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The anesthetic efficacy of articaine in buccal

infiltration of mandibular posterior teeth
Douglas Robertson, John Nusstein, Al Reader,
Mike Beck and Melissa McCartney
J Am Dent Assoc 2007;138;1104-1112

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R E S E A R C H The anesthetic efficacy of articaine in buccal infiltration of mandibular posterior teeth Douglas Robertson. it could be an additional technique for the clinician to consider. and Steubenville. W. John Nusstein.000 epinephrine at another appointment. Section of Endodontics. Al Reader. lidocaine. when the study described in this article was conducted. articaine. Methods. Vol.2@osu. Beck is an emeritus associate professor. MS A J ✷ D A ✷ IO N T A I Dr. Columbus. College of Dentistry. 2010 ® Background.000 epiICLE nephrine and 2 percent lidocaine with 1:100. MA. successful pulpal anesthesia ranged from 45 to 67 percent. crossover study comparing N the degree of pulpal anesthesia achieved by means of C U U IN G ED mandibular first molar buccal infiltrations of two anes. 12th Ave. Columbus.V. Reader is a professor. Ohio. Section of Endodontics. Columbus. 4 percent articaine with 1:100. Failure rates (never achieving two consecutive pulp test readings of 80) in these same studies1. The Ohio State University. For a mandibular buccal infiltration of the first molar.org August 2007 Copyright ©2007 American Dental Association. Therefore. College of Dentistry. The authors conducted a prospective. T S ABSTRACT CON uccessful buccal infiltration anesthesia of the mandibular posterior teeth would be advantageous to both clinicians and patients. College of Dentistry. Mikesell and colleagues1 and Nusstein and colleagues. Downloaded from jada. mandible. Section of Oral Biology. Section of Endodontics. DDS. infiltration.000 epinephrine will result in a higher success rate than will 2 percent lidocaine with 1:100. successful pulpal anesthesia ranged from 75 to 92 percent. The Ohio State University. Dr. e-mail “reader.. 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). With the lidocaine formulation. DDS. College of Dentistry. double-blind. Ohio 43210. 305 W. With the articaine formulation.000 epinephrine at one appointment and one cartridge of 2 percent lidocaine with 1:100.edu”. DDS. The Ohio State University. All rights reserved. but the duration of pulpal anesthesia will decline over 60 minutes with either formulation. Dr. Mike Beck. He now has a practice limited to endodontics in Wheeling. Local anesthetics. Columbus.A 3 RT thetic solutions: 4 percent articaine with 1:100.000 epinephrine.org on April 16. The injections were administered during two separate appointments spaced at least one week apart. 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. Key Words. 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. The Ohio State University. Dr. JADA 2007. MS. Melissa McCartney.138(8):1104-12. Dr. Robertson was a graduate student in endodontics. Address reprint requests to Dr. 1104 JADA. Pulpal anesthesia declined slowly over 60 minutes with both formulations. The Ohio State University. MS. Conclusion and Clinical Implications. if a buccal infiltration would reduce the slow onset and failure of pulpal anesthesia.ada. Results.2 using lidocaine and articaine formulations in inferior alveolar nerve blocks. There was a significant difference (P < . Columbus.ada.000 epinephrine. randomized. DDS.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 . McCartney is an assistant professor. MS.05) in anesthetic success between the lidocaine and articaine formulations for each of the four teeth.. Reader. Meechan and colleagues3 reported that buccal or buccal-pluslingual infiltrations of a cartridge of 2 percent lidocaine with 1:100. Nusstein is an associate professor and the chair. College of Dentistry. 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. DDS. 138 http://jada.2 ranged from 17 to 19 percent for the first molar.

