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Effectiveness of intraligamental anesthesia in controlling the hyperesthesia

during tooth preparation

Article  in  Drug Invention Today · January 2018

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 Research Article

Effectiveness of intraligamental anesthesia in controlling

the hyperesthesia during tooth preparation
Kyaarthini Subramaniam, M. Dhanraj, Ashish R. Jain*

ABSTRACT

Introduction: Efficient pain management is crucially important for a dental procedure to be successful. The fear of dental
pain is so strong in some patients that it makes them decline treatment. A local anesthesia which is administered painlessly
and efficaciously is absolutely important in the management of pain and the fear-induced anxiety states. Intraligament
anesthesia is commonly used to control hyperesthesia during tooth preparation as it is efficient and easy to perform. It is
preferred in treatment procedures involving the mandibular teeth. Aim: The aim of the study was to evaluate the effectiveness
of intraligament anesthesia in controlling hyperesthesia during tooth preparation. Materials and Methods:  This study
was conducted on 12 (male = 8, female = 4) partially edentulous patients to Saveetha Dental College requesting fixed
prosthodontic treatment. The patients were randomly allocated in two groups, Groups A and B, respectively. Group A
was intraligament infiltration and Group B was subperiosteal infiltration. The intraligament infiltration was administered
using an insulin syringe containing lignocaine hydrochloride 2% with adrenaline 1:80000 and a 30-gauge needle at buccal
(mesiobuccal), lingual, mesial, and distal aspect of the tooth to be prepared. After the administration of injection, the patient
underwent tooth preparation and graded hypersensitivity during tooth preparation in a visual analog scale (VAS) ranging
from 0 to 100. Result: The mean VAS scores for intraligamental and superiosteal infiltration were 1.83 ± 0.77 and1.66 ±
0.69, respectively. Mann–Whitney U-test was performed to assess the differences between the means at 5% significance,
and no statistically significant difference between both the techniques was observed. Conclusion: This study inferred both
intraligament infiltration and subperiosteal infiltration were equally effective in controlling hypersensitivity during tooth
preparation.

KEY WORDS: Anesthesia, Hyperesthesia, Intraligamental, Tooth preparation, Subperiosteal

INTRODUCTION receive intraoral injections and so lost or delayed their

Efficient pain management is crucially vital for a
dental procedure to achieve success. The concern of
dental pain is therefore sturdy in some patients that
it makes them decline treatment.[1] Anesthesia that is
administered painlessly and effectively is completely
necessary within the management of pain and also the
fear-induced anxiety states.
Williamson and Hoggart have shown that the concern
of pain in dentistry is closely related to the most
common methodology for blocking pain throughout
dental procedures that is intraoral administration of
local anesthetics. Bahlb reported that patients with
concern for dentistry had reconceived anxiety to
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appointments.[2]
Pain is also abolished by interrupting the pathways
that carry the data of the stimulation from the
periphery of the body to the central nervous system,
by interfering the central system, or by removing
the stimulation. Local anesthetics (LAs) have the
capability to block sensory conductivity of stimuli
that are harmful from reaching the central system.
Thus, LA is that the most typically utilized technique
of achieving pain management in dentistry.[3,4] Tsirlis
et al. conducted comparative studies of conductivity
and intraligamentary anesthesia in tooth preparation
of mandibular molars. They found no statistically
vital differences within the complications of the
inflammation kind.[5]
Tooth extraction is one among the most common
procedures in oral surgery that needs the

Department of Prosthodontics, Saveetha Dental College, Saveetha University, Chennai, Tamil Nadu, India

*Corresponding author: Dr.  Ashish R. Jain, Department of Prosthodontics, Saveetha Dental College and Hospital,
Saveetha University, Ponamalle High Road, Chennai – 600  127, Tamil Nadu, India. Phone: +91-9884233423.
E-mail: dr.ashishjain_r@yahoo.com

