Comparison of 4% articaine with epinephrine (1:100,000) and without epinephrine in inferior alveolar block for tooth extraction: double-blind randomized clinical trial of anesthetic efficacy


      The purpose of this clinical prospective, randomized, double-blind study was to compare the anesthetic efficacy of 4% articaine with epinephrine (1:100,000) and without epinephrine in inferior alveolar nerve block anesthesia for extractions of mandibular teeth.

      Study Design

      Eighty-eight patients received intraoral inferior alveolar nerve blocks using 4% articaine with 1:100,000 epinephrine (n = 41; group 1) or without epinephrine (n = 47; group 2) for extractions of mandibular teeth. The primary objectives were differences in onset as well as in length of soft tissue anesthesia. The amount of anesthetic solution, need of a second injection, pain while injecting, pain during treatment, postoperative pain, and possible complications were surveyed.


      In both groups, anesthesia was sufficient for dental extractions. In group 1, a significantly faster onset of the anesthetic effect (7.2 min vs. 9.2 min; P = .001) and a significantly longer duration of soft tissue anesthesia (3.8 h vs. 2.5 h; P < .0001) were seen. There was no significant difference in the amount of anesthetic solution needed, in the need for a second injection, in the injection pain, in pain during treatment, or in postoperative analgesia. In both groups, no complications were seen.