the investigator administered 120 total infiltrations (60 of articaine and 60 of lidocaine).000 epinephrine and a cartridge of 4 percent articaine with 1:100.16.) and one cartridge of 4 percent articaine with 1:100.ada. 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.R.000 epinephrine (Xylocaine. 2010 mandibular first molars. The senior author administered the infiltration injections by using the standard masked cartridges and an aspirating syringe equipped with a 27gauge 11⁄2-inch needle. JADA.. Before the experiment. MATERIALS AND METHODS Using the guidelines established by The Ohio State University (Columbus) Human Subjects Review Committee.11. by Costa and colleagues. Many researchers have evaluated articaine and found it to be a safe and effective local anesthetic agent. we conducted a prospective. August 2007 1105 Downloaded from jada. 138 http://jada. The Ohio State University Human Subjects Review Committee approved the study.23 Articaine and prilocaine/lidocaine have shown an equivalent effect in infiltration anesthesia in the maxilla12-14. we masked the lidocaine and articaine cartridges with opaque labels and wrote the corresponding six-digit codes on each cartridge. had a history of significant medical conditions. Additional studies are needed to test the efficacy of articaine in infiltration anesthesia of mandibular posterior teeth. One of the investigators (D. At the beginning of each appointment and ABBREVIATION KEY. had active sites of pathosis in the area of injection or were unable to give informed consent.12. 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). the senior author) randomly administered to the 60 blinded subjects buccal infiltration injections of one cartridge of 2 percent lidocaine with 1:100. we recorded only the random numbers on the data collection sheets. large restorations and periodontal disease.) in two separate appointments spaced at least one week apart.1. In a 2000 response to a letter to the editor of JADA by Schertzer. Del.000 epinephrine (Septocaine. none had histories of trauma or sensitivity. Septodont. To further blind the experiment. we randomly assigned the two anesthetic formulations six-digit numbers from a random number table.ada. were pregnant. We checked all anesthetic formulations to ensure that they had not expired.19. We excluded potential subjects who were younger than 18 years or older than 60 years.org Copyright ©2007 American Dental Association. VAS: Visual analog scale. AstraZeneca. York. Pa.R E S E A R C H SUBJECTS. A recent study by Kanaa and colleagues25 compared a cartridge of 2 percent lidocaine with 1:100. were allergic to local anesthetics or sulfites. and we obtained written informed consent from each subject before enrolling him or her in the study.000 epinephrine for buccal infiltration anesthesia of the mandibular first molar. For the second infiltration in each subject. Clinical examinations indicated that all teeth were free of caries. . The test teeth we chose for the experiment were the first and second molars and first and second premolars. the investigator used the same side randomly chosen for the first infiltration. All rights reserved.15. Therefore. the low success rate with the lidocaine solution would not allow profound pulpal anesthesia for clinical procedures.org on April 16. Obviously. With this crossover design. New Castle. were taking any medications that could affect anesthetic assessment.18.24 which showed articaine to have a longer duration.4 Malamed stated that articaine would provide improved local anesthetic activity. Sixty infiltrations were administered on the right side and 60 on the left side. Vol. 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.17 except in one study. We randomly assigned each subject to one of the two formulations to determine which anesthetic formulation was to be administered at each appointment. randomized. Under sterile conditions. and each subject served as his or her own control. we chose 60 adult subjects who were in good health and were not taking any medications that would alter their perception of pain.5-23 Repeated clinical trials have failed to demonstrate that articaine is statistically superior to lidocaine in achieving mandibular anesthesia.

modstrate a difference in anesthetic success of ± 20 erate pain. Trained research then we viewed him or her as being unreliable personnel performed all preinjection and postinand ineligible to participate in the study. if his or her lip and each subject a visual analog scale (VAS) and tongue were numb. The Place a mark on the line below to show the amount of pain that you feel JADA. The the control tooth. At two minutes. Analytic Technology. the con(Figure 1). the senior tion. a 170-millimeter line marked with tents of 50 articaine cartridges and 50 lidocaine various terms describing levels of pain. They applied toothpaste to the probe tip. Wash. he or she minutes. At three cotton rolls and dried it with gauze. with the electric pulp tester. He or she recorded the number assoresponded positively to an inactivated pulp tester. research personnel asked each subject every three Before the injection. We defined onset of pulpal anesthesia as d114 mm or greater. Downloaded from jada. We asked all subjects to complete postinjection As noted above. the senior author administered surveys after each infiltration administered all infiltrations. needle placement and deposition of solution. each subject rated the milliliter–increment divisions. which he or repeated this cycle of testing every three minutes she then placed midway between the gingival for 60 minutes. author individually expressed. placing As the criterion for pulpal anesthesia. The Heft-Parker visual analog scale (VAS) used for assessment of pain. pain for each injection phase on the VAS. 138 http://jada. ciated with the initial sensation. That is. The jection tests. With a nondirecmild pain (including the descriptors of “faint. we tested the period of one minute (the solution deposition experimental teeth and the control contralateral phase). no pain. canine two times with an electric pulp tester One minute after completion of the infiltration.ada. they tested the control canine. Immedicartridges into a graduated syringe with 0. All rights reserved.01ately after the infiltration. for 60 minutes. He placed the needle gently into the alveolar mucosa (the needle insertion phase) and advanced it until None Faint Weak Mild Moderate Strong Intense Maximum Possible he estimated it to be at or just above the apexes of the first Figure 1. The millimeter molar (the needle placement demarcations were not shown on the patients’ VAS.” “intense” and “maximum utive pulp test readings of 80. To interpret the data.R E S E A R C H tion buccal to the mandibular first molar at each appointment.05 and a power of 80 percent. we divided at the pulp tester’s maximum output (a reading of the VAS into the following four categories: 80). by means of a The scale we used was the Heft-Parker VAS26 standard syringe with a 27-gauge needle.” tional α risk of . He administered a single infiltra(making a potential total of 120 surveys).) to the research assistants performed pulp testing on record baseline vitality. if the subject output (80). Vol. we used a mark on the scale where it best described his or a complete absence of response from the subject her pain level. After the research the second and first molars. At every third cycle. asked him or her to rate the pain experienced To measure the amount of anesthetic solution during each phase of the injection: needle inserdelivered with an aspirating syringe. by assistant set the rate of current at 25 seconds to means of an inactivated electric pulp tester to test increase from no output (0) to the maximum the subject’s reliability.org August 2007 Copyright ©2007 American Dental Association. 2010 1106 . bisecting the approximate location of the mesial Millimeters 0 23 36 54 85 114 144 170 and distal roots. (Kerr. when we obtained two consecutive readings of 80 dmore than 0 and less than or equal to 54 mm. We considered anesthesia to be successful d0 mm. thetic formulation over a before any injections were given. the senior author showed minutes. He deposited the anestional Association for the Study of Pain from PAIN: Heft and Parker. the contralateral canine. severe pain (including the the time when we obtained the first of two consecdescriptors of “strong. possible”).ada. Redmond. percent. Reprinted with permission of the Interna26 phase). sample size of 60 subjects was required to demondmore than 54 mm to less than 114 mm. a “weak” and “mild”). they assistant isolated the tooth to be tested with tested the second and first premolars.org on April 16. they tested margin and the occlusal edge of the tooth.

