Robertson Artic vs Lido JADA 2007

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2007;138;1104-1112 J Am Dent Assoc

Mike Beck and Melissa McCartneyDouglas Robertson, John Nusstein, Al Reader,

infiltration of mandibular posterior teethThe anesthetic efficacy of articaine in buccal

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1104 JADA, Vol. 138 http://jada.ada.org August 2007

Background. The authors conducted a prospective,

randomized, double-blind, crossover study comparing the degree of pulpal anesthesia achieved by means of

mandibular first molar buccal infiltrations of two anes-

thetic solutions: 4 percent articaine with 1:100,000 epi-

nephrine and 2 percent lidocaine with 1:100,000 epinephrine.

Methods. Each of 60 blinded adult subjects randomly received two

buccal infiltrations at the first molar site: one cartridge of 4 percent arti-

caine with 1:100,000 epinephrine at one appointment and one cartridge of 2

percent lidocaine with 1:100,000 epinephrine at another appointment. The

injections were administered during two separate appointments spaced at

least one week apart. The authors used an electric pulp tester to assess the

first and second molars and the first and second premolars for pulpal anes-

thesia in three-minute cycles for 60 minutes. They considered anesthesia tobe successful when they obtained two consecutive pulp test readings of 80

(meaning the subject evidenced no response at the maximum output on the

pulp tester).

Results. With the lidocaine formulation, successful pulpal anesthesia

ranged from 45 to 67 percent. With the articaine formulation, successful

pulpal anesthesia ranged from 75 to 92 percent. There was a significant dif-

ference ( P < .05) in anesthetic success between the lidocaine and articaine

formulations for each of the four teeth. Pulpal anesthesia declined slowly

over 60 minutes with both formulations.

Conclusion and Clinical Implications. For a mandibular buccal

infiltration of the first molar, 4 percent articaine with 1:100,000 epineph-

rine will result in a higher success rate than will 2 percent lidocaine with1:100,000 epinephrine, but the duration of pulpal anesthesia will decline

over 60 minutes with either formulation.

Key Words. Local anesthetics; articaine; lidocaine; infiltration; mandible.

JADA 2007;138(8):1104-12.

S

uccessful buccal infiltra-

tion anesthesia of themandibular posterior

teeth would be advanta-

geous to both cliniciansand patients. Mikesell and col-leagues1 and Nusstein and col-leagues,2 using lidocaine and arti-

caine formulations in inferioralveolar nerve blocks, found that

slow onset of anesthesia (achieving two consecutive pulp test readings

of 80 after 15-16 minutes) occurredwith both formulations from 12 to

19 percent of the time in the firstmolar. Failure rates (never

achieving two consecutive pulp testreadings of 80) in these samestudies1,2 ranged from 17 to 19 per-

cent for the first molar. Therefore, if a buccal infiltration would reduce

the slow onset and failure of pulpalanesthesia, it could be an additional

technique for the clinician toconsider.

Meechan and colleagues3

reported that buccal or buccal-plus-

lingual infiltrations of a cartridge of

2 percent lidocaine with 1:100,000epinephrine were effective (achiev-

ing two consecutive readings of 80with the electric pulp tester) only 32

to 39 percent of the time for pulpalanesthesia in permanent

ABSTRACT

A R T I C L E

3

Dr. Robertson was a graduate student in endodontics, College of Dentistry, The Ohio State University, Columbus, when the study described in this article was

conducted. He now has a practice limited to endodontics in Wheeling, W.V., and Steubenville, Ohio.

Dr. Nusstein is an associate professor and the chair, Section of Endodontics, College of Dentistry, The Ohio State University, Columbus.

Dr. Reader is a professor, Section of Endodontics, College of Dentistry, The Ohio State University, 305 W. 12th Ave., Columbus, Ohio 43210, e-mail

“[email protected]”. Address reprint requests to Dr. Reader.

Dr. Beck is an emeritus associate professor, Section of Oral Biology, College of Dentistry, The Ohio State University, Columbus.

Dr. McCartney is an assistant professor, Section of Endodontics, College of Dentistry, The Ohio State University, Columbus.

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The anesthetic efficacy of articaine

in buccal infiltration of mandibularposterior teethDouglas Robertson, DDS, MS; John Nusstein, DDS, MS; Al Reader, DDS, MS; Mike Beck, DDS, MA;Melissa McCartney, DDS, MS

Copyright ©2007 American Dental Association. All rights reserved.

