ORIGINAL RESEARCH

https://doi.org/10.5005/jp-journals-10005-2734
International Journal of Clinical Pediatric Dentistry
Volume 17 | Issue S-1 | Year 2024

Split-mouth Comparison of Anesthetic Efficacy of Articaine and Lidocaine for Extractions of Deciduous Maxillary Teeth: A Randomized Controlled Trial

Jayashree L Jankar1, Bhushan J Pustake2

1Department of Pediatric and Preventive Dentistry, Pandit Deendayal Upadhyay Dental College & Hospital, Solapur, Maharashtra, India

2Department of Pedodontics and Preventive Dentistry, Mahatma Gandhi Vidyamandir’s Karmaveer Bhausaheb Hiray Dental College & Hospital, Nashik, Maharashtra, India

Corresponding Author: Jayashree L Jankar, Department of Pedodontics and Preventive Dentistry, Mahatma Gandhi Vidyamandir’s Karmaveer Bhausaheb Hiray Dental College & Hospital, Nashik, Maharashtra, India, Phone: +91 9820656654, e-mail: jayashreejankar@gmail.com

ABSTRACT

Purpose: To clinically evaluate whether 4% articaine administered alone as a single buccal infiltration in deciduous maxillary tooth extraction can provide favorable palatal anesthesia compared to buccal and palatal infiltrations using 2% lidocaine.

Materials and methods: A prospective, double-blind, split-mouth, randomized controlled clinical study was carried out on 60 children comprising 36 females and 24 males in the age group of 5–10 years. During two separate appointments, children randomly received either 4% articaine with 1:1,00,000 epinephrine (group I—experimental) as buccal infiltration alone, or 2% lidocaine with 1:80,000 epinephrine (group II—control) as buccal plus palatal infiltration. Second local anesthetic agent was administered at least 1 week apart from first administration. Efficacy of anesthesia was assessed using subjective [Wong–Baker Faces Pain Scale (WBFPS)] and objective [sound, eye, motor (SEM)] scales along with occurrence of any adverse effects.

Results: For infiltration procedure, 4% articaine (group I) had statistically highly significant (p < 0.001) pain scores on WBFPS as well as on SEM scale compared to 2% lidocaine (group II). According to WBFPS (p = 0.43) and SEM (p = 0.32) scores, the pain on extraction between 4% articaine and 2% lidocaine was statistically insignificant.

Conclusion: About 4% articaine buccal infiltration showed better clinical anesthetic efficacy, thus providing effective palatal anesthesia due to its enhanced vestibule-palatal diffusion with no significant postanesthetic complications. Hence, articaine can be used as an alternative to lidocaine in children for extractions of deciduous maxillary teeth.

Keywords: Articaine, Lidocaine, Children

How to cite this article: Jankar JL, Pustake BJ. Split-mouth Comparison of Anesthetic Efficacy of Articaine and Lidocaine for Extractions of Deciduous Maxillary Teeth: A Randomized Controlled Trial. Int J Clin Pediatr Dent 2024;17(S-1):S6–S10.

Source of support: Nil

Conflict of interest: None

INTRODUCTION

One of the most essential components of child behavior guidance is pain control during dental procedures. An important aspect that may shape the relationship between a pedodontist and a child patient is the successful administration of local anesthesia.1 Therefore it is vital at each visit to decrease discomfort and to mitigate painful situations as responses develop progressively negative after a series of four to five injections.1

Local anesthetic is both the salvation as well as the bane of modern dentistry.1 It is frequently applied during dental treatment of pediatric groups for providing pain-free treatment, and ensure comfort as well as cooperation.2

Pain after palatal injection is the most frequently perceived symptom in pediatric dentistry and is a significant concern.2 Therefore a number of methods are used to diminish the discomfort of intraoral injections like application of topical anesthetic being a well-known and often used option,3 transcutaneous electronic nerve stimulation (TENS), computerized injection systems, pressure administration, precooling of the palate and eutectic combination of local anesthesia. However, none of them received worldwide acceptance.4

Topical anesthesia is effective mainly on surface tissues and tissues deep to the area of application are inadequately anesthetized.4 Even though surface anesthesia permits a less traumatic needle penetration, the density of palatal soft tissues and its well-founded adherence to the underlying bone tissues, along with rich neural innervations, make the pain of varied intensity of palatal injection inadequately tolerated, particularly by children.5 Hence, it is essential to search for an anesthetic agent for which palatal injection can possibly be avoided.

