PEDIATRIC DENTISTRY V 43 / NO 5 SEP / OCT 21

BRIEF COMMUNICATION

Articaine Infiltration Versus Lidocaine Inferior Alveolar Nerve Block for Anesthetizing
Primary Mandibular Molars: A Randomized, Controlled, Double-Blind Pilot Study
Ivan L. Zhang, DMD, MS1 • Evelina Kratunova, BDS, MDS, DChDent2 • Ian Marion, DDS, MS3 • Marcio A. da Fonseca, DDS, MS4 • Michael Han, DDS5

Abstract: Purpose: The purpose of this study was to compare the effectiveness of articaine local infiltration to lidocaine inferior alveolar nerve
block (IANB) for restorative treatment of primary mandibular molars (PMM). Methods: Four- to 10-year-old children who needed PMM restorations
were enrolled according to inclusion criteria and randomly allocated into the articaine or lidocaine group. One operator administered all local
anesthesia. Using the Modified Behavioral Pain Scale (MBPS), 15 trained and calibrated examiners, blinded to LA type, evaluated the subjects’
reactions during LA administration and treatment. Children rated their experience using the Wong-Baker FACES Pain Rating Scale (WBS). Sub-
jects’ blood pressure and pulse throughout the visits were recorded. Statistical analysis included independent t-tests, Mann Whitney-U, and re-
peated measures analysis of variance (P<0.05). Examiner reliability was determined by Cohen’s kappa score. Results: Thirty subjects (53 percent
male; mean age: 6.3 years) participated. While the mean total scores for articaine (2.13 MBPS; 0.53 WBS) were better than for lidocaine (3.07
MBPS; 1.33 WBS), there were no statistically significant differences between groups. All physiological measurements were within normal limits.
Conclusions: This pilot study indicated that articaine infiltration might be as effective as a lidocaine inferior alveolar nerve block for restorative
treatment of primary mandibular molars; however, a larger sample is required to confirm these findings. (Pediatr Dent 2021;43(5):344-8)
Received January 29, 2021 | Last Revision July 12, 2021 | Accepted July 13, 2021
KEYWORDS: LOCAL ANESTHESIA, ARTICAINE, LIDOCAINE, PRIMARY MOLAR, PEDIATRIC DENTISTRY

Successful local anesthesia (LA) is of paramount importance,
as it alleviates anxiety, cultivates trust, and promotes a safe
and positive experience during the delivery of dental care for
children.1 Techniques for LA, such as infiltration and nerve
blocks, are commonly used in pediatric dentistry. Local infil-
tration is technically simpler due to direct visualization, min-
imal depth of needle penetration, and low risk of errors. 2,3
An inferior alveolar nerve block (IANB) is technically more
challenging and has been associated with a greater risk of
complications as well as varying success, ranging from 55
percent to 92 percent.4,5
A variety of LA agents with diverse properties are clinically
available.6 Since its introduction in 1948, lidocaine has been
the standard of choice with efficacy and safety proven through
extensive research and wide clinical use.6 Articaine is a newer
amide LA, approved for dental anesthesia in individuals four
years and older. 7,8 Unlike other amides, articaine is derived
from thiophene instead of benzene.8 This substitution confers
increased liposolubility and potency, allowing articaine to be
1 Dr. Zhang is a pediatric dentist in private practice in Washington, D.C., USA. 2Dr.
Kratunova is clinical associate professor; 3Dr. Marion is a clinical assistant professor and
predoctoral director; and 4Dr. da Fonseca is Chicago Dental Society Foundation profes-
sor and head, all in the Department of Pediatric Dentistry; and 5Dr. Han is an assistant
professor and graduate program director, Department of Oral and Maxillofacial Surgery,
all in the College of Dentistry, University of Illinois at Chicago, Chicago, Ill., USA.
Correspond with Dr. Kratunova at evekrat@uic.edu
HOW TO CITE:
Zhang IL, Kratunova E, Marion I, da Fonseca MA, Han M. Articaine
infiltration versus Lidocaine inferior alveolar nerve block for anestheti-
zing primary mandibular molars: A randomized, controlled, double-
blind pilot study. Pediatr Dent 2021;43(5):344-8.
more readily diffusible through hard and soft tissues. 7,8 Addi-
tionally, its distinctive ester group accelerates its dual break-
down in both plasma and liver, which decreases the risk of
systemic toxicity. 8 Evidence from the literature suggests that
the unique properties of articaine enable its effective per-
meability through dense mandibular bone, permitting LA of
mandibular molars through local infiltration. 3 Mandibular
cortical bone shows reduced density among children, which may
facilitate the success of articaine local infiltration in pediatric
patients.8,9 In comparison, a gold standard for anesthetizing
primary mandibular molars (PMM) with lidocaine remains the
IANB.1
Safe and efficacious use of articaine in adults has been
confirmed from a large number of studies.3,10,11 However, re-
search focusing on children remains limited and of lower
quality.7,12 A recent systematic review and meta-analysis eval-
uated 11 eligible publications that compared the effectiveness
of articaine with lidocaine in pediatric dental anesthesia based
on the Facial Pain Scale and Visual Analog Scale.13 The authors
concluded that the effectiveness of articaine was better than
the gold standard lidocaine in pediatric dentistry.13
There is a lack of agreement among researchers on whether
articaine infiltration can replace lidocaine IANB for treatment
of PMM, and there is insufficient guidance on specific clinical
scenarios (e.g., restorative treatment, pulp therapy, exodon-
tia) where such substitution may be beneficial or preferably
avoided.7,9,12
The purpose of this pilot study was to evaluate the effec-
tiveness of mandibular infiltration anesthesia with four percent
articaine hydrochloride (HCl) with 1:100,000 epinephrine in
comparison to IANB with two percent lidocaine HCl with
1:100,000 epinephrine in pediatric patients during restorative
dental care of PMM and to test this methodology for the feasi-
bility of a larger trial.

