The Efficacy of Supplemental Intraosseous Anesthesia After Insufficient Mandibular Block

It is a well-known scientific fact that only a small percentage of infiltration of inferior alveolar nerve is clinically proven to be efficient. The objective of this study was to determine the anesthetic efficacy of supplemental intraosseous injection, used after the insufficient classical mandibular block that didn't provide deep pulp anesthesia of mandibular molar planed for extraction. The experimental teeth consisted of 98 mandibular molars with clinical indication for extraction. Based on the history of disease, we indicated the extraction of the tooth. After that each tooth was tested with a electric pulp tester P1. We tested the pulp vitality and precisely determined the level of vitality. After that, each patient received classical mandibular block, and the pulp vitality was tested again. If the pulp tester indicated negative vitality for the certain mandibular molar, and the patient didn't complain about pain or discomfort during the extraction, the molar was extracted and the result was added to anesthetic success rate for the classical mandibular block. If, five minutes after receiving the mandibular block, the pulp tester indicated positive vitality (parameters of vitality) or the patient complained about pain or discomfort (parameters of pain and discomfort), we used the Stabident intraosseous anesthesia system. Three minutes after the application of supplemental intraosseous injection the molar was tested with the pulp tester again. The anesthetic solution used in both anesthetic techniques is lidocaine with 1:100.000 epinephrine. The results of this study indicate that the anesthetic efficacy of the mandibular block is 74.5%, and that supplemental intraosseous anesthesia, applied after the insufficient mandibular block, provides pulpal anesthesia in 94.9% of mandibular molars. The difference between anesthetic efficacy of the classical mandibular block and anesthetic efficacy of the supplemental intraosseous anesthesia, applied after the insufficient mandibular block, is obvious.


Introduction
Retrospective analysis shows that need for supplement to ineffi ciency of mandibular block was noticed , when Magnes and co-workers() published their fi rst study, which at the same time promoted intraosseous anesthesia.Technique described in this study was very popular during early seventies.Th e fi rst study, which elaborated scientifically in overwhelming manner all properties of system of instraosseous anesthesia was published by Leonard () this study brought data of workability of this method and described proper technique of application of Stabident system.Coggins and co-workers() published  effi ciency of supplemental intraosseous anesthesia in maxillary and mandibular molars and announced to the scientifi c public success of supplemental intraosseous anesthesia, by measuring vitality of the fi rst lower molars and brought results of success of .In December  Reisman and Reader() investigated eff ects of supplemental intraosseous anesthesia in vital tooth, which require endodontic treatment.Th ey have published that  of patients requested additional anesthesia after mandibular block because of subjective feeling of pain in attempt of endodontic treatment.Th e fi rst intraosseous anesthesia showed success of  and the second was successful in  cases.In January  Gallatin and co-workers,() published the study, which apart from effi ciency of intraosseous anesthesia, cleared up impact of intraosseal anesthesia on heartbeat, what was for the certain period of time subject of scientific discussions.Analyzing relevant studies related to intraosseous local anesthesia, which was published recently, it is concluded that there is not published study, which would bring results on effi ciency of additional intraosseous anesthesia when extracting of vital teeth with clinical indication for extraction.

Material and Methods
Teeth sample are  mandibular molars, which show signs of vitality and clinical indication for extraction was established.Operative procedure was done with respect to ethical standards regulated by Helsinki Declaration.After history procedure and establishment of indication for extraction, standard apparatuses for testing of tooth pulp P (Jugodent) is to be tested vitality of tooth in subject, and precisely determined level of vitality on the scale  to .Th e fi rst to patient is to be applied classical mandibular block.Five minutes after application of mandibular block again is to be tested vitality of tooth pulp in the same way and subjective feeling of numbness of lower lip and tongue.Patients to whom apparatus for vitality shows that tooth in subject is entirely under anesthesia ( on the vitality scale), and do not complain about discomfort or pain at the time of work, are to be treated by extraction of tooth in the standard manner, their results are registered into the research chart in order to enter into fi nal percentage relation on success of mandibular block.Patients whose tooth show signs of vitality on apparatus for measure of vitality of tooth pulp ( to  on the vitality scale)  minutes after application of mandibular block or if they complain about discomfort and pain at the time of extraction attempt, what would understand absence of full aff ect of conventional block, to them are applied intraosseous Stabident anesthesia, following the rules of application recommended by manufacturer, as described above.Th ree minutes after application of intraosseous anesthesia the following parameters are followed up and registered in the research chart: . Vitality test graded on the scale from  to  .Subjective feeling of discomfort at the time of extraction graded from  to .

Results
After  References
PROHIĆ ET AL.: THE EFFICACY OF SUPPLEMENTAL INTRAOSSEOUS ANESTHESIA AFTER INSUFFICIENT MANDIBULAR BLOCK lar molars and published percentage of success of .Th e same year Dunbar et al().published success of additional intraoseal anesthesia by measuring of vitality of the fi rst lower molars and brought results on success of .Reisman and co-workers.()researched effi ciency of additional intraoseal anesthesia in vital teeth which require endodontic treatment.Th ey published extremely low percentage of success of conventional block with data that  of teeth after classical block required additional anesthesia because of subjective feeling of pain at the time of attempt of entering of endodont instrument into root channel of vital tooth.Quoted publications represent scientifi c base for further research.Taking sample of  mandibular molars we got percentage success of classical mandibular block of .Percentage of success responding to up to now studies, which light up problem of eff ect of mandibular block.Out of total number of teeth  require additional intraoseal anesthesia.From this group of teeth, which show insufficient effect of classical mandibualar block  show positive vitality signs and after application of intraoseal anesthesia positive vitality sign is registered on one sample only.
application of conventional mandibular block, out of total number of mandubular block under anesthesia - teeth,  of them have positive signs of numbness of lower lip and tongue of the side in subject, negative vitality test and show absolute absence of pain during the work.Out of this come out that percentage of success of classical mandibular block is ..Tooth extraction was not made in those cases where vitality signs are positive in order to avoid pain and discomfort in patients at the time of extraction.Number of mandibular molars with negative test of vitality and show absence of pain during the work ( molars) is statistically signifi either positive vitality test ( to  on the vitality scale) or some pain and discomfort at the time of extraction attempt ( to  on discomfort scale) is  teeth.Out of total number of mandibular molars under anesthesia  minutes after application of classical mandibular block, seven of them show vitality signs ( to  on the vital-SAMIR PROHIĆ ET AL.: THE EFFICACY OF SUPPLEMENTAL INTRAOSSEOUS ANESTHESIA AFTER INSUFFICIENT MANDIBULAR BLOCK ity scale) and eighteen mandibular molars show apart from negative test of vitality.Out of total twenty fi ve molars, which showed either positive vitality test or some painfulness and discomfort at the time of extraction attempt, statistically signifi cant were less molars () which show vitality signs than number of molars, which show apart from negative vitality test painfulness at the time of extraction attempt (eighteen molars).Value χ test is χ = .,d.f.=, and level of signifi cance p<..tion attempt ( to  on discomfort scale) intraosseous anesthesia was applied too.Total number of such mandibular molars is  teeth.Out of eighteen mandibular molars  minutes after application of intraosseous anesthesia  fail to show any discomfort or pain at the time of extraction attempt ( on discomfort scale).Th e fi rst study which brings results on effi ciency of additional intraoseal anesthesia published Leonard () In clinical study author published success of intraoseal anesthesia of .Coginns and co-workers() published effi ciency of primary intraoseal anesthesia in mandibu-SAMIR