Around 2% lidocaine has been the “gold standard” for the past 50 years to which all novel local anesthetics agents are compared and considered most efficacious anesthetic agent for use in pediatric and adult patients.6

Articaine is acquiring acceptance in dental practices due to its distinctive pharmacokinetics and effective bone penetration.7 It is different from other local anesthetic drugs due to its thiophene ring that enables it more potent and high lipid soluble and enables it to infiltrate more easily through hard and soft tissues. Besides this, articaine has a great affinity for plasma protein binding and it is the only amide local anesthetic drug to have an ester group that permits it to be quickly broken down into its inactive state.8

The rationale for the wider use of articaine is mainly due to the fact that it has high diffusion through soft tissue and bone, prompt onset, significant quality of anesthesia, and low incidence of adverse drug reactions than lidocaine.8 Articaine delivers complete anesthesia through infiltration procedure due to its greater tissue penetration ability.9

Abundant research studies are documented in the literature comparing anesthetic effectiveness of articaine and lidocaine for extractions of permanent teeth, whereas there are very few studies available on the use of articaine for deciduous maxillary teeth extraction.

The intent of the present study was to clinically assess whether 4% articaine hydrochloride given alone as a sole buccal infiltration for deciduous maxillary teeth extraction can ensure satisfactory palatal anesthesia compared to buccal and palatal infiltrations by 2% lidocaine hydrochloride. Efficacy of anesthesia was evaluated as a level of discomfort or pain felt by patient using subjective and objective scales.

MATERIALS AND METHODS

The present study was executed over a period of 18 months after attaining institutional ethical approval. Informed consent was obtained from parents/guardians and they were clarified in detail regarding the study procedures and anticipated risks and benefits.

A prospective, double-blinded randomized controlled clinical trial was implemented among 60 children of age group of 5–10 years and each child (as participant) performed as his or her own control in the study.

Inclusion Criteria

  • Children of age group of 5–10 years who needed administration of local anesthetic agent for bilateral extractions of maxillary deciduous teeth.

  • Children falling in the Frankl behavior rating scale of positive and definitely positive.

  • Only children whose parental consent was obtained before procedure.

Exclusion Criteria

  • Sensitivity to sulfites or amide group of local anesthetics.

  • Presence of severe or uncontrolled systemic disease in which tooth extraction is contraindicated.

  • Presence of soft tissue infection in adjacent areas of proposed injection site.

  • Children who were taking any medications that could affect pain perception or anesthetic evaluation.

Materials Used in This Study

  • Topical anesthesia (benzocaine gel 15 mg; Mucopain, ICPA, India).

  • Cotton applicator tips.

  • Four percent articaine hydrochloride with 1:1,00,000 epinephrine (adrenaline).

  • Two percent lidocaine hydrochloride with 1:80,000 epinephrine (adrenaline).

  • Thirty-gauge ultrashort needle (Septoject needles, Septodont, France).

  • Aspirating dental injection syringe (Septodont, Titanium-medium).

Treatment Procedure

In all children, thorough medical history, clinical examination, and preoperative radiographs were taken. A total of 60 children fulfilling inclusion and exclusion criteria and who required bilateral extractions of maxillary deciduous teeth were selected for the study.

All infiltrations were accomplished by first trained operator with slow administration of nearly 1 mL/minute, leading to better safety and diminished trauma. Deciduous maxillary teeth in 60 children (right or left side of the maxillary arch) were randomly divided by the first investigator using the toss of a coin into two groups. Children attained either 4% articaine hydrochloride with 1:1,00,000 adrenaline (experimental group) or 2% lidocaine hydrochloride with 1:80,000 adrenaline (control group) as first administration. Second local anesthetic agent was administered at least 1 week apart from first administration.

