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Patients experiencing irreversible inflammation of the dental pulp tend to have a less anesthetic effect of the Inferior alveolar nerve block. Aim of this study was to assess the role of preoperative administration of alprazolam along with inferior alveolar nerve block in patients experiencing permanent damage to the dental pulp. This study included one hundred patients experiencing severe inflammation of the dental pulp involving the mandibular molars and was a potentially randomized double blinded study. 45 minutes prior to administration of the inferior alveolar nerve block the patients were either given 0.5mg of alprazolam or a placebo drug. An interval of 15 minutes was given between the IAN block injection and the initiation of access cavity preparation. Lack of sensation in the lip area was noted for all patients.

A visual analogue scale recording was used for every patient to record any stimuli to pain during cavity preparation and initial instrumentation. No or mild response to pain was recorded as a successful outcome. The information was examined using t test and chi square test. The patients given preoperative alprazolam had 52% rate of success. The success rate was 44% (the P value = 0.402), in the control group, showing no statistically significant difference. Giving preoperative 0.5mg alprazolam did not improve the effectiveness of the IAN block in patients with permanent deterioration of the dental pulp.

Key Words: Alprazolam, inferior alveolar nerve block, irreversible pulpitis, anxious patients.


When carrying out root canal treatments, the primary aim of the dentist is to achieve adequate local anesthesia.1 When treating mandibular molars the standard approach to achieve localized numbness is to administer an inferior alveolar nerve block.2

Psychological factors are one of the most common causes of failure of the IAN block. Anxious patients experiencing severe dental pain tend to have a decreased effect of the anesthesia. Alprazolam, most commonly used to treat agitated patients is an anxiolytic drug belonging to the new generation of 1,4 benzodiazepines, is also used as an antidepressant and also to tend to patients having nervousness.5 The Corah Dental Anxiety Scale is the most frequently used dental anxiety scale and is easy to use.6

Many studies have been conducted to refine the failure of inferior alveolar nerve block such as Lindemann and co-authors have deduced the impact of sublingual triazolam and another study using triazolam showed 43% success compared to 57% success with the placebo drug, showing no notable difference (P=.43) between the two groups.7 Ehrich and co-authors concluded that triazolam is safe and superior to diazepam as anxiolytic in patient with endodontic pain.

As the above mentioned studies show, the variability of results in terms of efficacy provides with a strong rationale to conduct this study in our population. A review of literature shows that no local studies have been conducted to evaluate the efficacy of preoperative alprazolam.

The purpose for conducting this research was to determine the efficacy of administering 0.5mg of alprazolam orally before starting the procedure, on the success of inferior alveolar nerve block with 2% lignocaine containing 1:100 000 epinephrine for patient with symptoms of permanent pulpal damage and to provide pain free treatment in anxious patients with irreversible pulpitis.


One hundred patientstook part in the study (fifty of which were in alprazolam group and fifty patients in control group). Sample size calculated by WHO calculator. Approval was taken from the ethical committee. Risks and benefits were discussed with each patientand a verbal and written consent was obtained from the patient, both in English and Urdu languages. Data were collected by non-probability consecutive sampling technique.

Inclusion Criteria:

* Patients of either sex.

* Patients aged from 18 to 65 years.

* Moderate or severe pain in a rst or second mandibular molars, vital mandibular molar teeth asses clinically.

* Patient with moderate anxiety level score > 9.

* Informed consent granted.

* Patient history of spontaneous pain lasts for more than 30 seconds with VAS score 3-6 (moderate pain) or 7-10(severe pain) after removal of cold stimulus and is confirmed by cold testing.

Exclusion Criteria:

* Pregnant patients.

* Patient allergy to benzodiazepine group of drug.

* History of significant medical problems such as; COPD, sleep apnea, myasthenia gravis.

* Lactating patients.

* Patients with no reaction to cold testing.

* Inability to give informed consent.

* Patients who receive intrapulpal and buccal infiltration with inferior alveolar nerve block.

Preoperative pain scoring by visual analogue scale (VAS) will determine the pain level and preoperative anxiety level by Corah dental anxiety scale will determine the patient anxiety level. The study is double blind study as the patient and investigator are unaware of the given medication. Sealed envelope method technique is used for randomizing the symptomatic irreversible pulpitis patient. Envelopes of same size and colors will be placed in a box by an independent person having labels as A and B along with 0.5mg alprazolam in one envelope and placebo (same color and size of alprazolam) in another envelope. The patient will be asked to pick one envelop and open it show the label to independent person and take the medicine inside the envelope 45 min before giving IANB using1.8ml of 2% lignocaine containing 1:100 000 epinephrine injected with a metallic syringe.

After 15 min three steps would be performed to check the IANB success in both groups (1) lip numbness (2) cold test (3)none or mild pain during endodontic access and initial instrumentation.


Out of 100 patients half of them were males and half were females. The age range was 20 to 50 years with an average age range of 30+-5 years. There wasno notable change between gender, age, preoperative pain level and Corah dental anxiety scale between two groups (P>.05). There was no statistically significant difference in success rate between two groups (P= .402). It has been analysed thatIANB is more effective in mandibular first molars when two groups were compared.




