intraosseous posterior teeth

g'l
lea
A comparisonof two
intraosseous
anesthetictechniques
in mandibular
posteriorteeth
,ULIAIIIE GALIATIIII, D.D.S.' M'S.i AL READER'
D.D.s., M.s.t JOHttl USSTEI , D-o'S', IUI'S'' MIKE
aECK, D.o.s- |vl.A.; JOE! Ii,EAVER, D'D'S" Ph'D'
he intraosseous,or IO, injectioû involves
Dlacementof a localanesrheli.dirpctlyinlô
ihe cancellou.boneadiacentio lhe roothlo
be ânesthetized-An IO injection svstem marketed under the name Stabident (Faidia""
Dental.Miami) hâs beenavailablefor a nurnberof
ofa pe orâtor'lriven bv
is
.,".rs. ittis
"omposed
"vstehandpieceând â solid2?a slow_speeal
qauge \À.rewith a beveledend that.
lte t$.o ivhen activated, drills a small bole
primaYY through the cortical plâte (Figure 1) Th€
iûlràosseous ânesthetic solution is delivered to cancelultlainiection lous bone thrcugh the 21-gauge
short iojector needleplaced in the hole
techniqrtes
made by the Pedorator.
cvele sianilàt
The Stabident iniection svstem has
regârding been evaluated âs a pdmary injectionaneslùeti
L€onârd1rcpo ealthat a ûajority of
successr ons€t. extractions were successful with this
who
duration and syst€m. Cogginsând colleâgues,'
Stabident svstem as a pflmary
used
the
pe.ceived heart
iniection in vârious $oups of maxillary
râte incteâsas" ând mandibular teeth, reported a 75 percent rate ofsuccess(alefinedas no
pulp
l,esting,for rhc mandrbu)arfirsl molar'
resuonseto
reportedlhât for mandibular
neoloet. anA
"otteagues"
primarv
Stâbidpnt lO rnjeciion of2
firit Àolars, rhe
epinephane$ âs more
l:100.000
Dercêntlioocainewilh
l'hansas a
pulp
Lesringr
rno
l,o
successful response
p'rcenL
mepi\acâincof
3
primary iniection
Srabidenl,
l4t6
2003
JADA,Vol.134,November
â.iiÉÀijÉinniq"e e
Fi
sezfid inlraoés€oE t€ch-
trique-the X-tiP sysêm
Lake
-ot-tip Technoloeies,
bæt
bæû
çood,
NJ.Hus
wood,NJ.HÉS
.ô:QEP'Â
'f?rclÉ
introduced,bùt to scientifi"
the
-
sùdies havê yet compared it's
ê.frectiveneéÊto that of the StebideÛt
6yst€m. The âutlors und€Itook a studv to
compâr€ thê iwo s)€tems' dnesthetic out@mes in primâry inhaoss€oùs injeciiotr in '
mandibulâI post€rior t€eth
The authors, Éing a cros$ver '
ttlethods.
design, tùdorùy administÆed â prmarv
St€bidert iDtraosseous itjection ùd a pnmâIy X-tip iatraosseous injection, at two
sepa$te appointments, to 41 sùbjecLs Sub- .jects wÉæ asked iftheY Pdceived ù
ingeâse in heârt râte with the htraosseoÙs
injections. The reseârch tfâm blind-tést€d - r
each subjeci s tust mola!, secoDdmolar Ùd
se@ndpremolar with a plrlp test€r at two_
mirut€ cycles for 60 minutes âfter tlE injectior Anesthesia wæ oDsidered successfrn
when two @ns€cutive pulp t€ster reâdings
Results. Anesi}etic sùc.essrates for the
Siâbiil€nt Le.hnique â!d th€ X-tip bech'
dque, respectively, weie 93 percent Ùd 93
percent foï the 6Ét molù; 95 percênt €nd
95 perænt for the secondmolar; and 81 p€r.ent ald 83 pùcent for the se@nd Pre
molâr, with no sigdÊcani differcûces
(P > .05) betwæn the two techniques For
both intraosseous echniques, olet of
pulpal anesthe.siao.cured withù tÀe fir€t
two minutes, but the duEtion of anesthe$a
declined st€adily overthe 60 mhut€sEighty-five perænt ofthe sùbjecis had a
peit€ived ingease in heirt rlat€ with the
abbjdeDt iqjsbron ald 93 percent wiLh the
X-tip injection.with no sisnincâd difre'ences(P > .05)betwe€nthe techniq'r€s
conclusions and Clini.al
lrnplications. ltle two Primary
intEoss€ous injection techniques were
ilar æssdins ângtÀetic sùccess'onset'
dùration arld Perc€iwd hedt rat€
Écieases.