      To minimize the epinephrine-induced side effects, 4% articaine without epinephrine is a suitable anesthetic agent for dental extractions in the mandible after inferior alveolar nerve block anesthesia. There could be less postoperative discomfort due to the shorter duration of anesthesia without increased postoperative pain.
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        • Malamed S.F.
        • Gagnon S.
        • Leblanc D.
        Articaine hydrochloride: a study of the safety of a new amide local anesthetic.
        J Am Dent Assoc. 2001; 132: 177-185
        • Vree T.B.
        • Gielen M.J.
        Clinical pharmacology and the use of articaine for local and regional anaesthesia.
        Best Pract Res Clin Anaesthesiol. 2005; 19: 293-308
        • Becker D.E.
        • Reed K.L.
        Essentials of local anesthetic pharmacology.
        Anesth Prog. 2006; 53 (Quiz:9-10): 98-108
        • Leuschner J.
        • Leblanc D.
        Studies on the toxicological profile of the local anaesthetic articaine.
        Arzneim Forschung. 1999; 49: 126-132
        • Jastak J.T.
        • Yagiela J.A.
        Vasoconstrictors and local anesthesia: a review and rationale for use.
        J Am Dent Assoc. 1988; 3: 623-630
        • Santos C.F.
        • Modena K.C.
        • Giglio F.P.
        • et al.
        Epinephrine concentration (1:100,000 or 1:200,000) does not affect the clinical efficacy of 4% articaine for lower third molar removal: a double-blind, randomized, crossover study.
        J Oral Maxillofac Surg. 2007; 65: 2,445-2,452
        • Cheraskin E.
        • Prasertsuntarasai T.
        Use of epinephrine with local anesthesia in hypertensive patients. IV. Effect of tooth extraction on blood pressure and pulse rate.
        J Am Dent Assoc. 1959; 58: 61-68
        • Goldstein D.S.
        • Dionne R.
        • Sweet J.
        • et al.
        Circulatory, plasma catecholamine, cortisol, lipid, and psychological responses to a real-life stress (third molar extractions): effects of diazepam sedation and of inclusion of epinephrine with the local anesthetic.
        Psychosom Med. 1982; 44: 259-272
        • Mochizuki M.
        • Yokota S.
        • Murata Y.
        • et al.
        Changes in heart rate and blood pressure during dental procedures with local anesthesia.
        Anesth Prog. 1989; 36: 234-235
        • Ryder W.
        The electrocardiogram in dental anaesthesia.
        J Anesth. 1970; 25: 46-62
        • Hasse A.L.
        • Heng M.K.
        • Garrett N.R.
        Blood pressure and electrocardiographic response to dental treatment with use of local anesthesia.
        J Am Dent Assoc. 1986; 113: 639-642
        • Vanderheyden P.J.
        • Williams R.A.
        • Sims T.N.
        Assessment of ST segment depression in patients with cardiac disease after local anesthesia.
        J Am Dent Assoc. 1989; 119: 407-412
        • Elad S.
        • Admon D.
        • Kedmi M.
        • et al.
        The cardiovascular effect of local anesthesia with articaine plus 1:200,000 adrenalin versus lidocaine plus 1:100,000 adrenalin in medically compromised cardiac patients: a prospective, randomized, double blinded study.
        Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008; 105: 725-730
        • Edmondson H.D.
        • Roscoe B.
        • Vickers M.D.
        Biochemical evidence of anxiety in dental patients.
        BMJ. 1972; 4: 7-9
        • Kubota Y.
        • Toyoda Y.
        • Kubota H.
        • Asada A.
        Epinephrine in local anesthetics does indeed produce hypokalemia and ECG changes.
        Anesth Analg. 1993; 77: 867-868
        • Petitpain N.
        • Goffinet L.
        • Cosserat F.
        • Trechot P.
        • Cuny J.F.
        Recurrent fever, chills, and arthralgia with local anesthetics containing epinephrine-metabisulfite.
        J Clin Anesth. 2008; 20: 154
        • Goulet J.P.
        • Perusse R.
        • Turcotte J.Y.
        Contraindications to vasoconstrictors in dentistry: part III.
        Oral Surg Oral Med Oral Pathol. 1992; 74: 692-697
        • Cioffi G.A.
        • Chernow B.
        • Glahn R.P.
        • Terezhalmy G.T.
        • Lake C.R.
        The hemodynamic and plasma catecholamine responses to routine restorative dental care.
        J Am Dent Assoc. 1985; 111: 67-70
        • Niwa H.
        • Sugimura M.
        • Satoh Y.
        • Tanimoto A.
        Cardiovascular response to epinephrine-containing local anesthesia in patients with cardiovascular disease.
        Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001; 92: 610-616
        • Bader J.D.
        • Bonito A.J.
        • Shugars D.A.
        A systematic review of cardiovascular effects of epinephrine on hypertensive dental patients.
        Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002; 93: 647-653
        • Yagiela J.A.
        Adverse drug interactions in dental practice: interactions associated with vasoconstrictors.
        J Am Dent Assoc. 1999; 130: 701-709
        • Lipp M.
        • Dick W.
        • Daublander M.
        • Fuder H.
        • Stanton-Hicks M.
        Exogenous and endogenous plasma levels of epinephrine during dental treatment under local anesthesia.
        Reg Anesth. 1993; 18: 6-12
        • Meechan J.G.
        • Jastak J.T.
        • Donaldson D.
        The use of epinephrine in dentistry.
        J Can Dent Assoc. 1994; 60 (31-4): 825-828
        • Tofoli G.R.
        • Ramacciato J.C.
        • de Oliveira P.C.
        • Volpato M.C.
        • Groppo F.C.
        • Ranali J.
        • et al.
        Comparison of effectiveness of 4% articaine associated with 1:100,000 or 1:200,000 epinephrine in inferior alveolar nerve block.
        Anesth Prog. 2003; 50: 164-168
        • Schulz K.F.
        • Altman D.G.
        • Consort M.D.
        Statement: updated guidelines for reporting parallel group randomised trials.
        BMC Med. 2010; 8: 18
        • Malamed S.F.
        Handbook of local anesthesia.
        4th ed. Mosby, St. Louis1997
        • Kämmerer P.W.
        • Al-Nawas B.
        The surgical removal of wisdom teeth.
        Quintessenz. 2010; 61: 1329-1336
        • Sierra-Rebolledo A.
        • Delgado-Molina E.
        • Berini-Aytis L.
        • Gay-Escoda C.
        Comparative study of the anesthetic efficacy of 4% articaine versus 2% lidocaine in inferior alveolar nerve block during surgical extraction of impacted lower third molars.
        Med Oral Patol Oral Cir Bucal. 2007; 12: E139-E144
        • Lemay H.
        • Albert G.
        • Helie P.
        • et al.
        Ultracaine in conventional operative dentistry.
        J Can Dent Assoc. 1984; 50: 703-708
        • Lima-Júnior J.L.
        • Dias-Ribeiro E.
        • de Araújo T.N.
        • Ferreira-Rocha J.
        • Honfi-Júnior E.S.
        • Sarmento C.F.
        • et al.
        Evaluation of the buccal vestibule-palatal diffusion of 4% articaine hydrochloride in impacted maxillary third molar extractions.
        Med Oral Patol Oral Cir Bucal. 2009; 14: E129-E132
        • Hersh E.V.
        • Moore P.A.
        • Papas A.S.
        • Goodson J.M.
        • Navalta L.A.
        • et al.
        • Soft Tissue Anesthesia Recovery Group
        The anesthetic efficacy of 4 percent articaine 1:200,000 epinephrine: two controlled clinical trials.
        J Am Dent Assoc. 2006; 137: 1572-1581
        • Petrikas A.
        • Egorova V.A.
        • Ermilova K.V.
        Articaine and adrenaline combinations efficacy for dental anesthesia.
        In: Stomatologiia (Mosk). 2009; 88: 24-26