Clinical Research
A Prospective, Randomized Single-blind Evaluation
of Effect of Injection Speed on Anesthetic Efficacy
of Inferior Alveolar Nerve Block in Patients
with Symptomatic Irreversible Pulpitis
Vivek Aggarwal, MDS,* Mamta Singla, MDS,† Sanjay Miglani, MDS,* Sarita Kohli, MDS,*
and Mohammad Irfan, MDS*
Abstract
Introduction: Speed of injection may affect the solution
spread in the pterygomandibular space. It was hypothe-
sized that speed of injection will affect the anesthetic
efficacy of inferior alveolar nerve block (IANB) in
patients with symptomatic irreversible pulpitis.
Methods: Fifty-nine adult volunteers who were actively
experiencing pain participated in this prospective,
randomized, single-blind study. The patients were
divided into 2 groups on a random basis and received
either slow or rapid IANB with 3.6 mL of 2% lidocaine
with 1:200,000 epinephrine. Endodontic access prepa-
ration was initiated after 15 minutes of the initial
IANB. Pain during treatment was recorded by using
the Heft-Parker visual analogue scale. The primary
outcome measure, and the definition of success, was
the ability to undertake pulp access and canal instru-
mentation with no or mild pain (Heft-Parker visual
analog scale score < 55 mm). Secondary outcome
measure was the solution deposition pain. Statistical
analysis was performed by using Mann-Whitney U
test and c2 test. Results: Slow and rapid injections
gave 43% and 51% success rates, respectively. The
difference was statistically insignificant. Slow injections
produced less solution deposition pain than rapid injec-
tions. Conclusions: Rate of injection has no effect on
anesthetic success of IANB, but slow injections were
more comfortable than rapid injections. (J Endod
2012;38:1578–1580)
Key Words
Anesthetic success, inferior alveolar nerve block,
irreversible pulpitis, speed of injection
From the *Department of Conservative Dentistry and
Endodontics, Faculty of Dentistry, Jamia Millia Islamia, New
Delhi, India; and †SGT Dental College, Gurgaon, India.
Address requests for reprints to Dr Vivek Aggarwal, Depart-
ment of Conservative Dentistry and Endodontics, Faculty of
Dentistry, Jamia Millia Islamia, New Delhi, India 110024.
E-mail address: drvivekaggarwal@gmail.com
0099-2399/$ - see front matter
Copyright ª 2012 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2012.08.006
1578 Aggarwal et al.
E ndodontic management of mandibular posterior teeth usually requires inferior alve-
olar nerve block (IANB) anesthesia. IANB has a high failure rate especially in patients
with inflamed pulpal tissues (1–8). The IANB involves deposition of local anesthesia
solution in pterygomandibular space, thus allowing the solution to spread into the
tissue space and bathe the inferior alveolar nerve just before it enters the
mandibular foramen (9). The spread of the local anesthetic solution toward its neural
target is dependent on various factors including volume of the solution injected and
speed of the injection (1). An increase in the tissue spread will increase the length
of nerve exposed to the anesthetic solution (1). Raymond et al (10) demonstrated
that the incidence of block in a fiber population is directly proportional to the length
of the nerve exposed to the lidocaine.
It has been suggested by Hargreaves and Keiser (1) that an increased speed of
injection will enhance the spread of anesthetic solution and may lead to longer sections
of nerve being exposed to local anesthetic. However, Kanaa et al (11) reported that
’’slow IANB injection produced significantly more episodes of no pulp response than
rapid IANB injection, in mandibular first molars, premolars and lateral incisors.’’
Various authors who were evaluating the effect of injection speed on spread of solution
in medical local anesthetic injections have reported that rapid injections do not influ-
ence the spread of solution (12, 13). The effect of speed of injection while
administrating IANB in patients with pulpal inflammation is poorly described in the
literature.
The purpose of the present prospective, randomized, single-blind study was to
comparatively evaluate the anesthetic efficacy and injection pain of slow and rapid injec-
tions of 3.6 mL of 2% lidocaine with 1:200,000 epinephrine in patients with symptom-
atic irreversible pulpitis.
Materials and Methods
Sixty adult volunteer subjects, who reported in the dental emergency department,
participated in this prospective, randomized, single-blind study. The primary outcome
(end point) was defined as success or failure, which was indicated as the ability to
undertake pulp access and canal instrumentation until apical one-third with no or
mild pain (Heft-Parker visual analogue scale [HP VAS] score < 55 mm). The solution
deposition pain on HP VAS was taken as a secondary outcome of trial. The sample size
calculation consisted of a level type I error of 0.05 for a single-tailed test and b level type
II of 0.20. A power analysis indicated that a sample size of 54 subjects would give 80%
power to detect a 25% difference in the success rate of 2 test groups. A dropout rate of
10% was assumed, and 30 subjects were enrolled in each group. An ethical clearance
was taken from the departmental review committee, and informed written consent was
obtained from each subject.
