The Journal of the American Dental Association
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

J Am Dent Assoc, Vol 138, No 8, 1104-1112.
© 2007 American Dental Association
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Robertson, D.
Right arrow Articles by McCartney, M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Robertson, D.
Right arrow Articles by McCartney, M.
Related Collections
Right arrow Pharmacology

RESEARCH

JADA Continuing Education

The anesthetic efficacy of articaine in buccal infiltration of mandibular posterior teeth

Douglas Robertson, DDS, MS, John Nusstein, DDS, MS, Al Reader, DDS, MS, Mike Beck, DDS, MA and Melissa McCartney, DDS, MS


   ABSTRACT
TOP
 ABSTRACT
SUBJECTS, MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
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 anesthetic solutions: 4 percent articaine with 1:100,000 epinephrine 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 articaine 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 anesthesia in three-minute cycles for 60 minutes. They considered anesthesia to be 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 difference (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 epinephrine will result in a higher success rate than will 2 percent lidocaine with 1:100,000 epinephrine, but the duration of pulpal anesthesia will decline over 60 minutes with either formulation.

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

Abbreviations: VAS: Visual analog scale

Successful buccal infiltration anesthesia of the mandibular posterior teeth would be advantageous to both clinicians and patients. Mikesell and colleagues1 and Nusstein and colleagues,2 using lidocaine and articaine formulations in inferior alveolar nerve blocks, found that slow onset of anesthesia (achieving two consecutive pulp test readings of 80 after 15–16 minutes) occurred with both formulations from 12 to 19 percent of the time in the first molar. Failure rates (never achieving two consecutive pulp test readings of 80) in these same studies1,2 ranged from 17 to 19 percent for the first molar. Therefore, if a buccal infiltration would reduce the slow onset and failure of pulpal anesthesia, it could be an additional technique for the clinician to consider.

Meechan and colleagues3 reported that buccal or buccal-plus-lingual infiltrations of a cartridge of 2 percent lidocaine with 1:100,000 epinephrine were effective (achieving two consecutive readings of 80 with the electric pulp tester) only 32 to 39 percent of the time for pulpal anesthesia in permanent mandibular first molars. Obviously, the low success rate with the lidocaine solution would not allow profound pulpal anesthesia for clinical procedures.

In a 2000 response to a letter to the editor of JADA by Schertzer,4 Malamed stated that articaine would provide improved local anesthetic activity. Many researchers have evaluated articaine and found it to be a safe and effective local anesthetic agent.5–23 Repeated clinical trials have failed to demonstrate that articaine is statistically superior to lidocaine in achieving mandibular anesthesia.1,11,12,15,18,19,23 Articaine and prilocaine/lidocaine have shown an equivalent effect in infiltration anesthesia in the maxilla12–14,16,17 except in one study, by Costa and colleagues,24 which showed articaine to have a longer duration.

A recent study by Kanaa and colleagues25 compared a cartridge of 2 percent lidocaine with 1:100,000 epinephrine and a cartridge of 4 percent articaine with 1:100,000 epinephrine for buccal infiltration anesthesia of the mandibular first molar. The articaine formulation had a success rate of 64 percent (as gauged by the attainment of two consecutive pulp test readings of 80)—significantly higher than that of the lidocaine formulation (39 percent).

Additional studies are needed to test the efficacy of articaine in infiltration anesthesia of mandibular posterior teeth. Therefore, we conducted a prospective, randomized, double-blind crossover study to compare the degree of pulpal anesthesia achieved with an articaine formulation versus that achieved with a lidocaine formulation in a mandibular first molar buccal infiltration.


   SUBJECTS, MATERIALS AND METHODS
TOP
 ABSTRACT
 SUBJECTS, MATERIALS AND METHODS
RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Using the guidelines established by The Ohio State University (Columbus) Human Subjects Review Committee, we chose 60 adult subjects who 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 medical conditions, were taking any medications that could affect anesthetic assessment, had active sites of pathosis in the area of injection or were unable to give informed consent. The Ohio State University Human Subjects Review Committee approved the study, and we obtained written informed consent from each subject before enrolling him or her in the study.

