Advances in Oral and Maxillofacial Surgery 8 (2022) 100335

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Advances in Oral and Maxillofacial Surgery

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Comparison of the anaesthetic effects of 4% articaine hydrochloride and

2% lidocaine hydrochloride for maxillary molar extraction: A randomized
double blind crossover study
Olufemi Adigun a, *, Chibuzo Chimezie Uguru b, Oladimeji Adeniyi Akadiri c
a
Department of Oral and Maxillofacial Surgery, University of Nigeria Teaching Hospital, Ituku-ozalla, Enugu, Nigeria
b
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, University of Nigeria Nsukka Enugu Campus, Nigeria
c
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, University of Port-Harcourt, Port-Harcourt, Nigeria

A R T I C L E I N F O A B S T R A C T

Keywords: Many reports in Europe and America have suggested that articaine has superior dental.
Comparison anaesthetic properties over lidocaine. However, none of these studies was carried out in a black population.
Anaesthetic effects This study was designed to evaluate if the reported superior efficacy of articaine compared to lidocaine as a local
Articaine
anaesthetic agent for dental extraction is equally applicable to infiltration anaesthesia in a black population.
Lidocaine
Patients between ages of 18–40 years were selected for the study. The result showed that articaine had a faster
onset of anaesthesia and longer duration of action compared with lidocaine, however the differences were not
statistically significant. The median times of onset were 2.60 min and 2.88 min for articaine and lidocaine
respectively; while the median durations of anaesthesia were 31.45 min and 30.46 min for articaine and lido­
caine respectively. Articaine also achieved more profound anaesthesia compared with lidocaine; 87.5%
compared to 62.5% of participants indicated zero point on a 10 cm visual analog scale (VAS), and 12.5%
compared to 37.5% marked the 1 cm point on the scale in Articaine and Lidocaine groups respectively. Articaine
diffused through the maxilla from buccal infiltration to cause palatal anaesthesia better than lidocaine; as 75%
compared to 50% indicated the 1 cm point and 0% compared to 25% indicated the 2 cm point on VAS in
Articaine and Lidocaine groups respectively. Therefore, the choice between 4% Articaine and 2% Lidocaine in
dental practice should be based on personal preference since the two agents are both safe and have comparable
properties.
Clinical trial registration number: PACTR201802003023333.

1. Introduction anaesthesia, the success of buccal infiltration in the maxilla to achieve

In the search for less allergic compounds with a faster onset, the
amide-type local anaesthetic lignocaine was synthesized by Swedish
chemist Nils Löfgren in 1943 and marketed as lidocaine in 1949 [1].
Since then, other amide local anaesthetic agents have been introduced
and used clinically for their favourable onset time and duration. Among
this group, articaine entered dentistry practice in 1973 [1]. In 1984, it
was released in Canada, followed by the UK in 1998, the rest of Europe
and the USA in 2000, and Australia in 2005.
Since its approval in the USA, articaine has become rapidly accepted
because of the many published reports suggesting superior dental
anaesthetic properties, including the ability to achieve more profound
palatal anaesthesia, and the success of mandibular infiltration to replace
inferior alveolar block anaesthesia [2]. Due to its reported superior
clinical properties, the drug has captured a major portion of local
anaesthesia usage by dentists throughout the world [2].
Despite the proven advantages of articaine in dentistry and the rapid
uptake of its use in preference to lignocaine within the western coun­
tries, it is yet to be available in clinical practice in Nigeria. The impli­
cation of this is that the Nigerian dental patients may actually have been
denied the benefits of artcaine over the years. However, before drawing
such a conclusion, it is pertinent to demonstrate that articaine provides
the reported benefits among Nigerian-Africans since all of the evidence
so far were derived from non-African populations. This study is therefore

* Corresponding author.
E-mail address: adigunolufemi23@yahoo.com (O. Adigun).