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JADA, Vol. 138 http://jada.ada.org August 2007 1105

mandibular first molars. Obviously, the low suc-

cess rate with the lidocaine solution would notallow profound pulpal anesthesia for clinical

procedures.In a 2000 response to a letter to the editor of

JADA by Schertzer,4 Malamed stated that arti-caine would provide improved local anestheticactivity. Many researchers have evaluated arti-

caine and found it to be a safe and effective localanesthetic agent.5-23 Repeated clinical trials have

failed to demonstrate that articaine is statisti-cally superior to lidocaine in achieving

mandibular anesthesia.1,11,12,15,18,19,23 Articaine andprilocaine/lidocaine have shown an equivalent

effect in infiltration anesthesia in themaxilla12-14,16,17 except in one study, by Costa and

colleagues,24 which showed articaine to have a

longer duration. A recent study by Kanaa and colleagues25 com-

pared a cartridge of 2 percent lidocaine with1:100,000 epinephrine and a cartridge of 4 per-

cent articaine with 1:100,000 epinephrine forbuccal infiltration anesthesia of the mandibular

first molar. The articaine formulation had a suc-cess rate of 64 percent (as gauged by the attain-

ment of two consecutive pulp test readings of 80)—significantly higher than that of the lido-

caine formulation (39 percent). Additional studies are needed to test the effi-

cacy of articaine in infiltration anesthesia of mandibular posterior teeth. Therefore, we con-ducted a prospective, randomized, double-blind

crossover study to compare the degree of pulpalanesthesia achieved with an articaine formula-

tion versus that achieved with a lidocaine formu-lation in a mandibular first molar buccal

infiltration.

SUBJECTS, MATERIALS AND METHODS

Using the guidelines established by The Ohio

State University (Columbus) Human Subjects

Review Committee, we chose 60 adult subjectswho were in good health and were not taking any

medications that would alter their perception of pain. We excluded potential subjects who were

younger than 18 years or older than 60 years,were allergic to local anesthetics or sulfites, were

pregnant, had a history of significant medicalconditions, were taking any medications that

could affect anesthetic assessment, had activesites of pathosis in the area of injection or were

unable to give informed consent. The Ohio StateUniversity Human Subjects Review Committee

approved the study, and we obtained written

informed consent from each subject beforeenrolling him or her in the study.

One of the investigators (D.R., the seniorauthor) randomly administered to the 60 blinded

subjects buccal infiltration injections of one car-tridge of 2 percent lidocaine with 1:100,000 epi-nephrine (Xylocaine, AstraZeneca, York, Pa.) and

one cartridge of 4 percent articaine with1:100,000 epinephrine (Septocaine, Septodont,

New Castle, Del.) in two separate appointmentsspaced at least one week apart. With this

crossover design, the investigator administered120 total infiltrations (60 of articaine and 60 of

lidocaine), and each subject served as his or herown control. Sixty infiltrations were administered

on the right side and 60 on the left side. For the

second infiltration in each subject, the investi-gator used the same side randomly chosen for thefirst infiltration.

The test teeth we chose for the experiment

were the first and second molars and first andsecond premolars. We used the contralateral

canine as the unanesthetized control to ensurethat the pulp tester was operating properly and

that the subject was responding appropriatelyduring each experimental portion of the study.

Clinical examinations indicated that all teethwere free of caries, large restorations and peri-

odontal disease; none had histories of trauma orsensitivity.

Before the experiment, we randomly assigned

the two anesthetic formulations six-digit numbersfrom a random number table. We randomly

assigned each subject to one of the two formula-tions to determine which anesthetic formulation

was to be administered at each appointment. Tofurther blind the experiment, we recorded only

the random numbers on the data collectionsheets.

Under sterile conditions, we masked the lido-

caine and articaine cartridges with opaque labelsand wrote the corresponding six-digit codes on

each cartridge. We checked all anesthetic formu-lations to ensure that they had not expired. The

senior author administered the infiltration injec-tions by using the standard masked cartridges

and an aspirating syringe equipped with a 27-gauge 11 ⁄ 2-inch needle.

At the beginning of each appointment and

ABBREVIATION KEY. VAS: Visual analog scale.


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before any injections were given, we tested the

experimental teeth and the control contralateralcanine two times with an electric pulp tester

(Kerr, Analytic Technology, Redmond, Wash.) to

record baseline vitality. After the researchassistant isolated the tooth to be tested withcotton rolls and dried it with gauze, he or sheapplied toothpaste to the probe tip, which he or

she then placed midway between the gingivalmargin and the occlusal edge of the tooth. The

assistant set the rate of current at 25 seconds toincrease from no output (0) to the maximum

output (80). He or she recorded the number asso-ciated with the initial sensation. Trained research

personnel performed all preinjection and postinjection tests.

Before the injection, the senior author showedeach subject a visual analog scale (VAS) andasked him or her to rate the pain experienced

during each phase of the injection: needle inser-tion, needle placement and deposition of solution.

The scale we used was the Heft-Parker VAS26

(Figure 1), a 170-millimeter line marked with

various terms describing levels of pain. Immedi-ately after the infiltration, each subject rated the

pain for each injection phase on the VAS, placing a mark on the scale where it best described his or

her pain level. To interpret the data, we divided

the VAS into the following four categories:d0 mm, no pain;

dmore than 0 and less than or equal to 54 mm,mild pain (including the descriptors of “faint,”

“weak” and “mild”);dmore than 54 mm to less than 114 mm, mod-

erate pain;d114 mm or greater, severe pain (including the

descriptors of “strong,” “intense” and “maximumpossible”).

