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Periodontai ligament anesthesia - A clinical evaluation Eriksen HM, Aamdal H, Kerekes K. PeriodonLal ligamenL anes- thesia. 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. Harald M. Erihsen, Hilde Aamdal and Kasmer Kerekes Oepartmenf of Operative Dentistry and Endodon- tics, 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. 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 anal- gesia may lead to biLe wounds in children and men- tally retarded persons. Accidental damage to nerve trunks or blood vessels may occur resulting in par- esthesia or hematoma. In addition, fairly large doses mighL be applied in order to obLain suOicient anal- gesia of the desired region. Periodontai ligamenl injection has been intro- duced 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 in- jected with pressure in order Lo obtain diffusion around the root. Several investigations conclude la- vorably for periodonlal ligament anesLhesia (1-7) and hisLologic invesLigaLions have shown minor Lis- sue damage (1,8-10). FurLhermore, Lhe advantage of seleclive anesthesia as a diagnostic Lool is empha- sized (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 aherna- tive or as a supplement to conventional techniques in connection with endodonLic LreatmenL. Material and methods The invesLigaLion included 339 teeth in paLients referred for endodonLic treaLment at the Depart- ment 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 conven- Lional 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 eval- uaLing Lhe aLLiLude of both operaLors and patients Lowards periodontai ligament injection was also in- cluded 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 injec- tion. This difference was found to be statistically 267

Periodontal ligament anesthesia — A clinical evaluation

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Page 1: Periodontal ligament anesthesia — A clinical evaluation

Periodontai ligament anesthesia - A clinicalevaluationEriksen HM, Aamdal H, Kerekes K. PeriodonLal ligamenL anes-thesia. A clinical evaluaLion. Endod Dent TraumaLoI 1986; 2:267-269.

AbsLract ~ PeriodonLal ligamenL (PDL) injecLion was used eitheras an alternative or as a supplement Lo conventional anesLhesiatechniques (CA) in connecLion with endodontic irealment of 339teeth. Adequate analgesia was obtained more irequenLly wiLh CAthan wiLh PDL. However, total lack of effecL was registered onlyin a few cases for boLh Lechniques. PDE was found Lo be ofparLicular value in Lhe mandibular posLerior segmenLs whereconvenLional Lechniques mosL frequenLly failed.

Harald M. Erihsen, Hilde Aamdal andKasmer KerekesOepartmenf of Operative Dentistry and Endodon-tics, Dental Factilty, University of Oslo, Oslo,Norway

Key words: denfal anesthesia, periodonfal ligament.

Harald M. Eriksen, Odontologiklinikkene, P.O.Box1109 Blindern, 0317 Oslo 3, Norway.

Accepted for publication 28 April 1986.

Pain control during dental treatment is generallyachieved by local anesthesia. Local infiUraLion andlocal block anesthesia are ihe mosL commonly usedmeLhods. Local infiltration is usually sufficient inmaxilla and the mandibular anLerior regions whilemandibular block anesLhesia is regularly applied forLhe posLerior mandibular segmenLs.

However, conventional methods may have someuntoward side-effects. Unnecessary soft tissue anal-gesia may lead to biLe wounds in children and men-tally retarded persons. Accidental damage to nervetrunks or blood vessels may occur resulting in par-esthesia or hematoma. In addition, fairly large dosesmighL be applied in order to obLain suOicient anal-gesia of the desired region.

Periodontai ligamenl injection has been intro-duced in order to reduce the side-effects linked toconvenLional Lechniques. Thin (30 gauge) needlesare inserted into the gingival crevice towards theperidontal ligamenL. The anesLhelic solution is in-jected with pressure in order Lo obtain diffusionaround the root. Several investigations conclude la-vorably for periodonlal ligament anesLhesia (1-7)and hisLologic invesLigaLions have shown minor Lis-sue damage (1,8-10). FurLhermore, Lhe advantageof seleclive anesthesia as a diagnostic Lool is empha-sized (5, 11). However, pulpal ischemia has beenreported (12). This may render the pulp vulnerableto damage of iatrogenic origin.

The purpose of ihe present investigation was Loevaluate the effecLiveness of periodonLal ligamenLanesthesia when used by supervised denLal students.

The method was evaluated either as an aherna-tive or as a supplement to conventional techniquesin connection with endodonLic LreatmenL.

Material and methods

The invesLigaLion included 339 teeth in paLientsreferred for endodonLic treaLment at the Depart-ment of Endodontics, DenLal Faeulty, Universily ofOslo. All tooth groups were represented and theLeeLh had fully developed rools and viLal pulps.

