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DOI: 10.1055/s-0045-1802589
Saudi Dentists' Awareness about “Hot Tooth” and Its Management
- Abstract
- Introduction
- Materials and Methods
- Results
- Discussion
- Conclusion
- Limitations of Study
- References
Abstract
Objective Management of “hot tooth” can be a problem in dental practice, and this study assessed the general practitioners and internees' knowledge and management about the “hot tooth” condition.
Materials and Methods An online cross-sectional study was conducted among general dental practitioners and internees of Saudi Arabia using a structured close-ended questionnaire. Knowledge and management of “hot tooth” was compared between general practitioners and internees, males and females, and dentists with graduate or postgraduate qualifications, job status, and work location. Data were analyzed using the Chi-squared test and binary regression analysis with statistical significance level of p ≤0.050.
Results Three hundred twenty nine participants comprised 57% females, 67% aged ≤29 years. In total, 94% had bachelor degree qualification, 58% were general practitioners, and 42% were internees. In addition, 27% were from eastern region; 81% had 5 or less years of practice; 56% study participants had heard about hot tooth and 35% knew the cause; 39% have faced hot tooth cases; 48% experienced embarrassment during management; 48% were able to solve the problem; 66% used lidocaine as local anesthesia (LA); 20% used three or more carpules, 76% had no knowledge of LA technique for hot tooth; 81% used intraosseous and intra-ligament technique; and 63% knew the toxic dose of LA solutions. General dental practitioners were significantly (p = 0.037) higher in number to face the hot tooth cases, solve the problem (p ≤ 0.001), and know the toxic dose of LA (p = 0.031). Binary regression analysis showed that males as compared to females, general dentists to internees, public sector to private sector had shown a significant (p ≤ 0.007) exposure to hot tooth condition and its management.
Conclusion A simple majority of dental practitioners of this study sample had knowledge of “hot tooth” and a small number have faced the problem. Majority of dentists had no knowledge of LA technique to manage hot tooth. Respectively, internees have shown further less knowledge and experience.
#
Introduction
A “hot tooth” refers to a clinical condition associated with an extreme pain response, typically related to irreversible pulpitis and often resistant to standard anesthetic protocols.[1] Pain management is a key component of quality dental care services and has been shown to significantly affect patient perceptions, compliance with treatment, or the success of procedures.[2] Pain control in dentistry, especially orofacial pain with injured pulp tissues, continues to be an area of exploration and clinical attention.[3] This represents an urgent condition often seen by dentists, especially in endodontic practice, significantly adding to patient discomfort, chairside time, and also clinician anxiety.[4] Considering the high prevalence of dental diseases and urgent need for pain control in affected individuals, evaluation of Saudi dentists' readiness to manage this clinical issue is important.[5]
A “hot tooth” typically presents a challenge when attempting to achieve adequate anesthesia because of increased sensitization of nerves and modified pain pathways in the inflamed pulp tissue.[6] Therefore, a reasonable knowledge of both the pathophysiology of this condition and the methods that are capable of providing effective anesthesia is essential for dental clinicians.[4] The safe use of local anesthetics (LAs) underpins dental practice as an effective means to relieve pain, both due to insufficient knowledge concerning the toxicological limits and the associated risk of potentially lethal systemic effect, including central nervous system toxicity or cardiovascular incidents.[7] With more intense doses occasionally needed to make a tooth “hot,” it is even more critical that practitioners understand the threshold of LA used to avoid potential problems.[8] Recommendations for improving outcomes of anesthetic techniques include buffered anesthetics and supplemental anesthetic delivery methods including intraosseous injections during irreversible pulpitis cases. Nevertheless, the implementation of these high-level techniques is reliant upon clinician knowledge and experience.[9]
Nusstein et al[6] emphasize the efficacy of buffered anesthetics and intraosseous injections in improving anesthetic success rates in cases of inflamed pulps. Similarly, Aggarwal et al[9] report challenges such as limited access to advanced anesthetics and variability in training, underscoring the unique regional barriers faced by practitioners. These studies collectively emphasize the critical role of advanced anesthetic techniques and contextualize the challenges faced by Saudi practitioners.
