Mepivacaine-Tramadol on the Success of Inferior Alveolar Nerve Block in Symptomatic Irreversible Pulpitis

Symptomatic Irreversible Pulpitis Clinical Trial

Official title:

Efficacy of the Combination Mepivacaine-Tramadol on the Success of Inferior Alveolar Nerve Block in Patients With Symptomatic Irreversible Pulpitis: a Randomized Clinical Trial.

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT02110966
• Other study ID #: CEIFE-008-014
• Status: Completed
• Phase: Phase 4
• First received: April 8, 2014
• Last updated: October 30, 2014
• Start date: April 2014
• Est. completion date: October 2014

Study information

• Verified date: October 2014
• Source: Universidad Autonoma de San Luis Potosí
• Contact: n/a
• Is FDA regulated: No
• Health authority: Mexico: Ethics Committee
• Study type: Interventional

Clinical Trial Summary

The purpose of this study is to evaluate the success of inferior alveolar nerve block, after the local application of Mepivacaine plus Tramadol in patients with symptomatic irreversible pulpitis. Also, to evaluate the duration of the anesthetic effect when using Mepivacaine plus Tramadol in the same anesthetic technique and patients group.

Hypothesis:

Local application of mepivacaine plus tramadol increases the successful of inferior alveolar nerve block in patients with irreversible pulpitis.

Description:

The treatment of pain is an integral part of Endodontics, this must be controlled before, during and after treatment. The inferior alveolar nerve block is the most common anesthetic technique used in mandibular teeth during endodontic treatments. Several studies have reported that it is more difficult to obtain anesthetic success in patients with irreversible pulpitis. There is a 33-80% of failure in the inferior alveolar nerve block in patients with irreversible pulpitis.

Some of the more accepted theories for local anesthetic failure establish that inflammation induce tissue acidosis causing ion traping of the local anesthetics enabling the molecules to cross the cell membrane, also inflammatory mediators may sensitize the neurons by interacting with specific receptors leading to periphery sensibilization. Tissue injury may alter the composition, distribution and activity of sodium channels expressed on nociceptors and this may have profound implications in local anesthetic failure. On the other hand, there is a specific group of tetrodotoxin resistant sodium channels four times less sensitive to lidocaine which increase their activity during inflammation.

Some ways to control pain is through pharmacological synergism. Tramadol has been proposed as pharmacological adjuvant to local anesthesia and it can improve the anesthetics success and the duration of the anesthetic effect. However, oral administration of drugs can cause adverse systemic effects, and that's why local application is an alternative to increase its concentration on the local damaged tissue reducing the possibility of interactions with other drugs and adverse effects. Another advantage of the combination of Mepivacaine with Tramadol is that it reduces the number of injections in patients and it is less traumatic.

Tramadol is centrally acting drug but also a local anesthetic and analgesic effect it has been reported. It acts at multiple sites producing different action mechanisms. Some studies suggest that the use of Tramadol can improve the effect of Mepivacaine in the inferior alveolar nerve block. The blockade of the nervous conduction with Tramadol is 80% more effective if it is compared with some anesthetics like lidocaine.

There are few studies evaluating local application of tramadol. In the field of dentistry tramadol using for local anesthetic adjuvant has been studied in oral surgery, so it is important to evaluate it in the field of endodontics to provide better pain management during treatments.

Thus, the aim of the study is to evaluate the success of inferior alveolar nerve block with the local application of Mepivacaine plus Tramadol in patients with symptomatic irreversible pulpitis, and also to evaluate the duration of the anesthetic effect when using Mepivacaine plus Tramadol in the anesthetic technique. This study was designed as a double-blind, randomized clinical trial. Following the guidelines suggested by CONSORT group for planning and reporting clinical trials. The ethics committee of the Faculty of Dentistry of San Luis Potosi University approved the study design. All of the subjects will be informed of the possible risk of endodontic therapy and experimental treatments and will sign institutionally approved consents forms.

In total 50 patients will be included in this study. The sample size calculation was performed with a Type I error of 0.05 and statical power of 80% using the difference in duration of anesthetic effect between two groups and taking into account previous studies related to the local effect of tramadol in clinical studies where it is used to assess the time of anesthetic effect.

