CONSORT Randomized Clinical Trial
Efficacy of Articaine versus Lidocaine in
Supplemental Infiltration for Mandibular First
versus Second Molars with Irreversible Pulpitis:
A Prospective, Randomized, Double-blind
Clinical Trial
Michael R. Shapiro, DMD, MS,*† Neville J. McDonald, BDS, MS,* Richard J. Gardner, DDS, MS,*‡
Mathilde C. Peters, DMD, PhD,* and Tatiana M. Botero, DDS, MS*
Abstract
Introduction: Profound pulpal anesthesia is difficult to
achieve in mandibular molars with irreversible pulpitis
(IP). However, there are no published randomized
controlled clinical trials comparing the success of supple-
mental buccal infiltration (BI) in mandibular first versus
second molars with IP. The purpose of this prospective,
randomized, double-blind study was to compare the effi-
cacy of 4% articaine with 2% lidocaine for supplemental
BIs in mandibular first versus second molars with IP after
a failed inferior alveolar nerve block (IANB). This study’s
sample was combined with data from a previous trial.
Methods: One hundred ninety-nine emergency subjects
diagnosed with IP of a mandibular molar were selected
and received an IANB with 4% articaine. Subjects who
failed to achieve profound pulpal anesthesia, determined
by a positive response to cold or pain upon access,
randomly received 4% articaine or 2% lidocaine as a sup-
plemental BI. Endodontic access was begun 5 minutes af-
ter infiltration. Success was defined as less than mild pain
during endodontic access and instrumentation on the
Heft-Parker visual analog scale. Results: There was a
25% IANB success rate with 4% articaine. The success
rate for articaine supplemental BI in first molars was
61% versus 63% for second molars (P > .05). The success
of lidocaine in first molars was 66%, but for
second molars it was 32% (P = .004). Conclusions:
The success rate for IANB with 4% articaine was 25%. Ar-
ticaine and lidocaine had similar success rates for supple-
mental infiltration in first molars, whereas articaine was
significantly more successful for second molars. However,
because BI often did not provide profound pulpal anes-
thesia, additional techniques including intraosseous anes-
thesia may still be required. (J Endod 2018;44:523–528)
From the *Department of Cariology, Restorative Sciences, and Endodontics, University of Michigan School of Dentistry, Ann Arbor, Michigan; †Private Practice
Limited to Endodontics, West Bloomfield, MI; and ‡Private Practice Limited to Endodontics, Ann Arbor, MI.
Address requests for reprints to Dr Tatiana M. Botero, School of Dentistry, University of Michigan, 1011 N University Rm. 2309, Ann Arbor, MI 48109-1078. E-mail
address: tbotero@umich.edu
0099-2399/$ - see front matter
Copyright ª 2018 American Association of Endodontists.
https://doi.org/10.1016/j.joen.2017.10.003
JOE — Volume 44, Number 4, April 2018
Downloaded for Anonymous User (n/a) at Pontifical Catholic University of Chile from ClinicalKey.com by Elsevier on June
13, 2022. For personal use only. No other uses without permission. Copyright ©2022. Elsevier Inc. All rights reserved.
Key Words
Articaine, inferior alveolar nerve block, infiltration, irreversible pulpitis, lidocaine,
mandibular molars
O ne of the most difficult
situations dentists
routinely face is a patient
Significance
Mandibular molars with irreversible pulpitis present
challenges in achieving profound pulpal anes-
who presents a mandib-
thesia. This study showed that buccal infiltration
ular molar with symptom-
with articaine significantly improves success rates
atic irreversible pulpitis
for mandibular second molars. Articaine and lido-
(IP). Frequently called a
caine showed similar success rates for mandibular
‘‘hot’’ tooth, such teeth
first molars.
often present a significant
challenge in achieving
adequate pulpal anesthesia. Three studies investigated mandibular posterior teeth
with IP using an inferior alveolar nerve block (IANB) and supplementary techniques
after IANB failure (1–3). They found that achieving complete pulpal anesthesia is
often difficult for the clinician. Even for subjects with healthy asymptomatic
mandibular molars, IANB has a significant failure rate of 10%–39% (1–4).
Unfortunately, the success rate of IANB in mandibular molars with IP drops to
approximately 24% (4, 5).
Despite theoretical advantages, clinical studies of the Gow-Gates and Vazirani-
Akinosi techniques have shown no difference in success rates (6). As an alternative,
supplemental injections can be used including buccal infiltration (BI), periodontal lig-
ament (PDL) injections (7), intraosseous injection (IO), local infiltration, and intrapul-
pal injections.
A relatively easy, safe, and comfortable alternative to conventional IANB is a
mandibular BI injection, which, despite the thicker cortical plate, has been shown to
be effective for mandibular molar anesthesia in asymptomatic patients (8). Several
studies have used 4% articaine BI as a supplemental infiltration for mandibular molars
with IP (1–3, 9). As a representative example, Ashraf et al (1) showed a success rate of
29% with 2% lidocaine BI, whereas there was 71% success using articaine. However, a
Successful Articanie Mandibular Molar Buccal Infiltration 523
CONSORT Randomized Clinical Trial
nonsupplemented IANB (either by 4% articaine or 2% lidocaine) was
successful only 14% of the time (1).
Rogers et al (5) published the first randomized, double-blind,
clinical trial of the efficacy of BI of 4% articaine versus 2% lidocaine
when articaine was used for IANB. They found 4% articaine to be signif-
icantly more effective than 2% lidocaine, with success rates of 62% and
37%, respectively.
The studies by Ashraf et al (1) and Roger et al (5) also found
apparent differences in success between first and second molars.
Rogers et al found that the success rate of approximately 62% for arti-
caine was similar for first and second molars. However, the success rate
for lidocaine dropped significantly from 53% to 18% in first versus
second molars. In contrast, Ashraf et al found that infiltration for
