JADA+ Content
This review does not in any way substitute for professional advice and should not be regarded as clinical guidance. As
always, any evidence should be carefully considered by clinician and patient to ensure that in their views, all potentially
desirable consequences outweigh all potentially undesirable consequences.
JADA+ Clinical Scans
Romina Brignardello-Petersen, DDS, MSc, PhD
There seem to be no differences in
pain during infiltration and time to
anesthesia onset between buffered and
unbuffered local anesthetics
Aulestia-Viera PV, Braga MM, Borsatti MA. The effect of
adjusting the pH of local anaesthetics in dentistry: a sys-
tematic review and meta-analysis [published online ahead of
print January 29, 2018]. Int Endod J. https://doi.org/
10.1111/iej.12899.
Key words. General dentistry; anesthesia; buffer; infiltration
pain; pH; time-to-onset; systematic review.
Clinical relevance. Successful local anesthesia is key when
performing many dental treatments. Anesthetic infiltration,
however, may be painful owing to anesthetic solution’s acidic
nature and may cause anxiety in patients. Thus, using buffered
local anesthetics has the potential benefits of less pain and
reduced time to anesthesia onset.
Study summary. The authors conducted a systematic review
to compare the effects of buffered and traditional local anes-
thetics on pain during infiltration and the time to onset of the
anesthesia. They searched 4 electronic databases through
April 2017 for randomized clinical trials addressing this
question in adult participants. They found 14 trials* that
included a total of 780 participants† and assessed the effects of
buffering lidocaine, bupivacaine, and articaine, all with
epinephrine buffered with bicarbonate. Meta-analyses showed
that there were no differences in pain during infiltration when
participants received buffered and unbuffered local anesthetics
in either normal or inflamed tissue‡ or in inferior alveolar
nerve blocks (IANB) or other infiltrative techniques.§ When
participants with inflamed tissues received buffered anesthetics,
the time to anesthesia onset was 1.37 minutes shorter
than when they received unbuffered anesthetics.{ When
participants received IANB with buffered anesthetics, the time
to anesthesia onset was 1.26 minutes shorter than when they
received it with unbuffered anesthetics.# There were no
differences in time to anesthesia onset between buffered and
unbuffered anesthetics in participants with normal tissue or
when they were receiving infiltrative techniques.**
JADA n(n) n http://jada.ada.org n n 2018
Strengths and limitations. We have some minor concerns
about the methods the authors used to conduct this systematic
review. The search strategy and the methods for addressing
studies with 3 treatment arms could have followed higher
standards. However, it is unlikely that these issues had con-
sequences that affected the results importantly. According to
the authors’ assessment, only 4 of the trials had a low risk of
bias. This decreases how much confidence we can place in the
results of the meta-analysis. In addition, the pain outcome
results were inconsistent across studies, and the studies
suggesting benefits did not have a low risk of bias. Overall,
the meta-analyses suggested that there were no important
differences in pain during infiltration or time to anesthesia
onset between buffered and unbuffered local anesthetics.
The observed benefits in time to anesthesia onset for
patients with inflamed tissue and those receiving IANB were
small and unlikely to be important to patients. Consequently,
this evidence does not support the use of buffered over
unbuffered local anesthetics and vice versa when pain during
infiltration and time to anesthesia onset are the outcomes
driving the clinical decision. This decision, however, should
also be informed by evidence about the comparative
effectiveness of the 2 anesthetics on other outcomes
important to patients, such as pain during the dental
procedure, need for rescue anesthetics, and satisfaction. n
https://doi.org/10.1016/j.adaj.2018.03.006
Copyright ª 2018 American Dental Association. All rights reserved.
Address correspondence to Dr. Brignardello-Petersen at e-mail rominabp@
gmail.com
Disclosure. Dr. Brignardello-Petersen did not report any disclosures.
* 6 with a parallel design and 8 with a split-mouth or crossover design,
according to the authors’ classification.
† Participants had “normal tissue conditions” in 10 studies, abscesses in
2, pulpitis in 1, and periapical lesions in 1.
‡ Mean difference (MD) (95% confidence interval [CI]), e7.38 (e15.67
to 0.91) and e4.41 (e15.25 to 6.43) comparing buffered and unbuffered
anesthetics in normal and inflamed tissue, respectively. Pain measured on a
scale ranging from 0 to 100, in which higher scores represented worse
pain.
§ MD (95% CI), e12.96 (e33.40 to 7.47) and e3.69 (e9.58 to 2.20)
comparing buffered and unbuffered anesthetics in inferior alveolar nerve
block and other infiltrative techniques, respectively.
{ MD (95% CI), e1.37 minutes (e2.03 to e0.70).
# MD (95% CI), e1.26 minutes (e1.40 to e1.10).
** MD (95% CI), e0.43 minutes (e1.38 to 0.52); and e0.44 minutes
(e1.28 to 0.39) comparing buffered and unbuffered anesthetics when
participants had normal tissue or were receiving infiltrative techniques,
respectively.
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