Introduction: This systematic review evaluated the use of buffered versus non-buffered lidocaine to increase the efficacy of inferior alveolar nerve block (IANB). Materials and Methods: Randomized, double-blinded studies from PubMed, Web of Science, Cochrane Library, Embase, and ProQuest were identi...
Introduction: This systematic review evaluated the use of buffered versus non-buffered lidocaine to increase the efficacy of inferior alveolar nerve block (IANB). Materials and Methods: Randomized, double-blinded studies from PubMed, Web of Science, Cochrane Library, Embase, and ProQuest were identified. Two of the authors assessed the studies for risk of bias. Outcomes included onset time, injection pain on a visual analog scale (VAS), percentage of painless injections, and anesthetic success rate of IANB. Results: The search strategy yielded 19 references. Eleven could be included in meta-analyses. Risk of bias was unclear in ten and high in one study. Buffered lidocaine showed 48 seconds faster onset time (95% confidence interval [CI], -42.06 to -54.40; P < 0.001) and 5.0 units lower (on a scale 0-100) VAS injection pain (95% CI, -9.13 to -0.77; P=0.02) than non-buffered. No significant difference was found on percentage of people with painless injection (P = 0.059), nor success rate (P = 0.290). Conclusion: Buffered lidocaine significantly decreased onset time and injection pain (VAS) compared with non-buffered lidocaine in IANB. However due to statistical heterogeneity and low sample size, quality of the evidence was low to moderate, additional studies with larger numbers of participants and low risk of bias are needed to confirm these results.
Introduction: This systematic review evaluated the use of buffered versus non-buffered lidocaine to increase the efficacy of inferior alveolar nerve block (IANB). Materials and Methods: Randomized, double-blinded studies from PubMed, Web of Science, Cochrane Library, Embase, and ProQuest were identified. Two of the authors assessed the studies for risk of bias. Outcomes included onset time, injection pain on a visual analog scale (VAS), percentage of painless injections, and anesthetic success rate of IANB. Results: The search strategy yielded 19 references. Eleven could be included in meta-analyses. Risk of bias was unclear in ten and high in one study. Buffered lidocaine showed 48 seconds faster onset time (95% confidence interval [CI], -42.06 to -54.40; P < 0.001) and 5.0 units lower (on a scale 0-100) VAS injection pain (95% CI, -9.13 to -0.77; P=0.02) than non-buffered. No significant difference was found on percentage of people with painless injection (P = 0.059), nor success rate (P = 0.290). Conclusion: Buffered lidocaine significantly decreased onset time and injection pain (VAS) compared with non-buffered lidocaine in IANB. However due to statistical heterogeneity and low sample size, quality of the evidence was low to moderate, additional studies with larger numbers of participants and low risk of bias are needed to confirm these results.
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문제 정의
However, the effect of alkalinization of lidocaine in mandibular nerve block remains controversial. This systematic review and meta-analysis aimed to focus on these types of studies to determine whether sodium bicarbonate buffered lidocaine is effective in shortening analgesic onset time, increasing success rate, and reducing injection pain in dental patients receiving an IANB.
가설 설정
Buffered lidocaine versus non-buffered lidocaine. Forest plot comparisons: a) Onset time in seconds and b) IANB success rate. CI: confidence interval.
제안 방법
The use of buffered lidocaine has raised some clinical questions that need further research to be answered: Will buffered lidocaine reduce the injection pain and onset time of IANB in patients with symptomatic irreversible pulpitis or acute apical abscess? Additional studies also are needed to eliminate other sources of variability previously described in the literature. Common problems associated with the included studies were as follows: varies dosage and percentage with anesthesia, unbalanced dosage of lidocaine in experimental and control groups, different concentration of epinephrine, supplemental administration of anesthesia other than IANB, small sample size, and inconsistent method of outcome assessments. Future studies might look at the effectiveness of buffered lidocaine in both symptomatic and asymptomatic patients with different routes of anesthetic administration.
). Data extraction included the authors and years of recruitment, demographics of participants and sample size, intervention methods for the study and control groups, study design, and the outcome results for each study (Table 2). The two independent reviewers (J.
In order to evaluate whether patients’ ages affect the VAS pain score on injection, another meta-analysis was conducted which grouped the studies by population (results not shown).
Primary outcome measures were the onset of time of anesthesia in seconds, anesthetic success rate of IANB, the percentage of patients with painless IANB injection, and the pain during IANB injection measured via VAS. Anesthetic success rate of IANB was defined as the tooth without pain or with mild pain during endodontic access[14,15].
A recent systematic review [32] has been published in 2018, and has a different PICO question compared to the current systematic review. The aim of the previous systematic review was to investigate the efficacy of buffered local anesthetics in reducing infiltration pain and anesthesia onset time in dentistry. Three IANB studies as well as infiltration studies in adult patients were included.
For continuous data, the authors used difference in means with 95% CIs. Whenever parallel design and split-mouth design crossover studies were included, the authors conducted paired and independent tests with the same results. For the two studies [13,17] that provided median, 95% CIs and/or interquartile range (IQR), the methods described by Wan et al.
대상 데이터
In that systematic review, it is unclear how VAS pain data was obtained for two studies [12,18] and pediatric patients were not included. The results of our review are applicable to people aged from 6 years to 81 years, of both genders, who received IANB injection with 1-2% lidocaine with epinephrine. There was significant heterogeneity in all conducted meta-analyses.
This systematic review included eleven studies with 508 participants. Of these eleven studies, one study had high risk of bias [11] while the remaining ten studies had unclear risk of bias.
이론/모형
[3], and reported in Table 2. The authors used a random-effects model on combined estimates of effect except when only two studies were included in a meta-analysis, and then the fixed-effect model will be used. Statistics reported were the Cochrane Q test [26] and the I2 statistic [27].
The quality of evidence assessment and summary of the review findings were conducted using the software GRADEprofiler (GRADEPro), which follows the Cochrane Collaboration and Grading of Recommen- dation, Assessment, Development and Evaluation (GRADE) Working Group recommendations [24].
성능/효과
As this could be a source of bias because the effectiveness of local anesthetic can be affected by local tissue inflammation [2], the authors conducted a sensitivity analysis including symptomatic and asymptomatic patients with similar results. The overall strength of the evidence, according to the GRADE system, was moderate for injection pain for IANB using VAS scores and percentage of patients with painless IANB injection, and low for success rate of IANB and onset time.
후속연구
There is moderate quality of evidence to support the use of buffered lidocaine in IANB local anesthesia to decrease injection pain by 5 units on a scale of 0-100 and low quality of evidence to support the effectiveness in reducing onset time. Due to the small sample size and the small number of included studies, further studies are needed to confirm these results. Thus, there is inadequate evidence at this point to recommend the buffered lidocaine for IANB local anesthesia in patients in need of dental treatment.
Common problems associated with the included studies were as follows: varies dosage and percentage with anesthesia, unbalanced dosage of lidocaine in experimental and control groups, different concentration of epinephrine, supplemental administration of anesthesia other than IANB, small sample size, and inconsistent method of outcome assessments. Future studies might look at the effectiveness of buffered lidocaine in both symptomatic and asymptomatic patients with different routes of anesthetic administration. More standardized clinical trials are needed to provide higher level of evidence to determine the benefits of buffered lidocaine for IANB local anesthesia in dental treatment.
참고문헌 (34)
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