As noted above, the senior author administeredall infiltrations. He administered a single infiltra-

tion buccal to the mandibular

first molar at each appoint-ment, bisecting the approxi-

mate location of the mesialand distal roots. He placed the

needle gently into the alveolarmucosa (the needle insertionphase) and advanced it until

he estimated it to be at or justabove the apexes of the first

molar (the needle placementphase). He deposited the anes-

thetic formulation over aperiod of one minute (the solution deposition

phase).One minute after completion of the infiltration,

the research assistants performed pulp testing on

the second and first molars. At two minutes, theytested the second and first premolars. At threeminutes, they tested the control canine. Theyrepeated this cycle of testing every three minutes

for 60 minutes. At every third cycle, they testedthe control tooth, the contralateral canine, by

means of an inactivated electric pulp tester to testthe subject’s reliability. That is, if the subject

responded positively to an inactivated pulp tester,then we viewed him or her as being unreliable

and ineligible to participate in the study. Theresearch personnel asked each subject every three

minutes, for 60 minutes, if his or her lip andtongue were numb.

To measure the amount of anesthetic solution

delivered with an aspirating syringe, the seniorauthor individually expressed, by means of a

standard syringe with a 27-gauge needle, the con-tents of 50 articaine cartridges and 50 lidocaine

cartridges into a graduated syringe with 0.01-milliliter–increment divisions.

As the criterion for pulpal anesthesia, we useda complete absence of response from the subject

at the pulp tester’s maximum output (a reading of

80). We considered anesthesia to be successfulwhen we obtained two consecutive readings of 80

with the electric pulp tester. With a nondirec-tional α risk of .05 and a power of 80 percent, a

sample size of 60 subjects was required to demon-strate a difference in anesthetic success of ± 20

percent. We defined onset of pulpal anesthesia asthe time when we obtained the first of two consec-

utive pulp test readings of 80.We asked all subjects to complete postinjection

surveys after each infiltration administered(making a potential total of 120 surveys). The

Figure 1. The Heft-Parker visual analog scale (VAS) used for assessment of pain. The millimeterdemarcations were not shown on the patients’ VAS. Reprinted with permission of the Interna-tional Association for the Study of Pain from PAIN: Heft and Parker.26

Millimeters 0

None Faint Weak Mild Moderate Strong Intense MaximumPossible

23 36 54 85 114 144 170

Place a mark on the line below to show the amount of pain that you feel


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subjects rated pain in the injection

area, using the same VAS as previouslydescribed, immediately after the numb-

ness wore off and for the next threedays each morning on arising. We also

instructed patients to describe andrecord any problems, other than pain,that they experienced. We received 115

completed postinjection surveys.We used logistic regression to ana-

lyze group comparisons between thearticaine and lidocaine formulations for

incidence of pulpal anesthesia andanesthetic success. We adjusted inci-

dences of pulpal anesthesia by using the step-down Bonferroni method of

Holm. To make between-group com-

parisons for onset time, we used theWilcoxon matched pairs signed ranktest. We made between-group compari-sons of needle insertion, needle place-

ment and solution deposition pain andpostoperative pain by means of analysis

of variance with a Tukey-Kramer mul-tiple comparison test. We considered

comparisons significant at P < .05.

RESULTS

Sixty adult subjects, 34 women and 26

men, aged 19 to 51 years with anaverage age of 27 years, participated inthe study.

Table 1 shows the subjects’ anes-thetic success rates. For the articaine

formulation, successful pulpal anes-thesia ranged from 75 to 92 percent.

For the lidocaine formulation, suc-cessful pulpal anesthesia ranged from

45 to 67 percent. The articaine formula-tion was significantly better than the lidocaine

formulation in achieving pulpal anesthesia for

each of the four teeth (Table 1). Figures 2 through5 present the incidence of pulpal anesthesia (pulp

test readings of 80) for the articaine and lidocaineformulations over time. Each figure shows signifi-

cant differences between the two formulations( P < .05).

Table 2 (page 1109) presents data on the onsetof pulpal anesthesia. For the articaine formula-

tion, onset of pulpal anesthesia ranged from 4.2 to4.7 minutes. For the lidocaine formulation, onset

of pulpal anesthesia ranged from 6.1 to 11.1 min-utes. The articaine formulation was significantly

faster than the lidocaine formulation for each of

the four teeth (Table 2).

Table 3 (page 1110) shows subjects’ experienceof pain on injection. There were no significant dif-

ferences between the two anesthetic formulationsin terms of this variable.

Table 4 (page 1110) presents postinjection painscores. There were no significant differences

between the anesthetic formulations in terms of this variable. The only reported postinjection

complications were bruising and slight swelling inthe area of the injection. For lidocaine, 5 percent

(three of 59) of the subjects reported swelling and2 percent (one of 59) reported bruising. For arti-

TABLE 1

Percentages and numbers of subjects whoexperienced anesthetic success.

TOOTH PERCENTAGE (NO./TOTAL)

OF SUBJECTS EXPERIENCING ANESTHETIC SUCCESS,

BY ANESTHETIC FORMULATION

P VALUE

* There were significant differences ( P < .05) between the articaine and lidocaineformulations as analyzed by means of logistic regression.

† Some teeth were missing from the 60 subjects owing to extractions for orthodontictreatment.

