JICDRO is a UGC approved journal (Journal no. 63927)

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ORIGINAL RESEARCH
Year : 2021  |  Volume : 13  |  Issue : 1  |  Page : 28-34

Comparison of lignocaine versus articaine local anesthetic solutions in periodontal therapies administered by computerized anesthetic delivery system


Department of Periodontology, JSS Dental College and Hospital, JSS Academy of Higher Education and Research, Mysore, Karnataka, India

Date of Submission14-Aug-2020
Date of Decision19-Feb-2021
Date of Acceptance02-Mar-2021
Date of Web Publication26-Jun-2021

Correspondence Address:
Dr. P C Deepika
Room No. 9, Department of Periodontology, JSS Dental College and Hospital, Mysore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jicdro.jicdro_52_20

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   Abstract 


Objectives: To compare the depth and duration of anesthesia experienced by the patient between lignocaine and articaine anesthetic solutions and to evaluate pain perception and intraoperative anxiety by computer-controlled injection while administering these anesthetic solutions. Materials and Methods: The clinical trial was designed as a randomized, single-center, double-blinded, parallel arm, and comparative study. Examiner and study patients were blinded to treatment assignment during the study. Patients were divided into three groups based on treatment to be performed (Root Planing 30, Curettage 30, and Surgery 20) and were anesthetized with articaine in one quadrant and lignocaine in another quadrant by computer-controlled anesthetic device (WAND®). The duration of anesthesia was self-reported by the patients and was calculated by paired t-test. The pain and anxiety scores were calculated on Wong Baker's Facial Pain/Anxiety Scale' by Chi-square test. Results: Articaine had longer duration of anesthesia than lignocaine in all the three groups (P < 0.000). Articaine showed significantly lesser pain scores than lignocaine in Root Planing Group (P < 0.000). There was no significant difference in anxiety scores between different groups. Conclusion: Articaine has longer duration of anesthesia. Articaine administration was less painful than lignocaine administration.

Keywords: Anxiety, articaine, duration, lignocaine, pain, WAND


How to cite this article:
Vivek HA, Deepika P C, Sharma M. Comparison of lignocaine versus articaine local anesthetic solutions in periodontal therapies administered by computerized anesthetic delivery system. J Int Clin Dent Res Organ 2021;13:28-34

How to cite this URL:
Vivek HA, Deepika P C, Sharma M. Comparison of lignocaine versus articaine local anesthetic solutions in periodontal therapies administered by computerized anesthetic delivery system. J Int Clin Dent Res Organ [serial online] 2021 [cited 2021 Dec 9];13:28-34. Available from: https://www.jicdro.org/text.asp?2021/13/1/28/319526




   Introduction Top


For the success of any dental procedure, profoundness of anesthesia is of paramount importance.[1] Painless anesthesia is critical for achieving confidence of the patient.[1] When local anesthesia is administered properly it affords advantages such as patient comfort, cooperation, and increased operator performance.[2] Despite the skill of the operator and care with which injection is administered the pain of the injection and the anxiety that comes with it continue to plague the profession.

Numerous studies have been conducted in an effort to alleviate pain and discomfort associated with injection.[3] Various techniques to increase the profoundness of local anesthesia by the traditional method have been tried including topical anesthetic, increased injection time, light hand approach, excellent chairside manners, preliminary supportive communication, gentle touch, and intra pocket anesthesia but with limited results.[4],[5],[6]

In the quest to achieve painless administration of local anesthesia, the WAND® (Milestone Scientific, Livingston, NJ) which is a computer-controlled local anesthetic device has been developed as a potential means to reduce or virtually eliminate the pain associated with dental injections.[4] It has been reported to show significantly less or painless delivery of local anesthesia thus benefiting the patient as compared to delivery of anesthesia by manual syringe.[4]

Dentistry has always prided itself on being as close to “painless” as possible.[7] In the late 1940s a new group of local anesthetic compounds, the amides, were introduced.[7] The initial amide local anesthetic, lidocaine (Xylocaine), and revolutionized pain control in dentistry worldwide.

A new amide local anesthetic, articaine hydrochloride was introduced by Rusching et al. in 1969[7] [Figure 1]. Articaine has a molecular weight of 320.84.1.[7] Articaine is the only widely used local anesthetic that also contains an ester group.[7] In addition, it is unique among local anesthetics in that it is the only local anesthetic which possesses a thiophene group (in place of a benzene ring).[7] This gives articaine greater liposolubility which causes faster diffusion and deeper penetration thus making the drug quite appreciable in dentistry.[7]
Figure 1: molecular representation of articaine hydrochloride

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The biotransformation of articaine occurs in both the plasma (hydrolysis by plasma esterase) and liver (hepatic microsomal enzymes).[7] Articainic acid, the primary metabolite, is pharmacologically inactive.[7] Articaine is eliminated through the kidneys.[7] Approximately 5% to 10% is excreted unchanged.[7]

However, the evidence basis for articaine's reputation is not entirely clear. Despite articaine's popularity, there is contradictory evidence to support the claims. In a meta-analysis done by Vandana Katyal the findings indicated that articaine injection can cause more post injection pain in the area injected than lignocaine.[8]

Clinically, lignocaine continues to remain the choice of anesthesia for administration. Moreover, the literature shows research of comparison between these two drugs only pertaining to the pediatric population with no study emphasizing on adult patients with periodontal disease.

