cooling before administering the buccal infiltration anesthesia in maxillary molars. As in the previous database review, none of the two addressed the research questions. Also, it was found that none of the articles from Taylor and Francis search provided sufficient information to answer the research questions. Finally, three relevant articles from PubMed44–46 searches were analyzed and among them, two articles were found to answer the research question. Except for the two articles, there is no study documented from 2001 to 2023 on the identification of pain response during the administration of intrapulpal pressure from the searches done within the limitations of this review.
It is surprising to observe that there is no article found to be relevant to research question 1 and only two articles could answer research question 2.44,45 First article identified the effect of the thickness of the needle gauge on pain perception during intrapulpal pressure. The results of the clinical trial showed that a 31 gauge needle provided adequate anesthesia with less pain during injection. The second article explained the reduction of pain following the use of topical benzocaine gel before intrapulpal anesthesia.45 Results are tabulated in Table 3.
|202044||Suresh Nandini et al.||To assess the pain perception during intrapulpal anesthesia using thinner gauge needles and syringes with or without topical anesthesia as an adjunct||Clinical study; randomized trial; assessed pain with visual analog scale||Thinner the needle gauge, less painful was the intrapulpal injection|
|201545||Sooraparaju et al.||To determine whether the topical application of benzocaine gel along with hyaluronidase to the pulp chamber could reduce the pain felt with the intrapulpal injection technique||Clinical study; assessed pain with visual analog scale||Topical application of 20% benzocaine gel with hyaluronidase to exposed pulp reduces the pain during intrapulpal injection|
The systematic literature review could demonstrate that there is no article published that identified the pain scale on administration of intrapulpal anesthesia (research question 1) under the limitations of this systematic review. However, there were two articles published that suggested methods to reduce pain during administration of intrapulpal anesthesia (research question 2). Further clinical studies are needed to analyze the pain response in such situations.
The detailed analysis of the available literature through this systematic review reaffirms the need to encourage more research in the area of intrapulpal anesthesia, particularly the pain perception during administration. This systematic literature review brought forth the gray areas to work in these dental procedures. The risk of bias could not be avoided due to the smaller number of articles satisfying the research question. This highlights the gap in the literature that can be addressed by prospective researchers.
Krithika Arumbakkam Chakravarthy https://orcid.org/0000-0003-3775-9160
Venkata Madhavi Lalitha https://orcid.org/0000-0001-9150-3882
2. AAE. Taking the pain out of restorative dentistry and endodontics: current thoughts and treatment options to help patients achieve profound anesthesia. Endodontics: Colleagues for Excellence 2009. www.aae.org.
9. Malamed SF. The management of pain and anxiety. In: Cohen S, Burns RC, (Eds). Pathways of the Pulp, 7th edition. St. Louis: CV Mosby Co; 1988. pp. 665–666.
10. Yavari HR, Jafari F, Jamloo H, et al. The effect of submucosal injection of corticosteroids on pain perception and quality of life after root canal treatment of teeth with irreversible pulpitis: A randomized clinical trial. J Endod 2019;45(5):477–482. DOI: 10.1016/j.joen.2019.01.005.
11. Aggarwal V, Singla M, Miglani S, et al. Efficacy of articaine versus lidocaine administered as supplementary intraligamentary injection after a failed inferior alveolar nerve block: A randomized double-blind study. J Endod 2019;45(1):1–5. DOI: 10.1016/j.joen.2018.09.012. Epub 2018 Dec 6. PMID: 30527595.
12. Karataş E, Sümbüllü M, Kahraman ÇY, et al. Association between single-nucleotide polymorphisms in candidate genes and success of pulpal anesthesia after inferior alveolar nerve block. J Endod 2023;49(1):18–25. DOI: 10.1016/j.joen.2022.09.004.
13. Kayaoglu G, Gürel M, Saricam E, et al. Predictive model of intraoperative pain during endodontic treatment: Prospective observational clinical study. J Endod 2016;42(1):36–41. DOI: 10.1016/j.joen.2015.09.021. Epub November 12, 2015. PMID: 26577872.
14. Elsharrawy EA, Elbaghdady YM. A double-blind comparison of a supplemental interligamentary injection of fentanyl and mepivacaine with 1:200,000 epinephrine for irreversible pulpitis. J Pain Symptom Manage 2007;33(2):203–207. DOI: 10.1016/j.jpainsymman.2006.07.020.
