The conventional technique of lower alveolar nerve block continues to be the most widely used anesthetic method in the approach to posterior mandibular teeth. However, this method can negatively affect the operative workflow, as it is subject in itself to a failure rate of up to 20-25%, subject to a further increase – from 30 to 90% – in case of concomitant irreversible acute pulpitis. The phenomenon, not limited to the site under consideration, has not yet been fully understood. Therefore, several methods are proposed in order to overcome the problem: recourse to alternative methods with higher success rates, additional injections (to be adopted under specific conditions), increase in the pharmacological dosage, intervention on quantitative additives (increase in concentration of vasoconstrictor), or qualitative (intervention on pH, introduction of vasoconstrictors, not catecholamines). Finally, one option is to use premedication methods for the anesthetic procedure.

This alternative was recently considered in a systematic review published in BioMed Research International, which included a total of 35 papers from the PubMed and Cochrane databases. Some of the most significant conclusions are given below.

It is important to point out that the aim is not to carry out a standardized clinical protocol; the administration of a drug is a choice that is always up to the doctor because of the general and specialized clinical picture of the patient   at the time of treatment.

NSAIDs: can they help in lower alveolar nerve block?

The pharmacological class to which most of the attention has been devoted is logically represented by NSAIDs. A meta-analysis of 2017 established that these drugs are able to increase the effectiveness of the lower alveolar nerve block regardless of local anesthetic, volume, and any additional injections. Specifically, ibuprofen is the most studied molecule in this field. Used alone, this drug has actually provided conflicting indications and, therefore, contrary to the general consideration mentioned above, the current indication is to prefer the use combined with mepivacaine as a local anesthetic.

The same ibuprofen has also been studied in combination with different molecules. In particular, reference should be made to paracetamol, with which it constitutes a duo of drugs widely used in pediatric patients. Recent studies have also confirmed the efficacy of the combination ibuprophene-paracetamol in the implementation of the anesthetic method in question.

Ibuprofen, a molecule derived from propionic acid, is, as mentioned, the most documented NSAID in combination with the lower alveolar nerve block. This is now the standard in the procedure; however, it is not exclusive in this regard. In fact, there is a certain interest in the subclass of oxicam, i.e. the derivatives of enolic acid. Ketorolac has also provided good indications in comparison with diclofenac: both molecules, in this case, belong to the group of derivatives of acetic acid.

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