Hence, the aim of this study is to compare lignocaine versus articaine local anesthetic solutions in periodontal therapies administered by WAND® with an emphasis on the pain perception and anxiety levels.


   Materials and Methods Top


Experimental design

The clinical trial was designed as a randomized, single-center, double-blinded, parallel arm, and comparative study. Clinician and study patients were blinded to treatment assignment during the study.

Sample size estimation

Based on the prevalence of periodontitis as 28% (p), confidence interval of 95% (z) and confidence level of 10% (d), Sample size (N) was calculated by formula.

N = z2 pq/d2 where q equals 1−p. The value was 77. Hence, a sample size of 80 was decided.

The prevalence of periodontitis in adults is considered to be 14%.[9]

Study population

Totally, 104 patients were examined and 93 patients in need of periodontal treatment were selected for the study. The patients ranged in age from 25 to 54 years. The mean age was 33.479 years [Table 1].
Table 1: Patient demographic and clinical data

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Of the patients selected, five patients declined to participate in the study. Two patients were pregnant, one was under sedative-hypnotic medication, two patients were uncontrolled diabetics, two were suffering from uncontrolled hypertension and hence were not included in this study. One patient fell sick so was also excluded from this study. Hence, the study population included 80 patients, of which, 32 were female and 48 were male. The study was carried on from January 2014 to August 2014.

The research was conducted in agreement with the guidelines of the Helsinki Declaration as revised in 1975. The study proposal was submitted for approval and clearance was obtained from the ethical committee, of our institution. An informed consent was obtained from each patient.

The following inclusion criteria were used:

Patient willing to take part in the study, age group 18–45 years, patients in whom the use of local anesthesia (Lignocaine and Articaine) is not contraindicated due to hypersensitivity or any other systemic condition.

The following exclusion criteria were used:

Pregnant/nursing women, patients on uncontrolled systemic disease unfit for any periodontal procedure, patients who are otherwise not able to understand and interpret the Wong Baker's Facial Pain/Anxiety Scale' (WBFPS)/(WBFAS) [Figure 2] due to mental challenge or any other reason (Those on medication such as antipsychotics, anti-depressants, and sedative-hypnotics).
Figure 2: wong baker's facial pain/anxiety scales

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For the selected patients at the first examination demographic and medical data were recorded. The whole oral cavity was clinically assessed to examine periodontal conditions and necessary radiographs if required were taken. The patients were divided into Root Planing group (n = 30), Curettage group (n = 30), and Surgical intervention Group (n = 20) as indicated.

Clinical examination

First visit

The patient underwent ultrasonic scaling after which he/she was scheduled for Root Planing/Curettage or Surgical intervention in the subsequent appointments.

Second visit

This visit was scheduled after a gap of 15 days. On this appointment, the quadrants were randomly selected by computer randomization and one quadrant was allotted to articaine group, whreas contralateral quadrant was allotted to lignocaine group. The local anesthesia was delivered using WAND® equipment.

Injection by the WAND®

[Figure 3] The WAND® (Milestone Scientific, Inc., Livingston, N. J.) was the equipment used for computer-controlled local anesthesia delivery. The equipment comprised of disposable component handpiece component and a computer control unit. Handpiece was an ultra-light pen-like handle, which was linked to an anesthetic cartridge, with plastic microtubing. The procedure was followed as per the manufacturer's instructions. The delivery of local anesthesia was done under cruise control mode of the equipment at slow speed, regulated by a pedal. 1.8 ml single-use anesthetic cartridge of lignocaine (Lignospan special-Septodent-France, consisting of 2% lidocaine with 1:80,000 epinephrine) and 1.7 ml anesthetic cartridge of articaine (Septanest special Septodont-France, consisting of 4% articaine with 1:100000 epinephrine) were used.
Figure 3: computer-controlled local anesthetic device showing cartridge and WAND handpiece mounted on the device

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All the injections were administered by WAND® in the cruise control mode of the equipment.

The volume of local anesthesia administered for each block was standardized and divided arbitrarily, as the anesthetic cartridge was not calibrated by the manufacturer.