sisl
p0r
tic'
Ib,
a2
tior
mlr
l
sit{
gui
sls
ùe
(ih
sh
apr
!id
Ho
Xr
blil
IO
'ni
5t
lo
pet
Cil
i
ï
8ld,
lrc
3pl
t R E S É A R a l t
4 percent succæs râte versus a ![5 percent sucÉte, resp€ctively. Châmberlain and col,
i found that 95 percent ofpâtients were
anesthetized for operative dentistry
when using the Stabident IO injectioû
-A second inhaosseouB s].stem is on the market:
X-tip (X-tip Teehnoloeies,Lâkewood,N.J.)
ia deliverysystem.TheX-tip systemcon-
oftwo pârl"s:a drill ând a guide sleevecomt (Figure 2 ). The driJl a specialhollow
eâds the guide sleeve through the corplâLe.whereiL is separarpdand withdmwn.
lle remâiûiûg guide sleeve is designed to accept
z7-gaugeûeeille to iûject the driestheticsolution.The guide sleeveis removed dfter the lO
is compl€te.
iojection
Both the Stabident and X-tip intraosseous sj,slsnsn6instruct tàe user to locâte the perfomtion
lite in attâched gingivâ. However, because the
guidesleeve remains in ptace rÀ.ith the X,tip
3Ftem,we felt it coùld be used in alveolar
Ducosa
ât a more âpicâl location. Occasionally,
tùeStabident system fâils or cannot be used at
coronallocâtionbecauceofpeaodonraldr-rdeeppockeBror lack ofinrerproximalspace
oasp
{heleeth are too closetoqetber./.We wondêred
rhether the alternâtive X-tip system, used rn an
lpicallùcâtion, woutd be as efficacious in DruridinCpùlpal anesthesia as the Stabident sysiem.
llowever,therc were no scientfic studies on the
system or th€ placement of an IO injection
amoreapical position.
r.W€ undertook a prospectjve,
randomized
Ùbdedstudy ro compâre an apicâl primary X-tip
ù{ection with a coronal primary Stabident IO
ion in mandibulâr posterior teeth.
, IIIIATERIALS AND METHODS
-oneadult subjectsparticipâted in this
. the subjectswerc in goodhealth ând were
taLjng âny medications thât would âlter thelr
ion ofpain. The human subjects æview
Ittee ofThe Ohio State Univemity,
, âpproved the study, ând we obtained
Itt€n ifformed consent from each subject.
wetested 24 mândibutar left and t7 risht
with the fiIst molar, second molar and
premolaras the test teeth.We usedthe
canine as the unânesthetized cont{ ÊûsuïethâI, Lbepulp tesfer was operâtjrts
rc.ly and that the subject wâs responding
duriûg the erperiment. Clinicâl
Flg@ t. lhê Stâbidè
Dêrtotârtor (Fàtrfàx oêrtàt,
Miml), â 3olid 2t.9â!gê DiE wfth â b€vêtéd ènd, whi.h
is plà..d tn â slow-spee.t lÈrdpi4,
FiguE 2. Tho X.dp ân*ttelià
dcllrry
systèm lx.itp
TèôrologlÉ,
Lkcwood,
x.J-) .061.l'
oa àn x,tip {top)
dt.t spârât s itrto two pàrt ! tbê dritt (à .F.<t.t holtd
trêèdlê) .nd tùi.lê d.€re Mpærn
ftofton).
exâminationsindicated that all teeth were ftee of
cades,largerestorationsand periodontaldisease,
and that nonehad a hislory oftraumâ osensitivity.
Two appointmentsat least two weeksapart
w€reschedùled
for eaehofthe 41 subjects.
: Accordingto the study's crossoverdesign,each
subjectrândomly receivedeither tfie Stabident IO
injection or the X-tip IO iûj€ction using 1.8 millimete$ of2 percentlidocàinewith 1:100,000
epinephrinefxJlocainewith epLnephj"in€
Ashazeneca,Wilmington, Del.) ât two separate
appointmenh. Assignedra]ldom numbers determined the order of IO syst€mâalninistrâtion. T'he
principal investigâtor (J.G.) gave âll IO injectio.s.