https://doi.org/10.1016/j.adoms.2022.100335
Received 20 July 2022; Accepted 21 July 2022
Available online 12 August 2022
2667-1476/© 2022 The Authors. Published by Elsevier Ltd on behalf of British Association of Oral and Maxillofacial Surgeons. This is an open access article under
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
O. Adigun et al.
intended to compare the onset, duration, effectiveness and adverse ef­
fects of articaine with lidocaine in maxillary molar extractions. The
outcome may inform the need for a possible paradigm shift in dental
anaesthesia practice in Nigeria and other black African population.
2. Materials and methods
Patients were selected from among healthy adult patients between
ages of 18–40 years who required bilateral extraction of corresponding
firm maxillary molars at the Oral and Maxillofacial Surgery Clinic of the
University of Nigeria Teaching Hospital, Enugu. The sample size was
determined using the formula for two-sample cross over comparison
study accommodating 10% attrition rate. A minimum sample size of 14
extractions per each arm of the study (i.e Articaine group and Lidocaine
group) was calculated. Materials used are anaesthetic agents [1.7 ml
cartridges of 2% lidocaine hydrochloride 1:100,000 epinephrine (Sep­
todont) and 1.7 ml cartridges of 4% articaine hydrochloride 1:100,000
epinephrine (Septodont)]; standard armamentarium for local anaes­
thesia and dental extraction [Dental syringe (aspirating), 27 gauge
dental needle (short.), mouth mirrors, sickle probes, appropriate
extraction forceps, dental elevators]. Other research materials were a
stop-watch, and a Visual Analog Scale (VAS) charts.
The study adopted a crossover double blind design. Patients who
satisfied the inclusion criteria were treated based on a standard protocol
which was explained to them before recruitment into the study. Baseline
vital signs were taken before administration of local anaesthetic agent
and after completion of extraction in all subjects to determine any
possible adverse reactions such as hypersensitivity, fever and chills [3].
Each patient underwent extraction on either side of the upper jaw at an
interval of two weeks to allow for metabolic wash out of the anaesthetic
drug. Maxillary molars of the same position on opposite sides of the jaw
were selected to eliminate or reduce the confounding effects of alveolar
bone discrepancy [4,5]. One side of the jaw was anaesthesised with 4%
articaine; 1:100,000 adrenaline while the other side had 2% lidocaine;
1:100,000 adrenaline.
The side of the jaw on which extraction was first done was based on
clinical judgment as determined by severity of signs and symptoms.
Randomization of the first extraction into Articaine or Lidocaine arm
was done by a trained assistant using flipping of a coin method. The
second extraction naturally took the alternative anaesthetic agent. The
labels on the cartridges were removed by the trained assistant; and each
type of anaesthetic agents was put into a separate labeled container kept
by the assistant. For each extraction procedure, the trained assistant
dispensed an anaesthetic and recorded the side of the jaw for which the
drug would be administered. A single surgeon performed all the tooth
extractions; the surgeon and the patients were blind to the specific type
of local anaesthetic used on each side.
To anaesthesise second and third molar, about 1 ml of the local
anaesthetic agent was deposited in the upper buccal sulcus at a position
between the two teeth. In anaesthesising the first molar, dental needle
was oriented along the long axis of the tooth and about 1 ml of anaes­
thetic agent was deposited in the upper buccal sulcus, adjacent to the
roots of the first molar. Palatal anaesthesia was given approximately half
way between the palatal gingival margin and midline of the palate at a
point corresponding to the tooth for extraction.
For each extraction, buccal anaesthetic infiltration was administered
first. Then onset of anaesthesia was determined using a stopwatch. This
was the time duration from start of administration of buccal anaesthetic
agent to the time of patients’ first report of numbness around the tooth
which was confirmed objectively by probing the corresponding gingival
crevice. Patients’ perceived pain experience during probing was recor­
