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195]

Original Article

A comparative evaluation of the efficacy of different mandibular

anesthetic techniques in patients with irreversible pulpitis
ABSTRACT
Aim: To determine the most efficacious anaesthetic technique in irreversible pulpitis by comparing the anaesthetic efficacies of Gow-Gates,
Vazirani-Akinosi, Inferior alveolar nerve block with buccal infiltration and conventional Inferior alveolar nerve block (IANB) using 2% Lidocaine
with 1:80,000 epinephrine as the anaesthetic agent in mandibular first molars.
Methodology: 120 patients with inflamed vital pulp and lingering pain on removal of the stimulus were randomly divided into 4 groups in
which the local anaesthetic was administered by the different techniques. Group I (n = 30) Gow-Gates technique. Group II (n = 30) Vazirani-
Akinosi technique. Group III (n = 30) IANB with buccal infiltration. Group IV (n = 30) Conventional IANB. Anaesthesia was considered effective
when ''no pain'' or "mild pain" felt by the patient during access preparation.
Results: The Statistical software used were SAS 9.2, SPSS 15.0, Stata 10.1, MedCalc 9.0.1, Systat 12.0 and R environment ver.2.11.1. The
results demonstrated that the Gow-Gates technique showed greater anaesthetic success (66.7%) followed by Vazirani Akinosi technique (60%)
as compared to the conventional IANB. There was however no statistical significance observed between the groups.
Conclusion: Gow Gates mandibular conduction block may increase the anaesthetic success rates in cases of irreversible pulpitis in mandibular
molars as compared to other techniques.

Keywords: Buccal infiltration, Gow‑Gates mandibular conduction block, inferior alveolar nerve block, irreversible
pulpitis, lidocaine, local anesthesia, Vazirani‑Akinosi technique

INTRODUCTION of 44%–81%.[3,4] The inflammatory changes and anatomical

Dental treatment has been synonymous with pain since time
immemorial, and this is the sole reason why patients are
anxious in seeking it. Administration of local anesthesia is
one of the first clinical procedures before the commencement
of the endodontic treatment. Hence, efficient pain control is
of utmost importance.
variations could be the contributing factors.
It has been shown that combining IANB with buccal
infiltration (BI) provided more effective anesthesia with the
success rates of 65.4% as compared to 14.8% of IANB with
1.8 ml anesthetic solution in irreversible pulpitis.[5]

Rini Sharma, Jayakumar T, Lekha S,

Local anesthetics are highly effective in producing anesthesia
in normal tissue, commonly fail in endodontic cases that
present with an inflamed pulp.[1] The inferior alveolar
nerve block (IANB) has been the most frequently used
local anesthetic technique for the endodontic treatment
of mandibular teeth. [2] Attaining successful mandibular
anesthesia in irreversible pulpitis has been a challenge
for the clinicians as its associated with high failure rates
Srirekha A, Srinivas Panchajanya, Shwetha RS,
Kamal Odedra
Department of Conservative Dentistry and Endodontics,
The Oxford Dental College, Bengaluru, Karnataka, India
Address for correspondence: Dr. Rini Sharma,
Department of Conservative Dentistry and Endodontics, The
Oxford Dental College, Bommanahalli, Bengaluru ‑ 560 068,
Karnataka, India.
E‑mail: rini30@rediffmail.com

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How to cite this article: Sharma R, Jayakumar T, Lekha S, Srirekha A,

DOI:
Panchajanya S, Shwetha RS, et al. A comparative evaluation of the efficacy
10.4103/endo.endo_67_17 of different mandibular anesthetic techniques in patients with irreversible
pulpitis. Endodontology 2018;30:45-9.

© 2018 Endodontology | Published by Wolters Kluwer - Medknow 45

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Sharma, et al.: Anesthetic efficacy in irreversible pulpitis

