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Periodontai ligament anesthesia - A clinical evaluation

Eriksen HM, Aamdal H, Kerekes K. PeriodonLal ligamenL anesthesia. A clinical evaluaLion. Endod Dent TraumaLoI 1986; 2: 267-269. AbsLract ~ PeriodonLal ligamenL (PDL) injecLion was used either as an alternative or as a supplement Lo conventional anesLhesia techniques (CA) in connecLion with endodontic irealment of 339 teeth. Adequate analgesia was obtained more irequenLly wiLh CA than wiLh PDL. However, total lack of effecL was registered only in a few cases for boLh Lechniques. PDE was found Lo be of parLicular value in Lhe mandibular posLerior segmenLs where convenLional Lechniques mosL frequenLly failed. Pain control during dental treatment is generally achieved by local anesthesia. Local infiUraLion and local block anesthesia are ihe mosL commonly used meLhods. Local infiltration is usually sufficient in maxilla and the mandibular anLerior regions while mandibular block anesLhesia is regularly applied for Lhe posLerior mandibular segmenLs. However, conventional methods may have some untoward side-effects. Unnecessary soft tissue analgesia may lead to biLe wounds in children and mentally retarded persons. Accidental damage to nerve trunks or blood vessels may occur resulting in paresthesia or hematoma. In addition, fairly large doses mighL be applied in order to obLain suOicient analgesia of the desired region. Periodontai ligamenl injection has been introduced in order to reduce the side-effects linked to convenLional Lechniques. Thin (30 gauge) needles are inserted into the gingival crevice towards the peridontal ligamenL. The anesLhelic solution is injected with pressure in order Lo obtain diffusion around the root. Several investigations conclude lavorably for periodonlal ligament anesLhesia (1-7) and hisLologic invesLigaLions have shown minor Lissue damage (1,8-10). FurLhermore, Lhe advantage of seleclive anesthesia as a diagnostic Lool is emphasized (5, 11). However, pulpal ischemia has been reported (12). This may render the pulp vulnerable to damage of iatrogenic origin. The purpose of ihe present investigation was Lo evaluate the effecLiveness of periodonLal ligamenL anesthesia when used by supervised denLal students. The method was evaluated either as an ahernative or as a supplement to conventional techniques in connection with endodonLic LreatmenL. Harald M. Erihsen, Hilde Aamdal and Kasmer Kerekes
Oepartmenf of Operative Dentistry and Endodontics, Dental Factilty, University of Oslo, Oslo, Norway

Key words: denfal anesthesia, periodonfal ligament. Harald M. Eriksen, Odontologiklinikkene, P.O.Box 1109 Blindern, 0317 Oslo 3, Norway. Accepted for publication 28 April 1986.

Material and methods The invesLigaLion included 339 teeth in paLients referred for endodonLic treaLment at the Department of Endodontics, DenLal Faeulty, Universily of Oslo. All tooth groups were represented and the LeeLh had fully developed rools and viLal pulps. Periodontai ligamenL injecLion was arbiLrarily chosen in 135 cases and conventional anesthesia techniques in 127 cases. In addition, periodonLal ligamenL injection was used as a supplement in 88 cases during a prolonged investigation period when adequate responses were not obLained by convenLional techniques. The responses were classified as adequaLe: pulpeetomy could be performed without pain; partial: pulpecLomy could be performed with Lolerable discomforL; unacceptable: pulpeetomy could not be performed due Lo intolerable pain. Ligmaject was used for Lhe periodontai ligament injection. Xylocaine 2Omg7ml with Adrenaline 1: 50 000 was used routinely. In a few cases where vasoconstrictor was conLraindicated, Carbocaine dental 30mg/ml was applied. A quesLionnaire evaluaLing Lhe aLLiLude of both operaLors and patients Lowards periodontai ligament injection was also included in the invesdgation. Results The overall results are given in Table 1. AdequaLe response was obtained in 78% of Lhe 127 teelh anesthetized wilh conventional techniques while an adequate response was obtained in only 61% of the 135 teeth treated with periodonfal ligament injection. This difference was found to be statistically 267