ded based on his or her indication on a VAS chart 10 min after the buccal
infiltration.
Before instituting palatal infiltration, anaesthesia of the palatal
crevice was similarly tested 10 min after buccal infiltration and
perceived pain experience recorded based on the VAS. This was to assess
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Advances in Oral and Maxillofacial Surgery 8 (2022) 100335
the bucco-palatal diffusion of each anaesthetic agent. Afterwards, con­
ventional palatal infiltration was administered and a 4 min waiting time
was observed before testing for palatal anaethesia.
In essence, patients recorded pain experience on four occasions. First
10 min after buccal infiltration when the buccal gingival sulci was
probed. Second when the palatal gingival sulci was probed following
buccal infiltration. Third 4 min after palatal injection when palatal sulci
was probed and fourth, immediately after extraction, to record the
overall pain experience during the extraction.
One cartridge of articaine or lidocaine was used for each extraction.
In cases when depth of anaesthesia achieved was not sufficient to ensure
painless extraction, additional volume of anaesthetic agent was given
and recorded. Effectiveness of anaesthesia was recorded by the
researcher based on patients’ VAS score at the various points detailed
above for each side of the jaw. The duration of anaesthesia was recorded
as the interval between the onset and return of sensation (Secondary
outcome). Patients were seated in the clinic till anaesthesia worn off.
The volumes of articaine and lidocaine used were recorded and
compared.
2.1. Statistical analysis/Data management
The SPSS Statistical software (version 20) was used for data entry,
validation and analysis. Data collected were summarized with descrip­
tive statistics. Means of continuous variables were compared using
student t-test or Mann Whitney test, while categorical variables were
tested using chi-square. All tests were 2-tailed and significant at equal or
less than 0.05. (p ≤ 0.05).
3. Results
Fig. 1 showed the flow diagram of subjects through the enrolment,
allocation, follow-up and data analysis stages of the research. Subjects
assessed for eligibility were 1320. Out of this number 1299 subjects
were excluded; while 21 subjects were randomised into the study. Each
of the randomised subjects was allocated into both articaine and lido­
caine arms. Two out of the 21 were lost to follow-up by failing to come
for extraction scheduled for second visit after first extraction. Three
patients were excluded from analysis due to traumatic extractions.
Sixteen patients were analysed. The study was discontinued when the
calculated sample size was reached. Figs. 2 and 3 showed visual
normality tests for time of onset and duration of anaesthesia respec­
tively. Time of onset and duration of anaesthesia were not normally
distributed in articaine; thus, the non-parametric alternative of student’s
t-test known as the Mann-Whitney U test was done as shown in Table 1.
Fig. 4 showed visual normality test for duration of extraction, which
were normally distributed in both agents and thus student’s t-test was
used as shown in Table 1. Table 1 showed that articaine has shorter time
of onset of 2.60 min compared to lidocaine which was 2.85 min.
Duration of action of articaine was 31.45 min compared to lidocaine
which was 30.46 min. Duration of extraction in articaine and lidocaine
were 3.97 min and 3.44 min respectively. No statistically significant
differences exist in all the parameters measured. Table 2 showed effec­
tiveness of anaesthesia and ability to diffuse from buccal sulcus to cause
anaesthesia of palatal nerves in articaine and lidocaine arms. Effec­
tiveness was measured in buccal sulcus 10 min after buccal infiltration,
and by patient at the end of extraction; while ability to diffuse was
measured in palatal sulcus 10 min after buccal infiltration. Depth of
anaesthesia was increased in both arms 4 min after palatal infiltration.
4. Discussion
Several studies have been done comparing time of onset and duration
of actions of articaine with lidocaine. Many of them concluded that
articaine had faster onset of action and longer duration of anaesthesia
[6–10]. However, the extent of the differences and how statistically
O. Adigun et al. Advances in Oral and Maxillofacial Surgery 8 (2022) 100335