The limited success rate of the conventional IANB led to the The null hypothesis of this study was that there would be
development of alternative techniques such as Gow‑Gates no difference in the efficacy of the anesthesia achieved
mandibular nerve block and Vazirani‑Akinosi technique.[6] The irrespective of the technique of administration of local
Gow‑Gates technique involves a wide mouth opening that is anesthesia for the mandible.
not feasible in patients with reduced mouth opening or any
extra oral swelling diminishing extra oral landmarks. Often in MATERIALS AND METHODS
clinical practice, patients present with endodontic emergencies
and have reduced mouth opening.[7] Akinosi, therefore, One hundred and twenty systemically, healthy adult patients
developed a closed mouth technique for such patients.[8] who had been referred to the Department of Conservative
Dentistry and Endodontics, diagnosed with irreversible
There has been a scarcity of studies comparing the pulpitis of mandibular first molars requiring emergency
different anesthetic techniques in irreversible pulpitis. [9] root canal therapy were selected for the study. Based on the
Hence, the purpose of this randomized clinical study was previous literature on outcome variables on pain score with
to determine the most efficacious anesthetic technique minimum difference of any pair‑wise group, 90% statistical
for irreversible pulpitis cases by comparing the anesthetic power and 5% level of significance, the sample size of 120
efficacies of Gow‑Gates mandibular conduction block, was selected for the study with thirty patients in each of the
Vazirani‑Akinosi technique, IANB with BI and conventional four groups.[10]
IANB (control) using 2% lidocaine with 1:80,000 epinephrine
as the anesthetic agent in mandibular first molars. The participants were experiencing pain and not taking
any medication that would alter pain perception. Ethical
Table 1: Comparison of postinjection pain/discomfort in four clearance was sought from the College Review Committee,
groups studied and an informed consent was obtained from each participant.
Pain comfort Group I Group II Group III Group IV Total (%) Preoperative radiographs were obtained.
(%) (%) (%) (%)
No pain 15 (50) 10 (33.3) 10 (33.3) 9 (30) 44 (36.7)
The inclusion criteria for the study were active pain in a
Mild pain 5 (16.7) 8 (26.7) 4 (13.3) 4 (13.3) 21 (17.5)
Moderate pain 4 (13.3) 7 (23.3) 10 (33.3) 9 (30) 30 (25)
mandibular molar; prolonged response to cold testing with an
Severe pain 6 (20) 5 (16.7) 6 (20) 8 (26.7) 25 (20.8) ice stick and an electric pulp tester (Digitest: model number
Total 30 (100) 30 (100) 30 (100) 30 (100) 120 (100) D626D, Parkell Inc., Brentwood, New York, USA); absence of
P=0.605, not significant, Fisher’s exact test any periapical radiolucency on radiographs, except a widened
periodontal ligament; a vital coronal pulp on access opening;
Table 2: Successful anesthesia and patient’s ability to understand the use of pain scales.
Successful Group I Group II Group III Group IV Total (%)
anesthesia (%) (%) (%) (%) Before initiating the treatment, the patients were asked to
Successful 20 (66.7) 18 (60) 14 (46.7) 13 (43.3) 65 (54.2) rate their pain on a 170 mm Heft–Parker visual analog scale
anesthesia
(HP VAS). The millimeter marks were removed, and the scale
Not successful 10 (33.3) 12 (40) 16 (53.3) 17 (56.7) 55 (45.8)
anesthesia was divided into four categories: “no pain” corresponded to
Total 30 (100) 30 (100) 30 (100) 30 (100) 120 (100)
P=0.222, not significant, Chi‑square test 70 Successful Anesthesia

Not Successful Anesthesia

60
50 PostComfort
45
50
40 No pain
35 Mild pain 40
Percentage

30
Percentage

Moderate pain
25 30
Severe pain
20
20
15
10 10
5
0 0
Group I Group II Group III Group IV Group I Group II Group III Group IV

Graph 1: Comparison of postinjection pain/discomfort in four groups Graph 2: Comparison of successful anesthesia among the groups

