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race Evans, DMD, MS,* John Nusstein, DDS, MS,† Melissa Drum, DDS, MS,†

l Reader, DDS, MS,† and Mike Beck, DDS, MA†

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bstracthe purpose of this prospective, randomized, double-lind crossover study was to evaluate the anestheticfficacy of 4% articaine with 1:100,000 epinephrinend 2% lidocaine with 1:100,000 epinephrine in max-

llary lateral incisors and first molars. Eighty subjectsandomly received, in a double-blind manner, maxillaryateral incisor and first molar infiltrations of one car-ridge of 4% articaine with 1:100,000 epinephrine or% lidocaine with 1:100,000 epinephrine at two sep-rate appointments spaced at least 1 week apart. Inaxillary lateral incisors, articaine exhibited a signifi-

antly higher anesthetic success rate of 88% whenompared with a 62% success rate with lidocaine. Inaxillary first molars, articaine had a similar success

ate to lidocaine (78% vs 73%), and there was noignificant difference between the two solutions. Inonclusion, a maxillary infiltration of 4% articaine with:100,000 epinephrine statistically improved anestheticuccess when compared with 2% lidocaine with:100,000 epinephrine in the lateral incisor but not inhe first molar. (J Endod 2008;34:389–393)

ey Wordsrticaine, infiltration, lidocaine, maxillary

From *Private Practice, Zanesville, Ohio; and †Division ofndodontics, The Ohio State University, Columbus, Ohio.

Address requests for reprints to Dr Melissa Drum, Divisionf Endodontics, College of Dentistry, The Ohio State University,05 West 12th Avenue, Columbus, OH 43210. E-mail address:[email protected]/$0 - see front matter

Copyright © 2008 by the American Association ofndodontists.oi:10.1016/j.joen.2008.01.004

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OE — Volume 34, Number 4, April 2008

axillary infiltration anesthesia is a common method to anesthetize maxillary teeth.Previous studies (1–13) have evaluated the success of maxillary infiltrations

sing the electric pulp tester. Using a volume of 1.8 mL or less and various anestheticormulations, pulpal anesthetic success (obtaining maximum output with an electriculp tester) ranged from 64% to 100%.

Articaine has been reported to provide improved local anesthetic activity (14).any studies have evaluated articaine and found it to be a safe and effective local

nesthetic agent (15–25). Repeated clinical trials have failed to show that articaine istatistically superior to lidocaine in inferior alveolar nerve block anesthesia (16 –17,0 –21, 25). Infiltration anesthesia in the maxilla has shown an equivalent effect forrticaine, prilocaine, and lidocaine (4 – 6, 17) except for one study by Costa et al. (11),hich showed a prolonged duration with articaine. However, in buccal infiltration of theandibular first molar, 4% articaine with 1:100,000 epinephrine resulted in a higher

uccess rate than using 2% lidocaine with 1:100,000 epinephrine (26, 27).The efficacy of 4% articaine with 1:100,000 epinephrine in providing pulpal an-

sthesia when administered to human maxillary teeth needs further investigation tonsure its appropriate clinical use. The purpose of this prospective, randomized, dou-le-blind, crossover study was to compare the degree of pulpal anesthesia obtained with% articaine with 1:100,000 epinephrine and 2% lidocaine with 1:100,000 epinephrine

n maxillary lateral incisors and first molars.

Materials and MethodsEighty adult subjects participated in this study. All subjects were in good health and

ere not taking any medication that would alter pain perception as determined by aritten health history and oral questioning. Exclusion criteria were as follows: younger

han 18 or older than 65 years of age, allergies to local anesthetics or sulfites, preg-ancy, a history of significant medical conditions, taking any medications that may affectnesthetic assessment, active sites of pathosis in area of injection, and inability to givenformed consent. The Ohio State University Human Subjects Review Committee ap-roved the study, and written informed consent was obtained from each subject.

