Comparative Evaluation of Local Infiltration of Articaine, Articaine Plus Ketorolac, and Dexamethasone on Anesthetic Efficacy of Inferior Alveolar Nerve Block with Lidocaine in Patients with Irreversible Pulpitis Vivek Aggarwal, MDS,* Mamta Singla, MDS, † Abbas Rizvi, MDS,* and Sanjay Miglani, MDS* Abstract Introduction: The inferior alveolar nerve block (IANB) has a poor success rate in patients with irreversible pul- pitis. The purpose of this study was to evaluate the effect of ketorolac and dexamethasone infiltration along with standard IANB on the success rate. Methods: Ninety-four adult volunteers who were actively experi- encing pain participated in this prospective, random- ized, double-blind study. All patients received standard IANB of 2% lidocaine with 1:200,000 epinephrine. Twenty-four patients did not receive any supplemental infiltrations (control). Twenty-four patients received supplemental buccal infiltration of 4% articaine with 1:100,000 ephinephrine, and 24 patients received supplemental buccal infiltration of 1 mL/4 mg of dexa- methasone. It was planned to give supplemental buccal infiltration of 1 mL/30 mg of ketorolac tromethamine in 26 patients, but the first 2 patients experienced severe injection pain after ketorlac infiltration and were excluded from the study. In the subsequent patients, 0.9 mL of 4% articaine was infiltrated before injecting ketorolac. Endodontic access preparation was initiated after 15 minutes of initial IANB. Pain during treatment was recorded by using a Heft-Parker visual analog scale. Success was recorded as none or mild pain. Results: Statistical analysis was done by using nonparametric c 2 tests. Control IANB gave 39% success rate. Buccal infiltration of articaine and articaine plus ketorolac significantly increased the success rate to 54% and 62%, respectively (P < .05). Supplementary dexameth- asone infiltration gave 45% success rate, which was insignificant with control IANB. Conclusions: Articaine and ketorolac infiltration can increase the success rate of IANB in patients with irreversible pulpitis. None of the tested techniques gave 100% success rate. (J Endod 2011;37:445–449) Key Words Articaine, dexamethasone, inferior alveolar nerve block, irreversible pulpitis, ketorolac M anagement of endodontic pain is an important factor in reducing fear and anxiety in endodontic procedures. Thorough knowledge of local anesthetic solutions and proper use of local anesthesia techniques are necessary for pain-free dental treatment (1). The inferior alveolar nerve block (IANB) is the standard and most commonly used technique for achieving pulpal anesthesia for mandibular endodontic procedures. The IANB has high failure rate especially in patients with irreversible pulpitis (2–7). Various mechanisms have been proposed in the past to explain the high failure rate of IANB. The most plausible explanation can be the activation of nociceptors by inflammation and associated central mechanisms (8–10). Inflammatory mediators reduce the threshold for activation of nociceptor neurons to a point that a minor stimulus now might fire these neurons (10). This inflammatory process is mediated via prostaglan- dins, which are end products of arachidonic acid metabolism, produced via cycloox- ygenase pathway (11, 12). Prostaglandins act by sensitizing nerve endings to bradykinins and histamines, hence enhancing the pain and tenderness of inflammation (7–9, 12–14). It has been shown that inflamed pulps have high levels of arachidonic acids and their metabolites. Also, high levels of arachidonic acid metabolites in dental pulps have been associated with presence of pain. Ketorolac tromethamine was developed as an intramuscular nonsteroidal anti- inflammatory drug (NSAID) with potent prostaglandin synthesis inhibition efficacy. It is a pyrrolo-pyrrole derivative and is as effective as morphine or meperidine for pain relief after orthopedic or disk surgery (15–17). It seems logical (18) to deposit an anti-inflammatory drug near the tooth to decrease the effect of inflammatory mediators and increase the success rates. Also, administration of NSAID before pain onset will lead to a therapeutic level at the time of pain onset. Penniston and Hargreaves (18) have shown that periapical infiltration of ketorolac tromethamine can provide significant analgesic effects. But some authors have shown that periapical infiltration of ketorolac tromethamine can cause severe transient injection pain, leading to discontinuation of the treatment (19). Another preventive strategy for reduction of intraoperative endodontic pain might be the use of glucocorticoids (20, 21). Dexamethasone is a potent glucocorticoid with anti-inflammatory efficacy 25 times that of hydrocortisone. Mehrvarzfar et al (22) have shown that supraperiosteal infiltration of dexamethasone can reduce or even prevent postoperative pain in patients with irreversible pulpitis. Corbett et al (23) found that efficacy of buccal or buccal plus lingual infiltrations of 4% articaine with epinephrine for first molar pulp anesthesia was similar to that of an IANB by using lidocaine with epinephrine. Aggarwal et al (4) have shown that supple- mental periapical infiltrations of 4% articaine can significantly increase the success rate in patients with irreversible pulpitis. Various authors have shown that only buccal or From the *Department of Conservative Dentistry and Endodontics, Faculty of Dentistry, Jamia Millia Islamia, New Delhi; and † Department of Conservative Dentistry and Endodontics, Institute of Dental Sciences and Technology, Mod- inagar, India. Address requests for reprints to Dr Vivek Aggarwal, Depart- ment of Conservative Dentistry and Endodontics, Faculty of Dentistry, Jamia Millia Islamia, New Delhi, India. E-mail address: drvivekaggarwal@gmail.com 0099-2399/$ - see front matter Copyright ª 2011 American Association of Endodontists. doi:10.1016/j.joen.2011.01.016 CONSORT Randomized Clinical Trial JOE — Volume 37, Number 4, April 2011 Effect of Ketorolac and Dexamethasone Infiltration along with Standard IANB on Irreversible Pulpitis 445