J Dent Anesth Pain Med.  2019 Dec;19(6):323-341. 10.17245/jdapm.2019.19.6.323.

Interventions for anesthetic success in symptomatic irreversible pulpitis: A network meta-analysis of randomized controlled trials

• Sivaramakrishnan G
• Alsobaiei
• Sridharan

• KMID: 2466648
• DOI: http://doi.org/10.17245/jdapm.2019.19.6.323

Abstract

BACKGROUND
Local anesthetics alone or in combination with adjuncts, such as oral medications, have routinely been used for pain control during endodontic treatment. The best clinical choice amongst the vast numbers of agents and techniques available for pain control for irreversible pulpitis is unclear. This network meta-analysis combined the available evidence on agents and techniques for pulpal anesthesia in the maxilla and mandible, in order to identify the best amongst these approaches statistically, as a basis for future clinical trials.
METHODS
Randomized trials in MEDLINE, DARE, and COCHRANE databases were screened based on inclusion criteria and data were extracted. Heterogeneity was assessed and odds ratios were used to estimate effects. Inconsistencies between direct and indirect pooled estimates were evaluated by H-statistics. The Grading of Recommendation, Assessment, Development, and Evaluation working group approach was used to assess evidence quality.
RESULTS
Sixty-two studies (nine studies in the maxilla and 53 studies in the mandible) were included in the meta-analysis. Increased mandibular pulpal anesthesia success was observed on premedication with aceclofenac + paracetamol or supplemental 4% articaine buccal infiltration or ibuprofen+paracetamol premedication, all the above mentioned with 2% lignocaine inferior alveolar nerve block (IANB). No significant difference was noted for any of the agents investigated in terms of the success rate of maxillary pulpal anesthesia.
CONCLUSION
Direct and indirect comparisons indicated that some combinations of IANB with premedication and/or supplemental infiltration had a greater chance of producing successful mandibular pulpal anesthesia. No ideal technique for maxillary anesthesia emerged. Randomized clinical trials with increased sample size may be needed to provide more conclusive data. Our findings suggest that further high-quality studies are required in order to provide definitive direction to clinicians regarding the best agents and techniques to use for mandibular and maxillary anesthesia for irreversible pulpitis.

Keyword

Pain; Pulpitis; Root Canal Therapy

MeSH Terms

Acetaminophen
Anesthesia
Anesthetics, Local
Carticaine
Lidocaine
Mandible
Mandibular Nerve
Maxilla
Odds Ratio
Population Characteristics
Premedication
Pulpitis*
Root Canal Therapy
Sample Size
Acetaminophen
Anesthetics, Local
Carticaine
Lidocaine

Figure

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  Fig. 1 PRISMA flow diagram

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  Fig. 2 Risk-of-bias of included studies.

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  Fig. 3 Forest plot for direct comparison of treatments in the mandible

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  Fig. 4 Forest plot for indirect comparison of treatments in the mandible

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  Fig. 5 Forest plot for indirect comparison of treatments in the maxilla

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