the pulpal anesthetic efficacy of articaine versus lidocaine in ......approval of articaine for...

17JADA Middle East vol 2 No 4 Jul-Aug 2011

Recognizing the importance of providing profound anes-thesia for patients under-going invasive dental pro-

cedures, clinicians continually seekto identify an anesthetic solutionthat provides the highest successrate at an affordable cost. Dentistsin the United States have a varietyof anesthetic solutions at their dis-posal (Table 1). Although these solu-tions are considered to be generallyeffective in providing patients witha pain-free oral environment fordental treatment, local anestheticfailure remains a common problemin certain instances. Clinicians con-stantly have sought an anestheticsolution with a better success ratethan that of available anesthetics,which has been demonstrated to bewell below 100 percent, particularlyin procedures affecting the posteriormandible.1-4

Although for some time anestheticsolutions containing lidocaine havebeen used more widely in the UnitedStates than have solutions con-taining other anesthetics, the U.S.Food and Drug Administration’sapproval of articaine for local anes-

Dr. Brandt was a graduate student, Department of Cariology, Restorative Sciences and Endodontics, School of Dentistry, University of Michigan, Ann Arbor,when this article was written. He now is a private practitioner in Jackson, Mich.Ms. Anderson is an emerging technologies librarian, Taubman Health Sciences Libraries, University Library, University of Michigan, Ann Arbor.Dr. McDonald is a clinical professor of dentistry, Department of Cariology, Restorative Sciences and Endodontics, School of Dentistry, University of Michigan,Ann Arbor.Dr. Sohn is an associate professor of dentistry, Department of Cariology, Restorative Sciences and Endodontics, School of Dentistry, University of Michigan,Ann Arbor.Dr. Peters is a professor of dentistry, Department of Cariology, Restorative Sciences and Endodontics, School of Dentistry, University of Michigan, Room 2345,1011 N. University, Ann Arbor, Mich. 48109, e-mail “[email protected]”. Address reprint requests to Dr. Peters.

The pulpal anesthetic efficacy of articaineversus lidocaine in dentistryA meta-analysis

Ryan G. Brandt, DDS, MS; Patricia F. Anderson, MLIS; Neville J. McDonald, BDS, MS; Woosung Sohn, DDS, PhD, DrPH; Mathilde C. Peters, DMD, PhD

AB ST RACTBackground. The authors evaluated pub-lished evidence from controlled clinical trialsregarding the efficacy of two local anesthetic solu-tions in providing successful pulpal anesthesia. Methods. The authors searched MEDLINE andEmbase databases to identify peer-reviewed random-ized controlled trials in which researchers directly compared arti-caine and lidocaine local anesthetic solutions in adult partici-pants. They extracted study characteristics and outcomes data asa basis for meta-analysis. They completed subgroup analyses forboth infiltration and mandibular inferior alveolar block anes-thetic techniques.Results. Articaine solutions had a probability of achieving anes-thetic success superior to that of lidocaine, with an odds ratio of2.44 (95 percent confidence interval [CI], 1.59-3.76; P < .0001). Thegreater odds ratio for articaine increased to 3.81 (95 percent CI,2.71-5.36; P < .00001) when the authors analyzed only infiltrationdata. There was weaker, but still significant, evidence of articaine’sbeing superior to lidocaine for mandibular block anesthesia, withan odds ratio of 1.57 (95 percent CI, 1.12-2.21; P = .009), and no dif-ference when the authors considered only symptomatic teeth. Clinical Implications. Research evidence supports using arti-caine versus lidocaine for achieving pulpal anesthesia when theinfiltration mode of administration is used. It is premature to rec-ommend articaine for mandibular block anesthesia in casesinvolving irreversible pulpitis.Key Words. Systematic review; anesthesia; articaine; lidocaine.JADA 2011;142(5):493-504.

JADA 142(5) http://jada.ada.org May 2011 493

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To Add On page 12 add: © 2011 American Dental Association. Republished by Medical Online Publication SAL with permission of American Dental Association. All rights reserved. JADA 2011, Volume 142, No 5, Page 478-479 On page 17 add: © 2011 American Dental Association. Republished by Medical Online Publication SAL with permission of American Dental Association. All rights reserved. JADA 2011, Volume 142, No 5, Page 493-504 On page 31 add: © 2011American Dental Association. Republished by Medical Online Publication SAL with permission of American Dental Association. All rights reserved. JADA 2011, Volume 142, No 5, Page 531-539 On page 40 add: © 2011 American Dental Association. Republished by Medical Online Publication SAL with permission of American Dental Association. All rights reserved. JADA 2011, Volume 142, No 5, Page 506-513 On page 49 add: © 2011 American Dental Association. Republished by Medical Online Publication SAL with permission of American Dental Association. All rights reserved. JADA 2011, Volume 142, No 4, Page 411-414 On page 54 add: © 2011 American Dental Association. Republished by Medical Online Publication SAL with permission of American Dental Association. All rights reserved. JADA 2011, Volume 142, No 4, Page 406-409 On page 59 add: © 2011 American Dental Association. Republished by Medical Online Publication SAL with permission of American Dental Association. All rights reserved. JADA 2011, Volume 142, No 4, Page 441-444 On page 63 add: © 2011 American Dental Association. Republished by Medical Online Publication SAL with permission of American Dental Association. All rights reserved. JADA 2011, Volume 142, No 5, Page 553-555 On page 66 add: © 2011 American Dental Association. Republished by Medical Online Publication SAL with permission of American Dental Association. All rights reserved. JADA 2011, Volume 142, No 5, Page 574 10 JADA Middle East vol 2 No 4 July-August 2011

18 JADA Middle East vol 2 No 4 Jul-Aug 2011494 JADA 142(5) http://jada.ada.org May 2011

thetic use has given clinicians another choice.Lidocaine has been available in the UnitedStates for more than 60 years, whereas articainewas approved for use in the United States in

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ABBREVIATION KEY. EPT: Electric pulp testing. HCl: Hydrochloride. IAN: Inferior alveolar nerve.RCT: Randomized controlled trial. VAS: Visualanalog scale.

TABLE 1

Available local anesthetic solutions.DURATION OF ACTION

SOLUTION TRADE NAME INFILTRATION(PULPAL)

NERVEBLOCK

(PULPAL)

DURATIONOF EFFECT INSOFT TISSUE

MILLIGRAMSPER

CARTRIDGE

Short Duration,Plain

Lidocainehydrochloride

(HCl) 2percent

Xylocaine (DentsplyPharmaceutical, York, Pa.)