344 LOCAL ANESTHESIA: PRIMARY MANDIBULAR MOLARS

 PEDIATRIC DENTISTRY V 43 / NO 5 SEP / OCT 21

Methods articaine) and never exceeded. 1,7 This study used the more
The Institutional Review Board of the University of Illinois conservative dose limit for articaine (five mg/kg instead of
Chicago granted permission to conduct this prospective, seven mg/kg) recommended in the literature 7 in order to
double-blind, parallel-design RCT. Participants were recruited exercise full safety precautions. No advanced behavior mana-
according to strict inclusion criteria (Table 1) from the pool gement modalities (i.e., nitrous oxide/oxygen analgesia/
of patients attending the postgraduate clinic of the Department anxiolysis, oral sedation) were used in conjunction with the
of Pediatric Dentistry, College of Dentistry, University of LA. The operator recorded baseline demographic and clinical
Illinois Chicago. The principal investigator approached pa- information in an initial data capture form. During the admin-
tients and their parents/legal guardians with age-appropriate istration of LA, the subject’s reactions were evaluated by dental
verbal and written (patient information leaflet) explanations assistants (examiners A) using the Modified Behavioral Pain
of the study. Sufficient time for consideration was provided Scale (MBPS). 15 The MBPS utilizes objective assessment of
before obtaining parental consent and assent from the child. observed behavior using three parameters indicative of pain:
Subjects were allocated into either an articaine or lidocaine facial expression; bodily movements; and level of crying (values
group using the method of random digit table, range from zero to four with zero being the most optimal).16
created in Microsoft Excel 2018 (Microsoft
Inc., Redmond, Wash., USA). The allocation
was concealed in a sealed envelope, which
was opened by the operator at the time of LA
administration.
The armamentarium for the study
included 20 percent benzocaine gel topical
anesthetic (LolliCaine, Centrix, Inc., Shelton,
Conn., USA), two percent lidocaine HCl
with 1:100,000 epinephrine (Henry Schein
Lidocaine, Novocol, Cambridge, Ontario,
Canada), four percent articaine HCl with
1:100,000 epinephrine (Septocaine, Septo-
dont, Lancaster, Pa., USA) both in 1.7 ml
cartridges, as well as 27-gauge long needles
for the IANB and 30-gauge short needles,
b o t h m a n u f a c t u re d by He n r y S c h e i n
(Melville, N.Y., USA). All injections were
given using a self-aspirating syringe (A-
Titan, Orchard Park, N.Y., USA).
One designated operator (EK), an ex-
perienced pediatric dentist, administered
the LA for all participants. The operator fol-
lowed a step-by-step guide (textbook
described)14 to standardize the LA technique
delivery and used their own clinical judgment
on the required LA amount for successful
anesthesia. The maximum LA agent dosage
was calculated based on the child’s weight Figure. Consolidated Standards of Reporting Trials (CONSORT) 2010 Flow Diagram21 of the
(4.4 mg/kg for lidocaine and 5.0 mg/kg for Study Process.

