CONSORT Randomized Clinical Trial

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
Mohammad D. Kanaa, DDS, PhD, John M. Whitworth, BChD, PhD, and John Gerard Meechan, BDS, PhD
Abstract
Objective: The objective of this study was to compare the efcacy of supplementary repeat inferior alveolar nerve block with 2% lidocaine and epinephrine, buccal inltration with 4% articaine with epinephrine, intraligamentary injection, or intraosseous injection (both with 2% lidocaine with epinephrine) after failed inferior alveolar nerve block (IANB) for securing pain-free treatment in patients experiencing irreversible pulpitis in mandibular permanent teeth. Methods: This randomized clinical trial included 182 patients diagnosed with irreversible pulpitis in mandibular teeth. Patients received 2.0 mL of 2% lidocaine with 1:80,000 epinephrine as an IANB injection. Patients who did not experience pain-free treatment received randomly 1 of 4 supplementary techniques, namely repeat lidocaine IANB (rIANB), articaine buccal inltration (ABI), lidocaine intraligamentary injection (PDL), or lidocaine intraosseous injection (IO). Successful pulp anesthesia was considered to have occurred when no response was obtained to the maximum stimulation (80 reading) of the pulp tester, at which time treatment commenced. Treatment was regarded as being successfully completed when it was associated with no pain. Data were analyzed by c2 and Fisher exact tests. Results: Of the 182 patients, 122 achieved successful pulpal anesthesia within 10 minutes after initial IANB injection; 82 experienced pain-free treatment. ABI and IO allowed more successful (pain-free) treatment (84% and 68%, respectively) than rIANB or PDL supplementary techniques (32% and 48%, respectively); this was statistically signicant (P = .001). Conclusions: IANB injection alone does not always allow pain-free treatment for mandibular teeth with irreversible pulpitis. Supplementary buccal inltration with 4% articaine with epinephrine and intraosseous injection with 2% lidocaine with epinephrine are more likely to allow pain-free treatment than intraligamentary and repeat IANB injections with 2% lidocaine with epinephrine for patients experiencing irreversible pulpitis in mandibular permanent teeth. (J Endod 2012;38:421425)

Key Words
Buccal inltration, inferior alveolar nerve block, irreversible pulpitis, mandibular permanent teeth, repeat inferior alveolar nerve block, supplementary local anesthetic techniques

he inferior alveolar nerve block (IANB) does not always provide satisfactory anesthesia for patients with irreversible pulpitis (1, 2). IANB has been associated with poor success with both 2% lidocaine and 4% articaine solutions (3). Intraosseous anesthesia (IO) is a supplementary technique that achieves higher success than IANB alone for patients diagnosed with irreversible pulpitis (2, 4). Other local anesthetic techniques, however, do exist (59). The present study compared the efcacies of 4 supplementary techniques after failure of IANB in patients experiencing irreversible pulpitis in a mandibular permanent tooth. The primary outcome measure was the provision of pain-free treatment. The effects of the different methods on the response to electronic pulp testing were also investigated. The null hypothesis was that supplementary repeat IANB with 2% lidocaine with epinephrine, buccal inltration of 4% articaine with epinephrine, and intraligamentary injection or intraosseous injection of 2% lidocaine with epinephrine after a failed IANB are equally effective in allowing pain-free treatment for mandibular permanent teeth with irreversible pulpitis.

Materials and Methods

This was a randomized clinical trial (ISRCTN18143187) that included healthy patients aged 18 years or older who attended a dental emergency clinic in a teaching hospital and had irreversible pulpitis in a mandibular tooth. Institutional and ethical approvals were obtained, and patients presenting with irreversible pulpitis in one tooth and an asymptomatic vital tooth on the opposite side of the arch (which acted as an internal control of pulp tester function) were invited to participate. To eliminate bias in recruitment, the diagnosis of irreversible pulpitis was determined by individuals with no involvement in the clinical trial. Patients with allergies or sensitivities to lidocaine, articaine, or other ingredients in the anesthetic solutions were excluded. Patients with