Using a crossover design, 40 subjects received two sets of maxillary lateral incisornfiltrations and 40 subjects received two sets of maxillary first molar infiltrations at twoeparate appointments spaced at least 1 week apart. For each lateral incisor or firstolar, the two sets of injections consisted of using one cartridge of 2% lidocaine with

:100,000 epinephrine and one cartridge of 4% articaine with 1:100,000 epinephrine.With the crossover design, 80 infiltrations were administered for both the lateral

ncisor and first molar, and each subject served as his/her own control. Twenty maxil-ary right lateral incisors and 20 maxillary left lateral incisors were used. Twenty max-llary right molars and 20 maxillary left molars were used. The same side chosen for theirst infiltration was used for the second infiltration. The same tooth was used at bothisits for each anesthetic solution. The contralateral canine was used as the control tonsure that the pulp tester was operating properly and that the subject was respondingppropriately. A visual and clinical examination was conducted to ensure that all teethere free of caries, large restorations, crowns, and periodontal disease and that nonead a history of trauma or sensitivity.

Before the injections, at both appointments, the experimental tooth and the con-ralateral canine (control) were tested three times with the electric pulp tester (Analytic
echnology Corp, Redmond, WA) to obtain baseline information. The teeth were iso-
Articaine and Lidocaine for Maxillary Infiltrations 389

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ated with cotton rolls and dried with an air syringe. Toothpaste waspplied to the probe tip, which was placed in the middle third of theacial or buccal surface of the tooth being tested. The value at the initialensation was recorded. The current rate was set at 25 seconds toncrease from no output (0) to the maximum output (80). Trainedersonnel who were blinded to the anesthetic solutions administered allreinjection and postinjection tests.

Before the experiment, the two anesthetic solutions were ran-omly assigned six-digit numbers from a random number table. Theandom numbers were assigned to a subject to designate which anes-hetic solution was to be administered at each appointment.

Under sterile conditions, the lidocaine and articaine cartridgesere masked with opaque labels, and the cartridge caps and plungersere masked with a black felt-tip marker. The corresponding six-digitodes were written on each cartridge label. All anesthetic solutions werehecked to ensure that the anesthetic solution had not expired. Thenfiltration injections were administered using the standard maskedartridges and an aspirating syringe equipped with a 27-G 1½-in needle.

Before the injection, each subject was shown a visual analog scaleVAS) and was asked to rate the pain for each phase of the injectionncluding needle insertion, needle placement, and deposition of solu-ion. A Heft-Parker VAS (28) was used in this study (Fig. 1). Immediatelyfter the infiltration, each subject rated the pain for each injection phasen the VAS. The VAS was a 170-mm line with various descriptive terms.he subjects placed a mark on the scale where it best described theirain level. To interpret the data, the VAS was divided into the followingour categories. No pain corresponded to 0 mm on the scale. Mildain was defined as greater than 0 mm and less than or equal to 54m. Mild pain included the descriptors of faint, weak, and mild

ain. Moderate pain was defined as greater than 54 mm and lesshan 114 mm. Severe pain was defined as equal to or greater than14 mm. Severe pain included the descriptors of strong, intense,nd maximum possible.

Before each injection, topical anesthetic gel (20% benzocaine;atterson Dental Supply, Inc, St. Paul, MN) was passively placed with aotton tip applicator for 60 seconds at the injection site. A standardaxillary infiltration injection was administered with an aspirating sy-

inge and a 27-G 1½-in needle (Sherwood Medical Co, St. Louis, MO).he target site was centered over the root apex of the maxillary lateralncisor or between the mesiobuccal and distobuccal root apices of the

axillary first molar. The needle was gently placed into the alveolarucosa (needle insertion phase) with the bevel toward bone and ad-

anced until the needle was estimated to be at or just above the apex ofhe lateral incisor or the apices of the first molar (needle placementhase). The anesthetic formulation was deposited over a period of 1inute (solution deposition phase). All infiltrations were given by the

enior author (GE).The depth of anesthesia was monitored with the electric pulp

ester. At 1 minute after the infiltration injection, pulp test readings werebtained for the experimental tooth (first molar or lateral incisor) andhe contralateral maxillary canine. The testing continued in 3-minute

igure 1. The Heft-Parker Visual Analog Scale (VAS) used for the assessment of
ain. The millimeter demarcations were not shown on the patient’s VAS. †
90 Evans et al.