5 minutes Notindicated

2 hours 36

MepivacaineHCl 3 percent

Carbocaine (Eastman Kodak,Rochester, N.Y.), Isocaine(Septodont, New Castle,

Del.), Mepivacaine (Hospira,Lake Forest, Ill.; HenrySchein, Melville, N.Y.),Polocaine (Dentsply

Pharmaceutical), Scandanest(Novocol Pharmaceutical,

Cambridge, Ontario,Canada)

20 to 30minutes

45 to 65minutes

2 to 3 hours 54

Prilocaine HCl4 percent

Citanest Plain (DentsplyPharmaceutical)

10 to 15minutes

45 to 65minutes

3 to 4 hours 72

NormalDuration, WithVasoconstrictor

Articaine HCl4 percent

withepinephrine

1:100,000

Articadent (DentsplyPharmaceutical), Septocaine

(Septodont), Zorcaine(Eastman Kodak)

60 to 75minutes

Up to 120minutes

3 to 5 hours 68


withepinephrine

1:200,000


(Septodont)

60 to 75minutes

Up to 120minutes

3 to 5 hours 68

Lidocaine HCl2 percent

withepinephrine

1:50,000

Lidocaine (CarestreamHealth, Rochester, N.Y.;Hospira; Henry Schein),

Lignospan Forte (NovocolPharmaceutical),

Octocaine 50 (Septodont),Xylocaine (Dentsply)

55 to 65minutes

80 to 90minutes

3 to 5 hours 36


withepinephrine

1:100,000

Lidocaine (CarestreamHealth; Hospira; Henry

Schein), Lignospan Standard(Novocol Pharmaceutical),


55 to 65minutes

80 to 90minutes

3 to 5 hours 36


withlevonordefrin

1:20,000

Carbocaine (EastmanKodak), Isocaine

(Septodont), Mepivacaine(Henry Schein), Polocaine

(Dentsply), Scandanest(Novocol Pharmaceutical)

40 to 60minutes

60 to 90minutes

3 to 5 hours 36


withepinephrine

1:200,000

Citanest Forte (Dentsply) 35 to 45minutes

50 to 70minutes

3 to 6 hours 72

Long Duration BupivacaineHCl 0.5

percent withepinephrine

1:200,000

Bupivacaine (Hospira),Marcaine (Carestream

Health), Vivacaine (NovocolPharmaceutical)

Up to 7 hours Up to 7hours

Up to 12 hours 9


19JADA Middle East vol 2 No 4 Jul-Aug 2011494 JADA 142(5) http://jada.ada.org May 2011

thetic use has given clinicians another choice.Lidocaine has been available in the UnitedStates for more than 60 years, whereas articainewas approved for use in the United States in

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ABBREVIATION KEY. EPT: Electric pulp testing. HCl: Hydrochloride. IAN: Inferior alveolar nerve.RCT: Randomized controlled trial. VAS: Visualanalog scale.

TABLE 1

Available local anesthetic solutions.DURATION OF ACTION

SOLUTION TRADE NAME INFILTRATION(PULPAL)

NERVEBLOCK

(PULPAL)

DURATIONOF EFFECT INSOFT TISSUE

MILLIGRAMSPER

CARTRIDGE

Short Duration,Plain

Lidocainehydrochloride

(HCl) 2percent

Xylocaine (DentsplyPharmaceutical, York, Pa.)

5 minutes Notindicated

2 hours 36


Carbocaine (Eastman Kodak,Rochester, N.Y.), Isocaine(Septodont, New Castle,

Del.), Mepivacaine (Hospira,Lake Forest, Ill.; HenrySchein, Melville, N.Y.),Polocaine (Dentsply

Pharmaceutical), Scandanest(Novocol Pharmaceutical,

Cambridge, Ontario,Canada)

20 to 30minutes

45 to 65minutes

2 to 3 hours 54


Citanest Plain (DentsplyPharmaceutical)

10 to 15minutes

45 to 65minutes

3 to 4 hours 72

NormalDuration, WithVasoconstrictor


withepinephrine

1:100,000


(Septodont), Zorcaine(Eastman Kodak)

60 to 75minutes

Up to 120minutes

3 to 5 hours 68


withepinephrine

1:200,000


(Septodont)

60 to 75minutes

Up to 120minutes

3 to 5 hours 68


withepinephrine

1:50,000

Lidocaine (CarestreamHealth, Rochester, N.Y.;Hospira; Henry Schein),

Lignospan Forte (NovocolPharmaceutical),


55 to 65minutes

80 to 90minutes

3 to 5 hours 36


withepinephrine

1:100,000

Lidocaine (CarestreamHealth; Hospira; Henry

Schein), Lignospan Standard(Novocol Pharmaceutical),


55 to 65minutes

80 to 90minutes

3 to 5 hours 36


withlevonordefrin

1:20,000

Carbocaine (EastmanKodak), Isocaine

(Septodont), Mepivacaine(Henry Schein), Polocaine

(Dentsply), Scandanest(Novocol Pharmaceutical)

40 to 60minutes

60 to 90minutes

3 to 5 hours 36


withepinephrine

1:200,000

Citanest Forte (Dentsply) 35 to 45minutes

50 to 70minutes

3 to 6 hours 72

Long Duration BupivacaineHCl 0.5

percent withepinephrine

1:200,000

Bupivacaine (Hospira),Marcaine (Carestream

Health), Vivacaine (NovocolPharmaceutical)

Up to 7 hours Up to 7hours

Up to 12 hours 9



April 2000. Articaine is available as a 4 percentsolution, and lidocaine is available as a 2 percentsolution. Both can be combined with various con-centrations of vasoconstrictors. Articaine con-tains a thiophene ring, instead of the benzenering found in lidocaine and other amide localanesthetics; this allows the molecule to diffusemore readily through the nerve membrane owingto increased lipid solubility.5,6 A second moleculardifference is the ester linkage incorporated intothe articaine molecule, which results in hydrol-ysis of articaine by plasma esterases. Ninety to95 percent of articaine is metabolized in theblood by plasma esterases, with the remainderbeing broken down in the liver,5 whereas approxi-mately 90 percent of lidocaine is metabolized bythe liver. The articaine solution’s plasma half-lifehas been reported to be as short as 20 minutes,5versus lidocaine’s half-life of approximately 108minutes in healthy patients.7 Adverse reactionsto articaine are characteristic of those associatedwith other amide-type anesthetics.8 For a healthyadult weighing 70 kilograms, the maximum dosefor a local anesthetic solution equates to sevencarpules (1.7 milliliters) of 4 percent articaine or13 carpules (1.8 mL each) of 2 percent lidocaine.5

Since its introduction at the turn of the cen-tury, this relatively new solution rapidly hasbecome popular with clinicians because of thehope that it may provide increased efficacy. Infact, articaine accounted for approximately 25percent of total sales of dental anesthetics in theUnited States in 2007, second only to lidocaineat 54 percent.9 Although investigators havedesigned various clinical trials to compare arti-caine with a variety of other available anes-thetic solutions, published data do not support aclear superiority of articaine in terms of anes-thetic efficacy. Thus, clinicians still may wonderwhich anesthetic solution will afford them thebest chance of success for a given procedure,particularly in cases of irreversible pulpitis.