formulations over time. We used logistic regression to analyze group comparisons between the articaine and lidocaine formulations for incidence of pulpal anesthesia and anesthetic success. For lidocaine.2 to complications were bruising and slight swelling in the area of the injection. BY ANESTHETIC FORMULATION Articaine Lidocaine Second Molar 75 (45/60) 45 (27/60) .0001* First Premolar† 86 (49/57) 61 (35/57) . onset of pulpal anesthesia ranged from 4. aged 19 to 51 years with an average age of 27 years.05.1 min2 percent (one of 59) reported bruising. needle placement and solution deposition pain and postoperative pain by means of analysis of variance with a Tukey-Kramer multiple comparison test. we used the Wilcoxon matched pairs signed rank test.000 epinephrine and 2 percent lidocaine with 1:100.org on April 16. successful pulpal anesresponse to electrical pulp testing at the maximum setting (percentage of 80/80 thesia ranged from 75 to 92 percent. For the articaine Figure 2.05) between the articaine and lidocaine formulations as analyzed by means of logistic regression. We made between-group comparisons of needle insertion. We also instructed patients to describe and record any problems. The only reported postinjection of pulpal anesthesia. participated in 1 7 13 19 25 31 37 43 49 55 the study.0001* First Molar 87 (52/60) 57 (34/60) .05). other than pain. We received 115 completed postinjection surveys.org Copyright ©2007 American Dental Association. For the lidocaine formulation.0001* P VALUE * There were significant differences (P < . ./TOTAL) OF SUBJECTS EXPERIENCING ANESTHETIC SUCCESS. 34 women and 26 men. Incidence of second molar anesthesia as determined by a lack of formulation. PULP TEST READINGS OF 80 (%) RESULTS TABLE 1 100 ◆ Articaine ■ Lidocaine ❋ ❋ ❋ ❋ ◆ ◆ ◆ ❋ ❋ ❋ ❋ ◆ ◆ ◆❋ ◆ ❋ ◆ ❋ ❋ ◆ ◆ ❋ 50 ◆ ◆ ■ ◆ ❋ ■ ◆ ■ ■ ■ ■ ◆ ■ ◆ 25 ■ ◆ ◆ ■ ■ ■ ■ ■ ■ ■ ◆ ◆ ■ ■ ■ ■ 0 ■ 75 Sixty adult subjects. Significant differences (P < . The articaine formulafaster than the lidocaine formulation for each of tion was significantly better than the lidocaine the four teeth (Table 2). 138 http://jada. Figures 2 through of pain on injection. Table 1 shows the subjects’ anesTIME (MINUTES) thetic success rates. All rights reserved. onset (three of 59) of the subjects reported swelling and of pulpal anesthesia ranged from 6. at each postinjection time interval.0001* Second Premolar 92 (55/60) 67 (40/60) . Vol. using the same VAS as previously described. We considered comparisons significant at P < . immediately after the numbness wore off and for the next three days each morning on arising. August 2007 1107 Downloaded from jada.7 minutes. † Some teeth were missing from the 60 subjects owing to extractions for orthodontic treatment. For artiutes. To make between-group comparisons for onset time. TOOTH PERCENTAGE (NO.000 epinephrine. 45 to 67 percent. 2010 subjects rated pain in the injection area. There were no significant differences (P < . For the articaine formulation. We adjusted incidences of pulpal anesthesia by using the step-down Bonferroni method of Holm.05) are marked with an cessful pulpal anesthesia ranged from asterisk (*). The articaine formulation was significantly JADA.ada.1 to 11. There were no significant dif5 present the incidence of pulpal anesthesia (pulp ferences between the two anesthetic formulations test readings of 80) for the articaine and lidocaine in terms of this variable.ada.R E S E A R C H Percentages and numbers of subjects who experienced anesthetic success. 5 percent 4. sucmulations: 4 percent articaine with 1:100. Each figure shows signifiTable 4 (page 1110) presents postinjection pain cant differences between the two formulations scores. between the anesthetic formulations in terms of Table 2 (page 1109) presents data on the onset this variable. pulp test readings). for the two anesthetic forFor the lidocaine formulation. formulation in achieving pulpal anesthesia for Table 3 (page 1110) shows subjects’ experience each of the four teeth (Table 1). that they experienced.