Trâined personnel,who were blinded to the
tpe of IO systemsâdministered,performed all
preinjection ând postinjectiontests- The hained
researchassistantsr,eeredentâI or hygiene students specifrcallyhâined in conductingclinical
triah. At the beginningofeach appointment and
,ADA,Vol.134 November2003 l47t
i - s E A R c ! l l
the ooinl qently reslingagarnstbone lhêprrn'
beforeaûy ioiecl,ionswere grven, the rêsearch
cheeh
.ioi in'eltiguio. uctiuat'd the hândpieteaLiull
teeth and the
o"t"onrl"i t"","d th"
with
light
perforator'
iheh€
speedwhrle pushing th"
"*periment'al
wjth a Kerr pulp lesler
t
Lnrml canine rhree times
q,ith
wjfhdra$lng
the
oiessur.,againsrbonc.sLrghtly
r to record
1e'''ùi. Tect'ootogv.Rrd]nond' Wash
against
âgarn
pushjng
it
;erforaror and [hen
be
baseline vitalitv. AÎ-er isolating the Lootj w
Lone Sneconrinuedrhis acrionunl-i1she observed
gâuze'
tested with cotln mll. ând drfing il with
foritl
a breâkthrough feêlingor Lhepêrforator\as
the
ihe rÀearcl a"si"taot applied toothpaste to
\
alwaJi
as
dctuplacêdro length The handpiPce
*f'r"t ** placed mjdwav hêtween rbe
TheIi
;ated \ hile rhe pêrloralorwas withrn boneLo
edge
"'àl"iio,
i""itooiftt ei"gi""lrrlargin and irs occlusâl
occur
I-tiP r
might
if
prevent lodging or breakâge that
at 25 secon'ls to increâse
.ut" *."
Tt u
ùe fol
rotatmg'
stop
"et
lhe oerforator was allowed to
no outpuLr0 r to the ms,.imumoulput r80\'
1
Àom"o.".tt
lvilh
that
as
one
ûe defrned an easv perforatioû
nrrmber ar
The r.se*ch u"si"Latrt recordFdthe
jn
reclinl
serond'
Ù'itrg
five
couldb" complcr.d lebsrhan
initial sensatioû.
Pnnc
orlS light pressureand a difficuli p€rforâr'on'â"
The IO injectton
Stabident administration'
deieu
lhat rcqÙred moderalePres_
one
with the Stabidett system was
five
sec_
than
tsrfor
sule, requrrcd longer
given in the followitg manner'
onds to penehate the cortical bone
We defned an easY
With the subjects in a reclrtmg
nrât€h
or both- Before inserting the 2?iûvestigâtor
position, the pdncipal
ùe Sti
perfoaation as one
needle
o"uoe ultra short Stabident
âetermined the area of Pedoration
the
thât co|rld b€
PriD'
;hr;sh the pedoration,
bv the horizontal line of the buccal
soitti:
less
investigator bent the needle ai
in
cipal
€ornpled
gingival margins ofthe first and
sii€,to
tàe hub to a 4s-degree angle
se<onds
five
ihan
lrne
vertical
seconalmolars and 3
inû]tr
allow for ease of insertion. She
uting onltt ligltt
that Dassedthmugh the interdentâl
110û,
with
blotted the aæâ of perforation
papiûâ on the distal aspect of the
press||rer ând a
gauge
hema sterile cotton roll to conhol
hrit molar. She selected a Point
Fiveû
diffic$It perforation
orrhage and identifv the perfomtion
pnnc4
aDproximatelY2 mjllimeteÉ below
on
âs one that rcqÛired
site (a small dot ofhemoffhage
the intersection ofthese lines as the
the blanched gingiva). She held tbe
modeaate Plessuie'
pmbe
perforatioû site if the site rtas rn
stândard sYringein a Pen-Snpprng
i.eqr|ired longer ihân
attached gingiva. If ihis point wâs
tne
into
fashion, insertealthe needle
five sêcond' to
adrail
in âlveolar mucosa (as it was rn lwo
pedoration site and deiivered 18
lidocai
penekate the Gorticâl
subiects), she moved the injection
mL of 2 Percent iidocaine wrth
opal
ir
sit;to iust above the jùtction of the
botlt.
or
bone
1:100,000epinephrine over a on€'
X-tip
s
attach;d eingiva and the alveolar
minute period.lf the PrincipaL
invesLigatorencouûter€dback_pres'
The DrirlciDal investigator anesoressure Shepu
surerd'fined as grearerrhan lighl hnger
finge.
