The purpose of this systematic review and meta-analysis was to compare the effectiveness of articaine in pediatric dental anesthesia with the gold standard local anesthetic lidocaine using the Facial Pain Scale (FPS) and Visual Analog Scale (VAS).
The Hall technique has acceptable clinical and radiographic results comparable to that of the stainless steel crown technique for treatment for carious primary molar teeth with multi-surface lesions.
A decrease of canine overbite occurs at the time of treatment in the HT group. However, alterations to overbite subside by six months after treatment.
The clinical and radiographic performance of modified atraumatic restorative treatment was not satisfying for the treatment of multisurface caries of primary molars.
More evidence is required for clinical use, especially regarding children’s comfort and acceptance of HT.
Considering acceptable clinical and radiographic results and other advantages of HT, including less treatment time, technique simplicity, and showing high parental satisfaction, HT offers a treatment option for treatment of multisurface caries of primary molars
unpleasant sensation or emotional experience associated with potential tissue damage
(Gorczyca et al. 2013)
effective management of pain →positive relationship
(Odabas et al. 2012 & Kusu and Akyuz 2008)
positive attitude→ future dental treatments by dentists
thiophene ring instead of benzene →↑lipid solubility & diffusion
buccal/pulpal and palatal anesthesia with buccal infilt
rapid onset of action, high potency, plasma protein binding, excellent anesthetic properties, safe
(Malamed et al. 2000)
Articaine mechanism of action= lidocaine & mepivacaine
↓absorption of articaine + active components via local vasoconstriction
maintains ↑concentration of anesthetic agent for prolonged period
similar effectiveness to lidocaine
no systematic review analyzing its effectiveness based on subjective pain evaluation scales.
clinics frequently. To overcome the inconsistencies in the literature and bridging the knowledge gap, the present meta analysis was conducted to evaluate the anesthetic efficacy of articaine versus lidocaine in pediatric patients. The results of this analysis provide strong evidence that articaine is a better anesthetic agent based on subjective pain evaluating scales.
Pain control is one of the most important aspect of patient management in a dental operatory. The introduction of LAs has made dental procedures near painless. Lidocaine is considered a gold standard LA for the past five decades. Despite this effective measure of pain control, multiple needle insertions make pediatric patients quite apprehensive. Using articaine as an anesthetic agent has reduced the need for multiple injections.
to some extent, making LA administration relatively comfortable for children. Articaine is preferred because of its unique characteristics, high lipid solubility, and greater diffusion through the tissues.
superior properties of articaine
articaine not used as frequently
importance of pain management
lidocaine→ gold standard →multiple needle insertion apprehensive pediatric patient
articaine ↓need for multiple injections, more comfortable for children, high lipid solubility, greater diffusion
As in any study, strengths and limitations do exist, even in the present study design. The authors conducted this study with utmost methodological accuracy, inclusive of evaluation of the risk of bias and quality of evidence. They have highlighted eligibility criteria, conducted a comprehensive database search, and performed an independent and paired evaluation of all the included studies. Moreover, GRADE was used to evaluate the strength and quality of the evidence concerning the anesthetic effectiveness of the two agents.
Few confounding factors were taken into consideration while assessing the results of the present study. In most studies, different volumes of articaine and lidocaine had been injected but were assessed as e q u a l. Need for supplemental injections had been assessed by only two studies.
The site and route of administration were also different in most studies. The efficacy of both anesthetic agents was compared in nerve blocks in some studies and infiltration in others. Another important aspect is that the studies mostly assessed pain during the procedure but not at the time of LA administration. The sample size of the studies included was small, and the teeth selected along with the skill of operators giving injections varied greatly among different studies.
confounding factors taken into account
different volumes of articaine and lidocaine had been injected but assesed as equal
(Chenchugopal et al. 2017 & Ghadimi et al. 2018 & Jaikaria et al. 2017 & Mittal et al. 2015 & Rathi et al. 2019)
need for supplemental injections
(Ram and Amir 2006 & Arali and Myrti 2015)
site and route
IANB and infiltration
pain during treatment not at the time of administration
small sample size in studies
type of tooth/ operator skill giving LA →varied greatly
Anesthetic effectiveness was evaluated based on subjective symptoms reported by patients using pain evaluating scales. Adverse effects and onset and duration of anesthesia were also based on patients or parents reporting. Objective signs using pulp tests during or before the procedure were not assessed, which could lead to false-negative results. Subjective evaluation
of pain may not be completely reliable, as it can determine soft tissue anesthesia but not pulpal anesthesia. Hence, more studies should be conducted that are based on the objective assessment of anesthetic effectiveness of articaine.
Articaine proved to be a better anesthetic agent using both FPS and VAS. Funnel plots obtained on analyzing the parameters using both FPS and VAS were symmetric inverted plots indicating an absence of publication bias and low study heterogeneity. The scatter may be because of sampling variations alone.
adverse effects and onset and duration based on parents report
objective signs not assessed →can lead to false negative
soft tissue anesthesia Vs pulpal anesthesia
articaine better than lidocaine
funnel plots →symmetric inverted plots →absence of publication bias & low study heterogeneity
scatter→ sampling variations
Time and duration of anesthesia not included due to lack of data in the individual studies
Factors like time and duration of anesthesia and adverse effects were also reviewed but couldn’t be included in the meta analysis due to lack of data in the individual studies. Upon reviewing these factors, it was observed that the time of onset of anesthesia was less for articaine and no significant difference in adverse effects was reported between the two agents. Early
onset and prolonged effect of anesthesia, like soft tissue numbness, was also reported with articaine. This meta-analysis aimed to provide an outline of the clinical effectiveness of lidocaine and articaine in pediatric patients. All relevant studies that comprehensively compared the two agents were included, despite the confounding factors and potentially higher risk of bias.
time of onset less for articaine
no significant difference in adverse effects
articaine→early onset and prolonged anesthesia
1. The effectiveness of articaine as a local anesthetic in pediatric dentistry depending on the subjective symptoms of children was better than the gold standard Lidocaine.
2. Significantly less postprocedural pain was reported by patients following articaine administration.
3. There was a statistical difference favoring articaine over lidocaine, but this may have limited clinical significance due to the small rating difference in the Facial Pain Scale.
Take Home Message
better effectiveness of articaine compared to lidocaine
further investigation of superiority by taking into account more objective symptoms
prolonged sensory disturbances with articaine
nerve damage more common with 4% solution compared to 2%
(Hass and lennon 1995)
reports showing no difference in the incidence of paraesthesia using IANB using lignocaine and articaine