Postoperative Pain of Two Intraosseous Anesthetic Techniques: DISCUSSION

In: Anesthesia

23 Oct 2009

For the Stabident and X-Tip™ techniques, needle insertion for the infiltration injection, into alveolar mucosa, resulted in mild pain ratings, with 2-10% of the subjects reporting moderate pain and no reports of severe pain (Table 1). The mean VAS ratings were 34 for the Stabident technique and 28 for the X-Tip™ technique, which would be in the range of weak pain (Figure 3). There was no significant difference (P > .05) between the X-Tip™ and Stabident techniques. This would be expected because the technique and location of needle insertion was identical regardless of the IO system utilized. Coggins et al reported a 20% incidence of moderate pain and no reports of severe pain with needle insertion, into the attached gingiva, for the infiltration injection of the mandibular first molar. Replogle et al reported only a 2% incidence of moderate pain with infiltration, into attached gingiva, of the mandibular first molar. Generally, the results of the current study and the studies by Replogle et al and Coggins et al would indicate that needle insertion, either into attached gingiva or alveolar mucosa, may result in a 2-20% incidence of moderate pain. No topical anesthetic was applied in this study, although it is recommended by the Stabident and X-Tip™ manuals. Topical anesthetic was not applied to the mucosal injection site because we wanted to measure the pain of the infiltration injection. The use of topical anesthetic has been advocated as an aid in reducing the pain of needle insertion. While Rosivack et al demonstrated the effectiveness of topical anesthetic, Gill and Orr and Kincheloe et al showed no significant pain reduction with the use of topical anesthetic. Martin et al found that if the patient thought they were receiving topical, whether they did or not, pain ratings were lower. Therefore, the most important aspect of using topical anesthetic may not be its clinical effectiveness but rather the psychological effect on the patient who feels the practitioner is doing everything possible to prevent pain.

For both IO techniques, solution deposition for the infiltration injection resulted in a higher incidence of pain than needle insertion, with 22-27% of the subjects reporting moderate pain and 0-2% reporting severe pain (Table 1). The mean VAS ratings were 48 for the Stabident technique and 39 for the X-Tip™ technique, which would be in the weak to mild range (Figure 3). There were no significant differences (P > .05) between the 2 techniques. Once again, this would be expected because solution deposition was identical for the 2 techniques. Replogle et al and Coggins et al reported a low incidence of moderate pain (2%) and no reports of severe pain with solution deposition, into the attached gingiva, at the mandibular first molar site. The fewer reports of moderate and severe pain in these studies may relate to the volume of anesthetic solution injected. The previous studies used 0.1 mL of anesthetic solution whereas the current study used 0.6 mL. We elected to give 0.6 mL of anesthetic solution because of the need to anesthetize either the coronal Stabident perforation site or the apical X-Tip™ site at each appointment. Another factor for differences in pain between the studies would be the site of solution deposition—the alveolar mucosa versus attached gingiva. Perhaps the alveolar mucosal site would result in more moderate pain than the attached gingival site. However, it is unknown how much the site contributed to the pain of injection versus the volume of solution. Generally, we can state that solution deposition of 0.6 mL of 2% lidocaine with 1:100,000 epinephrine for infiltration in alveolar mucosa, for the mandibular first molar, could result in moderate pain being experienced about 25% of the time. The potential for severe pain is small. female viagra online

Perforation pain ratings were similar for the Stabident and X-Tip™ systems, with no statistical differences between the 2 techniques (Table 2). The mean VAS ratings were 39 for the Stabident technique and 39 for the X-Tip™ technique—which would be in the weak to mild range (Figure 3). Moderate pain was reported in ap proximately 25% of the subjects, with 1 (2%) report of severe pain (Table 2). Replogle et al and Coggins et al reported 0-7% of subjects had moderate pain and none had severe pain with a primary Stabident perforation at the mandibular first molar site. The differences between the current study and those of Replogle et al and Cog-gins et al may relate to operator technique or differences in patient population. Because there was no difference in perforation pain with the X-Tip™ and Stabident systems, we can speculate that the site of perforation (coronal or apical) was not a factor in the pain of perforation. Generally, the results of the current study and the studies by Replogle et al and Coggins et al would indicate that there is a potential for moderate perforation pain in 7-25% of patients and a small potential for severe pain when either system is used as a primary technique in the mandibular first molar.