ycles for a total of 60 minutes. At every third cycle, the control tooth, theontralateral canine, was tested by an inactivated electric pulp tester toest the reliability of the subject (ie, if the subject responded positively ton inactivated pulp tester then they were not reliable and could not besed in the study).

All subjects were asked to complete postinjection surveys afterach infiltration administered (160 injection surveys). The subjectsated pain in the injection area using the same VAS as previously de-cribed immediately after the numbness wore off and again each morn-ng on arising for 3 days. Patients were also instructed to describe andecord any problems, other than pain, that they experienced.

No response from the subject at the maximum output (80 reading)f the pulp tester was used as the criterion for pulpal anesthesia. Anes-

hesia was considered successful when two consecutive 80 readingsith the pulp tester were obtained within 10 minutes after the infiltra-

ion. With a nondirectional alpha risk of 0.05 and a power of 80%, aample size of 40 subjects per tooth group was required to show aifference in anesthetic success of �25%.

The data were analyzed statistically. Group comparison betweenhe articaine and lidocaine formulations for anesthetic success wasnalyzed by using the exact McNemar test. Between-group comparisonsf needle insertion, needle placement, and solution deposition pain andostoperative pain were made by using analysis of variance with aukey-Kramer multiple-comparison test. Comparisons were consid-red significant at p � 0.05.

ResultsFor the lateral incisor, 25 men and 15 women ranging in age from

0 to 36 years, with an average age of 25 years, participated in this study.or the first molar, 21 men and 19 women ranging in age from 20 to 33ears with an average age of 24 years participated.

The onset of pulpal anesthesia is listed in Table 1. Table 2 showshe percentages of successful pulpal anesthesia. There was a statisticallyigher success rate for the articaine solution versus the lidocaine solu-

ion for the maxillary lateral incisor. For the maxillary first molar, thereas no significant difference in anesthetic success between solutions.he incidence of pulpal anesthesia (80 readings across time) for the

wo anesthetic solutions is presented in Figures 2 and 3.The pain of injection is presented in Table 3. There were no sig-

ificant differences between the two anesthetic solutions for any phasesf the injection. Postinjection pain scores are presented in Table 4.here was a significant difference between the two anesthetic solutionshen subjective numbness wore off. There were no significant differ-nces between solutions for days 1 through 3. The only reported postin-ection complications were bruising and slight swelling in the area of the

ABLE 1. The Onset of Pulpal Anesthesia (minutes � standard deviation)

Articaine Lidocaine

Lateral incisor* 2.5 (�1.22) 3.0 (�1.73)First molar† 3.3 (�2.35) 3.7 (�2.29)

Lidocaine, n � 25; articaine, n � 35.

Lidocaine, n � 29; articaine, n � 31.

ABLE 2. Percentages and Number of Subjects Who Experienced Anestheticuccess

Articaine Lidocaine

Lateral incisor* 88% (35/40) 62% (25/40)First molar† 78% (31/40) 72% (29/40)

There was a significant difference (p � 0.05) between the solutions.

There was no significant difference (p � 0.05) between the solutions.

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njection. Four percent (3/80) reported swelling (1 molar with lido-aine, 1 molar with articaine, and 1 lateral with lidocaine), and 1%1/80) reported bruising (1 lateral incisor with articaine). There wereo reports of paresthesias.