After administration of anesthesia, patients' pain perception regarding the experience of the local anesthetic injection was done, using WBFPS [Figure 4].
Figure 4: evaluation with Wong baker's facial pain/anxiety scale

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Periodontal treatment phase

During this phase necessary periodontal therapy was performed, on one side of the selected arch after the confirmation of the onset of local anesthesia effect.

Furthermore, during this phase, evaluation of the patient anxiety was graded on WBFAS.

Third visit

This visit was scheduled after minimum washout period of 24 h.

During this visit, periodontal therapy of the contralateral side on the selected arch was done, by the local anesthetic solution other than the solution used during first anesthetic exposure. All the phases and evaluations were same as that of the first visit.

The patients belonging to the surgical intervention group were scheduled for surgery after performing phase 1 therapy.

Statistical analysis

The data obtained were subjected to statistical analysis using IBM SPSS statistics for Windows, Version 20.0 (IBM corp., Armonk, N.Y, USA). The comparison of duration of anesthesia was done by paired t-test. The intragroup comparison of pain score was done by Chi-square test. Values of P < 0.05 were considered to be statistically significant.


   Results Top


The flow chart of the experimental study design is presented in [Figure 5]. A total of 80 patients were selected for the study, who received both the types of local anesthetic solutions–”Lignocaine hydrochloride and Articaine hydrochloride.”
Figure 5: consort chart

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The mean values of pain were calculated [Table 2], [Table 3], [Table 4]. Paired sample t-test, Chi-square test were the statistical tests used for comparison of various variables.
Table 2: Mean values of Wong Baker's Facial Pain Scale scores in root planning group

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Table 3: Mean values of Wong Baker's Facial Pain Scale scores in surgical group

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Table 4: Mean values of Wong Baker's Facial Pain Scale scores in curettage group

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The results of this study are described under the following headings:

  1. Assessment of pain perception
  2. Assessment of anxiety
  3. Duration of anesthesia.


Assessment of “pain perception” by-”Wong baker's facial pain scale” scores

The WBFPS scores between articaine and lignocaine were significant in Root Planing group with articaine showing less pain score than lignocaine. However, nonsignificant difference was observed, in the mean values of WBFPS scores, between the local anesthetic solutions in the other groups [Table 5], [Table 6], [Table 7] and [Figure 6].
Table 5: Comparison of pain scores between lignocaine and articaine in root planning group

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Table 6: Comparison of pain scores between lignocaine and articaine in curettage group

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Table 7: Comparison of pain scores between lignocaine and articaine in surgery group

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Figure 6: the figure shows Articaine having significantly longer duration of anesthesia than lignocaine

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Assessment of “anxiety” by “Wong baker's facial anxiety scale”

The intraoperative anxiety experienced by patients in all procedures was nonsignificant.

Assessment of duration of anesthesia

A very highly significant difference was observed between the duration of anesthesia of articaine hydrochloride and lignocaine hydrochloride with articaine showing a significantly longer duration as compared to lignocaine (P < 0.000) [Table 8] and [Figure 7].
Table 8: Comparison of duration of anesthesia between articaine and lignocaine with articiane showing significantly longer action than lignocaine

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Figure 7: the figures shows comparison of mean values of Wong baker's facial pain scale scores of the two groups

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   Discussion Top


The results of this study quantify the previous research based on the comparison of articaine hydrochloride and lignocaine hydrochloride in several ways and fills up the lacunae present in the use of advanced anesthetic techniques in the day-to-day clinical dental practice.

A cross-over split-mouth design was adopted for this study, where the patient receiving one type of local anesthetic solution on one side of the arch, subsequently received the other type of local anesthetic solution on the contralateral side of the same arch. Hence, the patient himself acted as a control.

The duration of anesthesia was calculated in this study. The starting point of this parameter was the point when the anesthetic solution was administered to the patient till the time the anesthesia wore off and patients' normal sensation returned back. The time at which the block was administered was informed to the patient at the end of procedure and the patient was asked to follow-up the timing. The patients were asked to record the timing when the anesthesia wore off. This timing was reported by patient to the operator later by telephone call.

The patients were divided into Root Planing group (n = 30), Curettage group (n = 30), and Surgical intervention group (n = 20) as indicated.

The volume of anesthetic solution to be delivered and the time taken for the delivery of each local anesthetic block was standardized and followed the guidelines.[10]

The gauge of the needle used was standardized being 26-gauge long needle. Even though the washout period was of minimum 24 h, all the patients were treated after a gap of 3–4 days in the contralateral quadrant.

In the surgical group, the patients were taken up for surgery after completion of basic therapy, and anesthesia which was administered on day of surgery was considered part of study.

