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.

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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

allaying their fear and anxiety

• LA →double edged sword in pediatric dentistry
• comfort & painless treatment
• LA →most common source of fear and dental anxiety
• 2% lidocaine gold standard since 1941

(Malamed 2012)

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pain upon insertion→ apprehensive child

• reducing the need for supplemental injections and multiple needle insertion in the oral mucosa
• controlling the ↑failure rate of IANB
• controlling excessive pain→ palatal infilt

(Claffey et al. 2004)

Techniques not used universally used to reduce discomfort of LA injection:

• topical anesthetics
• transcutaneous electronic nerve stimulation (TENS)
• computerized injection system
• pH buffering
• eutectic mixture of LA
• warming the anesthetic solution

Articaine

• 1976
• amide and ester
• biotransformation:

• plasma →plasma esterase

• liver →microsomal enzymes

• 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
• vasoconstrictor
• ↓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.

Discussion

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.

• subjective symptoms

• 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

Conclusion

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

Knowledge exchange

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

(Mikesell et al. 2005 and pogrel 2007)

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Efficacy of Articaine vs Lignocaine

Malamed et al. 2000

• RCT
• 4% articaine 1:100K adrenaline and 2% lidocaine 1:100K
• 4-13 years
• Safe and effective

Arali and Mytri 2015

• Comparison of 4% articaine (infilt) and 2% ligno (IANB)
• RCT
• 40 children
• 5-8 yrs
• Less pain in articaine
• Less need for supplemental injections with articaine

Arrow 2012

• 4% articaine (1:100K adr) with 2% ligno (1:80K adr)
• IANB or buccal infilt in children in mandibular FPM
• Higher success rate with IANB, less painful than infilt
• 25% mod- severe pain after clinician determined that LA was successful

Meta- analysis ,→better analgesia achieved by articaine vs lignocaine:

Katayal 2010 ( 1.31 times more FPM anaesthesia achieved with articaine vs lignocaine, using infilt)

Brandt et al. 2011 ( successful pulpal analgesia, articaine produced analgesia 2.44 times more than ligno)

infilt with articaine more effective than infilt with ligno for FPM:

• Katyal 2010
• Brandt et al. 2011

buccal infilt with 4% articaine= articaine 4% IANB

(Poorni et al. 2011)

more successful FPM analgesia using buccal infilt with articaine compared to ligno IANB

(Corbett et al. 2008 )

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