Received on: 02-03-2018; Revised on: 19-04-2018; Accepted on:24-05-2018

1020 Drug Invention Today | Vol 10 • Issue 6 • 2018

 Kyaarthini Subramaniam, et al
administration of LA for painless procedure.[6] Other
than the extraction of tooth, LA is being administered
during tooth preparation also to reduce the sensitivity
during tooth preparation. There are various strategies
for the administration of LA to stop complications.
One such technique known as the ILT introduced
within the early 20th century. This intraligamentary
or periodontal technique[7] had normal dental syringe
with blind placement of a hollow bore metal needle
on the gingival fissure. This method is known as non
trephinating intraosseous injection these days.
ILT usually needs deposition of minimum 0.2 ml of
local anesthetic solution for each root of the tooth. It
is administered within the locality of the tooth to be
extracted so the injury to the important structures will
be avoided. To reduce the discomfort caused by the
injection of the anesthetic solution, Meechen suggests
the utilization of anesthesia with cream or spray.
Intraligamentary anesthesia has been widely utilized
in dental practice within the recent years.
The clinical efficacy of the intraligamentary
anesthesia has been proven and described in the
literature. This method of dental anesthesia was found
to be efficient for all procedures usually performed
with local infiltration and/or nerve blocks, i.e., cavity
preparations, vital pulpectomies, crown preparation,
and dental extractions. The benefit of this technique
lies mainly in the avoidance of any form of a nerve
block and its undesirable post-operative effects.[8] The
anesthesia is achieved by forcing a 30-gauge needle
into the intraligament through the gingival sulcus
until resistance is felt. The ejection of the anesthetic
solution into the ILT is facilitated by exerting a very
high pressure using a special syringe.
There are no other post- injection complications
other than few localized minor pain, which were
reported by the patients. This pain lasted for a few
hours in some cases, up to 2 days in others. No
mobility of injected teeth was noticed at any time
after the procedure. Neither periodontal abscesses nor
pocket formations were seen, even in periodontally
involved teeth,[9] where spread of infection could be
suspected. Radiographs that were taken shortly after
and up to 6 months following the injection did not
show any changes in the alveolar bone. In spite of
these observations, one can expect a minimal degree
of damage to the periodontal tissues which may
occur when practising the intraligamentary method
of injection. This damage may be caused by a direct
trauma to the ILT tissue or cemental surface scratches
made by the needle tip. The anesthetic material
injected under pressure should be evaluated as well.[10]
Many patients experience severe hypersensitivity
during restorative procedures involving tooth
preparation. This hypersensitivity referred as
Drug Invention Today | Vol 10 • Issue 6 • 2018
hyperesthesia, and the commonly used management
strategies to advance this phenomenon include
administration of local anesthesia. The commonly
used local anesthetic techniques are inferior alveolar
nerve block (IANB) and subperiosteal infiltration.
This technique is prone to certain complication and
intraligamental anesthetic technique may be viable
alternative under such conditions. However, the
effectiveness of this technique needs to be explored
in controlling hyperesthesia during tooth preparation.
Hence, the present study was undertaken with the aim
to evaluate the effectiveness of intraligament anesthesia
in controlling hyperesthesia during tooth preparation.
MATERIALS AND METHODS
A convenient sample size of 12 consecutive patients
who visited Saveetha Dental College, Chennai, with
a chief concern of fixed replacement of missing tooth
participated in the study. The study was performed to
patients who were undergoing fixed partial denture
treatment. The study included 8 male and 4 female
participants with ages ranging between 25 and 40
years old who were systemically healthy.[11] The
patients were randomly divided equally into two
groups, Groups A and B, respectively.
Patients in GroupAwere given LAwith intraligamentary
infiltration, whereas patients in Group B were given
local anesthesia through subperiosteal infiltration.