One of the investigators (D.R., the senior author) randomly administered to the 60 blinded subjects buccal infiltration injections of one cartridge of 2 percent lidocaine with 1:100,000 epinephrine (Xylocaine, AstraZeneca, York, Pa.) and one cartridge of 4 percent articaine with 1:100,000 epinephrine (Septocaine, Septodont, New Castle, Del.) in two separate appointments spaced at least one week apart. With this crossover design, the investigator administered 120 total infiltrations (60 of articaine and 60 of lidocaine), and each subject served as his or her own control. Sixty infiltrations were administered on the right side and 60 on the left side. For the second infiltration in each subject, the investigator used the same side randomly chosen for the first infiltration.

The test teeth we chose for the experiment were the first and second molars and first and second premolars. We used the contralateral canine as the unanesthetized control to ensure that the pulp tester was operating properly and that the subject was responding appropriately during each experimental portion of the study. Clinical examinations indicated that all teeth were free of caries, large restorations and periodontal disease; none had histories of trauma or sensitivity.

Before the experiment, we randomly assigned the two anesthetic formulations six-digit numbers from a random number table. We randomly assigned each subject to one of the two formulations to determine which anesthetic formulation was to be administered at each appointment. To further blind the experiment, we recorded only the random numbers on the data collection sheets.

Under sterile conditions, we masked the lidocaine and articaine cartridges with opaque labels and wrote the corresponding six-digit codes on each cartridge. We checked all anesthetic formulations to ensure that they had not expired. The senior author administered the infiltration injections 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 before any injections were given, we tested the experimental teeth and the control contralateral canine two times with an electric pulp tester (Kerr, Analytic Technology, Redmond, Wash.) to record baseline vitality. After the research assistant isolated the tooth to be tested with cotton rolls and dried it with gauze, he or she applied toothpaste to the probe tip, which he or she then placed midway between the gingival margin and the occlusal edge of the tooth. The assistant set the rate of current at 25 seconds to increase from no output (0) to the maximum output (80). He or she recorded the number associated with the initial sensation. Trained research personnel performed all preinjection and postinjection tests.

Before the injection, the senior author showed each subject a visual analog scale (VAS) and asked him or her to rate the pain experienced during each phase of the injection: needle insertion, needle placement and deposition of solution. The scale we used was the Heft-Parker VAS26 (Figure 1Go), a 170-millimeter line marked with various terms describing levels of pain. Immediately 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:


Figure 1
View larger version (24K):
[in this window]
[in a new window]

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

 
– 0 mm, no pain;
– more than 0 and less than or equal to 54 mm, mild pain (including the descriptors of "faint," "weak" and "mild");
– more than 54 mm to less than 114 mm, moderate pain;
– 114 mm or greater, severe pain (including the descriptors of "strong," "intense" and "maximum possible").

As noted above, the senior author administered all infiltrations. He administered a single infiltration buccal to the mandibular first molar at each appointment, bisecting the approximate location of the mesial and distal roots. He placed the needle gently into the alveolar mucosa (the needle insertion phase) and advanced it until he estimated it to be at or just above the apexes of the first molar (the needle placement phase). He deposited the anesthetic formulation over a period 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, they tested the second and first premolars. At three minutes, they tested the control canine. They repeated this cycle of testing every three minutes for 60 minutes. At every third cycle, they tested the control tooth, the contralateral canine, by means of an inactivated electric pulp tester to test the 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. The research personnel asked each subject every three minutes, for 60 minutes, if his or her lip and tongue were numb.

To measure the amount of anesthetic solution delivered with an aspirating syringe, the senior author individually expressed, by means of a standard syringe with a 27-gauge needle, the contents 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 used a complete absence of response from the subject at the pulp tester’s maximum output (a reading of 80). We considered anesthesia to be successful when we obtained two consecutive readings of 80 with the electric pulp tester. With a nondirectional {alpha} risk of .05 and a power of 80 percent, a sample size of 60 subjects was required to demonstrate a difference in anesthetic success of ± 20 percent. We defined onset of pulpal anesthesia as the time when we obtained the first of two consecutive 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 subjects rated pain in the injection area, using the same VAS as previously described, immediately after the numbness wore off and for the next three days each morning on arising. We also instructed patients to describe and record any problems, other than pain, that they experienced. We received 115 completed postinjection surveys.