Eriksen et al.
Table 1. The results of periodonfal Iigamenf (POL) injection compared wifh convenfional anesthesia fechniques (CA) and POL used as a supplemenf when CA failed (CA + POL). The responses fo CA + PDL was regisfered over a prolonged period. The difference befween PDL and CA was sfafisfically significanf (0.01 < p < 0 . 0 2 for )c^=9.05) using chi-square fesf. Results of anesfhesia, all foofh groups included Adequafe POL CA CA + POL Partial Unaccepfable

pain after periodontai ligament injection was reported in a few cases. Discussien It is mandalory boLh for Lhe paLient and the operator to have acceptable tmalgcsia during pulpeetomy. A higher frequency of adequate responses lo conventional techniques than to the periodonLal ligamenL injection was found in Lhe present investigation. This indicaled that, properly administered, the conventional techniques were more reliable than the periodontai ligament procedure. However, if partial anesLhesia with minor discomfort was considered acceptable, no difference beLween Lhe Lwo Lechniciues seemed Lo exisL. The overall success-raLe of 6 1 % for PDL anesLhesia (Table 1) and 69% when considering posLerior mandibular regions exclusively (Table 2) confirmed Lhe results reporLed by Malamed (6). The observed success-raLes for convenLional techniques were also in good agreement with generally accepLed figures (13). Furthermore, lhe periodonLal ligamenL injecLion mighL have cerlain advantages in the posLerior mandibular region (Table 2). The invesLigation demonsLraLed LhaL periodontai ligamenL injecLion migliL be a valuable supplemenL if convenLional Lechniques fail. Periodontai ligamenL injeeLion was well accepLed by a majoriLy of boLh operaLors and paLienLs. The duraLion of Lhe periodonLal ligament injection is reporLed Lo be equal to conventional anesthesia Lechniques (6). These observations left us with the periodontai ligament Lechnicjue as a valuable allernative for minor operaLive procedures requiring local analgesia. Unnecessary soft tissue analgesia was minimized and normal funcLions were noL impaired (14). FurLhermore, Lhe risks of hematoma and parelhesia due to unintended nerve damage are avoided. Reduced amounls of anesthetic solution may be supplied (1, 3, 10). However, the periodonLal ligamenL technique is reported to produce extensive pulpal ischemia (12). This effecL may in parL be responsible for Lhe anesthesia iLself and, conceivably, the pulpal tolerance may be reduced. Precautions should Lherefore be Laken when periodonLal ligamenL injecLion is used for operative procedures on vital leeth (15). In the present investigation, level of sensitivity Lo pulpeetomy was used as the parameter. Individual pain thresholds and tolerance may vary and lhe results should therefore be considered as a subjective, but clinically relevant, evaluaLion of local anesLhesia techniques. A few patienLs reporLed posLo]3erative discomforL, mainly Lenderness Lo percussion and chewing after periodontai ligamenL injecLion (1, 3, 6). This may

135 127 88

82 (61%) 99 (78%) 49 (56%)

47 (35%) 25 (20%) 28 (32%)

6 (4%) 3 (2%) 1 (12%) 1

significanL (p<0.02, chi-square tesl). However, when including Lhe parLial responses, Lhere was no diflerence belween the lwo anesthesia techniques. Only a few unacceptable re.sponses were observed. Periodontai ligament injection was also used as a supplemenL in 88 cases where convenLional anesthesia techniques failed. This was done during a prolonged period and Lhe results (Table 1) show LhaL adequaLe or parLial responses were oblained in 88% of the eases treated. A slaLisLical evaluaLion of Lhis approach eompared wilh lhe lwo techniques applied alone is irrelevant because Lhis combined technique was LesLed on selecLed cases over a prolonged period. Mandibular block anesLhesia appeared Lo be the conventional technique demonstrating the highest frequency of failures in our sLudenL clinic. The resuhs obLained for Lhe posLerior mandibular regions by lhe three differenL procedures LesLed are Lherefore considered of parLicular inLeresL and are presenLed in Table 2. The resuhs demonsLraled lhat periodonLal ligament injection and the convenLional mandibular block anesthesia techniques were equally successful in this region. FurLhermore, adequaLe response Lo periodontai ligament injecLion was obLained in 577o and partial response in anoLher 36% of 42 cases where the conventional mandibular block anesLhesia Leehnique failed iniLially. Based on the results from the quesLionnaire a majoriLy of operaLors (90%,) and padenLs (70%) were in favor of periodontai ligament injecLion compared with convenlional lechniques. PostoperaLive