Among the experimental group, the buccal mucosa was dried with cotton gauze, and then topical anesthesia (Mucopain) was applied with cotton applicator tip to the buccal injection site for 1 minute. This was followed by use of 4% articaine with 1:1,00,000 adrenaline at the buccal site.

With specific to control group (group II), similar protocols were implemented except that after topical anesthetic application, 2% lidocaine with 1:80,000 adrenaline was infiltrated buccally and palatally.

After examination for the objective signs of local anesthesia by a sharp periosteal elevator, the second trained operator did all extractions that were blinded to used anesthetic agents.

Outcome Measures

Efficacy of anesthesia was evaluated using subjective and objective scales.

Wong–Baker Faces Pain Scale (WBFPS)10-12 was utilized for the subjective evaluation of the intensity of the pain perceived by children. The child was given a set of six cartoon faces with multiple facial expressions which ranged from a smile, laughter, and/or tears. Each face had an allocated numerical value ranging from 0 to 5. Children were probed to choose the facial expression that best exemplified their own experiences of discomfort instantly after infiltration and extraction methods for both groups.

The second investigator who was blinded to the anesthetic agent, observed and scored the response of the child during infiltration and extraction procedures for both groups using sound, eye, motor (SEM) scale designed by Wright et al.13,14 and graded scores from 0 to 3.

Occurrence of any adverse effects—any adverse reaction or severe adverse effects of 4% articaine and 2% lignocaine in all 60 children were observed clinically.

The data was retrieved and analyzed using Statistical Package for Social Sciences (SPSS) software version 18. The distribution of the data in the present study was non-normal. So, it was analyzed using nonparametric test, and pain severity scores were calculated and compared for statistical significance using “Wilcoxon signed-rank test.” p-value < 0.05 was taken as statistically significant.

RESULTS

A total of 60 children comprising 24 males and 36 females participated in this study. The mean age of study population was observed to be 7.1 ± 1.3 years. Around 120 maxillary teeth were extracted which included—lateral incisor (30%), canine (10%), first molar (40%), and second molar (20%).

There was female preponderance (69.2%) in the age group of 5–8 years compared to age-group of 8–10 years (42.9%) and male predominance (57.1%) belonging to age-group of 8–10 years compared to participants of 5–8 years (30.8%). However, this difference observed between gender and age-groups was not significant statistically (Chi-squared test). Hence, the study population was homogenously distributed as compared to gender and age-group.

The results showed that lidocaine group (I) had higher mean scores for pain as compared to articaine group (II) mean scores on WBFPS as well as on SEM scale for infiltration procedure (Figs 1 and 2). This difference found was statistically highly significant (FPS scale: Z = 6.13; p < 0.001, SEM scale: Z = 6.48; p < 0.001). This indicates that articaine had less pain score as compared to lidocaine for infiltration procedure. Immediately after extraction, lidocaine group (II) had higher mean scores for pain as compared to articaine group (I) mean scores on WBFPS (subjective) (Fig. 3), but the difference observed was not significant statistically (Z = 0.79; p = 0.43). Whereas lidocaine group (II) had comparable mean scores for pain with respect to articaine group (I) mean scores on SEM scale (objective) (Fig. 4) during extraction and the difference observed was not significant statistically too (Z = 1.0; p = 0.32).

Fig. 1: Comparison of articaine (group I) and lidocaine (group II) on FPS scale (infiltration)

Fig. 2: Comparison of articaine (group I) and lidocaine (group II) on SEM scale (infiltration)

Fig. 3: Comparison of articaine (group I) and lidocaine (group II) on FPS scale (extraction)

Fig. 4: Comparison of articaine (group I) and lidocaine (group II) on SEM scale (extraction)

In both groups, that is in all 60 children, no significant postanesthetic complications were observed clinically.

