Extraction of Maxillary Teeth Using Articaine Without a Palatal Injection: A Comparison Between the Anterior and Posterior Regions of the Maxilla

Can Single Buccal Infiltration With 4% Articaine Induce Sufficient Analgesia for the Extraction of Maxillary Teeth? A Systematic Literature Review

This systematic review evaluates the efficacy of single buccal infiltration of articaine for extracting upper teeth. A search of the PubMed, Ovid SP, Scopus, Embase, and Cochrane databases for English-language studies published between 2000 and 2021 was performed on August 26, 2022, based on the pre-specified question using the MeSH terms [(buccal) and (articaine) and (infiltration) and (dental)]. Of the 16 clinical trials identified involving 1,339 patients, six compared the subjective procedural pain associated with single buccal infiltration of articaine with that of lidocaine, three of which reported reduced pain and the other three greater success in extraction for the articaine group. Four of the 16 studies compared the procedural pain associated with single buccal infiltration of 4% articaine with double (buccal and palatal/lingual) infiltration; two reported insignificant differences between the groups; and the other two reported greater success using buccal and palatal injections. Five of the 16 studies compared the procedural pain associated with single buccal articaine with double buccal and palatal/lingual infiltration of 2% lidocaine and reported insignificant differences. The other of the 16 studies compared the subjective pain associated with single buccal infiltration of 4% articaine 1:100:000 with single buccal infiltration of 4% articaine 1:200:000 and found a statistically significant difference. All of these studies concluded that upper permanent maxillary teeth can be extracted using only a 4% articaine buccal infiltration, but further investigation is necessary to determine whether this approach can replace the gold standard of buccal and palatal infiltration.

A Split-Mouth Clinical Comparative Evaluation of the Anesthetic Efficacy of Articaine and Lignocaine for Maxillary Bicuspids Extraction

Aim The study compared the anesthetic effectiveness of articaine and lignocaine when premolars are extracted bilaterally for orthodontic purposes. Material and methods This prospective split-mouth study was performed on 30 cases selected from orthodontic referral patients reporting to the Oral and Maxillofacial Surgery Department at Maharaja Ganga Singh Dental College and Research Center, Rajasthan, India, for bilateral extraction of premolars under local anesthesia. We used 4% articaine hydrochloride and adrenaline 1:100000 (AH) as group A and 2% lignocaine hydrochloride with adrenaline 1:100000 (LH) on the control side as group B. For premolar anesthetization, 0.6-1.6 ml of AH and 1-2 ml of LH were injected submucosally in the buccal vestibular area. The extraction procedure was then carried out after achieving adequate anesthesia. The pain was assessed with Visual Analog Scale. The average onset time and duration of anesthesia were recorded. Data collected were summarized with descriptive statistics. The SPSS version 23.0 (IBM Corp., Armonk, New York) was used for data entry, validation, and analysis. Means of continuous variables were compared using the student t-test. All tests were 2-tailed and significant at equal or less than 0.05. (p≤0.05). Results When comparing the overall anesthetic efficiency, Group A had a lower overall pain score of 0.43 while Group B had a higher overall pain score of 2.9. The average onset time of anesthesia in Group A was 1.2 minutes and 2.55 minutes in Group B. In Group A, the average duration of anesthesia was 70 minutes, and 46.5 minutes in Group B. These parameters were statistically significant with a p-value of <0.05. Conclusion The study concluded that as an alternative to lignocaine, articaine could be used effectively for maxillary premolar extractions for orthodontic reasons obviating palatal injection which is very painful to the patient.

The Clinical Efficacy of EMLA as a Topical Anesthetic Agent Instead of Palatal Injection During Maxillary Dental Extractions: A Randomized Controlled Trial

Background

Even after the invention of the modern injection techniques, palatal injection still remains a painful experience for patients, and this pain is attributed to the presence of rich nerve complement and displacement of tightly adherent palatal mucosa during anesthesia.

Aim

To check the clinical efficacy of EMLA as a topical anesthetic agent instead of palatal injection during maxillary dental extractions.

Methodology

The trial includes a total of 102 participants, in whom maxillary molar extractions were indicated, were randomly divided into the experimental group (eutectic mixture of local anesthesia (EMLA) topical application was used along with buccal injection) and control group (palatal injection along with buccal injection). Pain perception during extraction was recorded using the visual analog scale (VAS).