Periodontai ligamenL injecLion was arbiLrarilychosen in 135 cases and conventional anesthesiatechniques in 127 cases. In addition, periodonLalligamenL injection was used as a supplement in 88cases during a prolonged investigation period whenadequate responses were not obLained by conven-Lional techniques. The responses were classified as -adequaLe: pulpeetomy could be performed withoutpain; partial: pulpecLomy could be performed withLolerable discomforL; unacceptable: pulpeetomycould not be performed due Lo intolerable pain.

Ligmaject® was used for Lhe periodontai ligamentinjection. Xylocaine 2Omg7ml with Adrenaline 1:50 000 was used routinely. In a few cases wherevasoconstrictor was conLraindicated, Carbocainedental 30mg/ml was applied. A quesLionnaire eval-uaLing Lhe aLLiLude of both operaLors and patientsLowards periodontai ligament injection was also in-cluded in the invesdgation.

Results

The overall results are given in Table 1. AdequaLeresponse was obtained in 78% of Lhe 127 teelhanesthetized wilh conventional techniques while anadequate response was obtained in only 61% of the135 teeth treated with periodonfal ligament injec-tion. This difference was found to be statistically

267

Page 2: Periodontal ligament anesthesia — A clinical evaluation

Eriksen et al.

Table 1. The results of periodonfal Iigamenf (POL) injection compared wifhconvenfional anesthesia fechniques (CA) and POL used as a supplemenfwhen CA failed (CA + POL). The responses fo CA + PDL was regisferedover a prolonged period. The difference befween PDL and CA was sfafisficallysignificanf (0.01 <p<0 .02 for )c^=9.05) using chi-square fesf.Results of anesfhesia, all foofh groups included

Adequafe Partial Unaccepfable

POLCACA + POL

13512788

829949

(61%)(78%)(56%)

472528

(35%)(20%)(32%)

6311

(4%)(2%)(12%)

significanL (p<0.02, chi-square tesl). However,when including Lhe parLial responses, Lhere was nodiflerence belween the lwo anesthesia techniques.Only a few unacceptable re.sponses were observed.

Periodontai ligament injection was also used as asupplemenL in 88 cases where convenLional anes-thesia techniques failed. This was done during aprolonged period and Lhe results (Table 1) showLhaL adequaLe or parLial responses were oblained in88% of the eases treated. A slaLisLical evaluaLion ofLhis approach eompared wilh lhe lwo techniquesapplied alone is irrelevant because Lhis combinedtechnique was LesLed on selecLed cases over a pro-longed period. Mandibular block anesLhesia ap-peared Lo be the conventional technique demon-strating the highest frequency of failures in our sLu-denL clinic. The resuhs obLained for Lhe posLeriormandibular regions by lhe three differenL pro-cedures LesLed are Lherefore considered of parLicularinLeresL and are presenLed in Table 2.

The resuhs demonsLraled lhat periodonLal liga-ment injection and the convenLional mandibularblock anesthesia techniques were equally successfulin this region. FurLhermore, adequaLe response Loperiodontai ligament injecLion was obLained in 577oand partial response in anoLher 36% of 42 caseswhere the conventional mandibular block anes-Lhesia Leehnique failed iniLially.

Based on the results from the quesLionnaire amajoriLy of operaLors (90%,) and padenLs (70%)were in favor of periodontai ligament injecLion com-pared with convenlional lechniques. PostoperaLive

Table 2. The response fo various anesfhesia fechniques in fhe mandibularposferior segmenfs; periodontai Iigamenf (POL) injecfion, convenfional anes-thesia technique (CA) and periodonfal Iigamenf injecfion used as a supplemenfwhere convenfional mandibular block technique failed (OA + POL). Theresponses fo CA -i- PDL was registered over a prolonged period.Results of anesfhesia, posferior mandibular regions

Adequafe Parfial Unaccepfable

PDLCACA PDL

413542

29 (71%)24 (69%)24 (57%)

11 (27%)10 (28%)15 (36%)

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

pain after periodontai ligament injection was re-ported in a few cases.

Discussien

It is mandalory boLh for Lhe paLient and the oper-ator to have acceptable tmalgcsia during pulpeeto-my. A higher frequency of adequate responses loconventional techniques than to the periodonLalligamenL injection was found in Lhe present investi-gation. This indicaled that, properly administered,the conventional techniques were more reliable thanthe periodontai ligament procedure. However, ifpartial anesLhesia with minor discomfort was con-sidered acceptable, no difference beLween Lhe LwoLechniciues seemed Lo exisL. The overall success-raLeof 6 1 % for PDL anesLhesia (Table 1) and 69%when considering posLerior mandibular regions ex-clusively (Table 2) confirmed Lhe results reporLedby Malamed (6). The observed success-raLes forconvenLional techniques were also in good agree-ment with generally accepLed figures (13).