tletizeâ the alveolar mùcosal soft tissue adjâcent
o0
handr"m delivêrthP solui.ion)
perlorarionsite wiLh a srprapê- oo the syringe
l,othê deLermined
soluriondepositionshe rolatedthF neFoLF
fiosteal infilt'âtion injecl,ionof0 6 mL of 2 per
q",rter rurn and.reatrFmpted
;;;;;;i"';;;;
lorator
cent lidocaine with 1:100,000epinephriûe
not successtuLsne
was
deDosition.Tf this
ro
lipmn
deposiredtjùough a 30 gâuge neeille âltâched
rei oueatl. ne"ate und cbeckedir for blockâge
ihe
$-dee:
an aspirating s:r'inge Frve mùuies all€r
four
W}"n ir -a. bto"keo,.hirh hâppenedwitb
slow-str
innlt."tion iii""tlon. oressur"ças appliedat t}le
a new neeillewas used Tl it wâs not
subiecrsr,
!ushin
Jeærmined pàrforarion sile with â periodônraI
in
ti"if."a, it'" oti""ip"t invesrigâtor reperfôrât'ed
orobe.Ifthe subjectfell,pain $hich happened
wrttr rithdi
iiï"'i"'t"" "1". ""i,"*ary wiih onesubject)
iCain.
'
iwo cases, the principal investigator adrnitistered
a ne\\ perforaLorand completed the injectron
t\rougi
an aaditiond d.s mI- of 2 percent lidocaine with
th€
À compl.rionof rhe deposilion ofsolurion
xaspl:
epinePhrine
1:100.000
gude
'i". ioJ i""".tigrto' periomed a mock
,,
The cortical bone was perforated with the
wouu
sleeve"emoval so all treâtment procedures
Stabident p€rforator (a beveled-eniled solid wire
gurde
mock
Ûo((
The
I
ne
identical
idenlicaL
tsuJv'
subFcr.
m lhê
to
LhêsubJêcr.
seem
,; -il llreper
,Jl
anachedto a plasrlchub' in a conlra-ângleslowbv mimrcto!Ë
accomplished
was
removal
sleeve
speedhandpiece.Thê principal inveslrgator
qit
iiï"."""î"'" r.' ""-"*"à tr'. x-t+ e"'ae,"t"eL1
piacedthe perforator through the gingivâ ând ori
De
the
retracted
investigator
''u
principal
The
wjrh
plâte
jt
coriicai
ù,rt,
Lhe
peipendi-rlarll
inted
l4t6
2003
vol 134November
JADA,
I R E S E A B C I f
lbeek,plâcedthe tip of
ùe hemostatin contact
ftità the anesthetizedginiiva and rctated the
ienostat back and forth
lorthree to five seconds.
! X-tip aalninistrâtion,
TheIO irjection with the
Xlip systemwas given in
1[efollowing manner.
Withthe subjectsin a
rcclidngposition, the
Fincipalinvestigator
the area of
determined
tsrforatiot to be in alveolarmucosâ(approxiEately3-7 mm inïerior to
lABLE
ItreStabidert perforation site) at a site disral to
themandibular first molar. The âlveolar mucosal
!0fttissue, adjacent to the detennined perforation
8ite,was anesthetized with a suprapedosteâl
inÂitrâtionof 0.6 mL of2 percent lidocaine lvith
1100,i100
epinephrine depositedthrcugh â 30
pugeneedleattached to arl âspirating s].ringe.
Iiveminutes after the infiltrâtion injection, the
ldncipalinv€stigator âpplied pressùre at the
deterïrired pedoration site with a perioContal
Fobe.Ifthe subject felt pâin (which was the case
riih five subjects),the principal investigator
eûrmistercdan additional0.3 mL of2 percent
with 1:100,000
epinephrire.The pdnnvestigâtor secùæd the guide sleeveofthe
system âgainst the drill via finger pressure
the red protective covering was withdiawn
pulled the âlveolar mucosâtaut, using the
of the other hand, to minimize engaging
mucosaltissueduring rora[ionof thê pe,{o. The principal investigâtor pushed the perthrough the aiveolff mucosa until the Xcontâctedbone. Holding the drill at a
angle to the bone, she activated rhe
speedhandpiecear Êrll speed\ahilelighd)
tbe pedorator against bone,slightly
rMingit and then pushing it âgâinst bone
She continued this action until a "break,
ugh feeljDg\^âs obseruedor lhe pFrforaLor
placedto length. The handpiecewas always
while the perforator was within bone to
todging or brealage that might occur if
9erforatorwasallowedto stoprotating
usFdlhe samedefiDirion.for easyano diffiledorâtions as with the Stâbident pmcedurc.
principâI investigator tàen vrithdrcw tàe
ùill
ftom the guide sleeve,leaving the sleevein place.