Additionelectrical pulp testing at the maximum setting (percentage of 80/80 pulp test readings).100 ❋ ❋ ■ Lidocaine ◆ Articaine ◆ ◆❋ ❋ ◆ ❋ ❋ ❋ ❋ ◆ 75 ◆ ◆ ◆ ◆ ❋ ❋ ◆ ❋ ❋ ◆ ■ ◆ ❋ ■ ◆ 50 ❋❋ ■ ◆ ■ ■ ■ ◆ ■ ◆ ■ ■ ◆ ◆ ◆ ■ 25 ❋ ■ ◆ ■ ◆ ■ ■ ■ ■ ■ ■ ■ 0 ■ the first three minutes and lasted throughout the 60-minute testing period. DISCUSSION 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 col1 7 13 19 25 31 37 43 49 55 leagues27 and Certosimo and Archer. In all subjects cess (Table 1) and incidence of pulpal anesthesia who achieved lip numbness.000 epinephrine. Incidence of first molar anesthesia as determined by a lack of response to in vital asymptomatic teeth. we found a response to electrical pulp testing at the maximum setting (percentage of 80/80 higher success rate (57 percent) for the pulp test readings). 138 http://jada. Significant differences (P < .05) are marked with an asterisk (*). Incidence of second premolar anesthesia as determined by a lack of with 1:100. Downloaded from jada. Significant differences (P < .023 mL (SD) and from the lidocaine cartridges was 1. 4 percent (two of 56) of the subjects be related to the greater number of subjects reported swelling and no subjects reported enrolled in our study or to differences in subject bruising. 2010 PULP TEST READINGS OF 80 (%) PULP TEST READINGS OF 80 (%) R E S E A R C H .000 epinephrine and 2 percent lidocaine first molar when we used the same defiwith 1:100. leagues. The mean (± standard deviation [SD]) amount expressed from the articaine cartridges in milliliters was 1. it occurred within (Figures 2-5) were significantly better with the 1108 JADA.05) are marked with an nition as that of Kanaa and colasterisk (*). at each postinjection time interval.org on April 16. All rights reserved. A success rate of 57 percent would either solution. at each postinjection time interval. populations between our study and that of Kanaa No subjects reported tongue numbness with and colleagues.ada. pulp test readings of less than 80 experienced pain during operative pro100 ❋ ❋ ❋❋ ❋ ❋ cedures in asymptomatic teeth.76 ± 0.000 epinephrine and 2 percent lidocaine with 1:100. for the two anesthetic formulations: 4 percent articaine with 1:100. for the two anesthetic formulations: 4 perally. Ninety-eight percent (59 of 60) of not be clinically acceptable for procedures the subjects had lip numbness with the articaine requiring profound pulpal anesthesia.28 These studies showed that an absence TIME (MINUTES) of patient’s response to an 80 reading was an assurance of pulpal anesthesia Figure 3.000 strated that patients who had electric epinephrine. There❋ ◆ ◆ ◆ ◆ ◆ ❋ ❋ fore.25 This higher success rate may caine.000 epinephrine. ■■ ■ ◆ ◆ ■ Studies by Meechan and colleagues3 ■ ■ ■ ◆ and Kanaa and colleagues25 demon25 ■ Lidocaine ◆ Articaine strated a 39 percent success rate ■ ■ (obtaining two consecutive 80 readings with the electric pulp tester) when 0 administering a cartridge of 2 percent 2 8 14 20 26 32 38 44 50 56 lidocaine with 1:100.022 mL.76 ± 0. we ◆ ◆ ◆ ❋ ❋ ❋ concluded that using the electric pulp ◆ ◆ ❋❋ 75 ◆ ◆ ❋ tester before beginning dental pro◆ ◆ ■ ❋ ■ ■ ■ ■ ◆ ■ ■ cedures on asymptomatic vital teeth ◆ ■ ■ would provide the clinician with a reli■ 50 ◆ ■ able indicator of pulpal anesthesia. solution and 100 percent (60 of 60) had lip numbFor each of the four test teeth.org August 2007 Copyright ©2007 American Dental Association. Certosimo and Archer28 demoncent articaine with 1:100. on the basis of these studies. Vol. anesthetic sucness with the lidocaine solution. TIME (MINUTES) Using a cartridge of 2 percent lidocaine Figure 4.ada.000 epinephrine in a buccal infiltration of the first molar.