46 Endodontology / Volume 30 / Issue 1 / January‑June 2018

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Sharma, et al.: Anesthetic efficacy in irreversible pulpitis
0 mm; “faint, weak, or mild” pain to 0–54 mm; “moderate”
pain to 55–114 mm; and “strong, intense, and maximum
possible” pain to more than 114 mm [Table 1 and Graph 1].[9]
The patients were randomly allotted into four groups
with thirty patients each. Group IV patients received
standard IANB injections using 2% lignocaine with 1:80,000
epinephrine (LIGNOx 2% A, Warren). The solution was injected
using 27‑gauge long needles (Unlock, Hindustan Syringes and
Medical Devices). After reaching the target area, aspiration
was performed, and 2.2 mL solution was deposited at a rate
of 1 mL/min.
Group I received Gow‑Gates mandibular conduction block
anesthesia. The patient was asked to widely open his/her
mouth. A line was imagined from the intertragic notch to
the angle of the mouth, along which the needle was inserted
across the mesiopalatal cusp of the ipsilateral upper second
molar keeping the syringe parallel to the divergence of
the tragus. The needle was advanced until bony contact at
condylar head was made, withdrawn slightly, aspiration was
performed, and 2.2 mL anesthetic solution was deposited.
The patient was asked to keep his mouth open for a further
2 min.
Group II received Vazirani‑Akinosi closed‑mouth anesthesia.
The ipsilateral cheek was retracted while the patient’s mouth
was closed, and the solution was injected by advancing
the needle parallel to the occlusal plane at the level of the
maxillary mucogingival junction. The needle was advanced
until the hub was level with the distal surface of the maxillary
second molar. After aspiration, 2.2 mL anesthetic solution
was deposited.
Group III received IANB with BI of 2% lignocaine with 1:80,000
epinephrine. After administration of 2.2 mL of anesthetic by
the IANB, a BI of 1.1 mL of anesthetic solution is deposited.[9]
After administration of the anesthetic agent, the patient was
asked if his or her lip was numb. If profound lip numbness
was not recorded within 15 min, the block was considered
to be unsuccessful, and the patients were excluded from the
study. No response from the patient at the maximum output
current flow from the pulp tester was used as the criteria for
pulpal anesthesia.
Patients were instructed to raise their hand if any pain was
felt during the endodontic access preparation. In the case of
pain, the procedure was stopped, and patients were asked to
rate the pain on HP VAS. Anesthesia was considered effective
when there was “no pain” or “mild pain.”
Endodontology / Volume 30 / Issue 1 / January‑June 2018
RESULTS
Statistical analysis of collected data: The collected data were
subjected to statistical analysis using the ANOVA, Student’s
t‑test, Chi‑square, and Fisher’s exact tests P < 0.05. The
statistical software, namely, SAS version 9.2, SPSS version
15.0, Stata version 10.1, MedCalc version 9.0.1, Systat version
12.0, and R environment version 2.11.1 (IBM, USA) was used
for the analysis of the data.
One hundred and twenty adult volunteer participants, 59 men
and 61 women, with an average age of 30 years, participated
in this study. The samples were age‑ and gender‑matched
with P = 0.951 and 0.224, respectively.
Patients reported with a mean initial pain value (VAS score)
of 107.62 ± 37.48 that indicated moderate‑to‑severe pain.
The comparison of the initial pain values in the four groups
showed no statistical significance with P = 0.859.
The percentage of successful anesthesia was highest in Group
I with 66.7% followed by Group II (60%) and Group III (46.7%).
In Group IV (control), the percentage of successful anesthesia
was the least at 43.3% [Table 2 and Graph 2]. There was no
statistical significance with P = 0.222 between the groups
studied; hence, the null hypothesis of the study was accepted.
DISCUSSION
An important requirement before initiating any endodontic
procedure is the ability to achieve and maintain profound
pulpal anesthesia as it helps reduce patient anxiety and
improves the operator’s comfort and efficiency.
Perception and transmission of endodontic pain is carried out
by C and A delta fibers.[11] The nociceptors are activated by
mild temperature or pH changes in an inflamed pulp as their
activity is modified by inflammatory mediators (prostaglandins
and kinins). Hence, the pain experienced during irreversible
pulpitis is considerably greater in intensity.
As mandible has a thick and nonporous outer cortical plate,
nerve blocks are administered at a site away from the teeth
being treated.[6] Patients with irreversible pulpitis have
shown eight times higher rates of anesthetic failures than the
normal individuals.[12] The incidence of mechanical‑allodynia
in patients presenting with irreversible pulpitis was 57.2%.
Root canal treatment in teeth with irreversible pulpitis is
