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ORIGINAL ARTICLE

Comparative Study of the Anesthetic Efficacy of 4% Articaine

Versus 2% Lignocaine in the Inferior Alveolar Nerve Block
During the Surgical Extraction of Impacted Mandibular
ThirdMolars
M. James Antony Bhagat, Vinod Narayan, M. R. Muthusekhar, Ashish R. Jain1
Departments of Oral and Maxillofacial Surgery, Saveetha University, 1Department of Prosthodontics, Tagore Dental College and Hospitals, Chennai,
Tamil Nadu, India

ABSTRACT
Background: Pain control through the truncal block of the inferior alveolar nerve is one of the locoregional anesthetic techniques
most widely used in oral surgery, affording comfort and safety for both the patient and operator when used correctly.
Aim: To compare the anesthetic efficacy of both 4% articaine and 2% lignocaine with epinephrine in the truncal block of the
inferior alveolar nerve during surgical removal of the impacted mandibular third molars. Materials and Methods: Arandomized,
doubleblind, clinical trial was conducted of 360patients programmed for the surgical extraction of symmetrical lower third
molars in the context of the Master of Oral Surgery and Implantology(Saveetha Dental College, Saveetha University, Chennai,
India). Following the obtainment of informed consent, two operators performedsurgery on an extemporaneous basis, using as
local anesthetic 4% articaine or 2% lignocaine, with the same concentration of a vasoconstrictor(epinephrine 1:100,000).
The study variables for each anesthetic were: Latency (time to action) and duration of anesthetic effect, the need of
reanesthetizing the surgical zone, and intraoperative pain intensity measured objectively using the Visual Analog Scale(VAS)
and Faces Pain Scale(FPS). Data were analyzed using the Independent ttest and Chisquare test. Results: Astatistically
significant difference (P < 0.05) was observed in the mean duration of the anesthetic effect (216.98 minutes for 4%
articaine vs. 158.49 minutes for 2% lignocaine). The amount of anesthetic solution and the need to reanesthetize the
surgical field showed clinical differences in favor of articaine, although a statistically significant difference was not seen. The
VAS and FPS scores were statistically significant when compared with 2% lignocaine(P<0.05). Conclusion: We conclude
that 4% articaine has better anesthetic efficacy as compared to 2% lignocaine. This can be explained based on its different
chemical structure, liposolubility, increased proteinbinding ability, diffusion in soft tissue, and increased pulpal anesthesia.

KEY WORDS: Articaine, faces pain scale, latency, lignocaine, visual analog scale

INTRODUCTION According to the type of intermediate alkyl linkage

Pain is one of the most commonly experienced symptoms
in dentistry, and nothing that is done by a dentist for the
patient is of greater importance than the administration of
a drug that prevents pain during dental treatment. Local
anesthetics are chemicals that block nerve conduction
in a specific, temporary, and reversible manner, without
affecting the patients consciousness.[1] The molecule
consists of two poles: Ahydrophilic tertiary or secondary
amino group and a lipophilic aromatic ring[Figure1].
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between them, they are classified into estertype
anesthetics with an aminoester bond, whose prototype
is procaine, and the amidetype anesthetics, with an
aminoamide bond, whose prototype is lidocaine. Pain
control through a truncal block of the inferior alveolar
nerve is one of the locoregional anesthetic techniques most
widely used in oral surgery, affording comfort and safety
to both the patient and operator, when used correctly.
The choice of anesthetic solution should be based on
three main clinical considerations: Anesthetic potency,
latency (time to onset of anesthesia), and duration of
the anesthetic effect. Other important considerations
are the pharmacokinetics (absorption, distribution,
metabolization, and excretion) and toxicity of the drug.[2]

Address for Correspondence:

Dr. Ashish R. Jain,
DOI:
R House c1, No3, Manonmani Ammal Road, Pavapuri,
10.4103/2249-9725.132975
Kilpauk,Chennai600010, Tamil Nadu, India.
E-mail:dr.ashishjain_r@yahoo.com

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Bhagat, et al.: Anesthetic efficacy of two different local anesthetic drugs in surgical removal of impacted mandibular third molars