second molars was more effective than for first molars.
Because no study has yet compared the success rate of supple-
mental anesthesia in first and second molars in a randomized,
double-blind clinical trial, the purpose of this prospective clinical trial
was to determine whether there is a difference in the pulpal anesthetic
efficacy of 68 mg articaine (with 0.017 mg epinephrine) and 34 mg
lidocaine (with 0.017 mg epinephrine) using supplemental infiltration
for first or second mandibular molars. In addition, the study combines
the results of this study with those of Rogers et al (5) in order to increase
the sample size and, thus, the power function of statistical tests.
Materials and Methods
Prestudy Phase
To determine the appropriate sample size for this study, an a priori
power analysis was conducted based on relevant information in the
study by Rogers et al (5), which found no statistically significant differ-
ence (ie, P > .05) between the success of articaine and lidocaine in first
molars and no statistically significant difference between the success of
articaine in first and second molars. nQuery  nTerim 3.0 software
(Statistical Solutions, Boston, MA) was used to performed power calcu-
lations using the Fisher exact test. A sample size of 100 subjects was
planned in order to yield a combined sample size of 200.
The study was approved by the Institutional Review Board at the
University of Michigan, Ann Arbor, MI (IRB00001999) and registered
on Clnicaltrials.gov (NCT01496846) (Supplemental Figs. 1 and 2 are
available online at www.jendodon.com). Rogers et al’s (5) clinical pro-
tocol was followed.
The volunteer subjects were patients of record at the University of
Michigan School of Dentistry who had pain in a mandibular molar. The
same operator (M.R.S.) provided screening, diagnosis, and anesthesia.
However, a separate operator often conducted the actual root canal
treatment. The patient’s medical history was reviewed to ensure no con-
traindications to dental treatment or the local anesthetic.
To qualify for the study, subjects had to meet the accepted Amer-
ican Association of Endodontics diagnostic criteria for a mandibular
first or second molar with symptomatic IP (10). Specifically, each pa-
tient had to have a history of greater than moderate pain in a lower first
or second molar as measured by the Heft-Parker visual analog scale
(VAS) (11) and lingering sensitivity to cold upon testing with Endo-
Ice (1,1, 1, 2 tetrafluoroethane; Hygenic Corp, Akron, OH). Exclusion
criteria included molars with an apical radiolucency or that were
necrotic upon endodontic access.
Following Rogers et al’s protocol (5), each patient was asked to
rate his or her pretreatment, postinjection, and posttreatment pain
on a Heft-Parker VAS by touching an iPad (Apple Inc, Cupertino, CA)
screen with a pain scale labeled with pain descriptors. In addition to
‘‘no pain,’’ the HP-VAS data were collapsed into 3 categories for ease
of reporting. No pain corresponded to 0 mm. Mild pain was operation-
524 Shapiro et al.
Downloaded for Anonymous User (n/a) at Pontifical Catholic University of Chile from ClinicalKey.com by Elsevier on June
13, 2022. For personal use only. No other uses without permission. Copyright ©2022. Elsevier Inc. All rights reserved.
ally defined as a rating >0 mm and #54 mm. This range included the
descriptors faint, weak, and mild pain. Moderate pain was operationally
defined as >54 mm and <114 mm. Severe pain was defined as
$114 mm. The latter range included the following descriptors: strong,
intense, and maximum possible (11).
To standardize the administration of anesthesia from patient to pa-
tient, all anesthesia was delivered using the Midwest Comfort Control
Syringe (Dentsply Professional, Des Plaines, IL). The syringe allows
the operator to select from a predetermined rate of anesthesia deter-
mined by the technique of administration (eg, block, infiltration,
palatal, PDL, or intraosseous).
The study’s flowchart is shown in Figure 1. After a 60-second appli-
cation of topical benzocaine (20%; Centrix, Shelton, CT), all study sub-
jects received an initial IANB of 1.7 mL 4% articaine with 1:100,000
epinephrine (Articadent; Dentsply Pharmaceutical, York, PA). The
IANB involved a 27-G needle on the block setting of the Comfort Control
Syringe. The needle insertion was performed slightly lateral to the mid-
dle portion of the pterygomandibular raphe to contact bone with the
needle bevel directed toward the bone, slightly withdrawn, and aspi-
rated, and the solution was deposited with the Midwest Comfort Control
syringe at a rate of 0.02 mL/s.
IANB effectiveness was assessed 15 minutes postinjection by ques-
tioning the patient about lip numbness. If the patient did not show pro-
found lip numbness, the block was considered missed, and the patient
was excluded from data analysis. If the patient reported lip numbness,
the study proceeded to cold testing (Fig. 1). The inflamed tooth as well
as the adjacent molar and premolar were cold tested with Endo-Ice us-
ing a size #3 saturated cotton pellet on the coronal third of the mesio-
buccal line angle of the molars and the coronal third on the buccal side
of the premolars. A positive cold response on the inflamed molar was
considered a failed block, at which point the patient received a
randomly assigned supplemental BI. After a negative cold response,
the tooth was isolated with a dental dam, and before initiating access,
subjects were instructed to report, during access, any pain felt beyond
mild discomfort (VAS rating >54 mm). IANB success was operationally
defined as the ability to access and instrument the tooth with no pain or
not more than mild pain. Subjects who experienced pain beyond the
established criteria for success were considered to have had a ‘‘failed
block.’’ These subjects were randomly assigned to a supplemental infil-
tration treatment (Fig. 1).
Figure 1. The study flowchart; this figure depicts the flow of patients through
the study.
JOE — Volume 44, Number 4, April 2018

