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The purpose of this study was to find out if by decreasing the volume of anesthetic solution with same vasoconstrictor accompanied by extended waiting time before initiating dental treatment would be clinically effective to achieve successful anesthesia in routine dental work.

This in vivo investigation was carried out on hundred volunteers (36 males and 64females aged 14 years and above) who were randomly selected as only patients with odd national number attending the Dental Department of Prince Ali Bin Al Hussein Military Hospital.

It was found that waiting for a sufficient time after administering local anesthesia to be effective and to be of a clinical significance, half carpule of local anesthesia was found effective in 85 (85%) patients; only 15 (15%) patients needed remaining half of local anesthesia carpule.

It was concluded that half carpule of 4% articaine with 1:100,000 epinephrine with a 5-minute waiting time produced adequate anesthesia in 85% subjects. No statistically significant different in gender was found.

Key Words: Articaine, Gender, Local Anesthesia, half carpule.


Fear and anxiety from pain are considered the most important aspect that the dentist must manage properly during most of the dental procedures. There are multiple local anesthetic solutions that are used nowadays, so the dentists should have a good understanding of the anesthetic agents, their mechanism of action, and their clinical effectiveness.1

One essential and critical step in Dentistry is to have painless dental procedure, at the same time the extra volume of any medication is not advisable and local anesthesia is no exception. A minimum amount of local anesthetic solution should be used to avoid the harmful side effect.2

This will also give us a better opportunity to observe our patients against any adverse effect that could happen before initiating dental treatment.

During the use of anesthetic solutions, it is important for the clinician to understand the onset, depth, and duration of anesthetic agent in order to choose the right one for the patient. Ideally, the selected anesthetic agents should have a shorter onset time and should be sufficient and stay all the time necessary to do and finish the specific procedure, without an extended recovery period.

Articaine is considered an amide and safe local anesthetic with a specific characteristic in its structure that includes a substitute of the aromatic ring with a thiophenic ring which gives it multiple clinical advantages, including the lipo-solubility of the drug, its superior diffusion through bony tissue as well as its duration of action (1.5 times >that of lidocaine) and only surpassed by ultra-long acting anesthetics such as ropivacaine and bupivacaine. A second molecular difference between articaine and other amide local anesthetics, the extra ester group in its structure allowing hydrolysis of the drug both by plasma esterases and by liver microsomal enzymes.4,5 The volume of local anesthetic solution needed to achieve pulpal anesthesia during local infiltration ranged between 0.5 to 2.0 mL.6

The purpose of this study was to find out if by decreasing the volume of anesthetic solution with same vasoconstrictor concentration accompanied by extended waiting time before initiating dental treatment would be clinically effective to achieve successful anesthesia.



This in vivo investigation was carried out on one hundred volunteers (36 males and 64 females aged 14 years and above) who were randomly selected as only patients with odd national number attending the Dental Department of Prince Ali Bin Al Hussein Military Hospital. This clinic deals with dental work that includes routine dental fillings like amalgam and composites. All patients had a free medical history and they were not sensitive to any anesthetic agent or its conservative and they were not taking any medication that may affect the response to the local anesthetic agent. Also, patients with trauma or ulceration in the oral cavity were excluded from this study. The Royal Medical Services Ethics Committee approval was obtained. Patients did not known the volume of anesthetic solution that was injected but were informed that an extra volume will be immediately administered once they have experienced pain during dental procedures.

This is routine in our daily dental work when we give an extra volume of anesthetic solution or we use an alternative technique once the patient feels pain after subjective/objective signs of successful anesthesia.

Pain assessment and experiment

Infiltration local anesthesia was given to the assigned tooth/teeth where for routine dental work (Cavity preparation for Amalgam, Composite or Glass Ionomer Cement) were needed. Only half the cartridge 0.9 ml of 4% articaine HCl with 1:100,000 epinephrine by Septodent(r) were administered by one dentist using a short needle gauge 27 (Tg Ject Sterilized Disposable Dental Needles, UK) was given to all patients with the bevel facing toward the periosteum into the alveolar mucosa and the solution was deposited in one minute. There was 5 minute waiting before proceeding with dental treatment.

The treatment was carried out by another dentist who began with probing the infiltration area using sterile short needle gauge 27 without penetrating the sub-mucosal tissue and by asking the patient if they feel numbness. If no pain was felt by the patient, the dental practitioner proceeded to cavity preparation in each specific tooth. During the procedure if the patient felt any pain this was recorded by the operating dentist and the patient was given the remaining 0.9 mL or more until the patient felt no pain. In either condition, the procedure was completed painlessly.


A total of 100 dental patients consisting of 64 (64%) females and 36 (36%) males were included in the study. (Table 1) Table 2 shows the number of patients who were given half carpule of local anesthesia and patients who needed another carpule half of local anesthesia to be effective. Half carpule of local anesthesia was sufficient to be effective in 85 (85%) patients. Only 15 (15%) patients required another half of local anesthesia carpule. Table 3 shows the relation between gender and efficiency of local anesthetic 4 (11.1%) of 36 males needed to be given another half of carpule compared with 11 (17.19%) of 64 female need to be given another half of carpule, which are statistically insignificant p value > 0.05.





