Good pain management is important to ensure reduction of anxiety and improve patient comfort during dental treatment. This can be particularly challenging during root canal treatment in teeth with symptomatic irreversible pulpitis. While lidocaine (lignocaine) is the most commonly used local anaesthetic in dentistry and number of trial sand reviews have suggested that articaine is more effective than lidocaine in achieving profound dental pulp anaesthesia.
The aim this umbrella review was to whether articaine or lidocaine is the most appropriate local anaesthetic solution for teeth with irreversible pulpitis undergoing root canal treatment.
The review protocol was registered in the PROSPERO database and searched conducted in the PubMed, EBSCOhost and Scopus databases. Systematic reviews comparing anaesthetic efficacy between articaine and lidocaine/lignocaine in patients undergoing root canal treatment in maxillary and/ or mandibular teeth with irreversible pulpitis and published in English were considered.
Two independent reviewers selected studies, extracted data with study quality being assessed using the AMSTAR tool. Disputes were settled by a third reviewer. The primary outcome was successful pulpal anaesthesia in maxillary and mandibular teeth with irreversible pulpitis undergoing root canal treatment. Secondary outcomes included, pain intensity during injection, time of onset of pulpal anaesthesia and adverse effects.
- 5 reviews were included
- 2 were from the USA, 1 each from China, Malaysia and the UK.
- 2- 5 databases were searched for the reviews.
- 3 – 15 RCTs were included in the reviews.
- All reviews were classified as high quality with AMSTAR scores ranging from 8–11.
- 4 reviews reported articaine had greater success that lidocaine 1 reporting no difference.
- 3 reviews performed separate analysis for the maxilla with 2 reporting more success for articaine and 1 no difference.
- 1 review reported a lower pain score during injection with articaine, but the data was from one RCT. 1 review (4 RCTs) reported that articaine was associated with a more rapid onset of pulpal anaesthesia than lidocaine.
- 2 reviews reported on adverse effects, 1 review reporting no adverse effects from a single RCT with the second review reporting that articaine was associated with a lower percentage of patients suffering adverse events than lidocaine.
The authors concluded: –
- There is sufficient evidence to conclude that articaine is associated with higher local anaesthetic success rates than lidocaine following IANBs, infiltrations and supplemental injections during root canal treatment of teeth with irreversible pulpitis;
- there is limited evidence to suggest that the injection of articaine is less painful than the injection of lidocaine in patients with irreversible pulpitis undergoing root canal treatment;
- there is limited evidence to suggest that articaine is associated with a more rapid onset of pulpal local anaesthesia than lidocaine in teeth with irreversible pulpitis undergoing root canal treatment;
- there is limited evidence to suggest that articaine local anaesthetic injections are associated with fewer adverse events than lidocaine;
- numerous reporting deficiencies and gaps in knowledge have been identified.
The reviewers have adopted a good approach to the review registering their protocol on the PROSPERO database a priori and searching 3 major databases. However, they have restricted their inclusion criteria to review published in English which might exclude relevant reviews. As only a small number of primary studies were included in the reviews it would have been interesting to know the total number of unique studies included in the 4 reviews. The authors have uses the original AMSTAR tool to appraise the quality of the reviews although AMSTAR-2 has been available since 2017. This has an additional number of items with the overall rating being based on weaknesses in critical domains.
The authors also highlight flaws and inconsistencies in the quality of the included primary studies highlighting the need for consistency of reporting and the use of internationally recognised disease definitions and reporting guidelines and tools. Wider agreement on reporting common outcomes sets in line with the COMET initative would help the dissemination of both primary research and the efforts of systematic reviewers.
Nagendrababu V, Duncan HF, Whitworth J, Nekoofar MH, Pulikkotil SJ, Veettil SK, Dummer PMH. Is articaine more effective than lidocaine in patients with irreversible pulpitis? An umbrella review. Int Endod J. 2019 Sep 6. doi:10.1111/iej.13215. [Epub ahead of print] Review. PubMed PMID: 31491042.