Lidocaine synthesized by Lofgren in 1943, was the first

amide anesthetic prepared for local application[Figure2].
Its potency is presently regarded as the standard for
comparison with other local anesthetics. Lidocaine
is the local anesthetic most widely used for pain
control, as its pharmacokinetic charecteristics and
low toxicity, when compared with other estertype
anesthetics, make it safe for use in dental practice.
Articaine hydrochloride (HCL) or 4 methyl3(1oxo2
propylamino)propionamido)2thiopenecarboxylic Figure1: Structure of the local anesthetic molecule
acid methyl ester hydrochloride, was synthesized by
Rusching etal. in 1969, under the name of carticaine.
It was first marketed in Germany in 1976, [Figure3].
The pharmacological characteristics of this anesthetic are
responsible for its main advantages with respect to other
local anesthetics, which include the substitution of the
aromatic ring with a thiopenic ring, which increases the
liposolubility of the drug as well as its potency. Moreover,
articaine is the only amide local anesthetic containing an
ester group in its molecular structure, thus allowing the
metabolization of the drug both by plasma esterases and Figure2: Structure of lignocaine
by liver microsomal enzymes. The clinical advantages of
articaine include, the duration of its anesthetic effect and
its superior diffusion through bony tissue.[3]

The present study compares the anesthetic efficacy of

4% articaine and 2% lidocaine, both with epinephrine, on
application as the truncal block of the inferior alveolar nerve
during the surgical extraction of impacted lower third molars.

MATERIALS AND METHODS

This study was conducted at the Department of Oral and
Figure3: Structure of articaine
Maxillofacial Surgery, Saveetha Dental College, Saveetha
University, Chennai, India. The Institutional Scientific
Reduced mouth opening(Mouth opening above 30mm
Review Board and the Ethics Committee approved the
was considered normal).
protocol of this study.
Overview of the study design
Selection of subjects
A randomized, doubleblinded, controlled clinical trial
Inclusion criteria
comparing the efficacy of 4% articaine (Articaine 4%
Subjects without systemic disorders or antecedents of
Inibsa, Inibsa, Barcelona, Spain) and 2% lignocaine
complications associated with local anesthetics, and
for the surgical removal of the mandibular third molar.
presenting with impacted lower third molars requiring
(Total sample size for each group was n=360).
ostectomy and tooth sectioning for extraction, were included.
GroupI 4% Articaine group(Study group)
Exclusion criteria GroupII 2% lignocaine group(Control group).
Subjects younger than 15years, older than 50years
Statistical analysis
Pregnancy
Level of significance at 5%(0.05),
Concomitant cardiac disease, neurological disease, liver
or renal disease, hyperthyroidism, diabetes mellitus, The following methods of statistical analysis have been
and immunosuppression used in this study
Evidence of soft tissue infection near the proposed Independent ttest
injection site (localized periapical or periodontal Chisquare test using the SPSS Version12.0 statistical
infections were permitted) package throughout.