From the Centre for Oral Health Research, Newcastle University, Newcastle upon Tyne, England. Address requests for reprints to Dr John Gerard Meechan, Newcastle University, Centre for Oral Health Research, School of Dental Sciences, Framlington Place, Newcastle upon Tyne, United Kingdom. E-mail address: john.meechan@ncl.ac.uk 0099-2399/$ - see front matter Copyright 2012 American Association of Endodontists. doi:10.1016/j.joen.2011.12.006

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a medical history that might compromise their well-being (eg, unstable angina) or data collection (eg, facial paresthesia) were also excluded. A power calculation based on data after IANB (42% success) or IANB plus IO (88% success) in providing pain-free treatment of teeth with irreversible pulpitis (1) dictated that a sample with 21 subjects in each supplementary technique group would have 90% power of detecting differences between treatments at the 5% level. Baseline pulp sensitivity of the tooth with irreversible pulpitis was recorded before the initial IANB injections by using an electronic pulp tester (Analytic Technology, Redmond, WA). Pulp tester function and validity of the reading were assessed rst by using a control unanesthetized tooth on the opposite side of the jaw (the matching contralateral tooth was used when present) once before the initial IANB. This also served to acquaint patients with the working of the pulp tester. All patients were given an IANB by using the direct or Halstead approach. After aspiration, 2.0 mL of 2% lidocaine HCl with 1:80,000 epinephrine (Lignospan Special; Septodont, Kent, England) was deposited slowly at a rate of 2 mL min1. After the initial IANB, pulp testing was repeated on the test tooth every 2 minutes for 10 minutes or until it was possible to achieve a maximum reading of 80 without sensation, whichever was sooner. Patients in whom the initial IANB secured pulp anesthesia (80 reading without sensation) received the dental treatment they chose (extraction or pulp extirpation) after consultation with the treating clinician. A note was made of whether the treatment was completed without any pain. Patients for extraction received additional injections as necessary with 2% lidocaine with epinephrine to secure soft-tissue anesthesia. Patients in whom the initial IANB did not secure pulpal anesthesia within 10 minutes or those who felt pain during their treatment received 1 of 4 supplementary local anesthetic injections. The choice of supplementary injection was determined by one of the authors (J.G.M.) with a web-based program for randomization (http://department.obg.cuhk.edu.hk/researchsupport/Random_integer. asp). The 4 treatments were the following. 1. Repeat lidocaine IANB (rIANB) (2.0 mL of 2% lidocaine HCL with 1:80,000 epinephrine) was administered as previously. 2. With buccal inltration (ABI), 2 mL of 4% articaine HCL with epinephrine 1:100,000 (Septanest, Deproco, Kent, UK) was deposited adjacent to the tooth apex buccally. Injections were given slowly during a period of 30 seconds with a standard aspirating dental cartridge syringes. 3. With intraligamentary injection (PDL), a specialized intraligamentary dental cartridge syringe was tted with an ultra-short needle (6 mm). After application of an antiseptic solution to the site of penetration (1013), the needle was inserted at 30 to the long axis of the tooth at the mesiobuccal aspect of the roots (14), penetrating until it was wedged between the tooth and the crestal bone (15). The needle bevel faced the root to ease advancement of the needle. Anesthetic (0.18 mL of 2% lidocaine with 1:80,000 epinephrine) was deposited into the periodontal ligament for each root during a period of 20 seconds (13). The needle remained in its position for 10 seconds after injection. 4. With IO to avoid the pain associated with cortical perforation, 0.2 mL of 2% lidocaine with epinephrine (1:80,000) was inltrated buccally for soft-tissue and periosteal anesthesia at the perforation site. Cortical perforation was achieved with the X-tip intraosseous anesthesia delivery system (Maillefer Dentsply, Ballaigues, Switzerland) attached to a slow-speed handpiece according to the manufacturers instructions. The operator identied the mucogingival junction and determined 2 lines running at right angles to one another as follows: the horizontal line ran along the buccal gingival margins of the teeth, and the vertical line bisected the distal interdental papilla of the tooth. The point of penetration was 2 mm apical to the intersection of the 2 lines. Patients who had bone recession clearly identied by radiographs received the perforation 37 mm apical to the intersection of the lines. One mL of lidocaine (2%) with epinephrine (1:80,000) was deposited slowly into the cancellous space during a period of 60 seconds (8). All injections, pulp tests, and subsequent dental treatments were performed by a single operator (M.D.K.). Pulp sensitivity of the test tooth was recorded at 2 minutes after each supplementary injection and again at 5 minutes if pulp anesthesia (no response at 80 pulp tester reading) was not conrmed at 2 minutes. If it was not possible to achieve an 80 pulp tester reading without sensation after 5 minutes, the patient was not included in the treatment arm of the study, and their emergency treatment was completed with supplementary measures according to best local practice. Treatment began as soon as a negative response to pulp testing was secured. Each patient was invited to evaluate their treatment as pain-free or not. If any pain was felt during treatment, this was considered failure, and the patient was managed according to local best practice. All analyses were undertaken with SPSS software (SPSS 17.0; SPSS Inc., Chicago, IL). Data were subjected to c2 and Fisher exact test analysis (supplemental CONSORT ow chart is available at www. jendodon.com).

