Faculty of Dentistry, University of Toronto, Toronto, Ontario, Canada.
Faculty of Dentistry, University of Toronto, Toronto, Ontario, Canada; Department of Dentistry, Sunnybrook Sciences Health Centre, University of Toronto, Toronto, Ontario, Canada.
J Endod. 2019 Dec;45(12):1435-1464.e10. doi: 10.1016/j.joen.2019.09.002. Epub 2019 Oct 7.
Several strategies have been investigated for achieving successful pulpal anesthesia during endodontic treatment of mandibular molars with symptomatic irreversible pulpitis. However, comprehensive evaluation and identification of the most efficacious and safe intervention are lacking. We aimed to determine this using network meta-analysis.
MEDLINE, Embase, Cochrane Central, CINAHL, and Scopus databases were searched. Study selection and data extraction were performed in duplicate. Eligible randomized controlled trials were meta-analyzed to estimate the treatment effects (odd ratios [ORs]; 95% credible interval (CrI) and surface under the cumulative ranking curve (SUCRA)]. CINeMA software (University of Bern, Bern, Switzerland) was used to assess the quality of results.
Thirty-seven interventions from 46 studies were identified. Compared with the common practice of an inferior alveolar nerve block with 2% lidocaine, a supplemental intraosseous injection was ranked the most efficacious with very low to moderate confidence (2% lidocaine + preoperative nonsteroidal anti-inflammatory drugs [NSAIDs] + acetaminophen [OR = 74; 95% CrI, 15-470; SUCRA = 97%], 2% lidocaine + preoperative NSAIDs [OR = 46; 95% CrI, 8-420; SUCRA = 94%], 2% lidocaine [OR = 33; 95% CrI, 14-80; SUCRA = 93%], 2% lidocaine + preoperative opioids + acetaminophen [OR = 20; 95% CrI, 4.4-98; SUCRA = 86%], and 4% articaine [OR = 20; 95% CrI, 6.3-96; SUCRA = 87%]) followed by supplemental buccal and lingual infiltrations using 4% articaine + preoperative NSAIDs (OR = 18; 95% CrI, 6-56; SUCRA = 86%; very low confidence). No major safety concerns were reported.
Very low- to moderate-quality evidence suggests intraosseous injection using 2% lidocaine with 1:100,000 epinephrine or 4% articaine with 1:100,000 epinephrine or buccal and lingual infiltrations of 4% articaine with 1:100,000 epinephrine are superior strategies to achieve pulpal anesthesia during endodontic treatment of mandibular molars with symptomatic irreversible pulpitis. Preoperative NSAIDs or opioids with or without acetaminophen may increase the efficacy of these injections.
在有症状的不可复性牙髓炎的下颌磨牙的根管治疗中，已经研究了几种实现成功牙髓麻醉的策略。然而，缺乏对最有效和最安全的干预措施的综合评估和识别。我们旨在使用网络荟萃分析来确定这一点。
检索 MEDLINE、Embase、Cochrane 中心、CINAHL 和 Scopus 数据库。研究选择和数据提取由两人独立进行。对合格的随机对照试验进行荟萃分析，以估计治疗效果（比值比[ORs]；95%可信区间[CrI]和累积排序曲线下面积[SUCRA]）。使用 CINeMA 软件（伯尔尼大学，瑞士伯尔尼）评估结果质量。
从 46 项研究中确定了 37 种干预措施。与使用 2%利多卡因进行下牙槽神经阻滞的常规做法相比，骨内注射被认为是最有效的，置信度为低到中度（2%利多卡因+术前非甾体抗炎药[NSAIDs]+对乙酰氨基酚[OR=74；95%CrI，15-470；SUCRA=97%]，2%利多卡因+术前 NSAIDs[OR=46；95%CrI，8-420；SUCRA=94%]，2%利多卡因[OR=33；95%CrI，14-80；SUCRA=93%]，2%利多卡因+术前阿片类药物+对乙酰氨基酚[OR=20；95%CrI，4.4-98；SUCRA=86%]，4%阿替卡因[OR=20；95%CrI，6.3-96；SUCRA=87%]），其次是使用 4%阿替卡因+术前 NSAIDs 的颊侧和舌侧浸润（OR=18；95%CrI，6-56；SUCRA=86%；置信度低）。没有报告重大安全问题。
低至中度质量证据表明，使用 2%利多卡因加 1:100,000 肾上腺素或 4%阿替卡因加 1:100,000 肾上腺素的骨内注射，或使用 4%阿替卡因加 1:100,000 肾上腺素的颊侧和舌侧浸润，是治疗有症状的不可复性牙髓炎的下颌磨牙根管治疗中实现牙髓麻醉的较好策略。术前 NSAIDs 或阿片类药物，单独或联合使用对乙酰氨基酚，可能会增加这些注射的疗效。