DiscussionWe based our use of the pulp test reading of 80 (signaling maxi-

um output) as a criterion for pulpal anesthesia on the studies ofreven and colleagues (29) and Certosimo and Archer (30). These

tudies (29, 30) showed that no patient response to an 80 readingnsured pulpal anesthesia in vital, asymptomatic teeth. Additionally,ertosimo and Archer (30) showed that electric pulp test readings of

ess than 80 resulted in pain during operative procedures in asymptom-tic teeth. Therefore, using the electric pulp tester before beginningental procedures on asymptomatic, vital teeth will provide the clinicianreliable indicator of pulpal anesthesia.

The success of the infiltration of the lidocaine solution was 62% inhe lateral incisor (Table 2). Various authors (1–9) have evaluated theuccess of maxillary infiltrations using the electric pulp tester. Gener-lly, the results of these studies showed successful anesthesia rangingrom 64% to 100%. It is very difficult to compare the results of therevious studies to the current study because the authors used different

igure 3. The incidence of maxillary first molar pulpal anesthesia as deter-ined by the lack of response to electrical pulp testing at the maximum setting

percentage of 80 readings) at each postinjection time interval for the articaine

igure 2. The incidence of maxillary lateral incisor pulpal anesthesia as deter-ined by the lack of response to electrical pulp testing at the maximum setting

percentage of 80 readings) at each postinjection time interval for the articainend lidocaine solutions.

nd lidocaine solutions. §


osages of anesthetic agents and vasoconstrictors and evaluated differ-nt teeth. Nusstein et al. (10), Gross et al. (12), and Mikesell et al. (13)sed a similar methodology to the current study and showed an 85%,7%, and 97% success rate, respectively, for the lateral incisor with an

nfiltration of 1.8 mL of 2% lidocaine with 1:100,000 epinephrine. Re-arding the first molar, the success rate was 72% with the lidocaineolution (Table 2). Gross et al. (12) and Mikesell et al. (13) used aimilar methodology to the current study and showed an 82% and 100%uccess rate, respectively, for the first molar with an infiltration of 1.8L of 2% lidocaine with 1:100,00 epinephrine. The success rate for

oth the lateral incisor and first molar in the current study were lowerhan in previous studies (10, 12, 13) and may relate to population orperator differences. In general, the infiltration injection of 1.8 mL of

ABLE 3. Mean Pain Ratings (�standard deviations) for Articaine andidocaine for Each Injection Phase

Injection Phase Articaine* Lidocaine* p Value†

Needle insertionLateral incisor 24 � 29 23 � 24 0.9934First molar 17 � 14 20 � 16 0.9555

Needle placementLateral incisor 26 � 22 25 � 23 0.9943First molar 22 � 21 19 � 16 0.8731

Solution depositionLateral incisor 59 � 33 51 � 33 0.5378First molar 44 � 29 36 � 26 0.4405

n � 80).

Mean values are in millimeters as measured on the VAS plus standard deviations.

There were no significant differences (p � 0.05) between the anesthetic solutions.

ABLE 4. Mean Pain Ratings for Articaine and Lidocaine for Each Postinjectionay

Postinjection Day Mean* p Value

Day 0†Lateral incisor

Articaine 29 � 27 0.0049‡Lidocaine 15 � 18

First molarArticaine 26 � 27 0.0035‡Lidocaine 13 � 15

Day 1Lateral incisor

Articaine 15 � 18 0.2888§Lidocaine 6 � 9

First molarArticaine 13 � 20 0.2506§Lidocaine 4 � 12







� 80 for lidocaine; n � 80 for articaine.

Mean values are in millimeters as measured on the VAS plus standard deviations.

Rating at time subjective numbness wore off.

There was a significant difference (p � 0.05) between the anesthetic solutions.

There was no significant difference (p � 0.05) between the solutions.