We used logistic regression to analyze group comparisons between the articaine and lidocaine formulations for incidence of pulpal anesthesia and anesthetic success. We adjusted incidences of pulpal anesthesia by using the step-down Bonferroni method of Holm. To make between-group comparisons for onset time, we used the Wilcoxon matched pairs signed rank test. We made between-group comparisons of needle insertion, needle placement and solution deposition pain and postoperative pain by means of analysis of variance with a Tukey-Kramer multiple comparison test. We considered comparisons significant at P < .05.


   RESULTS
TOP
 ABSTRACT
 SUBJECTS, MATERIALS AND METHODS
 RESULTS
DISCUSSION
 CONCLUSION
 REFERENCES
 
Sixty adult subjects, 34 women and 26 men, aged 19 to 51 years with an average age of 27 years, participated in the study.

Table 1Go shows the subjects’ anesthetic success rates. For the articaine formulation, successful pulpal anesthesia ranged from 75 to 92 percent. For the lidocaine formulation, successful pulpal anesthesia ranged from 45 to 67 percent. The articaine formulation was significantly better than the lidocaine formulation in achieving pulpal anesthesia for each of the four teeth (Table 1Go). Figures 2Go through 5GoGoGo present the incidence of pulpal anesthesia (pulp test readings of 80) for the articaine and lidocaine formulations over time. Each figure shows significant differences between the two formulations (P < .05).


View this table:
[in this window]
[in a new window]

  		TABLE 1 Percentages and numbers of subjects who experienced anesthetic success.

 

Figure 2
View larger version (50K):
[in this window]
[in a new window]

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

 

Figure 3
View larger version (53K):
[in this window]
[in a new window]

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

 

Figure 4
View larger version (50K):
[in this window]
[in a new window]

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

 

Figure 5
View larger version (52K):
[in this window]
[in a new window]

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

 
Table 2Go (page 1109) presents data on the onset of pulpal anesthesia. For the articaine formulation, onset of pulpal anesthesia ranged from 4.2 to 4.7 minutes. For the lidocaine formulation, onset of pulpal anesthesia ranged from 6.1 to 11.1 minutes. The articaine formulation was significantly faster than the lidocaine formulation for each of the four teeth (Table 2Go).


View this table:
[in this window]
[in a new window]

  		TABLE 2 Onset of pulpal anesthesia, in minutes.

 
Table 3Go (page 1110) shows subjects’ experience of pain on injection. There were no significant differences between the two anesthetic formulations in terms of this variable.


View this table:
[in this window]
[in a new window]

  		TABLE 3 Mean pain ratings for articaine and lidocaine for each injection phase.

 
Table 4Go (page 1110) presents postinjection pain scores. There were no significant differences between the anesthetic formulations in terms of this variable. The only reported postinjection complications were bruising and slight swelling in the area of the injection. For lidocaine, 5 percent (three of 59) of the subjects reported swelling and 2 percent (one of 59) reported bruising. For articaine, 4 percent (two of 56) of the subjects reported swelling and no subjects reported bruising.


View this table:
[in this window]
[in a new window]

  		TABLE 4 Mean pain ratings for articaine and lidocaine for each postinjection day.

 
No subjects reported tongue numbness with either solution. Ninety-eight percent (59 of 60) of the subjects had lip numbness with the articaine solution and 100 percent (60 of 60) had lip numbness with the lidocaine solution. In all subjects who 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 articaine cartridges in milliliters was 1.76 ± 0.023 mL (SD) and from the lidocaine cartridges was 1.76 ± 0.022 mL.


   DISCUSSION
TOP
 ABSTRACT
 SUBJECTS, MATERIALS AND METHODS
 RESULTS
 DISCUSSION
CONCLUSION
 REFERENCES
 
We based our use of the pulp test reading of 80—signaling maximum output—as a criterion for pulpal anesthesia on the studies of Dreven and colleagues27 and Certosimo and Archer.28 These studies showed that an absence of patient’s response to an 80 reading was an assurance of pulpal anesthesia in vital asymptomatic teeth. Additionally, Certosimo and Archer28 demonstrated that patients who had electric pulp test readings of less than 80 experienced pain during operative procedures in asymptomatic teeth. Therefore, on the basis of these studies, we concluded that using the electric pulp tester before beginning dental procedures on asymptomatic vital teeth would provide the clinician with a reliable indicator of pulpal anesthesia.