Evidence-based medicine is based on assess-ment of the quality of evidence relevant to therisks and benefits of treatments. The Centre forEvidence-Based Medicine in Oxford, England,defined “evidence-based medicine” as “the con-scientious, explicit, and judicious use of currentbest evidence in making decisions about thecare of individual patients.”10 The authors ofsystematic reviews can condense the results ofmany studies into valid and unbiased sum-maries of the best available evidence for a spe-cific clinical problem.11 This type of overviewmay help clinicians stay current while the liter-ature greatly expands. Systematic reviews canprovide an objective summary of the best avail-

able evidence so as to help dentists and theirpatients make informed choices.12 To date, onlyone meta-analysis has been published in whichinvestigators compared the anesthetic successrates of articaine and lidocaine.13 The author ofthis recent review, however, included only dataoriginating from studies that were published inEnglish and involved the use of a specific type ofpain rating scale. In our review, we aim to offera more broad comparison regarding the efficacyof articaine and lidocaine solutions when usedto achieve profound pulpal anesthesia in adults.

METHODSLiterature search. We prepared a protocol andfollowed it throughout the review. In December2009, we identified eligible studies through anelectronic search of MEDLINE and Embasedatabases. We also identified National Libraryof Medicine Medical Subject Heading terms thatwould help us locate the potential studies forreview. The detailed search strategies for eachdatabase were as follows:dMEDLINE: “(((exp Anesthesia, Dental/ (9655)”OR “(exp Anesthesia/ AND (exp Dentistry/ ORexp Stomatognathic system/ OR exp Stomatog-nathic diseases/)))” AND “(exp Carticaine/” OR “septocaine.mp.” OR “ultracaine.mp.” OR“articaine.mp.” OR “carticaine.mp.” OR “Thiophenes/))”dEmbase: “(((‘articaine’/exp OR articaine)” OR “(‘carticaine’/” OR “carticaine)” OR > “(‘ultracaine’/exp” OR “ultracaine)” OR “septocaine” OR “ ‘thiophene > derivative’/de)”AND “(‘dentistry’/exp” OR “(‘mouth’/exp ORmouth)))”

Selection criteria. We selected an articlefor inclusion in the review if it met the followingcriteria: dthe investigators evaluated the pulpal anes-thetic effect of local anesthetic solutions of arti-caine comparatively with lidocaine, using vol-umes of at least 1.0 mL per administration andin combination with a vasoconstrictor;dthe review concerned clinical trials thatinvolved adult human participants;dthe review was published in a peer-reviewedjournal in the period from January 1970through December 2009;dit provided original data generated by meansof a comparative design.

We excluded an article if it did not satisfy theabove criteria, if it did not describe or define themethods for evaluating anesthetic success or ifit did not describe in detail the techniques foradministering the anesthetic solution.

Initially, we reviewed only the titles of the

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496 JADA 142(5) http://jada.ada.org May 2011

articles generated by the electronic search, elim-inating a possible source of bias by masking our-selves as to knowledge of the author or thejournal. We first excluded all obviously irrele-vant records (judging only from titles). Next, wereviewed the abstracts of the potential studiesidentified from the title search for appropriate-ness, and we attempted to include as manystudies as possible even if we found the method-ology to be unclear after we reviewed theabstract. At this point, we obtained full-textcopies of all relevant and potentially relevantstudies that appeared to meet the inclusion cri-teria, or for which there were insufficient datain the title and abstract to facilitate a clear deci-sion. We fully assessed these articles.

To locate relevant articles that were not iden-tified by means of the electronic search, we con-ducted a hand search and a table-of-contentssearch. In our hand search, we reviewed the ref-erence lists of all articles that met the inclusioncriteria in an attempt to identify any additionalstudies. In our table-of-contents search, after wereviewed the journal of origin for each study wehad not excluded after abstract review, we tar-geted the journals that accounted for 80 percentof the included studies. We then reviewed thetable of contents for every issue of these jour-nals for the most recent two years of their publi-cation. Additional efforts to supplement thesearch results included searching of books andconference proceedings and the solicitation ofrecommendations from experts in the field.

Data extraction. Using full-text articles, weextracted for analysis detailed information thatincluded, but was not limited to, study type(such as randomized clinical trial, controlledclinical trial, case-control study), populationcharacteristics (for example, participants’ ages),local anesthetic solution and technique investi-gated, means of analyzing anesthetic success(such as electric pulp testing [EPT] or visualanalog scale [VAS] of pain measurement), preop-erative status of specific teeth tested (vital, irre-versibly inflamed or unspecified), missing dataand adverse outcomes. With respect to localanesthetic solutions and techniques investi-gated, we extracted the following details: typeand dose in milligrams of anesthetic used, con-centration of vasoconstrictor, location of admin-istration (arch, specific tooth and aspect[buccal/lingual]) and technique used (infiltrationor nerve block). The outcomes of interest wereanesthetic success or failure, as defined by eachcomparative trial.

Quality assessment. We recorded on thedata abstraction form the methodological

quality of included trials and the indicators ofquality we used. These included proper random-ized allocation of participants to their respectivestudy groups, as well as masking of participantsand evaluators.

We considered a clinical trial “randomized” ifit involved the generation of random sequencesby means of random numbers or tables, a tossedcoin or any other means. If the authors merelyused the term “randomized” or “randomly allo-cated” but did not provide detailed informationregarding the exact method of randomization,we deemed the trial to be “unclear” as regardsto the randomization and sought clarificationfrom the original authors. We considered alloca-tion “concealed” if the article described meas-ures of allocation concealment such as the use ofopaque sealed and sequentially numberedenvelopes, or if anesthetic cartridges were indi-vidually indistinguishable and numberedsequentially. We deemed the examiners of eachtrial to be properly masked if the outcomeassessor could not determine the group to whicha participant had been assigned randomly. Werecorded reporting of adverse events as beingpresent if the authors provided information onsuch events or noted it as “not mentioned” if theauthors did not include a description of anyadverse effects in the results. We considered the“intent to treat” adequate in studies for whichtreatment effects had been observed and evalu-ated on the same day of intervention. For thetrials in which investigators had used acrossover design, we noted whether no lossesoccurred and whether outcome data were avail-able for all randomly assigned participants.Thus, in our “intent to treat” analysis, weincluded all participants in these trials. Weassessed analysis appropriateness and reviewedfunding sources for included trials to evaluateany potential funding bias.