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% lidocaine with 1:100,000 epinephrine may not always be 100%uccessful because of the individual variations in response to the drugdministered, operator differences, variations of anatomy, and toothosition. Because we studied a young adult population, the results ofhis study may not apply to children or the elderly.

The success of the infiltration of the articaine solution was 88% inhe lateral incisor and 78% in the first molar. Haas et al. (4, 5) com-ared infiltrations of articaine and prilocaine formulations in maxillaryanines and second molars. They found no statistical differences be-ween the two anesthetic formulations. The success rates (80 readingsn the pulp tester) of the articaine solution were 65% for the caninenfiltration and 95% for the second molar infiltration. The successate for the canine (65%) was lower than the success rates of 88% forhe lateral incisor in the current study, and the success rate of 78% forhe first molar was lower than recorded by Haas et al. (4, 5). Differencesn the subject population, use of different teeth, use of a smaller numberf subjects, use of 1.5 mL of anesthetic solution, or the use of 4%rticaine solution with 1:200,000 epinephrine in Haas’s studies (4, 5)ay account for differences in success rates.

For the lateral incisor, anesthetic success (Table 1) was signifi-antly better with the articaine formulation. The exact mechanism of thencreased efficacy of articaine is not known. We can speculate on a few

echanisms. Borchard and Drouin (31) found that a lower concentra-ion of articaine (thiophene derivative) was sufficient to block an actionotential when compared with other amide anesthetics (benzene deriv-tives). Potocnik et al. (32) in a study of rat sensory nerve conductionound that both 2% and 4% articaine were superior to 2% lidocaine inlocking nerve conduction. However, with increased intensity of nervetimulation, the compound action potential recovered for 2% articaineut not for 4% articaine. In a clinical study (33) comparing 2% and 4%rticaine for infiltration anesthesia, the 4% articaine solution had aonger duration but not an increase in efficacy. It may be that factorsther than the concentration may be responsible for the clinical efficacyf articaine. For instance, the unique chemical structure of articainethe thiophene ring not possessed by other local anesthetic agents) mayacilitate better diffusion of the anesthetic solution to the teeth.

The statistically significant higher success rate of the articaineolution in the lateral incisor but not in the first molar may be related tohe anesthetic solution diffusion to encompass all the roots of the first

olar (ie, the palatal root is farther away from the buccal bone than theateral incisor root). Gross et al. (12) provided some support for thisheory when they compared 2% lidocaine with 1:100,000 epinephrineith 0.5% bupivacaine with 1:200,000 epinephrine in the maxillary

ateral incisor and first molar and found a significantly higher anestheticuccess for the lidocaine solution when compared with the bupivacaineolution in the lateral incisor but not the first molar. Therefore, evenhough articaine may have a propensity for a higher success rate be-ause of its higher potency or its unique chemical structure, consider-tions of maxillary anatomy may explain why there are differences in thencisor versus the first molar region.

In the lateral incisor, the onset time was 3.0 minutes for the lido-aine solution (Table 1). Gross et al. (12), Mikesell et al. (13), andusstein et al. (10), using 1.8 mL of 2% lidocaine with 1:100,000pinephrine, reported onset times for the lateral incisor of 2.5, 2.9, and.1, respectively. Except for Nusstein et al. (10), the results are similaror the current study. In the first molar, the onset time was 3.7 minutesor the lidocaine solution. Gross et al. (12) and Mikesell et al. (13)sing 1.8 mL of 2% lidocaine with 1:100,000 epinephrine reportednset times for the first molar of 4.3 and 4.7 minutes, respectively. Thealues only varied by 1 minute when compared with the current study.ther authors (1–9) have reported onset times of 2 to 5 minutes for
axillary infiltrations using lidocaine solutions. Therefore, in general, i
92 Evans et al.

nset times for maxillary infiltrations with a lidocaine solution wouldange from 2 to 5 minutes (1–10, 12, 13). Pulp testing the tooth with anlectric pulp tester or Endo-Ice (Hygenic Corp., Akron, OH) will give thelinician a reliable indicator of onset of pulpal anesthesia.