Second Molar

First Molar

Second Premolar

First Premolar†

Articaine Lidocaine

75 (45/60)

87 (52/60)

92 (55/60)

86 (49/57)

45 (27/60)

57 (34/60)

67 (40/60)

61 (35/57)

.0001*

.0001*

.0001*

.0001*

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TIME (MINUTES)

P U

L P T E S T R E A D I N G S O F 8 0 ( % )

Articaine Lidocaine

Figure 2. Incidence of second molar anesthesia as determined by a lack ofresponse to electrical pulp testing at the maximum setting (percentage of 80/80pulp test readings), at each postinjection time interval, for the two anesthetic for-mulations: 4 percent articaine with 1:100,000 epinephrine and 2 percent lidocainewith 1:100,000 epinephrine. Significant differences (P < .05) are marked with anasterisk (*).


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caine, 4 percent (two of 56) of the subjects

reported swelling and no subjects reportedbruising.

No subjects reported tongue numbness witheither solution. Ninety-eight percent (59 of 60) of

the subjects had lip numbness with the articainesolution and 100 percent (60 of 60) had lip numb-

ness with the lidocaine solution. In all subjectswho achieved lip numbness, it occurred within

the first three minutes and lasted

throughout the 60-minute testing period.

The mean (± standard deviation[SD]) amount expressed from the arti-

caine cartridges in milliliters was 1.76± 0.023 mL (SD) and from the lidocainecartridges was 1.76 ± 0.022 mL.

DISCUSSION

We based our use of the pulp testreading of 80—signaling maximum

output—as a criterion for pulpal anes-thesia on the studies of Dreven and col-

leagues27 and Certosimo and Archer.28

These studies showed that an absence

of patient’s response to an 80 reading

was an assurance of pulpal anesthesiain vital asymptomatic teeth. Addition-ally, Certosimo and Archer28 demon-strated that patients who had electric

pulp test readings of less than 80 expe-rienced pain during operative pro-

cedures in asymptomatic teeth. There-fore, on the basis of these studies, we

concluded that using the electric pulptester before beginning dental pro-

cedures on asymptomatic vital teethwould provide the clinician with a reli-

able indicator of pulpal anesthesia.Studies by Meechan and colleagues3

and Kanaa and colleagues25 demon-

strated a 39 percent success rate(obtaining two consecutive 80 readings

with the electric pulp tester) whenadministering a cartridge of 2 percent

lidocaine with 1:100,000 epinephrine ina buccal infiltration of the first molar.

Using a cartridge of 2 percent lidocainewith 1:100,000 epinephrine, we found a

higher success rate (57 percent) for the

first molar when we used the same defi-nition as that of Kanaa and col-

leagues.25 This higher success rate maybe related to the greater number of subjects

enrolled in our study or to differences in subjectpopulations between our study and that of Kanaa

and colleagues. A success rate of 57 percent wouldnot be clinically acceptable for procedures

requiring profound pulpal anesthesia.For each of the four test teeth, anesthetic suc-

cess (Table 1) and incidence of pulpal anesthesia(Figures 2-5) were significantly better with the

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TIME (MINUTES)

P U L P T E S T R E A D I N G S

O F 8 0 ( % )

Articaine Lidocaine

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A D I N G S O F 8 0 ( % )

Articaine Lidocaine

Figure 3. Incidence of first molar anesthesia as determined by a lack of response toelectrical pulp testing at the maximum setting (percentage of 80/80 pulp test read-ings), at each postinjection time interval, for the two anesthetic formulations: 4 per-cent articaine with 1:100,000 epinephrine and 2 percent lidocaine with 1:100,000epinephrine. Significant differences (P < .05) are marked with an asterisk (*).

Figure 4. Incidence of second premolar anesthesia as determined by a lack ofresponse to electrical pulp testing at the maximum setting (percentage of 80/80pulp test readings), at each postinjection time interval, for the two anesthetic for-

mulations: 4 percent articaine with 1:100,000 epinephrine and 2 percent lidocainewith 1:100,000 epinephrine. Significant differences (P < .05) are marked with anasterisk (*).


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articaine formulation. The exact mecha-

nism of the articaine’s increased effi-cacy is not known; however, we can

speculate about a few mechanisms.Borchard and Drouin29 found that a

lower concentration of articaine (whichis a thiophene derivative) was sufficientto block an action potential when com-

pared with other amide anesthetics (allof which were benzene derivatives).

Potocnik and colleagues,30 in a study of sensory nerve conduction in rats, found

that both 2 and 4 percent articainewere superior to 2 percent lidocaine in

blocking nerve conduction. However,with increased intensity of nerve stimu-

lation, the compound action potential

recovered for 2 percent articaine butnot for 4 percent articaine. In a clinicalstudy31 comparing 2 percent and 4 per-cent articaine’s efficacy in infiltration

anesthesia, investigators found that the4 percent articaine solution had a

longer duration but not greater efficacy.It may be that factors other than the

concentration may be responsible forarticaine’s clinical efficacy. For

instance, the unique chemical structureof articaine—meaning its thiophene

ring, which is not possessed by otherlocal anesthetic agents—may facilitatebetter diffusion of the anesthetic solu-

tion to the teeth.Regardless of the mechanism, we

found that articaine was superior tolidocaine. Our results support those of

Kanaa and colleagues,25 who found thatan articaine formulation had a higher

success rate than did a lidocaine formulation inachieving buccal infiltration anesthesia of the

first molar. The success rate for the first molar

was higher in our study (87 percent) than thatrecorded by Kanaa and colleagues25 (64 percent).