All the subjects voluntarily will presented at the Postgraduate Endodontics Clinic of the Faculty of Dentistry at San Luis Potosi University. The select subjects will have a diagnosis of symptomatic irreversible pulpitis in the first and second mandibular molars.

The patients will be diagnosing with the cold test and they will indicate their pain scores using numerical rating scale, this is a 11 point scale where the ends points are the extremes of no pain and the worst pain. Accordingly, no pain corresponded with 0, mild pain with 1-3, moderate pain with 4-6 and severe pain 7-10. The control group will receive the inferior alveolar nerve block using 1.8 ml of Mepivacaine 2% epinephrine 1: 100000 and 1.3 ml of Mepivacaine 2% epinephrine 1:100000 mixed with 0.5 ml of Tramadol (50mg/ml) will be used for the anaesthetic blockade in the experimental group. After 15 minutes, the anesthetic blockade will be assessed by a three step examination: lip numbess, positive/negative response to cold testing and clinical discomfort during endodontic access. Inferior alveolar nerve block success will be defined as the absence of pain during any of these evaluations and if patients report pain an analogue visual scale will be used.

Statics normal distribution will be tested by the student's t test. A non-parametric chi- squared test was performed to identify statistically differences between the groups; the level of significance was set at p˂ 0.05.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 56
• Est. completion date: October 2014
• Est. primary completion date: October 2014
• Accepts healthy volunteers: Accepts Healthy Volunteers
• Gender: Both
• Age group: 18 Years to 50 Years

Eligibility

Inclusion Criteria:

• Subjects diagnosed with symptomatic irreversible pulpitis in the first and second mandibular molars.

Exclusion Criteria:

• Pregnancy

• Hypersensitivity to local anesthetics and Tramadol

• Teeth with insufficient tooth structure for restoration, periodontal disease, root resorption, root fracture

• Systemic diseases: diabetes, uncontrolled hypertension.

• Patients taking drugs or narcotics.

• Patients who have used analgesics in the last 8 hours.

• Patients ingested IMAOS and tricyclic antidepressants 14 days before.

• Patients ingested carbamazepine (anticonvulsants)

• Patients in active treatment with ketoconazole and erythromycin.

Study Design

Allocation: Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Parallel Assignment, Masking: Double Blind (Subject, Investigator), Primary Purpose: Treatment

Related Conditions & MeSH terms

• Pulpitis
• Symptomatic Irreversible Pulpitis

Intervention

Drug:
• Mepivacaine
Drug: Tramadol 1.8 ml of Mepivacaine 2% epinephrine 1:100000.
• Mepivacaine plus Tramadol
0.5 ml of Tramadol mixed with 1.3 ml of Mepivacaine.

Locations

Country	Name	City	State
Mexico	Endodontics Master Degree program, Dentistry Faculty, San Luis Potosi University	San Luis Potosi

Sponsors (1)

Lead Sponsor	Collaborator
Daniel Chavarría Bolaños

Country where clinical trial is conducted

Mexico, 

References & Publications (18)

Altunkaya H, Ozer Y, Kargi E, Ozkocak I, Hosnuter M, Demirel CB, Babuccu O. The postoperative analgesic effect of tramadol when used as subcutaneous local anesthetic. Anesth Analg. 2004 Nov;99(5):1461-4; table of contents. — View Citation

Ceccheti MM, Negrato GV, Peres MP, Deboni MC, Naclério-Homem Mda G. Analgesic and adjuvant anesthetic effect of submucosal tramadol after mandibular third molar surgery. Oral Surg Oral Med Oral Pathol Oral Radiol. 2014 Mar;117(3):e249-54. doi: 10.1016/j.o — View Citation

Cohen HP, Cha BY, Spångberg LS. Endodontic anesthesia in mandibular molars: a clinical study. J Endod. 1993 Jul;19(7):370-3. — View Citation

Güven M, Mert T, Günay I. Effects of tramadol on nerve action potentials in rat: comparisons with benzocaine and lidocaine. Int J Neurosci. 2005 Mar;115(3):339-49. — View Citation

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Henry MA, Hargreaves KM. Peripheral mechanisms of odontogenic pain. Dent Clin North Am. 2007 Jan;51(1):19-44, v. Review. — View Citation

