Jordi Ortega-Martínez1*, Elvira Ferrés-Amat2, Eduard Ferrés-Padró3 and Federico Hernández-Alfaro4
1Professor, Medicine, Surgery and Oral Implantology Department, Dental School, International University of Catalonia, Spain
2DDS, A. Professor, Medicine, Surgery and Oral Implantology Department, Dental School, International University of Catalonia, Spain
3Professor, Medicine, Surgery and Oral Implantology Department, Dental School, International University of Catalonia, Spain
4Professor and Head of Department of Medicine, Surgery and Oral Implantology, Dental School, International University of Catalonia, Spain
Received: 19 June, 2017; Accepted: 28 June, 2017; Published: 29 June, 2017
Jordi Ortega-Martínez, Faculty of Dentistry. Universitat Internacional de Catalunya, Josep Trueta s/n 08195, Sant Cugat del Vallès, Barcelona, Spain, E-mail:
Ortega-Martínez J, Ferrés-Amat E, Ferrés-Padró E, Hernández-Alfaro F (2017) Prospective clinical trial on the effectiveness of Topical Anesthetic in second stage surgeries of Dental Implants. J Dent Probl Solut 4(3): 048-053
© 2017 Ortega-Martínez J, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Anaesthetics; Topical anaesthesia; Oral mucosa; Dental implants; Second stage surgery
Objectives: The aim of this study is to evaluate the effectiveness of gel topical anaesthesia in second surgeries of dental implants according to the different treated areas of the oral cavity, as well as the type of oral mucosa in which is effective.
Material and methods: Thirteen partially and completely edentulous patients with 30 implants in total were included in the study. The oral mucosa was dried and the anesthetic gel (Benzocaine 20%) was applied with a cotton roll for 2 minutes. The effectiveness was evaluated with an exploratory probe. Those implants whose cover screw was not submerged in a depth higher than 2-4 mm were selected. In the event of the gel topical anaesthesia not being effective, reinforcement with conventional infiltrative anaesthesia was made. Pain was measured with Visual Analogue Scales (VAS), and the gum thickness with periodontal probe. A one-way Anova and a Pearson correlation were used to perform the statistical analysis (p≤0.05).
Results: The 66.67% of the sample needed reinforcement through conventional anesthetic infiltration. No statistically significant differences were found in the comparison of pain with different gum thickness (p=0.59), although a higher feeling of pain was actually observed in those patients who were firstly subjected to a second-stage surgery (p=0.0335).
Conclusion: The use of gel topical anaesthesia cannot be considered as the sole treatment to eliminate the feeling of pain, but as a coadjuvant to infiltrative anesthesia. No significant differences have been found between the different treated areas of the oral cavity, nor in the thickness or type of oral mucosa
Pain is one of the most ancient worries of human being and was considered as a natural event of human body. The development of basic sciences allowed the control of pain to carry out certain surgical acts .
In view of the need of painless dental treatments, turning to anesthesiology becomes necessary. The percentage of patients having fear of the anesthetic injection is especially high [1-4].
Topical anesthetic has been used for decades with certain indications regarding intra-oral use, with the particular aim of eliminating the painful feeling produced by the infiltration of other local anesthetics or the reduction of nauseas in diagnostic procedures, which affect the pharyngeal area, such as exploring the pharyngeal or laryngeal area or endoscopies of high digestive via [1,2,5-7].
So far the use of topical anaesthesia in dentistry has been more popular between those specialized in pediatric dentistry, but the great demand of adult patients for an initial topical anaesthesia to avoid pain produced by needle has lead to the development by the chemical industry of gels and nebulizers with ideal effectiveness and non-toxic for human beings [1,6,8,9]. Topical anaesthesia acts on the terminal nervous branches of the superficial mucosa [10,11]. Therefore, it can be assumed that in an intervention affecting only this area, with restricted depth, an unnecessary anesthetic puncture might be avoided.
Currently, dental implants used in prosthetic oral rehabilitation can be made in a surgical stage (with the healing cap initially exposed to the oral medium) or in two surgical stages (implant submerged under the gum and not exposed to the oral cavity) [12-14].
Second-stage surgeries of dental implants are made in implants that have been submerged placed and must be uncovered through a second surgical act in order to conform the surrounding mucosa and perform the prosthetic restoration to be supported [13,14]. They are frequently made in a very thin keratinized gum or free gingivae in which the implant cover screw is visible, and rising up the periosteum is not necessary to have it removed [15,16]. The patient comes from a dental implant surgery in which has experienced several punctures. The trauma that might suffer the patient before a new puncture to infiltrate anaesthesia could be worse than applying topical anaesthesia with a minimum surgical incision.