Before inserting the 27 gauge X-tip needle into
the guide sleeve,she beût the needle at the hub to
a 60- to 8o-degreeângle to allow for eâseofi4ser
tion. She held the standæd s].ringe in a pengripping fashion, and irserted the needleinto the
guide sleeveto its hub and delivered 1.8 mL of
2 percent Iidocaine\.ith 1:100,000epinephrine
over a one-mimrte period. lfthe principal investigator encounteredback-pressùre(definerias
geâter than light finger pressure on the slringe
handle to deliver the solution) on solution deposition, sh€ rotâted the needle approximately o!equarter hlrn and reattempted deposition. If this
was not successful, she rcmoved th€ needle and
checkedit for blockage.No needleswere blocked.
Owing to backflow of the anesthetic solution into
the oml cavity in one subject, the pdncipal investigator removed the guide sleeve using a hemostat tnd reperforatedrhe siLewirh a ncw peIÎorator and completed the inj€ction.
On completing deposition of sotution, the prin.rpâl invesrigârorremovedùe g1lidesleeveusing
a hemostat. She rated the r€movat of the guide
clêevccomponentas easy rwithin five sec;nds, or
diJficult (rcquircal more than five seconds).
For both the Stâbident and X,tip technrques,
the principal investigâtor instructed each sùbject
to close his or her eyes during all injections, and
durirg the âctuâl or mock guide sleeve rcmoval,
to ensure blinding ofthe techliques. The research
pe$onnel were not present during the Stabident
or X-tip injections.
At one ûirute aIïer completion ofthe IO injection, the research assistants pe?formed pulp
testing on the the frrst ând secord xxolais. At hÀio
ininutes, they tested the second premolar and
JADA,Vol- r34. Nolenber 2003 t4t9
',ii'",;;ît'f,..'';;.*""
thei
l-til
lerct
F'
''i"i*i
a r " t a 2 6 t 4 4 I 5 o
fl rE (i lrltrEs)
,. 0". ';'"'ion forpulpâl.anesrhêsia
s pârt to drÊ
lu."n." ott".pont" on rhe subjert
pÙrp
rhe
of
".r
p'i ''n a0 rpadins)
i"'J-î*
ur when
",t
successf
hêsia
l'lll- ï. ."".ta"r"a -esr
\!ith a
nss
readi
80
rve
iiiii'".
r'J t" *".ecut
'nJii,e.tionor
"
urpr'ri'k "19i5Î"11^."^l**
"t
sizeof 40 'ubleclsvrâs
stmpl"
perc.nt.
a
àô
or = 30 pÊfi"qi."à ià a""'""'' '"Le a difference
EATC
ol4
( 1 0t
Éie
Jo
'*j""n" li'f'' s,ruia"nrandX-tip
ânêspulpâl
of
**. incidence
i;"î"ir1.t. "* heartrareincr.ase'rpalpira'
ii""J,I..."*'a
we
ii^i.' ri" '.*'r'".i, ,nd ea'eofperrorations
pa
nsons
com
in" v.tl"-" *"i wc mâde
ares
"."J
on'errrmeofpulpal
i"i""-. if+',*"*
comtank-l"'r
"t
sisned
*t'*-on
irrl.,,
ar P 05
sisi'iÊcanr
".i'eih;
a"'ed
rr".i." -Ë; "".l"
eas'
din'
*ï,::'#:::'iliHs",u,i.';"u1v tno"'
"om'
jni'c'i0ns
Fis!É 3 rni.tere ot€6q*:":iii:illfl
1""
:Hir:::iËHtri'"ir.:Ï;
r,ry;::i-:H?i
t*ff.'f:i$
'l-";
'"r*'
*" t:
ff"ii*ii*JËlî;i#;
r"*ry:i'r"' o'"
i.iieliËi"ilË;-;
'liËl,il"Ë:ïi;*;;;.ry^._'-'
lljl,lËii
jt?,*j*;:Jff
Ëf
i;lËllxHi:,ii!ËËËr:*:*.#LH,i:T**
*'"" bvx'rip
lii i'?'il'i{iù'{!'-11;;;"'**o""'
;Ë;;;"n"';'tu*d
ffi1;i:ii':iii'
ilii:f
râk4ood'
;;;;Iosié,
irr'
RESULTS
1? women'
Fôn\.onPadulr suJjecls24 men and
I
É
lglirT.