Results

Mean VAS score for 'injection' in control group patients was 5.2 ± 2.08 in contrast to no pain in experimental group. In experimental group, mean VAS score on 'probing' was 0.92 ± 1.50. VAS score on 'extraction' in EMLA group was little higher though the difference was not statistically significant. The overall experience using Liekert's scale was higher in experimental group (4.0 ± 0.76) as compared to (3.3 ± 0.82) in control group leading to higher overall satisfaction among patients who underwent extraction in the experimental group.

Conclusion

EMLA application produced a satisfactory level of anesthesia in the palatal tissue when compared with the palatal injection.

Articaine use does not routinely eliminate the need for palatal injections for primary maxillary molar extractions: a randomized cross-over clinical trial

Purpose

The aim of this study was to compare single buccal infiltration of 4% articaine versus routine buccal and palatal injections of 2% lidocaine during bilateral extraction of maxillary primary molars.

Methods

Thirty healthy children aged 6–9 years old requiring bilateral extraction of maxillary primary molars were enrolled into the trial. Randomization was performed in two steps. Routine buccal and palatal infiltrations were administered using 2% lidocaine in the control side. Four percent articaine was used for single buccal infiltration in the intervention side. WBFP scale (Wong-Baker FACES Pain scale) was employed for subjective assessment of pain. For objective evaluation of pain, FLACC scale (Face, Legs, Activity, Cry, Consolability) and physiological parameters of blood pressure and pulse rate were recorded.

Results

Analyses did not show any significant differences in blood pressure, pulse rate, and FLACC scale between groups (P value > 0.05). However, statistically lower WBFP scores were observed in articaine group as compared to lidocaine group (P value < 0.05); the difference was less than one unit which is not clinically considerable.

Conclusion

Single buccal infiltration of 4% articaine can be administered as an alternative for conventional infiltration of 2% lidocaine to avoid fear or uncooperative behavior of the child patient. However, the assessment of palatal tissue anesthesia is quite necessary before the procedure is initiated. In case of failure in achieving palatal anesthesia, a palatal injection should be given.

The effect of single buccal infiltration anesthesia of 4% articaine with either 1:100,000 or 1:200,000 epinephrine on pulpal blood flow and anesthesia of maxillary first molars and second premolars in humans

OBJECTIVES

The aim of this study was to determine the effect of single buccal infiltration of 4% articaine with either 1:100,000 (EP100) or 1:200,000 (EP200) epinephrine on pulpal blood flow (PBF), pulpal anesthesia and soft tissue anesthesia of maxillary first molars and second premolars in human subjects.

MATERIALS AND METHODS

Fifteen healthy volunteers with intact maxillary first molars and second premolars received an infiltration of 4% articaine with either EP100 or EP200 at buccal aspect of maxillary first molars. The PBF, pulpal anesthesia and soft tissue anesthesia were assessed with a laser Doppler flowmeter (LDF), an electric pulp tester (EPT) and Aesthesiometer II, respectively.

RESULTS

Articaine (4%) with either EP100 or EP200 produced PBF reduction in maxillary first molars (injected teeth) by 68.09 and 69.83%, and produced PBF reduction in second premolars (adjacent teeth) by 76.81 and 75.02%, respectively at 15 min post injection. Duration of PBF returned to baseline was 159.00 ± 21.06 (EP100) and 159.00 ± 31.97 (EP200) min in the molars, and 161.00 ± 20.02 (EP100) and 159.00 ± 25.86 (EP200) min in the premolars. The onset of pulpal anesthesia was 2.80 ± 1.26 (EP100) and 3.07 ± 1.28 (EP200) min in the molars, and 2.13 ± 0.52 (EP100) and 2.40 ± 0.83 (EP200) min in the premolars; the duration of pulpal anesthesia was 74.53 ± 24.16 (EP100) and 76.27 ± 34.03 (EP200) min in the molars, and 82.53 ± 31.03 (EP100) and 75.60 ± 37.17 (EP200) min in the premolars. Buccal tissue anesthesia was found in both teeth (100%), but palatal anesthesia was achieved by 13.33% in the premolars and 6.67% in the molars for each solution.

CONCLUSIONS

Single buccal infiltration to maxillary first molar produced PBF reduction and successful pulpal anesthesia, evaluated by EPT, in both first molar and second premolar. This anesthetic technique also produced high success of buccal tissue anesthesia, but demonstrated very low success for palatal tissue anesthesia.

CLINICAL RELEVANCE

Single buccal infiltration to maxillary first molar is potent enough for pulpal and buccal tissue anesthesia, except palatal tissue anesthesia, in both first molar and second premolar.

