How can local anaesthesia be improved in the management of irreversible pulpitis?

Background Pain management in endodontic treatment is often managed with local anaesthetic, occasionally supplemented with oral medication. Currently, there is little evidence to suggest the best combination of local anaesthetic and oral medication to provide optimal pain control in symptomatic irreversible pulpits. A network meta-analysis was carried out to identify the best agent/technique for pulpal anaesthesia in both the maxilla and mandible in irreversible pulpits.Methods Electronic searches of Medline, Cochrane Central and Google Scholar. Reference lists of suitable studies along with manual searches to identify further appropriate studies were also carried out. Sixty-one randomised controlled trials (RCTs) were identified, investigating different local anaesthetic agents, methods of administration, and the adjunct use of medications and alternative therapies. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used for data collection. Heterogeneity was assessed using chi-squared and I2 tests. Studies comparing the same interventions were pooled to define direct comparison estimates. A common comparator was used to compare indirect comparison estimates. Odds ratio and 95% confidence intervals were used to estimate effect.Results The results were presented on forest plots; 53 studies investigated irreversible pulpitis in the mandible, seven studies in the maxilla and one in both. In the mandible, inferior alveolar nerve block (IANB) with 2% lidocaine was the control. Direct comparison of outcomes found that the best interventions in the mandible were pre-medication with aceclofenac and paracetamol followed by IANB, or IANB with 2% lidocaine with buccal infiltration with 4% articaine, both compared to the control alone. Indirect comparison found pre-medication with ibuprofen and paracetamol before IANB to be the best intervention compared to the control. No significant differences were found between the interventions in the maxilla.Conclusion The quality of all the included evidence was very low and further studies need to be carried out, focusing on larger sample sizes and better quality of studies.