Comparison of anaesthetic efficacy of 4% articaine buccal infiltration versus 2% lidocaine inferior alveolar nerve block for pulpotomy in mandibular primary second molars

Seyedeh Hediyeh Daneshvar; Dariush Dorani; Mir Mahdi Daneshvar

doi:10.4103/jisppd.jisppd_21_21



ORIGINAL ARTICLE

Year : 2021 \| Volume : 39 \| Issue : 3 \| Page : 299-302

Comparison of anaesthetic efficacy of 4% articaine buccal infiltration versus 2% lidocaine inferior alveolar nerve block for pulpotomy in mandibular primary second molars

Seyedeh Hediyeh Daneshvar¹, Dariush Dorani², Mir Mahdi Daneshvar³
¹ Assistant Professor, Dental Sciences Research Center, Department of Pediatric Dentistry, School of Dentistry, Guilan University of Medical Sciences, Rasht, Iran
² Dentist, Private Practice, Guilan University of Medical Sciences, Rasht, Iran
³ Department of Prosthodontics Dentistry, School of Dentistry, Guilan University of Medical Sciences, Rasht, Iran

Date of Submission	17-Jan-2021
Date of Decision	17-Feb-2021
Date of Acceptance	02-Mar-2021
Date of Web Publication	22-Nov-2021

Correspondence Address:
Dr. Seyedeh Hediyeh Daneshvar
Department of Pediatric Dentistry, Dental Sciences Research Center, School of Dentistry, Guilan University of Medical Sciences, Rasht
Iran

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jisppd.jisppd_21_21

Abstract

Background: Pain control and proper anesthesia during pulp therapy is one of the most important aspects of behavior management in pediatric dentistry. Aims: This study compared the success rate of inferior alveolar nerve block (IANB) using 2% lidocaine and infiltration using 4% articaine for pulpotomy of mandibular primary second molars. Settings and Design: The present clinical trial was conducted on 40 children aged 5–8 referred to the Department of Pediatric Dentistry, Guilan University of Medical Sciences, who needed pulpotomy treatment in both mandibular second molars. The patients were randomly divided into two groups (A and B). Subjects and Methods: At the first session, Group A received articaine infiltration and Group B experienced IANB using lidocaine. At the next visit, this trend was reversed. Pain intensity was measured upon the initiation of the pulp exposure using a facial image scale (FIS) and the patients' behavior during pulpotomy was measured using sound eye motor (SEM). Statistical Analysis Used: Wilcoxon signed-rank test was used for the analysis of data. A significant level of differences was taken as P ≤ 0.05. Results: According to FIS, the pain upon the initiation of the pulp exposure was significantly lower in the lidocaine group (P = 0.028). Patients' behavior was also significantly better in the lidocaine group according to SEM (P = 0.028). Conclusions: IANB using lidocaine has higher anesthetic efficacy in the pulp therapy of the mandibular primary second molars compared to articaine infiltration.

Keywords: Articaine, infiltration, lidocaine, pulpotomy

How to cite this article:
Daneshvar SH, Dorani D, Daneshvar MM. Comparison of anaesthetic efficacy of 4% articaine buccal infiltration versus 2% lidocaine inferior alveolar nerve block for pulpotomy in mandibular primary second molars. J Indian Soc Pedod Prev Dent 2021;39:299-302

How to cite this URL:
Daneshvar SH, Dorani D, Daneshvar MM. Comparison of anaesthetic efficacy of 4% articaine buccal infiltration versus 2% lidocaine inferior alveolar nerve block for pulpotomy in mandibular primary second molars. J Indian Soc Pedod Prev Dent [serial online] 2021 [cited 2021 Nov 29];39:299-302. Available from: https://www.jisppd.com/text.asp?2021/39/3/299/330705

