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Can 4% Articaine Buccal Infiltration Replace Inferior Alveolar Nerve Block (IANB) with 2% Xylocaine for Pulp Therapy in Primary Mandibular Molars? A Systematic Review

Abstract Aim and objective This systematic review aims to compare the efficacy of 4% articaine buccal supraperiosteal/infiltration to that of inferior alveolar nerve block (IANB) with 2% xylocaine in providing pulpal anesthesia for carrying out pulp therapy of deciduous mandibular molars in children. Materials and methods PubMed, Cochrane Registry, and Ovid SP were searched in the timeframe between years 1991 and 2020 with appropriate MeSH terms. Full texts were selected only after a preliminary screening of relevant titles and abstracts. Results Five studies were involved for the final qualitative analysis. The parameter sought for was “Pain during pulp therapy after injection with buccal supraperiosteal/infiltration (4% articaine) or IANB (2% lignocaine) in primary mandibular molars. Three studies evaluated objective pain (operator reported) during pulp therapy, reported significantly lower pain scores with articaine buccal infiltration (BI). Among the two studies that evaluated subjective pain, one study reported a significantly lower pain score with the articaine BI group. The other study reported no difference statistically between both groups. Conclusion Under the bounds of this systematic review, BI with 4% articaine might be equivalent to IANB with 2% lignocaine for providing pulpal anesthesia required for pulp therapy procedures in primary mandibular molars; however, the quality of evidence is low, more number of well-controlled studies with adequate sized sample should be conducted out to verify the same. How to cite this article Tirupathi SP, Rajasekhar S, Ganesh M, et al. Can 4% Articaine Buccal Infiltration Replace Inferior Alveolar Nerve Block (IANB) with 2% Xylocaine for Pulp Therapy in Primary Mandibular Molars? A Systematic Review. Int J Clin Pediatr Dent 2021;14(3):420–425.


IntroductIon
Pain control is the foremost aspect of pediatric dentistry. Inferior alveolar nerve block (IANB) is irrefutably one among the most painful, 1 and the most important injections for performing invasive procedures like pulp therapies, primary tooth extractions in the mandibular arch in children. Owing to anatomical variations of mandibular foramen which is placed more antero-inferiorly, discomfort can be much more in children during IANB. 2 Failure rates of IANB are also fairly high which will require additional supplemental anesthesia which is more traumatic to the child. 3 Articaine is an ester group local anesthetic with a thiopentone ring, which has greater lipid solubility that is claimed to have higher diffusion properties than lignocaine.
Many studies reported that buccal infiltration (BI) alone with articaine can allow its diffusion into palatal tissues and provide sufficient anesthesia for carrying out invasive procedures on maxillary teeth without the need for adjective palatal anesthesia. [4][5][6][7][8][9][10][11] Similarly, many studies in the adult population have mentioned that buccal supraperiosteal (infiltration) injection alone with articaine is equipotent to IANB with lignocaine. [12][13][14][15][16][17] Within the limits of our understanding, no systematic review so far has compared the efficacy of buccal supraperiosteal injection with articaine and IANB with lignocaine in children for the specific outcome of pain related to pulp therapy. The current systematic review aims to compare and evaluate the efficacy of BI with articaine and IANB with lignocaine in providing pulpal anesthesia for carrying out pulp therapy in primary mandibular molars in children.

Eligibility Criteria
Randomized controlled trials (RCTs) which juxtaposed 4% articaine BI to IANB with 2% xylocaine for inducing pulpal anesthesia for pulp therapy in primary mandibular molars were evaluated. Nonrandomized trials, observational studies, narrative and systematic reviews, were excluded. Double articles were removed. Suitable articles were then included for a full-text evaluation (Flowchart 1).
Data analysis was performed by three reviewers. The outcome sought for was "pain during pulp therapy after injection with buccal infiltration or IANB in primary mandibular molars". Only Qualitative analysis of data was carried out, data pooling was not done as there are very few studies are available.

Attributes of Included Studies
The features of the five included studies are represented in Table 2. Among them, two were published in the year 2016 and three were published in 2018.