The success rate for the first molar for the canine infiltration and 63 percent for the was higher in our study (87 percent) than that second molar infiltration.3 ± 2.000 epinephrine and 2 percent lidocaine with 1:100.7 ± 4. Differrelated to the greater number of subjects we ences in the subject population or the use of 4 pertested or to population differences. When comparing the results of our study with Haas and colleagues13.0001† Second Molar (29) of articaine—meaning its thiophene ring. in minutes. the compound action potential Figure 5.000 epinephrine. cent articaine’s efficacy in infiltration anesthesia. Kanaa and colleagues.6 Second Premolar (41) better diffusion of the anesthetic solu.2 in which either articaine or mandibular canines and second molars.org on April 16. Therefore. who found that an articaine formulation had a higher success rate than did a lidocaine formulation in anesthetic formulations. Our results support those of † There were significant differences (P < . Significant differences (P < . ◆ ❋ 75 29 Borchard and Drouin found that a ◆ ❋ lower concentration of articaine (which ◆ ■ ◆ ❋ ■■ is a thiophene derivative) was sufficient ■■ ◆ ❋ ■ ■ 50 ◆ ❋ to block an action potential when com■■ ■ ◆◆ pared with other amide anesthetics (all ■ ■ ◆ ◆ of which were benzene derivatives). people.5 .14 this study may not apply to children or elderly may explain their lower success rate. investigators found that the TABLE 2 4 percent articaine solution had a longer duration but not greater efficacy.000 studied a young adult population. with increased intensity of nerve stimuTIME (MINUTES) lation. However.1 ± 3. They lidocaine formulations were used.org Copyright ©2007 American Dental Association. The success rate for the recorded by Kanaa and colleagues25 (64 percent). we * Subjects with anesthetic failures were not included. 138 http://jada. All rights reserved. at each postinjection time interval.1 7.6 ± 4.4 6.R E S E A R C H PULP TEST READINGS OF 80 (%) articaine formulation.0137† 4.7 ± 2. concentration may be responsible for BY FORMULATION articaine’s clinical efficacy.1 First Premolar (35) tion to the teeth.0 11.0002† 4.3 6.9 ± 6. we can ❋ ◆◆ ◆ ◆ ◆ ❋ ◆ ◆ ◆ ◆ speculate about a few mechanisms. Onset of pulpal anesthesia. second molar was lower than the 75 percent sucThe higher success rate in our study may be cess rate recorded in our study (Table 1). Regardless of the mechanism. lidocaine. . the unique chemical structure 4.14 compared infiltrations those of two previous studies of the inferior alveof articaine and prilocaine formulations in the olar nerve block1. in a study of ■ ■ ■ ■ ■ sensory nerve conduction in rats.ada. however. Incidence of first premolar anesthesia as determined by a lack of response recovered for 2 percent articaine but to electrical pulp testing at the maximum setting (percentage of 80/80 pulp test readnot for 4 percent articaine.0014† 4. The success rates (a achieving buccal infiltration anesthesia of the reading of 80 on the pulp tester) were 65 percent first molar. and only matched pairs could be statistically analyzed. ■ 25 ◆ 30 Potocnik and colleagues.ada. which is not possessed by other .1 ± 9. 2010 JADA. the results of epinephrine in Haas and colleagues’ studies13. OF ONSET OF PULPAL ANESTHESIA* P VALUE SUBJECTS) IN MINUTES ± STANDARD DEVIATION. For Articaine Lidocaine instance. we found that found no statistical differences between the two the success rate was higher in the present study August 2007 1109 Downloaded from jada. The exact mecha100 nism of the articaine’s increased effi❋ ❋ ❋ ❋ ❋ ❋ ❋❋ cacy is not known. found ■ Lidocaine ◆ Articaine ■ ■ that both 2 and 4 percent articaine 0 were superior to 2 percent lidocaine in 1 8 14 20 26 32 38 44 50 56 blocking nerve conduction. It may be that factors other than the TOOTH (NO.05) are marked with an asterisk (*). the number of subjects included in the evaluation of found that articaine was superior to onset of anesthesia differed from the total number of subjects.3 First Molar (33) local anesthetic agents—may facilitate . for the two anesthetic formulations: 4 per31 study comparing 2 percent and 4 percent articaine with 1:100. Because we cent articaine solution with 1:200.05) between the articaine and lidocaine 25 formulations as analyzed by mcans of logistic regression. In a clinical ings). Vol.2 ± 3.