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Bhagat, et al.: Anesthetic efficacy of two different local anesthetic drugs in surgical removal of impacted mandibular third molars
Periapical radiographs were used to assess the composite
difficulty scores of the impacted mandibular third molars
based on the:
Winters classification[4]
Mesioangular(score 1)
Horizontal(score 2)
Vertical(score 3)
Distoangular(score 4).
Pell and Gregory ramus classification[5]
Class 1 Adequate space exists between the second
molar and anterior border of the ramus,(score 1)
Class2 Little space exists between the second molar
and anterior border of the ramus,(score 2)
Class 3 No space exists between the second molar
and anterior border of the ramus,(score 3).
Pell and Gregory occlusal classification[5]
Level A Occlusal surface of tooth in line with the
occlusal surface of the second mandibular molar,
(score 1)
Level B Occlusal surface of tooth at the cementoenamel
junction(CEJ) of the second mandibular molar, (score 2)
Level C Occlusal surface of tooth below the CEJ of
the second mandibular molar,(score 3).
Composite score=Wi+Rc+Oc
The patients demographic values were recorded.
Diagnosis, amount of local anesthetic solution required,
and the need to reanesthetize during the surgical procedure
were noted down.
Latency of anesthesia (onset of anesthesia of the lower
lip or, in a common mans terms, start of a tingling
sensation in the lower lip): A stop watch was used to
note down the onset. Once the needle was withdrawn
after administering the inferior alveolar nerve block the
stop watch was started and stopped when the patient
started to feel a tingling sensation of the lower lip. The
standard anesthetic procedure was performed using the
landmarkbased technique described by Malamed.[4,5]
After the inferior alveolar nerve block local anesthetic
solution had infiltrated into the vestibular and retromolar
trigone adjacent to the impacted tooth, to anesthetize the
buccal nerve and to reduce bleeding from the soft tissue
on raising the flap, the patient was advised to note down
the time when he/she felt that the anesthetic effect of the
lower lip was lost.
Duration of the anesthetic effect(loss of anesthetic effect
of the lower lip/time between onset of anesthesia and
ceasing of soft tissue numbness) is recorded via telephonic
interview.
110
After the surgical removal of impacted teeth, the VAS
and FPS chart is shown to the patient and the scores
are marked by the patient, based on the intraoperative
pain they underwent during the surgical procedure. The
details of the Visual Analog scale(VAS) and Faces Pain
scale(FPS) were explained to the patients before the start
of the surgical procedure.
The visual analog scale was shown to the patients and they
were asked to choose a particular scale, with regard to how
they felt during the surgical procedure. (Intraoperative
pain intensity: 0Absolutely no pain, 1Very mild pain,
2 to 4Mild pain, 5 to 7Moderate pain, 8, 9Severe
pain, 10unbearable pain).
The faces pain scale represents various emotional
graphics. The patient is asked to choose from the graphical
representation of emotions on how he/she felt during the
surgical procedure.(intraoperative pain intensity).
After the surgical procedure all the patients were prescribed.
Cap. Amoxicillin 500mg(TID),
Tab. AcelclofenacParacetamol(BID).
RESULTS
The findings of the study accept the null hypothesis(H0)
that there is no significant difference between the two
local anesthetic solutions and reject the alternative
hypothesis (Ha). All data were analyzed by using
the statistical program of social science (SPSS Inc,
Chicago, USA).
The mean age of the participants in the articaine group
was 28.42years and the mean age of the participants in
the lignocaine group was 29.33years, and the difference
was not statistically significant(P=0.231)[Table1].
In Group I, 57.2% (103) were male patients and
42.8% (77) were female patients. In the Group II,
58.8% (106) were male patients and 41.2% (74) were
female patients. Overall, 58%(203) were male patients and
42%(147) were female patients. There was no statistical
significance(P=0.74)[Table2].
In Group I, 87 (48.3%) had mesioangular impaction,
37 (20.7%) had horizontal impaction, 16 (8.8%) had
vertical impaction, and 40 (22.2%) had distoangular
Table1: Age distribution of the two groups
Group No. Mean Std. deviation Std. error mean
Articaine 180 28.42 6.849 0.511
Lignocaine 180 29.33 7.537 0.562
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Bhagat, et al.: Anesthetic efficacy of two different local anesthetic drugs in surgical removal of impacted mandibular third molars

impaction. In Group II, 82 (45.5%) had mesioangular
impaction, 41(22.9%) had horizontal impaction, 17(9.4%)
had vertical impaction, and 40(22.2%) had distoangular
impaction. There was no statistical difference between the
two groups (P=0.94) [Table3].
The mean composite difficulty score for Group I was
4.76 and for GroupII was 4.91 there was no statistical
difference between the two groups (P=0.204) [Table4].
The mean score on the VAS for GroupI was 2.19 and for
Group II was 3.16. The mean score for the intervention
group was comparatively less and there was a statistical
difference between the two groups(P<0.05)[Table4].
The mean score on the FPS for GroupI was 2.32 and for
Group II was 3.10. The mean score for the intervention
group was comparatively less and there was a statistical
difference between the two groups(P<0.05)[Table4].