The onset values for the articaine solution ranged from 2.5 to 3.3inutes (Table 1) and varied less than a minute from the lidocaine

alues for the same tooth. In comparing articaine with lidocaine orrilocaine solutions in maxillary infiltration, some studies (6, 17) haveound no statistical difference in onset, whereas a study by Costa et al.11) found a faster onset with articaine. Costa et al. (11) found statis-ically faster onset with 4% articaine (1:100,000 and 1:200,000 epi-ephrine) when compared with 2% lidocaine with 1:100,000 epineph-ine. However, the onset times of 1.6, 1.4, and 2.8 minutes for the threeolutions had onset differences of around a minute and would not belinically significant. In general, we can state that one cartridge of 4%rticaine with 1:100,000 epinephrine will provide an onset around 3 tominutes for maxillary infiltrations and would be similar to a lidocaine

olution in clinical use.Figure 2 shows the decline of pulpal anesthesia over 60 minutes for

he lateral incisor. For the lidocaine solution, approximately 50% of theubjects had pulpal anesthesia at 30 minutes and 30% at 45 minutes.usstein et al. (10), Gross et al. (12), and Mikesell et al. (13) showedimilar declining rates of pulpal anesthesia when using 1.8 mL of 2%idocaine with 1:100,000 epinephrine. The articaine solution showed aimilar pattern for the decline of pulpal anesthesia except all the per-entages of 80 readings were higher (Fig. 2). For the first molar, alower decline of pulpal anesthesia was shown for both the articaine andidocaine solutions than in the lateral incisor, with little differencesetween the two solutions (Fig. 3). Gross et al. (12) and Mikesell et al.13) showed a similar pattern of declining pulpal anesthesia of the firstolar when using 1.8 mL of 2% lidocaine with 1:100,000 epinephrine.

In comparing articaine with lidocaine or prilocaine solutions inaxillary infiltration, some studies (6, 17) have found no statistical

ifference in duration, whereas a study by Costa et al. (11) found anrticaine solution prolongs duration. Costa et al. (11) found in maxil-ary posterior teeth that 4% articaine with 1:200,000 epinephrine had atatistically significant longer duration time of 57 minutes and an evenonger duration with 4% articaine with 1:100,000 epinephrine (dura-ion time of 66 minutes) when compared with a duration time of 39

inutes with 2% lidocaine with 1:100,000 epinephrine. However, only0 subjects were used in the study, which may have affected the out-ome. Therefore, except for the results of Costa et al. (11), if an hour ofulpal anesthesia is required for the lateral incisor or first molar, nei-

her solution will provide the necessary duration when a cartridge ofnesthetic solution is administered. Recently, Mikesell et al. (13)howed that increasing the amount of lidocaine from 1.8 mL to 3.6 mLrovided a statistically longer duration of pulpal anesthesia for the lat-ral incisor and first molar. Further research needs to be performedith increasing amounts of articaine to prolong the duration of pulpalnesthesia.

Injection pain was not significantly different between the articainend lidocaine formulations (Table 3). Likewise, Kanaa et al. (26) andobertson et al. (27) found no significant difference in injection dis-omfort between articaine and lidocaine formulations for mandibularuccal infiltration of the first molar. The pain ratings of the needle

nsertion and placement were generally in the faint to weak pain area ofhe VAS (Fig. 1, Table 3). However, solution deposition values wereigher than the first two stages of the injection for both solutions. Theain ratings with both solutions were higher in the lateral incisor than

he first molar and for the articaine solution was in the moderate range.ross et al. (12) also found higher pain ratings for solution deposition

n the maxillary lateral incisor compared with the maxillary first molar.

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enerally, Kanaa et al. (26) and Robertson et al. (27) found the pain ofandibular infiltration of the first molar to be in the mild range when

sing articaine or lidocaine formulations. Therefore, deposition of so-ution in the maxillary lateral incisor could be more painful than solu-ion deposition in the buccal mandibular infiltration of the first molar.