Data analysis. We conducted all statisticalanalysis of the extracted data by using software(Review Manager [RevMan] Version 5.0.25, TheNordic Cochrane Centre, The Cochrane Collabo-ration, Copenhagen, Denmark). We included inthe final analyses only data regarding 4 percentarticaine and 2 percent lidocaine, both with1:100,000 vasoconstrictor. We calculated the Qstatistic value according to the method ofCochran Q test to test for heterogeneity amongthe studies. We estimated treatment differenceand expressed it graphically in a forest plot.

RESULTSSearch results. Our original electronicsearches of MEDLINE and Embase databases

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articles generated by the electronic search, elim-inating a possible source of bias by masking our-selves as to knowledge of the author or thejournal. We first excluded all obviously irrele-vant records (judging only from titles). Next, wereviewed the abstracts of the potential studiesidentified from the title search for appropriate-ness, and we attempted to include as manystudies as possible even if we found the method-ology to be unclear after we reviewed theabstract. At this point, we obtained full-textcopies of all relevant and potentially relevantstudies that appeared to meet the inclusion cri-teria, or for which there were insufficient datain the title and abstract to facilitate a clear deci-sion. We fully assessed these articles.

To locate relevant articles that were not iden-tified by means of the electronic search, we con-ducted a hand search and a table-of-contentssearch. In our hand search, we reviewed the ref-erence lists of all articles that met the inclusioncriteria in an attempt to identify any additionalstudies. In our table-of-contents search, after wereviewed the journal of origin for each study wehad not excluded after abstract review, we tar-geted the journals that accounted for 80 percentof the included studies. We then reviewed thetable of contents for every issue of these jour-nals for the most recent two years of their publi-cation. Additional efforts to supplement thesearch results included searching of books andconference proceedings and the solicitation ofrecommendations from experts in the field.

Data extraction. Using full-text articles, weextracted for analysis detailed information thatincluded, but was not limited to, study type(such as randomized clinical trial, controlledclinical trial, case-control study), populationcharacteristics (for example, participants’ ages),local anesthetic solution and technique investi-gated, means of analyzing anesthetic success(such as electric pulp testing [EPT] or visualanalog scale [VAS] of pain measurement), preop-erative status of specific teeth tested (vital, irre-versibly inflamed or unspecified), missing dataand adverse outcomes. With respect to localanesthetic solutions and techniques investi-gated, we extracted the following details: typeand dose in milligrams of anesthetic used, con-centration of vasoconstrictor, location of admin-istration (arch, specific tooth and aspect[buccal/lingual]) and technique used (infiltrationor nerve block). The outcomes of interest wereanesthetic success or failure, as defined by eachcomparative trial.

Quality assessment. We recorded on thedata abstraction form the methodological

quality of included trials and the indicators ofquality we used. These included proper random-ized allocation of participants to their respectivestudy groups, as well as masking of participantsand evaluators.

We considered a clinical trial “randomized” ifit involved the generation of random sequencesby means of random numbers or tables, a tossedcoin or any other means. If the authors merelyused the term “randomized” or “randomly allo-cated” but did not provide detailed informationregarding the exact method of randomization,we deemed the trial to be “unclear” as regardsto the randomization and sought clarificationfrom the original authors. We considered alloca-tion “concealed” if the article described meas-ures of allocation concealment such as the use ofopaque sealed and sequentially numberedenvelopes, or if anesthetic cartridges were indi-vidually indistinguishable and numberedsequentially. We deemed the examiners of eachtrial to be properly masked if the outcomeassessor could not determine the group to whicha participant had been assigned randomly. Werecorded reporting of adverse events as beingpresent if the authors provided information onsuch events or noted it as “not mentioned” if theauthors did not include a description of anyadverse effects in the results. We considered the“intent to treat” adequate in studies for whichtreatment effects had been observed and evalu-ated on the same day of intervention. For thetrials in which investigators had used acrossover design, we noted whether no lossesoccurred and whether outcome data were avail-able for all randomly assigned participants.Thus, in our “intent to treat” analysis, weincluded all participants in these trials. Weassessed analysis appropriateness and reviewedfunding sources for included trials to evaluateany potential funding bias.

Data analysis. We conducted all statisticalanalysis of the extracted data by using software(Review Manager [RevMan] Version 5.0.25, TheNordic Cochrane Centre, The Cochrane Collabo-ration, Copenhagen, Denmark). We included inthe final analyses only data regarding 4 percentarticaine and 2 percent lidocaine, both with1:100,000 vasoconstrictor. We calculated the Qstatistic value according to the method ofCochran Q test to test for heterogeneity amongthe studies. We estimated treatment differenceand expressed it graphically in a forest plot.

RESULTSSearch results. Our original electronicsearches of MEDLINE and Embase databases

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identified 165 and 174potentially eligible arti-cles, respectively. Weremoved duplicate records,and after our initialscreening of first titles andthen abstracts, we identi-fied 35 potentially rel-evant clinical trials for fullreview. The various lan-guages of the publicationswere English, German,Croatian and Russian. Wesecured translations ofnon-English articles tofacilitate proper appraisal.We excluded two articlesabout studies involvingpartially or strictly pedi-atric populations.14,15 Onearticle described an inves-tigation of anesthesia inrelation to surgical inter-ventions that did notinclude any form of assess-ment of pulpal anesthesia;therefore, we excluded it.16

We excluded nine articleson the basis of their specific methodologies, suchas absence of randomization, lack of control par-ticipants or nonstandardized assessment ofpulpal anesthesia.17-25 In addition, we excludedarticles in which investigators only assessedinjection pain,26,27 cardiovascular effects or othersystemic effects.28-30 We excluded three trialsbecause the solutions being compared were con-founded by the preadministration of additionalanesthetic before the comparison.31-33 Two trialsdid not meet the minimum volume require-ments as stated in the inclusion criteria.34,35

The remaining 13 studies, all of which weincluded in our review, had been published inseven journals: British Dental Journal; TheJournal of the American Dental Association;Journal of Endodontics; Oral Surgery, Oral Med-icine, Oral Pathology, Oral Radiology, andEndodontology; Quintessence International;Scandanavian Journal of Dental Research; andSchweizerische Monatsschrift für Zahnmedizin.Neither the tables of contents search of thesejournals nor the other search efforts located anyadditional trials that had not already been iden-tified in the previous electronic search. At theend of the search process, then, we considered atotal of 13 articles eligible. Their data form thebasis of this review (Figure 1).

General study characteristics. We catego-

rized each of the 13 included studies1-3,36-45 asrandomized, controlled clinical trials in whichresearchers investigated pulpal anesthesia inadult participants (Table 2).