15. Weitz D, Ordinola-Zapata R, McClanahan SB, et al. National Dental Practice-Based Research Network Collaborative Group. Preoperative factors associated with anesthesia failure for patients undergoing nonsurgical root canal therapy: A national dental practice-based research network study. J Endod 2021;47(12):1875–1882. DOI: 10.1016/j.joen.2021.09.005.
16. Visconti RP, Tortamano IP, Buscariolo IA. Comparison of the anesthetic efficacy of mepivacaine and lidocaine in patients with irreversible pulpitis: A double-blind randomized clinical trial. J Endod 2016;42(9):1314–1319. DOI: 10.1016/j.joen.2016.06.015.
17. MacDonald E, Drum M, Nusstein J, et al. Anesthetic success using nitrous oxide and a combination of lidocaine/clonidine for the inferior alveolar nerve block and the effects on blood pressure and pulse in patients with symptomatic irreversible pulpitis: A prospective, randomized, double-blind study. J Endod 2021;47(4):558–565. DOI: 10.1016/j.joen.2020.12.014.
18. Aggarwal V, Jain A, Kabi D. Anesthetic efficacy of supplemental buccal and lingual infiltrations of articaine and lidocaine after an inferior alveolar nerve block in patients with irreversible pulpitis. J Endod 2009;35(7):925–929. DOI: 10.1016/j.joen.2009.04.012.
19. Peñarrocha M, Bandrés A, Peñarrocha MA, Bagán JV. Relationship between oral surgical and endodontic procedures and episodic cluster headache. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;92(5):499–502.
20. Poorni S, Veniashok B, Senthilkumar AD, et al. Anesthetic efficacy of four percent articaine for pulpal anesthesia by using inferior alveolar nerve block and buccal infiltration techniques in patients with irreversible pulpitis: A prospective randomized double-blind clinical trial. J Endod 2011;37(12):1603–1607. DOI: 10.1016/j.joen.2011.09.009.
21. Aggarwal V, Singla M, Kabi D. Comparative evaluation of effect of preoperative oral medication of ibuprofen and ketorolac on anesthetic efficacy of inferior alveolar nerve block with lidocaine in patients with irreversible pulpitis: A prospective, double-blind, randomized clinical trial. J Endod. 2010;36(3):375–378. DOI: 10.1016/j.joen.2009.11.010.
22. Jung IY, Kim JH, Kim ES, et al. An evaluation of buccal infiltrations and inferior alveolar nerve blocks in pulpal anesthesia for mandibular first molars. J Endod 2008;34(1):11–13. DOI: 10.1016/j.joen.2007.09.006.
23. Hegde V, Shanmugasundaram S, Shaikh S, et al. Effect of preoperative oral steroids in comparison to anti-inflammatory on anesthetic success of inferior alveolar nerve block in mandibular molars with symptomatic irreversible pulpitis – a double-blinded randomized clinical trial. J Endod 2023;49(4):354–361. DOI: 10.1016/j.joen.2023.01.007.
24. Zanjir M, Lighvan NL, Yarascavitch C, et al. Efficacy and safety of pulpal anesthesia strategies during endodontic treatment of permanent mandibular molars with symptomatic irreversible pulpitis: A systematic review and network meta-analysis. J Endod 2019;45(12):1435–1464.e10. DOI: 10.1016/j.joen.2019.09.002.
25. Chen LS, Nusstein J, Drum M, et al. Effect of a combination of nitrous oxide and intraligamentary injection on the success of the inferior alveolar nerve block in patients with symptomatic irreversible pulpitis. J Endod 2021;47(12):1890–1895. DOI: 10.1016/j.joen.2021.08.013.
26. Topçuoğlu HS, Arslan H, Topçuoğlu G, et al. The effect of cryotherapy application on the success rate of inferior alveolar nerve block in patients with symptomatic irreversible pulpitis. J Endod 2019;45(8):965–969. DOI: 10.1016/j.joen.2019.05.001.
27. Shapiro MR, McDonald NJ, Gardner RJ, et al. Efficacy of articaine versus lidocaine in supplemental infiltration for mandibular first versus second molars with irreversible pulpitis: A prospective, randomized, double-blind clinical trial. J Endod 2018;44(4):523–528. DOI: 10.1016/j.joen.2017.10.003.
