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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 13  |  Issue : 2  |  Page : 81-85

Hemodynamic changes in pediatric dental patients using 2% lignocaine, buffered lignocaine, and 4% articaine in pediatric dental procedures


Department of Pedodontics and Preventive Dentistry, University College of Medical Science (University of Delhi) and GTB Hospital, Delhi, India

Date of Submission21-May-2020
Date of Decision13-Feb-2021
Date of Acceptance24-Mar-2021
Date of Web Publication22-Jun-2021

Correspondence Address:
Amit Khatri
Departrment of Pedodontics and Preventive Dentistry, University College of Medical Science (University of Delhi) and GTB Hospital, Delhi - 110 095
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jorr.jorr_19_20

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  Abstract 


Background: The purpose of this study was to compare the hemodynamic changes (blood pressure, heart rate and oxygen saturation) when using three different local anesthetic agents such 2% Lignocaine with 1:200,000 epinephrine, Buffered Lignocaine and 4% Articaine with 1:200,000 epinephrine with inferior alveolar nerve block in pediatric dental patients.
Methods: A double blind crossover study was designed where in 48; 5-10 year old patients received three sections of inferior alveolar nerve block injections in three appointments which scheduled one week apart. Blood pressure, heart rate and oxygen saturation was measured before and after administration.
Results: When applying three factors ANOVA, no statistically significant difference was found between Lignocaine and Buffered Lignocaine, Buffered Lignocaine and Articaine in all the three parameters(P > 0.05 ).
Conclusion: This findings in hemodynamic changes from this study reveals that all the three anesthetic agents are safe in children aged 5-10 years.

Keywords: Articaine, buffered lignocaine, hemodynamic, lignocaine


How to cite this article:
Khatri A, Afsal M M, Kalra N, Tyagi R, Kulood M K. Hemodynamic changes in pediatric dental patients using 2% lignocaine, buffered lignocaine, and 4% articaine in pediatric dental procedures. J Oral Res Rev 2021;13:81-5

How to cite this URL:
Khatri A, Afsal M M, Kalra N, Tyagi R, Kulood M K. Hemodynamic changes in pediatric dental patients using 2% lignocaine, buffered lignocaine, and 4% articaine in pediatric dental procedures. J Oral Res Rev [serial online] 2021 [cited 2021 Dec 2];13:81-5. Available from: https://www.jorr.org/text.asp?2021/13/2/81/319005




  Introduction Top


Effective pain management of child, especially an anxious one, is a challenge to every dentist. Controlling pain is the key to successful dental treatment of nearly all patients, particularly children. Pain control in dentistry play an important part in reducing the fear and anxiety associated with dental procedures, especially in children. The most commonly used local anesthetic agent is 2% lignocaine which, is the gold standard and considered the most efficacious anesthetic agent for use in pediatric and adult patients. However, some studies have discussed the ineffectiveness of lidocaine in more invasive procedures or when a better distribution into the tissue is necessary, especially in the bone tissue. Considering these factors, there has been continuous attempt to look a more efficacious anesthetic agent.[1]

In 1992, Malamed reported an approach of the addition of sodium bicarbonate immediately prior to anesthetic administration to increase the pH value of anesthetic solution, which significantly increases the amount of active anesthetic form available.[2] This can reduce the onset of action of the anesthesia by increasing the concentration of uncharged basic form and facilitating the penetration of lignocaine into nerve cell. It has also been suggested that alkalizing the acidic solution can reduce the pain caused during the administration of local anesthesia.

Similar to lignocaine, articaine is also commonly used anesthetic agent that was originally synthesized as carticaine in 1969 and entered clinical practice in Germany in 1976. Articaine is a unique amide local anesthesia in that it contains a thiophene, instead of benzene ring. The thiophene ring allows greater lipid solubility and potency as greater portion of the administered dose can enter neurons. It is the only amide anesthetic containing an ester group, allowing hydrolyzation in unspecific blood esterases. It possesses the ability to diffuse through hard and soft tissues more reliably than lidocaine, thus providing more profound anesthesia.[3]

Hemodynamic changes during dental procedure can be attributed to both stresses during the procedure and presence of vasoconstrictor, epinephrine in the local anesthetic solution. Epinephrine is added to slow down the systemic absorption of local anesthetic agent thus prolonging the action and intensity of block. Despite the beneficial properties of vasoconstrictors, there are some systemic concerns. In addition, pain, stress, fear, and anxiety during dental treatment that are caused by lack of pain control and poor anesthesia may be responsible for the systemic endogenous release of catecholamines, which may lead to autonomic responses such as hypertension and arrhythmias.[4]

Monitoring hemodynamic changes during dental procedures in children allows the dentist to immediately identify situations of increased risk, establish an early diagnosis, prevent possible complications, and operate with increased safety. The purpose of this study was to evaluate the hemodynamic changes associated with 2% lidocaine with 1: 200,000 epinephrine, buffered lignocaine, and 4% articaine with 1: 200,000 epinephrine.