Study outcomes. Investigators in three ofthe included studies used the VAS to assessanesthetic efficacy, defining success as the par-ticipant’s rating pain as being no greater thanthat considered mild on the pain scale. Ninestudies used electric methods as a measure ofanesthetic success. Researchers in one studyused both techniques in their investigation.

OUTCOMES OF DATA ANALYSESFour of the 13 included studies provided datafrom independent samples. Lacking reporting ofdata in crossover studies necessary to calculatethe dependent odds ratio, we included bothdesigns in the overall analysis and forest plot(Figure 2, page 500).1-3,36-45

We found strong evidence of heterogeneityamong the estimated treatment effects of these13 studies. For all studies combined, the χ2 valueassociated with the test of heterogeneity was23.469 (P = .005). The Cochrane Collaboration46

recommended using a P value < .10, rather thanthe conventional cut-point of P = .05. Addition-ally, if the χ2 value is larger than the df, there isstrong evidence of heterogeneity. For these rea-

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Potentially relevant articles identified fromMEDLINE (n = 165) and Embase (n = 174)by means of electronic search strategy

(total N = 339)

Additional searching� Reference lists� Table of contents� Handbooks and conference proceedings� Solicitation of expert recommendations (n = 0)

Duplicate records removed(n = 128)

Articles excluded on basis oftitle and abstract

(n = 176)

Full-text articles critically appraised to justifyinclusion of potentially relevant studies

for review (n = 35)

Articles excluded that did notfulfill inclusion criteria

(n = 22)

Articles included in meta-analysis(n = 13)

Figure 1. Flow diagram of the process of manuscript identification and selection. Thirteenstudies were included in the meta-analysis.




sons, we used a random-effects model of statis-tical analysis, as fixed-effects models are used incases with no evidence of heterogeneity.

Figure 21-3,36-45 presents a forest plot of oddsratios of treatment differences between the two

anesthetic solutions. The combined effect of arti-caine was 2.44 times more likely to produceanesthetic success than was that of lidocaine,and the results were statistically significant (95 percent confidence interval [CI], 1.59-3.76).

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TABLE 2

Characteristics of included studies.

AUTHOR, YEAR METHODS NO. OF PARTICIPANTS

Srinivasan andColleagues,36 2009

Compared articaine with lidocaine when delivered via buccalinfiltration for maxillary posterior teeth diagnosed with

irreversible pulpitis

40

Tortamano andColleagues,37 2009

Compared articaine with lidocaine during pulpectomy inpatients with irreversible pulpitis in mandibular posterior

teeth, subsequent to IAN† block

40

Evans and Colleagues,38

2008Compared articaine with lidocaine in maxillary infiltrations

of first molars and lateral incisors80

Sherman and Colleagues,39

2008Compared articaine with lidocaine in patients with

irreversible pulpitis in either maxillary or mandibularposterior teeth

40

Robertson andColleagues,1 2007

Compared articaine with lidocaine when given via buccalinfiltration in mandibular posterior teeth, testing from first

premolar to second molar

60

Kanaa and Colleagues,40

2006Compared articaine with lidocaine in mandibular buccal

infiltrations of first molars31

Berlin and Colleagues,41

2005Compared articaine with lidocaine when administered via

computer-controlled intraligamentary injections inmandibular posterior teeth

51

Costa and Colleagues,42

2005Compared articaine with lidocaine for maxillary infiltration

of posterior teeth20

Mikesell and Colleagues,3

2005Compared articaine with lidocaine when administered via

IAN block, testing molars, premolars and incisors57

Claffey and Colleagues,2

2004Compared articaine with lidocaine when administered viaIAN block in patients experiencing irreversible pulpitis in

mandibular posterior teeth

72

Oliviera and Colleagues,43

2004Compared a standard 2.15-milliliter volume of articaine with

the same amount of lidocaine for buccal and lingualinfiltration of maxillary canine teeth

20

Ruprecht and Knoll-Köhler,44 1991

Compared infiltrations of articaine and lidocaine formaxillary central incisors

10

Winther and Nathalang,45

1972Compared the anesthetic efficacy of maxillary infiltrations of1.0-mL articaine for lateral incisors with the same volumes of

lidocaine and mepivacaine

39

* VAS: Visual analog scale.† IAN: Inferior alveolar nerve.‡ EPT: Electric pulp testing.




When we calculated weighted odds ratiosfrom data regarding infiltration anesthesia only(Figure 3),1,36,38-40,42-45 the value increased to 3.81in favor of articaine, indicating an obvious supe-riority of articaine to lidocaine.

Subgroup analysis according toRCT design (that is, RCT withindependent groups versus cross -over design) showed that theoverall finding for infiltrationanesthesia did not change owingto the study design (data notshown). Articaine was shown to beclearly superior.

To enable comparison of theoutcomes of the four mandibularblock studies, we included in theanalysis only data for premolarsand molars from these studies.When we isolated data regardingmandibular block analysis (Figure4A, page 501),2,3,37,39 the weightedodds ratio decreased to 1.57, andarticaine showed a statisticallysignificant better performance (95 percent CI, 1.12-2.21).

When we included only theresults of independent-samplestudies in the mandibular blockanalysis (Figure 4B, page 501),2,37,39

the odds ratio was 1.61 (95 percentCI, 0.74-3.53) and thus we deter-mined that the results no longerwere significantly different.

DISCUSSIONIn this systematic review, weexamined the literature regardingthe use of the local anestheticsolutions articaine and lidocaine,with the goal of evaluating differ-ences in providing anesthetic suc-cess. We targeted and identifiedwell-designed clinical trials inwhich investigators comparedthese two solutions directly. Thir-teen studies fulfilled the inclusioncriteria, and data from them thatrelated to 4 percent articaine and2 percent lidocaine both with1:100,000 vasoconstrictor servedas the basis for a meta-analysis ofthe extracted data. Meta-analysisis the statistical pooling of dataacross studies to generate pooledestimates of effects.47 Benefits ofmeta-analysis include the ability

to improve the power of small studies to answerquestions, and meta-analysis also can helpdetect biases and deficiencies in the design,analysis and interpretation of research.48 Thesemethods can highlight needed improvements in

S T O R YC O V E R

TABLE 2 (CONTINUED)

EVALUATIONSCALE USED

CONCLUSIONS

VAS* Articaine’s success rates were 100 percent for both the firstmolar and the first premolar, and lidocaine’s success rates

were 30 percent in the first premolar and 80 percent in thefirst molar; there was a highly statistically significant

difference

EPT,‡ VAS For patients reporting no pain or mild pain duringpulpectomy, the success rate of articaine

(65 percent) was higher than that of lidocaine (45 percent);however, differences were not statistically significant

EPT In maxillary lateral incisors, articaine exhibited a statisticallysignificantly higher success rate

