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Year : 2021  |  Volume : 13  |  Issue : 5  |  Page : 721-724  

A prospective study to assess the efficacy of 4% articaine, 0.5% bupivacaine and 2% lignocaine using a single buccal supraperiosteal injection for maxillary tooth extraction

Department of Oral and Maxillofacial Surgery, Sri Ramachandra Faculty of Dental Sciences, SRIHER, Chennai, Tamil Nadu, India

Date of Submission11-Oct-2020
Date of Acceptance24-Nov-2020
Date of Web Publication05-Jun-2021

Correspondence Address:
Deepak Chandrasekaran
Associate Professor, Dept of Oral & Maxillofacial Surgery, Sri Ramachandra Faculty of Dental Sciences, SRIHER, Chennai, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpbs.JPBS_659_20

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Introduction: The aim of this study was to demonstrate if articaine hydrochloride administered alone as a single buccal infiltration in maxillary tooth extraction can provide adequate palatal anesthesia as compared to buccal and palatal injection using lidocaine and bupivacaine. Materials and Methods: A prospective double-blinded trial was conducted on 150 patients who required maxillary tooth extraction. The patients were divided into three different groups consisting of 50 patients each. Each group was administered with 4% articaine into buccal vestibular mucosa of the tooth to be extracted, 2% lignocaine and 0.5% bupivacaine was injected into buccal and palatal side of the tooth to be extracted, respectively. Following the tooth extraction, all patients were asked to complete a 10-score Visual Analog Scale (VAS) and 5-score facial pain scale (FPS) to assess the pain on extraction. Results: According to the VAS and FPS scores, the pain on extraction between buccal infiltration of articaine and the routine buccal and palatal infiltration of lignocaine was statistically significant. Conclusion: The routine use of a palatal injection for extraction of maxillary teeth may not be required when articaine is used as a local anesthetic solution.

Keywords: Articaine, local infiltration, tooth extraction

How to cite this article:
Chandrasekaran D, Chinnaswami R, Shanthi K, Dhiravia Sargunam A E, Kumar K S, Satheesh T. A prospective study to assess the efficacy of 4% articaine, 0.5% bupivacaine and 2% lignocaine using a single buccal supraperiosteal injection for maxillary tooth extraction. J Pharm Bioall Sci 2021;13, Suppl S1:721-4

How to cite this URL:
Chandrasekaran D, Chinnaswami R, Shanthi K, Dhiravia Sargunam A E, Kumar K S, Satheesh T. A prospective study to assess the efficacy of 4% articaine, 0.5% bupivacaine and 2% lignocaine using a single buccal supraperiosteal injection for maxillary tooth extraction. J Pharm Bioall Sci [serial online] 2021 [cited 2022 Dec 6];13, Suppl S1:721-4. Available from:

   Introduction Top

The practice of dentistry has never been without the use of local anesthetics.[1] Numerous local anesthetics drugs have been formulated and used for this purpose. Local Anesthetic injections are painful and are frequently feared by the patients. Thus, a painless treatment procedure is considered one of the important practices of dentistry. Various research has aimed to discover a safer and more efficient drug. The palatal injection causes severe pain due to injection.[2] The possible reasons could be the palatal mucosa binds tightly to the underlying periosteum, which has abundant palatal innervation and displacement of tissues while giving injection.[1] One of the common complication of palatal injection include sloughing ulcer in the palatal mucosa. Out of all the injection, administration of palatal injections is less tolerated by patients. This is identified as the most hurtful procedure in dentistry and has been an etiology of fear in dentistry. About 5% of the population procrastinate dental treatment as they are scared of injection.[3] In this article, a prospective double blinded randomized control trial, prospective double-blinded study was formulated to identify whether single buccal infiltration alone is ideal for tooth extraction without a need for palatal injection and to compare the efficacy of 2% xylocaine, articaine and 0.5 Bupivacaine with 1:100,000 adrenaline when used for this technique.

