|Year : 2017 | Volume
| Issue : 2 | Page : 76-80
Comparative evaluation of the efficacy of 4% articaine and 2% lidocaine in children during the primary maxillary molar extractions
Astha Jaikaria, Seema Thakur, Parul Singhal, Deepak Chauhan, Cheranjeevi Jayam
Department of Pedodontics and Preventive Dentistry, Himachal Pradesh Government Dental College and Hospital, Shimla, Himachal Pradesh, India
|Date of Web Publication||25-Jan-2018|
Dr. Astha Jaikaria
Room Number 310, Third Floor, Department of Pedodontics and Preventive Dentistry, Himachal Pradesh Government Dental College and Hospital, IGMC, Shimla - 171 001, Himachal Pradesh
Source of Support: None, Conflict of Interest: None
Aims: This study aims to compare and evaluate the efficacy of 4% articaine and 2% lidocaine in children during the primary maxillary molar extractions. Materials and Methods: A total of 102 patients were randomly selected for the study who required maxillary molar extractions and received buccal infiltration either using lidocaine or articaine. Results: Higher mean value for facial pain scale for lidocaine suggesting lesser effectiveness of infiltration was seen in the results. Statistically insignificant changes were seen in heart rate, blood pressure, and difference in Face, Legs, Activity, Cry, and Consolability Scale between articaine and lidocaine. Higher pain scores with lidocaine compared to articaine are shown in the results of the study but are not statistically significant. Conclusions: It can be concluded that articaine is better alternative to lidocaine for local anesthesia in pediatric patients.
Keywords: Articaine, lidocaine, local anesthesia, pediatric dentistry
|How to cite this article:|
Jaikaria A, Thakur S, Singhal P, Chauhan D, Jayam C. Comparative evaluation of the efficacy of 4% articaine and 2% lidocaine in children during the primary maxillary molar extractions. Indian J Oral Health Res 2017;3:76-80
|How to cite this URL:|
Jaikaria A, Thakur S, Singhal P, Chauhan D, Jayam C. Comparative evaluation of the efficacy of 4% articaine and 2% lidocaine in children during the primary maxillary molar extractions. Indian J Oral Health Res [serial online] 2017 [cited 2021 Mar 3];3:76-80. Available from: https://www.ijohr.org/text.asp?2017/3/2/76/223929
| Introduction|| |
Pain control in dentistry plays an important part in reducing the fear and anxiety associated with dental procedures, especially in children. Two percent lignocaine is the gold standard and considered the most efficacious anesthetic agent for use in pediatric and adult patients; there has been a continuous attempt to look for a more potent and effective anesthetic agent.
Articaine is a commonly used local analgesic that was introduced to the German market in 1976. Articaine differs from the other amide local anesthetics because it contains a thiophene ring which allows greater lipid solubility, facilitating diffusion across the lipid-rich nerve membrane to access target receptors. It also contains an ester group so that hydrolyzation occurs in the plasma by nonspecific cholinesterases, and further metabolism and excretion, primarily in the kidneys.
It is an intermediate-potency, short-acting local anesthetic with a fast onset of action. Due to half-life of 20–40 min as compared to 90 min for lidocaine, the risk for systemic toxicity with articaine is minimized, especially during lengthy appointments where additional doses of anesthetic need to be administered.,
With increased diffusion, it can produce profuse pulpal as well as palatal anesthesia after maxillary buccal infiltrations, thus enabling the clinicians to avoid painful nerve block, especially in children.,
It may be the analgesic of choice in children over 4 years of age. There is also available literature on articaine that shows that it is safe for use in pediatric patients of all ages.
The aim of this study is to evaluate and compare the efficacy of 4% articaine and 2% lidocaine in children during the primary maxillary molar extractions.
| Materials and Methods|| |
This was a randomized, triple-blind design study.
One hundred and two 5–12-year-old children who were undergoing dental treatment at the Department of Pedodontics and Preventive Dentistry, Himachal Pradesh Government Dental College, Shimla, participated in the study. Children were physically and mentally healthy and assessed as being cooperative, having behavioral ratings positive or definitely positive, according to the Frankl Behavior Classification Scale.
All participating children required primary maxillary molar extraction. No patients were treated under any kind of sedation or received any treatment that could modify their behavior or awareness of pain. The exclusion criteria were allergies to local anesthetics or sulfites, history of significant medical conditions, taking any medications that might affect anesthetic assessment, and active state of pathosis in the area of injection. The procedures and possible discomforts or risks were fully explained to the parents, and their informed consents were obtained.
Children were randomly selected employing the envelope method and divided into Group A (1.8 ml of 2% lidocaine HCl with adrenaline bitartarate 1:100,000) and Group B (1.7 ml of 4% articaine HCl with epinephrine 1:100,000). Standard 2 ml syringe (24-gauge, 25 mm) was used for buccal and palatal infiltrations. A preoperative radiograph was taken before extraction. All injections were performed by the same dentist who had been calibrated for the technique of administering local anesthetic. The clinician administering the anesthetic, patient receiving the anesthetic, and evaluator of the Face, Legs, Activity, Cry, and Consolability (FLACC) scale were blind to the anesthetic administered. All the interventions were performed in a dental hospital clinical setting.
Mucosal tissues at the injection site were dried with a gauze, and topical anesthetic (Lidayn spray, Lovincare) was applied and left in place for 1 min. Local anesthetic solution was injected slowly at an average rate of 1 ml/min. Symptomatic testing of soft tissue (buccal and palatal) anesthesia was undertaken 5 min after the completion of anesthetic administration, and if deemed adequate, treatment was commenced. With the given buccal infiltration, a supplemental palatal infiltration with 0.3–0.4 ml of 2% lidocaine or 4% articaine was administered in Group A and B, respectively, if palatal anesthesia was inadequate. After achieving both buccal and palatal anesthesia, the tooth was extracted.
For subjective evaluation, the Wong-Baker Facial Pain Scale (FPS) was used. For objective evaluation, the FLACC Scale was used. As hemodynamic parameters of heart rate and blood pressure recordings are physiological indicators of pain response, they were recorded using a sphygmomanometer.
Three sets of readings: 3 min before injection (Stage 1), during injection (Stage 2), and 3 min after extraction (Stage 3) were recorded.
Immediately after the extraction, the patients were questioned about the amount of pain they had perceived during the extraction and asked to select the facial expression that best represented his/her experience/discomfort.
| Results|| |
The total number of participants in this study was 102 (61 males and 46 females), with 51 participants in each group. In the lidocaine Group A, there were 34 (66.66%) males and 17 (33.33%) females; in the articaine Group B, there were 27 (51%) males and 24 (49%) females [Figure 1]. The mean FPS values (± standard deviation [SD]) were found to be higher in the lidocaine group versus the articaine group (2.200 ± 2.148 vs. 1.400 ± 1.294), but the difference was not statistically significant, as per the Mann–Whitney test (P = 0.089) as seen in [Figure 2].
While comparing the two groups according to FLACC parameter [Figure 3], no smile or expression was seen in 32 patients (62.74%) in lidocaine group and in 22 patients (43.13%) in articaine group such that profound anesthesia had been obtained. Occasional frown or grievance was seen in 16 patients (31.37%) in lidocaine group and in 29 patients (56.86%) in articaine group. Frequent/constant clenching which was associated with high levels of pain was seen in three patients (0.05%) in lidocaine group and in zero patients (0%) in articaine group. These values were found to be statistically insignificant (P = 0.078).
|Figure 3: Comparison of Face, Legs, Activity, Cry, and Consolability values between the two groups|
Click here to view
Thirty-six (70.58%) patients in lidocaine group showed relaxed, normal position in terms of leg movement while this figure was more in articaine group with 47 patients (92.15%). Uneasy, restless, and tense legs were seen in 12 patients (23.52%) in lidocaine group while it was less in articaine group with only four patients (0.07%). Kicking and drawing up of legs were seen only in lidocaine group in three patients (0.05%). The difference in the leg category, however, was found to be statistically insignificant (P = 0.380).
Forty-three patients (84.31%) lay quietly in normal position in lidocaine group while this number was 46 patients (90.19%) in articaine group. Six patients (11.76%) patients squirmed, shifted back and forth during the treatment in the lidocaine group while five patients (9.81%) did the same in the articaine group. Arched, rigid, jerking activity was seen in two patients (0.03%) only in the lidocaine group. The value of Pearson's Chi-square was statistically insignificant (P = 0.686).
No crying was observed in 24 patients (47.05%) in the lidocaine group and 33 patients (64.70%) in the articaine group. Moan, an occasional complaint, was seen in 25 patients (49.01%) in the lidocaine group and 33 patients (64.70%) in the articaine group. Two patients (0.03%) only in the lidocaine group cried frequently, screamed or sobbed, or frequently complained. The difference in the cry category, however, was found to be statistically insignificant (P = 0.787).
Thirty patients (58.82%) in the lidocaine group and 29 patients (56.86%) in the articaine group who were content relaxed during the treatment while 19 patients (37.25%) in the lidocaine group and 21 patients (41.17%) in the articaine group were reassured by touching, hugging, talked to, distractable during the treatment. Two patients (0.03%) in the lidocaine group only were difficult to console and comfort and this number was zero in the articaine group. The difference in the consolability category, however, was found to be statistically insignificant (P = 0.973).
Heart rate and blood pressure
Student's t-test was used to evaluate heart rate and blood pressure.
The mean (±SD) of heart rate [Figure 4] increased slightly from Stage 1 (94.42 ± 18.07) to Stage 2 (100.66 ± 23.10) and to Stage 3 (100.14 ± 17.71) in the lidocaine group. In the articaine group, it also increased slightly from Stage 1 (92.44 ± 16.23) to Stage 2 (97.88 ± 19.66) and to Stage 3 (98.44 ± 15.50).
The mean (±SD) of systolic blood pressure [Figure 5] increased slightly from Stage 1 (109.4 ± 3.92) to Stage 2 (114.0 ± 4.10) and to Stage 3 (115.88 ± 4.20) in the lidocaine group. In the articaine group, there was also not much variation in systolic blood pressure readings, which were Stage 1 (107.16 ± 4.16), Stage 2 (111.38 ± 4.67), and Stage 3 (113.96 ± 3.69).
|Figure 5: Comparison of mean systolic blood pressures between the two groups|
Click here to view
Application of Student's t-test for two independent groups found no statistically significant difference between the two group readings. There were not many differences in the diastolic blood pressure readings for Stage 1 (66.56 ± 4.91), Stage 2 (66.96 ± 4.10), and Stage 3 (67.08 ± 3.64) in the lidocaine group [Figure 6].
|Figure 6: Comparison of mean diastolic blood pressure values between articaine and lignocaine groups|
Click here to view
There were few differences in diastolic blood pressure readings for Stage 1 (63.40 ± 3.00), Stage 2 (65.64 ± 2.67), and Stage 3 (67.04 ± 2.92) in the articaine group. Comparing diastolic blood pressure readings in the two groups, there was no statistically significant difference.
| Discussion|| |
This study compares the efficacy of 4% articaine with 2% lidocaine during the extraction of primary molars.
Investigations of the efficacy of 2% versus 4% articaine solution in children showed no clinically relevant differences with respect to depth of anesthesia and freedom from pain from the procedures performed.,
Articaine produced shorter duration of action as compared to lidocaine. This is in contrast to the study by Ramd and Amir, according to which articaine produced longer soft tissue numbness as compared to articaine. However, in our study, articaine was used for infiltration unlike their study where articaine was used as an inferior alveolar nerve block.
Clinical trials comparing the time of onset of clinical anesthesia and the duration and depth of anesthesia have shown that 4% articaine provides significantly shorter time of anesthesia as well as greater consistency than 2% articaine.,,, Toxicity of 4% articaine as compared to lowered concentrations was found to be nonsignificant.
There are studies in the literature that favor articaine for its excellent pediatric safety and efficacy profile. Zółkowska et al. have reported that like all other anesthetic agents, articaine is safe in epileptic patients. This study showed no adverse effects and no complications. It also showed articaine to be safer and more effective than others. This study is in accordance with study by Malamed et al., suggesting 4% articaine with 1:100000 adrenaline is safe and have a low risk of toxicity.,
After administration of 4% articaine with different epinephrine concentrations (1:100,000 and 1:200,000), no severe adverse effects in children were observed. Both solutions were shown to be efficient and safe.,
These results agree with the results of other studies, where higher pain scores were observed with lidocaine versus articaine but were not statistically significant.,,
Adverse drug effects such as headache, infection, paresthesia, and facial edema were not reported in any of the two groups. Accidental lip injury was not reported in any of the cases as patients were carefully instructed against biting their lips post extraction. In the present study, a supplementary palatal injection was found to be necessary to achieve adequate anesthesia with both lidocaine and articaine.
| Conclusions|| |
Based on this study's results, articaine is effective as a local anesthetic and can be used as an alternative to lidocaine in pediatric patients. Lower mean values for FPS and stable hemodynamic parameters during infiltration make articaine a likely choice as anesthetic in pediatric patients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
McLure HA, Rubin AP. Review of local anaesthetic agents. Minerva Anestesiol 2005;71:59-74.