(88 percent) when compared with lidocaine (62 percent);differences were not significant for first molars (78 percent

versus 73 percent)

VAS Overall anesthetic success was 87.5 percent in both arches;articaine was as effective as, but not statistically superior to,

lidocaine

EPT Lidocaine resulted in anesthetic success ranging from 45 to67 percent, whereas articaine resulted in a success rateranging from 75 to 92 percent; articaine did result in a

statistically significant higher success rate for mandibularbuccal infiltrations

EPT Success rates were 65 percent for articaine and 39 percentfor lidocaine, resulting in a statistically significantly greater

chance for anesthetic success with articaine

EPT Success rates were 74 percent for lidocaine and 86 percentfor articaine solutions; there was no statistical difference

between the two solutions

EPT There were no statistical differences between articaine andlidocaine in terms of anesthetic success

EPT Lidocaine resulted in anesthetic success ranging from 2 to48 percent, whereas articaine resulted in a range of 4 to 54

percent; there was no statistical difference between thearticaine and lidocaine solutions

VAS The success rates of lidocaine (23 percent) and articaine (24percent) revealed no statistical difference; neither solutionresulted in an acceptable rate of success for patients with

irreversible pulpitis

EPT All administrations resulted in pulpal anesthetic success;onset and duration of anesthesia were not statistically

different between the two groups

EPT No statistically significant differences were observed interms of anesthetic success, although articaine offered a

longer duration of anesthesia

EPT Articaine compared well with the other solutions, with the2 percent solution providing a frequency of anesthesia close

to 100 percent



the quality of the data to achieve optimal evidence-based clinical practice. In this way,meta-analysis can be a useful tool in planning anew clinical trial in clinical situations for whichthe evidence is sparse.

The results of this meta-analysis showed thatin a clinical situation, articaine was more likelyto produce anesthetic success than was lido-caine. This higher overall odds ratio of achievinganesthetic success with articaine indicates thatthere is an advantage to using this local anes-thetic. This investigation provided a high level ofevidence in support of articaine’s having greatersuccess than other anesthetic solutions when

used for pulpal anesthesia in dental applications.These results corroborate the findings of arecent meta-analysis that also favored articaineover lidocaine in terms of anesthetic success.13

This review certainly is not without limita-tions. The quality of the underlying studies, theconsistency of results across studies and theprecision of the pooled data affect the strengthof inference from systematic reviews consider-ably.32 Another limitation is the methodologicalheterogeneity of the trials included in thisreview, including variability of masking pro-cedures, evaluation and definition of anestheticsuccess, sample size, experience of operator and

S T O R YC O V E R

Berlin and Colleagues,41 2005

Claffey and Colleagues,2 2004

Costa and Colleagues,42 2005

Evans and Colleagues,38 2008

Kanaa and Colleagues,40 2006

Mikesell and Colleagues,3 2005

Oliviera and Colleagues,43 2004

Robertson and Colleagues,1 2007


Sherman and Colleagues,39 2008

Srinivasan and Colleagues,36 2009

Tortamano and Colleagues,37 2009

Winther and Nathalang,45 1972

TOTAL (95% CI)

TOTAL EVENTS

Heterogeneity: τ2 = 0.22; χ2 = 23.469 (P = .005); I2 = 62%.Z test for overall effect: Z = 4.05 (P < .0001).CI: Confidence interval.

125

9

20

66

20

118

20

201

20

19

20

13

30

681

153

37

20

80

31

334

20

237

20

20

20

20

30

1,022

107

8

20

54

12

92

20

136

20

16

11

9

28

533

153

35

20

80

31

334

20

237

20

20

20

20

40

1,030

16.3

9.1

Not applicable

13.2

9.7

19.3

Not applicable

17.8

Not applicable

3.1

2.0

7.5

2.0

100.0

1.92 (1.12-3.28)

1.08 (0.37-3.22)

Not estimable

2.27 (1.08-4.77)

2.88 (1.03-8.07)

1.44 (1.03-2.00)

Not estimable

4.15 (2.68-6.43)

Not estimable

4.75 (0.48-46.91)

33.87 (1.80-636.88)

2.27 (0.64-8.11)

26.75 (1.51-473.03)

2.44 (1.59-3.76)

STUDY OR SUBGROUP, YEAR EventsExperimental Control

ADMINISTRATION

Total Events Total WEIGHT (%)ODDS RATIO

(95% CI)ODDS RATIO

(95% CI)

0.01 0.1 1 10 100Favors experimental Favors control

Figure 2. Forest plot of odds ratios from the 13 trials included in the meta-analysis comparing lidocaine versus articaine in terms ofoverall treatment effects, suggesting that articaine has a 2.44 times greater likelihood of anesthetic success than does lidocaine.


ADMINISTRATION


(95% CI)ODDS RATIO

(95% CI)

Costa and Colleagues,42 2005

Evans and Colleagues,38 2008

Kanaa and Colleagues,40 2006

Oliviera and Colleagues,43 2004

Robertson and Colleagues,1 2007



Srinivasan and Colleagues,36 2009

Winther and Nathalang,45 1972

TOTAL (95% CI)

TOTAL EVENTS

20

66

20

20

201

20

10

20

27

404

20

80

31

20

237

20

10

20

28

466

20

54

12

20

136

20

8

11

23

304

20

80

31

20

237

20

9

20

30

467

Not applicable

26.4

11.9

Not applicable

57.6

Not applicable

1.1

0.8

2.2

100.0

Not estimable

2.27 (1.08-4.77)

2.88 (1.03-8.07)

Not estimable

4.15 (2.68-6.43)

Not estimable

3.71 (0.13-103.11)

33.87 (1.80-636.88)

8.22 (0.94-71.82)

3.81 (2.71-5.36)


Heterogeneity: χ2 = 4.915 (P = .43); I2 = 0%.Z test for overall effect: Z = 7.71 (P < .00001).CI: Confidence interval.

Figure 3. Forest plot of odds ratios of lidocaine versus articaine from infiltration studies only, showing articaine to have a treatmenteffect 3.81 times greater than that of lidocaine.


25JADA Middle East vol 2 No 4 Jul-Aug 2011 JADA 142(5) http://jada.ada.org May 2011 501

preoperative pulpal status. Clinical practi-tioners should recognize these inherent limita-tions, understand the results and apply themjudiciously to patient care.