The Efficacy of 4% Articaine Versus 2% Lidocaine in Inducing Palatal Anesthesia for Tooth Extraction in Different Maxillary Regions

PURPOSE

This study was conducted to ascertain the efficacy of buccal injection of articaine compared to lidocaine in inducing palatal anesthesia in different maxillary regions.

MATERIALS AND METHODS

This double-blinded, randomized clinical trial included 300 patients who referred for extraction of 1 maxillary tooth. The patients were categorized into 3 strata according to the extraction area (anterior, premolar, molar), and then randomly assigned to 2 groups based on the administered medication. The first group received buccal infiltration by 0.6 mL of 2% lidocaine, whereas the second group was buccally administered using 0.6 mL of 4% articaine. After a waiting period of 2 minutes, the failure or success in achieving palatal anesthesia was assessed by the instrumentation technique. In cases of failed anesthesia, an additional 0.6 mL of the same anesthetic was given, and the procedure was repeated if palatal anesthesia was not attained after a 2-minute delay. If pain remained 2 minutes after the third injection, a supplemental palatal infiltration was administered and the extraction was attempted.

RESULTS

The success rate of buccal infiltration in achieving palatal anesthesia was 82.7% in the articaine group and 1.3% in the lidocaine group. There was a significant difference in the success rate and drug volume required to induce palatal anesthesia between the 2 groups (P < .001), but no significant difference was found between different maxillary regions, using either of the medications (P > .05).

CONCLUSIONS

Articaine can be considered as a suitable alternative to lidocaine for eliminating painful palatal infiltration in the extraction of maxillary teeth.

Is the only buccal infiltration anesthesia enough for extraction of mandibular anterior incisors and premolar teeth? A split-mouth randomized clinical trial

OBJECTIVES

The issue of needing additional lingual injection in extractions of mandibular premolar and incisors is still not clarified. The aim of this study is to investigate whether it is necessary to perform lingual injection in addition to buccal infiltration anesthesia in mandibular incisors and premolar teeth extractions.

MATERIALS AND METHODS

Sixty-six patients who admitted to our clinic for the removal of bilateral mandibular anterior teeth were included in the present study. Patients were divided into two groups. The experimental group received only 1.5 ml of 2% lidocaine with 1:80,000 epinephrine by injection into the buccal vestibule of the tooth. The control group received 1.5 ml of 2% lidocaine with 1:80,000 epinephrine by buccal injection into the buccal side and 0.3 ml same lidocaine solution injected into the lingual side of the tooth. After 5 min, tooth was extracted and each patient was asked to record the intensity of injection and extraction pain by 0-100 mm and a 10-point Visual Analogue Scale (VAS) and six-pointed Face Pain Scale (FPS).

RESULTS

The injection pain scores were significantly higher in terms of the VAS 0-10 point and 0-100 mm and FPS in the control group to which additional lingual injections were applied than the experimental group (p < 0.05). No statistically significant differences were found in all three scales between the groups in terms of extraction pain (p > 0.05). The mean extraction pain scores were lower in the experimental group according to the three scales. No additional anesthetic injection and post-operative complications were observed in all patients.

CONCLUSIONS

The extraction of mandibular incisors and premolar teeth can only be done with only the buccal infiltration.

CLINICAL RELEVANCE

In the extraction of mandibular anterior teeth, it can be performed with less anesthetic amount without the need for an additional lingual injection.

Single buccal infiltration of high concentration lignocaine versus articaine in maxillary third molar surgery

Background

This research evaluated the numbness produced by lignocaine at an equal or higher concentration than that of 4% articaine through a single point of injection for maxillary third molar surgery. This randomized double-blind study was conducted to compare the anesthetic efficiency of 4% lignocaine with that of 4% articaine in impacted maxillary third molar surgery using a single buccal infiltration alone.

Methods

The study participants were 30 healthy patients requiring the bilateral surgical removal of symmetrically-positioned maxillary third molars. Using a split-mouth design, each patient randomly received buccal infiltration of 1.7 ml of 4% lignocaine and 1.7 ml of 4% articaine during two separate appointments. After 15 minutes of anesthetic injection, surgery was performed by the same surgeon using a consistent technique on both sides. Pinprick test pain scores of the buccal and palatal gingiva of the maxillary third molar after 10 minutes and 15 minutes latencies, pain scores during the surgery, the need for supplemental anesthesia, and patients' satisfaction with anesthetic efficiency were recorded. Surgery performed without supplemental anesthesia was categorized as successful.

