Intranasal anesthetic spray for maxillary anterior teeth

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1 Research Article Intranasal anesthetic spray for maxillary anterior teeth Gayathri R. Menon, James David Raj* ABSTRACT Aim: The aim of this study is to analyze the effect of intranasal anesthetic spray for maxillary anterior teeth. Objective: The objective of this study is to determine and assess the effect of intranasal anesthetic spray for maxillary anterior teeth. Materials and Methods: Thirty patients having mild-to-moderate endodontic pain were selected, of which 15 patients receiving intranasal (IN) anesthetic spray and the next 15 receiving infiltration. Baseline pain level was noted before the spray was given and pain level was noted 30 min after administration of the spray. Result: From this study, it was evident that there is a significant in the visual analog scale score infiltration and IN anesthetic spray. Conclusion: The pilot clinical study shows that the post-operative effects of IN lignocaine can be used as an adjuvant for performing maxillary anterior root canal therapy. KEY WORDS: Endodontic pain, Infiltration, Intranasal spray, Lignocaine INTRODUCTION Anxiety is the frequent basis of dental fear. Local anesthetics in dentistry have been categorized as amides, i.e., lignocaine, mepivacaine, prilocaine, and esters which are cocaine, benzocaine, procaine, tetracaine, and butacaine. [1] They are chemicals that will block the nerve conduction in a specific, temporary, and reversible manner without affecting the patient s consciousness. [2] Local anesthesia forms the backbone of pain control techniques in the dental profession. Local anesthetics represent the safest and most effective method for managing pain associated with dental treatment. [3] They are the only drugs that prevent the nociceptive impulse from reaching the patient s brain. The science of controlling odontogenic pain is progressing as does the understanding of the mechanisms of pain detection, processing, and perception. [4] Pain has been described as a complex multidimensional and biopsychosocial event, which has individualized objective and subjective events, making the perception of pain very different between individuals. [5] Anesthesia within the dental profession is typically administered orally which has the main disadvantage Access this article online Website: jprsolutions.info ISSN: of decreased absorption rates and delayed onset. Anesthesia administered through parenteral routes has increased drug absorption and shorter times of onset. Intranasal (IN) drug delivery takes advantage of a large surface area of mucosal tissue in the nasal and sinus cavities for rapid absorption into the bloodstream. [6] Lignocaine is commonly referred to as lidocaine. It is an amide local anesthetic agent. [7] Lignocaine that has shown high efficacy in inhibiting cyclooxygenase enzymes and controlling pain is indicated for the management of moderate-to-severe acute pain. The half-life of lignocaine is 4 6 h, and it is metabolized in the liver. None of the metabolites possesses significant anesthetic efficacy. [8] Lignocaine has anesthetic efficacy that is similar to standard dosages of morphine and meperidine. [9] Due to its efficient ability to control inflammatory pain, lignocaine has been shown to decrease the need for opioids post-operatively. [10] Various techniques to give a maxillary anesthesia are as follows: Supraperiosteal injection, posterior superior alveolar (PSA) nerve block, middle superior alveolar (MSA) nerve block, infraorbital nerve block, palatal anesthetic, greater palatine nerve block, and nasopalatine nerve block. Supraperiosteal Injection Supraperiosteal injection is also known as local infiltration and is the most frequent technique for Department of Conservative and Endodontics, Saveetha Dental College, Saveetha University, Chennai, Tamil Nadu, India *Corresponding author: Dr. James David Raj, Department of Conservative and Endodontics, Saveetha Dental College, Saveetha University, Chennai , Tamil Nadu, India. Phone: jamesdraj@gmail.com Received on: ; Revised on: ; Accepted on:

