Articaine use in children: a review.
Local analgesia can be one of the most challenging aspects of paediatric dentistry. An ideal agent should provide maximum efficacy using a minimum number of injections while causing negligible adverse effects. While lidocaine has been the gold standard local analgesia agent for the past 50 years, the search for a more effective agent has continued. Articaine was developed in Germany in the early 1970s, but its use in Ireland and the UK only came to the fore in 2006 during a shortage in supply of lidocaine. Since then articaine has become increasingly popular for adult dentistry, however an uncertainty exists among dentists regarding the safety of articaine in children. Although the safety and efficacy of articaine has been proven and it is reported to be comparable [Malamed et al., 2000a] or superior to lidocaine [Brandt et al., 2011], a survey of American general and paediatric dentists found that the majority of respondents still prefer lidocaine for use in children [Brickhouse et al., 2008].
How is articaine different? Articaine hydrochloride is an amide type local analgesia [Malamed, 1997]. It acts in a similar way to other amide analgesia but its unique chemical structure offers advantages over traditional amide analgesias. Articaine contains a thiophene ring which makes it more potent and more lipid-soluble, thereby enabling it to diffuse more readily through both hard and soft tissue. In addition, articaine has a high affinity for plasma protein binding and it is the only amide analgesia to contain an ester group; this allows it to be rapidly broken down into its inactive state, thus decreasing systemic toxicity [Malamed et al., 2000a; Oertel et al., 1997]. Articaine is manufactured as a 4% solution with 1:100,000 or 1:200,000 adrenaline in 2.2ml and 1.7ml glass dental cartridges. Both concentrations impart a rapid onset of analgesia and a similar degree of pulpal (approximately 1 hour) and soft tissue analgesia (3-5 hours) [Malamed et al., 2000a].
Is articaine safe to use in children? Articaine 4% 1:100,000 is reported to be a well-tolerated, safe and effective local analgesia for use in children [Dudkiewicz et al.,1987; Wright et al., 1989; Malamed et al., 2000a; Malamed et al., 2001; Ram and Amir, 2006; Adewumi et al., 2008; Katyal at el., 2010]. Articaine is 1.5 times as potent as lidocaine [Wright et al., 1989; Malamed, 1997] so administration uses a smaller volume of solution but a higher concentration of drug. This reduced volume may be of value in decreasing the discomfort of analgesia administration, particularly where co-operation in children is inadequate. Wright specifically investigated the use of articaine in paediatric dental patients less than 4 years of age with promising results [Wright et al., 1989], however the manufacturers still do not recommend it for children younger than 4 years. A recent systemic review had to conclude that there was insufficient data to support use of articaine in very young children [Katyal et al., 2010]. Precautions when using articaine are similar to those when using other amide products, specifically in children under 4 years of age. As with all medication, dosage should be calibrated on a mg/kg basis for children. Metabolism of articaine is age dependent and the clearance and volume of distribution decreases with increasing age [Oertal et al., 1999]. Due to these age related differences in pharmacokinetics, it has been reported that there is no need to fix a lower mg/kg articaine dose limit for children [Jakobs et al., 1995]. The current child dosage recommendation for articaine is 7mg/kg (Table 1); however some authors have advocated a lower limit of <5mg/kg for children aged 4-12 years, especially if used in conjunction with sedative agents [Wright et al., 1989]. In any case, while smaller volumes of articaine can be administered it must be remembered that the concentration of articaine is twice that of lidocaine so that the safe number of cartridges must be halved (Table 1). This maximal dosage could easily be exceeded if dentists are not vigilant in children.
