Postoperative Pain of Two Intraosseous Anesthetic Techniques: MATERIALS AND METHODS

In: Anesthesia

21 Oct 2009

Forty-one adult subjects, 24 men and 17 women, participated in this study. The subjects were in good health and were not taking any medications that would alter pain perception. The Ohio State University Human Subjects Review Committee approved the study and written informed consent was obtained from each subject.

Twenty-four mandibular left and 17 right sides were tested, with the first molar chosen as the tooth to receive the IO injections. Clinical examinations indicate that all teeth were free of caries, large restorations, and periodontal disease, and that none had a history of trauma or sensitivity.

Two appointments at least 2 weeks apart were scheduled for each of the 41 subjects. Longer intervals than 2 weeks were scheduled if the subject reported postoperative problems with the first IO injection. With a repeated-measures design, each subject randomly received either the Stabident IO injection or the X-Tip™ IO injection at 2 separate appointments. Assigned random numbers determined the order of IO system administration. The principal investigator gave all IO injections. dutasteride hair loss

The IO injection with the Stabident system was given in the following manner. With the subjects in a reclining position, the area of perforation was determined by the horizontal line of the buccal gingival margins of the first and second molars and a vertical line that passed through the interdental papilla on the distal aspect of the first molar. A point approximately 2 mm below the intersection of these lines was selected as the perforation site if the site was in attached gingiva. If this point was in alveolar mucosa (2 subjects), the injection site was moved just above the junction of the attached gingiva and alveolar mucosa. The alveolar mucosal soft tissue, adjacent to the determined perforation site, wasanesthetized with a supraperiosteal infiltration injection of 0.6 mL of 2% lidocaine with 1: 100,000 epinephrine (Xylocaine, AstraZeneca, Wilmington, Del) deposited through a 30-gauge needle attached to an aspirating syringe. Five minutes after the infiltration injection, pressure was applied at the determined perforation site with a periodontal probe. If the subject felt pain, an additional 0.3 mL of 2% lidocaine with 1:100,000 epinephrine was administered (2 subjects). The pain of needle insertion and solution deposition of the additional infiltration injection was not recorded for these 2 subjects. The cortical bone was perforated with the Stabident perforator (a bevel-ended solid wire attached to a plastic hub) in a contra-angle, slow-speed handpiece. The perforator was placed through the gingiva and was oriented perpendicular to the cortical plate. With the point gently resting against bone, the handpiece was activated, at full speed, while pushing the perforator, with light pressure, against bone and then slightly withdrawing the perforator and then pushing it again against bone. This action was continued until a “break through” feeling was observed or the perforator was placed to length. The handpiece was always activated while the perforator was within bone to prevent lodging or breakage that might occur if the perforator was allowed to stop rotating. An easy perforation was defined as a perforation that could be completed in less than 5 seconds using only light pressure. A difficult perforation was defined as a perforation that required moderate pressure and/or took longer than 5 seconds to penetrate the cortical bone. Before inserting the 27-gauge ultrashort Stabident needle through the perforation, the needle was bent at the hub to a 45-degree angle to allow for ease of insertion. The area of perforation was blotted with a sterile cotton roll to control hemorrhage and identify the perforation site (a small dot of hemorrhage on the blanched gingiva). The standard syringe was held in a pen-gripping fashion, and the needle was inserted into the perforation site and 1.8 mL of 2% lidocaine with 1:100,000 epinephrine was delivered over a 1-minute time period. If back-pressure (defined as greater than light finger pressure on the syringe handle to deliver the solution) was encountered on solution deposition, the needle was rotated approximately a quarter turn and deposition was reattempted. If this was not successful, the needle was removed and checked for blockage. When blocked (4 subjects), a new needle was used. If not blocked, the site was reperforated (1 subject) with a new perforator and the injection completed. The pain of the reperforation was not recorded for this 1 subject. At completion of the deposition of solution, a mock guide sleeve removal was performed so all treatment procedures would seem identical to the subject. The mock guide sleeve removal was accomplished by mim icking the procedure to remove the X-Tip™ guide sleeve. The operator retracted the subject’s cheek, placed the tip of the hemostat in contact with the anesthetized gingiva, and moved the hemostat back and forth for 3-5 seconds.