DISCUSSION

In the current study, 4% articaine buccal infiltration is found to have better clinical usefulness which is less mean pain scores than lidocaine using WBFPS and comparable mean pain scores using SEM scale; both statistically not significant. It may be elucidated that articaine is distinctive among amide local anesthetics agents because of thiophene ring which upsurges its lipid solubility.14 Due to its greater lipid solubility which decides to what extent, the molecules infiltrate nerve membrane, articaine diffuses more effectively through soft tissues than other local anesthetic agents, thus attaining greater intraneural concentration, widespread longitudinal dissemination as well as impactful conduction blockade.9

The present study did not reveal any statistically significant difference among the groups pertaining to age or gender, which is in accordance with studies conducted by Kolli et al.,9 Wright et al.,13 Ram et al.15

Both anesthetic agents were compared in the same patient, thereby necessitating similar resources, techniques as well as duration. This enables the comparison between articaine and lidocaine in similar patient, in two various appointments reasonable as well as unbiased.16

Odabas et al.2 did not find any significant difference for the second vs first administration about the children’s reaction as well as their self-rating of the injections. Meechan and Day17 stated that pain due to buccal injection was not affected by the injection orders that were used between the solutions. However, the injection order utilized in the existing study could not impact the study findings.

Ram et al.15 reported a lack of significant differences between both solutions (2% lidocaine and 4% articaine) about efficacy, even though the anesthetic solutions were of various concentrations.

The findings of this study coincide with Somuri et al.,3 who detected no statistically significant difference in pain scores in 4% articaine and 2% lidocaine for bilateral extraction of maxillary permanent premolars. They also observed that no younger participants who were <20 years old had pain on extraction in the articaine group. This may be attributed to the porous thin bone of the maxilla which enables the diffusion of local anesthetics. Also, the current study was performed among children <10 years of age, which could be the reason for higher vestibule-palatal diffusion of articaine, therefore giving effective palatal anesthesia with buccal infiltration alone.

In the present study, WBFPS and SEM scale pain scores showed statistically significant differences (p < 0.001) for infiltration procedure and statistically insignificant differences (p > 0.05) for extraction procedure in articaine and lidocaine groups which corroborate with the study results of Fan et al.18 Same inferences were also reported by Badcock et al.19

Maljaei et al.,4 Kolli et al.,9 and Oliveira et al.20 presented same outcomes without any statistically significant association between 4% articaine buccal infiltration and 2% lidocaine buccal and palatal infiltrations. Malamed et al.14 observed no significant differences in pain relief between 4% articaine and 2% lidocaine. Visual analog scale (VAS) scores showed that articaine can be an effective local anesthetic among pediatric groups and is as effective as lidocaine when measured on VAS. Authors mentioned that 4% articaine with 1:100,000 adrenaline is found to be safe as well as effective local anesthetic for its application in the field of pediatric dentistry.

Evans et al.,21 Hassan et al.,22 and Sharma et al.23 found statistically significant differences in the perception of pain which is incongruous to the outcomes of the current study as lidocaine was used bucally as well as palatally and did not reveal any statistical significant differences in the perception of pain.

In the present study, there was no incidence of any adverse reaction in both groups which is in accordance with Wright et al.,13,24 Dudkiewicz et al.,25 Malamed et al.,8,14 Kolli et al.,9 Luqman et al.,7 Hassan et al.22 According to Hawkins et al.,26 emphasized the action of articaine on prompt inactivation of plasma esterase leading to very limited adverse drug reactions. Yapp et al.,27 studied the applications of articaine in clinical dentistry and specified that it has benefits of less toxicity, good local infiltration, and greater biological safety over other amides.

Although buccal infiltration with 4% articaine shows less mean pain scores (WBFPS—subjective) and comparable mean pain scores (SEM scale—objective) than 2% lidocaine; both statistically insignificant, but still articaine may be taken as an effective alternative to lidocaine for local anesthesia among pediatric population.

Therefore, additional randomized controlled clinical trials with greater sample size must be implemented to yield significant levels of evidence to utilize such child-friendly approach in pediatric dentistry. Providing comfortable palatal anesthesia is considered to be a practice builder that not only enhances the trust and treatment acceptance among patient but also lessens personal stress level.15

CONCLUSION

The following conclusions can be drawn from the data obtained in our study:

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