Results
This study included 182 patients (133 men, 73.1%, and 49 women, 26.9%) who ranged in age between 18 and 66 years (mean, 31.9 years; standard deviation, 10.0). Of the 182 mandibular teeth, 162 were molars (93 rst, 62 second, and 7 third molars), 18 premolars (3 rst and 15 second premolars), and 2 anteriors (1 lateral incisor and 1 canine).

Successful Pulp Anesthesia and Treatment Outcomes after Initial IANB Injection Of the 182 patients who received an IANB injection, 122 (67.0%) experienced a negative response to pulp testing (80 reading) within 10 minutes. No signicant differences were noted in the distribution of negative responses to pulp testing between anteriors, premolars, and molars (Table 1) after IANB injection alone (c2, P = .35). There were no signicant differences in the number of negative responses to pulp testing in patients who chose to have pulp extirpation and those who opted for extraction (62 of 97, 63.9%, and 60 of 85, 70.6%, respectively; c2, P = .34; Fisher exact test, P = .35). The overall mean onset time of pulp anesthesia as determined by pulp testing for the 122 patients who recorded a negative response to pulp testing was 5.58 minutes (standard deviation, 2.58 minutes; median, 6.0 minutes; minimum, 2.0 minutes; maximum, 10.0 minutes).
TABLE 1. Response to Pulp Testing in Mandibular Anteriors, Premolars, and Molars after IANB Injection Pulp tester response Tooth type
Anteriors Premolars Molars Total

Negative N (%)
2 (100.0) 10 (55.6) 110 (67.9) 122

Positive N (%)
0 (0.0) 8 (44.4) 52 (32.1) 60

Total N (%)
2 (1.1) 18 (9.9) 162 (89.0) 182

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TABLE 2. Relationship between Treatment Outcomes and Treatment Option in 122 Patients with No Response to Pulp Testing after Initial IANB Injection Treatment outcome after IANB injection
Pulp extirpation Extraction Total

Success N
42 40 82

Failure N
20 20 40

TABLE 4. Treatment Success of Supplementary Techniques after Failed IANB Injection in 100 Patients with Irreversible Pulpitis in Mandibular Permanent Teeth Treatment outcomes
Success Failure Total

%
67.7 66.7 67.2

%
32.3 33.3 32.8

Total N
62 60 122

rIANB N
8 17 25

ABI N
21 4 25

PDL N
12 13 25

IO N
17 8 25

Total %
68 32

%
32 68

%
84 16

%
48 52

N
58 42 100

%
58 42 100

Only 82 (67%) of these 122 patients experienced pain-free treatment after the initial IANB injection. The results in Table 2 show that in the 122 patients with negative pulp testing responses after IANB injection, there were no significant differences between those who opted for pulp extirpation and those who preferred tooth extraction (c2, P = .90; Fisher exact test, P = 1.0).