One major challenge posed by this meta-analysis was the difference in the methods usedby the investigators in the included trials interms of assessing the success of pulpal anes-thesia. Achieving the soft-tissue signs of localanesthesia is a poor predictor for the presence of profound pulpal anesthesia.49 Thus, our inves-tigation focused on trials in which researchersevaluated the presence or absence of pulpalanesthesia by using electric testing or VAS.Researchers have used EPT to correlate a max-imum reading of 80 on the device to indicateprofound pulpal anesthesia.50,51 Additionally,research has demonstrated that EPT readingsof lower than 80 were associated with painduring operative procedures in asymptomaticteeth.51 Most investigators interested in deter-mining pulpal anesthesia use the EPT method.In this method, anesthetic success often isdefined as the percentage of participants whoachieve two consecutive EPT readings of 80

within 15 minutes of anesthetic administrationand sustain this lack of responsiveness continu-ously for 60 minutes. These criteria help removesome of the subjectivity in assessing pulpalanesthesia, although the evaluation still relieson a patient’s response. The behavior of thepatient and the responses seen in control teethalso require the clinician’s careful attention.52

Using electric testing as a more objective meansof determining pulpal anesthesia has beenuseful in improving the clarity of research out-comes in the area of local anesthesia in den-tistry. The investigators in 10 of the 13 studiesincluded in this review used an electric device todetermine anesthetic success, and those in theother three used solely the VAS (Table 2).

Evaluation of the efficacy of local anestheticsin dentistry is more difficult in symptomaticteeth. One of the most difficult situations thatdentists face routinely is effectively anes-thetizing a tooth that contains an acutelyinflamed vital pulp. In such instances, successrates for traditional anesthetic methods maydrop to unacceptable levels.53 Compounding theproblem is the lack of reliability in determining

S T O R YC O V E R


ADMINISTRATION


(95% CI)ODDS RATIO

(95% CI)


Mikesell and Colleagues,3 2005



TOTAL (95% CI)

TOTAL EVENTS

9

107

9

13

138

37

220

10

20

287

8

83

8

9

108

35

220

11

20

286

9.8

81.0

1.9

7.2

100.0

1.08 (0.37-3.22)

1.56 (1.07-2.28}

3.38 (0.29-39.32)

2.27 (0.64-8.11)

1.57 (1.12-2.21)



Heterogeneity: τ2 = 0.00; χ2 = 1.143 (P = .77); I2 = 0%.Z test for overall effect: Z = 2.59 (P < .009).CI: Confidence interval.


ADMINISTRATION


(95% CI)ODDS RATIO

(95% CI)




TOTAL (95% CI)

TOTAL EVENTS

9

9

13

31

37

10

20

67

8

8

9

25

35

11

20

66

51.8

10.2

38.0

100.0

1.08 (0.37-3.22)

3.38 (0.29-39.32)

2.27 (0.64-8.11)

1.61 (0.74-3.53)

Heterogeneity: τ2 = 0.00; χ2 = 1.132 (P = .57); I2 = 0%.Z test for overall effect: Z = 1.19 (P = .23).CI: Confidence interval.

A

B

Figure 4. Forest plots of articaine versus lidocaine: mandibular block treatment effects (posterior teeth only). A. Analysis includingboth crossover and independent-sample studies (four trials), indicating a slight advantage of articaine (1.57 times) over lidocaine. B. Analysis of independent-sample studies only (inflamed teeth) indicated that there was no difference in treatment effect between the anesthetic solutions used.



pulpal anesthesia by means of electric testing.Even a lack of response to EPT may not guar-antee that a tooth is experiencing profoundpulpal anesthesia.50,54 Several explanations forthe failure of anesthetic solutions in patientswith such teeth appear in the literature. Nervesarising from inflamed tissues have alteredresting potentials and decreased excitabilitythresholds.55 It also is known that certainclasses of sodium channels are resistant to the action of local anesthetics. A class oftetrodotoxin-resistant sodium channels havebeen shown to be resistant to the measures oflocal anesthetics.56 These channels have beendemonstrated to be upregulated during theinflammatory process and are thought to con-tribute to instances of orofacial hyperalgesia.57

Additionally, pulps that have been diagnosedwith irreversible pulpitis may have an increasedexpression of sodium channels.58 These findingshelp explain why dental patients who seektreatment of pain arising from pulpal pathosismay have difficulty experiencing profoundpulpal anesthesia.

The authors of four of the included studies (twostudies that involved infiltration36,39 and threethat involved mandibular block2,37,39) investigatedlocal anesthetic success in patients who requireddental treatment in teeth that had a preoperativediagnosis of irreversible pulpitis. Because of theaforementioned difficulty in using EPT in suchteeth, the investigators in these four studies usedthe VAS to define the outcome after local anes-thetic administration. This psychometricresponse scale has been used as a measurementinstrument for subjective characteristics such asdental pain, and it has been used successfully indentistry primarily for patients who are sympto-matic preoperatively.2,36,37,39 Although the numberof studies and each study’s sample size weresmall, the data for symptomatic teeth showedthat both infiltration and block administrationhad a treatment effect in favor of articaine, whichin cases involving the use of mandibular blockwas not significant (Figure 4B).

One likely reason that the use of articainehas grown among dentists in the United Statesis the hope that it may become the agent ofchoice for the inferior alveolar nerve (IAN)block. Corbett and colleagues25 reported that the efficacy of 4 percent articaine infiltration(1:100,000 epinephrine) compared with that of 2 percent lidocaine IAN block (1:80,000 epineph-rine) was not significantly different for anes-thetic success in mandibular first molars. Addi-tionally, Jung and colleagues59 found that thesuccess rate of a standard volume of articaine

was not different when used in either buccalinfiltration or IAN block. However, successfulanesthesia after buccal infiltration in mandib-ular posterior teeth appears to be not as likelywhen a lidocaine solution is used. Indeed,researchers in two clinical investigations havestated that articaine resulted in a significantlyhigher success rate for mandibular buccal infil-tration when compared with lidocaine.1,40 All ofthe studies cited in this paragraph wereaccounted for in our systematic review and con-tributed to the final outcome of our review.

Several authors have raised concern that theadministration of articaine solutions could beassociated with an increased risk of incitingadverse events such as paresthesia.8,60-62 Evalu-ating such associations is outside the scope ofthis review. However, among the 1,022 inde-pendent administrations of articaine, the variousauthors reported no presence of short-term orlong-term paresthesia. Reporting of adverseevents among the included trials was not stan-dardized, with several of the authors making nomention of the presence or absence of complica-tions associated with the administration of arti-caine or lidocaine. Investigators in future trialsshould report clearly the presence of adverseevents or state explicitly if none occurred.

CONCLUSIONSWhen comparing the newer articaine solutionwith the gold standard of lidocaine, we identi-fied an emerging trend in our review of pub-lished research. The results of these studiesoften have demonstrated that articaine has asuperior anesthetic efficacy, even though properstatistical scrutiny frequently revealed thatsuch differences were not always statisticallysignificant. The findings of our meta-analysissummarize the unbiased direct comparison ofarticaine and lidocaine and support the argu-ment that articaine does provide a higher rateof anesthetic success. This evidence-basedreview is aimed to aid clinicians in makinginformed, judicious decisions when selecting alocal anesthetic solution.