The higher success rate in our study may berelated to the greater number of subjects we

tested or to population differences. Because westudied a young adult population, the results of

this study may not apply to children or elderlypeople.

Haas and colleagues13,14 compared infiltrationsof articaine and prilocaine formulations in the

mandibular canines and second molars. Theyfound no statistical differences between the two

anesthetic formulations. The success rates (areading of 80 on the pulp tester) were 65 percent

for the canine infiltration and 63 percent for the

second molar infiltration. The success rate for thesecond molar was lower than the 75 percent suc-

cess rate recorded in our study (Table 1). Differ-ences in the subject population or the use of 4 per-

cent articaine solution with 1:200,000epinephrine in Haas and colleagues’ studies13,14

may explain their lower success rate.When comparing the results of our study with

those of two previous studies of the inferior alve-olar nerve block1,2 in which either articaine or

lidocaine formulations were used, we found thatthe success rate was higher in the present study

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P U L P T E S T R E A D I N G S O F 8 0 ( % )

Articaine Lidocaine

Figure 5. Incidence of first premolar anesthesia as determined by a lack of responseto electrical pulp testing at the maximum setting (percentage of 80/80 pulp test read-ings), at each postinjection time interval, for the two anesthetic formulations: 4 per-cent articaine with 1:100,000 epinephrine and 2 percent lidocaine with 1:100,000 epi-nephrine. Significant differences (P < .05) are marked with an asterisk (*).

TABLE 2

Onset of pulpal anesthesia, in minutes.

TOOTH (NO. OFSUBJECTS)

ONSET OF PULPAL ANESTHESIA*IN MINUTES ± STANDARD DEVIATION,

BY FORMULATION

Articaine Lidocaine

P VALUE

* Subjects with anesthetic failures were not included, and only matched pairs could bestatistically analyzed. Therefore, the number of subjects included in the evaluation of onset of anesthesia differed from the total number of subjects.

† There were significant differences ( P < .05) between the articaine and lidocaineformulations as analyzed by mcans of logistic regression.

Second Molar (29)

First Molar (33)

Second Premolar (41)

First Premolar (35)

4.6 ± 4.0

4.2 ± 3.1

4.3 ± 2.3

4.7 ± 2.4

11.1 ± 9.5

7.7 ± 4.3

6.9 ± 6.6

6.1 ± 3.1

.0001†

.0002†

.0014†

.0137†


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for the first molar, second premolar and first pre-

molar. Success rates in our study were 87 percentfor the first molar, 92 percent for the second pre-

molar and 86 percent for the first premolar, whilesuccess rates (two consecutive pulp test readings

of 80) for the inferior alveolar nerve blocks haveranged from 81 to 83 percent for the first molar,

from 73 to 80 percent for the second premolar andfrom 77 to 89 percent for the first premolar. The

second molar success rate of 75 percent was lower

than the 91 to 93 percent success rate (two consec-utive readings of 80) shown in the study by Mike-

sell and colleagues1 for the inferior alveolar nerveblock using articaine. Concerning onset of pulpal

anesthesia, six studies32-37 of the inferior alveolarnerve block, using 1.8 mL of 2 percent lidocaine

with 1:100,000 epinephrine, found onset timesranging from eight to 11 minutes for the first

molar and eight to 12 minutes for the first pre-molar. Because onset of pulpal anesthesia

occurred within five minutes (Table 2) for the subjects in our study with the articaine formulation,

infiltration provided a quicker onset

than did an inferior alveolar nerveblock when articaine was used. How-

ever, as shown in Figures 2 through 5,pulpal anesthesia declined steadily

during the 60 minutes, whereas in astudy by Fernandez and colleagues,38

once subjects experienced pulpal anes-

thesia with the inferior alveolar nerveblock using 1.8 mL of 2 percent lido-

caine with 1:100,000 epinephrine, theysustained pulpal anesthesia for an

average of 2 hours and 24 minutes.Duration of pulpal anesthesia is a sig-

nificant disadvantage of buccal infiltra-tion in mandibular posterior teeth.