Valid Male###36###36.0###36.0###36.0







Not Effective###15###15.0###15.0###15.0







half car-


###P value


###= 0.12*

full car-




In this study, maxillary infiltration anesthesia was used to assess the efficacy of local anesthetic solution because maxillary infiltration has a higher rate of suc- cess than mandibular anesthesia.3 We use articaine as a local anesthetic solution because of its availability in our department and most of studies have reported a superior efficacy of articaine than other routinely used local anesthetic solutions.7 Clinical Research Associates reported that a majority of 94 dentists surveyed claimed that articaine's effects were more profound than other routinely used anesthetic solutions.8

Sreekumar and Bhargava compared maxillary infiltration anesthesia with 1.2 mL and 1.0 mL of articaine with epinephrine and concluded that a faster onset, a greater success rate, and a longer duration was achieved when a volume of 1.2 mL was used than when volumes <1.0 mL were used.1

Srinivasan and Kavitha compared the effect of two local anesthetics (4% articaine and 2% lidocaine) in posterior maxilla in patients with irreversible pulpitis and they concluded that the efficacy of 4% articaine was superior to 2% lidocaine for maxillary buccal infiltration.8

Alan et al compared the anesthetic efficacy of 2% lidocaine with 1:100,000 epinephrine (1.8 mL and 3.6 mL) for maxillary infiltrations and they concluded that the onset of pulpal anesthesia was not statistically different between the two volumes, however the 3.6 mL volume provided a statistically longer duration of pulpal anesthesia for the lateral incisors, first premolars, and first molars.9

Studies done by Martinez et al reported that the mean latency of articaine was 2.01 minutes.11 While other authors reported that the time of onset of articaine was between 1-2 minutes. This difference was due to the variations in the amount of vasoconstrictor present in the anesthetic solution that has been studied.6,12 To ensure the effect of the injected first half of the carpule, we waited for 5 minutes. Most of studies have reported that the onset of maxillary infiltration anesthesia takes from 2-3 minutes.13,14

Results of the present study show that 0.9 mL of articaine with a 5 minute waiting time was sufficient in 85% of patients and anesthesia was completely successful. In only 15% of patients another 0.9 ml was given (total 1.8 ml) to achieve pulpal anesthesia. Percentage of females who required a full carpule was slightly higher than males with no clinical significance. This agreed with Pleym et al who found no difference in anesthetic effect between males and females.15


1 K. Sreekumar and D. Bhargava. Comparison of onset and duration of action of soft tissue and pulpal anesthesia with three volumes of 4% articaine with 1:100,000 epinephrine in maxillary infiltration anesthesia. Oral Maxillofac Surg 2011; 15:195-99.

2 Salonen M, Forssell H, Scheinin M: Local dental anaesthesia with lidocaine and adrenaline. Effects on plasma catecholamines, heart rate and blood pressure. Int J Oral MaxillofacSurg 1988; 17: 392-94.

3 Paula Cristina, Maria Cristina. Anesthetic Efficacy of 3 Volumes of Lidocaine With Epinephrine in Maxillary Infiltration Anesthesia. Anesth Prog 2008; 55:29-34.

4 Malamed SF, Gagnon S, Leblanc D. Articaine hydrochloride: a study of the safety of a new amide local anesthetic. J Am Dent Assoc 2001;32:177-85.

5 Oertel R, Rahn R, Kirch W. Clinical pharmacokinetics of articaine. Clin Pharmacokinet 2007; 33:417-25

6 Malamed SF. Handbook of Local Anesthesia. 5th ed. St Louis, Mo: Mosby; 2004: 53-59, 160-64.

7 Narasimhan Srinivasan and Mahendran Kavitha. Comparison of anesthetic efficacy of 4% articaine and 2% lidocaine for maxillary buccal infiltration in patients with irreversible pulpitis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009; 107: 133-36.

8 Christensen, G.J. Treating the potential problem patient. Journal of the American Dental Association 2001; 132 (11), 1591-93.

9 Alan Mikesell, Melissa Drum and Al Reade. anesthetic efficacy of 1.8 ml and 3.6 ml of 2% lidocaine with 1:100,000 epinephrine for maxillary infiltrations. JOE - 2008; 34(2).

10 Costa, C.G. et al. Onset and duration periods of articaine and lidocaine on maxillary infiltration. Quintessence International 2005; 36 (3), 197-201.

11 Martinez-Gonzalez JM, Benito-Pena B, Fernandez-Caliz F, San Hipolito-Marin L, Penarrocha_DiagoM. Estudio comparative entre el bloqueo mandibular directo y la tecnica de Akinosi. Med Oral 2008; 8:143-49

12 Berini-Aytes L, Gay-Escoda C. Anestesia odontologica 2000, 2nd edn. Ediciones Avances Medico-Dentales, S.L, Madrid

13 Lee S, Reader A, Nusstein J, Beck M, Weaver J. Anesthetic efficacy of the anterior middle superior alveolar (AMSA) injection. Anesthesia progress. 2004; 51(3): 80.

14 Perry DA, Loomer PM. Maximizing pain control. The AMSA Injection can provide anesthesia with few injections and less pain Dimensions of Dental Hygiene. 2003; 1: 28-33.

15 Pleym H1, Spigset O, Kharasch ED, Dale O. Gender differences in drug effects: implications for anesthesiologists. Acta Anaesthesiol Scand. 2003 Mar; 47(3): 241-59.
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Publication:Pakistan Oral and Dental Journal
Article Type:Report
Date:Dec 31, 2016

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