Introduction

Successful anesthesia and pain control is a major concern during pulpotomy treatment in children.^[1] Inferior alveolar nerve block (IANB) is the most commonly used injection technique to anesthetize mandibular primary second molars. Unfortunately, IANB has some complications such as transient facial paralysis, trismus, local anesthetic injected into the blood vessel, and prolonged soft-tissue anesthesia which result in self-inflicted trauma such as biting of lip/cheek and damage to the sphenomandibular ligament. Furthermore, the failure rate of IANB has reached the highest level of 44%–48%.^{[2],[3],[4],[5]} The most common cause of this failure is the diversity of the anatomic structure of the mandible bone among the patients. Size and degree of projection of lingual, the angle between the body and the ramus of mandible, and patient's age are effective in the success rate of IANB.^{[6],[7],[8],[9]} Buccal infiltration (BI) is a simpler technique compared to IANB but due to the low penetration of lidocaine through the buccal cortical plate, BI using lidocaine is not as effective as the IANB for achieving profound anesthesia in mandibular primary second molars.^[10],[11] It has been claimed that articaine is more effective than lidocaine due to containing a thiophene ring which enhances its lipid solubility and allows the solution to easily cross the lipid membrane. Its plasma protein binding is higher than that observed with many local anesthetics.^[12]

Majority of studies regarding its effectiveness have been performed in adults and literature supporting its use in children is sparse. The aim of this study was to compare the anesthetic efficacy of IANB using 2% lidocaine and BI using 4% articaine for pulpotomy of mandibular primary second molars.

Subjects and Methods

This study protocol was approved by the Ethics Committee of Guilan University of Medical Sciences (IR.GUMS.REC.1399.225).

This randomized crossover clinical trial (IRCT20200622047887N1) was conducted on 40 children (5-8 years of age) referred to the Department of Pediatric Dentistry, Guilan University of Medical Sciences, who needed pulpotomy treatment in both mandibular primary second molars.

Children with neurological disorders with sensory disturbances, difficulties in communication, uncooperative behavior (class 1 and 2 in Frankel scale), history of allergic reactions to local anesthetic solutions, medical conditions contraindicating the use of local anesthetics containing epinephrine, and evidence of soft-tissue infection/inflammation near the area of injection were excluded from the study.

Written informed consent was obtained from all the parents. The patients were randomly divided into two groups (A and B) using random number table in Excel 2013 (Microsoft Corporation, WA, USA). At the first session, Group A received 1.8 mL of 4% articaine with 1:100,000 epinephrine (DarouPakhsh Co, Tehran, Iran) as BI and Group B received 1.8 mL of 2% lidocaine with 1:80,000 epinephrine (DarouPakhsh Co, Tehran, Iran) as IANB. At the next visit with at least an 1-week interval from the first appointment, this trend was reversed.

Prior to the injection, topical anesthetic gel (Benzotop, DFL, Rio de Janeiro, Brazil) was applied with a cotton roll for 30 s. Local anesthetic solutions were delivered using a standard aspirating syringe with a 27-gauge needle (Septodont, France). The length of the needle was 11 mm in BI and 25 mm in IANB injection. Anesthetic solutions were injected at a rate of approximately 1 mL/min. All the injections were performed by a single pedodontist. After the administration of local anesthetic by either technique and wait of 10–15 min for induction of anesthesia, pedodontist started caries removal.

Upon the initiation of the pulp exposure, each child was asked to select the facial expression that best represented his/her feeling of discomfort according to the facial image scale^[13] [Figure 1].

Figure 1: Facial image scale

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During the pulpotomy, the staff member who was blinded to the type of anesthetic solutions evaluated the patients' behavior using the sound eye motor (SEM) scale^[14] [Table 1].

Table 1: Sound, eye, motor scale for the assessment of child's behavior

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Wilcoxon signed-rank test was used for the analysis of data. A significant level of difference was taken as P ≤ 0.05.

Results

Forty children, 23 boys and 17 girls, 5–8 years of age (average 6.72 ± 0.96 years) participated in this randomized clinical trial. The mean of pain felt upon the pulp exposure according to the FIS scale was 2.17 ± 0.75 in the lidocaine group and 2.52 ± 0.78 in the articaine group, indicating significantly better patient feeling in the lidocaine group (P = 0.028). Pain value reported by children is shown in [Table 2].

