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British Journal of Oral and Maxillofacial Surgery 49 (2011) e72e75

Effect of alkalinisation of lignocaine for intraoral nerve block

on pain during injection, and speed of onset of anaesthesia
Vinay Mohan Kashyap a, , Rajendra Desai b,1 , Praveen B. Reddy c,2 , Suresh Menon a,3
a
b
c

Oral and Maxillofacial Surgery, Vydehi Institute of Dental Sciences, Bangalore, India
Oral and Maxillofacial Surgery, College of Dental Sciences, Davangere, Karnataka, India
Oral and Maxillofacial Surgery, ITS Dental College and Hospital, Muradnagar, UP, India

Accepted 13 April 2011

Available online 18 May 2011

Abstract
Injections of lignocaine as local anaesthetic for pain control in oral and maxillofacial surgery can themselves be painful. The time of onset
of anaesthesia is from 3 to 5 min. Sodium bicarbonate has been used worldwide to reduce both these drawbacks to the injection, so making
procedures more acceptable. This randomised prospective trial of 100 patients aged 1855 years who were given 3 nerve blocks (inferior
alveolar, lingual, and long buccal) was designed to assess the effect of alkalinisation of the lignocaine solution with sodium bicarbonate. All
patients were given 2% lignocaine hydrochloride with adrenaline 1:80,000 and 50 patients were randomly allocated to be given 8.4% sodium
bicarbonate in a 1/10 dilution. Pain was measured on a visual analogue scale (VAS). No patient given the injection with sodium bicarbonate
complained of pain, compared with 39/50 (78%) not given sodium bicarbonate (p < 0.0001). The mean (SD) time (seconds) to onset of local
anaesthesia in the group given sodium bicarbonate was 34.4 (9.8) compared with 109.8 (31.6) in the control group (p < 0.001). Our results have
confirmed the efficacy of the alkalinised local anaesthetic solution in reducing pain on injection and resulting in quicker onset of anaesthesia.
2011 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Lidocaine; Alkalinisation; Sodium bicarbonate; Pain; Onset of anaesthesia

Introduction
The injection of local anaesthetic agents into the skin and
mucous membranes is one of the most common minor surgical manoeuvres. It is often the only painful part of a dental
procedure.
Although the patient may be told that the injection will
feel like a mosquito bite, it is often much worse.1 To minimise the patients discomfort during a procedure has obvious
Corresponding author at: No. 542, 13th Main, Sector 7, HSR Layout,
Bangalore 102, India. Tel.: +91 9886977220.
E-mail addresses: vnyz@yahoo.co.uk, maxfacvnyz@gmail.com
(V.M. Kashyap).
1 Tel.: +91 9844265673.
2 Tel.: +91 9630457070.
3 Tel.: +91 9900601478.

benefits for both the patient and the surgeon. Although it

is short-lived, the perceived pain of the injection of local
anaesthetic is bad enough for some patients to decline further interventions under local anaesthesia. To give additional
analgesics, or sedatives, or both, can be impractical and time
consuming; it is even at times contraindicated.2 Of the many
reasons for pain at the site of injection, the acidity of the
solution is thought to be important. This can be neutralised
with sodium bicarbonate and used for nerve blocks. There is
overwhelming evidence that buffered local anaesthetics cause
less pain during injection, and some patients have reported
no pain at all.3
We have studied the effect of adding sodium bicarbonate
to the local anaesthetic solution on the pain of injection and
also on the time before for the onset of anaesthesia.

0266-4356/$ see front matter 2011 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/j.bjoms.2011.04.068

V.M. Kashyap et al. / British Journal of Oral and Maxillofacial Surgery 49 (2011) e72e75

e73

Table 1
Results (n = 50 in each group).
Variable

Lignocaine without sodium bicarbonate

Lignocaine with sodium bicarbonate

p value

Pain
No pain
Mean (SD) onset of anaesthesia (s)

39
11
109.8 (31.6)

0
50
34.4 (9.8)

<0.0001
<0.001

Each group was given 2% lignocaine plus 1:80,000 adrenaline.

Patients and methods

This prospective study was approved by the human studies
review board, after which 100 healthy adult patients aged
1855 years gave their written consent to participate. They
were among patients who were to have procedures under local
anaesthesia in the mandibular region.
Assuming that 80% of all patients given local anaesthetic injections have pain during injection, and anticipating
a 75% reduction in pain using solutions containing sodium
bicarbonate, the sample size was calculated that would
have a level of significance of 5% with a power of
80%.
All patients were given standard nerve blocks: inferior
alveolar, lingual, and long buccal nerve. All 100 patients
were given all three nerve blocks. All patients selected
were evaluated for physical status and patients with systemic diseases that contraindicated injections of lignocaine
with adrenaline were excluded from the study. Patients were
randomly divided into two groups of 50 each using simple random sampling technique. Slips of paper containing
numbers 1100 were numbered randomly divided into two
groups: control and study group. Each patient picked a slip
and had the treatment to which they had been allotted randomly.
The control group was given lignocaine hydrochloride with adrenaline 1:80,000 solution by injection. The
study group was given the same solution but with sodium
bicarbonate.2,4 A total of 8.4% sodium bicarbonate 3 ml was
added to a 30 ml vial containing 2% lignocaine hydrochloride with 1:80,000 adrenaline solution, which yielded a 1/10
dilution.
All patients had the procedure explained to them. Both the
operators and patients were unaware of which anaesthetic the
patient had been given. The two groups had their pain evaluated during injection and onset of anaesthesia. All injections
in both groups were given using non-pyrogenic, non-toxic,

sterile, single-use syringes with a luer lock and 25G 1.5 in.
needle. A maximum of 2.5 ml solution was used for all three
blocks.
Pain during injection was assessed using a four-point
scale: 0 = no pain, 1 = mild pain (pain reported only in
response to questioning and without any behavioural signs),
2 = moderate pain (pain reported in response to questioning
and accompanied by signs, or pain reported spontaneously
without questioning), and 3 = severe pain (strong vocal
response or response accompanied by grimaces, withdrawal
of the arm, or tears).5 Pain during injection was defined as
pain that was described by the patient on a four-point Visual
Analogue Scale (VAS)5 during injection of the solution and
not on the needle-prick itself.
The time of onset of anaesthesia is defined as the first
sensation of numbness or tingling in the anaesthetised region.
It was calculated from the point of retrieval of the needle after
the injection. A straight probe was used to assess the onset of
anaesthesia by inserting it in the gingival sulcus of the teeth
in the area of anaesthesia. The results were quantified and
analysed.
Data from the VAS were analysed using the chi square
test, and times of onset of anaesthesia were analysed using
Students t-test. Probabilities of less than 0.05 were accepted
as significant.

Results
The pH of both solutions were evaluated using a standard
pH meter; 3.05 was the measured pH for 2% lignocaine with
1:80,000 adrenaline (Lignox 2% A, Warren Pharmaceuticals,
India) and 7.38 for 2% lignocaine with 1:80,000 adrenaline
with a 1/10 addition of 8.4% sodium bicarbonate.
Among patients given solutions without sodium bicarbonate, 11 experienced no pain, 31 mild pain, 8 moderate pain,
and 0 severe pain during injection, from which can be deduced

Table 2
Comparison of onset of anaesthesia in the study groups.
Group I (patients receiving 2%
lidocaine with 1:80,000
adrenaline solution)

Onset of anaesthesia (s)

*unpaired Students t- test

t* value

Significance

Mean SD

Group II (patients receiving 2%

lidocaine with 1:80,000
adrenaline solution alkalinised
with sodium bicarbonate
Mean SD

109.76 31.63

34.40 9.82

16.08

p < 0.001 highly

significant

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V.M. Kashyap et al. / British Journal of Oral and Maxillofacial Surgery 49 (2011) e72e75

Importance of pH of the local anaesthetic solution

Fig. 1. Ion trapping of the RNH+ ions caused by alkalinisation of sodium

bicarbonate.18

that 11 patients had no pain and the rest had pain. There was
a significant difference between the control and the study
group as none of those given local anaesthetic with sodium
bicarbonate had any pain during injection (Table 1).
All patients given injections containing sodium bicarbonate had a more rapid onset of anaesthesia than the control
group. The time to achieve anaesthesia was greatly reduced
when buffered injections were given (Table 2).

Discussion
Pain
Pain is defined as an unpleasant emotional experience usually
initiated by a noxious stimulus and transmitted over a specialised neural network to the central nervous system where
it is interpreted as such.6 It is one of the most common symptoms in dentistry, and a serious concern for the dentist. The
pain of the local anaesthetic injection has several causes, one
being the acidity of the solution itself. The speed of injection
also has an important role; pain is caused by the increase in
volume in the tissues that causes pressure.7 Though painless
injections can be given when the solution is injected slowly,
acidity can be dealt with by altering the pH of the solution.
There is a consensus that, for nerves with intact sheaths, local
anaesthetics are more potent in alkaline, than in neutral or
acid, conditions.8 This was achieved in the present study by
adding sodium bicarbonate to the solution.9

Commercially available 2% lignocaine with 1:80,000

adrenaline solutions have a low pH (3.3).12 Although reducing the pH extends the shelf life of the solution to around
36 months, and prevents the early oxidation of adrenaline,
the solution is more likely to produce a burning sensation on
injection and a slower onset of anaesthesia.13
Increasing the pH of the local anaesthetic solution speeds
the onset of its action,13 increases its effectiveness, and makes
the injection more comfortable. Alkalinising or increasing the
pH of the solution can be achieved by adding sodium bicarbonate. This increases the free base form of the lignocaine
molecule and alkalinises the solution, thereby reducing the
pain during injection.13
We added 8.4% sodium bicarbonate to local anaesthetic
solution in a dilution of 1/10 (3 ml of sodium bicarbonate
to 30 ml of local anaesthetic solution).2,4 This reduced the
pH from 3.05 to 7.38, which caused the availability of the
lipophilic uncharged lidocaine molecules (RN), also called
the base, to be more available for diffusion into the membrane
of the nerve as the solution was close to the physiological
tissue pH of 7.4. This reduced the pain caused by the injection
itself.
When sodium bicarbonate is added it is also available in
the tissues as bicarbonate ion, which alkalinises the extracellular pH. When extracellular pH is increased by the addition
of bicarbonate, the decreased intracellular pH (through diffusion of carbon dioxide produced from the reaction of
hydrogen and hydrogen carbonate in extracellular fluid) may
also play a part in increasing the effect of the local anaesthetic block through protonation of intracellular free-base
local anaesthetic (ion trapping) and increasing the concentration gradient for the free-base local anaesthetic across the
plasma membrane (Fig. 1).7
No patient given local anaesthetic solution containing sodium bicarbonate had any pain during injection.
Erramouspe,9 Martin,14 Davies,3 and Sarvela et al.12 all concluded that using alkalinised solutions had obvious benefits
in reducing the pain during injection of the local anaesthetic
agent; our results confirmed this. However, Chow et al.15
found no change in the intensity of pain using alkalinised
solutions. The reduction in pain can also be attributed to
the availability of the lipophilic uncharged molecule (RN)
causing a faster onset of action of anaesthesia.
Onset of anaesthesia

Pharmacology of sodium bicarbonate

Sodium bicarbonate is a systemic alkalinising agent. It
increases the plasma bicarbonate concentration, buffers
excess hydrogen ions, and raises the pH of the blood, thereby
reversing clinical signs of acidosis.10 We used sodium bicarbonate to increase the pH of the local anaesthetic solution to
a more physiological pH.11

The free base form of the local anaesthetic agent is

more lipid-soluble, and so diffuses quickly into the membrane of the nerve. The cytoplasm was acidified by the
membrane-permeating carbon dioxide leading to the intracellular trapping of the cationic2 form of the local anaesthetic
agent (Fig. 1). Increasing the extracellular pH with a constant extracellular concentration of local anaesthetic results
in a greater intracellular concentration of local anaesthetic

V.M. Kashyap et al. / British Journal of Oral and Maxillofacial Surgery 49 (2011) e72e75

and more complete inhibition of sodium currents, whether

or not the intracellular carbon dioxide concentration or pH
changes. When extracellular pH is increased by the addition
of bicarbonate, decreased intracellular pH through diffusion
of carbon dioxide may also have a role in increasing the
local anaesthetic block. Sodium bicarbonate ions also nonspecifically reduce the margin of safety for nerve conduction,
and may have a direct action on the binding of the local
anaesthetic to the sodium channel.16 Gros,17 and Ritchie
et al.18 concluded that the addition of sodium bicarbonate
to solutions of lignocaine reduced the duration of onset of
anaesthesia, and was effective in reducing pain during the
injection.4

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