E
' "ii"o",ii
.i]",'';
aseofo6
'b anaverase
0ls
sig
|oll
alll
pai
âre.pre"enLpo
iiili*n'Li^ succe5s
9:
I E o
in anêsthelr'Ing
i n L f r er a b l e R a L e so f ' u c c e s s
f2 : s
Jï1",
i;H:i'',iï;
n:l':.ru*,:".i
d
the
eith
F
rhcsrahrdcnL sig
."'li,oi,". 0".'""- têêrnu-srng
X-r
*
ao
la
26
:t4
4:
50
5a
s5 pe"centrorrhesP'ond
l'"ï"'. ôÀ.*""i''
""a
;;i;;,;;,iàr perc'nrând83percenr'rorrhe
"
'::""r9;ir:ïiiÏïiil"'iJ""''ôî',ff
'::i:T
prespnl
5
of
i"r,n" ol '*"'.' fis*es 3 through
' 80readin€s'Tor ep
p'rp,r
,i"iâ"'*
.
"ttsthe'ia
"i
Ther:ewas no srgnnt
the two t€chnrques
ËH'Hï#ffi
i;;;;;
at
; ôËi b"t-"en rhe rwo LechnioLres
' "'":::i:ff
0,"*"
il;ii:Ï::,l"'iiiii;n"
This clcle ofteshns
contralâteral.conlrolcânine
T"l tî""ài.J*""
:;;;;i;;"*";
Thevlesredthe
t''o minuLes
ll!8o
for rhestabident,'Pch'
ri" or'r'". *"tas v'hether
IADA,Vol 134,November2003
tl
R,
h
I\
pl
ri
roinLrres\^'ith an inactive
reliabititvÆl
,i""'
i,i.'i".Ëîr".,
"ubiêcts
âfterrheIo
'' 60'ûinutes
iJ['i"î*î"po"a
'"'i,l'ro-I
ofanesthetic
deposition
--t*
r'hesub
"o"r
asked
*,iitli, tnî nn".to'l 'nvesrisaror
were
bearins
r'*n raelâsirit
iliiiiiiil"ï
Lhepatrenlwâs
il"i".l:
ii'.i"**
*...*'.tlI: Il.'lf;In;ii"'
i'0,"1ù'u'
rr 2
There was no signiftcant drteretce
""ï*a'i
h
"ffiî'Iirt"""tiiii:ï;ded
percett
in100
L
JADA, Vol. 134,November 2OO3
R E S E A R C t i l
respectively for the second preûolar, with no staolar nerve block. They recorded a high incidenqg
tisticâlly significânt differences between the techofpulpal anesthesia(100 percent); \'ith 85 to 90 $il c(
niques (Tâble, page 1429). Replogle and colpercent of the first molarc still anesthetized at
60 jrjectj
leagues3and Coggins and colleagues, also
minutês.
1r00.
reported lower anesthetic success Étes for the
Various authorsz+1{ have subjectively rcpon€d dteir
secord premolar when the Stabident system was
jn hêdri .are.or Dâlpi'aLroir
a pFrceivedincrFase
{ith'
ùsed as a primary injection ofthe fiIst molâr. The
46 ro 90 percentofsubjecrswirh rhe Srabid nr 1[
FNS.
lower anesthetic success lâte for the seconalpre,
injerrionof solurion.contâinin8 cpinFpbrir"ard
molâr most likely is relâted to the selection of the
levonoldefrin. In th€ cui.rent study, 8b percem
n
{oLrr
perforation site distal to th€ first molar. That is,
(35 of41) ofthe subjectsrcpofted that they per,
using a distal iqjection site to the first molal
ceiv€d an increasein heârt râte, in responseto
decreases the amount of anesthetic available to
quêsrioDing.
afi,FrrFceivingthe Srabidenii.Ipcthe second premolâr. As shown by Reitz and coltion and 93 percent after the X-iip injection.
leagues,eifpulpal anesthesiais reqùired of the
Replogleand colleagueslaâr}d Cogginsaûd colofI0
secondpremolar, selectingan IO injection site
leâgues'zfoundthat 60 percent and 75 percentof
wl
distal to this tooth would p.ovide bett€r pulpal
subjects,respectively,reported a perceived
$abn
ânesthesiathan selectingâ site distâlto the fiIst
increasein heart rate (as rcpo*ed viâ subject
molar,
questioning) with the Stâbident I0
rotic€
Oûset of pulpal anesthesia
rnjection of 1.8 mL of 2 percent lido. rCûf
occwrcd within the first 2 minut€s
fhê duration of pnlpal caine with 1:100,000epineph ne.