All anesthetic cartridges used in the study (1.7 mL 4% articaine
[Articadent] and 1.7 mL 2% lidocaine [Henry Schein, Dentsply Pharma-
ceutical, York, PA]) were subjected to block randomization (Research
Randomizer 3.0, Urbaniak and Plous, 2011). To prevent operators and
subjects from identifying an anesthetic being used, unlabeled cartridges
were numbered but were otherwise identical. The clinician (M.R.S.),
who was responsible for all patient management and each injection,
was neither involved with, nor aware of, which anesthetic was being
randomly assigned.
After a failed IANB, topical anesthetic was applied for 60 seconds,
and BI was performed with the assigned cartridge using the Comfort
Control Syringe. The injection site was adjacent to the affected molar,
bisecting the approximate location of the mesial and distal roots at
the mucobuccal fold. The needle was advanced to the estimated depth
just superior to the apices of the mandibular molar, and the anesthetic
was delivered at a rate of 0.017 mL/s. At 5 minutes postinfiltration, the
tooth was again cold tested (Fig. 1), and the infiltration was assessed as
either ‘‘success’’ or ‘‘failure.’’ If the tooth tested positive to cold, the pa-
tient received immediate rescue anesthesia. Otherwise, access was initi-
ated.
Subjects experiencing greater than mild pain during access into
the dentin when entering the pulp chamber or with the initial file place-
ment received rescue anesthesia because this infiltration was consid-
ered failed. The rescue anesthesia involved IO using the X-tip system
(Dentsply International, York, PA) per manufacturer’s recommenda-
tions. The IO was performed with 1.7 mL 4% articaine 1:100,000
Figure 2. The Consolidated Standards Of Reporting Trials flowchart.
JOE — Volume 44, Number 4, April 2018
Downloaded for Anonymous User (n/a) at Pontifical Catholic University of Chile from ClinicalKey.com by Elsevier on June
13, 2022. For personal use only. No other uses without permission. Copyright ©2022. Elsevier Inc. All rights reserved.
CONSORT Randomized Clinical Trial
epinephrine using the Midwest Comfort Control Syringe on the intraoss-
eous setting with a method similar to that of Dunbar et al (12). In the
rare instance that the IO was contraindicated, a PDL or intrapulpal in-
jection was given.
All patient data were entered into an online data input and man-
agement system (Snapdragon Media, LLC, Ann Arbor, MI) using an Ap-
ple iPad 2 (Apple Inc).
To statistically compare articaine and lidocaine solutions for anes-
thetic success after first establishing the data were not normally distrib-
uted, we used the chi-square test or the Fisher exact test on the raw data
depending on the number of data points in the table cells. To statistically
compare preoperative demographic variables and initial VAS scores
(preoperative VAS and age) within and between the treatment groups,
independent sample t tests were used. Additionally, we compared the
study by Rogers et al (5) and the current study for all of these variables
to find statistical differences between the 2 samples. Results were
considered significant when the P value was <.05.
Results
One hundred subjects participated in this study, each diagnosed
with a mandibular first or second molar with IP. Of these, 1 patient
did not show profound lip numbness at 15 minutes after the initial
IANB (‘‘missed’’ block) and was excluded from further data analysis.
Figure 2 illustrates the flow of subjects in the study.
Successful Articanie Mandibular Molar Buccal Infiltration 525
CONSORT Randomized Clinical Trial
As discussed earlier, the data from this study were combined with