Overall, the evidence suggests that articaine administration leads to few adverse events [Dudkiewicz et al., 1987; Wright et al., 1989; Ram and Amir, 2006], and is comparable to lidocaine in this respect [Malamed et al., 2000b; Malamed et al., 2001; Ram and Amir, 2006; Katyal, 2010] (Table 2). Allergy to local analgesia is uncommon and a patient allergic to articaine would likely have a similar allergy to other amide analgesia including lidocaine [Malamed et al., 2001]. Prolonged numbness has been reported as the most common adverse effect following articaine injection, particularly in children younger than 7 years [Adewumi et al., 2008]. Accidental injury to anaesthetised lips have been reported in about 2% of cases [Malamed et al., 2000b]. Adewumi and co-workers  reported that when using articaine, 40% of children experience numbness for 3 hours and 11% for 5 hours, and this prolonged numbness can induce anxiety. Interestingly, there was no association between prolonged numbness and the site or amount of articaine administered. Similarly, Ram and Amir  found the duration of soft tissue numbness following articaine injection was greater than that for lidocaine (3.43 [+ or -] 0.7 vs. 3.0 [+ or -] 0.8 hours). More recently, a randomised double blind study reported that articaine had a longer duration of soft tissue numbness than mepivacaine (140.69 +/- 49.76 versus 117.52 +/- 42.99 minutes) [Odabas et al., 2012]. Given the evidence presented above, parents of paediatric patients must be warned of the risk of self-inflicted soft tissue injury following use of articaine.
How effective is articaine compared to other analgesia in children? While the majority of the literature focuses on the use of articaine in adult populations, a few studies have investigated the efficacy and safety of articaine following use in children (Table 2). Malamed compared pain control achieved when using 4% articaine and 2% lidocaine in patients for simple and complex dental procedures [Malamed et al., 2000a]. When patients scored their perceived pain using a visual analogue scale (VAS), articaine was found to have a lower score for both simple and complex dental procedures indicating a more profound level of analgesia. Mikesell and colleagues reported that articaine achieved pulpal analgesia in 4-54% of cases compared to 2-48% for lidocaine following inferior alveolar nerve blocks (IANB) in patients of varying age ranges, although this difference was not significant [Mikesell et al., 2005]. Two recent meta-analyses comparing 4% articaine to 2% lidocaine provide strong evidence that articaine provides superior analgesia success [Brandt et al., 2011; Katyal, 2010]. Using successful pulpal analgesia in teeth with irreversible pulpitis as an outcome measure, Brandt concluded that articaine produced successful analgesia 2.44 times more often than lidocaine and was 3.81 times more effective when using an infiltration technique [Brandt et al., 2011]. Katyal investigated analgesia for patients requiring a wider range of dental treatments and concluded that articaine achieved analgesia of mandibular first permanent molars (FPM) 1.31 times that achieved with lidocaine [Katyal, 2010]. A comparison of articaine to analgesias other than lidocaine suggested no difference in the analgesia efficacy of 4% articaine 1:200,000 with 3% mepivacaine in 50 children aged 7-13 years [Odabas et al., 2012]. A study comparing articaine and prilocaine found that maxillary infiltration with prilocaine caused almost twice as many positive pain reactions than infiltration with articaine [Yilmaz et al., 2011]. In addition, using pain related behaviour scores to determine analgesia efficacy, articaine was found to be more effective than prilocaine during removal of coronal pulp yet the frequency of adverse events was similar for both analgesias. In summary, there is evidence that 4% articaine is comparable to or more efficacious than other analgesia agents used in children.
What about using articaine for mandibular block analgesia? The reluctance to use articaine for IANB in dentistry arose following initial reports of prolonged sensory disturbances with articaine use [Hass and Lennon, 1995]. The incidence of adverse drug reactions is similar among all local analgesia agents [Malamed et al., 2001] and most commonly occur due to accidental intravascular administration of LA solution or direct trauma to the tissues. Iatrogenic nerve damage following IANB is estimated to occur in about 1:500,000 blocks, with the lingual nerve more commonly affected and little information on the analgesia used [Meecham, 2009]. Hass and Lennon  reported that nerve damage was more common using a 4% analgesia agent like articaine compared to a 2% solution, although it has been suggested that over-reporting of such injuries are more likely when a new drug is introduced [Meecham, 2009]. Recent reports suggest that there is no difference in the incidence of paraesthesia following IANB using lidocaine or articaine [Mikesell et al., 2005; Pogrel, 2007]. Pogrel suggested that there was no increased risk of inferior alveolar nerve damage using articaine and adverse effects were reported in proportion to its usage [Pogrel, 2007].