Practitioners do come across the situation of hot tooth syndrome,[10] and such findings can be essential in the development of educational interventions aimed at better preparing dental professionals for complex clinical scenarios.[11] Different studies conducted in the Saudi context had emphasized the importance of dental education and continuous professional development to fill this knowledge gap among practitioners.[12] [13] However, among Saudi dental students and newly graduated dentists, there is theoretical understanding but low practical confidence to handle complex endodontic matters, such as the “hot tooth.” Such a gap between theoretical knowledge and clinical variables highlights the need for targeted educational opportunities with respect to advanced practices in anesthesia. The knowledge of the toxic dose for LAs has a broader implication than just a theoretical requirement, but rather it is part of clinical necessity particularly in high-risk procedures involving repetitive or higher doses.[7]
An assessment of the current knowledge and practices on management of “hot tooth” among practicing dentists and dental interns in Saudi Arabia is imperative. These evaluations are valuable not only for improving outcomes in individual patients, but also to improve dental care quality across Saudi Arabia. Thus, improving the ability of practitioners to manage hot tooth may have an impact on population oral health by reducing patient stress and increasing acceptance of dental treatment.[14]
The successful management of hot tooth and control of frightful pain is a keystone in endodontic practice worldwide.[15] Equally important is the evaluation of knowledge, in this sense with regard to the toxic dose of LAs.[16] Under-dosing is common in the dental setting and it stems from ignorance of the pharmacokinetics and dynamics of anesthetics.[17] [18] With a hot tooth, clinicians may administer further doses to achieve adequate anesthesia without considering the systemic effects.[7] Thus, this study may determine the extent of specific knowledge gaps to inform curricula with the aim of assisting dental education programs throughout Saudi Arabia. The study may provide insights into the development of knowledge and confidence in “hot tooth” management with experience by comparing data from newly qualified interns and early career general dental practitioners.
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Materials and Methods
This study adopted a cross-sectional design that was carried out during January 2023 using a convenience sampling to approach 400 potential participants through e-mail and WhatsApp. This study included general dental practitioners and interns working in both public and private health care settings in Saudi Arabia and the dentists undergoing training for internship during the study period. Diverse geographical representations helped achieve a broader perspective, while prescreening participants reduced potential selection bias inherent in convenience sampling.
Information was collected through a close-ended, self-administered questionnaire, English and Arabic based, in order to help increase sampling and inclusion of non-English speaking participants. The survey form consisted of two parts: the first part revolved around demographic data (age, gender, qualification level, job status, years of practice, type of workplace) and the second part contained 10 questions related to the knowledge and management of the “hot tooth” condition. The questions were developed through a systematic review of the literature and expert consultation among dentists. Expert review involved consultation with experienced endodontists to ensure content relevance, while pilot testing was conducted on a group of 20 participants (10 interns and 10 general practitioners) to assess clarity and practicality. Reliability testing, demonstrated by a Cronbach's alpha (α = 0.83), indicated good internal consistency, strengthening the validity of the findings.
SPSS Statistics version 24.0 (IBM Corp. New York, United States) was used to assist with data entry and statistical analysis. Continuous variables were described using mean and standard deviations and categorical variables were summarized with frequency and percentages. Binary logistic regression analysis was used to identify factors associated with dentists' awareness and clinical practice related to the “hot tooth” condition. The dependent variable for the regression model was an awareness and knowledge score of participants, divided according to median split (i.e., adequate vs. inadequate awareness). Potential independent variables were sex (male/female), qualification level (Bachelor of Dental Surgery/Master's degree or above), job status (general practitioner/intern), years of practice (>5 years/≤5 years), and place of work (private/public). The independent variables for subsequent steps were examined for high collinearity and the strength of associations was calculated using the adjusted odds ratio and 95% confidence interval. For the analyses, a p-value ≤0.05 was defined to be statistically significant.
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Results
Response was received from 329 (82%) participants. In total, 57% were females and 43% males. In addition, 67% were young (aged ≤29 years) and 33% were adults aged ≥30 years. In total, 94% had bachelor degree qualification and only 6% have higher qualifications. In addition, 58% were general practitioners and 42% internees; 56% were working in the public sector and 44% were in private practice; 27% were from Eastern region, 23% from central region, 21% from western region, and the rest from other regions of Saudi Arabia. In total, 86% had 5 or less years of practice ([Fig. 1]).