Studies by Meechan and colleagues3 and Kanaa and colleagues25 demonstrated a 39 percent success rate (obtaining two consecutive 80 readings with the electric pulp tester) when administering a cartridge of 2 percent lidocaine with 1:100,000 epinephrine in a buccal infiltration of the first molar. Using a cartridge of 2 percent lidocaine with 1:100,000 epinephrine, we found a higher success rate (57 percent) for the first molar when we used the same definition as that of Kanaa and colleagues.25 This higher success rate may be related to the greater number of subjects enrolled in our study or to differences in subject populations between our study and that of Kanaa and colleagues. A success rate of 57 percent would not be clinically acceptable for procedures requiring profound pulpal anesthesia.

For each of the four test teeth, anesthetic success (Table 1Go) and incidence of pulpal anesthesia (Figures 2Go–5GoGoGo) were significantly better with the articaine formulation. The exact mechanism of the articaine’s increased efficacy is not known; however, we can speculate about a few mechanisms. Borchard and Drouin29 found that a lower concentration of articaine (which is a thiophene derivative) was sufficient to block an action potential when compared with other amide anesthetics (all of which were benzene derivatives). Potocnik and colleagues,30 in a study of sensory nerve conduction in rats, found that both 2 and 4 percent articaine were superior to 2 percent lidocaine in blocking nerve conduction. However, with increased intensity of nerve stimulation, the compound action potential recovered for 2 percent articaine but not for 4 percent articaine. In a clinical study31 comparing 2 percent and 4 percent articaine’s efficacy in infiltration anesthesia, investigators found that the 4 percent articaine solution had a longer duration but not greater efficacy. It may be that factors other than the concentration may be responsible for articaine’s clinical efficacy. For instance, the unique chemical structure of articaine—meaning its thiophene ring, which is not possessed by other local anesthetic agents—may facilitate better diffusion of the anesthetic solution to the teeth.

Regardless of the mechanism, we found that articaine was superior to lidocaine. Our results support those of Kanaa and colleagues,25 who found that an articaine formulation had a higher success rate than did a lidocaine formulation in achieving buccal infiltration anesthesia of the first molar. The success rate for the first molar was higher in our study (87 percent) than that recorded by Kanaa and colleagues25 (64 percent). The higher success rate in our study may be related to the greater number of subjects we tested or to population differences. Because we studied a young adult population, the results of this study may not apply to children or elderly people.

Haas and colleagues13,14 compared infiltrations of articaine and prilocaine formulations in the mandibular canines and second molars. They found no statistical differences between the two anesthetic formulations. The success rates (a reading 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 the second molar was lower than the 75 percent success rate recorded in our study (Table 1Go). Differences in the subject population or the use of 4 percent articaine solution with 1:200,000 epinephrine 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 alveolar nerve block1,2 in which either articaine or lidocaine formulations were used, we found that the success rate was higher in the present study for the first molar, second premolar and first pre-molar. Success rates in our study were 87 percent for the first molar, 92 percent for the second pre-molar and 86 percent for the first premolar, while success rates (two consecutive pulp test readings of 80) for the inferior alveolar nerve blocks have ranged from 81 to 83 percent for the first molar, from 73 to 80 percent for the second premolar and from 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 consecutive readings of 80) shown in the study by Mike-sell and colleagues1 for the inferior alveolar nerve block using articaine. Concerning onset of pulpal anesthesia, six studies32–37 of the inferior alveolar nerve block, using 1.8 mL of 2 percent lidocaine with 1:100,000 epinephrine, found onset times ranging 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 2Go) for the subjects in our study with the articaine formulation, infiltration provided a quicker onset than did an inferior alveolar nerve block when articaine was used. However, as shown in Figures 2Go through 5GoGoGo, pulpal anesthesia declined steadily during the 60 minutes, whereas in a study by Fernandez and colleagues,38 once subjects experienced pulpal anesthesia with the inferior alveolar nerve block using 1.8 mL of 2 percent lidocaine with 1:100,000 epinephrine, they sustained pulpal anesthesia for an average of 2 hours and 24 minutes. Duration of pulpal anesthesia is a significant disadvantage of buccal infiltration in mandibular posterior teeth.