Table 2: Reported pain value upon the pulp exposure according to facial image scale

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The means of SEM values were 5.52 ± 1.47 in the lidocaine group and 6.35 ± 1.73 in the articaine group, indicating significantly better patient behavior in the lidocaine group (P = 0.028). However, there was no statistically significant difference between the two groups in terms of eye (P = 0.09) and motor (P = 0.1), but the sound was significantly lower in the lidocaine group (P = 0.04) [Table 3].

Table 3: Mean patient behavior with standard deviation during pulpotomy according to sound eye motor scale

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Discussion

An important need prior to pulp therapy in children is the ability to achieve profound anesthesia. The most commonly used injection technique for anesthetizing mandibular teeth is IANB. IANB produces unnecessary anesthesia of full quadrant and half tongue which could be annoying for children. BI is not without disadvantages, but it produces less unnecessary soft-tissue anesthesia.^[5] The aim of this randomized clinical trial was to find out an alternative technique which produces adequate anesthesia of mandibular primary second molars with fewer complications and without involving other adjacent structures. As articaine has a higher ability to diffuse through tissues, we compared the anesthetic efficacy of IANB using 2% lidocaine and BI using 4% articaine for pulpotomy of mandibular primary second molars.

The use of BI with articaine to obtain analgesia of mandibular posterior teeth has been tested predominantly in permanent teeth and the results suggest that BI with articaine is a valuable alternative to IANB with lidocaine. Electric Pulp Tester (EPT) was used in permanent teeth to determine the anesthetic depth that is more accurate than the self-report of pain in this study. However, pulp tester has inadequate reliability in children.^[15],[16]

Several scales are available for the assessment of pain. As pain is a multidimensional phenomenon, self-reporting is usually one of the best ways of evaluation in children. In most recent studies, Visual Analog Scale was used that consisted of a horizontal line measuring 100 mm which had the words “no pain” at one end and “unbearable” at the other. The children evaluated the pain during pulpotomy by placing a vertical line on the scale that could be vague and confusing for children.^[17],[18] In this study, FIS was used for assessment of discomfort and pain upon the pulp exposure. This self-reported scale is a simple tool which contains a row of five faces ranging from very happy to very unhappy. The children were asked to point at which face they felt most like at the moment of pulp exposure.^[13] The children reported significantly less discomfort and pain in the lidocaine group compared to the articaine group.

The childrens' behavior was also evaluated using the SEM scale^[14] during pulpotomy, indicating significantly better patient behavior in lidocaine group. As a pedodontist could not be blind to LA technique and there was a possibility of bias in assessing LA success by a dentist, a staff member who was blind to the LA technique registered the SEM scale. The pedodontist who participated in this study had 10-year clinical experience and has commonly used IANB for pulp therapy in children. Hence, the dentist s' skill level for IANB was high.

Similar to the results of our study, Arrow^[19] reported that lidocaine IANB was more successful than articaine BI. In contrast to our study, Ghadimi et al.^[1] reported better patient behavior in the articaine group. They used Modified Behavioral Pain Scale^[20] which contains parameters such as facial expression, cry, and movement while we used SEM scale.

Oulis et al.^[10] reported mandibular infiltration was less effective than mandibular block for pulpotomy of primary molars in children. In the study by Arali and Mytri,^[18] 4% articaine BI was more effective than 2% lidocaine IANB in achieving pulpal anesthesia. This difference could be due to the fact that the target teeth in our research were mandibular primary second molars, while Arali and Mytri studied primary first and second molars. Penetration of articaine through buccal cortical bone is dependent on density and porosity of bone which vary among different races. Furthermore, the buccal cortical bone in the mandibular primary second molar region is thicker than the first molar. Another reason for inconsistency could be related to the difference in epinephrine concentration, Arali and Mytri used 2% lidocaine with 1:100,000 epinephrine, while we used 2% lidocaine with 1:80,000 epinephrine.^[21]

Conclusions

Based on the results of this study, it can be concluded that lidocaine IANB has higher anesthetic efficacy in the pulp therapy of the mandibular primary second molars compared to articaine BI.