[Table 1] demonstrates distribution of study participants about their knowledge (q1–q4) and practices (q5–q10) of “hot tooth.” Males have shown better knowledge and practices as compared to females and statistical difference was highly significant (p ≤ 0.001) for q1–q3, q5, q7, and q8, and significant for other questions. Participants with higher qualification have shown significant difference (p ≤ 0.001) for q2, q7, q8, and q10, and p = 0.003–0.0012 for other questions. General dental practitioners were significantly (p = 0.037) higher in number to face the hot tooth cases, solve the problem (p ≤ 0.001), and know the toxic dose of LA (p = 0.031). Participants with more practice years have dealt more patients (p ≤ 0.001) with hot tooth condition and have better knowledge about toxic dose of LA solutions (p ≤ 0.001); however, participants' experience has shown no significant difference for q1, q6, q7, and q9. A comparison of public and private study participants exhibited significant difference (p ≤ 0.001) for q1, q2, and q5, and p ≥0.0012 for other questions. Overall average of participants about their knowledge for questions (q1–q4) is noted as 51%; however, only 40% have dealt the “hot tooth” cases, 48% felt embarrassed, and 34% solved the hot tooth problem.
*p = 0.003–0.012, **p ≤ 0.001 (chi-squared test).
Binary regression analysis showed that males are two times more aware of the hot tooth condition (p ≤ 0.001), cause of hot tooth (p ≤ 0.001), and solved the problem (p ≤ 0.001), and three times more dealt the condition (p ≤ 0.005) as compared to females. Internees have half times the knowledge and exposure to hot tooth with respect to general dentists (p ≤ 0.007). Public sector dentists have shown two times better knowledge (p ≤ 0.001) and one time better chance of dealing (p = 0.042) and solving (p ≤ 0.001) the hot tooth cases as compared to private sector dentists ([Table 2]).
Abbreviations: CI, confidence interval; GP, general practitioner; OR, odds ratio; SE, standard error.
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Discussion
There is a growing trend in research on hot tooth; it is key to clinical practice and requires multifaceted approaches for practitioners particularly those early in their careers.[10] This study has identified the potential knowledge deficits that may adversely affect the management of pain associated with endodontic treatments by exploring practitioners' knowledge. Findings of this study may be essential in guiding the development of educational interventions aimed at better preparing dental professionals for complex clinical scenarios.[11] Findings of this study are comparable with those conducted by Mariona and Antony,[10] where all study participants had knowledge of hot tooth and 87% faced the situation.
Practitioners faces different challenges to use recent advances in the challenging cases. Nusstein et al[6] reported the high cost of buffered anesthetics as a barrier and have highlighted the need for standardized training modules to improve adoption rates. However, Aggarwal et al[9] on the other hand emphasize cultural factors influencing patient compliance and access to resources, providing a comprehensive view of global challenges.[6]
Demographically, among participants of this study, females were higher in number than males, and young and general practitioners were more in number. Participants were higher in number from public sector and eastern region. Data are comparable with local demographics,[13] [19] which present males higher than females, more dental workforce in private sector as compared to public, and most dental specialists work in public sector. In the present study, male practitioners and those with higher qualifications demonstrated better knowledge and practices, emphasizing the need for targeted interventions for less-experienced practitioners. Additionally, the regression analysis revealed that practitioners in public sectors were more likely to encounter and manage hot tooth cases successfully, highlighting disparities that could inform resource allocation and training efforts in private sectors.
Knowledge of toxic dose of LAs is equally important.[16] Malamed[7] investigated the knowledge of Saudi dentists regarding the toxic dose of common LA solutions. The safe use of LAs underpins dental practice as an effective means to relieve pain; both due to insufficient knowledge concerning the toxicological limits and the associated risk of potentially lethal systemic effect, including central nervous system toxicity or cardiovascular incidents. Under-dosing is common in the dental setting and it stems from ignorance of the pharmacokinetics and dynamics of anesthetics.[17] [18] With a hot tooth, clinicians may administer further doses to achieve adequate anesthesia without considering the systemic effects.[7] In total, 63% participants of this study know the toxic level of LA solutions. Females, undergraduates, general practitioners, having longer experience, and private practitioners have shown better knowledge in this regard.
Comparing the practice-based questions, intense doses are occasionally needed to make a tooth “hot.” It is even more critical that practitioners understand the threshold of LA to avoid potential problems.[8] A good number of participants (47%) of this study have reported to use ≥3 carpules to manage hot tooth. Ramachandran et al[20] reported that 52.9% dentists increased the volume of anesthetic solution and 77.7% used lignocaine as solution, whereas in our study, 65% used lidocaine. The same study also reported that the most commonly used technique for a hot tooth was higher nerve blocks (34.5%), that is less than our study (66%). A study by Sohail et al[21] reported more dentists using the intraosseous technique and few of them using the nerve block; these data are inconsistent with our study data, reporting 5 and 56% respectively, which may explain the reason for nerve block showing failure in 44 to 81% cases and rate of success in hot tooth cases of 20%.[22] Additional buccal infiltration technique increases the success rate by 17 to 36%, our study participants (30%) have used this technique while managing hot tooth.[23] Intra-ligamentary injections are successful 74% of the time[22] and 14% of this study participants have used this technique. A study by Tadin et al[24] reported 40.6% study participants using nerve block, 47.8% intra-ligamental, and 38.8% intra-pulpal techniques; however, in this study, 36% used nerve block, 14% intra-ligamental, and 30% intra-pulpal techniques.