in the 6rst molar with both IO
The difrererce in heart râte
anesrthesia in ot|l
injection techniques (Figure 3, page
between the cuûent study and that
study. for both tO
1480).Replogleand colleagues3
and
in subjectsstudied by Replogleand
Cogginsând colleagues,also
têchniques, shoulred
colleaguesr.and Cogginsand colreported that a primary IO injecà sleâdy dealine oner
Ieagues'zprobably is retated to the
tion resulted in a fairly quick onset
greater number of anesthetic sucû|e 6o.minute
ofpulpal anesthesiâ.
cesses
dt€rr
in our study. That is, therc
observation pêriorr.
The dumtion ofputpal aneswoùld be a greater likelihood ofan
Tb
thesia in our study, for both IO
increasein heart Iate if more oftle
tecbniques, shor .ed a steady decline
an€sthetic werc delivered into thê
over the 60-minut€ observâtionperiod (Fi$res
cancellousbonerr 10r
3-5). For example,approximately Z6 percent
Four studieslr re15
have evaluated heart raæ
(Stabident technique)and 73 percent (X-tip techusing subjective questioning ând objective meâs.
niqùe) ofthe fimt molars weæ anesthetizedat B0
urements (electrocardio$am and puls€ oximehJ)
minuies (Fieule 3). At 60 minutes, approximately
during and after IO injections. The studies found
51 percent (Stabident technique) and 39 perceri
that subjective and objective ûeâsurements of
Cx-tip techniqùe) of the first molaN were still
heâft rate were similar for IO anesthesia.
anesthetized (Figure 3). Tbeie were ro signifrcant
Replogle and colleagues,areported 6? perceni
differenc€s between the two techniques ât any of
of her subjects objectively (elechocardiogram
the postiûjection intelvals. Other authors usmg
radlo
recordings) hâd an increased hea.rt rate with the
the Stabident technique as a primary injection
Stabident IO injection of 1.8 mL of 2 percent lido
alsoreporteda decliningrâreofpulpal ane6ilha]
caine with 1:100,000epinephrine. The mean
thesiâ.?'The principâlinvêsriearor
6houldbe
increâse was 28 beats per minute. Chamberlai!
aware of this when using either the Stabident or
forar
and colleaguesafound that the Stabideni IO i4je&
X-tip IO technique as a primary technique. In
andi
pêrcent
tion of2
lidocâinewith l:t00,000
operâtive and restorative procedùres ol 60 minFpinephrine resulred in a mFan heari raæ
utes'duration, the tme valu€ ofthe IO inj€ction
Co
increaêeof 12 beats per minute. Guglielmoand rj
may be its use as a supplemental injection.,orr
Stabi
.i
colleagues11reported tÀat the supplemental
Using 1.8 mL of2 percent lidocâine \À.ith
Stabident IO inj€ctiotr of 1.8 ûI oi either 2 per-rÊ
1: I 00.000epinephrine,
Itreol
Dunbar and colleaqrp"ro
cent lidocâine with 1:100,000epinephrine or 2 i .
and Guelielio ànd ^otteâgl'.sl;;;t*-"'--"
ratior
perceût mepivacaine\rith 1:20,000l€vo
Stâbident IO system in mandibulâr first molars
elrû
resulted in a mean increase in heârt rate of2g
as â supplemental injection to the infedor alve24 beats per minute (as measured with â
ÉA:
JADA,
Vol,134Nov€mber2OO3
I R Ê S E A R C H
) in 80 percent oftheir subjects.Stabile
colleaguesrs
foLnd Lhatthe supplemenrâl
IO
o11.8
mL
of 1.5 perceût etidocâinewith
iection
,000 €pinephrin€ resulted in a mealr hesrt
increæe of 32 beats per minùte (âs meâsured
a pulse oximeter) in 90 percent of their sùbGenerâ[y, all these studies showed that the
rate ætùrned to baseline readings within
ûrinutes
in most patients. Therefore, injecf0ùr:
of
anesthetic
solutions containing vasocontioû
shictors,using either the Stabident or X-tip sysl2ûs,woùld result in â hansient heârt rate
as àas been recor.dedin previous shrdies
increase
ofl0 injections.
