Articaine is superior to lidocaine in providing pulpal anesthesia Virginia Powell JADA 2012;143;897-898 The following resources related to this

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RESEARCH

CRITICAL

SUMMARIES

Articaine is superior to lidocaine in providing pulpal anesthesia

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A critical summary of Brandt RG, Anderson PF, McDonald NJ, Sohn W, Peters MC. The pulpal anesthetic efficacy of articaine versus lidocaine in dentistry: a meta-analysis. JADA 2011; 142(5):493-504. Virginia Powell, DMD

Systematic review conclusion. Articaine provides a higher rate of anesthetic success in anesthetizing pulpal tissues than does lidocaine, although the method of administration used and the patients pulpal status may diminish this effect. Critical summary assessment. Data from a randomized clinical trial provided evidence of the superior anesthetic qualities of 4 percent articaine compared with those of 2 percent lidocaine, although the difference possibly could be less evident if the teeth are inflamed or the method of delivery is by means of block injection. Evidence quality rating. Good.

Clinical question. Which anesthetic, 2 percent lidocaine or 4 percent articaine, is most likely to produce pulpal anesthesia in adult patients? Review methods. Following a prepared protocol, the authors searched two databases and conducted hand searches of the tables of contents in relevant journals. They solicited recommendations for additional articles from experts; they did not mention any unpublished reports. Inclusion criteria were peer-reviewed articles that were clinical trials, were published between January 1970 and December 2009, used pulpal anesthesia as the outcome variable and had a comparative design that resulted in original data. Exclusion criteria included lack of description in the

following areas: outcome variable, anesthetic technique and randomization method. The authors evaluated the quality of the trials by evaluating randomization methods and masking techniques. They also tested for heterogeneity. Main results. Articles in German, Croatian and Russian were translated to English. Thirteen studies met the inclusion criteria, resulting in a combined study population of 560 participants. Investigators in eight trials (300 participants) evaluated infiltration anesthesia, investigators in four trials (209 participants) evaluated block anesthesia, and investigators in one trial (51 participants) evaluated intraligamentary injections. The trials investigators used electric pulp testing (EPT), visual analog scales

(VAS), or a combination of the two to measure pulpal anesthesia. Trial investigators using EPT defined an anesthetized tooth as one that would register no response to a maximum reading of 80. Trial investigators using VAS defined an anesthetized tooth as one that would register no or mild pain when subjected to pulpal therapy. Heterogeneity among the trials was significant. Articaine was 2.44 times more likely to produce successful pulpal anesthesia than was lidocaine (95 percent confidence interval [CI], 1.59-3.76). When the authors evaluated infiltration anesthesia, the odds ratio increased to 3.81 (95 percent CI, 2.71-5.36). When they evaluated mandibular block, the odds ratio decreased to 1.57 (95 percent CI, 1.12-2.21). No adverse effects were reported. Conclusions. In a clinical situation, 4 percent articaine was more likely to produce successful pulpal anesthesia than was 2 percent lidocaine, and this effect was improved if the method of administration was infiltration.
No sources of funding for this systematic review were listed.

Dr. Powell is in private practice in Ukiah, Calif. She also is an evidence reviewer for the American Dental Association. Address reprint requests to Dr. Powell at 1901 S. Dora St., Ukiah, Calif. 95482, e-mail lvpowell@heganglassworks.com.

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CRITICAL

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COMMENTARY

Importance and context. The investigators of the small studies included in the review article provided mostly lukewarm endorsements of articaines superior anesthetic qualities. The authors of the review article combined the results of these small studies to provide a headto-head comparison of 4 percent articaine and 2 percent lidocaine. Strengths and weaknesses of the systematic review. The authors conducted a wellconsidered search strategy and defined reasonable inclusion criteria. By including nonEnglishlanguage articles in their review, as well as conducting interviews with experts to find unpublished studies, the authors increased the scope of evidence. They did not describe the demographics of the study populations clearly, and they presented data in graphs that were mislabeled. The outcome variablesuccessful pulpal anesthesiawas not defined clearly and, therefore, was subject to bias. The subgroup of inflamed versus noninflamed teeth was not reported. Therefore, the conclusion that articaine provided better anesthesia by means of infiltration may be overstated. When studies were grouped by infiltration, only 2 percent of the events involved inflamed teeth compared with 19 percent when the studies were grouped by mandibular block. The only time the use of articaine did not provide significantly superior anesthesia compared with the use of lidocaine was in a small subgroup of mandibular block studies that included only inflamed teeth. The results of this analysis may be suspect because of the small sample sizes and because inflamed teeth are more difficult to anesthetize. Therefore, tooth status rather than the type of anesthetic used may have been the more important factor. The discussion section provided a good

review of pain assessment with a focus on inflamed teeth. The authors, however, did not address why articaine may have performed better when applied by means of infiltration than by means of a nerve block. Strengths and weaknesses of the evidence. Study results were largely consistent, and confidence intervals overlapped for all metaanalyses. Heterogeneity was significant, and the use of multiple definitions of pulpal anesthesia with little rationale for scale may have contributed to this effect. The authors described inconsistencies with masking, sample size, anesthesia measurement, operator experience and patients pulpal status as limitations in the underlying studies. Overall, the total number of participants (N = 560) was small. It was unclear how the number of participants, events and total, as reported in the tables, were related. The number of dropouts and the reasons for the dropouts were not reported. Implications for dental practice. Four percent articaine is more likely to provide successful anesthesia than is 2 percent lidocaine for routine dental procedures. I
Disclosure. Dr. Powell did not report any disclosures. Critical Summaries is supported by grant G08 LM008956 from the National Library of Medicine and the National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Md. These summaries, published under the auspices of the American Dental Association Center for Evidence-Based Dentistry, are prepared by practitioners trained in critical appraisal of published systematic reviews who work under the mentorship of experts. The summaries are not intended to, and do not, express, imply or summarize standards of care, but rather provide a concise reference for dentists to aid in understanding and applying evidence from the referenced systematic review in making clinically sound decisions as guided by their clinical judgment and by patient needs. For more information on the evidence quality rating provided above and additional critical summaries, please visit http://ebd.ada.org.

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