Can articaine infiltration replace an IANB? Infiltration with articaine is more effective than infiltration with lidocaine for anaesthetising the mandibular FPM area in adults [Robertson et al., 2007; Katyal, 2010; Brandt et al., 2011]. Existing evidence also indicates that IANB with articaine is equivalent to IANB with lidocaine [Mikesell et al., 2005]. Where a lidocaine IANB produces inadequate analgesia, it has been shown that supplemental buccal infiltration with articaine increases success [Kanaa et al., 2006; Hasse et al., 2008 and 2009]. Therefore, if added analgesia is required following an IANB with lidocaine, articaine should be used.
Buccal infiltration with 4% articaine is equally effective as articaine IANB in anaesthetising mandibular molars with irreversible pulpitis [Poorni et al., 2011]. As there is no significant difference in successful pulpal analgesia, there is no benefit in using articaine as an IANB [Meecham, 2009]. Furthermore, more successful mandibular FPM analgesia has been reported following using buccal infiltration with articaine (70.4%) compared to lidocaine IANB (55.6%) [Corbett et al., 2008]. Therefore, there is evidence to suggest that IANB with lidocaine can be substituted by buccal infiltrations with articaine. However further paediatric specific studies are required to verify this finding in adults.
Are there other advantages of using articaine in children?
Avoidance of an IANB in children has advantages. Pain control for pulp therapy and extractions of primary molars can be successfully achieved with articaine infiltration alone. The avoidance of an IANB in children eliminates the risk of inferior alveolar and lingual nerve damage. Replacement of IANB injections of lidocaine with buccal infiltrations of articaine will reduce the extent of soft tissue analgesia experienced by the patient, thus eliminating the poorly tolerated experience of lingual nerve analgesia. Teeth with molar incisor hypomineralisation (MIH) can be difficult to anaesthetise adequately, and in the author's experience buccal infiltration with articaine appears to offer superior analgesia.
In adults, palatal diffusion occurs when articaine is administered as a buccal infiltration in the maxilla [Uckan et al, 2006]. Articaine infiltration has also been shown to improve the analgesia success in the maxillary lateral incisor area compared to lidocaine in adults [Evans et al., 2008]. This may be useful in the treatment of traumatic injuries in children and may avoid the need for palatal injections.
Many groups of patients may benefit from being able to avoid IANB for dental treatment, including children with special health care needs. Articaine buccal infiltration is currently being used as an alternative to IANB in patients with hereditary coagulation disorders to decrease need for factor replacement during the provision of restorative dental care. This is very cost-effective and allows some patients to receive treatment in primary care setting.
Articaine is a safe and effective local analgesia which offers many advantages when providing dental analgesia in children. Most noteworthy is the potential that IANB can be replaced by infiltration technique. Soft tissue analgesia may be prolonged, but the risk of other adverse reactions is similar to other local analgesia agents. It is important that the dose of articaine be calculated for each child as smaller volumes of the more concentrated local analgesia solution are required than lidocaine. Practitioners should be aware of the effectiveness of articaine to diffuse through bone and soft tissue to give excellent depth of analgesia, while avoiding block and palatal analgesia for dental treatment in children.
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R. Leith *, K. Lynch **, A.C. O'Connell *
* Dublin Dental University Hospital, Trinity College Dublin.
** Mayberry Dental Care, Kilnamanagh, Dublin, Ireland
Postal address: R. Leith, Dept of Public and Child Dental Health, Dublin Dental University Hospital, Trinity College Dublin, Lincoln Place, Dublin 2, Ireland.