05) between the anesthetic formulations.org August 2007 Copyright ©2007 American Dental Association.9957¶ 11 ± 22 9 ± 20 Day 2 anesthetic solution remained in both ≈ 1. mulations (Table 1). was marked externally as containing POSTINJECTION MEAN (± STANDARD DEVIATION) PAIN P VALUE 1. whereas in a Articaine Lidocaine study by Fernandez and colleagues. An intriguing aspect of our study is the pattern of anesthetic success for the four for the first molar. Even though the articaine cartridge for each postinjection day.9976¶ Day 0§ marked as 1.76 mL. using 1. found onset times proximity to the first molar injection site.ada.0000¶ 6 ± 18 5 ± 15 Day 3 cartridges after delivery of the solution * Mean values are in millimeters as measured on the visual analog scale. For the Lidocaine ‡ Articaine † lidocaine cartridge. Success rates in our study were 87 percent appeared to diffuse anteriorly from the first for the first molar. The relatively thick from 73 to 80 percent for the second premolar and mandibular bone in the second molar region may from 77 to 89 percent for the first premolar. Phillips ranging from eight to 11 minutes for the first and colleagues39 found the foramen to be in line molar and eight to 12 minutes for the first prewith the long axis of the second premolar 63 permolar. leading to the block using articaine. as shown in Figures 2 through 5.0000† 33 ± 29 32 ± 25 Needle Placement block using 1. second premolar and first preteeth (Figures 2-5). six studies32-37 of the inferior alveolar molar.org on April 16.38 24 ± 25 27 ± 26 . All rights reserved. the mental foramen is in nerve block. the anesthetic solution may sell and colleagues1 for the inferior alveolar nerve have entered the mental foramen. In general.05) between the anesthetic formulations.000 epinephrine. That is.ada. they * n = 60. Mean values are in millimeters as measured on the visual analog scale. 92 percent for the second premolar site. Buccal infiltration second molar success rate of 75 percent was lower over the second molar or buccal to the premolars than the 91 to 93 percent success rate (two consecneeds to be investigated further to determine its utive readings of 80) shown in the study by Mikesuccess.* BY FORMULATION tion expressed was 1. INJECTION PHASE MEAN (± STANDARD DEVIATION) PAIN P VALUE pulpal anesthesia declined steadily RATINGS. average of 2 hours and 24 minutes. Anatomically. Howfor each injection phase.9841¶ 15 ± 24 12 ± 24 Day 1 anesthetic solution expressed was 1. The hinder anesthetic diffusion. Concerning onset of pulpal higher success rates in the premolars and first anesthesia.8 mL.R E S E A R C H TABLE 3 1110 JADA. Because onset of pulpal anesthesia cent of the time. When not in line with the axis. 138 http://jada. The anesthetic solution molar.000 epinephrine.* BY FORMULATION during the 60 minutes.9795† Needle Insertion once subjects experienced pulpal anesthesia with the inferior alveolar nerve ≈ 1. with an aspirating syringe.76 mL.7 mL. sustained pulpal anesthesia for an † There were no significant differences (P > . but on average the . on average the anesthetic soluDAY RATINGS. articaine and lidocaine.8 mL of 2 percent lido. Vol. Duration of pulpal anesthesia is a sigTABLE 4 nificant disadvantage of buccal infiltraMean pain ratings for articaine and lidocaine tion in mandibular posterior teeth. Additionally. Downloaded from jada. while recorded for both the premolar and first molar success rates (two consecutive pulp test readings of 80) for the inferior alveolar nerve blocks have than for the second molar for both anesthetic forranged from 81 to 83 percent for the first molar. occurred within five minutes (Table 2) for the subthe foramen was within 2 mm of it mesially or jects in our study with the articaine formulation. a higher success rate was molar and 86 percent for the first premolar. The † n = 56. expressed was basically the same for ¶ There were no significant differences (P > . distally. Although we can speculate that the . § Rating score at time subjective numbness wore off. ever. the amount was 20 ± 23 18 ± 25 .9999† 36 ± 30 37 ± 36 Solution Deposition caine with 1:100. amount of anesthetic solution ‡ n = 59.8 mL of 2 percent lidocaine the apical area of the second premolar39 and in with 1:100. a small amount of . 2010 infiltration provided a quicker onset Mean pain ratings for articaine and lidocaine than did an inferior alveolar nerve block when articaine was used.

However. Anesthetic efficacy of different volumes of lidocaine with epinephrine for inferior alveolar nerve blocks. For articaine. because we did not always achieve pulpal anesthesia (Figure 2-5). 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. Kanaa and colleagues25 found no significant difference in injection discomfort between articaine and lidocaine formulations in mandibular buccal infiltration of the first molar. It would be unlikely that paresthesia would be reported in our study. When using an articaine formulation for buccal infiltration in the first molar region. 3. at the time anesthesia wore off. Figures 2 through 5 demonstrate the slow decline of pulpal anesthesia over 60 minutes. Vol. with the articaine formulation producing consistently faster onset (Table 2. comparisons are not possible. Schertzer ER Jr. the practitioner can use the electric pulp tester to evaluate the tooth under treatment for pulpal anesthesia before beginning the procedure. Corbett IP. There was a statistically significant difference in onset of pulpal anesthesia between the anesthetic formulations for each tooth type. Nusstein J. For lidocaine. 