Comparison of Efficacy and Patient Response between 2% Lidocaine and 4% Articaine during Routine Dental Extractions
Correspondence Address :
Dr. Shubham Kumar,
Senior Resident, Department of Dentistry, Sri Krishna Medical College and Hospital,
Muzaffarpur, Bihar, India.
E-mail: dr_shubham87@hotmail.com
Introduction:Local Anaesthetic (LA) agents are chemicals that reversibly block the transmission of action potential of nerve membrane. Lidocaine has established itself as the gold-standard owing to its excellent clinical properties with minimal side effects. Articaine, a relatively newer LA agent is reported to have better clinical properties than lidocaine.
Aim: To compare and evaluate the differences in total volume of LA agent used, onset of subjective symptoms and objective signs, total duration of anaesthesia achieved and postoperative pain assessment with 2% lidocaine and 4% articaine during routine dental extractions.
Materials and Methods: This randomised clinical study was conducted by the Department of Dentistry, Sri Krishna Medical College and Hospital, Muzaffarpur, Bihar, India, from October 2020 to February 2021. A total of 200 patients (107 females and 93 males) requiring mandibular molar extraction were included in the study. The patients were randomly divided into two study groups. Group-I patients were administered with 2% lidocaine while group-II patients were administered with 4% articaine. Complete demographic and clinical details of all the patients were recorded. The volume of LA agent used, onset time for subjective symptoms and objective signs and total duration of anaesthesia was recorded. Postoperative pain was recorded on Visual Analogue Scale (VAS) on a scale of 0 to 10. All the variables were recorded in Microsoft excel sheet and were analysed by Statistical Package for the Social Sciences (SPSS) version 21 software. A two-tailed p-value less than 0.05 (p<0.05) was considered statistically significant.
Results: A total of 200 patients participated in the study, where group-I patients (49 males and 51 females) had a mean age of 34.79±10.43 years and group-II patients (44 males and 56 females) had a mean age of 35.41±11.39 years. Statistically insignificant differences (p>0.05) were obtained for the following parametersvolume of LA agent used, onset time of subjective symptoms, onset time of objective signs and postoperative VAS scores. A statistically significant difference (p<0.05) was observed for total duration of anaesthesia.
Conclusion: Both 2% lignocaine and 4% articaine are equally effective LA agents in patients undergoing mandibular molar extractions. However, 2% articaine exhibited significantly higher duration of total anaethesia when compared to 2% lidocaine.
Inferior alveolar nerve block, Local anaesthetic agents, Mandibular first molar extraction, Visual analogue scale
Local anaesthesia has been defined as a loss in sensation in a circumscribed area of the body caused by depression of excitation in nerve endings or inhibition of the conduction process in peripheral nerves (1). Lidocaine (lignocaine) was the first amide linked LA agent synthesised in 1943 and has extensively been evaluated and documented for its effectiveness and safety profile. It is the most widely used LA agent and is considered as the gold standard. It is available as plain or in combination of varying concentration of vasoconstrictors that offers many clinical advantages (2),(3).
Another amide linked LA agent, articaine was first synthesised in 1969 and is being used worldwide safely with well documented studies (2),(4),(5). The molecular structure of articaine has a linked ester group, which facilitates its metabolism by plasma estrases as well as liver microsomal enzymes. Though, classified as short acting LA, it offers prolonged anaesthetic duration only to be surpassed by ultra-long acting agent such as bupivacaine (5). It is also reported to have superior diffusability through hard tissues (6). Though, many studies have been carried out in the past to compare both the LA agents, there is scant number of published data available for the local population of Bihar (4),(5). Therefore, the present study was designed to assess the efficacy and patient response to these two LA agents in patients undergoing routine dental extraction procedures.
This randomised clinical study was conducted at Department of Dentistry, Sri Krishna Medical College and Hospital, Muzaffarpur, Bihar, India, from October 2020 to March 2021 in accordance with revised Helsinki Declaration of 1975 after obtaining approval from the Institutional Ethical Committee vide letter number 25/20 (IEC, SKMCH).
Sample size calculation: The formula used to calculate the sample size required for this study at 95% confidence interval and 80% power of study was: n=2(Zα/2+Zβ)2 * σ2/d2 where, Zα/2=1.96 for a confidence level (α) of 95%, Zβ=0.84 for power of 80%, σ=standard deviation and d=size of the effect clinically worthwhile to detect (7). Using the above formula, a sample size of 96 patients per group was calculated and it was increased to nearest 100 to include 200 patients in the study (Table/Fig 1).