2 obtaining pulpal anesthesia for maxillary teeth. Although it is a simple procedure with a high success rate, there are various reasons for using other techniques whenever more than two or three teeth are involved in the treatment. The nerves that are anesthetized are large terminal branches of Figure 1: Application of intranasal anesthesia dental plexus. The region that is innervated by the large terminal branches of plexus, pulp, and root of the tooth, buccal periosteum, connective tissue, and mucous membrane are anesthetised. It is mainly used to provide pulpal anesthesia of the maxillary teeth when treatment is limited to one or two teeth. It is contraindicated in areas where there is infection or acute inflammation and dense bone covering the apices of the teeth. PSA Nerve Block PSA nerve block is one of the most commonly used nerve blocks to anesthetize maxillary teeth. Even though it is a successful procedure, several issues should be weighed when its use is considered, which include the extent of anesthesia produced and the potential for hematoma formation. When it is used to achieve pulpal anesthesia, the PSA nerve block is effective for maxillary third, second, and first molars. However, the mesiobuccal root of the maxillary first molar is not consistently innervated by the PSA nerve. It is also known as tuberosity block or zygomatic block. It will anesthetize PSA and branches. It anesthetizes pulps of maxillary third, second, and first molars (mesiobuccal root is not anesthetized). It is indicated when the treatment involves two or more maxillary molar, when supraperiosteal injection is contraindicated, and when supraperiosteal injection has proved ineffective. In case of high risk of hemorrhage instead of PSA, supraperiosteal or periodontal ligament injection is recommended. MSA Nerve Block MSA nerve is present in only 28% of population, therefore, limiting the clinical usefulness of this block. Figure 2: Access opening Figure 4: Visual analog scale Figure 3: Local anesthesia Figure 5: Mean visual analog scale pain scale 3031

3 If the infraorbital nerve block does not provide adequate anesthesia to the teeth distal of the canine or if the PSA injection does not provide anesthesia for the mesiobuccal root of the first molar, an MSA block injection should be administered. It anesthetizes pulps of maxillary first and second premolar and buccal periodontal tissues and bone over these same teeth. It is contraindicated in areas where there is an infection or acute inflammation and when there is no MSA nerve present. Infraorbital Nerve Block/Anterior Superior Alveolar (ASA) Nerve Block ASA provides profound pulpal anesthesia from the maxillary central incisor through the premolars in about 72% of patients. It is used in place of supraperiosteal injection. The ASA nerve block necessitates a smaller volume of local anesthesia ml versus 3.0 ml of supraperiosteal injection of the same teeth. It will anesthetize ASA, MSA, infraorbital nerve, inferior palpebral, lateral nasal, and superior labial. It anesthetizes pulps of maxillary central incisor through the canine on the injected side. In about 72% of patients, it anesthetizes pulps of maxillary premolars and mesiobuccal root of the first molar. It is contraindicated in discrete treatment areas and hemostasis of localized areas. Palatal Anesthesia Anesthesia of the hard palate is necessary for dental procedures involving manipulation of palatal soft or hard tissue. For many dental patients, palatal injection proves to be a very traumatic experience. Greater Palatine Nerve Block The greater palatine nerve innervates the palatal tissues and the bone distal to the canine on the side anesthetized. Minimum volume of solution provides profound hard and soft tissue anesthesia. Although potentially traumatic, the greater palatine nerve block is less so than the nasopalatine nerve block because tissues surrounding the greater palatine foramen are not as firmly adherent to bone and therefore are better able to accommodate the volume of solution deposited. It is also known as anterior palatine nerve block. It will anesthetize posterior portion of the hard palate and its overlying soft tissue anteriorly as far as the first premolar and medially to the midline. It is indicated when a palatal soft tissue anesthesia is necessary for a restorative treatment for more than two teeth and to control the pain during periodontal or oral surgical procedure involving the palatal soft and hard tissue and contraindicated when there are infection and inflammation at the site of injection site and smaller areas of therapy. Nasopalatine Nerve Block It is an invaluable technique for palatal pain control in that, with the administration of a minimum volume of anesthetic solution, a wide area of palatal soft tissue anesthesia is achieved. It is also known as incisive nerve block or sphenopalatine nerve block. It anesthetizes nasopalatine nerves bilaterally. The areas which get anesthetized are the anterior portion of the hard palate bilaterally from mesial of the right first premolar to mesial of the left first premolar. It is indicated when palatal soft tissue anesthesia is necessary and for pain control during periodontal or oral surgical procedures involving palatal soft and hard tissue. It is contraindicated when there is infection or inflammation and smaller area of therapy. [11] The purpose of this study was to evaluate the efficacy of IN lignocaine for the management of endodontic pain. The specific aims of this study were two-fold: 1. To compare the pre-operative anesthetic efficacy of the IN administration of lignocaine with placebo 2. To compare the post-operative anesthetic efficacy after IN lignocaine or placebo. MATERIALS AND METHODS Patients reporting to the clinic with a complaint of endodontic pain were selected for this study. The inclusion criteria were as follows: years and above 2. Reposted with a pain level 4 or greater in visual analog scale (VAS) 3. Patient having irreversible pulpitis. The exclusion criteria were as follows: 1. Asthma patients 2. pregnant ladies 3. Cardiovascular disease 4. If patients had difficulty or was unable to use nasal spray. Patients presenting to the clinics reporting endodontic pain on the verbal numeric scale at a level of 3 or greater out of 10 were screened as possible candidates for the study. Before starting the treatment, the patient was asked to sign the consent form for the study participation and also for root canal treatment. A proper clinical examination was done including the inside of the nose to ensure that there was no redness or swelling indicating inflammation. The patient was asked to fill the questionnaire consisting of VAS which has a horizontal line measuring 0 10 with 0 representing no pain and 10 representing the worst pain. Thirty patients experiencing mild-to-severe endodontic pain were selected to receive IN spray treatment with infiltration (n=15) and IN lignocaine (n=15) 30 min before endodontic treatment was started and immediately after the completion of endodontic treatment. Baseline pain levels were recorded before IN treatment. Lignocaine spray was used as a nasal spray for this study. There should not be air bubble 3032