   Materials and Methods Top

This prospective double-blinded trial was conducted in the oral and maxillofacial surgery department, Faculty of Dental Sciences, Sri Ramachandra Institute of Higher Education and Research Institute. The study included 150 patients, 57 males and 93 females, requiring extraction of maxillary teeth and mandibular anterior teeth. Inclusion criteria-includes all patients who can provide consent for tooth extraction between 18 and 45 years of age. Patients who have systemic conditions contraindicating tooth extraction, previous history of attempted extraction, patients who were not undergoing tooth extraction for the first time, known case of allergy to local anesthetics and patients unable to tolerate the extraction of teeth were excluded from the study. Informed consent as a mandatory protocol was obtained from all the patients. A proper medical history of the patients was obtained before the procedure. The study approval was acquired from the institutional ethics committee. Any maxillary tooth that requires removal was included in this study. The study subjects were divided into three different groups [Figure 1] consisting of 50 patients each and were double blinded. Group A patients were administered 4% articaine local anesthetic with 1:100,000 adrenaline (1.8 ml), Group B patients were administered 0.5% Bupivacaine local anesthetic with 1:100000 adrenaline (1.8 ml), and Group C local anesthetic was administered 2% lignocaine with 1:100,000 adrenaline (1.8 ml). The Operating surgeon and patients were blinded and any of the above injection was administered. After injection was administered, a 5 min delay was given for the anesthetic effect to take place [Figure 2]. The Visual Analog Scale (VAS) and Facial Pain Scale (FPS) were recorded preoperatively, after the administration of local anesthetic and post operatively. After administration of Local Anesthesia (LA), the pain score was assessed at 5 min, 7 min and 9 min. All the patients, pain assessment, was performed subjectively and objectively on 2-point discrimination test. If the pain is present even after 9 min, the procedure is considered unsuccessful and palatal injection is administered to extract the tooth. If pain was absent, the tooth extraction was performed, and the trial was considered as success, and the postoperative VAS and FPS are recorded. All the data were analyzed using windows SPSS 20.0 (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.) using Student's t-test.
Figure 1: Local anesthetic agents blinded into three groups

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Figure 2: Buccal supraperiosteal injection

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   Results Top

From this study, we found that after 5 min of LA drug administration. In Group A, 11 patients achieved successful palatal numbness and in 39 patients it was found to be absent. In Group B, two patients were successful and 48 patients failed, in Group C, all the 50 injections were painful. After 7 min, Group A had 50% success and 50% Failure, in Group B, three patients had success and 47 patients had failure. In Group C, no success was present in 50 patients. At the end of 9 min, in Group A, 49 patients had successful tooth extraction performed and one patient, Tooth extraction was not possible. In Group B, extraction was performed in 7 out of 50 patients. In Group C, extraction was performed in 2 out of 50 patients.

[Table 1] shows the VAS in Group A: preoperatively - 4.02, during LA: 0.24 and postoperatively: 0.22, Group B: preoperatively - 5.92, during LA: 2.62 and postoperatively: 5.32, Group C: preoperatively - 1.12, during LA: 2.36 and postoperatively: 6.88.
Table 1: Visual Analog Scale

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[Table 2] shows the Facial pain score in Group A: preoperatively - 1.78, during LA: 0.26 and postoperatively: 0.28, Group B: preoperatively - 2.12, during LA: 3.96 and postoperatively: 3.98, Group C: preoperatively - 2.22, during LA: 4.22 and postoperatively: 4.48.
Table 2: Facial Pain Scale

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   Discussion Top

Pain is a complex experience, which is very subjective and personal.[4] It involves constant interactions between the ascending and descending pathways.[5] Pain can be measured using VAS and FPS according to validity and consistency.[6] VAS has been found to be more sensitive.[4],[7] The main aim of palatal injection is to anesthetize the nasopalatine and greater palatine nerves, but the palatal mucosa is firmly adherent to the underlying periosteum and dense tissue, which makes the injection painful.[2] This is also because of the abundant nerve supply of the palate.[5] Numerous methods have been evolved to reduce the uneasiness of intraoral injections such as topical anesthesia, computerized injection systems, pressure administration, and transcutaneous electronic nerve stimulation.[2] However, there is not much substantiation that these methods are very efficacious and injections in the palatal region continue to be a painful experience to the patient. Pain is due to the displacement of palatal tissues rather than needle penetration. Hence, this technique is poorly tolerated by patients. Comfortable palatal anesthesia improves patient fidelity and good treatment endurance.