Discussion
The present investigation studied 4 different strategies to manage a failed IANB in teeth with irreversible pulpitis. These were repeating the initial IANB or 1 of 3 supplementary techniques. These additional methods were an intraligamentary or intraosseous injection with 2% lidocaine with epinephrine or a buccal inltration of 4% articaine with epinephrine. Claffey et al (3) reported success rates of 24% and 23% in 72 patients with irreversible pulpitis who received IANB injection by using either 4% articaine or 2% lidocaine, respectively. Simpson et al (16) noted that IANB with 3.6 mL of 2% lidocaine with 1:100,000 epinephrine produced success in 24% of mandibular posterior teeth with irreversible pulpitis in patients pretreated with placebo and 32% success in those pretreated with anti-inammatory medication. In a similar study to that of Simpson et al (16), Oleson et al (17) reported success of lidocaine IANB in 35% of patients after placebo pretreatment and 41% after pretreatment with ibuprofen. Another investigation (18) reported that of the 40 patients with irreversible pulpitis who received either 3.6 mL 2% lidocaine or 3.6 mL 4% articaine IANB injections (both with epinephrine 1:100,000), 70% and 65%, respectively, experienced negative responses to pulp testing. Of the 182 patients included in this study, 82 (45.1%) experienced successful treatment after IANB with 2% lidocaine with 1:80,000 epinephrine. This was higher than that reported by Claffey et al and Simpson et al, similar to that of Oleson et al, but lower than that noted by Rood (9). Rood reported 76% success after IANB injection alone in patients who underwent different dental procedures. This variation in success might be due to differences in diagnoses because the current study included only patients with independently conrmed irreversible pulpitis. Repeat injection has been described as a rst option when the initial injection is unsuccessful (19). A degree of success was obtained in the present study after rIANB injection (32%), but it was the least successful method. Intraligamentary injections have been used as a means to overcome failed conventional anesthesia. Walton and Abbot (20) reported a series of 120 patients in whom conventional local anesthetic injections for conservative and endodontic procedures failed. These authors noted that after one intraligamentary injection, 63% of the teeth were successfully anesthetized. After a second intraligamentary injection, success rose to 92%. Smith et al (12) noted similar success (93%) for intraligamentary injections in patients in whom conventional
TABLE 5. Treatment Success in 91 Mandibular Molar Teeth after rIANB, ABI, PDL, and IO Treatment rIANB outcome in molars N %
Success Failure Total

Successful Anesthesia and Treatment Outcomes after the 4 Supplementary Techniques Within the sample of 122 patients with a negative pulp response to testing after IANB, 82 experienced successful pain-free treatment without the need for supplementary injections. Of the remaining 100 patients, 60 had positive responses to pulp testing, and 40 felt pain on treatment after the initial IANB injection. These 100 patients were randomly allocated to receive 1 of 4 supplementary injections. Of the 60 patients who recorded positive responses to pulp testing after initial IANB injection, 16 were in the rIANB group, 12 in the ABI group, 14 in the PDL group, and 18 in the IO group. Although ABI and IO produced more successful pulpal anesthesia than rIANB or PDL supplementary techniques (Table 3), this was not signicant (c2, P = .17; likelihood ratio, P = .16). Of the 100 patients who received a supplementary technique after failed initial IANB, ABI and IO allowed more successful treatment than r IANB or PDL supplementary techniques (Table 4). This difference in success was statistically signicant (c2, P = .001; likelihood ratio, P = .001). There were signicant differences in treatment success after the 4 supplementary injection techniques (Table 5) in mandibular molars with irreversible pulpitis (c2, P = .001; likelihood ratio, P < .001) because more successes were noted after ABI and IO than after rIANB and PDL injections after failed IANB injection. Table 6 shows the results for molar teeth scheduled for extirpation. There were signicant differences in success rates between supplementary techniques, with ABI and IO again showing the best success (Fisher exact test, P = .05). Table 7 shows that there was no difference in the success of pulp extirpation or extraction after supplementary injections (c2, P = .71; Fisher exact test, P = .71). Table 8 shows the treatment type in relation to the supplementary anesthetic method used. There was no difference in distribution of treatments between anesthetic methods (c2, P = .26).
TABLE 3. Successful Pulp Anesthesia after 4 Supplementary Techniques in 60 Patients with Positive Responses to Pulp Testing after Initial IANB rIANB Pulp response N % ABI N % N PDL % N IO % N Total %