Several studies are focused on the possibility of avoiding this second surgical act to simplify the treatment and for the sake of convenience. Those studies compare both protocols (1 stage vs. 2 stages), as well as its indications and contraindications, although due to different clinical situations, such as the lack of primary stability or absence of keratinized mucosa, second-stage surgeries remain as an essential procedure [13,14,17,18].
The aim of this study is to prove that the use of topical anaesthesia is effective in oral surgical operations as second-stages to uncover the cover screw of a dental implant when it is already submerged. The null hypothesis is that topical anaesthesia is insufficient to eliminate pain in second surgeries of dental implants, and there are no differences in the effectiveness between maxilla and mandible. The Scientific Investigation Ethics Committee of the Universitat Internacional de Catalunya has approved this study.
Material and Methods
A data collection sheet was filled with the name, age, sex, intervention date, implants details, gingival biotype and the location are of the implant for every 13 patient, who also signed an specific inform consent of the study.
Inclusion and exclusion criteria
Patients who were made a second surgical stage of dental implants were included in the study. Therefore, the inclusion criteria will be the same than the criteria of the first stage. The inclusion criteria for implant placement were the following: patients with physical and psychical normality conditions, partial or complete edentulous selected to be treated with implants, non-smokers or controlled smokers (10 cigarettes /day maximum), healthy patients or whose local or systemic disease is controlled and does not contraindicate any type of implantological oral surgery.
Those patients who had not signed the informed consent of surgery and implants, those allergic to any component of the conventional local anaesthesia (infiltrative or topical), having active neoplasia, uncontrolled systemic disease or contraindicating the placement of dental implants were not candidates for its placing and therefore a second surgery would not be possibly done without a first one.
The specific inclusion criteria of the second-stage surgery of dental implants were that of the patients who had been subjected to a surgical treatment with implants and whose healing screw was superficially submerged (up to 4 mm measured with a periodontal probe once the topical anesthetic has taken effect).
All those patients who presented allergies to any type of component of the anesthetics, pregnancy, those who had not signed the surgery informed consent, who have had any type of analgesic in the last 24 hours or who have had peri-implant pathology during the healing period were excluded.
Every measurement was made by the same researcher in order to avoid discrepancies or possible bias. The evaluation of the implant depth was visually made, whereas the probing was carried out with a conventional exploratory probe in order to localize the cover screw; the measurement was done with a periodontal probe over the area, once the topical anaesthetic had been applied and its effect checked.
Application of the anaesthetic solution
A 0.12% Clorhexidine solution must be locally applied on the area to be treated (where the dental implant is localized) and dried with sterile gauze conventionally used in dentistry in order to favour the diffusion of the anesthetic preparation. The preparation (Hurricaine, 20%, Benzocaine, Laboratorios Clarben S.A. Madrid, Spain) impregnated in a cotton pellet was applied onto the area during a period of at least 2-3 minutes.
In the event of pain during the measurement, an injected anesthetic reinforcement (Ultracaín, 4% Articaine, Epinephrine 1:100.000, Laboratorios Normon S.A. Madrid, Spain) was applied, thereby avoiding that feeling to the patient during the treatment.
The pain perceived was recorded with the Visual Analogue Scale (VAS), which comprises a 10 cm line representing the continuous spectrum of the painful experience. The use of infiltrative anaesthesia required was also registered. The VAS line can be vertical or horizontal terminating in right-angles ends. Descriptions are to be found on the ends, being «no pain» at one end and «the worst conceivable pain» at the other, with no other description along the line [19,20]. The patient himself indicates his personal experience of each implant by writing a cross on the line.
Every patient underwent a previous radiographic control (periapical radiograph or orthopantomography) to estimate the localization, the conditions of the adjacent anatomic structures and the osseointegration of those implants. At the time of the surgery the implant was found visually, radiographically and with a conventional exploratory probe. At this point of the intervention, the possible discomforts of the patient were evaluated. Once the cover screw is localized, we will proceed to measure the depth at which that screw is placed with a periodontal probe (having marks which allow the exact millimeter depth measurement). If a depth higher than 2-4 mm is observed and the patient has not presented any discomfort, we will start the incision on a surface covering the dental implant with nº 3 flat handle scalpel having a scalpel blade of nº 15, 15c or 11. Once the implant was localized, its head was released by adapting the mucosa to the abutment shape. A circular scalpel or Punch having the diameter of the implant head was occasionally used. After preparing the mucosa, the cover screw is removed with a specific screwdriver and is placed in the corresponding healing abutment. The intervention area was sutured, if needed.