The option of extracting a maxillary permanent tooth without palatal injection is because the maxilla comprises a thin porous bone on the buccal aspect that aids in the diffusion of any local anesthetic agent.[2],[8]

The reversible nerve conduction blockade by articaine is similar to other amide local anesthetics.[9] However, articaine is quite different because it contains a thiophene group, which makes this drug lipid soluble. Therefore, articaine diffuses better through the nerve membrane than other local anesthetic drugs,[9] hence achieving higher intraneural concentration, extensive longitudinal spreading, and better conduction blockade.[10] To add to this action, articaine blocks ionic channels at lower concentrations than lidocaine.[11]

More than other local anesthetic agents, Articaine diffuses readily through both hard and soft tissue; hence, there is sufficient palatal tissue anesthesia.[2],[8] Uckan et al. successfully performed removal of maxillary permanent teeth by administering the only articaine into the buccal vestibular region of the tooth after a delay of 5 min without an additional palatal injection.[8]

H. Rusching et al. in 1969 prepared a amide type of local anesthetic agent with a chemical formula of 3-N-Propyl amno-Propinoylamine-2-carboxymethyl-4-methylthiophene hydrochloride and named it as Articaine. FDA approved its sales under 4% articaine solution with epinephrine 1:100,000. It is the only amide compound that contains an ester group. Metabolization of the drug takes place by plasma esterases and liver microsomal enzymes. It has same pKa and toxicity as Lidocaine but 1.5 times greater potency than lignocaine. Lignocaine is an amide local anesthetic prepared by Nils Lofgren in 1943. It is a 2-diethyl amino 2,6-acetoxylidide hydrochloride. It is metabolized in the liver and excreted in the kidney. Its pH-6.5, onset of action is 2–3 min and half-life – 1.6 h. Bupivacaine is an amide-type local anesthetic prepared by A. F. Ekhenstein in 1957. Its 1-butyl-2,6-pipecloxylidide. Its metabolized in the liver and excreted through the kidney. Its pH – 4–6.0, onset of action; 6–10 min and half-life: 2–7 h and Maximum recommended dose – 7 mg/kg.

From our study, we found that procedure pain was found to be in patients were 4% articaine local anesthetic with 1:100000 adrenaline was administered only via buccal injection, in patient were 0.5% Bupivacaine local anesthetic with 1:100000 adrenaline pain was found to better with 7 tooth extractions being performed than the lignocaine group. In the lignocaine group, only 2 tooth extractions were performed at the end of 9 min, thus making the use of lignocaine less useful for administering only buccal injection with higher postoperative pain.

   Conclusion Top

  • Articaine is an effective local anesthetic agent which can be administered on the buccal aspect to provide palatal anesthesia (98% cases). Bupivacaine and lignocaine can never be used with single buccal injection for tooth extraction. Subjective and objective assessment should be mandatorily performed before performing any tooth extraction.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Malamed SF, Gagnon S, Leblanc D. Efficacy of articaine: A new amide local anesthetic. J Am Dent Assoc 2000;131:635-42.  Back to cited text no. 1
Fan S, Chen WL, Yang ZH, Huang ZQ. Comparison of the efficiencies of permanent maxillary tooth removal performed with single buccal infiltration versus buccal and palatal injection. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:359-63.  Back to cited text no. 2
Milgrom P, Coldwell SE, Getz T, Weinstein P, Ramsay DS. Four dimensions of fear of dental injections. J Am Dent Assoc 1997;128:756-66.  Back to cited text no. 3
Briggs M, Closs JS. A descriptive study of the use of Visual Analogue Scales and Verbal Rating Scales for the assessment of postoperative pain in orthopedic patients. J Pain Symptom Manage 1999;18:438-46.  Back to cited text no. 4
Katz J, Melzack R. Measurement of pain. Surg Clin North Am 1999;9:231-52.  Back to cited text no. 5
Ponce de Leon S, Lara-Muñoz C, Feinstein AR, Wells CK. A comparison of three rating scales for measuring subjective phenomena in clinical research. II. Use of experimentally controlled visual stimuli. Arch Med Res 2004;35:157-62.  Back to cited text no. 6
Philip BK. Parametric statistics for evaluation of the visual analog scale. Anesth Analg 1990;71:710.  Back to cited text no. 7
Uckan S, Dayangac E, Araz K. Is permanent maxillary tooth removal without palatal injection possible? Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:733-5.  Back to cited text no. 8
Oertel R, Rahn R, Kirch W. Clinical pharmacokinetics of articaine. Clin Pharmacokinet 1997;33:417-25.  Back to cited text no. 9
Raymond SA, Steffensen SC, Gugino LD, Strichartz GR. The role of length of nerve exposed to local anesthetics in impulse blocking action. Anesth Analg 1989;68:563-70.  Back to cited text no. 10
Borchard U, Drouin H. Carticaine: Action of the local anesthetic on myelinated nerve fibres. Eur J Pharmacol 1980;62:73-9.  Back to cited text no. 11


  [Figure 1], [Figure 2]

  [Table 1], [Table 2]


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