ABI N % N

PDL % N

IO % N

Total %

Negative 9 56.3 10 83.3 7 50.0 14 77.8 40 66.7 Positive 7 43.7 2 16.7 7 50.0 4 22.2 20 33.3 Total 16 12 14 18 60 100.0

7 30.4 21 84.0 9 42.9 15 68.2 52 57.1 16 69.6 4 16.0 12 57.1 7 31.8 39 42.9 23 25 21 22 91 100.0

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TABLE 6. Treatment Success for Molar Teeth Having Extirpation in Relation to Supplementary Technique rIANB Treatment
Success Failure Total

TABLE 8. Treatment Choice in Relation to Supplementary Anesthetic Technique rIANB Treatment N % N ABI % N PDL % N IO % Total N %

ABI N % N
3 5 8

PDL % N

IO % N

Total %

6 43 11 85 8 57 2 15 14 100 13 100

38 11 73 31 55 62 4 27 19 45 100 15 100 50 100.0

Extirpation 16 64 13 52 10 40 16 64 55 55 Extraction 9 36 12 48 15 60 9 36 45 45 Total 25 100 25 100 25 100 25 100 100 100

methods failed. Childers et al (6) reported that there was no signicant difference between IANB alone (63%) and IANB plus intraligamentary injection (78%) with 2% lidocaine with 1:100,000 epinephrine in mandibular rst molars. Nusstein et al (7) noted that 56% of mandibular teeth with irreversible pulpitis that had failed anesthesia after IANB became anesthetized when 1.4 mL of 2% lidocaine with 1:100,000 epinephrine was administered as an intraligamentary injection by using a computerized delivery system. The success rates after intraligamentary injections reported in the present study were less than those in earlier investigations. This might be the result of some studies including teeth without irreversible pulpitis, and for others it could be the result of differences in volume of anesthetic administered by the intraligamentary route. Intraosseous injections are considered a useful supplementary method when managing a failed IANB. Nusstein et al (1) reported that all 21 patients with irreversible pulpitis who received intraosseous injections after failure of the initial IANB injection recorded a negative response to pulp testing, and that 19 of these (90%) went on to receive treatment (pulpectomy) with mild or no pain. This is higher than that reported in the current study after supplementary intraosseous injection, which allowed a satisfactory degree of successful treatment in 68% of patients with irreversible pulpitis. Parente et al (4) reported that a supplementary intraosseous injection of 0.450.9 mL of 2% lidocaine with 1:100,000 epinephrine produced successful anesthesia in 91% of mandibular posterior teeth with irreversible pulpitis. The lower success rate reported in the current study compared with the studies by Nusstein et al (1) and Parente et al (4) might be the result of the more stringent denition of success used in the present investigation. In addition, in the study by Nusstein et al (1), 1.8 mL of solution was injected by the intraosseous route, compared with 1.0 mL in the present investigation. The 1.0-mL dose was chosen in the present study because this is the amount recommended for this technique for single teeth (8). The use of buccal inltration anesthesia in the mandible has received much interest in recent years, principally because of the introduction of 4% articaine solutions (21). One investigation reported that buccal inltration with lidocaine produced 21% improvement after an IANB injection (9), but not for patients with irreversible pulpitis. The results of a volunteer study have shown that IANB with 2% lidocaine and epinephrine supplemented by buccal inltration with 4% articaine with epinephrine is more successful than IANB

TABLE 7. Treatment Outcomes in 100 Patients after Supplementary Injections According to Treatment Type Treatment outcomes after supplementary injections
Extirpation Extraction Total