Total subjects###50###50

Age range###20-50###20-50###.576





pain level*

Corah dental###10.2(4.5)###11.5(4.3)###.137

anxiety scale



No###24/50 48%###28/50 56%

Yes###26/50 52%###22/50 44%


Tooth Type###Placebo###Alprazolam

###group(n=50)###Group (N=50)

First Molar###19/40 (47.5%)###21/39 (53.8%)

Second Molar###3/10 (30%)###5/11 (45.4%)


The initial pain and anxiety levels of the patients were not remarkably distinct in both categories of patients, those receiving alprazolam and those receiving the placebo drug. The outcome of this study is similar to the results of Lindemann et al7 in which they stated that 0.25mg of sublingual triazolam could not improve the effectiveness of the inferior alveolar nerve block. It has been previously demonstrated in various unconscious patients studies such as Aissaoui et al8, young et al9 and Jackson and Johnson10, that conscious sedation during dental treatment has little or no effect on the pain threshold of the patients. The outcome of this study also correlates to the results of these studies. Minimizing the anxiety levels during endodontic treatment have shown a greater rate of patient satisfaction7, however this was not the focus of this study.

With reference to Malamed, it has been stated that the density of the mandible, minimal accessibility of the nerves and anatomical variations are some of the major reasons for failure to achieve successful local anesthesia in up to 20% of IANB injections11. Pre-existing agitation and fear of patients also causes reduced efficacy of the local anesthetic solution, as proved by Milgrom12. Psychological factors are one of the potential causes of IANB failures in patients who complain of pain even after receiving adequate local anesthetic injections.13

The use of benzodiazepines are commonly indicated for patients who have difficulty in achieving adequate local anesthesia due to its wide range of therapeutic index and rapid relieving properties.14

Various studies such as Oleson and co-authors, simpson and co-author16, Noguera-Gonzalez D and coauthor17 have shown an increased success rate of the IANB injections if the patients are administered preoperative analgesics.


This study showed negligible change in the potency of the IANB, in patients suffering from acute dental pain due to irreversible pulpitis, after prescribing oral anxiolytics however, it may have a positive effect on reducing the anxiety levels, making the patient and operator more comfortable during the procedures. These results could be re-verified using a larger sample size.


1 Webster Jr SW. Supplemental Intraseptal Anesthesia in Patients with Symptomatic Irreversible Pulpitis: The Ohio State University; 2015.

2 Nusstein JM, Reader A, Drum M. Local anesthesia strategies for the patient with a "hot" tooth. Dent Clin North Am. 2010;54(2):237-47.

3 Stanley W, Drum M, Nusstein J, Reader A, Beck M. Effect of nitrous oxide on the efficacy of the inferior alveolar nerve block in patients with symptomatic irreversible pulpitis. J Endod . 2012;38(5):565-69.

4 Cabrera CG, De Waisbaum RG, Nudelman NS. Kinetic and mechanistic studies on the hydrolysis and photodegradation of diazepam and alprazolam. Journal of physical organic chemistry. 2005;18(2):156-61.

5 Castaneda B, Ortiz-Cala W, Gallardo-Cabrera C, Nudelman NS. Stability studies of alprazolam tablets: effects of chemical interactions with some excipients in pharmaceutical solid preparations. Journal of Physical Organic Chemistry. 2009;22(9):807-14.

6 Marginean I, Filimon L. Modified Dental Anxiety Scale: A Validation study on Communities from the West Part of Romania. International Journal of Education and Psychology in the Community. 2012;2(1).

7 Lindemann M, Reader A, Nusstein J, Drum M, Beck M. Effect of sublingual triazolam on the success of inferior alveolar nerve block in patients with irreversible pulpitis. Journal of endodontics. 2008;34(10):1167-70.

8 Aissaoui Y, Zeggwagh AA, Zekraoui A, Abidi K, Abouqal R. Validation of a behavioral pain scale in critically ill, sedated, and mechanically ventilated patients. Anesthesia and Analgesia. 2005;101(5):1470-76.

9 Young J, Siffleet J, Nikoletti S, Shaw T. Use of a Behavioural Pain Scale to assess pain in ventilated, unconscious and/or sedated patients. Intensive and Critical Care Nursing. 2006;22(1):32-39.

10 Southerland JH, Brown LR. Conscious intravenous sedation in dentistry: a review of current therapy. Dental Clinics. 2016;60(2):309-46.

11 Feck AS, Goodchild J. The use of anxiolytic medications to supplement local anesthesia in the anxious patient. Compendium. 2005;26(3):183-90.

12 Milgrom P, Newton JT, Boyle C, Heaton LJ, Donaldson N. The effects of dental anxiety and irregular attendance on referral for dental treatment under sedation within the National Health Service in London. Community dentistry and oral epidemiology. 2010;38(5):453-59.

13 Ajarmah JA, Tbashat JM, Omor RA, Rassas EA, Rman KKA. Operators experience and the success rate of inferior alveolar nerve block anesthesia. Pakistan Oral and Dental Journal. 2013;33(1).

14 Shetkar P, Jadhav GR, Mittal P, Surapaneni S, Kalra D, Sakri M, et al. Comparative evaluation of effect of preoperative alprazolam and diclofenac potassium on the success of inferior alveolar, Vazirani-Akinosi, and Gow-Gates techniques for teeth with irreversible pulpitis: Randomized controlled trial. Journal of conservative dentistry: JCD. 2016;19(5):390.

15 Oleson M, Drum M, Reader A, Nusstein J, Beck M. Effect of preoperative ibuprofen on the success of the inferior alveolar nerve block in patients with irreversible pulpitis. J Endod. 2010;36(3):379-82.

16 Simpson M, Drum M, Nusstein J, Reader A, Beck M. Effect of combination of preoperative ibuprofen/acetaminophen on the success of the inferior alveolar nerve block in patients with symptomatic irreversible pulpitis. J Endod. 2011;37(5):593-97.

17 Noguera-Gonzalez D, Cerda-Cristerna B, Chavarria-Bolanos 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. J Endod. 2013;46(11):1056-62.
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Publication:Pakistan Oral and Dental Journal
Article Type:Clinical report
Date:Mar 31, 2018

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