PAIN ASSOCIATED WITH INTRAOSSEOUS ANESTHESIA WITH QUICKSLEEPER AND POST-OPERATIVE CONDITION OF THE PERFORATION SITE

SUMMARYPurpose : The aim of the study is to determine the pain during intraosseous anesthesia (IA) with the Quicksleeper and the post-operative state of the perforation site. Materials and methods: The subjects of the study were 58 patients who underwent successful intraosseous analgesia, indicated with treatment of caries or irreversible pulpitis of mandibular first and second molars. The Visual Analogue Scale was used to assess the pain during the perforation of the compact bone and during the infiltration of anesthetic solution into the cancellous bone. All 58 patients were followed up at the 24th hour and on the 7th day after the manipulation


INTRODUCTION
Intraosseous anesthesia (IA) involves intraosseous injection, whereby local anaesthetic is injected into the cancellous bone [1].The computer-assisted intraosseous system Quicksleeper exhibits some advantages, including less painful anesthesia, short onset, smaller doses, reduced soft tissue numbness, and the provision of palatal or lingual, as well as buccal, anesthesia with single needle penetration [1][2][3].
Pain during the performance of IA, as well as postoperative pain at the perforation site, are often described as disadvantages of this analgesia technique [4,5].The reasons for this are temperature changes accompanying the process of perforating the compact bone, traumatic tissue damage, the infiltration speed of the anaesthetic solution into the cancellous bone, and the subsequent increase in intraosseous pressure.
The aim of the study is to determine the pain during IA with the Quicksleeper (Dental Hi Tec, Cholet Cedex, France) and the post-operative state of the perforation site.

MATERIALS AND METHODS
This clinical study was conducted with a total of 58 patients who underwent successful intraosseous analgesia, indicating the treatment of caries or irreversible pulpitis of mandibular first and second molars.The study was approved by the Ethical Committee of the Medical University of Plovdiv (No. 6/10.11.2016).Written informed consent was obtained from every patient.
IA was performed with computer assisted system Quicksleeper in the following steps: -infiltrative anesthesia of soft tissue -0,3 mL anesthetic was infiltrated at a 15° angle in the perforation point (fig.1);

Fig. 1. Infiltrative anesthesia
The Visual Analogue Scale (VAS) was used to assess the pain during the execution of IA, which was completed by each patient after the anesthesia.The intensity of the pain was reported both during the perforation of the compact bone and during the infiltration of anesthetic solution into the cancellous bone.
All 58 patients participating in the clinical study were followed up at the 24th hour and on the 7th day after the manipulation.The following parameters were evaluated: * Condition of the perforation site and soft tissues around it.The presence of a reactive inflammatory process was examined by inspection and palpation at the site of the perforation.Color, swelling and exudation of the soft tissues around the perforation site are examined; * Presence of palpation pain in the area of the perforation was recorded using the VAS scale.

RESULTS
In 82,7% of the cases, perforation of compact bone is not accompanied by pain, while in 17,3% of the cases, there was mild pain.8 patients registered mild pain during anaesthetic infiltration (Table 1).
-perforation of compact bone -target point is 2 mm apical from the intersection of the horizontal (line passing through margo gingivalis) and vertical line (line dividing interdental septum) (fig.2);   After IA, a reactive inflammatory process was registered in 27% of the cases at 24 hours, while on the 7th day an inflammatory reaction was registered in only 6% of the cases.No patients with exudate were registered (Fig. 3, 4, 5).

DISCUSSION
The technique of IA was introduced in dentistry over four decades ago.The armamentarium has evolved from using a round bur, endodontic reamer, buetelrock drill to slow-speed 27-gauge perforator drills with guide sleeves [6].Nowadays, there is a wide variety of devices for IA, such as Stabident (Fairfax Dental Inc., Miami, FL), the X-tip system (Dentsply, York, PA), Anesto (W&H, DentalWerk Bürmoos, Austria) and computer assisted system Quicksleeper (Dental Hi Tec, Cholet Cedex, France), which allow using this technique as primary anesthesia, especially of the mandibular molars.
In 2021, Simeonova et al. summarizes the literature data regarding pain during and after intraosseous anesthesia [7].In the present study, 17.3% of patients reported mild pain when perforating the compact bone, and none reported moderate to severe pain.Slight pain during anesthetic infiltration into the spongiosa was recorded by 8 patients (Table 1).
(2) reported a 31% incidence of moderate-to-severe deposition pain using 3% mepivacaine [8,9].Reisman et al. (1997) reported, in 2 to 15% of cases, post-operative pain at the perforation site, which resolved in a short time, and in 4 to 5% -swelling, bruising or suppuration within two weeks [8].At the 24th hour, 20,7% of patients registered mild pain and 10,3% -moderately severe pain on palpation in the area of the perforation site.
The presence of a reactive inflammatory process (redness and slight tissue swelling) at the site of anesthesia was observed in 27% of patients.Exudation from the perforation hole was not detected in any case.After one week, the number of patients with pain on palpation (8,6% with mild pain) and reactive inflammation around the perforation site (6%) was significantly reduced.

Table 1 .
Assessment of pain during intraosseous anesthesia.

Table 2 .
Pain during palpation in the perforation site at 24 hours and 7th day after IA.At 24 hours after IA, 12 patients registered mild pain, 6 patients registered moderate pain at the perforation site.On the 7th day, we established mild pain in 4 patients (Table2).