28. Rogers BS, Botero TM, McDonald NJ, et al. Efficacy of articaine versus lidocaine as a supplemental buccal infiltration in mandibular molars with irreversible pulpitis: a prospective, randomized, double-blind study. J Endod 2014;40(6):753–758. DOI: 10.1016/j.joen.2013.12.022.
29. Shahi S, Mokhtari H, Rahimi S, et al. Effect of premedication with ibuprofen and dexamethasone on success rate of inferior alveolar nerve block for teeth with asymptomatic irreversible pulpitis: A randomized clinical trial. J Endod 2013;39(2):160–162. DOI: 10.1016/j.joen.2012.10.011.
31. Koteeswaran V, Ballal S, Natanasabapathy V, et al. Efficacy of endo-ice followed by intrapulpal ice application as an adjunct to inferior alveolar nerve block in patients with symptomatic irreversible pulpitis—A randomized controlled trial. Clin Oral Invest 2019;23:3501–3507. DOI: 10.1007/s00784-018-2768-4.
32. Jamil FA, Asmael HM, Al-Jarsha MY. The success of using 2% lidocaine in pain removal during extraction of mandibular premolars: a prospective clinical study. BMC Oral Health 2020;20:239. DOI: 10.1186/s12903-020-01228-x.
33. El Batawi HY. Effect of intraoperative analgesia on children’s pain perception during recovery after painful dental procedures performed under general anaesthesia. Eur Arch Paediatr Dent 2015;16:35–41.
34. Sreekumar K, Bhargava D. A prospective randomized double-blind study to assess the latency and efficacy of articaine and lignocaine in surgical removal of impacted mandibular third molars in Indian patients. J Stomat Occ Med 2012;5:10–14. DOI: 10.1007/s12548-011-0031-6.
35. Tanboga I, Eren F, Altınok, B. et al. The effect of low level laser therapy on pain during dental tooth-cavity preparation in children. Eur Arch Paediatr Dent 2011;12:93–95. DOI: 10.1007/BF03262786.
37. Gurucharan I, Sekar M, Balasubramanian S. et al. Effect of precooling injection site and cold anesthetic administration on injection pain, onset, and anesthetic efficacy in maxillary molars with symptomatic irreversible pulpitis: A randomized controlled trial. Clin Oral Invest 2002;26:1855–1860. DOI: 10.1007/s00784-021-04160-8.
38. Vahedi Z, Moshari A, Moshari M. Efficacy of adding dexmedetomidine to lidocaine to enhance inferior alveolar nerve block in patients with asymptomatic irreversible pulpitis: Double-blind randomized clinical trial. Clin Oral Invest 2022;26:4727–4734. DOI: 10.1007/s00784-022-04436-7.
39. Figueiredo R, Sofos S, Soriano-Pons E, et al. Is it possible to extract lower third molars with infiltration anaesthesia techniques using articaine? A double-blind randomized clinical trial. Acta Odontol Scand 2021:79(1):1–8. DOI: 10.1080/00016357.2020.1760348.
40. Thomas MS, Kundabala M. Pulp hyperthermia during tooth preparation: The effect of rotary instruments, lasers, ultrasonic devices, and airborne Particle abrasion. J Calif Dent Assoc 2012:721–731 DOI: 10.1080/19424396.2012.12220947.
42. Farhad A, Razavian H, Shafiee M. Effect of intraosseous injection versus inferior alveolar nerve block as primary pulpal anaesthesia of mandibular posterior teeth with symptomatic irreversible pulpitis: A prospective randomized clinical trial. Acta Odontol Scand 2018;76(6):442–447. DOI: 10.1080/00016357.2018.1428826.
44. Suresh N, Koteeswaran V, Natanasabapathy V, et al. Needle gauge influences pain perception during intrapulpal anaesthesia – A randomized clinical trial. Eur Endod J 2020;3:191–198. DOI: 10.14744/eej.2020.38358.
45. Sooraparaju SG, Abarajithan M, Sathish ES, et al. Anaesthetic efficacy of topical benzocaine gel combined with hyaluronidase for supplemental intrapulpal injection in teeth with irreversible pulpitis – A double blinded clinical trial. J Clin Diagn Res 2015;9(8):ZC95–ZC97. DOI: 10.7860/JCDR/2015/12575.6401.
46. Parirokh M, Samadi I, Nakhaee N, et al. Comparison of the anesthesia success rate in maxillary first and second molars with 3% prilocaine as the anaesthetic agent. Eur Endod J 2021;6(3):254–258. DOI: 10.14744/eej.2021.74755.
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