Rahn R, Ball B. Local Anesthesia in Dentistry – Articaine and Epinephrine for Dental Anesthesia. 1st
ed. Seefeld, Germany: 3M ESPE AG; 2001.
Becker DE, Reed KL. Local anesthetics: Review of pharmacological considerations. Anesth Prog 2012;59:90-101.
Lipp M, Daublander M. The German experience of articaine. In: Proceedings of the International Symposium on Local Analgesia in Dentistry. London: Faculty of General Dental Practitioners; 1999. p. 21-2.
Sloss DR. Articaine in dental practice. In: Proceedings of the International Symposium on Local Analgesia in Dentistry. London: Faculty of General Dental Practitioners; 1999. p. 23-4.
Nizharadze N, Mamaladze M, Chipashvili N, Vadachkoria D. Articaine-the best choice of local anesthetic in contemporary dentistry. Georgian Med News 2011;(190):15-23.
Brickhouse TH, Unkel JH, Webb MD, Best AM, Hollowell RL. Articaine use in children among dental practitioners. Pediatr Dent 2008;30:516-21.
Dean JA, Macdonald RE, Avery DR. Dentistry for the Child and Adolescent. 9th
ed. St. Louis, Mo., USA: Mosby, Inc.; 2011. p. 31.
Jakobs W, Schmidt J, Leiers C. Ultracain 2% with Epinephrine in Pediatric Dentistry. 6th
International Dental Congress on Modem Pain Control, Washington DC; 1991.
Rahn R, Hellenbrecht D, Oliapuram C, Feller K, Oertel R, Richter K. Serum Levels of Articaine in Adults. 7th
International Dental Congress on Modem Pain Control, Trier, Germany; 1994.
Ram D, Amir E. Comparison of articaine 4% and lidocaine 2% in paediatric dental patients. Int J Paediatr Dent 2006;16:252-6.
Haas DA, Harper DG, Saso MA, Young ER. Comparison of articaine and prilocaine anesthesia by infiltration in maxillary and mandibular arches. Anesth Prog 1990;37:230-7.
Winther JE, Patirupanusara B. Evaluation of carticaine – A new local analgesic. Int J Oral Surg 1974;3:422-7.
Raab WH, Muller R, Muller HF. Comparative studies on the anaesthetic efficiency of 2% and 4% articaine. Quintessence 1990;41:1208-16.
Ruprecht S, Knoll-Kohler E. Comparative study of equimolar solutions of lidocaine and articaine for anaesthesia. A randomized, double-blind cross-over study. Schweiz Monatsschr Zahnmed 1991;101:1286-90.
Wright GZ, Weinberger SJ, Friedman CS, Plotzke OB. Use of articaine local anesthesia in children under 4 years of age – A retrospective report. Anesth Prog 1989;36:268-71.
Zółkowska D, Pikuła A, Borzecki A, Sieklucka-Dziuba M. Interaction between local anesthetics and centrally acting antihypertensive drugs. Ann Univ Mariae Curie Sklodowska Med 2002;57:569-73.
Malamed SF. Handbook of Local Anaesthesia. 4th
ed. St. Louis: Mosby-Year Book; 1997. p. 63-4.
Dudkiewicz A, Schwartz S, Laliberté R. Effectiveness of mandibular infiltration in children using the local anesthetic ultracaine (articaine hydrochloride). J Can Dent Assoc 1987;53:29-31.
Malamed SF, Gagnon S, Leblanc D. A comparison between articaine HCl and lidocaine HCl in pediatric dental patients. Pediatr Dent 2000;22:307-11.
Arrow P. A comparison of articaine 4% and lignocaine 2% in block and infiltration analgesia in children. Aust Dent J 2012;57:325-33.
Silva LC, Santos TD, Santos JA, Maia MC, Mendonça CG. Articaine versus lidocaine for third molar surgery: A randomized clinical study. Med Oral Patol Oral Cir Bucal 2012;17:e140-5.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]