Fig. 1. Flow diagram of the progress through the phases of a crossover randomised trial of two arms (that is, enrolment, intervention allocation, follow-up and
data analysis).

Fig. 2. Visual normality test for time of onset of articaine and lidocaine.

significant they are, differ between studies. While some reported sta­
tistically insignificant differences [6,8,9], others observed significant
differences [7,10,11]. In this study, the median times of onset of 2.60
(1.41) minutes for articaine and 2.88 (1.79) minutes for lidocaine were
comparable with no statistically significant difference between them.
Similarly, the median duration of anaesthesia of 31.45 (17.01) minutes
for articaine and 30.46 (9.01) minutes for lidocaine was of no statistical
significance. This shows that even though articaine is faster in onset and
longer in action than lidocaine, any of the two anaesthetic agents could
be adopted in maxillary molar extraction without observable clinical

3
O. Adigun et al. Advances in Oral and Maxillofacial Surgery 8 (2022) 100335

Fig. 3. Visual normality test for duration of anaesthesia of articaine and lidocaine.

min for articaine and 49 ± 5.03 min for lidocaine in bilateral maxillary
Table 1
premolar extraction. The difference may be due partly to the heteroge­
Comparison of time of onset of anaesthesia, duration of anaesthesia and duration
neity of the study methodology. In this study, duration of anaesthesia
of extractions between articaine and lidocaine arms.
was measured from the time of onset to the moment anaesthesia began
Articaine Median Lidocaine Median Mann P-
to wear off as expressed by the patient; while in the other study, duration
(interquartile) (interquartile) Whitney- value
was taken to the time when anaesthesia had completely worn off. [7],
Time of onset of 2.60(1.41) 2.88(1.79) 108.50 0.462 Also, the differences in duration and time of onset of anaesthesia in our
anaesthesia/
mins
study were not significant compared to very significant differences by
Duration of 31.45(17.01) 30.46(9.01) 117.00 0.678 Shahid. This may be due to blinding and randomization used in the
anaesthesia/ present study which was not used in theirs.
mins Furthermore, this study supports the assertion that articaine achieves
Articaine Mean Lidocaine Mean t P- more profound anaesthesia and diffuses from buccal infiltration to effect
± SD ± SD
value palatal nerve anaesthesia. However, it was observed that this property
was shared by lidocaine; the difference is that articaine does it faster and
Duration of 3.97 ± 1.42 3.44 ± 1.57 1.002 0.325 better. Previous studies have reported similar findings [6–8,10,12–16].
extractions/
Lack of statistically significant differences in this study may be due to
mins
smaller sample size. However, considering that some other randomised
controlled trials with larger sample sizes such as Kambalimath’s study
disadvantage of one over the other. [9] with a sample size of 30, Malamed [8] with a sample size of 70 and
The duration of anaesthesia of 31.45 min and 30.46 min obtained for Natalia who used a sample size of 96 [6], similarly observed no statis­
articaine and lidocaine respectively were shorter compared to values tically significant differences, it may be that the advantages of articaine
reported in the study by Shahid et al. [7] The latter reported 72 ± 17.28 over lidocaine are actually marginal. This deduction can be further

Fig. 4. Visual test of normality for duration of extraction in articaine and lidocaine arms.

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O. Adigun et al. Advances in Oral and Maxillofacial Surgery 8 (2022) 100335

Table 2 patients who participated in the research gave consent. Patients gave
Comparisons of pain score with visual analog scale 10 min after buccal infil­ informed consent. Privacy of patients are respected.
tration, 4 min after palatal infiltration and by patients between articaine and
lidocaine arms. Declaration of competing interest
10 min after buccal infiltration Articaine Lidocaine X [2] P-value

N (%) N (%) None of the authors has conflict of interest.

Buccal gingival sulcus

0 15(93.8) 14(87.5) 3.034 0.219
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Ethics statement/confirmation of patient permission

Ethical approval was given by the appropriate authority. Also