Inclusion criteria: Systemically healthy patients aged 18-60 years without any co-morbidity who needed extraction of carious mandibular molars were included in the study.
Exclusion criteria: Individuals with grossly decayed teeth, teeth with periodontal problems/bone loss, presence of periapical pathology/sinus opening, impacted teeth and root stumps were excluded from the study.
A total of 200 such patients (107 females and 93 males) were selected from the outpatient pool and were randomly divided into two groups with 100 patients in each group:
Group-I: 100 patients underwent dental extraction under 2% lidocaine (Lignospan™, 2% lidocaine hydrochloride and epinephrine 1:1,00,000, Septodont, Canada)
Group-II: 100 patients underwent dental extraction under 4% Articaine (Septanest™, 4% articaine hydrochloride and epinephrine 1:1,00,000, Septodont, France)
Study Procedure
In this single blinded study, complete demographic profile and clinical details of all the patients were recorded. Local anaesthesia was achieved by Inferior Alveolar Nerve Block (IANB), Lingual Nerve Block and Long Buccal Nerve Block by a single operator. The mean duration of onset of subjective symptoms and objective signs were recorded and the mean amount of anaesthetic solution used was recorded. After the onset of objective signs, the tooth was extracted using least traumatic approach by a single operator. Postoperative instructions were explained to the patients and five days medication (amoxicillin 500 mg TDS and aceclofenac 100 mg BD) was prescribed.
Pain was recorded on VAS on a scale of 0 to 10 with 0 indicating no pain and 10 indicating worse pain after the completion of procedure (6). The patients were made to wait in the waiting area for postoperative follow-up and to access the duration of action of each LA agent.
Statistical Analysis
All the results were recorded in Microsoft Excel Sheet and were analysed by Statistical Package for the Social Sciences (SPSS) version 21 (IBM Corp., Chicago, Illinois, USA). Student t-test was used for evaluation of level of significance. A two-tailed p-value less than 0.05 (p<0.05) was considered statistically significant.
The comparative demographic characteristics (age and sex) for both the groups has been summarised in (Table/Fig 2). The mean age of the group-I patients was 34.79±10.43 years while that for group-II patients was 35.41±11.39 years. The onset of subjective symptoms in group-I and group-II patients was found to be 85.07±16.84 seconds and 83.76±13.79 seconds respectively while that for objective signs was found to be 180.84±14.57 seconds and 182.22±14.53 seconds, respectively. Intergroup comparison for these parameters yielded non-significant results p=0.54 and p=0.50, respectively as shown in (Table/Fig 3).
The average duration of anaesthesia for group-I and group-II patients came around 191.46±6.88 minutes and 194.70±9.16 minutes respectively which was significantly higher (p=0.0052) for group-II patients (Table/Fig 3). The average amount of LA agent used for both the groups was 2.21±0.41 mL for group-I and 2.14±0.38 mL for group-II patients. Statistically insignificant (p>0.05) difference was evidenced in the mean amount of anaesthetic solution used for both the groups (Table/Fig 3).
The mean postoperative VAS for group-I patients was 2.59±1.33 while that for group-II patients was 2.42±1.28. Non-significant (p>0.05) differences were obtained while comparing the mean VAS for both the study groups (Table/Fig 4).
Establishment of good LA effect is one of the important prerequisite before carrying out any invasive dental procedure. For a mandibular molar extraction, IANB technique is used with a suitable anaesthetic agent. However, the possibility of failure of IANB even with experienced operators ranges from 31-41% for mandibular first and second molars (8). In general, surgical anaesthesia requires the use of higher concentrations and doses. When a less intense block is demanded, the use of a lower concentration is intimated. The volume and concentration of the drug used for anaesthetic effect will affect the spread and extent of anaesthesia (6),(9),(10). The present study was undertaken to measure the efficacy of two different LA solutions and patient’s response in persons undergoing mandibular molar extraction procedures.
The present study reported a mean onset time of subjective symptoms in group-I (lidocaine 2%) and group-II (articaine 4%) patients to be 85.07±16.84 seconds and 83.76±13.79 seconds, respectively, while the objective signs were elicited by 180.84±14.57 seconds and 182.22±14.53 seconds, respectively. Another split-mouth study reported onset of subjective symptoms at 1.40 minutes and 1.35 minutes and objective signs after 2.15 minutes and 2.12 minutes for 2% lidocaine and 4% articaine groups, respectively (11).