Whenever possible, the papillary regeneration technique proposed by Palacci was made in the second-stage surgery. With this technique, a scalloped with gingival appearance and a papillary formation is obtained since the beginning of the surgery. It consists in pushing the keratinized gingivae from the palate/lingual towards the buccal direction so as to increase the tissue volume, thereby allowing the dissection and rotation of the pedicle flat, by falciform type incisions in the periimplant areas, to subsequently create the interimplantar papillae .
The patient was not subjected to any additional pharmacological treatment, so the only recommendations were painkillers in case of discomfort and also following the postoperative instructions.
Data collection and statistical analysis
Every analyzed data were moved to the Statgraphics Plus 5.1 program to carry out the statistical study. The statistical study consisted in relating quantitative and qualitative variables in a one-way Anova study (comparison of pain with type of implant, gingival biotype, position in the arch, first surgery, sex and subject) and only quantitative variables, so a correlation multivariable analysis was used (pain vs. gingival thickness).
The percentage of patients who needed reinforcement with conventional infiltrative anesthetic was calculated using tabulation and observing the bar diagram and the pie diagram. The possible statistically significant differences were individually analyzed, between means and standard deviations. The P-value was calculated checking if it was ≤ 0.05 and the charts were observed distinguishing between level code, means and 95.0 percentages, LSD intervals and the box-and-whisker plot.
Thirteen patients were included in the present study (3 men and 10 women, mean age 62.92±18.92), with a total amount of 30 implants. Each patient presented from 2 to 12 implants to be rehabilitated.
Every patient was treated with gel topical anesthetic (Hurricaine, 20%, Benzocaine Laboratorios Clarben S.A. Madrid, Spain) and, in the event of not being effective, a conventional anaesthetic technique was applied by infiltration (Ultracaín, 4% Articaine 1:100.000 Epinefrine, Laboratorios Normon S.A. Madrid, Spain). The 66.67% of the total amount of implants required reinforcement with infiltrative anaesthetic. Therefore, the data obtained in this study support the null hypothesis, this is, that topical anesthetic is insufficient to eliminate pain in second surgeries of dental implants, and there are no differences in the effectiveness between maxilla and mandible (Figure 1).
- Meechan JG (2000) Intra-oral topical anaesthetics: a review. J Dent 28: 3-14. Link: https://goo.gl/qPamHH
- Gunsolley JC (2005) The need for pain control during scaling and root planing. Compend Contin Educ Dent 26: 3-5. Link: https://goo.gl/nVwhkH
- Meechan JG (2001) The use of EMLA for an intraoral soft-tissue biopsy in a needle phobic: a case report. Anesth Prog 48: 32-34. Link: https://goo.gl/ZhRxgH
- Meechan JG, Thomason JM (1999) A comparison of 2 topical anesthetics on the discomfort of intraligamentary injections: a double-blind, split-mouth volunteer clinical trial. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 87: 362-365. Link: https://goo.gl/9Lc7En
- Carr MP, Horton JE (2001) Clinical evaluation and comparison of 2 topical anesthetics for pain caused by needle sticks and scaling and root planing. J Periodontol 72: 479-484. Link: https://goo.gl/v123xU
- Meechan JG (2002) Effective topical anesthetic agents and techniques. Dent Clin North Am 46: 759-766. Link: https://goo.gl/4TQ9vY
- Nusstein JM, Beck M (2003) Effectiveness of 20% benzocaine as a topical anesthetic for intraoral injections. Anesth Prog 50: 159-163. Link: https://goo.gl/tzVn6e
- Kohli K, Ngan P, Crout R, Linscott CC (2001) A survey of local and topical anesthesia use by pediatric dentists in the United States. Pediatr Dent 23: 265-269. Link: https://goo.gl/XwDbCe
- Kravitz ND (2007) The use of compound topical anesthetics: a review. J Am Dent Assoc 138: 1333-1339. Link: https://goo.gl/7mPq6g
- Bhalla J, Meechan JG, Lawrence HP, Grad HA, Haas DA (2009) Effect of time on clinical efficacy of topical anesthesia. Anesth Prog 56: 36-41. Link: https://goo.gl/qNQQh9