Results

The success rates of 4% lignocaine and 4% articaine (83.34% vs. 86.67%, P = 1.00) were not significantly different. Only 5 cases (4 cases in the articaine group and 1 case in the lignocaine group) reported mild pain and pressure sensation (NRS ≤ 1) on probing at the palatal side after 15 minutes of latency (P = 0.25). The pain scores of maxillary third molar surgery in the two groups were not significantly different (P > 0.05). Moreover, the statistical analysis confirmed the comparable patient satisfaction of two study groups (P = 0.284).

Conclusion

This study provides evidence that single buccal infiltrations of 4% lignocaine and 4% articaine have comparable anesthetic efficacy and success rates for impacted maxillary third molar surgery. Both 4% lignocaine and 4% articaine can produce effective palatal anesthesia and pain control using buccal infiltration alone after 15 minutes of latency.

Can single buccal infiltration with 4% articaine induce sufficient analgesia for the extraction of primary molars in children: a systematic literature review

This systematic review aims to determine if a single buccal infiltration (without palatal infiltration in the maxilla and Inferior Alveolar Nerve Block in the mandible) with 4% articaine can induce adequate analgesia for the extraction of primary molars (Maxillary and Mandibular) in children. PubMed, Ovid SP, and Embase were searched for studies published between January 1990 and March 2020 with the relevant MeSH terms. Titles and abstracts were screened preliminarily, followed by the full-texts of the included studies. Five articles were included for this systematic review. The outcome investigated was “Procedural pain during the extraction of primary molars after injection with single buccal infiltration of 4% articaine in comparison to single buccal infiltration, double infiltration (buccal and palatal/lingual), and inferior alveolar nerve block with 2% lignocaine.” Of the five studies that evaluated subjective pain during extraction, two reported no significant difference between the articaine and lignocaine groups, and the remaining three reported lower subjective pain during extraction in the articaine group. Only two studies evaluated objective pain scores during extraction, and both studies reported lower pain scores in the articaine group. There is insufficient evidence to justify the statement that a single buccal infiltration of 4% articaine alone is sufficient for the extraction of primary molars. Further evidence is required to justify the claim that palatal infiltrations and IANB can be replaced with the use of 4% articaine single buccal infiltration for the extraction of primary molars in children.

Buccal infiltration injection without a 4% articaine palatal injection for maxillary impacted third molar surgery

Objectives

Palatal infiltration is the most painful and uncomfortable anesthesia technique for maxillary impacted third molar surgery (MITMS). This approach could cause patients distress and aversion to dental treatment. The aim of this study was to evaluate the anesthetic efficacy of a buccal infiltration injection without a palatal injection in MITMS.

Materials and Methods

This prospective research study was a crossover split mouth-randomized controlled trial. Twenty-eight healthy symmetrical bilateral MITMS patients (mean age, 23 years) were randomly assigned to two groups. Buccal infiltration injections without palatal injections were designated as the study group and the buccal with palatal infiltration cases were the control group, using 4% articaine and 1:100,000 epinephrine. The operation started after 10 minutes of infiltration. Pain assessment was done using a visual analogue scale and a numeric rating scale after each injection and extraction procedure. Similarly, the success rate, hemodynamic parameters, and additional requested local anesthetic were assessed.

Results

The results showed that the pain associated with local anesthetic injections between both groups were significantly different. However, the success rates between the groups were not significantly different. Postoperative pain was not significant between both groups and a few patients requested an additional local anesthetic, but the results were not statistically significant. For hemodynamic parameters, there was a significant difference in systolic pressure during incision, bone removal, and tooth elevation. In comparison, during the incision stage there was a significant difference in diastolic pressure; however, other steps in the intervention were not significantly different between groups.

Conclusion

We concluded that buccal infiltration injection without palatal injection can be an alternative technique instead of the conventional injection for MITMS.

Anesthetic efficacy and safety of 2% lidocaine hydrochloride with 1:100,000 adrenaline and 4% articaine hydrochloride with 1:100,000 adrenaline as a single buccal injection in the extraction of maxillary premolars for orthodontic purposes

Background

Palatal injection of local anesthetics is the most painful injection. To obviate the need for palatal injections, local anesthetic agents with diffusibility are being investigated. Hence the present study was designed to analyze the anesthetic efficacy of 2% lidocaine hydrochloride (HCl) with 1:100,000 adrenaline and 4% articaine hydrochloride (HCl) with 1:100,000 adrenaline using single buccal infiltration for the extraction of maxillary premolars.