The latency (onset of anesthetic effect) mean time in The mean duration of the anesthetic effect for GroupI was
seconds was 73.36seconds for GroupI and 84.63seconds 216.98minutes and for GroupII it was 158.49minutes.
for Group II. There was a statistical difference between The mean duration of the anesthetic effect was different
the two groups(P=0.001)[Table4]. between the two groups and the results were statistically
significant[Table4].
Table2: Gender distribution of the two groups
Gender Group Total Need to reanesthetize during the surgical procedure
distribution Lignocaine Articaine was required in few cases in both the groups. In
count
Group I 8.6% and in Group II 14.9% required
Female 74 77 151
41.2% 42.8% 41.9% reanesthetization. These values were not statistically
Male 106 103 209 significant [Figure4].
58.8% 57.2% 58.1%
Total 180 180 360
100% 100% 100.0%
DISCUSSION
Dental extractions and mainly surgical removal of an
Table3: Diagnosis distribution of the two study groups
Distribution of Group Total impacted tooth are involved with pain, fear, and anxiety in
impacted teeth Lignocaine Articaine ambulatory and otherwise healthy patients. It is difficult,
MA if not impossible to quantify pain. The overall control of
Count 82 87 169 pain in exodontia and surgical removal of impacted teeth,
% of total 22.8 24.2 46.9
DA besides tissue handling, consists of the ability to place
Count 40 40 80 an analgesic solution accurately, in proper anatomical
% of total 11.1 11.1 22.2 relationship to the structures to be operated upon. Despite
V
Count 17 16 33 this, there is no doubt that the majority of patients who
% of total 4.7 4.4 9.2 go for treatment can be managed without resorting to
H
Count 41 37 78
anything other than good local anesthetic techniques. The
% of total 11.4 10.3 21.7 results of this randomized, doubleblinded study showed
Total that 4% articaine was clinically and statistically more
Count 180 180 360
% of total 50.0 50.0 100.0 significant when compared with 2% lignocaine, although
both contain adrenaline.

Table4: Distribution of the variables assessed in

thetwostudy groups
Variables Group No. Mean Std. Std.
deviation error
mean
Difficulty score Articaine 180 4.76 1.213 0.090
Lignocaine 180 4.91 1.105 0.082
Latency Articaine 180 73.36 30.126 2.245
Lignocaine 180 84.63 36.048 2.687
VAS Articaine 180 2.19 1.543 0.115
Lignocaine 180 3.16 2.053 0.153
FPS Articaine 180 2.32 1.351 0.101
Lignocaine 180 3.10 1.750 0.130
Duration of Articaine 162 216.98 65.686 5.161
anesthesia Lignocaine 164 158.49 53.553 4.182 Figure4: Need to reanesthetize during the surgical procedure,
VAS=Visual analog scale, FPS=Faces pain scale distribution of the two study groups