Lidocaine

19 (50%)
19 (50%)
40  14

120  29

119  35
121  24
(n = 38)
those of Rogers et al (5). No adverse events were recorded in this study
in 201 patients, after 277 articaine injections. There were no significant
differences between the 2 samples. The baseline demographics for the
combined samples are provided in Table 1.
There were 199 subjects in the combined sample, 98 first molars

Second molar
and 101 second molars. The mean age in the combined sample was

Articaine

17 (42%)
23 (58%)
38  15

132  25

140  23
127  26
(n = 40)
39  5 years, with 97 men and 102 women. Although there was a sig-
nificant difference between the number of male/female subjects within
the first molar articaine and first molar lidocaine groups (P = .035),
there were no other significant differences between any of the other

TABLE 1. Overall Combined Baseline Patient Demographics and Baseline Visual Analog Scale (VAS) Inferior Alveolar Nerve Block (IANB) and Buccal Infiltration Groups (n = 199)
groups (P > .05). There were no statistically significant differences

36 (46%)
42 (54%)
41  16

129  24

128  30
127  25
(P > .05) between any of the anesthetic techniques in VAS pain scores

(n = 78)
Overall
during anesthetic administration.

Buccal infiltration
Figure 3 shows the anesthetic success for the IANB, BI, and IO
techniques for first versus second molars. For first molars, compared
with a 28% success rate of IANB, BI was 63% successful, and IO was
92% successful. By contrast, for second molars, the success rates

Lidocaine

13 (38%)
22 (62%)
35  14

133  18

128  12
136  21
(n = 35)
were 23% for IANB, 50% for BI, and 79% for IO. For each anesthetic
technique, there were no significant differences in success between first
and second molars (P > .05).
Table 2 shows the success rates of articaine and lidocaine BI in
both first and second molars. BI was successful 63% of the time with

First molar
first molars and 47% of the time with second molars. Although not sta-