Table 2. The response fo various anesfhesia fechniques in fhe mandibular posferior segmenfs; periodontai Iigamenf (POL) injecfion, convenfional anesthesia technique (CA) and periodonfal Iigamenf injecfion used as a supplemenf where convenfional mandibular block technique failed (OA + POL). The responses fo CA -i- PDL was registered over a prolonged period. Results of anesfhesia, posferior mandibular regions Adequafe PDL CA CA 41 35 42 29 (71%) 24 (69%) 24 (57%) Parfial 11 (27%) 10 (28%) 15 (36%) Unaccepfable


1 (2%) 1 (3%) 3 (7%)


Periedontal ligament anesthesia

have been due Lo local, reversible damage lo periodontai sLructures (1, 7, 10). The high injecLion pressui-e caused fracLurc of a few anesthesia carpuies. The syringes specially designed tor jiieriodontal ligament injection have a shield around the carpuies preventing Lhe e\'entual spread of glass fragments in the oral cavity. Such shields are mandatory for proper use of lhe periodontai ligament injeclion technique.

FAULKNER R K . The high-presstire periodontai ligament injection. Br Dent J 1983; 154: 103 b. 3. I-iNnn7,OM A. Mitt satt att gora en lyekad rothinnebcdovning. Tandldkartidn 1982; 74: 223-5.
4. MATTHEWS RVV, STABLES D K . Intraligamentary dental an-

algesia by dental therapists. Br Dent j 1985; 159: 329.

.5. t.rrrNER M M , TAMSE A, KAFEE t. A new technique of sclee-

tive anesthesia fbr diagnosing ncute pulpitis in the mandible. J Fndod 1983; 9: 116 9. 6. MALAME15 SF. The periodontai ligament (PDL) injeetion: An alternative to inferior alveolar nerve block. Orat Surg 1982; 53: 117 21. 7. WALTON RE, AnHorr 1?J. Periodonlal ligamenl injeetion: A elinical evaluation. J Am Dent Assoe 1981; 103: 571 5.
8. BRANNSTROM M . , NORDENVALL KJ. Periodontai tissue

Periodontai ligamenl injection was found to be a fairly efficient and convenient method, even in the mandibular molar regions, but the success-rate was lower than for conventional lechniques. The procedure was well accepted by lhe patients. The durability of the analgesia obtained was found to be comparable to conventional techniques with less anestheLic soluLion applied. Slight postoperative pain occurred infrequently. The method was considered a valuable supplemenL lo conventional lechniques.
I. BR.ANNSIKOM M , PASMLEV OH, GAUHEROGLIO R . PDL Anesttiesia: Chnieat experience and reviews oj recent research, (iraliea

changes after intraligamentary anesthesia. J Dent Child 1982; 49:4-17-23. 9. FucHS O M . The periodontai ligament injection: Histological elfeets on the periodorititmi in dogs. J Ejidod 1983; 9: 4 1 1 5 .
10. WALTON R F , , GARNICK J J . The periodontai ligament injee-

tion: Histologic cU'ects on the periodontium in monkeys. J Endod 1982; 8: 22 6.

11. SIMON D E , JACOHS ' I ' L , WALKKR \VA. Intraligamentary anes-

thesia, an aid in endodontie diagnosis. Orat Sura 198''- )477 8. . s

12. KIM S , 1':D\VALI, f.. TROVVBRIDGE H , CHIEN S. Effects of local

anesthetics on pulpal blood How in dogs. 7 Dent Res 198463: 650 2.

13. COHEN S C , BURNS RG. Pattiways ofttiepulp. 3id ed. St. l.ouis:

C W Mosby Go 1984. p 650."

14. SMITH G N , WALTON RF,. Periodontai ligament injeetion:

Editoriale, Italy 198.5.

Distribution of injected solutions. Oral Surg 1983; 55: 232 8. 1.'). Status re])ort: the periodonlal liganienl injeclion J Am Dent Assoe 1983; 196: 222-4.