Table 1. Pharmacological data for Articaine and Lidocaine [Malamed, 1997; Malamed et al., 2000a; Malamed et al., 2001; Meecham, 2009] Duration of pulpal Duration of soft analgesia tissue analgesia (minutes) (hours) Articaine 4% 66 * 3-5 1:100,000 adrenaline [75.sup.+] Articaine 4% 56 * 3-5 1:200,000 adrenaline [45.sup.+] Lidocaine 2% 45 3-5 1:80,000 adrenaline mg dosage per LA Maximum dosage cartridge (mg / kg) Articaine 4% 88 in 2.2 ml * 7 1:100,000 adrenaline 68 in 1.7 [ml.sup.+] Articaine 4% 88 in 2.2 ml * 7 1:200,000 adrenaline 68 in 1.7 [ml.sup.+] Lidocaine 2% 44 in 2.2 mg 4.4 -7 1:80,000 adrenaline 34 in 1.7 ml Maximum number of 2.2ml cartridges for a 20 kg child Articaine 4% 1.6 1:100,000 adrenaline Articaine 4% 1.6 1:200,000 adrenaline Lidocaine 2% 2- 3.2 1:80,000 adrenaline * Septodont +3M Table 2. Studies investigating the efficacy and safety of articaine in children Study Number of subjects Age (years) Dudkiewicz et al., 1987 50 4-10 Wright et al., 1989 211 <4 Malamed et al., 2000a 1325 4-80 Malamed et al., 2000b 50 4-13 Malamed et al., 2001 1325 4-80 Mikesell et al., 2005 57 4-80 Ram et al., 2006 62 5-13 Adewumi et al., 2008 204 2-14 Katyal, 2010 Meta-analysis All ages 9 trials Brandt et al., 2011 Meta-analysis All ages 13 studies Yilmaz et al., 2011 162 6-8 Odabas et al., 2012 50 7-13 Study Local anaesthetic used Dudkiewicz et al., 1987 Articaine 4% 1:100000 vs. 1:200000 adrenaline Wright et al., 1989 Articaine 4% 1:100000 vs. 1:200000 adrenaline Malamed et al., 2000a Articaine 4% 1:100000 vs. Lidocaine 2% 1:100000 adrenaline Malamed et al., 2000b Articaine 4% 1:100000 vs. Lidocaine 2% 1:100000 adrenaline Malamed et al., 2001 Articaine 4% 1:100000 vs. Lidocaine 2% 1:100000 adrenaline Mikesell et al., 2005 IANB using Articaine 4% 1:100000 vs. Lidocaine 2% 1:100000 Ram et al., 2006 Articaine 4% 1:200000 infiltration vs. Lidocaine 2% 1:100000 adrenaline Adewumi et al., 2008 Articaine 4% 1:100000 adrenaline infiltration Katyal, 2010 Articaine 4% 1:100000 vs. Lidocaine 2% 1:100000 adrenaline Brandt et al., 2011 Articaine 4% vs.Lidocaine 2% Yilmaz et al., 2011 Articaine 4% 1:100000 vs. Prilocaine 3% with felypressin infiltration or IANB for primary molar pulpotomy Odabas et al., 2012 Articaine 4% 1:200000 vs. mepivacaine 3% Study Outcome Dudkiewicz et al., 1987 Anaesthesia successful in all cases No adverse effects reported Wright et al., 1989 No adverse effects noted (retrospective analysis) Malamed et al., 2000a Pain control Efficacy: No significant difference Malamed et al., 2000b Efficacy: Pain control during simple & complex procedures No significant difference in pain relief Safety; No serious adverse events Malamed et al., 2001 Safety: Adverse reactions similar: Articaine 22% vs Lidocaine 20%. Mikesell et al., 2005 Articaine pulpal anaesthesia: 4-54% Lidocaine pulpal anaesthesia: 2-48% No significant difference Ram et al., 2006 Efficacy similar Longer soft tissue numbness with articaine Few adverse events with either agent Adewumi et al., 2008 Prolonged numbness is most frequent adverse event: Occurs mostly in patients <7yrs Prolonged numbness may cause anxiety Katyal, 2010 Articaine more effective than lidocaine for anaesthetising lower FPM Similar adverse effects profile Brandt et al., 2011 Articaine provides a higher rate of anaesthetic success Stronger evidence for articaine's superiority with infiltration anesthesia than with mandibular block anaesthesia Yilmaz et al., 2011 Similar intensity of pain during administration of LA Pain related behaviour score for prilocaine 1.5 times higher than articaine when removing coronal pulp Similar adverse events Odabas et al., 2012 No difference in anaesthetic efficacy Longer soft tissue numbness with articaine
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|Author:||Leith, R.; Lynch, K.; O'Connell, A.C.|
|Publication:||European Archives of Paediatric Dentistry|
|Date:||Dec 1, 2012|
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