Recommendations for improving outcomes of anesthetic techniques recently include buffered anesthetics, articaine instead of lidocaine, and supplemental anesthetic delivery methods including intraosseous injections during irreversible pulpitis cases. Nevertheless, the implementation of these high-level techniques is reliant upon clinician knowledge and experience.[9] However, participants of this study have reported to use preferably nerve block and intra-pulpal, followed by other techniques.
The study has provided an insight into the assessment of knowledge and confidence in “hot tooth” management with experience by comparing data from newly qualified interns and early-career general dental practitioners. Additionally, implementing e-learning modules and hands-on courses focusing on advanced anesthetic techniques, like intraosseous injections and the use of buffered anesthetics, could further enhance practical knowledge and application in clinical settings. Such information is essential for dental educators and policy-makers trying to design curricula that prepare these new graduates with the skills they require for effective practice.[15] This enhances impact on population oral health by reducing patient stress and increases acceptance of dental treatment[14] by enhancing the patient satisfaction.[25]
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Conclusion
Just a simple majority of dental practitioners of this study sample had knowledge of “hot tooth” and a small number have faced the problem. Majority of dentists had no knowledge of the LA technique to manage hot tooth. Respectively internees have shown further less knowledge and experience. However, there is positive correlation of hot-tooth knowledge with male gender, higher qualification, more experience, and public and general practitioners. This study is thus well placed to provide valuable and immediate insights into the current knowledge, practices of Saudi dental practitioners, and interns in relation to tackling hot tooth cases while applying LAs safely. This will help contribute to a broader goal of enhancing standards in dental education and clinical practice across Saudi Arabia; ensuring dentists are equipped to provide safe and effective care for complex cases appropriately.
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Limitations of Study
This study used a cross-sectional study design and the self-reported responses were collected by sending the Google Forms link of the questionnaire to the WhatsApp number of the participants. WhatsApp numbers have a potential limitation of introducing selection bias.
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Conflicts of Interest
None declared.
Ethical Approval
Ethical approval was obtained from Deanship of Research and Postgraduate Studies, King Faisal University vide letter # KFU-REC-2022- MAY–ETHICS6 dated 25-05-2022.
Authors' Contributions
S.A.H.B. conceived the study, wrote initial and final draft preparation; A.At, A.A.H, A.As, A.A.F. collected and managed data analysis; M.F.U, A.A and R.J. prepared results, reviewed and edited the manuscript. All authors have critically reviewed the manuscript and agreed to the submitted version of the manuscript and are responsible for similarity index of the manuscript.
Data Availability Statement
Data are available upon request.
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References
- 1 Renton T. Chronic pain and overview or differential diagnoses of non-odontogenic orofacial pain. Prim Dent J 2019; 7 (04) 71-86
- 2 Thompson W, Howe S, Pitkeathley C, Coull C, Teoh L. Outcomes to evaluate care for adults with acute dental pain and infection: a systematic narrative review. BMJ Open 2022; 12 (02) e057934
- 3 Hargreaves K, Goodis H, Seltzer S, Bender IB. The Dental Pulp. 4th ed. Carol Stream, IL: Quintessence Publishing Co; 2002
- 4 Janani K, Teja KV, Harini KS, Vasundhara KA, Jose J. Tackling local anesthetic failure in endodontics. IntechOpen eBooks. IntechOpen 2021.