Table 1. INCLUSION AND EXCLUSION CRITERIA

Inclusion criteria Exclusion criteria

• Medically healthy (ASA* I) • Medically compromised (ASA* II-VI)

• 4-10 years old • <4 or >10 years old
Patient • History of prior dental treatment with local anesthesia • No history of prior dental treatment with local anesthesia
• Cooperative for prior dental treatment (Frankl score of 3 or 4) • Uncooperative for prior dental treatment (Frankl score of 1 or 2)
• English literacy • Poor English literacy

• Primary mandibular molar requiring restorative treatment due to: • Tooth other than primary mandibular molar
o Caries (including caries excavation resulting in pulp exposure • Primary mandibular molar requiring pulpectomy
Tooth and requiring a pulpotomy) • Primary mandibular molar requiring extraction
o Developmental defects
o Tooth surface loss (erosion/attrition)

* American Society of Anesthesiologists.

LOCAL ANESTHESIA: PRIMARY MANDIBULAR MOLARS 345

PEDIATRIC DENTISTRY V 43 / NO 5 SEP / OCT 21

The dental treatment was completed by a pediatric dental

pressure (BP) and pulse were monitored (DRE Patient Monitor
residents (examiners B), who assessed the subject’s reactions
Waveline EZ, DRE Inc., Louisville, Ky., USA) and recorded
during the restorative procedure also using the MBPS. A case-
at baseline, during injection, and every 10 minutes thereafter
appropriate isolation technique (rubber dam or Isolite isolation
during treatment. As physiologic surrogates of pain response,
system) was utilized. The subjects rated their subjective experi-
BP and pulse may exhibit increased values beyond age-
ence of the entire visit using the validated Wong-Baker adjusted normal values in the presence of distress.18 The parent/
FACES Pain Rating Scale (WBS, values ranging from zero to
guardian was provided with the principal investigator’s contact
10 with zero being most optimal).17 Each participant’s blood
information and advised to reach out if the subject experi-
enced any delayed adverse events (i.e., lip biting,
swelling, pain). Except for the operator, everyone
Table 2. OBJECTIVE AND PHYSIOLOGICAL MEASUREMENTS OF PAIN PERCEPTION else involved (parents/guardians, subjects, dental
Measure Group Mean Standard P-value ‡ assistants, and pediatric dental residents) was
value deviation blinded to the LA type. Data were gathered on
outcome forms by recording observable, subjec-
Lidocaine 1.33 0.617 tive, and physiological measures. The study
Facial expression Articaine 1.00 0.378 0.09 process is illustrated in the Figure.
All examiners (six examiners A and nine
Lidocaine 1.47 0.640
Cry 0.02 examiners B) were trained and calibrated regard-
MBPS#A* Articaine 1.00 0.378
ing using the MBPS. Each examiner watched
During LA Lidocaine 0.27 0.704 on two separate occasions (10 days apart) a
administration Movement 0.56 video of a child being treated in the dental
Articaine 0.13 0.516
chair by a dentist and rated the child’s behav-
Lidocaine 3.07 1.624