Even though the articaine cartridge was marked externally as containing 1.7 mL, on average the anesthetic solution expressed was 1.76 mL. For the lidocaine cartridge, the amount was marked as 1.8 mL, but on average the anesthetic solution expressed was 1.76 mL. In general, a small amount of anesthetic solution remained in both cartridges after delivery of the solution with an aspirating syringe. The amount of anesthetic solution expressed 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 2Go–5GoGoGo). The anesthetic solution appeared to diffuse anteriorly from the first molar site. That is, a higher success rate was recorded for both the premolar and first molar than for the second molar for both anesthetic formulations (Table 1Go). The relatively thick mandibular bone in the second molar region may hinder anesthetic diffusion. Buccal infiltration over the second molar or buccal to the premolars needs to be investigated further to determine its success. Additionally, the anesthetic solution may have entered the mental foramen, leading to the higher success rates in the premolars and first molar. Anatomically, the mental foramen is in the apical area of the second premolar39 and in proximity to the first molar injection site. Phillips and colleagues39 found the foramen to be in line with the long axis of the second premolar 63 percent of the time. When not in line with the axis, the foramen was within 2 mm of it mesially or distally. Although we can speculate that the buccal infiltration of the first molar may result in anesthetic solution’s entering the mental foramen, the superiority of articaine over lidocaine must be related to the higher potency of articaine or its unique chemical structure. However, if profound pulpal anesthesia is required for 60 minutes, the buccal infiltration of 1.8 mL of 4 percent articaine with 1:100,000 epinephrine will not provide the duration needed because of declining pulpal anesthesia. Figures 2Go through 5GoGoGo demonstrate the slow decline of pulpal anesthesia over 60 minutes.

There was a statistically significant difference in onset of pulpal anesthesia between the anesthetic formulations for each tooth type, with the articaine formulation producing consistently faster onset (Table 2Go, Figures 2Go–5GoGoGo). The quicker onset again may be related to the potency of articaine or its unique chemical structure. When using an articaine formulation for buccal infiltration in the first molar region, waiting approximately five minutes should ensure the onset of pulpal anesthesia (Table 2Go). Clinically, the practitioner can use the electric pulp tester to evaluate the tooth under treatment for pulpal anesthesia before beginning the procedure.27,28

The articaine and lidocaine formulations were not significantly different in terms of associated injection pain (Table 3Go). Likewise, Kanaa and colleagues25 found no significant difference in injection discomfort between articaine and lidocaine formulations in mandibular buccal infiltration of the first molar. The pain ratings of the three phases of injection generallly were in the faint-to-weak pain area of the VAS (Figure 1Go, Table 3Go). Kanaa and colleagues25 also found the pain of mandibular infiltration of the first molar to be in the mild range with use of articaine or lidocaine formulations.

The high incidence (98–100 percent) and duration (60 minutes) of unilateral lip numbness with both formulations in our study would indicate that a buccal infiltration of the first molar would result in subjective lip numbness. However, because we did not always achieve pulpal anesthesia (Figure 2Go–5GoGoGo), lip numbness should not be considered an indicator of pulpal anesthesia for this type of infiltration. The most likely reason for subjective 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 not affected. We did not use mucosal sticks to evaluate lingual mucosal gingival anesthesia. Kanaa and colleagues,25 after administering a buccal infiltration of the first molar, found lingual mucosal numbness in seven of 31 subjects after using an articaine formulation and in three of 31 subjects after using a lidocaine formulation.

Postinjection pain ratings, at the time anesthesia wore off, were not statistically different between the articaine and lidocaine formulations (Table 4Go). The incidence of pain decreased during the next three days. All of the pain ratings were less than the "faint" pain descriptor on the VAS (Figure 1Go). No other study has evaluated postinjection pain for a buccal infiltration in mandibular posterior teeth; therefore, comparisons are not possible. The only reported postinjection complications were bruising and slight swelling in the area of the injection. For lidocaine, 5 percent (three of 59) of subjects reported swelling and 2 percent (one of 59) reported bruising. For articaine, 4 percent (two of 56) reported swelling and none reported bruising. All complications resolved within three days except for a slight swelling reported with lidocaine by one subject on day three. Although there have been reports of paresthesia associated with articaine use,40,41 no subjects reported any paresthesia in our study, even though the injection site approximated the mental nerve. It would be unlikely that paresthesia would be reported in our study, because Haas and Lennon40 indicated that paresthesias are rare and unlikely with infiltration anesthesia.


