Dental Hypotheses

: 2018  |  Volume : 9  |  Issue : 4  |  Page : 80--83

The Effect of Using Articaine Versus Lidocaine for Inferior Alveolar Nerve Block on Pain After Root Canal Treatment: A Prospective, Randomized Clinical Study

Ali Ghazalgoo1, Masoud Saatchi1, Saber Khazaei1, Elham Shadmehr2,  
1 Department of Endodontics, Dental Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
2 Devision of Endodontics, Preventive and Restorative Dental Sciences Department, University of California San Francisco, California, USA

Correspondence Address:
Saber Khazaei
Dental Research Center, School of Dentistry, Isfahan University of Medical Sciences, Isfahan 81746-73461


Introduction: The control of pain associated with root canal treatment (RCT) is crucially important in endodontics. The aim of the present study was to compare the effect of using articaine versus lidocaine local anesthetics for inferior alveolar nerve block (IANB) on pain after RCT. Materials and Methods: Eighty-eight patients diagnosed with symptomatic irreversible pulpitis of a mandibular first molar were selected. The patients randomly received either a cartridge of lidocaine or articaine using IANB. RCT was initiated 15 min after the injection. Lip numbness was a requisite for all the patients. The post-operative pain was assessed by using 170-mm visual analog scale at 0, 2, 4, 6, 12, 18, 36, and 48 h after the treatment. The data were analyzed by SPSS 22 statistical software. Results: The mean total post-treatment pain in the lidocaine group was 37.1 ± 32.9 whereas it was 25.4 ± 26.4 for articaine group (P < 0.001). Pain at 4, 6, 12, 18, and 24 h after the RCT in articaine group was significantly less than the lidocaine group (P < 0.001). Conclusion: Using articaine for IANB may increase post-RCT comfort than lidocaine. Further study is needed to confirm the results.

How to cite this article:
Ghazalgoo A, Saatchi M, Khazaei S, Shadmehr E. The Effect of Using Articaine Versus Lidocaine for Inferior Alveolar Nerve Block on Pain After Root Canal Treatment: A Prospective, Randomized Clinical Study.Dent Hypotheses 2018;9:80-83

How to cite this URL:
Ghazalgoo A, Saatchi M, Khazaei S, Shadmehr E. The Effect of Using Articaine Versus Lidocaine for Inferior Alveolar Nerve Block on Pain After Root Canal Treatment: A Prospective, Randomized Clinical Study. Dent Hypotheses [serial online] 2018 [cited 2019 Mar 26 ];9:80-83
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Full Text


The most frequent pains of the maxillofacial region are the pains of the inflammatory pulp or periapical diseases. The control of the pain in dentistry and especially in endodontics is of great importance.[1],[2] The frequency of the occurrence of pain in patients who underwent root canal treatment (RCT) has been reported to be about 40%, suggesting the need to prevent these pains.[3] The factors that are important in the occurrence of RCT-related pains are as follows: patient’s age, gender, and tooth type[4]; presence of the preoperative pains[5]; immunologic, psychological, and microbial factors[6]; and also chemical mediators.[7]

Lidocaine is the gold standard anesthetic agent. It is an amide anesthetic with a short onset of action and an intermediate duration of anesthesia when associated with epinephrine. Articaine with a heterocyclic thiophene ring has been demonstrated to achieve higher success levels than lidocaine for infiltration anesthesia in the permanent mandibular molars.[8] Clinical advantages of articaine include the duration of its anesthetic effect and its superior diffusion through bony tissue.[9]

On the contrary, there is no comparison between articaine and lidocaine in terms of their effects on the root canal post-treatment pains. Therefore, the current trial was undertaken to compare the effect of using articaine versus lidocaine local anesthetics for inferior alveolar nerve block (IANB) on pain after RCT.

 Materials and Methods

In this prospective double-blind clinical trial study, the number of the teeth was calculated 44 for each group (totally 88 teeth) on a power estimation of 80% to detect a difference of 15 between the mean pain scores of two groups at α = 0.05. Therefore, 88 mandibular first molars with the irreversible pulpitis were selected from the patients referring to the Department of Endodontics, Isfahan University of Medical Sciences (IUMS), Isfahan, Iran, and were randomly assigned to the studied groups. Regional Bioethics Committee affiliated to IUMS approved the study design and protocol (#290250). Written informed consent was taken from each patient.

The criteria for the diagnosis of the irreversible pulpitis were spontaneous pain and severe or longer sensitivity to the cold test. The selected patients showed no drug interference or any systemic disease. Exclusion criteria were as follows: pregnancy, intake of medicines other than contraceptives, history of allergy to the components of the local anesthetic solutions, local anesthesia in the area at least 1 week before the experiment, periodontal disease, or a history of trauma or sensitivity in the teeth.[10]

The patients received either a cartridge of lidocaine 2% with 1:100,000 epinephrine (Lignospan; Septodont, Saint Maur des Fosses, France) or a cartridge of articaine 4% with 1:100,000 epinephrine (Septocaine; Septodont) using IANB. All cartridges had been masked with the opaque labels and the cartridge caps and the rubber plungers with a black felt-tip marker under the sterile conditions. The cartridges received a code not known to the operator who performed the injections. All injections were performed by one operator.

Lip numbness was a requisite for all the patients to initiate the treatment. The patient was asked for lip numbness 15 min after the injection. If profound lip numbness was not achieved, IANB was indicated as missed, and the patient was excluded from the study. One patient in the lidocaine group and three patients in the articaine group were excluded from the study as a result of a lack of profound lip numbness and replaced with other patients.