In this meta-analysis of the data from 13selected clinical trials, we found that the admin-istration of an articaine solution for local anes-thesia in dentistry has an advantage over lido-caine in respect to achieving pulpal anestheticsuccess. When we further stratified injectiontypes, we found that the evidence more stronglysupported articaine’s superiority to lidocainewith infiltration anesthesia; we found weak evi-dence for such differences in mandibular blockanesthesia. When we took into account various

S T O R YC O V E R


27JADA Middle East vol 2 No 4 Jul-Aug 2011502 JADA 142(5) http://jada.ada.org May 2011

pulpal anesthesia by means of electric testing.Even a lack of response to EPT may not guar-antee that a tooth is experiencing profoundpulpal anesthesia.50,54 Several explanations forthe failure of anesthetic solutions in patientswith such teeth appear in the literature. Nervesarising from inflamed tissues have alteredresting potentials and decreased excitabilitythresholds.55 It also is known that certainclasses of sodium channels are resistant to the action of local anesthetics. A class oftetrodotoxin-resistant sodium channels havebeen shown to be resistant to the measures oflocal anesthetics.56 These channels have beendemonstrated to be upregulated during theinflammatory process and are thought to con-tribute to instances of orofacial hyperalgesia.57

Additionally, pulps that have been diagnosedwith irreversible pulpitis may have an increasedexpression of sodium channels.58 These findingshelp explain why dental patients who seektreatment of pain arising from pulpal pathosismay have difficulty experiencing profoundpulpal anesthesia.

The authors of four of the included studies (twostudies that involved infiltration36,39 and threethat involved mandibular block2,37,39) investigatedlocal anesthetic success in patients who requireddental treatment in teeth that had a preoperativediagnosis of irreversible pulpitis. Because of theaforementioned difficulty in using EPT in suchteeth, the investigators in these four studies usedthe VAS to define the outcome after local anes-thetic administration. This psychometricresponse scale has been used as a measurementinstrument for subjective characteristics such asdental pain, and it has been used successfully indentistry primarily for patients who are sympto-matic preoperatively.2,36,37,39 Although the numberof studies and each study’s sample size weresmall, the data for symptomatic teeth showedthat both infiltration and block administrationhad a treatment effect in favor of articaine, whichin cases involving the use of mandibular blockwas not significant (Figure 4B).

One likely reason that the use of articainehas grown among dentists in the United Statesis the hope that it may become the agent ofchoice for the inferior alveolar nerve (IAN)block. Corbett and colleagues25 reported that the efficacy of 4 percent articaine infiltration(1:100,000 epinephrine) compared with that of 2 percent lidocaine IAN block (1:80,000 epineph-rine) was not significantly different for anes-thetic success in mandibular first molars. Addi-tionally, Jung and colleagues59 found that thesuccess rate of a standard volume of articaine

was not different when used in either buccalinfiltration or IAN block. However, successfulanesthesia after buccal infiltration in mandib-ular posterior teeth appears to be not as likelywhen a lidocaine solution is used. Indeed,researchers in two clinical investigations havestated that articaine resulted in a significantlyhigher success rate for mandibular buccal infil-tration when compared with lidocaine.1,40 All ofthe studies cited in this paragraph wereaccounted for in our systematic review and con-tributed to the final outcome of our review.

Several authors have raised concern that theadministration of articaine solutions could beassociated with an increased risk of incitingadverse events such as paresthesia.8,60-62 Evalu-ating such associations is outside the scope ofthis review. However, among the 1,022 inde-pendent administrations of articaine, the variousauthors reported no presence of short-term orlong-term paresthesia. Reporting of adverseevents among the included trials was not stan-dardized, with several of the authors making nomention of the presence or absence of complica-tions associated with the administration of arti-caine or lidocaine. Investigators in future trialsshould report clearly the presence of adverseevents or state explicitly if none occurred.

CONCLUSIONSWhen comparing the newer articaine solutionwith the gold standard of lidocaine, we identi-fied an emerging trend in our review of pub-lished research. The results of these studiesoften have demonstrated that articaine has asuperior anesthetic efficacy, even though properstatistical scrutiny frequently revealed thatsuch differences were not always statisticallysignificant. The findings of our meta-analysissummarize the unbiased direct comparison ofarticaine and lidocaine and support the argu-ment that articaine does provide a higher rateof anesthetic success. This evidence-basedreview is aimed to aid clinicians in makinginformed, judicious decisions when selecting alocal anesthetic solution.

In this meta-analysis of the data from 13selected clinical trials, we found that the admin-istration of an articaine solution for local anes-thesia in dentistry has an advantage over lido-caine in respect to achieving pulpal anestheticsuccess. When we further stratified injectiontypes, we found that the evidence more stronglysupported articaine’s superiority to lidocainewith infiltration anesthesia; we found weak evi-dence for such differences in mandibular blockanesthesia. When we took into account various

S T O R YC O V E R



RCT designs, we found the difference in successrates between articaine and lidocaine to be sta-tistically significant when the method of admin-istration was infiltration or mandibular block inhealthy teeth, but we found no statistically sig-nificant difference between the two when amandibular nerve block was used in sympto-matic teeth.

Implications for research. Well-designedand properly executed RCTs provide the bestevidence regarding the efficacy of health careinterventions, whereas trials with inadequatemethodological approaches may be associatedwith overestimation of treatment effects. Addi-tional well-designed and fully reported compar-ative effectiveness trials investigating the dif-ference in anesthetic success between articaineand lidocaine may further strengthen the evi-dence that formed the basis for this review.

Implications for practice. Clinicians mayexpect a solution of 4 percent articaine (with1:100,000 epinephrine) to provide a greaterprobability of anesthetic success than a solutionof 2 percent lidocaine (with 1:100,000 epineph-rine). The superiority of articaine is most signif-icant when used during local infiltration anes-thesia. Regarding the relative strength oftreatment effects among multiple quantitativestudies, we can state that within a 95 percentCI, the true odds ratio of articaine (2.44) indi-cates that this anesthetic is 1.59 to 3.76 timesmore likely to produce anesthetic success thanis lidocaine. When we considered infiltrationdata only, we found that the results of our meta-analysis indicated that articaine is an estimated3.81 times more likely to produce anestheticsuccess than is a similar volume of lidocaine.There is weak evidence that the use of articaineallows for a higher percentage of anesthetic suc-cess when administered via a mandibular block,and thus it is premature to recommend arti-caine as a substitute for lidocaine in achieving asuccessful mandibular block. �

Disclosure. None of the authors reported any disclosures.

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