   CONCLUSION
TOP
 ABSTRACT
 SUBJECTS, MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
REFERENCES
 
We conclude that a buccal infiltration of the first molar with a cartridge of 4 percent articaine with 1:100,000 epinephrine is significantly better than is such an infiltration with a cartridge of 2 percent lidocaine with 1:100,000 epinephrine in achieving pulpal anesthesia in mandibular posterior teeth. However, clinicians should be mindful that pulpal anesthesia likely will decline slowly over 60 minutes.


   FOOTNOTES
 

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 "reader.2{at}osu.edu". 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.


   REFERENCES
TOP
 ABSTRACT
 SUBJECTS, MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 

  1. Mikesell P, Nusstein J, Reader A, Beck M, Weaver J. A comparison of articaine and lidocaine for inferior alveolar nerve blocks. J Endod 2005;31(4):265–70.[Medline]

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

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

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

  5. Malamed SF, Gagnon S, Leblanc D. Articaine hydrochloride: a study of the safety of a new amide local anesthetic. JADA 2001;132(2): 177–85.[Abstract/Free Full Text]

  6. van Oss GE, Vree TB, Baars AM, Termond EF, Booij LH. Pharmacokinetics, metabolism, and renal excretion of articaine and its metabolite articainic acid in patients after epidural administration. Eur J Anaesthesiol 1989;6(1):49–56.[Medline]

  7. Oertel R, Rahn R, Kirch W. Clinical pharmacokinetics of articaine. Clin Pharmacokinet 1997;33(6):417–25.[Medline]

  8. 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(6):268–71.[Medline]

  9. Oertel R, Ebert U, Rahn R, Kirch W. The effect of age on pharmacokinetics of the local anesthetic drug articaine. Reg Anesth Pain Med 1999;24(6):524–8.[Medline]

  10. Malamed SF, Gagnon S, Leblanc D. A comparison between articaine HCl and lidocaine HCl in pediatric dental patients. Pediatr Dent 2000;22(4):307–11.[Medline]

  11. Malamed SF, Gagnon S, Leblanc D. Efficacy of articaine: a new amide local anesthetic. JADA 2000;131(5):635–42.[Abstract/Free Full Text]

  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. J Can Dent Assoc 1987;53(1):38–42.[Medline]

  13. 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(5):230–7.[Medline]

  14. Haas DA, Harper DG, Saso MA, Young ER. Lack of differential effect by Ultracaine (articaine) and Citanest (prilocaine) in infiltration anaesthesia. J Can Dent Assoc 1991;57(3):217–23.[Medline]

  15. Tofoli GR, Ramacciato JC, de Oliveira PC, Volpato MC, Groppo FC, Ranali J. Comparison of effectiveness of 4 percent articaine associated with 1:100,000 or 1:200,000 epinephrine in inferior alveolar nerve block. Anesth Prog 2003;50(4):164–8.[Medline]

  16. Vahatalo K, Antila H, Lehtinen R. Articaine and lidocaine for maxillary infiltration anesthesia. Anesth Prog 1993;40(4):114–6.[Medline]

  17. Oliveria PC, Volpato MC, Ramacciato JC, Ranali J. Articaine and lignocaine in infiltration anaesthesia: a pilot study. Br Dent J 2004;197(1):45–6.[Medline]

  18. Berlin J, Nusstein J, Reader A, Beck M, Weaver J. Efficacy of articaine and lidocaine in a primary intraligamentary injection administered with a computer-controlled local anesthetic delivery system. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;99(3):361–6.[Medline]

  19. Claffey E, Reader A, Nusstein J, Beck M, Weaver J. Anesthetic efficacy of articaine for inferior alveolar nerve blocks in patients with irreversible pulpitis. J Endod 2004;30(8):568–71.[Medline]

  20. Hersh EV, Giannakopoulos H, Levin LM, et al. The pharmacokinetics and cardiovascular effects of high-dose articaine with 1:100,000 and 1:200,000 epinephrine. JADA 2006;137(11):1562–71.[Abstract/Free Full Text]

  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.[Abstract/Free Full Text]

  22. Bigby J, Reader A, Nusstein J, Beck M, Weaver J. Articaine for supplemental intraosseous anesthesia in patients with irreversible pulpitis. J Endod 2006;32(11):1044–7.[Medline]

  23. Sierra-Rebolledo A, Delgado-Molina E, Berini-Aytis L, Gay-Escorda C. Comparative study of the anesthetic efficacy of 4% articaine versus 2% lidocaine in inferior alveolar nerve block during surgical extraction of impacted lower third molars. Med Oral Patol Oral Cir Bucal 2007;12(2):E139–44.[Medline]

  24. Costa CG, Tortamano IP, Rocha RG, Francischone CE, Tortamano N. Onset and duration periods of articaine and lidocaine on maxillary infiltration. Quintessesnce Int 2005;36(3):197–201.