Even though the articaine cartridge

was marked externally as containing 1.7 mL, on average the anesthetic solu-tion expressed was 1.76 mL. For thelidocaine cartridge, the amount was

marked as 1.8 mL, but on average theanesthetic solution expressed was

1.76 mL. In general, a small amount of anesthetic solution remained in both

cartridges after delivery of the solutionwith an aspirating syringe. The

amount of anesthetic solutionexpressed was basically the same for

articaine and lidocaine. An intriguing aspect of our study is

the pattern of anesthetic success for the four

teeth (Figures 2-5). The anesthetic solutionappeared to diffuse anteriorly from the first

molar site. That is, a higher success rate wasrecorded for both the premolar and first molar

than for the second molar for both anesthetic for-mulations (Table 1). The relatively thick

mandibular bone in the second molar region mayhinder anesthetic diffusion. Buccal infiltration

over the second molar or buccal to the premolars

needs to be investigated further to determine itssuccess. Additionally, the anesthetic solution may

have entered the mental foramen, leading to thehigher success rates in the premolars and first

molar. Anatomically, the mental foramen is inthe apical area of the second premolar39 and in

proximity to the first molar injection site. Phillipsand colleagues39 found the foramen to be in line

with the long axis of the second premolar 63 per-cent of the time. When not in line with the axis,

the foramen was within 2 mm of it mesially ordistally. Although we can speculate that the

TABLE 3

Mean pain ratings for articaine and lidocainefor each injection phase.INJECTION PHASE MEAN (± STANDARD DEVIATION) PAIN

RATINGS,* BY FORMULATION

Articaine Lidocaine

P VALUE

* n = 60. Mean values are in millimeters as measured on the visual analog scale.† There were no significant differences ( P > .05) between the anesthetic formulations.

Needle Insertion

Needle Placement

Solution Deposition

24 ± 25

33 ± 29

36 ± 30

27 ± 26

32 ± 25

37 ± 36

.9795†

≈ 1.0000†

.9999†

TABLE 4

Mean pain ratings for articaine and lidocainefor each postinjection day.POSTINJECTIONDAY

MEAN (± STANDARD DEVIATION) PAINRATINGS,* BY FORMULATION

Articaine† Lidocaine‡

P VALUE

* Mean values are in millimeters as measured on the visual analog scale.† n = 56.‡ n = 59.§ Rating score at time subjective numbness wore off.¶ There were no significant differences ( P > .05) between the anesthetic formulations.

Day 0§

Day 1

Day 2

Day 3

20 ± 23

15 ± 24

11 ± 22

6 ± 18

18 ± 25

12 ± 24

9 ± 20

5 ± 15

.9976¶

.9841¶

.9957¶

≈ 1.0000¶


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buccal infiltration of the first molar may result in

anesthetic solution’s entering the mentalforamen, the superiority of articaine over lido-

caine must be related to the higher potency of articaine or its unique chemical structure. How-

ever, if profound pulpal anesthesia is required for60 minutes, the buccal infiltration of 1.8 mL of 4percent articaine with 1:100,000 epinephrine will

not provide the duration needed because of declining pulpal anesthesia. Figures 2 through 5

demonstrate the slow decline of pulpal anesthesiaover 60 minutes.

There was a statistically significant differencein onset of pulpal anesthesia between the anes-

thetic formulations for each tooth type, with thearticaine formulation producing consistently

faster onset (Table 2, Figures 2-5). The quicker

onset again may be related to the potency of arti-caine or its unique chemical structure. Whenusing an articaine formulation for buccal infiltra-tion in the first molar region, waiting approxi-

mately five minutes should ensure the onset of pulpal anesthesia (Table 2). Clinically, the practi-

tioner can use the electric pulp tester to evaluatethe tooth under treatment for pulpal anesthesia

before beginning the procedure.27,28

The articaine and lidocaine formulations were

not significantly different in terms of associatedinjection pain (Table 3). Likewise, Kanaa and col-

leagues25

found no significant difference in injec-tion discomfort between articaine and lidocaineformulations in mandibular buccal infiltration of

the first molar. The pain ratings of the threephases of injection generallly were in the faint-to-

weak pain area of the VAS (Figure 1, Table 3).Kanaa and colleagues25 also found the pain of

mandibular infiltration of the first molar to be inthe mild range with use of articaine or lidocaine

formulations.The high incidence (98-100 percent) and dura-

tion (60 minutes) of unilateral lip numbness with

both formulations in our study would indicatethat a buccal infiltration of the first molar would

result in subjective lip numbness. However,because we did not always achieve pulpal anes-

thesia (Figure 2-5), lip numbness should not beconsidered an indicator of pulpal anesthesia for

this type of infiltration. The most likely reason forsubjective lip numbness is the close proximity of

the mental nerve to the first molar injection site.39

The complete lack of subjective tongue numbness

would indicate that the lingual nerve was notaffected. We did not use mucosal sticks to eval-

uate lingual mucosal gingival anesthesia. Kanaa

and colleagues,25 after administering a buccalinfiltration of the first molar, found lingual

mucosal numbness in seven of 31 subjects afterusing an articaine formulation and in three of 31

subjects after using a lidocaine formulation.Postinjection pain ratings, at the time anes-

thesia wore off, were not statistically different

between the articaine and lidocaine formulations(Table 4). The incidence of pain decreased during

the next three days. All of the pain ratings wereless than the “faint” pain descriptor on the VAS

(Figure 1). No other study has evaluated postinjection pain for a buccal infiltration in mandib-

ular posterior teeth; therefore, comparisons arenot possible. The only reported postinjection com-

plications were bruising and slight swelling in the

area of the injection. For lidocaine, 5 percent(three of 59) of subjects reported swelling and 2percent (one of 59) reported bruising. For arti-caine, 4 percent (two of 56) reported swelling and

none reported bruising. All complications resolvedwithin three days except for a slight swelling

reported with lidocaine by one subject on daythree. Although there have been reports of pares-

thesia associated with articaine use,40,41 no subjects reported any paresthesia in our study, even

though the injection site approximated themental nerve. It would be unlikely that pares-

thesia would be reported in our study, becauseHaas and Lennon40 indicated that paresthesiasare rare and unlikely with infiltration anesthesia.

CONCLUSION

We conclude that a buccal infiltration of the firstmolar with a cartridge of 4 percent articaine with

1:100,000 epinephrine is significantly better thanis such an infiltration with a cartridge of 2 per-

cent lidocaine with 1:100,000 epinephrine inachieving pulpal anesthesia in mandibular pos-

terior teeth. However, clinicians should be

mindful that pulpal anesthesia likely will declineslowly over 60 minutes. ■

1. Mikesell P, Nusstein J, Reader A, Beck M, Weaver J. A comparisonof articaine and lidocaine for inferior alveolar nerve blocks. J Endod2005;31(4):265-70.

2. Nusstein J, Reader A, Beck FM. Anesthetic efficacy of different vol-umes of lidocaine with epinephrine for inferior alveolar nerve blocks.Gen Dent 2002;50(4):372-5.

3. Meechan JG, Kanaa MD, Corbett IP, Steen IN, Whitworth JM.Pulpal anaesthesia for mandibular permanent first molar teeth: adouble-blind randomized cross-over trial comparing buccal and buccalplus lingual infiltration injections in volunteers. Int Endod J 2006;39(10):764-9.

4. Schertzer ER Jr. Articaine vs. lidocaine (letter). JADA 2000;131(9):1248, 1250; author’s response 1250.


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R E S E A R C H


5. Malamed SF, Gagnon S, Leblanc D. Articaine hydrochloride: astudy of the safety of a new amide local anesthetic. JADA 2001;132(2):177-85.

6. van Oss GE, Vree TB, Baars AM, Termond EF, Booij LH. Pharma-cokinetics, metabolism, and renal excretion of articaine and its metabo-lite articainic acid in patients after epidural administration. Eur J Anaesthesiol 1989;6(1):49-56.

7. Oertel R, Rahn R, Kirch W. Clinical pharmacokinetics of articaine.Clin Pharmacokinet 1997;33(6):417-25.8. Wright GZ, Weinberger SJ, Friedman CS, Plotzke OB. Use of arti-

caine local anesthesia in children under 4 years of age: a retrospectivereport. Anesth Prog 1989;36(6):268-71.

9. Oertel R, Ebert U, Rahn R, Kirch W. The effect of age on pharmaco-kinetics of the local anesthetic drug articaine. Reg Anesth Pain Med1999;24(6):524-8.

10. Malamed SF, Gagnon S, Leblanc D. A comparison between arti-caine HCl and lidocaine HCl in pediatric dental patients. Pediatr Dent2000;22(4):307-11.

11. Malamed SF, Gagnon S, Leblanc D. Efficacy of articaine: a newamide local anesthetic. JADA 2000;131(5):635-42.

12. Donaldson D, James-Perdok L, Craig BJ, Derkson GD, Richardson AS. A comparison of Ultracaine DS (articaine HCl) and Citanest forte(prilocaine HCl) in maxillary infiltration and mandibular nerve block. JCan Dent Assoc 1987;53(1):38-42.

13. Haas DA, Harper DG, Saso MA, Young ER. Comparison of arti-caine and prilocaine anesthesia by infiltration in maxillary and

mandibular arches. Anesth Prog 1990;37(5):230-7.14. Haas DA, Harper DG, Saso MA, Young ER. Lack of differential

effect by Ultracaine (articaine) and Citanest (prilocaine) in infiltrationanaesthesia. J Can Dent Assoc 1991;57(3):217-23.

15. Tofoli GR, Ramacciato JC, de Oliveira PC, Volpato MC, GroppoFC, Ranali J. Comparison of effectiveness of 4 percent articaine asso-ciated with 1:100,000 or 1:200,000 epinephrine in inferior alveolarnerve block. Anesth Prog 2003;50(4):164-8.

16. Vahatalo K, Antila H, Lehtinen R. Articaine and lidocaine formaxillary infiltration anesthesia. Anesth Prog 1993;40(4):114-6.

17. Oliveria PC, Volpato MC, Ramacciato JC, Ranali J. Articaine andlignocaine in infiltration anaesthesia: a pilot study. Br Dent J2004;197(1):45-6.

18. Berlin J, Nusstein J, Reader A, Beck M, Weaver J. Efficacy of arti-caine and lidocaine in a primary intraligamentary injection adminis-tered with a computer-controlled local anesthetic delivery system. OralSurg Oral Med Oral Pathol Oral Radiol Endod 2005;99(3):361-6.

19. Claffey E, Reader A, Nusstein J, Beck M, Weaver J. Anesthetic

efficacy of articaine for inferior alveolar nerve blocks in patients withirreversible pulpitis. J Endod 2004;30(8):568-71.