Total 0.06 ior using the MBPS form. Siegel and Castellan’s
Articaine 2.13 0.915 Kappa for nominal data, as concordance be-
Lidocaine 0.80 0.414 tween multiple raters, was used for calculating
Facial expression
Articaine 0.93 0.258
0.30 the inter-examiner agreement. Intrarater reli-
ability was statistically analyzed using the MBPS
Lidocaine 1.10 0.458 scores obtained from each examiner using
Cry 0.58
MBPS#B † Articaine 1.00 0 Cohen’s kappa coefficient.
Throughout Lidocaine 0 0 Data collected from the initial data capture
treatment Movement 1.00 forms and outcome data forms were transferred
Articaine 0 0
into Microsoft Excel 2018. IBM SPSS software
Lidocaine 1.87 0.743 (IBM, Armonk, N.Y., USA) was used for sta-
Total 0.75 tistical analysis. Data analysis included the use
Articaine 1.90 0.258
of both univariate descriptive statistics and
Lidocaine 96.3 10.2 bivariate statistics. Bivariate statistics included
At baseline
Articaine 103.9 12.9 independent t-tests, Mann Whitney-U tests, and
Systolic blood Lidocaine 102.5 13.2 repeated measures analysis of variance, with
pressure During injection
Articaine 103.0 16.0 0.11 Pillai’s trace used to determine significance for
(mm hg) the multivariate test. A P-value of <0.05 defined
Lidocaine 100.4 8.8 a statistically significant difference.
During treatment Articaine 101.2 9.4
Results
Lidocaine 55.9 12.6 Thirty subjects (age range equals four to 10 years;
At baseline
Articaine 56.9 10.1 6.3 years equals mean age; 53 percent male)
Diastolic blood Lidocaine 59.6 11.8 were recruited. Coincidentally, there were eight
pressure During injection
Articaine 53.2 6.8 0.21 males and seven females in each group. All
(mm hg) determinants for clinical success were satisfied,
Lidocaine 57.9 9.9 and none of the cases were considered failures.
During treatment Of the PMM treated in the lidocaine group,
Articaine 55.6 9.3
48 percent were first PMM and 52 percent
Lidocaine 88.3 15.7 were second PMM. In the articaine group, 65
At baseline
Articaine 81.3 13.8 percent were first PMM and 35 percent were
Lidocaine 93.9 15.0 second PMM. In the lidocaine group, the sub-
Pulse During injection
Articaine 85.8 9.6 0.03 jects received a total of five composite resin
(beats per min) restorations, 11 stainless steel crowns (SSCs), and
Lidocaine 90.0 12.6 three zirconia crowns. In the articaine group,
During treatment the treatments included four composite resin
Articaine 78.8 11.2
restorations and 14 SSC. Five subjects in the
* MBPS#A=Modified Behavioral Pain Scale, as evaluated by examiner #A (dental assistant). lidocaine group and three subjects in the arti-
† MBPS#B=Modified Behavioral Pain Scale, evaluated by examiner #B (pediatric dental resident). caine group received treatment on multiple
‡ P-values as listed were obtained using independent samples t-test, except for those of blood pressure teeth simultaneously. The articaine mean
and pulse, which were obtained using Pillai’s trace. volume (1.6 ml) per group was lower than for