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Bhagat, et al.: Anesthetic efficacy of two different local anesthetic drugs in surgical removal of impacted mandibular third molars
Latency and duration of anesthetic effect
The mean time of onset of the anesthetic effect for
Group I was found to be 72.71 seconds (1 minute and
12.71seconds) and for the GroupII, 84.4seconds (1minute
and 24.4 seconds). The latency, duration of anesthetic
effect of an anesthetic solution depends on a number of
factors, such as, intrinsic properties of the drug substance
used and the anesthetic technique employed. In this study
all the patients were administered inferior alveolar nerve
block with the classic technique, using the landmarkbased
technique described by Malamed.[6]
Accuracy of the administration techniques is another factor
influencing drug action. Other factors also affect the onset
and duration of local anesthetics, including, the affinity of
the local anesthetic to the lipid and protein components
within the nerve membrane, the intrinsic vasodilating
activity of the local anesthetic, the presence or absence
of a vasoconstrictor in the solution, and the vascularity
of the injection site. It is wellknown that the closer the
anesthetic pKa is to the pH of the local environment where
it is injected, the faster is its onset of action. Therefore, at
a tissue pH of 7.4 both 4% articaine and 2% lignocaine
have a pKa value of 7.8. However, in this study it has been
seen that 4% articaine had a better latency when compared
with 2% lignocaine. Articaine has many of the properties
of the most commonly used local anesthetics (lidocaine,
mepivacaine, and prilocaine) with the exception of the
aromatic ring and its degree of protein binding. Protein
binding of articaine is approximately 95%, as compared
to lignocaine, which has a protein binding of about 65%.
Articaine has a higher percentage, as compared to many
local anesthetics. Its chemical structure is different from
that of other local anesthetics, due to substitution of the
aromatic ring with a thiophenic ring. Moreover, the presence
of an additional ester ring provides articaine with increased
liposolubility and intrinsic potency. These differential
charecteristics are in turn clinically reflected by a shorter
latency. Cowan in his study found the latency of articaine in
application to a mandibular block to be 1.48minutes. This
may be because we measured the latency from the moment
of needle withdrawal from the patients soft tissues, while
in contrast, in the abovementioned study, they recorded
latency from the moment of needle insertion and injection
of the anesthetic.[7] Latency was around 56.03seconds for
articaine and 75.04seconds for 2% lignocaine as per the
study conducted by Alejandro, but in this case adrenaline
was used at 1:1,00,000 concentration, which may be the
reason for a shorter onset of anesthetic effect in this study.[8]
According to Malamed etal., the latency of 4% articaine in
the mandibular nerve block is 2-2.30minutes for articaine
and 2-3minutes for 2% lignocaine. The reason may be the
difference in the method of measuring the start of anesthetic
effect.[5] In our study, the start of anesthetic effect has been
112
measured based on the patients, that is, when they started
to feel the tingling sensation in the lower lip. However, in
all these studies 4% articaine had a comparatively lesser
latency period. Statistical significant results were obtained,
may be due to the increased sample size in this study.
Duration of the anesthetic effect
Duration of anesthetic effect of an anesthetic solution is
proportional to its degree of protein binding. Articaine
presents with one of the greatest proteinbinding
percentages of all amide local anesthetics, comparable
only to ultralongacting substances such as bupivacaine,
ropivacaine, and ethidocaine. The mean duration of the
anesthetic effect for 4% articaine was 217.20minutes
and for 2% lignocaine it was 158minutes. Increased
duration of the anesthetic effect gives comfort to the
patient postoperatively, due to the extended analgesia.
Latency and duration of the anesthetic effect for articaine
was both clinically and statistically significant. These
values were almost similar to the study conducted by
Alejandro etal.[7] The mean duration of anesthesia for
the 4% articaine group was 220.8minutes and for 2%
lignocaine it was 168.2minutes. In a study conducted
by Gregorio etal., in 2008, comparing the efficacy of
4% articaine and 0.5% bupivacaine, the mean duration
of anesthetic effect was 245.1016.60minutes for
articaine.[9] In a study conducted by Anna Trullenque
etal., in 2011, comparing bupivacaine and articaine, the
same results were obtained and it was concluded that
articaine seemed to be a more appropriate anesthetic for
extraction of mandibular molars, due to alonger duration
of the anesthetic effect in soft tissues, lower pain reported
by patients during the immediate postoperative period,
and the personal preference of patients for this drug.
Statistical significance may be obtained in this study
because of its increased sample size.[10] The long period
of analgesia for 4% articaine with 1:2,00,000 adrenaline,
finds an explanation in a study by Oertel etal., who
reported that the concentration of articaine in the
alveolus of a tooth after extraction was about 100times
higher than in the systemic circulation. This saturable
local articaine metabolism has been considered as
possibly contributing to the observed duration of the local
anesthetic effect, despite articaines very short systemic
half life. Moreover, the long duration of postoperative