Success N
31 27 58

Failure N
24 18 42

%
56.4 60.0 58.0

%
43.6 40.0 42.0

Total N
55 45 100

alone (22). Four percent articaine has been shown to be more effective than 2% lidocaine when used as buccal inltration to supplement IANB (23). The results of a double-blind trial showed that buccal plus lingual inltrations with articaine were signicantly more successful than similar injections with lidocaine (67% and 47%, respectively) when supplementing IANB injection (24). The greater efcacy of 4% articaine with epinephrine compared with 2% lidocaine with epinephrine after inltration in the mandible dictated the use of the former solution for this technique in the present study. Another study reported that supplementing 2% lidocaine IANB injection (epinephrine 1:100,000) with buccal inltration of 4% articaine (epinephrine 1:100,000) was successful in 58% of patients with irreversible pulpitis in mandibular posterior teeth (25). Simpson et al (16) reported that the success rates of buccal inltrations of 1.8 mL 4% articaine with 1:100,000 epinephrine to supplement failed IANB for mandibular teeth with irreversible pulpitis were 24% and 38% for patients pretreated with placebo or anti-inammatory drugs, respectively. The higher success in the present study (84%) might be the result of the injection of a larger volume of solution during the buccal inltration. The results of the present study show that more successful treatments were associated with the supplementary techniques of buccal inltration with 4% articaine with 1:100,000 epinephrine (84%) or intraosseous injection of 2% lidocaine with 1:80,000 epinephrine (68%), compared with intraligamentary injections with 2% lidocaine with epinephrine (48%) or repeat IANB (32%). In the 60 patients without negative pulp testing after initial IANB, ABI and IO produced more successful pulpal anesthesia (83.3% and 77.8%, respectively) than rIANB or PDL injection (56.3% and 50%, respectively), but these differences were not signicant. This might be the result of the low numbers in this subset analysis because a total population of at least 84 patients was dictated by the power calculation. It has been reported that it is more difcult to provide pain-free pulpectomy than tooth extraction (26). The current study produced similar success for both treatments after supplementary techniques, and this suggests that success is not affected by the selection of treatment in patients with irreversible pulpitis in mandibular permanent teeth. This is in contrast to the maxilla, in which the success of inltration anesthesia in teeth with irreversible pulpitis has been shown to be greater for extraction compared with pulp extirpation (27). This might be the result of the extra local anesthetic dose given in the palatal region for maxillary teeth before extraction; however, inherent differences between regional block and inltration techniques could also have an inuence. Although the results of this study show no difference in the success of anesthesia for extraction and pulpal extirpation, it might be that the supplementary injections used for soft-tissue anesthesia inuenced the extraction group. To reduce the number of variables, a subset analysis was performed that included only molar teeth that underwent extirpation. Evaluation of these data showed results consistent with the whole study population in that the supplementary buccal inltration or intraosseous injections were still the most successful techniques used.
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Conclusions
IANB injection alone does not always allow pain-free treatment for mandibular teeth with irreversible pulpitis. Buccal inltration of 2 mL 4% articaine with epinephrine and intraosseous injections of 1 mL 2% lidocaine with epinephrine allowed more pain-free treatments than intraligamentary injections of 0.2 mL of 2% lidocaine with epinephrine or repeat IANB injections for patients experiencing irreversible pulpitis in mandibular permanent teeth.
9. Rood JP. The analgesia and innervation of mandibular teeth. Br Dent J 1976;140: 2379. 10. Froum SJ, Froum SH, Malamed SF. The use of phentolamine mesylate to evaluate mandibular nerve damage following implant placement. Contin Educ Dent 2010; 31:5228. 11. Smith GN, Walton RE. Periodontal ligament injection: distribution of injected solutions. Oral Surg Oral Med Oral Pathol 1983;55:2328. 12. Smith GN, Walton RE, Abbott BJ. Clinical evaluation of periodontal ligament anesthesia using a pressure syringe. J Am Dent Assoc 1983;107:9536. 13. Gray RJ, Lomax AM, Rood JP. Periodontal ligament injection: with or without a vasoconstrictor? Br Dent J 1987;162:2635. 14. Schleder JR, Reader A, Beck M, Meyers WJ. The periodontal ligament injection: a comparison of 2% lidocaine, 3% mepivacaine, and 1:100,000 epinephrine to 2% lidocaine with 1:100,000 epinephrine in human mandibular premolars. J Endod 1988;14:397404. 15. Dreyer WP, van Heerden JD, de V Joubert JJ. The route of periodontal ligament injection of local anesthetic solution. J Endod 1983;9:4714. 16. Simpson M, Drum M, Nusstein J, Reader A, Beck M. Effect of combination of preoperative ibuprofen/acetaminophen on the success of the inferior alveolar nerve block in patients with symptomatic irreversible pulpitis. J Endod 2011;37:5937. 17. Oleson M, Drum M, Reader A, Nusstein M, Beck M. Effect of preoperative ibuprofen on the success of the inferior alveolar nerve block in patients with irreversible pulpitis. J Endod 2010;36:37982. 18. Tortamano IP, Siviero M, Costa CG, Buscariolo IA, Armonia PL. A comparison of the anesthetic efcacy of articaine and lidocaine in patients with irreversible pulpitis. J Endod 2009;35:1658. 19. Quinn CL. Injection techniques to anesthetize the difcult tooth. J Calif Dent Assoc 1998;26:6657. 20. Walton RE, Abbot BJ. Periodontal ligament injection: a clinical evaluation. J Am Dent Assoc 1981;103:5715. 21. Meechan JG. The use of the mandibular inltration anesthetic technique in adults. J Am Dent Assoc 2011;142(Suppl 3):19S24. 22. Kanaa MD, Whitworth JM, Corbett IP, Meechan JG. Articaine buccal inltration enhances the effectiveness of lidocaine inferior alveolar nerve block. Int Endod J 2009;42:23846. 23. Haase A, Reader A, Nusstein J, Beck M, Drum M. Comparing anesthetic efcacy of articaine versus lidocaine as a supplemental buccal inltration of the mandibular rst molar after an inferior alveolar nerve block. J Am Dent Assoc 2008;139: 122835. 24. Aggarwal V, Jain A, Kabi D. Anesthetic efcacy of supplemental buccal and lingual inltrations of articaine and lidocaine after an inferior alveolar nerve block in patients with irreversible pulpitis. J Endod 2009;35:9259. 25. Matthews R, Drum M, Reader A, Nusstein J, Beck M. Articaine for supplemental buccal mandibular inltration anesthesia in patients with irreversible pulpitis when the inferior alveolar nerve block fails. J Endod 2009;35:3436. 26. Miller A. A clinical evaluation of the Ligmaject periodontal ligament injection syringe. Dent Update 1983;10:63943. 27. Kanaa MD, Whitworth JM, Meechan JG. A comparison of the efcacy of 4% articaine with 1:100,000 epinephrine and 2% lidocaine with 1:80,000 epinephrine in achieving pulpal anesthesia in maxillary teeth with irreversible pulpitis. J Endod 2012;38:27982.