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 incidence of pain decreased during the next three days. CONCLUSION We conclude that a buccal infiltration of the first molar with a cartridge of 4 percent articaine with 1:100. The quicker onset again may be related to the potency of articaine or its unique chemical structure.40. 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. Kanaa and colleagues.org Copyright ©2007 American Dental Association. Beck FM. Whitworth JM. even though the injection site approximated the mental nerve.ada. Beck M. All rights reserved. Although there have been reports of paresthesia associated with articaine use.8 mL of 4 percent articaine with 1:100.39 The complete lack of subjective tongue numbness would indicate that the lingual nerve was not affected. JADA. lip numbness should not be considered an indicator of pulpal anesthesia for this type of infiltration. 2. 138 http://jada. However. J Endod 2005. Mikesell P. The most likely reason for subjective lip numbness is the close proximity of the mental nerve to the first molar injection site. because Haas and Lennon40 indicated that paresthesias are rare and unlikely with infiltration anesthesia. Table 3). Postinjection pain ratings. author’s response 1250.R E S E A R C H uate lingual mucosal gingival anesthesia. Clinically.000 epinephrine will not provide the duration needed because of declining pulpal anesthesia. Int Endod J 2006.28 The articaine and lidocaine formulations were not significantly different in terms of associated injection pain (Table 3). lidocaine (letter).50(4):372-5. No other study has evaluated postinjection pain for a buccal infiltration in mandibular posterior teeth. 1250.41 no subjects reported any paresthesia in our study.31(4):265-70.25 after administering a buccal infiltration of the first molar. were not statistically different between the articaine and lidocaine formulations (Table 4). The pain ratings of the three phases of injection generallly were in the faint-toweak pain area of the VAS (Figure 1. ■ 1. Reader A. Weaver J. waiting approximately five minutes should ensure the onset of pulpal anesthesia (Table 2). 39(10):764-9. Likewise. 5 percent (three of 59) of subjects reported swelling and 2 percent (one of 59) reported bruising. Kanaa MD. We did not use mucosal sticks to eval- .000 epinephrine is significantly better than is such an infiltration with a cartridge of 2 percent lidocaine with 1:100. A comparison of articaine and lidocaine for inferior alveolar nerve blocks. All of the pain ratings were less than the “faint” pain descriptor on the VAS (Figure 1). the superiority of articaine over lidocaine must be related to the higher potency of articaine or its unique chemical structure.org on April 16. Reader A. August 2007 1111 Downloaded from jada. JADA 2000. Figures 2-5). Nusstein J. Steen IN. Gen Dent 2002. All complications resolved within three days except for a slight swelling reported with lidocaine by one subject on day three.131(9): 1248. Meechan JG. 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. 2010 buccal infiltration of the first molar may result in anesthetic solution’s entering the mental foramen.27. clinicians should be mindful that pulpal anesthesia likely will decline slowly over 60 minutes. therefore. 4. if profound pulpal anesthesia is required for 60 minutes.ada. Articaine vs. However. the buccal infiltration of 1. 4 percent (two of 56) reported swelling and none reported bruising. The only reported postinjection complications were bruising and slight swelling in the area of the injection.000 epinephrine in achieving pulpal anesthesia in mandibular posterior teeth.

19(3): 146-50. and positional relationship to the mandibular second premolar. Sketelj J. Onset and duration periods of articaine and lidocaine on maxillary infiltration. Steinkruger G. double-blind comparison of bupivacaine and lidocaine for inferior alveolar nerve blocks. Saso MA. Reg Anesth Pain Med 1999. Beck M.40(4):114-6.000 epinephrine and 2 percent mepivacaine with 1:20. Fernandez C. Oertel R.000 epinephrine) for inferior alveolar nerve block. Kerby R.12(2):E139-44. Anesth Prog 1989. Clinical pharmacokinetics of articaine. A comparison of Ultracaine DS (articaine HCl) and Citanest forte (prilocaine HCl) in maxillary infiltration and mandibular nerve block.32(4):296-8. J Endod 2005.000) in local infiltration anesthesia in dentistry: a randomised double-blind study. 8. Rahn R. Francischone CE. Lennon D. Berlin J.32(11):1044-7.36(3):197-201. 25. Beck M. Kirch W. Volpato MC. Paessler L. Richardson AS. Nusstein J. 12. 6.48(1):9-15. Gagnon S. Oper Dent 1996. Young ER. Ranali J. Reader A. Boynes SG. Articaine for supplemental intraosseous anesthesia in patients with irreversible pulpitis. A comparison between articaine HCl and lidocaine HCl in pediatric dental patients. Ramacciato JC.33(6):417-25. Tofoli GR. Clin Oral Investig 2006. JADA 2006. A 21 year retrospective study of reports of paresthesia following local anesthetic administration. Weaver J. Reader A. Weaver J. 138 Bucal 2007. Haas DA. Tortamano N.000 epinephrine in inferior alveolar nerve block.000 and 1:200. Articaine is more effective than lidocaine or mepivacaine in rat sensory nerve conduction block in vitro. Rahn R. Delgado-Molina E. Hersh EV. Articaine and lidocaine for maxillary infiltration anesthesia. 