Articaine

24 (67%)
12 (33%)
40  14

136  26

133  27
143  25
(n = 36)
tistically significant (P = .051), this difference is suggestive of a trend
toward higher success in first molars. Articaine was equally successful
across molar types with a 61% success rate for first molars and a 63%
success rate for second molars (P > .05). However, lidocaine’s success
showed statistically significant differences across molar types with a

37 (52%)
34 (48%)
37  13

133  23

131  23
138  24
(n = 71)
66% success rate in first molars versus a 32% success rate in
Overall
second molars (P = .004). In first molars, articaine BI was successful
61% of the time, and lidocaine was successful 66% of the time
(P > .05). For second molars, the success rate of 63% for articaine
BI was statistically significantly better than the 32% success rate for lido-
caine (P = .006).
Second molar
(n = 101)

46 (46%)
55 (54%)
41  16

128  27

124  30
132  25
Discussion
The current investigation follows up the study by Rogers et al (5),
which compared the success rates of supplemental BI with either arti-
IANB (4% articaine)

caine or lidocaine in mandibular molars with IP after a failed IANB with

Administered

articaine. This article presents the final data of an additional 100 sub-
First molar

51 (52%)
47 (48%)
37  13

134  23

131  23
138  24
(n = 98)

jects combined with the data from Rogers et al, totaling 201 subjects
from the same population using the same protocol.
To statistically compare the data of the 2 studies for preoperative
variables (including preoperative VAS, sex, and age), independent
t tests were used. In the absence of any statistically significant differ-
ences, the 2 data sets were combined, totaling 201 subjects; 199 were
102 (52%)
(n = 199)

97 (48%)
39  15

131  26

129  26
132  25

used for analysis. Because the 2 studies are from the same patient pop-
Overall

ulation and use the same protocol, totaling 201 subjects, it is likely that
the combined results provide a better representation of the actual per-
formance of supplemental BI with articaine and lidocaine in first molars
(n = 73) and second molars (n = 77) than either study independently.
The findings of this combined study support the fact that, especially
Mean age (years  SD)

Mean initial VAS score

in cases of IP, IANB is an unpredictable anesthetic technique. The 25%

Total (mean VAS)
demographics

combined success rate of IANB is similar to that found by others (3–5,

Sex (mean VAS)
and VAS
Baseline

13, 14). This reinforces the need to have alternatives to IANB like BI. It is
SD, standard deviation.

important to note that, of the 201 subjects, there were only 2 instances
Female
Sex (n, %)

Male
Female

of unsuccessful lip anesthesia, which were considered as missed blocks

Male

and excluded.
The success rates of supplemental BI with articaine and lidocaine
in first molars were similar, 61% with articaine and 66% with lidocaine

526 Shapiro et al. JOE — Volume 44, Number 4, April 2018

Downloaded for Anonymous User (n/a) at Pontifical Catholic University of Chile from ClinicalKey.com by Elsevier on June
13, 2022. For personal use only. No other uses without permission. Copyright ©2022. Elsevier Inc. All rights reserved.