Whilethe heart rate incrcasewith the
Stabidentor X-tip IO injection of 2 percent lidotaùewità 1:100,000€pinephrine likely would be
roticedby the pâtient, it would not be clinically
signficantin most healthy patients.I{ Replogle
colleagues' addressedrne clinical sig.ni5Nnd
caaæ,
cardiovasculareffects and contrainditab0ns
to the use ofvasoconstdctorsin IO injecdons.
In patients whose medicâl condition or dr-ug
llrerapiessùggest cautior in administering aneslheticsolutions containing epinephrine or jevo0ûdefrin,3 percent mepivâcainewould be an
Âlt€rnative
for IO injections.It'ô
Ih€ Stabident and X-tip manuals;6 state thât
.
lùerei(a lâck of liD ane.ihe"iawhenthe IO iDjectioûis given. Lip numbress subjectively occurred
ù 100percent of the Stabident injections and in
qlercent ofthe X-tip injections.
Replogleand
oueaguesiand Coggins and colleagues, âlso
Eported
lip ânesthesiâwhen using 1.8 mL of2
Frcenlridorsinewith l:l00.000epinephrjaein a
lùnary Stâbident injection of the mandibùlar
[nimolar. Klein and colleasuest?demonstrât€d
riUrcomputer tomography that a Stabident
urlec!0! of 1.4 mL of a mi-rture of lidocâine with a
ical cortrâst medium, distal to the
frlst molars in dogs,showed
ullary depositionwith considerable
ofsolution from the mental
. This effect mây occur in humans as well
thereby account for the lip numbness (mental
se anesthesia) in the current stlrdy.
!0nceming the €ase of perforation, most
rdFntpel{orarions$ere raredas eas) ,76 per0ftlreiijecrionsr.The subjecri!e impression
opFrâtorexperiencêddu.ing â diÊficutt perfo(24 percent incidence)was that the bone
uore dense or thicker than nolmal. For the
pÊrforar)on.easy pêrforations were rccorded
in 78 percent ofthe perforations.There were no
stâtistical ditrerencesbetween the two techniques. Therefore, even though the X-tip perforaùon wâs performedin a morealicâl locêtion,the
two systems rrerc comp âble clinically in terms
ofease ofpedoration. None ofthe perforatoÉ
broke in either techrrique-that is, there was no
metal fractuÎe. Other aùthoNxqqrLalso reported a
lack ol perforator brcalage with the Stabident
sysiem.
Concerning the ease of guide sleeve removal
with the X-tip system,most were rated as easy
(68 percent ofihe injections). While dilficutt
rclllovâl (32 percent incidence)was basedon time,
it is worth mentioning that in appmnimately five
to se\en subjects/ l2-17 pe.cF.rr,.
gurdeslêêve
removal required both moderate efort and time.
ln one subject,the guide sleeveseparatedftom
the plastic sheâth and a 3-mm metal segment
prcjected from the bone. The principal investigator removed1t wiih Stieglirzfo.cep..This sas
the ûost difficult removal among those peformed
in this study. It is possiblethat the difficult
removals were related to bone density at the
apical location. Futurc studies may determin€ il
the injection site's location in the oral cayity
affects the diJncùlty ofguide sleeveremoval.
No subjects.epolted sFnptoms of a pulpal
nâture postoperatively, and all subjects who
received the IO injection ât the {irst apporntment
had similar baseline pulp test rcadings at th€
subsequent appointment. Other' authon,3.t3 t
hâve reported similar results.
collctustoll
The ûndings of our study indicate that when
pulpal anesthesiais required in a clinical proceduæ involving asfnptomatic mandibular first
molârs, both the Stâbident and X-tip intrâosseous
ânesthetic systemsusing 1.8 mL of2 percent lidocaiûe with 1:100,000epinephrine will prcvide
quick onset of anesthesia (within two minutes)
and an initiâl high râte (93 percent) of anesthesia. The adjacent secondmolar ârld second
prernolar had initial sùccessmtes olg5 percent
and 81 ro 83 pcrcenL.
respecti\ely.Ho*ever,borh
techniques resrited in a steady decline of pùlpal
ânesthesia over 60 minutes.
Concemingthe easeofperforarionÊ.
both systems rcsulted in eâsy perforations in ?6 to ?8 perceût of the subjects. Removal of the guide sleeve
in the X-Lipsyslemsâs raled âs easyin 68 pêrcent ofthe injections. Both systemsresulted in a
IADA,Vol, 134 Novenber2003 tlaO