- 5 Al-Hassan M, AlQahtani S. Preparedness of dental clinics for medical emergencies in Riyadh, Saudi Arabia. Saudi Dent J 2019; 31 (01) 115-121
- 6 Nusstein JM, Reader A, Drum M. Local anesthesia strategies for the patient with a “hot” tooth. Dent Clin North Am 2010; 54 (02) 237-247
- 7 Malamed SF. Handbook of Local Anesthesia, 6th ed. St. Louis, MO: Mosby; 2014
- 8 Antel R, Ingelmo P. Local anesthetic systemic toxicity. CMAJ 2022; 194 (37) E1288
- 9 Aggarwal V, Singla M, Kabi D. Management of the ‘hot tooth’: a literature review. J Endod 2022; 48: 317-324
- 10 Mariona RP, Antony SDP. Survey on knowledge and treatment of hot tooth syndrome by general dental practitioners. Int J Dentistry Oral Sci 2021; 8: 2889-2893
- 11 Bulmer JA, Currell SD, Peters CI, Peters OA. Endodontic knowledge, attitudes and referral patterns in Australian general dentists. Aust Dent J 2022; 67Suppl 1 (Suppl 1): S24-S30
- 12 Al-Madi EM, Alshiddi M, Al-Saleh S, Abdellatif H. Developing a dental curriculum for the 21st century in a new dental school in Saudi Arabia. J Dent Edu 2018; 82: 591-601
- 13 Alqahtani AS, Alqhtani NR, Gufran K. et al. Analysis of trends in demographic distribution of dental workforce in the kingdom of Saudi Arabia. J Healthc Eng 2022; 2022: 5321628
- 14 Minja IK, Kahabuka FK. Dental anxiety and its consequences to oral health care attendance and delivery. IntechOpen; 2019.
- 15 Sahu S, Kabra P, Choudhary E. Hot tooth – a challenge to endodontists. Int J Sci Res 2019; 8: 106-109
- 16 DeLuke DM, Cannon D, Carrico C, Byrne BE, Laskin DM. Is maximal dosage for local anesthetics taught consistently across U.S. dental schools? A national survey. J Dent Educ 2018; 82 (06) 621-624
- 17 Khalil H. Local anesthetics dosage still a problem for most dentists: a survey of current knowledge and awareness. The Saudi J Den Res 2014; 5: 49-53
- 18 Ghavimi MA, Kananizadeh Y, Hajizadeh S, Ghoreishizadeh A. Overview of local anesthesia techniques. In: MHK Motamedi, ed. A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2. London: InTechOpen; 2015
- 19 Alsalleeh F, Alohali M, Alzeer M, Aloseimi M, Almuflehi N, Alshiha S. Analyzing private dental clinics in Riyadh City, Saudi Arabia. Saudi Dent J 2018; 30 (01) 70-73
- 20 Ramachandran A, Khan SIR, Siddeeqh S, Gopinathan PA, Bijai LK, Iyer K. Management protocols of the hot tooth-a KAP survey among general dentists and endodontists. J Pharm Bioallied Sci 2023; 15 (Suppl. 01) S383-S390
- 21 Sohail Z, Chishty M, Sadiq M, Riaz F, Munawar M, Younus S. Assessment of knowledge and practice of fresh dental graduates, dental surgeons and specialists of multan about different LA techniques for mandibular teeth: a cross-sectional survey. Pak J Med Sci 2021; 15: 1745-1748
- 22 Lakiang D, Singh A, Arunagiri D, Singh P. Hot tooth: a review. J Dent Coll Azamgarh 2015; 1: 96-102
- 23 Haase A, Reader A, Nusstein J, Beck M, Drum M. Comparing anesthetic efficacy of articaine versus lidocaine as a supplemental buccal infiltration of the mandibular first molar after an inferior alveolar nerve block. J Am Dent Assoc 2008; 139 (09) 1228-1235
- 24 Tadin A, Aleric K, Jerkovic D, Gavic L. Knowledge, practice and self-reported confidence level of Croatian dentists in the use of local anesthesia: a cross-sectional study. Healthcare (Basel) 2023; 11 (14) 2006
- 25 Almehman BA, Mikwar Z, Balkhy A, Jabali H, Hariri BS, Baatiah NY. Measuring patient satisfaction and factors affecting it in the general surgery setting in Jeddah. Cureus 2019; 11 (12) e6497
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Article published online:
11 March 2025
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References
- 1 Renton T. Chronic pain and overview or differential diagnoses of non-odontogenic orofacial pain. Prim Dent J 2019; 7 (04) 71-86
- 2 Thompson W, Howe S, Pitkeathley C, Coull C, Teoh L. Outcomes to evaluate care for adults with acute dental pain and infection: a systematic narrative review. BMJ Open 2022; 12 (02) e057934
- 3 Hargreaves K, Goodis H, Seltzer S, Bender IB. The Dental Pulp. 4th ed. Carol Stream, IL: Quintessence Publishing Co; 2002
- 4 Janani K, Teja KV, Harini KS, Vasundhara KA, Jose J. Tackling local anesthetic failure in endodontics. IntechOpen eBooks. IntechOpen 2021.