Both of the anesthetic techniques were administered
before tooth preparation using a 2 ml insulin
syringe (30 gauge needle) containing 2% lignocaine
hydrochloride (HCl) with adrenaline 1:80000 which
is given at buccal (mesiobuccal), lingual, mesial,
and distal aspects of the tooth for intraligamentary
technique and around the apices of the roots for the
subperiosteal infiltration technique.[12]
The hyperesthesia condition was evaluated using
the visual analog scale (VAS) based on sensitivity
assessment which was given to the participants to be
filled during the tooth preparation. The VAS score was
prepared in English with easily identifiable analogs.
The VAS ranged 0–100, where 0 indicates “no
sensitivity,” while 100 referred “severe sensitivity.”
All the responses were recorded and analyzed
statistically.
RESULTS
Table  1 shows the percentage of sample size based
on gender. The age group of patients was chosen are
Table 1: Demographic data
Gender Number of patients n (%)
Male 8 (66)
Female 4 (34)
1021
 Kyaarthini Subramaniam, et al.
between 25 and 40 years old. The number of male
patients is 8 which is 66% and the number of female
patients is 4 which is 34%.
Table 2 shows the results of Mann–Whitney U-test.
The mean VAS value of intraligament infiltration was
1.83 ± 0.77 and subperiosteal infiltration was 1.66 ±
0.69, respectively. The U value was 17, Z value was
0.08,and P = 0.936 (P > 0.05)
DISCUSSION
Local anesthesia may be a process that triggers
a regional loss of sensitivity (pain) round the
administration site (infiltration anesthesia) or on the
trail of a nerve (nerve block anesthesia). A accessible
as a topical cream and as an injectable solution (local
anesthesia) in dentistry induces an analgesic impact by
interacting with neural cell membranes and troubling
metal binding. The resulting closure of voltage-gated
sodium channels prevents action potentials from
occurring and accounts for roughly 90th of local activity
of the amide-based anesthetic solutions, the foremost
unremarkably used inside clinical dentistry include:
Bupivacaine, articaine, lidocaine, prilocaine, and
mepivacaine. Comparatively insoluble, instable, and
weak basic, LA with buffering HCl acid to stabilize
the pH of the amide.[13] Since amides cause dilatation
and thus decrease the efficaciousness of the anesthesia,
vasoconstrictors such as endocrine and felypressin
are typically supplemental to make amends for the
dilatation, reduce the blood flow at the injection site,
and enhance the period of the anesthetic impact.
The largest and strongest bone of the face and the
mandible is formed from extremely dense cortical
bone that may usually hinder effective infiltration and
physiological state of nerves close.[14] Despite this
hindrance, the subsequent techniques are reported to
anesthetize the teeth within the mandible with some
success: IANB or mandibular block, buccal nerve
block, nerve blocks of the mental and incisive nerves,
Gow-Gates mandibular nerve block, Vazirani-Akinosi
closed mouth mandibular block, and supplementary
intraosseous anesthesia techniques such as intraseptal,
periodontal ligament (PDL), and traditional (direct)
intraligament anesthesia injection.[15] Failing to
anesthetize for dental procedures causes discomfort
and pain to the patient. The remaining intraosseous
Table 2: Mann–Whitney U‑test
Intervention Mean VAS U Z
technique
Intraligament 1.83±0.77 17 0.08 0.936
infiltration
Subperiosteal 1.66±0.69
infiltration
VAS: Visual analog scale
1022
anesthesia techniques (intraligament anesthesia,
PDL,
and intraseptal injections) anesthetize one
or additional
teeth in a quadrant (depending on the injection location,
concentration, and volume of resolution injected) and
supply a traumatic pulpal and periodontic anesthesia
but not lingual and facial anesthesia which is elicited
by mandibular nerve blocks.[16] The initial step is to
anesthetize the membrane that is accomplished by
infiltration anesthesia of the world wherever the bone
is perforated. A very small amount of topical anesthetic
is required for this step. Afterward, the cortical bone is
perforated and also the cancellous bone penetrated. By
injecting the solution directly into the cancellous bone
adjacent to the tooth
to be anesthetized, intraosseous
anesthesia techniques
give effective, localized pulpal,
and periodontic anesthesia but not extensive collateral
soft tissue anaesthesia.[17]