346 LOCAL ANESTHESIA: PRIMARY MANDIBULAR MOLARS


lidocaine (2.2 ml). Observed measurements of pain percep-
tion during LA administration and throughout dental
treatment are summarized in Table 2.
The mean MBPS score for crying during LA administra-
tion was 1.47 in the lidocaine group versus 1.00 in the
articaine group; this was the only MBPS parameter with a
statistically significant difference between groups (P=0.02).
The mean WBS score was 1.33 with a standard deviation
(±SD) of 1.45 for the lidocaine group and 0.53±0.92 SD for
the articaine group (P=0.08). The results of the physiological
measurements of pain response are presented in Table 2.
Multivariate repeated measures ANOVA found no statistically
significant difference in mean BP between groups. Pillai’s trace
revealed a statistically significant difference in the pulse values
over the three different time points between the two groups
(P=0.03). Mann-Whitney U test demonstrated a statistically
significant difference in the average pulse during treatment
(P=0.01); the mean treatment pulse for the lidocaine
group was higher than that for the articaine group by approxi-
mately 11.2 bpm. Each subject’s vital signs at different
periods were also compared to the normal range of a child
of the same age, according to the pediatric advanced life
support guidelines.19 None of the participants displayed any
atypical measurements beyond normal physiologic values.
Intraexaminer and interexaminer agreement analyses demon-
strated that all values were similar, which indicated excellent
agreement with the same examiner and between different
examiners (κ greater than 0.9).
Discussion
The only MBPS parameter that exhibited a statistically signi-
ficant difference was “cry during LA administration.” A higher
“cry” score may be due to the deeper needle penetration
required for IANB compared to infiltration. This finding is
consistent with research verifying that IANB was more painful
than other LA techniques.20
Because pain is primarily a subjective experience, self-
report measures are considered fundamental.17 Self-perceived
level of pain throughout the entire appointment, as measured
by the WBS scores, was lower in the articaine group; however,
the difference was not statistically significant. While the
objective, subjective, and physiologic measurements of pain
individually have inherent limitations, they collectively supple-
ment each other to generate a more comprehensive assessment
of the participant’s experience of pain. 16-18 When all clinical
outcomes (MBPS, WBS, physiologic vital signs) were collec-
tively considered, the two LA types performed equally well.
These results support findings from similar studies in which
higher pain scores were generally associated with lidocaine
than articaine but without any statistically significant differ-
ences.2,3,11,13 While this study did not differentiate between first
or second primary molars, a future full trial may investigate
potential differences in achieving successful infiltration anes-
thesia between these tooth types. One study limitation is the
lack of standardization of the LA amount.
The present study contributes to the growing evidence in
the literature that suggests articaine mandibular infiltration as
a useful tool in clinicians’ armamentarium in situations where
traditionally lidocaine IABN has been recommended. 7,10,13,14
This pilot trial tested the proposed methodology for the feasi-
bility of a full randomized controlled trial. A retrospective
sample size calculation based on the mean WBS scores for
articaine and lidocaine using two independent sample t-tests
PEDIATRIC DENTISTRY V 43 / NO 5 SEP / OCT 21
was performed and showed that, to reject the null hypothesis
of equal means with a power of 90 percent, a sample size of
48 participants in each group (n equals 96) would be required.
Conclusions
Based on this study’s results, the following conclusions can
be made:
1. Articaine infiltration was as effective as lidocaine
inferior alveolar nerve block for restorative treatment
of primary mandibular molars in pediatric patients.
2. A full trial is required to determine if articaine infil-
tration can be considered a suitable alternative to
routine IANB for restorative treatment of PPM in
children.
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14. Jones JE, Dean JA. Local anesthesia and pain control for
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Abstract of the Scientific Literature

Facilitators and barriers to home-based toothbrushing practices by parents of young children to reduce
tooth decay: A systematic review
This systematic review aimed to identify the barriers and facilitators of parental supervised toothbrushing (PSB). Studies investigating
parental involvement in home-based toothbrushing in children under eight years old and the impact on tooth decay were included. Of
the 10,176 articles retrieved, 68 articles were included. Barriers included: an inadequate toothbrushing environment and resources, knowl-
edge of what PSB entails and child behavior management. Facilitators were: increased oral health knowledge, the adaption of the social
environment to facilitate PSB and positive attitudes towards oral health. The review concludes that there are a comprehensive range of
barriers/facilitators to PSB acting across all domains and at multiple levels of influence. This review identifies the most popular domains,
thus informing the focus for supporting resources to supplement oral health conversations.

Comment: Instructing patients and their parents to brush their teeth twice daily with fluoridated toothbrush is part of the ABC’s of pre-
vention. However, it is not so simple. PSB is a complex behavior. Clinicians need to understand and be able to explore the wide range
of potential barriers and have practical suggestions to enable PSB. This review provides examples of different barriers and facilitators
and emphasizes the importance of listening to parents and exploring their story to identify the barriers and solutions that are relevant
to each family. AK
Address correspondence to Dr. Kara A. Gray-Burrows, School of Dentistry, Faculty of Medicine and Health, University of Leeds, Leeds, LS2
9JT, UK; email to: K.Gray-Burrows@leeds.ac.uk
Aliakbari E, Gray-Burrows KA, Vinall-Collier KA, et al. Facilitators and barriers to home-based toothbrushing practices by parents of
young children to reduce tooth decay: A systematic review. Clin Oral Invest 2021;25(6):3383-93.