After 15 min, access cavity was prepared, rubber dam was placed, and the root canal was instrumented using the crown-down technique. RCT was completed using lateral condensation of Gutta-percha and AH26 sealer (Dentsply, Detray, Germany) in a single appointment. The patients who felt pain during the treatment and needed supplemental anesthesia were also excluded from the study and replaced with other patients.

Before the injections, the patients received complete information regarding visual analog scale (VAS). In this study, a Heft-Parker VAS, a straight line of 170 mm, was used. The patients were asked to record the VAS scale at the point that best described their pain levels at 0, 2, 4, 6, 12, 18, 36, and 48 h. Patients were advised to use ibuprofen (400 mg) (Darou Pezeshk, Tehran, Iran) if experiencing pain informing the researchers.

Data were considered as mean (standard deviation) and analyzed by SPSS 22 (IBM Corp, Armonk, NY) using repeated measurement ANOVA and Mann–Whitney U-tests.


The mean total post-operative pain in patients anesthetized by lidocaine 2% was 37.1 ± 32.9 whereas it was 25.4 ± 26.4 for articaine 4% (P < 0.001). There were no significant differences between the two groups at 2, 36, and 48 h post-treatment time intervals (P = 0.683, 0.651, 0.441, respectively). On 4, 6, 12, 18, and 24 h after the RCTs, patients in articaine group experienced lower subjective pains than lidocaine (P < 0.001) [Table 1].{Table 1}

In lidocaine and articaine groups, 14 (31.8%) and 7 (15.9%) of patients, respectively, used ibuprofen (400 mg) (Darou Pezeshk).


Individuals who received lidocaine anesthetic solution recorded higher VAS scores than articaine group except to the immediately after the RCTs in which articaine group experienced higher pain ratings. This finding suggested that articaine anesthetic solution achieved higher success rates than lidocaine to control post-operative RCT pain. Furthermore, in total, the mean pain ratings were higher in lidocaine than articaine group. As the pretreatment VAS pain scores of patients in both the anesthetic groups were similar, the reported results can be related to the anesthetic solution efficacy to control the pain. The study participants also were of different age groups, therefore, the results can be applied for children or elderly. Furthermore, due to the lack of any significant effect of gender and age on the VAS pain scores, any possible effects of these parameters can be very small or even ignored.

The long-lasting effect of an anesthetic relates to its degree of protein binding as well as injection site or concentration of the vasoconstrictor present in the anesthetic solution. Articaine has significantly higher protein-binding percentages than all amide local anesthetics only similar to the ultra-long action materials like bupivacaine, ropivacaine, and etidocaine. This property is associated with a longer duration of the anesthetic effect.[11]

In the IANB, the anesthetic solution is injected near the nerve and the infiltration in the posterior region of the mandibular requires diffusion through the cortical plate. The better ability of articaine to diffuse through soft tissue and bone than other anesthetics is probably because of its thiophene group, which enhances its liposolubility.[9],[12]

In the present study, no significant differences were found between patients anesthetized by articaine and lidocaine at 2, 36, and 48 h post-operative time intervals. However, the VAS scores were significantly different on other time intervals.

Batista da Silva et al.[13] showed no significant differences between articaine and lidocaine in relation to the post-operative pain for incisive/mental nerve block resembling our findings.

The mean scores of 2% lidocaine and 4% articaine were not significantly different as shown by Sierra Rebolledo et al.,[11] when assessing anesthetic efficacy of 4% articaine versus 2% lidocaine in IANB during surgical extraction of the impacted lower third molars. Similar findings were also reported in other studies contrasting the performance of these two local anesthetics.[14],[15]

Kung et al.[16] in their meta-analysis study reported that there is an advantage using articaine over lidocaine for supplementary infiltration after mandibular block anesthesia but no advantage when used for mandibular block anesthesia alone or maxillary infiltration. Tortamano et al.[17] reported higher success rate with articaine solution than the lidocaine agents, although there were no significant differences in patients with irreversible pulpitis.

One study used classified ratings of VAS scores as mild, moderate, and severe which seems not to make a distinction between close VAS scores.[18] For this reason, we did not base our statistical analyses on the categorized VAS scores in the present study; however, we reported the frequency of different classified pain severity for both the groups.

The differences found in some studies could be because of the possible population differences or different doses of anesthetic solutions used. In the present study, a cartridge of anesthetic solution was used. This dose was selected because it has previously been found that an increase in dosage of local anesthetic does not increase its efficacy in all cases.[19] It seems that once the effective volume of the local anesthetic solution is achieved, no further benefit can be obtained by a further increase in dosage. In the case of lidocaine, this effective volume has been found to be 2.0 mL of solution.[19] In the present study, a cartridge of 1.8 mL was used in the lidocaine group.Subjective assessment of lidocaine and articaine in this study was done through VAS in which the patients were instructed to rate post-operative pain severity that has been shown to be valid. VAS ratings of the pain experiences provide a gross, however, validated, and useful measure of anesthetic efficacy. It can be applied for adults and children or the patients or investigators.[15],[20]


Within the limitations of this study, it was concluded that using articaine for IANB may increase post-RCT comfort than lidocaine. Further study is needed to confirm the results.

Financial support and sponsorship


Conflicts of interest

Saber Khazaei has editorial involvement with Dent Hypotheses.


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