Methods

A prospective, double-blind, crossover, randomized clinical study was performed on 60 consecutive systemically healthy patients with an age range of 15-30 years, requiring extraction of asymptomatic bilateral maxillary premolars for orthodontic purposes. They received 1ml buccal infiltration of 4% articaine HCl with 1:100,000 adrenaline on one side and 2% lidocaine HCl with 1:100,000 adrenaline on the other side. The extraction procedure on either side was scheduled 14 days apart. Parameters assessed were the time of onset of anesthesia, intraoperative discomfort, hemodynamic parameters, and the duration of analgesia. Analysis of the data was done using the Mann-Whitney test, the Wilcoxon test, the Kruskal-Wallis ANOVA test, and the chi-square test. Statistical significance was established at P < 0.05.

Results

Articaine showed a faster time of onset and longer duration of analgesia than lidocaine. However, the difference in the intraoperative discomfort and hemodynamic parameters was statistically insignificant.

Conclusion

Within the limitations of the study, it can be concluded that the extraction of maxillary premolars can be performed with a single buccal infiltration of 2% lidocaine HCl with 1:100,000 adrenaline, which is one of the most commonly used local anesthetic agent.

Comparison of the buccal injection versus buccal and palatal injection for extraction of permanent maxillary posterior teeth using 4% articaine: a split mouth study

In spite of the development of modern injection techniques, palatal injection is still a painful experience for patients. A plethora of techniques has been tested to reduce this. One such technique that has been claimed to work is administering articaine on the buccal side alone for the extraction of maxillary teeth due to its ability to diffuse through soft and hard tissues more reliably than other local anaesthetics. This split mouth study evaluated the efficacy of 4% articaine with 1:100000 adrenaline to avoid the painful palatal injection for bilateral permanent maxillary tooth extraction in 50 patients. The 100mm 10 point Visual Analog Scale/Wong Baker Facial Pain Scale was used to rate the amount of pain felt on injection, on probing the tissues prior to, or during, extraction, and one hour postoperatively. Although the buccal injection alone resulted in lower pain while injecting the anaesthetic, it did not result in the absence of pain before tooth extraction as has been suggested by various studies. A total of 74% patients required a palatal injection on the study side. We conclude that in most cases, when using a buccal injection alone, one cannot rely on the diffusion of articaine for effective palatal anaesthesia. Despite this, we suggest that as an initial option in young patients, the operator can consider avoiding the painful palatal injection by the use of articaine to prevent aversion to dental treatment. Postoperatively, the difference in pain levels was not statistically significant and no patient showed signs of lesions at the injection sites.

Efficacy of articaine vs lignocaine in maxillary and mandibular infiltration and block anesthesia in the dental treatments of adults: A systematic review and meta-analysis

The aim of the present systematic review and meta-analysis was to address the following Population, Intervention, Comparison, and Outcome question: Is the efficacy of articaine better than lignocaine in adults requiring dental treatment? Four percent articaine was compared with 2% lignocaine for maxillary and mandibular infiltrations and block anesthesia, and with the principal outcome measures of anesthetic success. Using RevMan software, the weighted anesthesia success rates and 95% confidence intervals (CIs) were estimated and compared using a random-effects model. For combined studies, articaine was more likely to achieve successful anesthesia than lignocaine (N = 18, odds ratio [OR]: 1.92, 95% CI: 1.45-2.56, P < 0.00001, I²  = 32%). Maxillary and mandibular infiltration studies showed obvious superiority of articaine to lignocaine (N = 8, OR: 2.50, 95% CI: 1.51-4.15, P = 0.0004, I²  = 41%). Maxillary infiltration subgroup analysis showed no significant difference between articaine and lignocaine (N = 5, OR: 1.69, 95% CI: 0.88-3.23, P = 0.11, I²  = 19%). For combined mandibular anesthesia studies, articaine was superior to lignocaine (N = 14, OR: 1.99, 95% CI: 1.45-2.72, P < 0.0001, I²  = 32%), with further subgroup analysis showing significant differences in both mandibular block anesthesia (N = 11, OR: 1.55, 95% CI: 1.19-2.03, P = 0.001), I²  = 0%) and mandibular infiltration (N = 3, OR: 3.87, 95% CI: 2.62-5.72, P < 0.00001, I²  = 0%), indicating that articaine is more effective than lignocaine in providing anesthetic success in routine dental procedures.