- 5 Al-Hassan M, AlQahtani S. Preparedness of dental clinics for medical emergencies in Riyadh, Saudi Arabia. Saudi Dent J 2019; 31 (01) 115-121
- 6 Nusstein JM, Reader A, Drum M. Local anesthesia strategies for the patient with a “hot” tooth. Dent Clin North Am 2010; 54 (02) 237-247
- 7 Malamed SF. Handbook of Local Anesthesia, 6th ed. St. Louis, MO: Mosby; 2014
- 8 Antel R, Ingelmo P. Local anesthetic systemic toxicity. CMAJ 2022; 194 (37) E1288
- 9 Aggarwal V, Singla M, Kabi D. Management of the ‘hot tooth’: a literature review. J Endod 2022; 48: 317-324
- 10 Mariona RP, Antony SDP. Survey on knowledge and treatment of hot tooth syndrome by general dental practitioners. Int J Dentistry Oral Sci 2021; 8: 2889-2893
- 11 Bulmer JA, Currell SD, Peters CI, Peters OA. Endodontic knowledge, attitudes and referral patterns in Australian general dentists. Aust Dent J 2022; 67Suppl 1 (Suppl 1): S24-S30
- 12 Al-Madi EM, Alshiddi M, Al-Saleh S, Abdellatif H. Developing a dental curriculum for the 21st century in a new dental school in Saudi Arabia. J Dent Edu 2018; 82: 591-601
- 13 Alqahtani AS, Alqhtani NR, Gufran K. et al. Analysis of trends in demographic distribution of dental workforce in the kingdom of Saudi Arabia. J Healthc Eng 2022; 2022: 5321628
- 14 Minja IK, Kahabuka FK. Dental anxiety and its consequences to oral health care attendance and delivery. IntechOpen; 2019.
- 15 Sahu S, Kabra P, Choudhary E. Hot tooth – a challenge to endodontists. Int J Sci Res 2019; 8: 106-109
- 16 DeLuke DM, Cannon D, Carrico C, Byrne BE, Laskin DM. Is maximal dosage for local anesthetics taught consistently across U.S. dental schools? A national survey. J Dent Educ 2018; 82 (06) 621-624
- 17 Khalil H. Local anesthetics dosage still a problem for most dentists: a survey of current knowledge and awareness. The Saudi J Den Res 2014; 5: 49-53
- 18 Ghavimi MA, Kananizadeh Y, Hajizadeh S, Ghoreishizadeh A. Overview of local anesthesia techniques. In: MHK Motamedi, ed. A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2. London: InTechOpen; 2015
- 19 Alsalleeh F, Alohali M, Alzeer M, Aloseimi M, Almuflehi N, Alshiha S. Analyzing private dental clinics in Riyadh City, Saudi Arabia. Saudi Dent J 2018; 30 (01) 70-73
- 20 Ramachandran A, Khan SIR, Siddeeqh S, Gopinathan PA, Bijai LK, Iyer K. Management protocols of the hot tooth-a KAP survey among general dentists and endodontists. J Pharm Bioallied Sci 2023; 15 (Suppl. 01) S383-S390
- 21 Sohail Z, Chishty M, Sadiq M, Riaz F, Munawar M, Younus S. Assessment of knowledge and practice of fresh dental graduates, dental surgeons and specialists of multan about different LA techniques for mandibular teeth: a cross-sectional survey. Pak J Med Sci 2021; 15: 1745-1748
- 22 Lakiang D, Singh A, Arunagiri D, Singh P. Hot tooth: a review. J Dent Coll Azamgarh 2015; 1: 96-102
- 23 Haase A, Reader A, Nusstein J, Beck M, Drum M. Comparing anesthetic efficacy of articaine versus lidocaine as a supplemental buccal infiltration of the mandibular first molar after an inferior alveolar nerve block. J Am Dent Assoc 2008; 139 (09) 1228-1235
- 24 Tadin A, Aleric K, Jerkovic D, Gavic L. Knowledge, practice and self-reported confidence level of Croatian dentists in the use of local anesthesia: a cross-sectional study. Healthcare (Basel) 2023; 11 (14) 2006
- 25 Almehman BA, Mikwar Z, Balkhy A, Jabali H, Hariri BS, Baatiah NY. Measuring patient satisfaction and factors affecting it in the general surgery setting in Jeddah. Cureus 2019; 11 (12) e6497