81 references

348 LOCAL ANESTHESIA: PRIMARY MANDIBULAR MOLARS

PEDIATRIC DENTISTRY V 43 / NO 5 SEP / OCT 21

14. Jones JE, Dean JA. Local anesthesia and pain control for 18. Saccò M, Meschi M, Regolisti G, et al. The relationship
the child and adolescent. In: McDonald RE, Avery DR, between blood pressure and pain. J Clin Hypertens 2013;
eds. Dentistry for the Child and Adolescent. 10 th ed. 15(8):600-5.

Abstract of the Scientific Literature

Philadelphia, Pa., USA: Elsevier; 2016:274-85.
15. Taddio A, Nulman I, Goldbach M, Ipp M, Koren G. Use
of lidocaine-prilocaine cream for vaccination pain in
19. Chameides L, Samson RA, Schexnayder SM, Hazinkski
MF, eds. Pediatric Advanced Life Support Provider
Manual. Dallas, Texas, USA: American Heart Association;
infants. J Pediatr 1994;124(4):643-8. 2016.
Facilitators
16. Taddio A,and barriers
O’Brien L, IpptoM, home-based toothbrushing
Stephens D, Goldbach M, 20. practices
Kaufmanby E, parents of Naveh
Epstein JB, youngE,children
Gorsky M, to Gross
reduce A,
tooth Koren G. Reliability
decay: A systematic and validity
reviewof observer ratings of Cohen G. A survey of pain, pressure, and discomfort in-
pain using the visual analog scale (VAS) in infants under- duced by commonly used oral local anesthesia injections.
This systematic review aimed
going immunization to identify
injections. Painthe barriers and facilitators of parental
2009;147(1):141-6. supervised
Anesth Prog toothbrushing (PSB). Studies investigating
2005;52(4):122-7.
parental
17. involvement
Garra G, SingerinAJ,home-based
Taira BR, ettoothbrushing
al. Validationinofchildren
the Wong-under 21.
eight Consolidated
years old and Standards
the impactofonReporting
tooth decay were
Trials included. Of
(CONSORT)
the 10,176
Bakerarticles
FACES retrieved, 68 articles
Pain Rating Scalewere included. Barriers
in pediatric emergencyincluded: an Flow
inadequate toothbrushing
Diagram. environment
Available and resources, knowl-
at: “http://www.consort-
edge department
of what PSBpatients.
entails and child
Acad behavior
Emerg Med management.
2010;17(1):50-4.Facilitators were:statement.org/consort-statement/flow-diagram”.
increased oral health knowledge, the adaption of the social
Accessed
environment to facilitate PSB and positive attitudes towards oral health. The review concludes
September 3, 2021.that there are a comprehensive range of
barriers/facilitators to PSB acting across all domains and at multiple levels of influence. This review identifies the most popular domains,
thus informing the focus for supporting resources to supplement oral health conversations.

Comment: Instructing patients and their parents to brush their teeth twice daily with fluoridated toothbrush is part of the ABC’s of pre-
vention. However, it is not so simple. PSB is a complex behavior. Clinicians need to understand and be able to explore the wide range
of potential barriers and have practical suggestions to enable PSB. This review provides examples of different barriers and facilitators
and emphasizes the importance of listening to parents and exploring their story to identify the barriers and solutions that are relevant
to each family. AK
Address correspondence to Dr. Kara A. Gray-Burrows, School of Dentistry, Faculty of Medicine and Health, University of Leeds, Leeds, LS2
9JT, UK; email to: K.Gray-Burrows@leeds.ac.uk
Aliakbari E, Gray-Burrows KA, Vinall-Collier KA, et al. Facilitators and barriers to home-based toothbrushing practices by parents of
young children to reduce tooth decay: A systematic review. Clin Oral Invest 2021;25(6):3383-93.

81 references

348 LOCAL ANESTHESIA:

ABSTRACT OF LIT PRIMARY MANDIBULAR MOLARS
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