The inclusion criteria for the study were active pain in the mandibular first or
second molar (>54 mm on the HP VAS of 170 mm) (14), a prolonged response to
cold testing with an ice stick and an electric pulp tester, the absence of any periapical
radiolucency on radiographs except for a widened periodontal ligament, a vital coronal
JOE — Volume 38, Number 12, December 2012

TABLE 1. Comparison of Age, Sex, and Solution Deposition Pain
Age (mean  standard deviation)* (y)
Gender
Solution deposition pain (HP VAS scale) (mean  standard deviation)†
*There was no statistically significant difference between the groups (P > .05).
†
There was a statistically significant difference between the groups (P = .0019).
pulp on access opening, American Society of Anesthesiologists class I or
II medical history, and the ability to understand the use of pain scales.
Exclusion criteria included known allergy or contraindications to any
content of local anesthetic solution, patients who were pregnant or
breastfeeding, history of known or suspected drug abuse, and patients
taking any drugs that could have affected the pain perception. Patients
having active pain in more than 1 mandibular molar were excluded
from the study. The treatment procedure and the use of pain scales
were explained to the patients. The millimeter marks were removed
from the scale, and the scale was divided into 4 categories: no pain
corresponded to 0 mm; faint, weak, or mild pain corresponded to
1–54 mm; moderate pain corresponded to 55–114 mm; and severe
pain corresponded to greater than 114 mm and included strong,
intense, and maximum possible pain (2).
The patients were randomly allocated to 2 treatment groups with
the help of an online random generator that used permuted block strat-
ified randomization protocol (randomization.com). Thirty patients
received slow IANB injections by using 3.6 mL of 2% lidocaine with
1:200,000 epinephrine (Xylocaine; AstraZeneca Pharmaceutical Prod-
ucts, Bangalore, India). The area of injection was dried by using sterile
gauze, and topical anesthesia of 20% benzocaine (Mucopain; ICPA,
Mumbai, India) was applied by using sterile cotton-tip applicator for
60 seconds. The solution was injected via a 5-mL disposable syringe
(Dispo Van, Faridabad, India) with a 31-mm 24-gauge needle (Adis;
Albert David Ltd, Mandideep, India). After reaching the target area, aspi-
ration was performed, and the solution was deposited during a period
of 120 seconds. No anesthetic solution was deposited during needle
insertion and placement. Another 30 patients received rapid IANB injec-
tions. The needle was penetrated as mentioned in the slow group. After
reaching the target area, aspiration was performed, and the solution was
deposited during a period of 30 seconds. The needle was kept in the
same place for another 90 seconds. After needle withdrawal, the
subjects were asked to rate the solution deposition pain on 170-mm
HP VAS.
After 15 minutes, each patient was asked whether his/her lip was
numb. If profound lip numbness was not recorded, the block was
considered unsuccessful, and the patients were excluded from the
study. A conventional access opening was initiated after isolation with
a rubber dam. Patients were instructed to raise their hand if any pain
was felt during the procedure. In case of pain during the treatment,
the procedure was stopped, and patients were asked to rate the pain
on the HP VAS. Success was defined as no pain or weak/mild pain
during endodontic access preparation and instrumentation (HP VAS
score < 55 mm).
The findings were recorded on a Microsoft Excel sheet (Microsoft
Office Excel 2003; Microsoft Corporation, Redmond, WA) for statistical
evaluation by using the program BioEstat (version 4.0; Mamiraua Insti-
tute, Belem, Brazil). Age, gender, and solution deposition pain of the
subjects were summarized by using means and standard deviations.
Multiple comparison analysis of variance (Mann-Whitney U test) and
t tests were used to determine significant differences at P < .05. The
anesthetic success of all groups was compared by using c2 tests.
JOE — Volume 38, Number 12, December 2012
Clinical Research
Slow injections Rapid injections
28.8  4.2; range, 21–35 27.5  4.4; range, 21–37
10 males 12 males
20 females 17 females
73  26 89  23
Results
Sixty adult volunteer subjects, 22 men and 38 women, with an
average age of 28 years and ranging from 21–37 years, participated
in this prospective, randomized, single-blind study. Of the original 60
patients, 1 patient receiving rapid injection did not have profound lip
numbness at 15 minutes and was excluded from the study. The age,
gender, and mean solution deposition pain of all the patients are pre-
sented in Table 1. Categorical representation of solution deposition
pain is presented in Table 2. There was no statistical difference between
the age (P = .22) and gender (P > .05) of patients receiving slow or
rapid injections. All patients included in the study had profound lip
anesthesia after 15 minutes. There was a significant difference in the
solution deposition pain of slow and rapid injection techniques
(P = .019).
