Clinical Research| Volume 45, ISSUE 3, P257-262, March 2019

Anesthetic Efficacy of Intranasal 3% Tetracaine plus 0.05% Oxymetazoline (Kovanaze) in Maxillary Teeth



      Needle-free anesthetic delivery is a promising alternative to traditional anesthetic routes of administration. The purpose of this study was to determine the patient preference for and pulpal anesthetic efficacy of a 3% tetracaine plus 0.05% oxymetazoline (Kovanaze) nasal spray in maxillary lateral incisors and first premolars.


      Fifty adult subjects randomly received a 3% tetracaine plus 0.05% oxymetazoline (Kovanaze) nasal spray and mock infiltration or a mock nasal spray and 2% lidocaine with 1:100,000 epinephrine infiltration at the maxillary lateral incisor or first premolar in 2 appointments spaced at least 1 week apart in a single-blind cross-over design. Pulpal anesthesia was evaluated with an electric pulp tester. Side effects and subject preferences were also recorded.


      Anesthetic success was significantly lower for the Kovanaze nasal spray and mock infiltration (22%–37%) than for the mock nasal spray and lidocaine infiltration (89%–91%). Subjects reported more unwanted effects (nasal drainage and congestion, burning, pressure, and sinus congestion) after the Kovanaze nasal spray and mock infiltration than the mock spray and maxillary infiltration. Before participating in the study, more subjects (56%) preferred the nasal spray route versus a standard infiltration (44%). After experiencing both routes of administration, 100% of subjects preferred the standard infiltration.