RoB
The risk of bias (RoB) was evaluated on seven-point criteria by Cochrane collaboration.
The RoB ( Fig. 1) was evaluated according to Cochrane guidelines. Randomization was mentioned in four studies. 19,20,22,23 Allocation concealment was carried out in two studies, 19,23 unclear in two studies, 20,22 and not carried out in one study. 18 Only two studies performed blinding of both participants and personnel. 20,23 Blinding of outcome assessment was done only in three studies. 20,22,23 Attrition bias is reported in one study. 19 Selective reporting bias is not present in any of the studies evaluated.

dIscussIon
Among the five studies evaluated, three followed the split-mouth design, and two studies followed a parallel arm trial. Children's age in the included articles was between 4 years and 10 years.
In the present systematic review, studies comparing BI with articaine directly to IANB with lignocaine for the outcome procedural pain related to pulp therapy (access opening, pulp extirpation) are evaluated.

Buccal Infiltration
Four percent of articaine was used in all the studies. The volume of articaine deposited as BI ranged between 0.8 and 1.8 mL across  Poorni 2011 Study was carried out on adults 4 Arrow 2012 Study was done in children but evaluated pain during restorative reasons, not for pulp therapy 5 Monterio 2015 Study was carried out on adults 6 Bartlett 2016 Study was carried out on adults 7 Zain 2016 Study was carried out on adults 8 Venkat Narayan 2017 Study was carried out on adults 9 Yilimaz 2018 Study was carried out on adults 10 Jorgenson 2020 Study was carried out on permanent first molar in children

Inferior Alveolar Nerve Block (IANB)
2% lignocaine was used in all the studies. The volume of lignocaine deposited was 1.8 mL in most of the studies. Epinephrine concentration ranged from 1:80,000 to 1:100,000.

Outcome Analysis
The only outcome evaluated in the current systematic review was procedural pain related to pulp therapy (access opening, pulp extirpation) between both BI-articaine and IANB-lignocaine. Among the five studies included for qualitative analysis, two studies evaluated subjective pain (child-reported pain), 18,19 and the three studies evaluated pain reaction (objective pain). 20,22,23 In two studies child-reported pain scores (subjective pain) were evaluated. 18,19 In the paper by Alzahrani and co-workers 2018, the child reported pain during pulp therapy was evaluated with Wong-Baker Faces Pain Scale (WB-FPS). In this study, both groups were compared for success rates (criteria for success was WB-FPS below 2) and the authors found no difference statistically among both groups. The study by Alinejhad 2018 used a modified version of the Faces Pain Scale (FPS). In this study, the articaine BI group (0.55 ± 0.68) reported significantly lower pain scales in comparison to the lignocaine IANB group (1.85 ± 1.08).
Three studies evaluated objective pain (operator reported) during pulp therapy. 20,22,23 Among the three, two studies evaluated the Modified Behaviour Pain Scale (MBPS), 20,23 and one study evaluated the sound eye motor (SEM) scale. 22 22 The study by Arali and Mytri 2016, pain during access opening was evaluated with MBPS, for access opening which was significantly lower for articaine BI (0.5 ± 0.18) when compared to lignocaine IANB (0.7 ± 0.26); p value < 0.05. 20 The paper by Ghadimi and coworkers 2018, pain due to coronal pulp extirpation was evaluated with MBPS which was significantly lower with articaine BI (3.13 ± 1.86) in comparison to lignocaine IANB (4.52 ± 2.55) group. 23 All the three studies reported significantly lower observer reported pain scores for articaine BI in comparison to lignocaine IANB. 20,22,23 The other measures evaluated which were not included in the present systematic review were pain during injection, 22,23 onset, duration of anesthesia, 20 which revealed no significant difference in both the groups.

conclusIon
Buccal infiltration with 4% articaine might be equivalent to IANB with 2% lignocaine for providing pulpal anesthesia required for pulp therapy procedures in primary mandibular molars however, the quality of evidence is low, more number trials with adequate sample size should be conducted to verify the same.