Postinjection pain ratings, at the time anesthesia wore off, weretatistically different between the articaine and lidocaine formulationsor both the lateral incisor and first molar (Table 4). Although therticaine formulation had statistically higher values than the lidocaineormulation, the pain ratings were in the faint to weak range on the VASFig. 1) and would be clinically insignificant. The incidence of painecreased over the next 3 days, which showed that neither solutionaused significant tissue damage. Robertson et al. (27) also found post-perative pain ratings for buccal infiltration of the mandibular firstolar to be in the mild range with decreasing pain ratings over 3 days.

n the current study, the only reported postinjection complications wereruising and slight swelling in the area of the injection. Four percent3/80) reported swelling and 1% (1/80) reported bruising. All compli-ations resolved within 3 days except for one subject who reportedlight bruising with articaine on day 3. Although there have been reportsf paresthesia associated with articaine use (34, 35), no subjects re-orted any paresthesia in the current study. It would be unlikely thataresthesia would be reported in the current study because Haas andennon (34) indicated that paresthesias are rare and unlikely withnfiltration anesthesia.

Regarding the labeling of the articaine cartridge as 1.7 mL, Rob-rtson et al. (27) measured the amount of anesthetic solution deliveredith an aspirating syringe by expressing the contents of 50 articaineartridges (Septocaine; Septodont Inc, New Castle, DE) and 50 lido-aine cartridges (Xylocaine; Astra Zeneca LP, York, PA) into a graduatedyringe with 0.01-mL increment divisions. They found that even thoughhe articaine cartridge was marked externally as containing 1.7 mL, onverage, the anesthetic solution expressed was 1.76 mL. For the lido-aine cartridge, the amount was marked as 1.8 mL, but on average thenesthetic solution expressed was 1.76 mL. In general, Robertson et al.27) found that both anesthetic cartridges had a small amount of solu-ion remaining in the cartridge after delivering the anesthetic solutionith an aspirating syringe. Therefore, based on Robertson’s results,oth anesthetic formulations expressed the same amount of anestheticolution.

In conclusion, a maxillary infiltration of 4% articaine with:100,000 epinephrine statistically improved anesthetic success whenompared with 2% lidocaine with 1:100,000 epinephrine in the lateralncisor but not in the first molar. Neither solution provided pulpalnesthesia for 1 hour.

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gesics. Int J Oral Surg 1977;6:51–9.3. Nordenram A, Danielsson K. Local anesthesia in elderly patients. An experimental

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(articaine) and Citanest (prilocaine) in infiltration anesthesia. J Can Dent Assoc1991;57:217–23.

5. Haas DA, Harper DG, Saso MA, Young ER. Comparison of articaine and prilocaineanesthesia by infiltration in maxillary and mandibular arches. Anesth Prog1990;37:230 –7.

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0. Nusstein J, Wood M, Reader A, Beck M, Weaver J. Comparison of the degree of pulpalanesthesia achieved with the intraosseous injection and infiltration injection using2% lidocaine with 1:100,000 epinephrine. Gen Dent 2005;53:50 –3.

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3. Mikesell A, Drum M, Reader A, Beck M. Anesthetic efficacy of 1.8 mL and 3.6 mL of2% lidocaine with 1:100,000 epinephrine for maxillary infiltrations. J Endod 2008;34:121–5.

4. Schertzer ER, Malamed SF. Articaine vs. lidocaine. J Am Dent Assoc 2000;131:1248,1250.

5. Malamed SF, Gagnon S, LeBlanc D. Articaine hydrochloride: a study of the safety of anew amide local anesthetic. J Am Dent Assoc 2001;132:177– 85.

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a prospective, randomized, double-blind comparison of articaine and lidocaine for maxillary...

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