Acknowledgments
The assistance provided by Christopher Hayward and Shaniff Makhani in the running of this investigation is gratefully acknowledged. Dr Meechan acts as a consultant for Septodont.

Supplementary Material
Supplementary material associated with this article can be found in the online version at www.jendodon.com (doi:10.1016/ j.joen.2011.12.006).

References
1. Nusstein J, Reader A, Nist R, Beck M, Meyers WJ. Anesthetic efcacy of the supplemental intraosseous injection of 2% lidocaine with 1:100,000 epinephrine in irreversible pulpitis. J Endod 1998;24:48791. 2. Reisman D, Reader A, Nist R, Beck M, Weaver J. Anesthetic efcacy of the supplemental intraosseous injection of 3% mepivacaine in irreversible pulpitis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;84:67682. 3. Claffey E, Reader A, Nusstein J, Beck M, Weaver J. Anesthetic efcacy of articaine for inferior alveolar nerve blocks in patients with irreversible pulpitis. J Endod 2004;30: 56871. 4. Parente SA, Anderson RW, Herman WW, Kimbrough WF, Weller RN. Anesthetic efcacy of the supplemental intraosseous injection for teeth with irreversible pulpitis. J Endod 1998;24:8268. 5. Yonchak T, Reader A, Beck M, Meyers WJ. Anesthetic efcacy 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;92:1325. 6. Childers M, Reader A, Nist R, Beck M, Meyers WJ. Anesthetic efcacy of the periodontal ligament injection after an inferior alveolar nerve block. J Endod 1996; 22:31720. 7. Nusstein J, Claffey E, Reader A, Beck M, Weaver J. Anesthetic effectiveness of the supplemental intraligamentary injection, administered with a computer-controlled local anesthetic delivery system, in patients with irreversible pulpitis. J Endod 2005;31:3548. 8. Meechan JG. Supplementary routes to local anaesthesia. Int Endod J 2002;35: 88596.

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