The duration of anaesthetic effect is directly proportional to the degree of protein binding of the LA agent. It is also determined by the accuracy of nerve block technique and the concentration of vasoconstrictor present (11). The mean duration of anaesthesia achieved in the 2% lidocaine group and 4% articaine group was recorded to be 191.46±6.88 minutes and 194.70±9.16 minutes, respectively with significantly higher duration of action for articaine group. Boonsiriseth K et al., reported a mean duration of 258.82 minutes and 287.55 minutes for 4% lidocaine and 4% articaine (12), where the statistical differences between the study groups were insignificant. Other studies however claimed significantly longer duration of anaesthesia with 4% articaine as compared to 2% lidocaine (13),(14), which is in accordance to the findings of the present study. This could be attributed to the fact that articaine is concentrated by 100 times on the alveolus compared to systemic circulation; thereby offering prolonged duration of anaesthesia (5).
In the present study, the mean amount of LA used for lidocaine group and articaine group was 2.21±0.41 mL and 2.14±0.38 mL, respectively. Though, the amount of articaine used was less compared to lignocaine, it was statistically insignificant. Similarly, in the study by Kambalimath DH et al., the mean amount of LA used for IANB was 1.86 mL and 1.73 mL for lignocaine and articaine with statistically insignificant difference (11). In the present study, apart from IANB, lingual and long buccal nerve blocks were also administered.
Pain has been defined as an unpleasant emotional experience usually incited by a noxious stimulus and transmitted over a specialised neural network to the central nervous system where it is interpreted as such (15). The present study reported a mean postoperative VAS score of 2.59±1.33 and 2.42±1.28 in lidocaine group and articaine group respectively with statistically insignificant differences. While Jain NK et al., reported significantly lower postoperative VAS for articaine group compared to lidocaine group for impacted mandibular 3rd molars (13), Kambalimath DH et al., reported non significant differences in VAS for both the groups following IANB (11). Ghazalgoo A et al., reported significantly lesser postoperative pain in articaine group compared to lignocaine group after endodontic treatment of mandibular 1st molars at 4 hours, 6 hours, 12 hours and 18 hours (16). Tortamano IP et al., reported a greater degree of pain absence during pulpectomy of mandibular posterior teeth with articaine compared to lidocaine (17). Zhang A et al., in a meta-analysis reported insignificant difference in intraoperative pain between the two groups (14).
Various researchers who compared the efficacy of 2% lidocaine/lignocaine with 4% articaine for extraction of teeth using nerve block or infiltration technique eventually concluded that articaine might provide faster onset and increased duration of anaesthesia, however no significant differences in patient’s pain score was present between the group (Table/Fig 5) (12),(13),(18),(19),(20),(21),(22),(23),(24),(25),(26),(27),(28),(29),(30).
Though, lidocaine has a well established safety profile documented over years, articaine on the other has few concerns pertaining to development of Methemoglobinemia, neuropathy, paresthesia and allergic reactions (11). Malamed SF et al., reported incidence of 22% and 20% adverse events in articaine group and lignocaine group and concluded that articaine is safe and effective LA agent for use in clinical dentistry (31). In the present study, none of the patients reported any incidence of adverse events for both the groups.
Limitation(s)
The limitations of the present study include only the use of mandibular nerve block technique in adult patients. The study could have been more insightful if it were used in split-mouth design. Also, the effects of both anaesthetic agents were not evaluated for the maxillary nerve blocks.
Within the limits of the present study, no significant differences were evident for both the study groups with respect to the total amount of anaesthetic agent used, onset of subjective symptoms and objective signs in the existing patient pool. However, 4% articaine exhibited significantly higher duration of total anaesthesia when compared to 2% lidocaine. No adverse events were reported for both the groups. The authors concluded that both 2% lignocaine and 4% articaine anaesthetic solutions are equally effective in clinical dental practice.
DOI: 10.7860/JCDR/2022/48796.16128
Date of Submission: Jan 31, 2021
Date of Peer Review: Mar 24, 2021
Date of Acceptance: Jan 24, 2022
Date of Publishing: Mar 01, 2022
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA
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