Figure 3. The success rates of various anesthetic techniques in first versus second molars.
(P > .05). However, in second molars, articaine was found to be signif-
icantly more effective, 63% versus 32% for lidocaine (P = .006).
Although the success of articaine was virtually the same for both first
and second molars (61% vs 63%), lidocaine’s success rate decreased
significantly to 31%. These results agree with previous studies (1, 3, 5,
15–17). All of these studies involved subjects with a mandibular molar
with IP who received supplemental BI with either 4% articaine or 2%
lidocaine after a failed IANB. Each study found that 4% articaine was
significantly better than 2% lidocaine for supplemental infiltration in
IP mandibular molars. However, in all the studies except Rogers et al
(5), lidocaine 2% was used for the IANB. Also, no study except Rogers
et al specifically examined the differences between first and second
mandibular molars. The 2011 meta-analysis by Brandt et al (18) found
that articaine as an infiltration was 3.8 times more likely to be successful
than lidocaine. A recent meta-analysis by Kung et al (19) found that, in
cases of a failed IANB, supplementary infiltration with 4% articaine was
3.55 times more successful in achieving profound anesthesia than 2%
lidocaine. Several studies, including those by Ashraf et al (1), Aggarwal
and Jain (2), and Yadav et al (13), found that articaine was significantly
better than lidocaine. However, because of the differences in the meth-
odology and techniques used by each, it is difficult to draw direct com-
parisons with these studies.
The results of this combined study agree with the findings of
Fowler et al (14) that articaine’s performance is similar for both first
and second molars. Lidocaine’s performance in BI for mandibular mo-
TABLE 2. Overall Combined Efficacy of Articaine and Lidocaine Buccal Infiltration in First Versus Second Molars by Sex (N = 149)
First molar (n = 71)
n (%)
Overall BI success 45/71 (63)
Anesthetic
Articaine (n = 76) 22/36 (61)
Male (n = 41) 14/24 (58)
Female (n = 35) 8/12 (67)
Lidocaine (n = 73) 23/35 (66)
Male (n = 32) 11/13 (71)
Female (n = 41) 12/22 (55)
BI, buccal infiltration.
*Significant difference.
JOE — Volume 44, Number 4, April 2018
Downloaded for Anonymous User (n/a) at Pontifical Catholic University of Chile from ClinicalKey.com by Elsevier on June
13, 2022. For personal use only. No other uses without permission. Copyright ©2022. Elsevier Inc. All rights reserved.
CONSORT Randomized Clinical Trial
lars with IP appears to vary depending on the area of administration. In
contrast to the studies by Ashraf et al (1) and Yadav et al (13), lido-
caine’s performance in the first molar region was found to be similar
to that of articaine. Because lidocaine’s success rate dropped to 32%
for second molars, its use for supplemental BI for lower molars with
IP may be unpredictable.
One possible explanation for the variability in the performance of
the 2 anesthetics lies in the anatomic differences in the regions of the
mandibular first and second molars (15). Studies have shown a consid-
erable difference in the thickness of the buccal bone overlying mandib-
ular first and second molars (16, 17). Therefore, the ability of an
anesthetic to penetrate through bone may play a crucial role in its
success in supplemental BIs.
It has been postulated that articaine’s unique thiophene ring struc-
ture provides superior and unique abilities to penetrate bone and other
tissues (20, 21). The lower pKa of articaine would translate into a
greater percentage of the drug in the active base form although
whether this is a meaningful improvement over lidocaine is debatable
(18, 21). Moreover, articaine’s greater lipid solubility improves
diffusion through both nerve sheaths (such as the inferior alveolar
nerve) and neural membranes of individual axons comprising a
nerve trunk. This too should improve the efficacy of articaine (see
Skjevik et al (22) for underlying molecular mechanisms).
Articaine’s unique properties seem to allow it to diffuse more
readily through bone than lidocaine. However, because the cortical
Second molar (n = 78)
n (%) P value
37/78 (47) .051
25/40 (63) .901
11/17 (65) .680
14/23 (61) .736
12/38 (32) .004*
7/19 (37) .007*
5/19 (23) .067
Successful Articanie Mandibular Molar Buccal Infiltration 527
CONSORT Randomized Clinical Trial
plate in the first molar area is thinner (16, 17), the difference in
performance would likely become less apparent. Indeed, studies
support the idea that much of the anesthetic effect in the first molar