The intraoperative anxiety was recorded by the WBFAS which has proved to be a reliable and valuable scale for assessment of anxiety.[3]

The pain perception was a parameter in this study. The pain experienced by the patient while administering the injection was measured in this study. The WAND® creates continuous positive solution pressure to deliver anesthetic solution that precedes needle path virtually eliminating the pain as needle penetrates through tissue. This essentially constitutes the principle of the equipment.

It was found that articaine was significantly less painful than lignocaine only in Root Planing group. However, it was insignificant in other two groups. The reason for same could not be explained.

Furthermore, the overall pain scores in our study were less. This goes in accordance with a study done by Meet Shah et al.[9] in which comparison between lignocaine anesthetic solution administered by WAND® versus traditional syringe has been done. This study showed high pain scores with traditional injection.

The overall observations of this study, suggest that the articaine hydrochloride resulted in significantly longer duration of anesthesia compared to lignocaine hydrochloride.

In a study conducted by Camila et al. in 2010 comparison between anesthetic efficacies of articaine versus lignocaine pertaining to incisive nerve block has been performed. This study focuses on pediatric dental patients and does not include any treatment procedure. It was found that articaine has significantly longer duration of anesthesia.

The results go in accordance with our study regarding duration of articaine. However, our study focused on periodontally compromised patients. Furthermore, most of the blocks have been compared in our study. Furthermore, in our study the anesthesia was followed by comprehensive tailored made treatment approach.

In another study performed by D. Ram et al. in 2006, comparison between the above two anesthetic solutions was done using traditional syringe. The study showed longer duration of anesthesia for articaine but equality between the efficacies of the two solutions. Furthermore, the study focused only on pediatric dental patients,[11] whereas our study focused on periodontally compromised patients.

The above two mentioned studies have used traditional syringe as a means to deliver local anesthesia whereas we have used WAND®.

Furthermore, most of the studies in this field have been conducted on pediatric patients with traditional anesthetic administration technique.[4],[11],[12],[13]

Ours is the first study to consider periodontally compromised adults. Furthermore, administration and comparison of local anesthesia by computer-controlled anesthetic delivery system in periodontally compromised patients with articaine and lignocaine has been performed for first time in our study to the best of our knowledge.

A very less pain experience was documented as the blocks were administered by WAND®. Hence, this system can be used in apprehensive patients.

However, the cost factor of WAND® equipment and associated armamentarium (disposable plastic microtubing) remains a matter of concern particularly in Indian scenario, and hence makes it difficult to be used in regular dental practice.

The present study has carefully considered all the factors and parameters that need to be assessed for local anesthetic solution for the purpose of dental treatment in periodontally compromised patients.


   Conclusion Top


An in vivo comparative study was carried out to evaluate the difference in pain perception, intraoperative anxiety, and duration of anesthesia' with two different local anesthetic solutions lignocaine and articaine.

On summarizing following conclusions were made from the data obtained:

  • Duration of anesthesia was significantly longer in areas anesthetized by articaine hydrochloride than lignocaine hydrochloride in all the procedures
  • The WBFPS scores between articaine and lignocaine were significant suggesting that articaine administration was less painful in all the procedures.


However, future research in the field of alternative methods of local anesthetic solutions in periodontal patients, considering the variations in anxiety patterns should be explored, to efficiently and comprehensively render dental treatment to the patient.

Acknowledgment

We would like to thank Dr. B. Nandlal (HOD), Dr. Srilatha, and Dr. Seema Deshmukh from the Department of Pediatrics and Preventive Dentistry for their support. Dr. Avinash BS and Dr. Bhagyalakshmi Avinash, Readers department of Periodontology and Orthodontics respectively, for statistical evaluation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Shah M, Shivaswamy S, Jain S, Tambwekar S. A clinical comparison of pain perception and extent of area anesthetized by Wand(®) and a traditional syringe. J Indian Soc Periodontol 2012;16:207-12.  Back to cited text no. 1
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Katyal V. The efficacy and safety of articaine versus lignocaine in dental treatments: A meta-analysis. J Dent 2010;38:307-17.  Back to cited text no. 8
    
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Malamed, Stanley F. Handbook of local anesthesia 6th edition. St. Louis, Missouri: Elsevier: 2013.  Back to cited text no. 10
    
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Ram D, Amir E. Comparison of articaine 4% and lidocaine 2% in paediatric dental patients. Int J Paediatr Dent 2006;16:252-6.  Back to cited text no. 11
    
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Batista da Silva C, Berto LA, Volpato MC, Ramacciato JC, Motta RH, Ranali J, et al. Anesthetic efficacy of articaine and lidocaine for incisive/mental nerve block. J Endod 2010;36:438-41.  Back to cited text no. 12
    
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Arrow P. A comparison of articaine 4% and lignocaine 2% in block and infiltration analgesia in children. Aust Dent J 2012;57:325-33.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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