      The 3% tetracaine plus 0.05% oxymetazoline (Kovanaze) nasal spray provided significantly less successful pulpal anesthesia than the lidocaine infiltration, was less preferable, and caused more unwanted effects.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Endodontics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Gatchel R.
        • Ingersoll B.
        • Bowman L.
        • et al.
        The prevalence of dental fear and avoidance: a recent survey study.
        J Am Dent Assoc. 1983; 107: 609-610
        • Milgrom P.
        • Fiset L.
        • Melnick S.
        • Weinstein P.
        The prevalence and practice management consequences of dental fear in a major US city.
        J Am Dent Assoc. 1988; 116: 641-647
        • Dionne R.
        • Gordon S.
        • McCullagh L.
        • Phero J.
        Assessing the need for anesthesia and sedation in the general population.
        J Am Dent Assoc. 1998; 129: 167-173
        • Hamilton J.
        Needle phobia: a neglected diagnosis.
        J Fam Pract. 1995; 41: 169-175
        • Ciancio S.G.
        • Hutcheson M.C.
        • Ayoub F.
        • et al.
        Safety and efficacy of a novel nasal spray for maxillary dental anesthesia.
        J Dent Res, Clinical Research Supplement. 2013; 92: 435-485
        • Hersh E.V.
        • Pinto A.
        • Saraghi M.
        • et al.
        Double-masked, randomized, placebo-controlled study to evaluate the efficacy and tolerability of intranasal K305 (3% tetracaine plus 0.05% oxymetazoline) in anesthetizing maxillary teeth.
        J Am Dent Assoc. 2016; 147: 278-287
        • Giannakopoulos H.
        • Levin L.M.
        • Chou J.C.
        • et al.
        The cardiovascular effects and pharmacokinetics of intranasal tetracaine plus oxymetazoline.
        J Am Dent Assoc. 2012; 143: 872-880
        • Hersh E.V.
        • Saraghi M.
        • Moore P.A.
        Intranasal tetracaine and oxymetazoline: a newly approved drug formulation that provides maxillary dental anesthesia without needles.
        Curr Med Res Opin. 2016; 32: 1919
        • Dreven L.J.
        • Reader A.
        • Beck M.
        • et al.
        An evaluation of an electric pulp tester as a measure of analgesia in human vital teeth.
        J Endod. 1987; 13: 233-238
        • Certosimo A.
        • Archer R.
        A clinical evaluation of the electric pulp tester as an indicator of local anesthesia.
        Oper Dent. 1996; 21: 25-30
        • Gaviola G.
        • Chen V.
        • Chia S.
        A prospective, randomized, double-blind study comparing the efficacy of topical anesthetics in nasal endoscopy.
        Laryngoscope. 2013; 123: 852-858
        • Adriani J.
        • Campbell D.
        Fatalities following topical application of local anesthetics to mucous membranes.
        J Am Med Assoc. 1956; 162: 1527-1530
        • Noorily A.
        • Otto R.
        • Noorily S.
        Intranasal anesthetic effects of lidocaine and tetracaine compared.
        Otolaryngol Head Neck Surg. 1995; 113: 370-374
        • Noorily A.
        • Noorily S.
        • Otto R.
        Cocaine, lidocaine, tetracaine: which is best for topical nasal anesthesia?.
        Anesth Analg. 1995; 81: 724-727
        • Drivas E.
        • Hajiioannou J.
        • Lachanas V.
        • et al.
        Cocaine versus tetracaine in septoplasty: a prospective, randomized, controlled trial.
        J Laryngol Otol. 2007; 121: 130-133
        • Davis K.
        • Channick C.
        Safety of topical tetracaine in patients undergoing flexible bronchoscopy.
        J Bronchology Interv Pulmonol. 2009; 16: 95-98
        • Ciancio S.G.
        • Marberger A.D.
        • Ayoub F.
        • et al.
        Comparison of 3 intranasal mists for anesthetizing maxillary teeth in adults: a randomized, double-masked, multicenter phase 3 clinical trial.
        J Am Dent Assoc. 2016; 147: 339-347
        • Covino B.
        • Giddon D.
        Pharmacology of local anesthetic agents.
        J Dent Res. 1981; 60: 1454-1459
        • Yagiela J.A.
        • Dowd F.J.
        • Johnson B.S.
        • et al.
        Pharmacology and therapeutics for dentistry.
        6th ed. Mosby Elsevier, St. Louis2011
        • Haenisch B.
        • Walstab J.
        • Herberhold S.
        • et al.
        Alpha-adrenoceptor agonistic activity of oxymetazoline and xylometazoline.
        Fundam Clin Pharmacol. 2010; 24: 729-739
        • Tobias J.D.
        Oxymetazoline (Afrin®): maybe there is more that we need to know.
        Paediatr Anaesth. 2014; 24: 795-798
        • Bayer Corporation
        FAQs plus tips for using Afrin nasal sprays.
        (Available at:) (Accessed June 26, 2018)
        • Evans G.
        • Nusstein J.
        • Drum M.
        • et al.
        A prospective, randomized, double-blind comparison of articaine and lidocaine for maxillary infiltrations.
        J Endod. 2008; 34: 389-393
        • Nusstein J.
        • Wood M.
        • Reader A.
        • et al.
        Comparison of the degree of pulpal anesthesia achieved with the intraosseous injection and infiltration injection using 2% lidocaine with 1:100,00 epinephrine.
        Gen Dent. 2005; 53: 50-53
        • Gross R.
        • McCartney M.
        • Reader A.
        • Beck M.
        A prospective, randomized, double-blind comparison of bupivacaine and lidocaine for maxillary infiltrations.
        J Endod. 2007; 33: 1021-1024
        • Mikesell A.
        • Drum M.
        • Reader A.
        • Beck M.
        Anesthetic efficacy of 1.8 mL and 3.6 mL of 2% lidocaine with 1:100,000 epinephrine for maxillary infiltrations.
        J Endod. 2008; 34: 121-125
        • Loetscher C.
        • Walton R.
        Patterns of innervation of the maxillary first molar: a dissection study.
        Oral Surg Oral Med Oral Pathol. 1988; 65: 86-90
        • Fitzgerald M.
        The occurrence of a middle superior alveolar nerve in man.
        J Anat. 1956; 90: 520-522
        • Heasman P.A.
        Clinical anatomy of the superior alveolar nerves.
        Br J Oral Maxillofac Surg. 1984; 22: 439-447
        • Jang J.K.
        • Kwak S.W.
        • Ha J.H.
        • Kim H.C.
        Anatomical relationship of maxillary posterior teeth with the sinus floor and buccal cortex.
        J Oral Rehab. 2017; 44: 617-625
        • Zhang W.
        • Skrypczak A.
        • Weltman R.
        Anterior maxilla alveolar ridge dimension and morphology measurement by cone beam computed tomography (CBCT) for immediate implant treatment planning.
        BMC Oral Health. 2015; 15: 1-8