www.dentallearning.
net
Articaine and Paresthesia
O
ne of the most important aspects of dental treat-
ment is pain control. Patient comfort is very im-
portant during dental treatment; thus, profound
anesthesia must be effectively and efficiently achieved.
Dentists are fortunate to have a number of local anes-
thetic agents in their armamentarium that are capable of
providing consistent, profound anesthesia of short onset
and duration with few side effects. One of these agents is
articaine, a member of the amide group of local anesthetic
agents.1 Articaine is unique among the amide anesthetics
in that it contains a thiophene ring instead of a benzene
ring, which endows it with higher lipid solubility. Clini-
cally, this translates into better diffusion through tissue
and greater ability to cross lipid membranes. It should be
noted that articaine is marketed in the United States as a
4% solution, not 2%, as is, for example, lidocaine. This
leads to a lower total number of carpules of articaine that
can be safely administered compared with lidocaine.2
Articaine also contains an ester side chain that enables
it to be broken down 90% to 95% by plasma car-
boxylesterases and broken down 5% to 10% by liver mi-
crosomal esterases.1 Other amide anesthetics do not
contain this ester side chain and are broken down exclu-
sively in the liver. Clinically, this is reflected in the shorter
half-life of articaine and, thus, in a lower systemic toxic-
ity.2 Isen reports that the elimination half-life for articaine
is 20 minutes, whereas that for lidocaine is 90 minutes—
information that is also provided on the product labeling
for both articaine and lidocaine 2% with epinephrine
Sylvia Irwin, DMD
Private Practice
Nutley, NJ
Phone: 973.667.1567
E-mail: drirwin@brightersmilesnj.com
Web site: brightersmilesnj.com
www.dentallearning.net
1:100,000.2 Furthermore, the consequences of an unin-
tended intravascular injection of an anesthetic agent are
lessened in healthy patients with the use of articaine ver-
sus lidocaine because of the decreased central nervous sys-
tem toxicity of articaine.3 Clinicians report numerous
advantages associated with the use of articaine that in-
clude rapid onset, long duration of effect, and superior
diffusion through bone. These advantages mean that in-
filtration anesthesia may often be used in areas that pre-
viously necessitated block anesthesia, and palatal injection
is often not required even for extraction; that more pro-
found anesthesia results; that the lesser amount of anes-
thetic agent required results in a smaller injection volume,
thus minimizing injection-induced pain; and that its use
results in a greater success rate with block anesthesia. Un-
fortunately, many of these claims have not been substan-
tiated by clinical research.4-7
There has also been controversy about claims of a
greater incidence of paresthesia resulting from the use of
articaine. Although articaine has been in use worldwide
for many years and is regarded as a safe anesthetic agent
for both adult and pediatric use, there were reports as
early as 1995 demonstrating a statistically significant
higher incidence of paresthesia associated with articaine.8
Progrel and colleagues again confirmed this in 2000, with
both the 1995 and 2000 studies finding an approximately
2:1 frequency of distribution of the paresthesias between
the lingual nerve and the inferior alveolar nerve.9
Malamed and colleagues in a 2001 study failed to con-
firm these data,4 and another study by Hawkins demon-
strated that the use of “high block” techniques was not
associated with an increased risk of parasthesia.10 The
most recent article by Garisto and colleagues on the oc-
currence of paresthesia secondary to the administration
of local anesthesia was published in the July 2010 issue of
the Journal of the American Dental Association.11 This
Dental Learning / April 2011 1
study analyzed incidents of paresthesias voluntarily re-
ported to the US Food and Drug Administration Adverse
Event Reporting System involving local anesthetics and
nonsurgical dental treatment from November 1997
through August 2008. In the 248 cases reported, prilo-
caine 4% was involved 7.3 times more than would be sta-
tistically expected based on its US market share, and
articaine 4% was involved 3.6 times more than would be
statistically expected.11 A total of 94.5% of the reported
paresthesias resulted from a mandibular nerve block, and
in 89% of those cases the lingual nerve was affected.11
The exact mechanism of paresthesia secondary to the
administration of local anesthesia in dentistry remains un-
known; however, it does appear that the incidence is
greater in mandibular block anesthesia using agents with
a concentration of 4% that includes articaine. Dentists
must be aware of this situation and should carefully weigh
the advantages and disadvantages of the use of articaine
4% for each patient.
References
1. Articaine (Package Insert). http://www.septodontusa.com/
sites/default/files/Septocaine-1_100000-et-1_200000_0.pdf.
2. Isen A. Articaine: pharmacology and clinical use of a re-
cently approved local anesthetic. Dent Today. 2000;19:72-
77.
3. Oertel R, Rahn R, Krisch W. Clinical pharmacokinetics of
articaine. Clin Pharmacokin. 1997;33:417-425.
2 Dental Learning / April 2011
4. Malamed S, Gagnon S, Leblanc D. Efficacy of articaine: a
new amide local anesthetic. J Am Dent Assoc. 2001;131:
635-642.
5. Rebolledo A, Molina E, Aytés L. Comparative study of the
anesthetic efficiency 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. Available at: http://scielo.isciii.es/pdf/medicorpa/
v12n2/12.pdf. Accessed: September 23, 2010.
6. Vahatalo K, Antila H, Lehtinen R. Articaine and lidocaine
for maxillary infiltration anesthesia. Anesth Prog. 1993;40:
114-116.
7. Haas DA, Harper DG, Saso MA, et al. Comparison of arti-
caine and prilocaine anesthesia by infiltration in maxillary
and mandibular arches. Anesth Prog. 1990;37:230-237.
8. Haas DA, Lennon D. A 21 year retrospective study of reports
of paresthesia following local anesthetic administration. J
Can Dent Assoc. 1995;61:319-320, 323-326,329-330.
9. Progrel A, Thamby SRI. Permanent nerve involvement re-
sulting from inferior alveolar nerve blocks. J Am Dent
Assoc. 2000;131:901-907.
10. Hawkins JM. Articaine: efficacy and paresthesia in dental
local anesthesia. PenWell Corporation, 2009. Available at:
http://www.ineedce.com/courses/1585/PDF/Articaine.pdf.
Accessed: September 23, 2010.
11. Garisto G, Gaffen A, Lawrence H, et al. Occurrence of
paresthesia after dental local anesthetic administration in
the United States. J Am Dent Assoc. 2010;141:836-844.
www.dentallearning.net