Effectiveness of different anesthetic methods for mandibular posterior teeth with symptomatic irreversible pulpitis: a systematic review and meta-analysis

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Abstract
Objective This systematic review aimed to assess the effectiveness of anesthetic methods for mandibular posterior teeth with symptomatic irreversible pulpitis, comparing to the inferior alveolar nerve block (IANB) by meta-analysis. Materials and methods Studies were identified from Cochrane Library, Embase, Lilacs, PubMed, Scopus, and Web of Science databases up to May 2021. Randomized clinical trials comparing the anesthetic success rate of IANB and any other alternative anesthetic method were included. The quality of the selected studies was assessed by the Cochrane Risk of Bias 2.0 tool. Meta-analyses using Mantel–Haenszel method and random-effect models were performed to find the pooled estimates of risk ratio (RR) with 95% confidence interval (CI). The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation approach. Results Twenty-two studies were selected, which included fourteen anesthetic methods. Two studies were classified as high risk of bias, five as uncertain risk and fifteen as low risk. Vazirani-Akinosi nerve block (VANB) [RR = 1.27; p = 0.007; 95% CI, 1.07–1.52; I2 = 0%] and intraosseous injection (IOI) [RR = 1.48; p = 0.04; 95% CI, 1.02–2.15; I2 = 46%] had superior effectiveness compared to IANB, with low certainty of evidence, as well as buccal infiltrations associated with IANB (BI + IANB) [RR = 1.84; p = 0.004; 95% CI, 1.22–2.79; I2 = 52%], with very low certainty. Conclusion Evidence suggests that buccal infiltrations associated with IANB, VANB, and IOI are more effective than IANB at anesthetizing posterior mandibular teeth with symptomatic irreversible pulpitis. Clinical significance Alternative primary methods of anesthesia might be indicated for mandibular posterior teeth presenting symptomatic irreversible pulpitis.

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