significantly more painful as compared to teeth with normal
or necrotic pulps due to reduced mechanical pain threshold
associated with mechanical‑allodynia.[13]
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Sharma, et al.: Anesthetic efficacy in irreversible pulpitis
Lidocaine hydrochloride is the gold standard for comparison
given its efficacy, low allergenicity, minimal toxicity, and
safety.[14] Despite the growing popularity of articaine for
mandibular anesthesia, lidocaine was preferred in the present
study due to the potential complications of articaine such as
paresthesia and the supporting evidence of studies showing
that there is no difference in anesthetic efficacy between
2% lidocaine and 4% articaine in healthy or inflamed lower
molars after IANB.[15,16]
Kohler et  al. have shown that 1.8 mL local anesthetic
solution is ineffective in providing adequate anesthesia with
Gow‑Gates mandibular conduction block.[17] Dr. Gow‑Gates
advocated a slightly greater volume of solution, and it is said
to aid in the high success of this technique.[6] Hence, in the
present study, a volume of 2.2 mL local anesthetic solution
was used instead of the standard 1.8 mL cartridges, in all
the groups for standardization. In Group III, an additional
1.1 mL of lidocaine was administered for BI following the
conventional IANB.[9]
In the present study, Group IV showed the least successful
anesthesia. This was in accordance with the findings of
the previous studies that reported failure rates of 44%–81%
in irreversible pulpitis. [3,4] This could be explained by
cross and accessory innervations by lingual, buccal, and
mylohyoid nerves or cervical plexus;[12] decrease in local
pH;[12] tachyphylaxis to anesthetic solutions;[12] activation
of nociceptors such as tetrodotoxin and capsaicin‑sensitive
transient receptor–potential vanilloid type 1.[12,18] Other
factors such as needle deflection have also been implicated.
The peripheral afferent neurons have voltage‑gated channels,
transient receptor–potential channels, pain‑modulating
opioid and G protein – coupled receptors along their
length.[12,18] Gow‑Gates and Vazirani‑Akinosi techniques have
shown a higher likelihood of bathing an accessory branch
of the inferior alveolar nerve with local anesthetic, as they
result in the drug being administered at a site higher than
that accomplished by the traditional IANB.[6]
In the present study, Group I gave a higher success rate than
conventional IANB. The site of solution deposition being
higher than that in conventional IANB and gravity aids in the
diffusion of the solution in an inferior direction that fills the
pterygomandibular space till the buccinator.[19] The length of
nerve exposed to anesthetic solution is significantly greater
as compared to the conventional IANB,[8,19] thus increasing
the number of voltage‑gated channels being exposed to
local anesthetic solution. Major limitations with Gow‑Gates
are the operator’s learning curve, dependence on extra oral
48 Endodontology / Volume 30 / Issue 1 / January‑June 2018
landmarks, and hematoma formation in case of accidental
injury to maxillary artery.
Vazirani‑Akinosi technique presented with a success rate of
60%. The higher success rate of this technique as compared
to the conventional IANB in cases of irreversible pulpitis
was in accordance with previous studies.[9,20] This technique
is particularly indicated if there is a history of IANB failure,
evidence of anatomical variability and accessory innervation,
trismus or a difficult visualization of the intraoral landmarks
for IANB.[6] The difficulties associated are the location of the
intraoral landmarks when the patient’s mouth is closed[6] and
the absence of a bony contact end‑point.[9]
In the present study, Group III showed a success rate of
46.7% which was higher than that of the control but lower
as compared to the Groups I and II; this was in accordance
with the previous studies.[21,22] Supplemental infiltrations
have shown to increase the success rates in patients with
irreversible pulpitis.[23‑25] Of the various reasons that could
be stated for the success of supplemental BI following IANB
in mandibular molars, the mental foramen and the multiple
minor perforations present in the body of the mandible aid
in the diffusion of the anesthetic solution into the cancellous
space.[25]
The drawbacks of this study include the dependence on the
patient’s perception and threshold for pain and the operator’s
skill in following the correct anesthetic technique. Further
clinical studies are warranted using different anesthetic
agents for these techniques.
CONCLUSION
Within the limitations of the present study, it can be
concluded that Gow‑Gates mandibular conduction block
may increase the anesthetic success rates in cases of
irreversible pulpitis in mandibular molars. However, none