analgesia evoked by articaine may be explained by its
ability to readily diffuse through the tissues due to the
presence of the thiopene group in the molecule, which
increases its liposolubility.[11] Although it is true that an
extended duration of soft tissue anesthesia is definitely a
qualityoflife detriment in pretty much all the patients
undergoing nonsurgical dental procedures, this is not
always the case with those undergoing surgery, especially
if there is significant soft tissue trauma.
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Bhagat, et al.: Anesthetic efficacy of two different local anesthetic drugs in surgical removal of impacted mandibular third molars
Anesthetic efficacy(Intraoperative pain
intensity, need to reanesthetize)
The intraoperative pain intensity was measured on VAS
and FPS. The mean VAS score for the articaine group was
2.18 and for the lignocaine group was 3.17. The patients
were instructed to score the intraoperative pain intensity.
The values were statistically and clinically significant. In
this study, the clinical evaluation of the efficacy of the two
anesthetic solutions was made by comparing the need for
reanesthetization during dental surgery, for the objective
assessment of anesthetic efficacy. In this study, 8.6% in the
articaine group and 14.9% in the lignocaine group required
reanesthetization during the surgical procedure. However,
the difference in the mean frequency of reanesthetization
failed to reach statistical significance. The percentage
reported for reanesthetization during the procedure, in
other studies, was high. These variations might be due to
the variations in the amount of local anesthetic solution
administered.[12] In the present study 2 to 4ml of local
anesthetic solution was used in all patients, inclusive of
the inferior alveolar nerve block and infiltration of the
anesthetic solution into the adjacent area. The difference
might be due to the difference in pain perception of the
patients, as the other studies were conducted in European
and American countries.[1315] In this study infiltration of
the local anesthetic solution into the retromolar region
and adjacent to the impacted tooth was done in order to
reduce intraoperative bleeding from the soft tissue and
to anesthetize the buccal nerve. The amount of local
anesthetic solution infiltrated into the adjacent tissues
might be different in these studies. In the other studies,
the composite difficulty score of the impacted mandibular
tooth was not discussed. Differences in the difficulty score
within the two groups were avoided by randomization.
There was an equal distribution of cases in this study.
A study done by Andrew Haase etal., compared the
anesthetic efficacy of articaine versus lidocaine, as a
supplemental buccal infiltration of the mandibular first
molar, after an inferior alveolar nerve block. Pulp testing
was done in all these cases. They defined anesthetic success
as the attainment of two consecutive 80 readings within
10minutes of the inferior alveolar nerve block and buccal
infiltration, and sustaining the 80 reading continuously
through the sixtieth minute. For the 4% articaine
formulation, pulpal anesthesia reached a plateau after the
initial gradual increase, and a fairly high percentage of 80
readings was maintained through the fiftieth minute,[16,17]
thus contributing to decreased VAS, FPS scores in the
articaine group.
When tooth sectioning is done, cuts are made through
the pulp chamber, which most patients complain is
accompanied with increased sensitivity and pain. Buccal
infiltration with articaine, which may have resulted in
Universal Research Journal of Dentistry May-August 2014 Vol 4 Issue 2
increased pulpal anesthesia, fairly reduces the VAS and
FPS in comparison to lignocaine.
The results of a systematic review by Katyal etal. provide
support for the argument that articaine is more effective
than lignocaine in providing anesthetic success in the first
molar region for routine dental procedures.[18] In addition,
both drugs appear to have similar adverse effect profiles. The
clinical impact of articaines higher postinjection pain scores
than lignocaine is negligible. Hence, articaine is a superior
anesthetic when compared with lignocaine for use in routine
dental procedures. Use in children under four years of age is
not recommended, as no data exists to support such usage.
CLINICAL IMPLICATIONS
Four percent articaine, although very expensive, was
selected based on its beneficial effects, such as, an increased
duration of anesthetic effect and better anesthetic efficacy.
CONCLUSION
We conclude that 4% articaine has better anesthetic
efficacy when compared with 2% lignocaine. This can
be explained based on its different chemical structure,
liposolubility, increased proteinbinding ability, diffusion
in the soft tissue, and increased pulpal anesthesia.
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17. AdewumiA, HallM, GuelmannM, RileyJ. The incidence of adverse
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18. Evans G, Nusstein J, Drum M, Reader A, Beck M. A prospective,
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How to cite this article: Antony Bhagat MJ, Narayan V, MuthusekharMR,
Jain AR. Comparative study of the anesthetic efficacy of 4% articaine
versus 2% lignocaine in the inferior alveolar nerve block during the
surgical extraction of impacted mandibular third molars. Univ Res J Dent
2014;4:108-14.
Source of Support: Nil, Conflict of Interest: None declared

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114 Universal Research Journal of Dentistry May-August 2014 Vol 4 Issue 2