The comparison of percentage of patients with successful anes-
thesia (no pain or weak/mild pain during endodontic access prepara-
tion and instrumentation) is presented in Table 3. Slow injections gave
43% success rate (13 of 30 patients), whereas rapid injections gave
51% success rate (15 of 29 patients). There was no significant differ-
ence between the anesthetic success rates of slow and rapid injections
(c2 = 0.0416, P = .52). None of the techniques gave 100% success
rate.
Discussion
Effective pain management during endodontic intervention of
symptomatic mandibular molars often poses a challenge for the clini-
cian (1–8). Single IANB with 1.8 mL of local anesthetic has a high
failure rate in patients with irreversible pulpitis (1). IANB deposits
the solution in the pterygomandibular space. Because of anatomic loca-
tion of mandibular foramen and bony prominence of linguale, the accu-
rate deposition of the local anesthetic solution on neural target may be
limited (9). The solution spreads in the pterygomandibular space
toward the inferior alveolar nerve, thus exposing the nerve to the local
anesthetic.
In the present study, the anesthetic efficacy of speed of injection
was evaluated as success or failure during endodontic management of
symptomatic mandibular molars by using 3.6 mL of 2% lidocaine with
1:200,000 epinephrine. The slow deposition of solution gave 43%
success rate, whereas rapid injection gave 51% success rate, with
no significant difference between the 2 techniques. Kanaa et al
(11) investigated the anesthetic efficacy and solution deposition
discomfort associated with slow (60 seconds) and rapid (15
seconds) IANBs by using 2.0 mL of 2% lidocaine with 1:80,000
epinephrine in healthy adult volunteers. The authors reported that
TABLE 2. Categorical Representation of Solution Deposition Pain
None Mild Moderate Severe
Slow injections 0% 30% (9/30) 60% (18/30) 10% (3/30)
Rapid injections 0% 11% (3/29) 69% (20/29) 20% (6/29)
Effect of Injection Speed on IANB 1579
Clinical Research
TABLE 3. Comparison of Percentages of Successful Anesthesia
Slow injections (%) Rapid injections (%)
Successful 13/30 patients (43) 15/29 patients (51)
anesthesia
There was no significant difference between the groups (P = .52).
there was significant difference in the percentage of volunteers with
no pulp response to maximal pulp tester stimulation after slow and
rapid IANB injections in mandibular molars, with slow injections
providing more episodes of complete pulpal anesthesia than rapid
injections. The authors suggested that slow injection would have
allowed for deeper penetration of local anesthetic into the nerve
trunk. In a crossover design, Whitworth et al (15) evaluated the effect
of speed of injection on efficacy, distribution, and duration of pulp
anesthesia after incisive/mental nerve block in adult volunteers with
asymptomatic teeth by using 2.0 mL lidocaine with 1:80,000 epineph-
rine slowly during 60 seconds or rapidly during 15 seconds. The
authors concluded that the speed of injection does not consistently
influence the efficacy, distribution, or duration of anesthesia after
incisive/mental nerve block injection. There are various confounding
factors in comparing the results of the present study with the results of
Kanaa et al and Whitworth et al. Whereas the present study investi-
gated anesthetic success in inflamed symptomatic pulps with
evaluation of pain during access opening and instrumentation, the
other studies evaluated response of uninflamed pulps by using an
electric pulp tester. Also the dose of solution injected was higher
(3.6 mL versus 2.0 mL) with different epinephrine concentrations
(1:200,000 versus 1:80,000).
An accurate position of the needle near the inferior alveolar nerve
is not always possible, and the solution has to diffuse through mass
movement (spread) toward the nerve trunk to block it. When the solu-
tion is scattered into a large area, the absorption of the solution into the
systemic blood circulation will increase (9, 10). In the present study
there was no significant difference between the anesthetic success of
slow and rapid deposition of solution. A possible explanation of this
could be the volume of the anesthetic solution injected that was used
in the study. The IANB was administered by using 3.6 mL of local
anesthetic. Kohler et al (16) have suggested that 3.6 mL probably fills
the pterygomandibular space more rapidly and provides a higher
concentration of anesthetic solution around the mandibular nerve
trunk with a less dilution effect. Some authors have found statistically
higher success rates with the 3.6-mL volume as compared with
1.8 mL of 2% lidocaine solution (17, 18).
In the present study, slow injection speed produced less solution
deposition pain than rapid rate of injection. Almost 70% of patients in
slow injection group had moderate-to-severe solution deposition pain,
whereas rapid injection produced moderate-to-severe pain in 89% of
patients. McCartney et al (19) retrospectively analyzed 102 IANBs in
patients with irreversible pulpitis by using 1.8–2.2 mL of 2% lidocaine
with 1:100,000 epinephrine. The authors reported that 66%–73% of
patients experienced moderate-to-severe pain during solution deposi-
tion. Although several studies evaluating the solution deposition pain
in healthy volunteers have reported much lower incidence of
moderate-to-severe pain, the higher incidence of pain in the present
study could be attributed to the larger volume of the anesthetic solution
and preoperative pain/anxiety of the patients (11). Because the study is
1580 Aggarwal et al.
a single-blind study, a possible limitation could be the introduction of
systematic bias in the results.