20. Hersh EV, Giannakopoulos H, Levin LM, et al. The pharmacoki-netics and cardiovascular effects of high-dose articaine with 1:100,000and 1:200,000 epinephrine. JADA 2006;137(11):1562-71.

21. Moore PA, Boynes SG, Hersh EV, et al. The anesthetic efficacy of 4 percent articaine 1:200,000 epinephrine: two controlled clinical trials.JADA 2006;137(11):1572-81.

22. Bigby J, Reader A, Nusstein J, Beck M, Weaver J. Articaine forsupplemental intraosseous anesthesia in patients with irreversible pul-pitis. J Endod 2006;32(11):1044-7.

23. Sierra-Rebolledo A, Delgado-Molina E, Berini-Aytis L, Gay-Escorda C. Comparative study of the anesthetic efficacy of 4% articaineversus 2% lidocaine in inferior alveolar nerve block during surgicalextraction of impacted lower third molars. Med Oral Patol Oral Cir

Bucal 2007;12(2):E139-44.24. Costa CG, Tortamano IP, Rocha RG, Francischone CE,

Tortamano N. Onset and duration periods of articaine and lidocaine onmaxillary infiltration. Quintessesnce Int 2005;36(3):197-201.

25. Kanaa MD, Whitworth JM, Corbett IP, Meechan JG. Articaineand lidocaine mandibular buccal infiltration anesthesia: a prospectiverandomized double-blind cross-over study. J Endod 2006;32(4):296-8.

26. Heft MW, Parker SR. An experimental basis for revising thegraphic rating scale for pain. Pain 1984;19(2):153-61.27. Dreven LJ, Reader A, Beck M, Meyers WJ, Weaver J. An evalu-

ation of the electric pulp tester as a measure of analgesia in humanvital teeth. J Endod 1987;13(5):233-8.

28. Certosimo AJ, Archer RD. A clinical evaluation of the electricpulp tester as an indicator of local anesthesia. Oper Dent1996;21(1):25-30.

29. Borchard U, Drouin H. Carticaine: action of the local anestheticon myelinated nerve fibres. Eur J Pharmacol 1980;62(1):73-9.

30. Potocnik I, Tomsic M, Sketelj J, Bajrovic FF. Articaine is moreeffective than lidocaine or mepivacaine in rat sensory nerve conductionblock in vitro. J Dent Res 2006;85(2):162-6.

31. Hintze A, Paessler L. Comparative investigations on the efficacyof articaine 4 percent (epinephrine 1:200,000) and articaine 2 percent(epinephrine 1:200,000) in local infiltration anesthesia in dentistry: arandomised double-blind study. Clin Oral Investig 2006;10(2):145-50.

32. Vreeland DL, Reader A, Beck M, Meyers W, Weaver J. An evalu-ation of volumes and concentrations of lidocaine in human inferioralveolar nerve block. J Endod 1989;15(1):6-12.

33. Hinkley SA, Reader A, Beck M, Meyers WJ. An evaluation of 4percent prilocaine with 1:200,000 epinephrine and 2 percent mepiva-caine with 1:20,000 levonordefrin compared with 2 percent lidocainewith 1:100,000 epinephrine for inferior alveolar nerve block. AnesthProg 1991;38(3):84-9.

34. Chaney MA, Kerby R, Reader A, Beck FM, Meyers WJ, Weaver J. An evaluation of lidocaine hydrocarbonate compared with lidocainehydrochloride for inferior alveolar nerve block. Anesth Prog 1991;38(6):212-6.

35. McLean C, Reader A, Beck M, Meryers WJ. An evaluation of 4%prilocaine and 3% mepivacaine compared with 2% lidocaine (1:100,000epinephrine) for inferior alveolar nerve block. J Endod 1993;19(3):146-50.

36. Ridenour S, Reader A, Beck M, Weaver J. Anesthetic efficacy of acombination of hyaluronidase and lidocaine with epinephrine in infe-rior alveolar nerve blocks. Anesth Prog 2001;48(1):9-15.

37. Steinkruger G, Nusstein J, Reader A, Beck M, Weaver J. The sig-

nificance of needle bevel orientation in achieving a successful inferioralveolar nerve block. JADA 2006;137(12):1685-91.

38. Fernandez C, Reader A, Beck M, Nusstein J. A prospective, ran-domized, double-blind comparison of bupivacaine and lidocaine for infe-rior alveolar nerve blocks. J Endod 2005;31(7):499-503.

39. Phillips JL, Weller RN, Kulild JC. The mental foramen: 1. Size,orientation, and positional relationship to the mandibular second pre-molar. J Endod 1990;16(5):221-3.

40. Haas DA, Lennon D. A 21 year retrospective study of reports of paresthesia following local anesthetic administration. J Can Dent Assoc 1995;61(4):319-20, 323-6, 329-30.

41. Miller P, Lennon D. Incidence of local anesthetic-induced neu-ropathies in Ontario from 1994-1998 (abstract 3869). J Dent Res2000;79(4):627.


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