Isiordia-Espinoza MA, Orozco-Solis M, Tobías-Azúa FJ, Méndez-Gutiérrez EP. Submucous tramadol increases the anesthetic efficacy of mepivacaine with epinephrine in inferior alveolar nerve block. Br J Oral Maxillofac Surg. 2012 Mar;50(2):157-60. doi: 10.101 — View Citation

Isiordia-Espinoza MA, Pozos-Guillén AJ, Martínez-Rider R, Herrera-Abarca JE, Pérez-Urizar J. Preemptive analgesic effectiveness of oral ketorolac plus local tramadol after impacted mandibular third molar surgery. Med Oral Patol Oral Cir Bucal. 2011 Sep 1; — View Citation

Kapral S, Gollmann G, Waltl B, Likar R, Sladen RN, Weinstabl C, Lehofer F. Tramadol added to mepivacaine prolongs the duration of an axillary brachial plexus blockade. Anesth Analg. 1999 Apr;88(4):853-6. — View Citation

Kargi E, Babuccu O, Altunkaya H, Hosnuter M, Ozer Y, Babuccu B, Payasli C. Tramadol as a local anaesthetic in tendon repair surgery of the hand. J Int Med Res. 2008 Sep-Oct;36(5):971-8. — View Citation

Noguera-Gonzalez D, Cerda-Cristerna BI, Chavarria-Bolaños D, Flores-Reyes H, Pozos-Guillen A. Efficacy of preoperative ibuprofen on the success of inferior alveolar nerve block in patients with symptomatic irreversible pulpitis: a randomized clinical trial. Int Endod J. 2013 Nov;46(11):1056-62. doi: 10.1111/iej.12099. Epub 2013 Apr 6. — View Citation

Pozos AJ, Martinez R, Aguirre P, Perez J. The effects of tramadol added to articaine on anesthesia duration. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006 Nov;102(5):614-7. Epub 2006 Jul 27. — View Citation

Pozos AJ, Martínez R, Aguirre P, Pérez J. Tramadol administered in a combination of routes for reducing pain after removal of an impacted mandibular third molar. J Oral Maxillofac Surg. 2007 Aug;65(8):1633-9. — View Citation

Robaux S, Blunt C, Viel E, Cuvillon P, Nouguier P, Dautel G, Boileau S, Girard F, Bouaziz H. Tramadol added to 1.5% mepivacaine for axillary brachial plexus block improves postoperative analgesia dose-dependently. Anesth Analg. 2004 Apr;98(4):1172-7, tabl — View Citation

Sawynok J. Topical and peripherally acting analgesics. Pharmacol Rev. 2003 Mar;55(1):1-20. Review. — View Citation

Stein C, Lang LJ. Peripheral mechanisms of opioid analgesia. Curr Opin Pharmacol. 2009 Feb;9(1):3-8. doi: 10.1016/j.coph.2008.12.009. Epub 2009 Jan 20. Review. — View Citation

Walton RE, Torabinejad M. Managing local anesthesia problems in the endodontic patient. J Am Dent Assoc. 1992 May;123(5):97-102. — View Citation

Wang JT, Chung CC, Whitehead RA, Schwarz SK, Ries CR, MacLeod BA. Effects of local tramadol administration on peripheral glutamate-induced nociceptive behaviour in mice. Can J Anaesth. 2010 Jul;57(7):659-63. doi: 10.1007/s12630-010-9301-9. Epub 2010 Mar 2 — View Citation

* Note: There are 18 references in all — Click here to view all references

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	success of the inferior alveolar nerve block	The anesthetic blockade will be assessed by a three step examination: lip numbess, positive/negative response to cold testing and clinical discomfort during endodontic access. Inferior alveolar nerve block success will be defined as the absence of pain during any of these evaluations and if patients report pain an analogue visual scale will be used. Also, the patient will reported the level of pain in the application of the inferior alveolar nerve block using mepivacaine and mepivacaine plus tramadol and local and systemic side effects will be monitored.	0-30 minutes	Yes
Secondary	Anesthetic effect duration	The time of the anesthetic effect will be evaluated in patients in whom anesthetic success is achieved, and also the consume of emergency and rescue post-operative analgesics. Side effects will also be monitored during this period.	0-14 hours	Yes