region actually occurs because of a ‘‘mental block,’’ with similar
results obtained by injecting anesthetic in the premolar region (23).
Kwon et al (23) found no statistical difference in performance among
second premolars, first molars, and second molars when 4% articaine
was used, suggesting much of the effect may be from a combination of
the mental block and diffusion through the bone. This supports the idea
that in the first molar area there would be less difference between arti-
caine and lidocaine, as found in our study. In addition, it is conceivable
that the use of articaine for IANB improves the success of BI with lido-
caine but only for the first molar region where the mental block effect
takes place. Further studies may be warranted to confirm these findings.
The present investigation used cold testing to help assess pulpal
anesthesia after IANB and at each subsequent stage of the treatment pro-
cess; it has excellent sensitivity and specificity and can be applied effectively
to any tooth (24). For IP mandibular molars, we found a poor correlation
between lip anesthesia, cold testing, and pulpal anesthesia after IANB,
which is consistent with prior studies (1, 25). This supports the notion
that lip anesthesia correlates very poorly to pulpal anesthesia and that
additional testing should be performed before initiating access (3, 4, 7).
The finding that many teeth tested negative to cold yet lacked pro-
found anesthesia on access highlights the need to find an accurate
method to assess pulpal anesthesia. Even having both lip numbness
and a lack of response to cold or electric pulp tests is not an indication
of pulpal anesthesia because most subjects still had pain (21, 26, 27).
One explanation might be that in teeth with IP the responses to electric
pulp tests or cold tests are related to fast and slow silent A-delta fibers,
respectively (28). Hence, it can be hypothesized that if the tetrodotoxin-
resistant sodium channels mostly appear on deeper nociceptive C fi-
bers, then neither negative nor positive responses to EPT and cold tests
indicate the success of anesthesia after the administration of anesthetic
agents because these C fibers might be responsible for the pain
response. The absence of adverse events in this study corroborates cur-
rent evidence-based knowledge about the safety of Articaine as local
anesthetic (18, 29, 30)
In conclusion, for mandibular molars with IP, we found the IANB
success rate with 4% articaine with 1:100,000 epinephrine to be 25%.
Supplemental BI with 4% articaine and 2% lidocaine was found to have
comparable success in the first molar region. BI with 4% articaine was
significantly more effective than 2% lidocaine for mandibular
second molars with IP. However, although BI improves the success
rate of pulpal anesthesia, additional techniques may still be required.
Acknowledgments
The authors wish to thank Dr Corey Powell for his invaluable
assistance in statistical analysis and Drs Stephen Margulis and
Marshal Shlafer for their time in reviewing and editing the original
masters thesis.
Supported by the Department of Cariology Restorative Science
and Endodontics, University of Michigan, School of Dentistry, Ann
Arbor, MI. Dr Shapiro completed this study as part of his master of
science degree.
The authors deny any conflicts of interest related to this study.
Supplementary Material
Supplementary material associated with this article can be
found in the online version at www.jendodon.com (https://doi.
org/10.1016/j.joen.2017.10.003).
528 Shapiro et al.
Downloaded for Anonymous User (n/a) at Pontifical Catholic University of Chile from ClinicalKey.com by Elsevier on June
13, 2022. For personal use only. No other uses without permission. Copyright ©2022. Elsevier Inc. All rights reserved.
References
1. Ashraf H, Kazem M, Dianat O, Noghehkar F. Efficacy of articacine versus lidocaine in
block and infiltration anesthesia administered in teeth with irreversible pulpitis: a
prospective randomized, double-blind study. J Endod 2013;39:6–10.
2. Aggarwal V, Jain A. Anesthetic efficacy of supplemental buccal and lingual infiltra-
tions of articaine and lidocaine after an inferior alveolar nerve block in patients with
irreversible pulpitis. J Endod 2009;35:925–9.
3. Matthews R, Drum M, Reader A, et al. Articaine for supplemental buccal mandibular
infiltration anesthesia in patients with irreversible pulpitis when the inferior alveolar
nerve block fails. J Endod 2009;35:343–6.
4. Claffey E, Reader A, Nusstein J, et al. Anesthetic efficacy of articaine for inferior alve-