In conclusion, the rate of injection has no effect on anesthetic
success of IANB of 3.6 mL of 2% lidocaine with 1:200,000 epinephrine.
Slow injections were more comfortable and produced less pain than
rapid injections.
Acknowledgments
The authors deny any conflicts of interests related to this
study.
References
1. Hargreaves KM, Keiser K. Local anesthetic failure in endodontics: mechanisms and
management. Endod Topics 2002;1:26–39.
2. Claffey E, Reader A, Nusstein J, et al. Anesthetic efficacy of articaine for inferior alve-
olar nerve blocks in patients with irreversible pulpitis. J Endod 2004;30:568–71.
3. Kanaa MD, Whitworth JM, Meechan JG. A prospective randomized trial of different
supplementary local anesthetic techniques after failure of inferior alveolar nerve
block in patients with irreversible pulpitis in mandibular teeth. J Endod 2012;38:
421–5.
4. Aggarwal V, Jain A, Debipada K. Anesthetic efficacy of supplemental buccal and
lingual infiltrations of articaine and lidocaine following an inferior alveolar nerve
block in patients with irreversible pulpitis. J Endod 2009;35:925–9.
5. Aggarwal V, Singla M, Rizvi A, Miglani S. Comparative evaluation of local infiltration
of articaine, articaine plus ketorolacand dexamethasone on anesthetic efficacy of
inferior alveolar nerve block with lidocaine in patients with irreversible pulpitis.
J Endod 2011;37:445–9.
6. Sampaio RM, Carnaval TG, Lanfredi CB, et al. Comparison of the anesthetic efficacy
between bupivacaine and lidocaine in patients with irreversible pulpitis of mandib-
ular molar. J Endod 2012;38:594–7.
7. Kreimer T, Kiser R 2nd, Reader A, et al. Anesthetic efficacy of combinations of 0.5
mol/L mannitol and lidocaine with epinephrine for inferior alveolar nerve blocks in
patients with symptomatic irreversible pulpitis. J Endod 2012;38:598–603.
8. Parirokh M, Ashouri R, Rekabi AR, et al. The effect of premedication with ibuprofen
and indomethacin on the success of inferior alveolar nerve block for teeth with irre-
versible pulpitis. J Endod 2010;36:1450–4.
9. Coleman RD, Smith RA. The anatomy of mandibular anesthesia: review and analysis.
Oral Surg Oral Med Oral Pathol 1982;54:148–53.
10. Raymond S, Steffensen S, Gugliano L, Strichartz G. The role of length of nerve
exposed to local anesthetics in impulse blocking action. Anesth Analg 1989;68:
563–70.
11. Kanaa MD, Meechan JG, Corbett IP, Whitworth JM. Speed of injection influences effi-
cacy of inferior alveolar nerve blocks: a double-blind randomized controlled trial in
volunteers. J Endod 2006;32:919–23.
12. Triffterer L, Machata AM, Latzke D, et al. Ultrasound assessment of cranial spread
during caudal blockade in children: effect of the speed of injection of local anaes-
thetics. Br J Anaesth 2012;108:670–4.
13. Prakash S, Bhartiya V, Pramanik V, et al. The effect of injection speed on the spinal
block characteristics of hyperbaric bupivacaine 0.5% in the elderly. J Anesth 2010;
24:877–81.
14. Heft MW, Parker SR. An experimental basis for revising the graphic rating scale for
pain. Pain 1984;19:153–61.
15. Whitworth JM, Kanaa MD, Corbett IP, Meechan JG. Influence of injection speed on
the effectiveness of incisive/mental nerve block: a randomized, controlled, double-
blind study in adult volunteers. J Endod 2007;33:1149–54.
16. Kohler BR, Castellon L, Laissle G. Gow-Gates technique: a pilot study for extraction
procedures with clinical evaluation and review. Anesth Prog 2008;55:2–8.
17. Aggarwal V, Singla M, Miglani S, et al. Comparative evaluation of 1.8 mL and 3.6 mL
of 2% lidocaine with 1:200,000 epinephrine for inferior alveolar nerve block in
patients with irreversible pulpitis: a prospective, randomized single-blind study.
J Endod 2012;38:753–6.
18. Yared GM, Dagher FB. Evaluation of lidocaine in human inferior alveolar nerve
block. J Endod 1997;23:575–8.
19. McCartney M, Reader A, Beck M. Injection pain of the inferior alveolar nerve block
in patients with irreversible pulpitis. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 2007;104:571–5.
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