Besides the conventional ILT injection,
intraligamentary injection has additionally been
supported inside the literature as an efficient primary
technique for local anaesthesia. In line with the studies
of Tung and Eichmiller[18] and Jing et al., articaine
and 1:100,000 epinephrine are very effective, with
92.1%, 53.0%, and 93.1% anesthetic success having
being rumored within the jaw pre-, first, and second
molar teeth severally, of patients with irreversible
pulpitis. Irreversible injury to dental medicine soft
tissue and computer-controlled force unit injection
was regarded to be a secure and effective primary
technique for endodontic access to jaw posterior teeth
with irreversible pulpitis.[19]
Intraosseous physiological condition confers several
edges and benefits. Despite the restricted variety
of studies revealed on intraosseous physiological
condition, in recent years, the prevailing literature
indicates extended support for its use.[20]
In children, no needle rotation is needed as a result
of the thin and porous nature of their bone, whereas
in adolescent and adult patients, a rotation (drilling)
is required to perforate the cortical plate.[21] Once the
needle is at the proper depth within the cancellous
bone, it is crucial to inject the topical anesthetic
(with a vasoconstrictor) slowly.[22] Despite the high
effectiveness rates according to several articles, one
reports associate ILT injection success of simply 78
with third mepivacaine and no agent (compared to
89 effectiveness mistreatment, a pair of local and
1:100,000 catecholamine)[23] for typical methods.
Clearly, the absence of catecholamine within the ILT
P
injections can have down the strength of the anesthetic
and so the effectiveness rate of the technique.[24] The
comparative study style might need a lot of impartial if
the sort of answer and concentration of vasoconstrictor
for each strategies of physiological state had been
controlled for.[25]
Drug Invention Today | Vol 10 • Issue 6 • 2018
 Kyaarthini Subramaniam, et al
Jing et al. completed the force unit injection to be an
efficient and safe primary technique in dental medicine
procedures for inframaxillary posterior teeth with
irreversible pulpitis.[26] Typically, these are terribly
laborious to anesthetize with typical IANB, whereas
sensitivity to biting and pain is rumored, which were
found to induce less soft tissue physiological state and
pain than the IANB.
By depositing resolution directly into the cancellous
bone close to the apex of the tooth, intraosseous
injection eliminates soft[27] tissue symptom and
prolonged physiological state of the teeth and
permits for quick, comfy onset of physiological state.
Intraligament injection has attained high preference
from patients over typical techniques.[21] During a
clinical setting, the quick onset, short length, and
high effectivity of delivered ILT ought to permit
operators to begin their procedures additional quickly
and see additional patients throughout the day,
especially advantageous for clinicians’ performing
arts conservative procedures. Another advantage of
ILT is that one will treat bilateral teeth within the
same appointment while not having to administer two
IANBs that are terribly uncomfortable for patients.
Moreover, palatal injections to put rubber dam
clasps become redundant because the ILT anesthesia
anesthetizes the odontology ligament, the pulp, and
therefore, the connected gingiva round the tooth.[28]
The result of the present study concluded that both
subperiosteal infiltration and IANB were equally
effective in controlling hyperesthesia during
tooth preparation. There are few limitations with
intraligament anesthesia, one is technique sensitivity
and multiple puncture site. However, there are several
advantages such as minimal tissue trauma, profound
anesthesia, no risk of hematoma or trismus and
minimal anesthetic recovery discomfort, and hence,
this technique can be used to control 8.
CONCLUSION
This study concluded that both intraligament
infiltration and subperiosteal infiltration were equally
effective in controlling tooth hypersensitivity during
tooth preparation. Hence, intraligamental technique
can be used as substitute for subperiosteal infiltration
in suitable clinical situation.
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Source of support: Nil; Conflict of interest: None Declared
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