4 formed in the spray. The spray should be pushed hard and fast to expel the spray in half a second or less. For an adult patient 2, IN spray was been given. Each spray has been given with a 4 5 min gap. One additional spray is given if adequate anesthesia has not been achieved 10 min after the second spray. The spray must be administered into the nasal cavity on the same side, i.e. ipsilateral as the planned dental procedure. The first spray should be given horizontal at approximately 90 angle so that it passes through the inferior meatus. The second spray should be given at approximately 45 angulation so that it passes through the middle meatus. Pain levels were recorded at 15 and 30 min after the initial IN dosing (before endodontic treatment) and 30 min after completion of endodontic treatment. RESULTS [Tables 1 and 2] 30 patients were enrolled in this study, of which, 15 patients were given IN anesthetic spray and the other 15 were given infiltration. The level of pain that was analyzed using VAS showed that, of the 15 patients who were given IN anesthetic spray, 14 patients scored the pain level from 6 to 8 in the VAS, whereas 1 patient gave the score as 9. A significant was detected between the two study groups in the average change in the pain scores from baseline and after the administration of IN spray. From this study, it was evident that there is a significant in the VAS score for infiltration and IN anesthetic spray. DISCUSSION In order to manage the pain during an endodontic procedure has always been a challenge and an area of continued interest. There are a number of local anesthetic agents that have been assessed for its efficiency, and there are various recent advancements in the method of administering it. [12] The most common problem that remains in dentistry is the patients fear of needles. Various clinical trials on the use of nasal spray to provide pulpal anesthesia for the maxillary anterior teeth are ongoing. IN spray has got plenty of advantages such as it helps in reducing the anxiety that is caused due to the dental injection, it would decrease the risk of disease associated with contaminated needles, and the nasal anesthesia would lower the number of patients complaint of lip swelling after the dental treatment. From this study, when comparing the change in the pain from the baseline levels to 30 min after administering IN anesthetic spray of lignocaine group showed a significant reduction in the pain. NSAIDs have been used to control the predominant inflammatory nature of the endodontic pain. The most convenient method to deliver anesthesia in a dental office is through oral route. The oral route has got various disadvantages including unpredictable absorption patterns, first-pass hepatic effect, and delayed onset. [13] CONCLUSION The pilot clinical study shows that the post-operative effects of IN lignocaine can be used as an adjuvant for performing maxillary anterior root canal therapy as larger surface area aids in faster absorption of local anesthesia and is pain free as it involves no syringes for delivering it. The clinical application of the present study could include the use of IN lignocaine pre-operative for a sustained pain relief post-operatively. Further study in the area of IN lignocaine for the control of endodontic pain should include a single higher dose of lignocaine. Table 1: Group statistics Group n Mean Standard deviation Standard error mean VAS scale Intranasal spray Infiltration VAS: Visual analog scale Table 2: Independent samples test VAS scale Equal variances assumed Equal variances not assumed Levene s test for equality of variances t test for equality of means F Significance t df Significance (2 tailed) Mean Standard error 95% Confidence interval of the Lower Upper

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