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Anesthetic efficacy and safety of 2% lidocaine hydrochloride with 1:100,000 adrenaline and 4% articaine hydrochloride with 1:100,000 adrenaline as a single buccal injection in the extraction of maxillary premolars for orthodontic purposes

Background Palatal injection of local anesthetics is the most painful injection. To obviate the need for palatal injections, local anesthetic agents with diffusibility are being investigated. Hence the present study was designed to analyze the anesthetic efficacy of 2% lidocaine hydrochloride (HCl) with 1:100,000 adrenaline and 4% articaine hydrochloride (HCl) with 1:100,000 adrenaline using single buccal infiltration for the extraction of maxillary premolars. Methods A prospective, double-blind, crossover, randomized clinical study was performed on 60 consecutive systemically healthy patients with an age range of 15-30 years, requiring extraction of asymptomatic bilateral maxillary premolars for orthodontic purposes. They received 1ml buccal infiltration of 4% articaine HCl with 1:100,000 adrenaline on one side and 2% lidocaine HCl with 1:100,000 adrenaline on the other side. The extraction procedure on either side was scheduled 14 days apart. Parameters assessed were the time of onset of anesthesia, intraoperative discomfort, hemodynamic parameters, and the duration of analgesia. Analysis of the data was done using the Mann-Whitney test, the Wilcoxon test, the Kruskal-Wallis ANOVA test, and the chi-square test. Statistical significance was established at P < 0.05. Results Articaine showed a faster time of onset and longer duration of analgesia than lidocaine. However, the difference in the intraoperative discomfort and hemodynamic parameters was statistically insignificant. Conclusion Within the limitations of the study, it can be concluded that the extraction of maxillary premolars can be performed with a single buccal infiltration of 2% lidocaine HCl with 1:100,000 adrenaline, which is one of the most commonly used local anesthetic agent.


INTRODUCTION
Local anesthetic agents are the backbone of pain control in dentistry and are considered the safest and the most effective drugs available for the prevention and manage-ment of pain in any oral surgical procedure. Various amide local anesthetic agents have been studied and reported in the literature [1]. Lidocaine an amide local anesthetic agent soon after its synthesis in 1943 by the Swedish chemist Nil Lofgren became a gold standard owing to its minimal side effects, rapid action, and effective pain control [2]. Later Rushing et al. (1969) synthesized the first amide local anesthetic agent with a lipophilic thiophene ring instead of the usual benzene ring and an additional ester group called carticaine which was changed to articaine in 1984. The presence of the thiophene ring increases the lipid solubility that gives the molecule better diffusibility than lidocaine, and higher protein binding that increases the duration of anesthesia.
It also has less central nervous system toxicity than lidocaine [3].
The extraction of maxillary teeth requires a palatal nerve block. Amongst all the local anesthetic techniques, palatal injection is the most painful as the palatal mucosa is highly dense and has firm adherence to the underlying bone. The maxillary bone is porous, this facilitates diffusion of the anesthetic solution from the buccal to the palatal aspect obviating the need for a palatal injection [4]. Various studies have claimed that articaine diffuses through the soft and hard tissues more reliably than other local anesthetic agents [5,6,7,8]. Only a few studies have evaluated the diffusivity of lidocaine [9,4].
Hence, the present study was conducted to analyze the anesthetic efficacy and safety of 2% lidocaine hydrochloride (HCl) with 1:100,000 adrenaline and 4% articaine hydrochloride (HCl) with 1:100,000 adrenaline using single buccal infiltration for the extraction of maxillary premolars, based on the hypothesis that there would be no significant difference amongst the two local anesthetic agents used as a single buccal infiltration technique in all outcome measures. The following formula was used to calculate the sample size required for this study at 95% confidence interval and 80% power of study.

METHODS
Where Z ɑ/2 is the critical value of the normal distribution at ɑ/2 (for a confidence level of 95%, ɑ is 0.05 and the critical value is 1.96), Z β is the critical value of the normal distribution at β (power of 80%, β is 0.2 and the critical value is 0.84), σ 2 is the population variance, and d is the difference that you would like to detect .

N = 41
Taking into account the cases not reporting for the second appointment, a sample size of 60 was devised.
Patients having localized infection, systemic diseases, allergy to sulfide or amide local anesthetic agents, and anxiety requiring a sedative or anxiolytic drugs were excluded from this study.
Informed consent was obtained from the patients for this study. Clinical examination was performed, and the patients were subjected to routine blood investigations.
Patients were explained about the study and the visual analog scale (VAS) [10]. The preoperative heart rate and blood pressure of each patient were recorded and were considered as the baseline.  Ltd., Maharashtra, India) on one side, and 2% lidocaine and was analyzed using the computer software

RESULTS
The study sample (N = 60) comprised 40 females and 20 males with a mean age of 18.96 ± 3.15 years (15-28 years) ( Table 1). The success rate for both groups was 100%. None of the patients required palatal re-anesthesia in both groups ( Fig. 1) [11]. Hemodynamic parameters such as the heart rate, systolic blood pressure, and diastolic pressure were    (Table 3).
In the present study, a longer duration of analgesia was observed with articaine (202.17 ± 48.35 min) than lidocaine (190.48 ± 38.43 min), but the difference was found to be insignificant (P = 0.886). No adverse effects were found with the use of both the anesthetic agents.  as the gold standard [4,9]. Therefore the present study was conducted to compare the efficacy and safety of 2% (anti-hypertensives, sedatives, and anti-depressants) may also lead to changes in the hemodynamic parameters [15].
The heart rate and the blood pressure (systolic and diastolic) were recorded at baseline, 10 min following injection, and post extraction.
In the present study, the heart rate transiently increased The results of the present study indicate that 4% articaine HCl with 1:100,000 adrenaline produced more effective and faster bucco-palatal anesthesia than 2% lidocaine HCl with 1:100,000 adrenaline. Similarly, lidocaine also showed diffusibility to the palatal tissue when only buccal infiltration was given and 5 min was allowed between the administration of local anesthesia and initiation of the procedure.
Hence, within the limitations of the study, it can be concluded that the extraction of maxillary premolars can be performed with a single buccal infiltration of 2% lidocaine HCl with 1:100,000 adrenaline which is one of the most commonly used local anesthetic agent, but with a longer latency period. Multi-centric trials with a larger sample size are needed to arrive at a logical conclusion.