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The IO injection with the X-Tip™ system was given in the following manner. With the subjects in a reclining position, the area of perforation was determined to be in alveolar mucosa at a site distal to the mandibular first molar. The perforation site was approximately 3-7 mm inferior to the Stabident perforation site without extending below the coronal aspect of the buccal shelf. The alveolar mucosal soft tissue, adjacent to the determined perforation site, was anesthetized with a supraperiosteal infiltration of 0.6 mL of 2% lidocaine with 1:100,000 epinephrine deposited through a 30-gauge needle attached to an aspirating syringe. Five minutes after the infiltration injection, pressure was applied at the determined perforation site with a periodontal probe. If the subject felt pain, an additional 0.3 mL of 2% lidocaine with 1:100,000 epinephrine was administered (5 subjects). The pain of needle insertion and solution deposition of the additional infiltration injection was not recorded for these 5 subjects. The guide sleeve of the X-Tip™ system was secured against the drill via finger pressure as the red protective covering was withdrawn. The alveolar mucosa was pulled taut, using the fingers of the other hand, to minimize engaging the mucosal tissue during rotation of the perforator. The perforator was pushed through the alveolar mucosa until the X-Tip™ contacted bone. Holding the drill at a 90-degree angle to the bone, the slow-speed handpiece was activated, at full speed, while pushing the perforator, with light pressure, against bone and then slightly withdrawing the perforator and then pushing it again against bone. This action was continued until a “break through” feeling was observed or the perforator was placed to length. The handpiece was always activated while the perforator was within bone to prevent lodging or breakage that might occur if the perforator was allowed to stop rotating. An easy or hard perforation was defined as outlined for the Stabident perforation. The drill was then withdrawn from the guide sleeve, leaving the guide sleeve in place. Before inserting the 27-gauge short X-Tip™ needle (21 mm) into the guide sleeve, the needle was bent at the hub to a 60-80° angle to allow for ease of insertion. The standard syringe was held in a pen-gripping fashion, and the needle was inserted into the guide sleeve to its hub and 1.8 mL of 2% lidocaine with 1:100,000 epinephrine was delivered over a 1-minute time period. If back-pressure (defined as greater than light finger pressure on the syringe handle to deliver the solution) was encountered on solution deposition, the needle was rotated approximately a quarter turn and deposition was reattempted. If this was not successful, the needle was removed and checked for blockage. No needles were blocked. Due to the backflow of the anesthetic solution into the oral cavity in 1 subject, the guide sleeve was removed using a hemostat and the site was reperforated with a new perforator and the injection completed. The pain of the reperforation was not recorded for this 1 subject. Upon completion of deposition of solution, the guide sleeve was removed using a hemostat. For both the Stabident and X-Tip™ techniques, each subject was instructed to close his/her eyes during all injections and during the actual or mock guide sleeve removal to blind the techniques.
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The subjects were instructed to rate the pain of the infiltration, IO injections, and mock or actual guide sleeve removal. The pain rating was done on a Heft-Parker visual analogue scale (VAS)9 (Figure 3). The scale consisted of a 170-mm line with various descriptive terms. The subjects placed a mark on the scale where it best described their pain level. The VAS was divided into 4 categories. No pain corresponded with 0 mm. Mild pain was defined as greater than 0 mm and less than or equal to 54 mm. Mild pain included the descriptors of faint, weak, and mild pain. Moderate pain was defined as greater than 54 mm and less than 114 mm. Severe pain was defined as equal to or greater than 114 mm. Severe pain included the descriptors of strong, intense, and maximum possible.

Figure 3. Heft-Parker visual analogue scale

Figure 3. Heft-Parker visual analogue scale (VAS) used for assessment of pain. The millimeter demarcations were not shown on the patients’ VAS scale.

A postinjection written questionnaire asked the subjects to rate the pain and any side effects in the area of the IO injection at the time initial numbness wore off and in the morning for 3 days following the appointment. The subjects used the same VAS for the pain ratings as was used for the pain of the intraosseous injection.
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The data were statistically analyzed. Comparisons of the pain ratings (IO and postoperative) were assessed using multiple Wilcoxon matched-pairs, signed-ranks tests. All P-values were adjusted using the step-down Bonferroni method of Holm. Postoperative sequelae of the 2 techniques were compared using the McNemar test. Comparisons were considered significant at P < .05.


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