  25. Kanaa MD, Whitworth JM, Corbett IP, Meechan JG. Articaine and lidocaine mandibular buccal infiltration anesthesia: a prospective randomized double-blind cross-over study. J Endod 2006;32(4):296–8.[Medline]

  26. Heft MW, Parker SR. An experimental basis for revising the graphic rating scale for pain. Pain 1984;19(2):153–61.[Medline]

  27. Dreven LJ, Reader A, Beck M, Meyers WJ, Weaver J. An evaluation of the electric pulp tester as a measure of analgesia in human vital teeth. J Endod 1987;13(5):233–8.[Medline]

  28. Certosimo AJ, Archer RD. A clinical evaluation of the electric pulp tester as an indicator of local anesthesia. Oper Dent 1996;21(1):25–30.[Medline]

  29. Borchard U, Drouin H. Carticaine: action of the local anesthetic on myelinated nerve fibres. Eur J Pharmacol 1980;62(1):73–9.[Medline]

  30. Potocnik I, Tomsic M, Sketelj J, Bajrovic FF. Articaine is more effective than lidocaine or mepivacaine in rat sensory nerve conduction block in vitro. J Dent Res 2006;85(2):162–6.[Abstract/Free Full Text]

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

  32. Vreeland DL, Reader A, Beck M, Meyers W, Weaver J. An evaluation of volumes and concentrations of lidocaine in human inferior alveolar nerve block. J Endod 1989;15(1):6–12.[Medline]

  33. Hinkley SA, Reader A, Beck M, Meyers WJ. An evaluation of 4 percent prilocaine with 1:200,000 epinephrine and 2 percent mepivacaine with 1:20,000 levonordefrin compared with 2 percent lidocaine with 1:100,000 epinephrine for inferior alveolar nerve block. Anesth Prog 1991;38(3):84–9.[Medline]

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

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

  36. Ridenour S, Reader A, Beck M, Weaver J. Anesthetic efficacy of a combination of hyaluronidase and lidocaine with epinephrine in inferior alveolar nerve blocks. Anesth Prog 2001;48(1):9–15.[Medline]

  37. Steinkruger G, Nusstein J, Reader A, Beck M, Weaver J. The significance of needle bevel orientation in achieving a successful inferior alveolar nerve block. JADA 2006;137(12):1685–91.[Abstract/Free Full Text]

  38. Fernandez C, Reader A, Beck M, Nusstein J. A prospective, randomized, double-blind comparison of bupivacaine and lidocaine for inferior alveolar nerve blocks. J Endod 2005;31(7):499–503.[Medline]

  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.[Medline]

  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.[Medline]

  41. Miller P, Lennon D. Incidence of local anesthetic-induced neuropathies in Ontario from 1994–1998 (abstract 3869). J Dent Res 2000;79(4):627.




This article has been cited by other articles:


Home page
 Journal of the American Dental AssociationHome page
A. Haase, A. Reader, J. Nusstein, M. Beck, and M. Drum
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, September 1, 2008; 139(9): 1228 - 1235.
[Abstract] [Full Text] [PDF]

Home page
 Journal of the American Dental AssociationHome page
D. Flanagan
EFFICACY OF ARTICAINE
J Am Dent Assoc, November 1, 2007; 138(11): 1418 - 1420.
[Full Text] [PDF]

Home page
 Journal of the American Dental AssociationHome page
E. L. Gladstein
MORE ABOUT ARTICAINE
J Am Dent Assoc, November 1, 2007; 138(11): 1420 - 1420.
[Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Robertson, D.
Right arrow Articles by McCartney, M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Robertson, D.
Right arrow Articles by McCartney, M.
Related Collections
Right arrow Pharmacology

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS