Assessment of Intraoperative Pain in Mandibular Third Molar Extractions with Articaine- A Retrospective Study
Keerthana Balaji1, Pradeep D2*
1 Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai 600077, Tamil Nadu, India.
2 Associate Professor, Department of Oral and Maxillofacial Surgery, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai 600077, Tamil Nadu, India.
*Corresponding Author
Pradeep D,
Associate Professor, Department of Oral and Maxillofacial Surgery, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai 600077, Tamil Nadu, India.
Tel: +91 9789936383
E-mail: pradeep@saveetha.com
Received: July 30, 2021; Accepted: August 10, 2021; Published: August 17, 2021
Citation:Keerthana Balaji, Pradeep D. Assessment of Intraoperative Pain in Mandibular Third Molar Extractions with Articaine- A Retrospective Study. Int J Dentistry Oral Sci. 2021;8(8):3839-3843. doi: dx.doi.org/10.19070/2377-8075-21000786
Copyright: Pradeep D©2021. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited.
Abstract
Pain control through block of the inferior alveolar nerve is one of the loco regional anaesthetic techniques most widely used in oral surgery. Comparative study is made of the anaesthetic efficacy of articaine versus lidocaine during the surgical extraction of mandibular third molars. This is a Retrospective study conducted in the university setting. This study included patients who reported to private dental hospital for the removal of mandibular third molars. Inclusion criteria of this study included patients who required removal of mandibular third molars and exclusion criteria included patients with drug allergies and patients who are pregnant or currently lactating. Data was collected and tabulated in excel. Data was analysed using IBM SPSS Statistical Analyzer(23.0 version). Frequency distribution and descriptive analysis were carried out. The association between the variables was analysed and assessed using Pearson Chi-square test. P value < 0.05 was considered to be statistically significant. Patients experienced less intraoperative pain with the administration of articaine compared to lidocaine. Anaesthetic efficacy and duration of action were found to be superior with articaine over lidocaine.
2.Introduction
3.Conclusion
4.References
Keywords
Intraoperative; Articaine; Lidocaine; Third Molar Extraction; Anaesthetic Efficacy.
Introduction
Pain control through block of the inferior alveolar nerve is one
of the loco regional anaesthetic techniques most widely used in
oral surgery. Various medications and analgesic techniques used
before the operation can prevent sensitization and postoperative
pain. To have an effective pain control in the majority of procedures
in dentistry which includes trauma management, osteotomies,
extractions and other surgical procedures, a number of local
anesthetics are present and are studied upon for their efficacy in
pain control and hence supremacy over the existing local anesthetics
[5, 37, 26, 1, 14]. Local anaesthetic agents are also used
in the surgical excision of salivary gland and salivary duct swelling
such as ranula [32]. The concept of local anesthetic action
is based on hindering the generation and conduction of nerve
impulses. Thus, the impulse is aborted, hindered from reaching
the brain and is not interpreted as pain by the patient. The choice
of anaesthetic solution should be based on three main clinical
considerations: anaesthetic potency, latency and duration of the
anaesthetic effects [6, 29, 53]. Lidocaine, synthesised by Löfgren
in 1943, was the first amide anaesthetic prepared for local application
[31]. Lidocaine is the local anaesthetic most commonly used
for pain control [30]. The emergence of articaine is generating
considerable interest because of its considerable faster onset of
action and longer duration of action and its comparable safety
and potency. Articaine hydrochloride or 4-methyl- 3-propinamido-
2-thiophene-carboxylic acid methyl ester hydrochloride, was
synthesised by Rusching in 1969 [22, 29]. The pharmacological
characteristics of this anaesthetic are responsible for its main advantages
with respect to other local anaesthetics and include substitution
of the aromatic ring with a thiopenic ring that increases
the liposolubility of the drug as well as its potency [23, 40]. Articaine
is the only amide local anaesthetic agent containing an ester
group in its molecular structure [12]. The clinical advantages of
Articaine include the duration of its anaesthetic effort – only surpassed
by ultra long acting anaesthetics and its superior diffusion
through Bony tissue [54]. The onset of Articaine is reported to
be 1-2 minutes. It was reported to be a safe anesthetic and could
be used safely in children was reported by Malamed. Vasodilator
activity affects both the anesthetic potency and the duration.
Greater vasodilator activity leads to increased blood flow to a region,
which leads to a rapid removal of anesthetic molecules from
the injection site. This will decrease both the anesthetic potency,
and duration. Both articaine and lidocaine as plain solutions without
a vasoconstrictor added would be ineffective and more toxic
because of their vasodilator activity. In order to improve both the
duration and safety, adrenaline is added which acts as a vasoconstrictor.
The ph of most of the anesthetic agents is acidic which
causes the discomfort during administration. To control the ph of
anesthetics, a number of additives are added to make it alkaline
such as bicarbonates or carbon dioxide which makes the drug administration
comfortable. The pH of plain local anesthetic solution
is approximately 5.5; vasoconstrictor containing solution is
about 4.5. The alkalinized solution has a faster onset of action
and relatively higher potency. The pain of tooth extraction varies
among individuals, and each extraction of an individual may
be quite different. After surgical procedures patients are most
commonly administered with antibiotics and analgesics to avoid
further complications [24, 16, 49, 44]. The duration of the anaesthetic
effect varies according to the amount of vasoconstrictor
added to the formulation [28].
Previously our team has a rich experience in working on various
research projects across multiple disciplines. (Jain, 2017 [14]); Varghese,
Ramesh and Veeraiyan, 2019 [55]); (Ashok and Ganapathy,
2019 [2]); (Padavala and Sukumaran, 2018 [33]); (Ke et al., 2019
[18]); (Ezhilarasan, 2018 [8]); (Krishnan et al., 2018 [35]); (Ezhilarasan,
Sokal and Najimi, 2018 [42]); (Pandian, Krishnan and Kumar,
2018 [11]); (Ramamurthy and Mg, 2018 [58]); (Gupta, Ariga
and Deogade, 2018 [36]); (Vikram et al., 2017); (Paramasivam,
Vijayashree Priyadharsini and Raghunandhakumar, 2020 [34]);
(Palati et al., 2020); (Samuel, Acharya and Rao, 2020 [48]). Now
the growing trend in this area motivated us to pursue this project.
This present study compares the efficacy of Articaine versus lidocaine
in application to inferior alveolar nerve blocks for the
surgical extraction of mandibular third molars by assessing the
duration of action of local anaesthetic agents used and intra operative
pain experienced by the patients.
Materials And Methods
This retrospective study was conducted in the university setting.
Data chosen for evaluation were patients who reported to a private
dental college for the removal of mandibular third molars.
The details of the patients were obtained from analysis of 86,000
patients from June 2019 to March 2020 from patient dental records.
The study was conducted after getting ethical approval
from the Institutional Ethical Committee (Ethical Approval
Number: SDC/SIHEC/2020/DIASDATA/0619-0320).Cross
verification was done with the help of patient dental records data.
To minimize sampling bias all data were included.
Inclusion criteria:
• Subjects above 18 years age.
• Subjects who required removal of impacted mandibular third
molars, prophylactic removal of mandibular third molars.
• Subjects with acute pericoronitis.
• Patient records with complete data and photographs during
follow up.
Exclusion criteria:
.
• Subjects with drug allergies.
• Subjects who are pregnant or currently lactating.
• Patient records with incomplete data.
A total of 128 records which satisfied the inclusion and exclusion
criteria were included in the study. The age range of patients
included for this study was 18-80 years. From the preoperative
and postoperative records of the study population, data such as
age, gender, postoperative findings and observations were obtained.
Data was downloaded from the patient dental records and
imported to Excel. Data which was not required were excluded.
Data was analysed using IBM SPSS Statistical Analyzer (23.0 version).
Frequency distribution and descriptive analysis were carried
out. The correlation and association between the variables were
analysed and assessed using Pearson Chi-square test.p value less
than 0.05 was considered to be statistically significant. Results
were obtained in the form of graphs.
Results & Discussion
This study included 128 participants. Among these 69.53% of patients
belonged to the age group 18-40 years, 20.31% of patients
belonged to the age group 41-60 years and remaining 10.16% of
patients belonged to the age group 61-80 years(Figure-1). Among these 46.09% were female participants and the remaining 53.91%
were male participants who underwent extraction of mandibular
third molars(Figure-2). In regard to the usage of local anaesthetic
agents among the study population, about 92.97% of patients
were administered with lignocaine with adrenaline while only
7.03% of patients were administered with articaine for the extraction
of mandibular third molars(Figure-3).In terms of local
anaesthetic agents used for the extraction, duration of action of
local anaesthetic agents was found to be shorter in 85.94% of
patients administered with lignocaine with adrenaline while only
0.78% of patients administered with articaine showed shorter
duration of action(Figure-4). About 86.72% of patients administered
with lignocaine with adrenaline showed higher incidence
of intraoperative pain while only 0.78% of patients administered
with articaine showed incidence of intraoperative pain during extraction
of mandibular third molar(Figure-5).
In this study, we compared the anaesthetic efficacy of articaine
and lignocaine. Results from this study showed that the duration
of action of articaine was found to be longer compared to
lignocaine and intra operative pain experienced by patients was
less with articaine than lignocaine and no complications were observed
in patients administered with articaine. The duration of
the effect of the local anesthetic is dependent on the injection
site or concentration of vasoconstrictor present in the anesthetic
solution, among other factors.
These results are in line with the results in a study conducted by
Deepashri H et al which also showed articaine to be more comfortable
to the patients which exhibits more profoundness, less
onset of action , less bleeding and larger duration of anaesthesia
[7]. Kashyap et al also stated that 4% articaine hydrochloride has
more efficacious local anaesthetic ability, mild injection pain and
reasonable duration of anaesthesia, low intraoperative pain and
reasonable duration of anaesthesia [17]. Silva Junior et al concluded
in their study that articaine has improved anaesthetic efficacy
in third molar extractions [51]. Alejandro sierra rebolledo
et al conducted a randomised controlled trial with the conclusion
of 4% articaine having better pharmacological performance compared
to 2% lidocaine in terms of its latency and duration of the
anaesthetic effect [50].
The duration of the anaesthetic effect of an agent is proportional
to the degree of protein binding. However, the duration of the effect
of the local anaesthetic is also dependent on the injection site
or concentration of vasoconstrictor present in the anaesthetic solution,
among other factors. Articaine presents one of the greatest
protein binding percentages of all amide local anaesthetics,
comparable only to ultra long action agents such as bupivacaine,
ropivacaine and etidocaine. This in turn implies a longer duration
of the anaesthetic effect [3]. In contrast, Ruprecht S et al in their
study concluded that there were no statistically significant differences
between the two solutions i.e., articaine and lignocaine in
their anaesthetic efficacy [46]. Gagnon S et al stated that there was
an increased incidence in nerve alterations leading to paresthesia
with the administration of 4% articaine [25]. Haas and Lennon in
a review of 143 paresthesias, found the latter to be more frequent
when articaine was used [13]. Therefore, dentists should have
sound knowledge regarding the properties usage and disposal of
local anaesthesia and its complications [38, 20].
Our institution is passionate about high quality evidence based
research and has excelled in various fields [39, 43, 57, 9, 41, 52, 56,
4, 27, 45, 47]. We hope this study adds to this rich legacy.
Figure 1: This bar graph represents the age distribution of the study population.Majority of the study population belonged to the age group 18-40 years i.e; 69.53%, 20.31% of patients belonged to the age group 41-60 years and remaining 10.16% of patients belonged to the age group 61-80.
Figure 2: This bar graph depicts the gender distribution of the study population.53.91% of patients were males and 46.09% of patients were females who underwent extraction of mandibular third molars.
Figure 3: This bar graph represents the usage of local anaesthetic agents among the study population.About 92.97% of patients were administered with lignocaine of adrenaline and only 7.03% of patients were administered with articaine for the extraction of mandibular third molars.
Figure 4: This bar graph represents the association between local anaesthetic agent used and duration of action of the local anaesthetic agents.X-axis represents the local anaesthetic agent used and Y-axis represents the number of patients who underwent mandibular third molar extraction. Pearson Chi square test was done,p value = 0.000>0.05 hence the association is statistically significant proving that local anaesthetic agent used influences duration of action in patients during mandibular third molar extraction.
Figure 5: This bar graph represents the association between local anaesthetic agent used and intraoperative pain experienced by patients during extraction of mandibular third molar.X-axis represents the local anaesthetic agent used and Y-axis represents the number of patients who underwent mandibular third molar extraction.Pearson Chi square test was done, p value = 0.000>0.05 hence the association is statistically significant proving that local anaesthetic agent used influences the intraoperative pain experienced by patients during mandibular third molar extraction.
Conclusion
Within the limitations of this study, it can be concluded intraoperative
pain was higher in patients with the administration of lignocaine
with adrenaline. Duration of action and anaesthetic efficacy
of articaine was found to be superior compared to lidocaine. Less
intraoperative pain was experienced by patients with the administration
of articaine in extraction of mandibular third molars.
However, owing to the small study population, it is necessary to
conduct multicentre studies with large population to further study
the anaesthetic efficacy of articaine.
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