- Roller NW, Ship II (1975) Lidocaine topical film strip for oral mucosal biopsies. J Oral Med 30: 55-58. Link: https://goo.gl/j3tUPd
- Abrahamsson I, Berglundh T, Moon IS, Lindhe J (1999) Peri-implant tissues at submerged and non-submerged titanium implants. J Clin Periodontol 26: 600-607. Link: https://goo.gl/JVrg5T
- Esposito M, Grusovin MG, Maghaireh H, Coulthard P, Worthington HV (2007) Interventions for replacing missing teeth: management of soft tissues for dental implants. Cochrane Database Syst Rev. Link: https://goo.gl/2mXZGw
- Esposito M, Grusovin MG, Martinis E, Coulthard P, Worthington HV (2007) Interventions for replacing missing teeth: 1- versus 2-stage implant placement. Cochrane Database Syst Rev. Link: https://goo.gl/krnmb1
- Oyster DK, Parker WB, Gher ME (1995) CO2 lasers and temperature changes of titanium implants. J Periodontol 66: 1017-1024. Link: https://goo.gl/CLe99J
- Yeh S, Jain K, Andreana S (2005) Using a diode laser to uncover dental implants in second-stage surgery. Gen Dent 53: 414-417. Link: https://goo.gl/y2RAHE
- Fiorellini JP, Buser D, Paquette DW, Williams RC, Haghighi D, et al. (1999) A radiographic evaluation of bone healing around submerged and non-submerged dental implants in beagle dogs. J Periodontol 70: 248-254. Link: https://goo.gl/RwyKpg
- Weber HP, Buser D, Donath K, Fiorellini JP, Doppalapudi V, et al. (1996) Comparison of healed tissues adjacent to submerged and non-submerged unloaded titanium dental implants. A histometric study in beagle dogs. Clin Oral Implants Res 7: 11-19. Link: https://goo.gl/Zdp82g
- Downie WW, Leatham PA, Rhind VM, Wright V, Branco JA, et al. (1978) Studies with pain rating scales. Ann Rheum Dis 37: 378-381. Link: https://goo.gl/wiXnJb
- Price DD, McGrath PA, Rafii A, Buckingham B (1983) The validation of visual analogue scales as ratio scale measures for chronic and experimental pain. Pain 17: 45-56. Link: https://goo.gl/umduVg
- Palacci P, Nowzari H (2008) Soft tissue enhancement around dental implants. Periodontol 2000 47: 113-132. Link: https://goo.gl/kJn9hB
- Stoltenberg JL, Osborn JB, Carlson JF, Hodges JS, Michalowicz BS (2007) A preliminary study of intra-pocket topical versus injected anaesthetic for scaling and root planing. J Clin Periodontol 34: 892-896. Link: https://goo.gl/7t6GEB
- Svensson P, Petersen JK, Svensson H (1994) Efficacy of a topical anesthetic on pain and unpleasantness during scaling of gingival pockets. Anesth Prog 41: 35-39. Link: https://goo.gl/HQj8u3
- Yoon RK, Chussid S (2009) Topical anesthesia for rubber dam clamp placement in sealant placement: comparison of lidocaine/prilocaine gel and benzocaine. Pediatr Dent 31: 377-381. Link: https://goo.gl/UM4KSm
- Kravitz ND, Kusnoto B (2006) Placement of mini-implants with topical anesthetic. J Clin Orthod 40: 602-604. Link: https://goo.gl/H4ST3U
- Reznik DS, Jeske AH, Chen JW, English J (2009) Comparative efficacy of 2 topical anesthetics for the placement of orthodontic temporary anchorage devices. Anesth Prog 56: 81-85. Link: https://goo.gl/Nbk2WY
- Berteretche MV, Hue O (2009) Topical anesthesia for prosthetic implant procedures. J Prosthet Dent 102: 128-129. Link: https://goo.gl/DbfR41
- Franz-Montan M, Ranali J, Ramacciato JC, de Andrade ED, Volpato MC, et al. (2008) Ulceration of gingival mucosa after topical application of EMLA: report of four cases. Br Dent J 204: 133-134. Link: https://goo.gl/5XV5sp
- Mehra P, Caiazzo A, Maloney P (1998) Lidocaine toxicity. Anesth Prog 45: 38-41. Link: https://goo.gl/HxD4jJ
- Branemark PI, Hansson BO, Adell R, Breine U, Lindstrom J, et al. (1977) Osseointegrated implants in the treatment of the edentulous jaw. Experience from a 10-year period. Scand J Plast Reconstr Surg Suppl 16: 1-132. Link: https://goo.gl/QkcfVW
- AlKhafagy HH (2010) Influence of cancellous bone rigidity on stress distribution in bone around dental implant: a finite element study. J Int Dent Med Res 3: 11-14. Link: https://goo.gl/7UESDm
- Zortuk M, Kilic E, Yildiz P, Leblebicioglu I (2011) Effect of parafunctional force on dental implant treatment in bruxism: a case report (two year results). J Int Dent Med Res 4: 25-29. Link: https://goo.gl/V3Y2Gm