The Stabident system uses a solid core perforator with a beveled end. The X-Tip™ perforator system has a drill and guide sleeve component. The outer guide sleeve component has a beveled end that is approximately 1-2 mm short of the needle drill. When unpackaged, the distance between the drill needle and guide sleeve component varies between 1 and 2 mm depending on the bevel of the guide sleeve. Both components rotate together when the handpiece is activated but it is unknown which component does the bulk of the cutting or whether they both contribute equally. Regardless, the X-Tip™ perforator component is larger in diameter than the Stabident perforator. We measured 25 Stabident perforators and 25 X-Tip™ perforators (drill and guide sleeve components). The average diameter was found to be 0.42 mm for the Stabident perforator and 0.63 mm for the X-Tip™ perforator. However, in terms of the pain of perforation, the larger diameter of the X-Tip™ system did not contribute to more pain with perforation (Table 2). viagra soft tabs online

Insertion of the IO needle, into either the guide sleeve (X-Tip™) or bone (Stabident), resulted in pain ratings that were similar for the Stabident and X-Tip™ systems, with no statistical differences between the 2 techniques (Table 2). The mean VAS ratings were 28 for the Stabident technique and 15 for the X-Tip™ technique— which would be less than weak pain (Figure 3). Moder­ate pain was reported in 5-10% of the subjects, with 1 (2%) report of severe pain (Table 2). Replogle et al and Coggins et al reported 2-8% of subjects had moderate pain and none had severe pain with needle insertion into bone, using a primary Stabident technique, at the mandibular first molar site. Clinically, insertion of the IO needle either directly into coronal bone (Stabident system) or into the guide sleeve component (X-Tip™ system) may result in moderate pain being experienced 2-10% of the time. The potential for severe pain is small.

For the X-Tip™ system used in the current study, insertion of the 21-mm needle into the 13-mm-long guide sleeve would result in 8 mm of the needle protruding into bone. Therefore, contact with cancellous bone would occur with both the Stabident needle insertion and X-Tip™ needle insertion. Viagra Super Active

Solution deposition pain ratings were similar for the Stabident and X-Tip™ systems, with no statistical differences between the 2 techniques (Table 2). The mean VAS ratings were 50 for the Stabident technique and 46 for the X-Tip™ technique—which would be in the weak to mild range (Figure 3). Moderate pain was reported 22-32% of the time and severe pain was reported in 2% of the subjects (Table 2). A majority of subjects either told the principal investigator who gave the injections, or noted on the VAS, that most of the pain experienced during IO deposition occurred during the initial few seconds. Replogle et al and Coggins et al, using a primary Stabident technique, reported 215% of subjects had moderate pain and 2% had severe pain with solution deposition at the mandibular first molar site. The differences between the current study and those of Replogle et al and Coggins et al may relate to operator technique or differences in patient population. Generally, the results of the current study and the studies by Replogle et al and Coggins et al would indicate that there is a potential for moderate solution deposition pain in 2-32% of patients when either system is used as a primary technique in the mandibular first molar. The potential for severe pain is small. zetia medication

Guide sleeve removal pain ratings were similar for the mock guide sleeve removal (Stabident system) and the actual guide sleeve removal (X-Tip™ system), with no statistical differences between the 2 techniques (Table 2). The mean VAS ratings were 9 for the mock guide sleeve removal (Stabident technique) and 8 for the X-Tip™ technique—which would be less than faint pain (Figure 3). Moderate pain was reported 2% of the time and there were no reports of severe pain (Table 2). Because the guide sleeve removal procedure for the Stabident technique was a mock procedure and no statistical differences were shown between techniques, guide sleeve removal for the X-Tip™ was not considered to be a painful procedure.


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