Acknowledgment

We thank Guilan University of Medical Sciences for their great support.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Ghadimi S, Shahrabi M, Khosravi Z, Behroozi R. Efficacy of articaine infiltration versus lidocaine inferior alveolar nerve block for pulpotomy in mandibular primary second molars: A randomized clinical trial. J Dent Res Dent Clin Dent Prospects 2018;12:97-101.
2.	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;30:568-71.
3.	Kaufman E, Weinstein P, Milgrom P. Difficulties in achieving local anesthesia. J Am Dent Assoc 1984;108:205-8.
4.	Meechan JG. Supplementary routes to local anaesthesia. Int Endod J 2002;35:885-96.
5.	Zain M, Rehman Khattak SU, Sikandar H, Shah SA, Fayyaz R. Comparison of anaesthetic efficacy of 4% articaine primary buccal infiltration versus 2% lidocaine inferior alveolar nerve block in symptomatic mandibular first molar teeth. J Coll Physicians Surg Pak 2016;26:4-8.
6.	Rayati F, Noruziha A, Jabbarian R. Efficacy of buccal infiltration anaesthesia with articaine for extraction of mandibular molars: A clinical trial. Br J Oral Maxillofac Surg 2018;56:607-10.
7.	Flanagan DF. The effectiveness of articaine in mandibular facial infiltrations. Local Reg Anesth 2016;9:1-6.
8.	Kim C, Hwang KG, Park CJ. Local anesthesia for mandibular third molar extraction. J Dent Anesth Pain Med 2018;18:287-94.
9.	Gazal G, Fareed WM, Zafar MS. Role of intraseptal anesthesia for pain-free dental treatment. Saudi J Anaesth 2016;10:81-6.
10.	Oulis CJ, Vadiakas GP, Vasilopoulou A. The effectiveness of mandibular infiltration compared to mandibular block anesthesia in treating primary molars in children. Pediatr Dent 1996;18:301-5.
11.	Sharaf AA. Evaluation of mandibular infiltration versus block anesthesia in pediatric dentistry. ASDC J Dent Child 1997;64:276-81.
12.	Isen DA. Articaine: Pharmacology and clinical use of a recently approved local anesthetic. Dent Today 2000;19:72-7.
13.	Buchanan H, Niven N. Validation of a Facial Image Scale to assess child dental anxiety. Int J Paediatr Dent 2002;12:47-52.
14.	Deepika A, Rao CR, Vinay C, Uloopi KS, Rao VV. Effectiveness of two flavored topical anesthetic agents in reducing injection pain in children: A comparative study. J Clin Pediatr Dent 2012;37:15-8.
15.	Kanaa MD, Whitworth JM, Corbett IP, Meechan JG. Articaineand lidocaine mandibular buccal inffltration anesthesia: A pro-spective randomized double-blind cross-over study. J Endod 2006;32:296-8.
16.	Robertson D, Nusstein J, Reader A, Beck M, McCartney M. The anesthetic efficacy of articaine in buccal infiltration of mandibular posterior teeth. J Am Dent Assoc 2007;138:1104-12.
17.	Havelka C, McTigue D, Wilson S, Odom J. The influence of social status and prior explanation on parental attitudes toward behavior management techniques. Pediatr Dent 1992;14:376-81.
18.	Arali V, Mytri P. Anaesthetic efficacy of 4% articaine mandibular buccal infiltration compared to 2% lignocaine inferior alveolar nerve block in children with irreversible pulpitis. J Clin Diagn Res 2015;9:ZC65-7.
19.	Arrow P. A comparison of articaine 4% and lignocaine 2% in block and infiltration analgesia in children. Aust Dent J 2012;57:325-33.
20.	Wong DL, Baker CM. Pain in children: Comparison of assessment scales. Pediatr Nurs 1988;14:9-17.
21.	Poorni S, Veniashok B, Senthilkumar AD, Indira R, Ramachandran S. Anesthetic efficacy of four percent articaine for pulpal anesthesia by using inferior alveolar nerve block and buccal infiltration techniques in patients with irreversible pulpitis: A prospective randomized double-blind clinical trial. J Endod 2011;37:1603-7.