of the techniques evaluated gave acceptable success rates.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. Meechan JG. Supplementary routes to local anaesthesia. Int Endod J
2002;35:885‑96.
2. Nusstein J, Reader A, Nist R, Beck M, Meyers WJ. Anesthetic efficacy of
the supplemental intraosseous injection of 2% lidocaine with 1:100,000
epinephrine in irreversible pulpitis. J Endod 1998;24:487‑91.
[Downloaded free from http://www.endodontologyonweb.org on Wednesday, November 21, 2018, IP: 114.125.124.195]
Sharma, et al.: Anesthetic efficacy in irreversible pulpitis
3. Ingle JI, Bakland LK. Preparation for endodontic treatment. In:
Endodontics. 5th ed. Hamilton, ON: BC Decker; 2002.
4. Matthews R, Drum M, Reader A, Nusstein J, Beck M. Articaine for
supplemental buccal mandibular infiltration anesthesia in patients with
irreversible pulpitis when the inferior alveolar nerve block fails. J Endod
2009;35:343‑6.
5. Parirokh M, Satvati SA, Sharifi R, Rekabi AR, Gorjestani H, Nakhaee N,
et al. Efficacy of combining a buccal infiltration with an inferior alveolar
nerve block for mandibular molars with irreversible pulpitis. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 2010;109:468‑73.
6. Haas DA. Alternative mandibular nerve block techniques: A review of
the Gow‑Gates and Akinosi‑Vazirani closed‑mouth mandibular nerve
block techniques. J Am Dent Assoc 2011;142 Suppl 3:8S‑12S.
7. Akinosi JO. A new approach to the mandibular nerve block. Br J Oral
Surg 1977;15:83‑7.
8. Meechan JG. How to overcome failed local anaesthesia. Br Dent J
1999;186:15‑20.
9. Aggarwal V, Singla M, Kabi D. Comparative evaluation of
anesthetic efficacy of Gow‑Gates mandibular conduction anesthesia,
Vazirani‑Akinosi technique, buccal‑plus‑lingual infiltrations, and
conventional inferior alveolar nerve anesthesia in patients with
irreversible pulpitis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2010;109:303‑8.
10. Suresh KP, Chandrasekhar S. Sample size estimation and power analysis
for clinical research studies. J Hum Reprod Sci 2012;5:7‑13.
11. Ikeda H, Tokita Y, Suda H. Capsaicin‑sensitive A delta fibers in cat tooth
pulp. J Dent Res 1997;76:1341‑9.
12. Owatz CB, Khan AA, Schindler WG, Schwartz SA, Keiser K,
Hargreaves KM, et al. The incidence of mechanical allodynia in patients
with irreversible pulpitis. J Endod 2007;33:552‑6.
13. Hargreaves KM, Keiser K. Local anesthetic failure in endodontics:
Mechanisms and management. Endod Topics 2002;1:26‑39.
14. Malamed SF. Handbook of Local Anesthesia. 5th ed. St. Louis: CV
Mosby; 2004.
15. Tortamano IP, Siviero M, Costa CG, Buscariolo IA, Armonia PL.
A comparison of the anesthetic efficacy of articaine and lidocaine in
Endodontology / Volume 30 / Issue 1 / January‑June 2018
patients with irreversible pulpitis. J Endod 2009;35:165‑8.
16. Claffey E, Reader A, Nusstein J, Beck M, Weaver J. Anesthetic efficacy
of articaine for inferior alveolar nerve blocks in patients with irreversible
pulpitis. J Endod 2004;30:568‑71.
17. Kohler BR, Castellón L, Laissle G. Gow‑Gates technique: A pilot study
for extraction procedures with clinical evaluation and review. Anesth
Prog 2008;55:2‑8.
18. Chaudhary P, Martenson ME, Baumann TK. Vanilloid receptor
expression and capsaicin excitation of rat dental primary afferent
neurons. J Dent Res 2001;80:1518‑23.
19. Gow‑Gates GA. Mandibular conduction anesthesia: A new technique
using extraoral landmarks. Oral Surg Oral Med Oral Pathol
1973;36:321‑8.
20. Goldberg S, Reader A, Drum M, Nusstein J, Beck M. Comparison of
the anesthetic efficacy of the conventional inferior alveolar, Gow‑Gates,
and Vazirani‑Akinosi techniques. J Endod 2008;34:1306‑11.
21. Parirokh M, Satvati SA, Sharifi R, Rekabi AR, Gorjestani H, Nakhaee N,
et al. Efficacy of combining a buccal infiltration with an inferior alveolar
nerve block for mandibular molars with irreversible pulpitis. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 2010;109:468‑73.
22. Fan S, Chen WL, Pan CB, Huang ZQ, Xian MQ, Yang ZH, et al.
Anesthetic efficacy of inferior alveolar nerve block plus buccal
infiltration or periodontal ligament injections with articaine in patients
with irreversible pulpitis in the mandibular first molar. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 2009;108:e89‑93.
23. Aggarwal V, Jain A, Kabi D. Anesthetic efficacy of supplemental buccal
and lingual infiltrations of articaine and lidocaine after an inferior
alveolar nerve block in patients with irreversible pulpitis. J Endod
2009;35:925‑9.
24. Yadav S. Anesthetic success of supplemental infiltration in mandibular
molars with irreversible pulpitis: A systematic review. J Conserv Dent
2015;18:182‑6.
25. Jena A, Shashirekha G. Effect of preoperative medications on the
efficacy of inferior alveolar nerve block in patients with irreversible
pulpitis: A placebo‑controlled clinical study. J Conserv Dent
2013;16:171‑4.
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