olar nerve blocks in patients with irreversible pulpitis. J Endod 2004;30:568–71.
5. Rogers B, Botero T, McDonald N, et al. Eficacy of articaine versus lidocaine as a
supplemental buccal infiltration in mandibular molars with irreversible pulpitis:
a prospective, randomized, double-blind study. J Endod 2014;40:753–8.
6. Goldberg S, Reader A, Drum M, et al. Anesthetic efficacy of the conventional inferior
alveolar, Gow-Gates and Varizani-Akinosi techniques. J Endod 2008;34:1306–11.
7. Abazarpoor R, Parirokh M, Nakhaee N, Abbot P. A comparison of different volumes
of articaine for inferior alveolar nerve block for molar teeth with symptomatic apical
periodontitis. J Endod 2015;41:1408–11.
8. Meechan J. Infiltration anesthesia in the mandible. Dent Clin North Am 2010;54:
621–9.
9. Parirokh M, Satvati S, Sharifi R, et al. Efficacy of combining a buccal infiltration with
an inferior alveolar nerve block for mandibular molars with irrevesible pulpitis.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:468–74.
10. American Association of Endodontists. AAE Endodontic Glossary, 9th ed. Chicago,
IL: American Association of Endodontists; 2012.
11. Aitken RC. Measurement of feelings using visual analogue scales. Proc R Soc Med
1969;62:989–93.
12. Dunbar D, Reader A, Nist R, et al. Anesthetic efficacy of the intraosseous injection
after an inferior alveolar nerve block. J Endod 1996;22:481–6.
13. Yadav M, Grewal M, Grewal S, Deshwal P. Comparison of preoperative oral ketor-
olac on anesthetic efficacy of inferior alveolar nerve block and buccal and lingual
infiltration with articaine and lidocaine in patients with irreversible pulpitis: a pro-
spective, randomized, controlled, double-blind. J Endod 2015;41:1773–7.
14. Fowler S, Drum M, Reader A, Beck M. Anesthetic success of an inferior alveolar
nerve block and supplemental articaine buccal infiltration for molars and premolars
in patients with symptomatic irreversible pulpitis. J Endod 2016;42:390–2.
15. Dohair D, Zobeidi M, Hannoueh K, et al. A CBCT measurement of the mandibular
buccal bone thickness in dentate adults. Oral Surg 2015;8:38–41.
16. Frankle KT, Seibel W, Dumsha TC. An anatomical study of the position of the mesial
roots of mandibular molars. J Endod 1990;16:480–5.
17. Jin GC, Kim KD, Roh B, et al. Buccal bone plate thickness of the Asian people.
J Endod 2005;31:430–4.
18. Brandt R, Anderson P, McDonald M, et al. The pulpal anesthetic efficacy of articaine
versus lidocaine in dentistry: a meta-analysis. J Am Dent Assoc 2011;142:493–504.
19. Kung J, McDonagh M, Sedgley CM. Does articaine provide an advantage over lido-
caine in patients with symptomatic irreversible pulpitis? A systematic review and
meta-analysis. J Endod 2015;41:1784–94.
20. Hsaiao-Wu GW, Susarla SM, White RR. Use of the cold test as a measure of pulpal
anesthesia during endodontic therapy: a randomized, blinded, placebo-controlled
clinical trial. J Endod 2007;33:406–10.
21. Isen D. Articaine: pharmacology and clinical use of a recently approved local anes-
thetic. Dent Today 2000;19:72–7.
22. Skjevik A, Haugh B, Lygre L, Teigen K. Intramolecular hydrogen bonding in articaine
can be related to superior bone tissue penetration: a molecular dynamics study. Bio-
phys Chem 2011;154:18–25.
23. Kwon H, Shin Y, Cho SY, et al. Factors affecting the success rate of buccal infiltration
anaesthesia in the mandibular molar region. Int Endod J 2014;47:1117–22.
24. Petersson K, Soderstrom C, Kiani-Anarski M, Levy G. Evaluation of the ability of thermal
and electrical tess to register pulp vitality. Endod Dent Traumatol 1999;15:127–31.
25. Mikesell P, Nusstein J, Beck M, Weaver J. A comparison of articaine and lidocaine
for inferior alverolar nerve blocks. J Endod 2005;31:265–70.
26. Tortamano I, Siviero M, Costa C, et al. A comparison of the anesthetic efficacy of ar-
ticaine and lidocaine in patients with irreversible pulpitis. J Endod 2009;35:165–8.
27. Nydegger B, Nusstein J, Reader A, Drum M. Anesthetic comparisons of 4% concen-
trations of articaine, lidocaine, and prilocaine as primary buccal infiltrations of the
mandibular first molar: a prospective randomized, double-blind study. J Endod
2014;40:1912–6.
28. Hargreaves K, Keiser K. Local anesthetic failure in endodontics: mechanisms and
management. Endod Topics 2002;1:26–39.
29. Katyal V. The efficacy and safety of articaine versus lignocaine in dental treatments: a
meta-analysis. J Dent 2010;38:307–17.
30. Malamed SF, Gagnon S, Leblanc D. Efficacy of articaine: a new amide local anes-
thetic. J Am Dent Assoc 2000;131:635–42.
JOE — Volume 44, Number 4, April 2018