18. 21. Beck M. Nusstein J. orientation. Kirch W.16(5):221-3. Lack of differential effect by Ultracaine (articaine) and Citanest (prilocaine) in infiltration anaesthesia. Derkson GD. Use of articaine local anesthesia in children under 4 years of age: a retrospective report. Hinkley SA. Hersh EV. Pain 1984. Size. Meryers WJ. 19.22(4):307-11. Carticaine: action of the local anesthetic on myelinated nerve fibres. Weaver J. Nusstein J. Antila H. Malamed SF. Lehtinen R. J Endod 2006. Moore PA. Beck FM. Weller RN.30(8):568-71.ada. JADA 2001. Pediatr Dent 2000.15(1):6-12. http://jada. Weaver J. et al. Beck M. Anesth Prog 2001. et al. An evaluation of 4% prilocaine and 3% mepivacaine compared with 2% lidocaine (1:100. 27. Ranali J. Reader A.24(6):524-8.R E S E A R C H 1112 JADA.137(11):1562-71.137(12):1685-91. Reader A. 15. 13. 26. An evaluation of 4 percent prilocaine with 1:200. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005. 11.132(2): 177-85. Nusstein J. Kulild JC. Vreeland DL. 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. 329-30. Corbett IP. J Can Dent Assoc 1987. Craig BJ. 24.13(5):233-8.19(2):153-61.50(4):164-8. The effect of age on pharmacokinetics of the local anesthetic drug articaine. Leblanc D. 29. Anesth Prog 2003. Borchard U. Anesth Prog 1990. metabolism. 17. Phillips JL. An evaluation of volumes and concentrations of lidocaine in human inferior alveolar nerve block. J Can Dent Assoc 1995. Miller P. J Endod 1987.85(2):162-6. J Endod 1993. A prospective. Chaney MA. Reader A. JADA 2006. James-Perdok L. Meyers WJ. Rocha RG.000 epinephrine. Meyers W. Harper DG. An evaluation of the electric pulp tester as a measure of analgesia in human vital teeth. Bajrovic FF. J Dent Res 2000. Tortamano IP. Br Dent J 2004. Leblanc D.000) and articaine 2 percent (epinephrine 1:200. 40. Eur J Anaesthesiol 1989. Volpato MC. 35.57(3):217-23. 23. Comparative investigations on the efficacy of articaine 4 percent (epinephrine 1:200. Anesthetic efficacy of articaine for inferior alveolar nerve blocks in patients with irreversible pulpitis. Tomsic M. Lennon D. Vree TB. GayEscorda C. Malamed SF. Articaine and lignocaine in infiltration anaesthesia: a pilot study.36(6):268-71. 36. Whitworth JM. Reader A. An evaluation of lidocaine hydrocarbonate compared with lidocaine hydrochloride for inferior alveolar nerve block. Berini-Aytis L. 32. randomized. 31. 10. Clin Pharmacokinet 1997. All rights reserved. Groppo FC. J Endod 2004. Gagnon S. Levin LM.79(4):627.000 levonordefrin compared with 2 percent lidocaine with 1:100. 39. Ramacciato JC. Anesth Prog 1993. Efficacy of articaine and lidocaine in a primary intraligamentary injection administered with a computer-controlled local anesthetic delivery system. Costa CG. Beck M. Oertel R. 30. Dreven L J. Leblanc D. 2010 5. Sierra-Rebolledo A. An experimental basis for revising the graphic rating scale for pain. Plotzke OB. Oliveria PC.53(1):38-42. A clinical evaluation of the electric pulp tester as an indicator of local anesthesia. Eur J Pharmacol 1980. Ebert U. J Dent Res 2006. Potocnik I. 9.31(7):499-503. Beck M. Reader A. The mental foramen: 1. Booij LH.38(6):212-6. and renal excretion of articaine and its metabolite articainic acid in patients after epidural administration. Articaine and lidocaine mandibular buccal infiltration anesthesia: a prospective randomized double-blind cross-over study. Drouin H. Giannakopoulos H. The significance of needle bevel orientation in achieving a successful inferior alveolar nerve block. Vahatalo K. Beck M. Certosimo AJ. Weaver J. Bigby J. Baars AM. Weinberger SJ.000 epinephrine: two controlled clinical trials.000 epinephrine for inferior alveolar nerve block. Meyers WJ. de Oliveira PC. Vol. Beck M. 7. Comparison of articaine and prilocaine anesthesia by infiltration in maxillary and mandibular arches. 37. J Can Dent Assoc 1991. Haas DA. JADA 2000. Hintze A. Donaldson D. 20. Articaine hydrochloride: a study of the safety of a new amide local anesthetic. Saso MA. Beck M.61(4):319-20.org August 2007 Copyright ©2007 American Dental Association. 22. Incidence of local anesthetic-induced neuropathies in Ontario from 1994-1998 (abstract 3869). Anesth Prog 1991. Med Oral Patol Oral Cir .org on April 16. Parker SR. 28.197(1):45-6. Harper DG. 33.10(2):145-50. The pharmacokinetics and cardiovascular effects of high-dose articaine with 1:100. JADA 2006. J Endod 1989. Efficacy of articaine: a new amide local anesthetic.21(1):25-30. Termond EF.99(3):361-6. Meechan JG. McLean C.37(5):230-7. Pharmacokinetics. Heft MW. Ridenour S.000 or 1:200. Meyers WJ. Weaver J.62(1):73-9. Wright GZ. Reader A. J Endod 1990. Claffey E. 41. Anesthetic efficacy of a combination of hyaluronidase and lidocaine with epinephrine in inferior alveolar nerve blocks. Comparison of effectiveness of 4 percent articaine associated with 1:100.38(3):84-9. Weaver J. Quintessesnce Int 2005. 38. J Endod 2006. 323-6. Archer RD. Haas DA.137(11):1572-81. The anesthetic efficacy of 4 percent articaine 1:200. 34. Nusstein J. Downloaded from jada. Young ER.6(1):49-56. Gagnon S. Anesth Prog 1991. Beck M. van Oss GE.131(5):635-42. Reader A.ada. Reader A. Malamed SF. 14. Reader A. 16. Weaver J. Friedman CS. Kanaa MD.