Inferior alveolar nerve block: can NSAIDs improve anaesthetic success?

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In patients with irreversible pulpitis undergoing root canal therapy it is important to achieve adequate anaesthesia of the pulp.  The inferior alveolar nerve block (IANB) is the usual technique for mandibular teeth although failure rates of between 43-83% have been reported in teeth with irreversible pulpitis. A number of studies have reported favourable outcomes with the use of non-steroidal anti-inflammatory drugs as a premedication to improve anaesthetic success.

The aim of this review was to assess the efficacy of non-steroidal anti-inflammatory drugs (NSAIDs) as oral premedication on the success of IANBs in irreversible pulpitis.


A search was conducted in the PubMed, EBSCOHost, Scopus and clinical trial registry ( databases were searched. Randomised controlled trials (RCTs) evaluating the effect of any NSAIDs as an oral premedication on the efficacy of IANBs in achieving anaesthesia in adult patients with irreversible pulpitis and undergoing nonsurgical root canal treatment were considered.  The primary outcome was the success rate of IANB anaesthesia.

Two reviewers independently selected studies, extracted data and assess risk of bias using the Cochrane tool. Meta-analysis was carried out using a random effects model and pooled risk ratio (RR) and 95% confidence intervals (CIs) presented.  The overall quality of the evidence was assessed using the GRADE approach.


  • 13 RCTs involving a total of 1174 patients were included.
  • 8 studies were considered to be at low risk of bias, 1 at unclear risk and 4 at high risk.
  • A number of NSAIDs were investigated; ibuprofen (300–600 mg), ketorolac (10 mg), diclofenac (50 mg), indomethacin (75 mg), lornoxicam (8 mg), piroxicam (20 mg), and naproxen sodium (550 mg).
  • Timing of the NSAIDs administration varied across the studies between 30, 45 and 60 minutes before IANB injection.
  • Meta-analysis found that the use of any NSAIDs significantly increased the anaesthetic success of INAB; RR = 1.96 (95% CI, 1.63–2.35) I2 = 6.8% [13 trials].
  • For only those 8 trials with a low risk of bias; RR = 1.92 (95% CI, 1.55–2.38) I2 = 13.7%.
  • Subgroup analyses showed a similar beneficial effect for ibuprofen, diclofenac, and ketorolac (RR = 1.83 [95% CI, 1.43-2.35], RR = 2.56 [95% CI, 1.46-4.50], and RR = 2.07 [95% CI, 1.47-2.90], respectively).
  • The GRADE evaluation showed that the accumulated evidence for premedication with NSAIDs demonstrated high quality for the success of IANB anaesthesia.


The authors concluded: –

available evidence from RCTs suggest that oral pre-medication with NSAIDs increases the success rate of IANBs in patients with irreversible pulpitis. A single dose of ibuprofen >400 mg should be considered as a standard premedication in endodontics to increase the success of IANBs in patients with irreversible pulpitis. Ketorolac 10 mg and diclofenac 50 mg are also effective alternative pre-medications to increase anaesthetic efficacy.


This well conducted meta-analysis demonstrates an improvement in IANB anaesthetic success for patients with irreversible pulpitis undergoing root canal treatment. This builds on findings from earlier reviews we have cover in earlier blogs (Dental Elf – 25th Jan 2017 and Dental Elf -13th Feb 2018) one of these being from the same group of authors.


Primary Paper

Nagendrababu V, Pulikkotil SJ, Veettil SK, Teerawattanapong N, Setzer FC. Effect of Nonsteroidal Anti-inflammatory Drug as an Oral Premedication on the Anaesthetic Success of Inferior Alveolar Nerve Block in Treatment of Irreversible  Pulpitis: A Systematic Review with Meta-analysis and Trial Sequential Analysis. J Endod. 2018 Jun;44(6):914-922.e2. doi: 10.1016/j.joen.2018.02.017. Epub 2018 Apr  27. Review. PubMed PMID: 29709297.

Other references

Dental Elf – 13th Apr 2018

Inferior Alveolar Nerve Block: improving anaesthetic success in patients with irreversible pulpitis


Dental Elf – 25th Jan 2017

Pre-operative analgesia for patients with pulpitis improved anaesthetic success

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