Inferior alveolar nerve block: mepivacaine-lidocaine no better than lidocaine alone suggests trial

shutterstock_17571817- injection

Achieving good local anaesthesia is a key element in modern dental practice. Studies have suggested that failure rates if inferior alveolar nerve (IAN) block range between 17-58%. Administration of 3% mepivacaine plain followed by 2% lidocaine with 1:100,000 epinephrine for IAN blocks is advocated by some clinicians as theoretically mepivacaine may decrease the pain of injection, provide quicker onset an increase anaesthetic success and possible potentiate the effect of the lidocaine.

The aim of this study was to compare the degree of pulpal anesthesia obtained with a combination of 3% mepivacaine/2% lidocaine (1:100,000 epinephrine) versus a combination of 2% lidocaine (1:100,000 epinephrine)/2% lidocaine (1:100,000 epinephrine) in IAN blocks.


100 asymptomatic adult patients (aged 18-65) were randomly given a combination of a 1-cartridge volume of 3% mepivacaine plus a 1-cartridge volume of 2% lidocaine with 1:100,000 epinephrine and a combination of a 1-cartridge volume of 2% lidocaine with 1:100,000 epinephrine plus a 1-cartridge volume of 2% lidocaine with 1:100,000 epinephrine for the IAN block at 2 separate appointments.

At the beginning of each appointment and before any injections were given, the experimental teeth and control contralateral canine were tested 3 times with the electric pulp tester to record baseline vitality. Pain was rated by the patient using the Heft-Parker visual analog scale (VAS). Patients rated pain for needle insertion, needle placement, and solution deposition. The molars, premolars, and incisors were tested with an electric pulp tester in 4-minute cycles for 60 minutes. Anesthetic success was defined as the subject achieving 2 consecutive 80 readings within 15 minutes after completion of the IAN blocks and sustaining the 80 reading for 60 minutes.


  • 100 patients (50 men; 50 women) participated
  •  There were no significant differences between the mepivacaine/lidocaine and lidocaine/lidocaine combinations for any of the teeth tested (P > .05).
  • Anesthetic success rates for each tooth type are shown below
Tooth Number Percentage anaesthetic success
Mepivacaine/lidocaine Lidocaine/lidocaine
Second molar 99 51% 57%
Frist molar 100 44% 40%
Second premolar 93 45% 41%
First premolar 97 53% 50%
Lateral incisor 100 30% 27%
Central incisor 100 10% 10%


  • The mean onset times for the mepivacaine/lidocaine combination ranged from 6.9 to 16.2 minutes, and mean onset times ranged from 6.0 to 12.2 minutes for the lidocaine/lidocaine combination


The authors concluded

The combination of 3% mepivacaine plus 2% lidocaine with 1:100,000 epinephrine was equivalent to the combination of 2 cartridges of 2% lidocaine with 1:100,000 epinephrine in terms of injection pain, onset time, and pulpal anesthetic success for the IAN block.


The trails involved 100 patients and used a cross-over design so 200 combination sets of IAN blocks were given. The clinical and trial methodology is also very clearly described and there is a good discussion of the findings.


Lammers E, Nusstein J, Reader A, Drum M, Beck M, Fowler S. Does the combination of 3% mepivacaine plain plus 2% lidocaine with epinephrine improve anaesthesia and reduce the pain of anesthetic injection for the inferior alveolar nerve block? A prospective, randomized, double-blind study. J Endod. 2014 Sep;40(9):1287-92. doi: 10.1016/j.joen.2014.04.015. Epub 2014 Jul 9. PubMed PMID: 25146009

Share on Facebook Tweet this on Twitter Share on LinkedIn Share on Google+