Furthermore, lhe periodonLal ligamenL injecLionmighL have cerlain advantages in the posLerior man-dibular region (Table 2). The invesLigation demon-sLraLed LhaL periodontai ligamenL injecLion migliL bea valuable supplemenL if convenLional Lechniquesfail. Periodontai ligamenL injeeLion was well ac-cepLed by a majoriLy of boLh operaLors and paLienLs.The duraLion of Lhe periodonLal ligament injectionis reporLed Lo be equal to conventional anesthesiaLechniques (6).

These observations left us with the periodontailigament Lechnicjue as a valuable allernative forminor operaLive procedures requiring local anal-gesia. Unnecessary soft tissue analgesia was mini-mized and normal funcLions were noL impaired (14).FurLhermore, Lhe risks of hematoma and parelhesiadue to unintended nerve damage are avoided. Re-duced amounls of anesthetic solution may be sup-plied (1, 3, 10). However, the periodonLal ligamenLtechnique is reported to produce extensive pulpalischemia (12). This effecL may in parL be responsiblefor Lhe anesthesia iLself and, conceivably, the pulpaltolerance may be reduced. Precautions shouldLherefore be Laken when periodonLal ligamenL injec-Lion is used for operative procedures on vital leeth(15).

In the present investigation, level of sensitivity Lopulpeetomy was used as the parameter. Individualpain thresholds and tolerance may vary and lheresults should therefore be considered as a subjec-tive, but clinically relevant, evaluaLion of local anes-Lhesia techniques.

A few patienLs reporLed posLo]3erative discomforL,mainly Lenderness Lo percussion and chewing afterperiodontai ligamenL injecLion (1, 3, 6). This may

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Page 3: Periodontal ligament anesthesia — A clinical evaluation

Periedontal ligament anesthesia

have been due Lo local, reversible damage lo peri-odontai sLructures (1, 7, 10).

The high injecLion pressui-e caused fracLurc ofa few anesthesia carpuies. The syringes speciallydesigned tor jiieriodontal ligament injection have ashield around the carpuies preventing Lhe e\'entualspread of glass fragments in the oral cavity. Suchshields are mandatory for proper use of lhe peri-odontai ligament injeclion technique.

Cenclusions

Periodontai ligamenl injection was found to be afairly efficient and convenient method, even in themandibular molar regions, but the success-rate waslower than for conventional lechniques. The pro-cedure was well accepted by lhe patients. The dura-bility of the analgesia obtained was found to becomparable to conventional techniques with lessanestheLic soluLion applied. Slight postoperativepain occurred infrequently. The method was con-sidered a valuable supplemenL lo conventional lech-niques.

References

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

algesia by dental therapists. Br Dent j 1985; 159: 329.t.rrrNER MM, TAMSE A, KAFEE t. A new technique of sclee-

tive anesthesia fbr diagnosing ncute pulpitis in the mandible.J Fndod 1983; 9: 116 9.MALAME15 SF. The periodontai ligament (PDL) injeetion:An alternative to inferior alveolar nerve block. Orat Surg1982; 53: 117 21.WALTON RE, AnHorr 1?J. Periodonlal ligamenl injeetion: Aelinical evaluation. J Am Dent Assoe 1981; 103: 571 5.BRANNSTROM M . , NORDENVALL KJ. Periodontai tissue

changes after intraligamentary anesthesia. J Dent Child 1982;49:4-17-23.FucHS OM. The periodontai ligament injection: Histologicalelfeets on the periodorititmi in dogs. J Ejidod 1983; 9: 4 1 1 5 .WALTON RF,, GARNICK J J . The periodontai ligament injee-

tion: Histologic cU'ects on the periodontium in monkeys. JEndod 1982; 8: 22 6.SIMON DE, JACOHS ' I 'L , WALKKR \VA. Intraligamentary anes-thesia, an aid in endodontie diagnosis. Orat Sura 198''- •)4-77 8. . s •

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anesthetics on pulpal blood How in dogs. 7 Dent Res 1984-63: 650 2.COHEN S C , BURNS RG. Pattiways ofttiepulp. 3id ed. St. l.ouis:

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