  Subjects and Methods Top


The study was conducted in the Department of Pedodontics and Preventive Dentistry, University College of Medical Science and Guru Teg Bahadur Hospital, Delhi, India, after due approval from the Institutional Review Board.

The sample size was determined by systematic sampling based on two treatment groups and two period cross over design. From the previous study, standard deviation was found 1.55 and expecting clinical difference in effectiveness of lidocaine and articaine for intraligamentary injection technique as one unit of the sample size of 40 subjects was required.[5] Adding 10% attrition rate, sample size of 45 was required. Forty-eight patients aged between 5 and 10 years (mean age of 7.5 years) of both genders (males 29/females 19) with Frankel behavior rating grade 3 and 4; had a minimum of three teeth requiring treatment (such as vital pulp therapy or extraction) under local anesthesia; children with the average height and weight for the age according to the Indian Academy of Pediatrics growth charts were included in the study. Exclusion criteria include patients who were allergic to local anesthesia; and medically compromised conditions. Fifty-three pulp therapies and 82 extractions were performed on these patients during the three visits. The study design was structured in accordance with the study conducted by Conway et al. wherein 3/3 balanced Latin square design was used. Six patients were recruited in two blocks and assigned their treatments. Since there was an odd number of the visit in the study, orthogonal Latin square was used in which each column represented the order of anesthetic agents (A, B, C) given to each subject to achieve a balance.[6] Each patient was randomly assigned to receive either 2% lignocaine with 1:200,000 epinephrine (Kwality Pharmaceuticals Ltd., Amritsar-India) (Solution I), buffered lignocaine (Solution II), or 4% articaine with 1:200,000 epinephrine (Septanest N., Septodont, France) (Solution III) for the first visit; the other two local anesthetic solutions were administered in the second and third visit randomly.

Buffered lignocaine was prepared freshly every time by a trained dental assistant not involved in the administration of the anesthetic formulation. It was prepared by mixing sodium bicarbonate with lignocaine solution in a 1:10 ratio by volume. A 30 ml vial of commercially available 2% lignocaine hydrochloride with 1:200,000 epinephrine and 3 ml of 8.4% bicarbonate (Neon Laboratories Ltd.,) were mixed into the vial to make the final preparation.[7] The pH of the commercially available solution was found to be 4.33, while the pH of the buffered solution was 7.32. Either solution, at a volume of 1.8 ml, was dispensed in a disposable 2 ml syringe with a 27-gauge needle, which was used for all inferior alveolar nerve block injections.

On the day of appointment, every patient was reassessed for inclusion and exclusion criteria. The monitoring procedures were standardized. All procedures in the study were performed in morning session with relaxed atmosphere and no preoperative anxiolytic medications were prescribed. A pulse oximeter (Hygeia, India) was applied to the left index finger of the patient once the patient is seated in the dental chair, then heart rate (HR) and blood pressure (BP) was measured with the help of a sphygmomanometer (OMRO Automatic BP Monitor model HEM-7120 India) and oxygen saturation was measured with the help of a battery operated pulse oximeter which is precalibrated prior recording data from every patient. Topical anesthetic agent (Precaine-B 20% Benzocaine) was applied over the injection site 1 min before injection. First researcher then administered local anesthetic solution using standardized Inferior Alveolar Nerve Block technique. The first researcher was handed the loaded syringe (2 ml disposable syringe with 27-gauge needle) by second researcher and was unaware of the type of local anesthesia that he was administering. HR, BP, and oxygen saturation were reassessed after the procedure using the same criteria and standardized methods by a trained assistant who was blinded to the study. Efficacy of the anesthetic solution was judged both subjectively and objectively. Objective signs were assessed by gingival probing using a blunt ended William's periodontal probe 30 s post injection and continued for every 15 s until the pain experienced by patient is completely abolished subjective signs were evaluated by inquiring the patient about numbness on the tongue, corner of mouth and lips every 30 s until the patient experienced complete numbness.

The data were recorded and subjected to statistical analysis using SPSS version 20 (IBM, Armonk, NY). Three factors analysis of variance (ANOVA) which was adjusted for subject block and visit (period) was used for analyzing the differences.


  Results Top


All 48 (29 males and 19 females) with an age range of 5–10 years (mean age 7.5) who have participated in the study patients reported regularly on recall appointment and were monitored for hemodynamic changes 5 min before and 5 min after the administration of different local anesthetic agent combinations [Table 1]. Follow-up period for changes in hemodynamics was determined based on a previous study by Knoll-Köhler et al.[8]
Table 1: Demographic data of all patients

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The mean hemodynamic changes of systolic BP, diastolic BP, HR and oxygen saturation are shown [Table 2]. The mean systolic and diastolic BP, HR increased following injection of all the three variants. Even though variations were observed between the three tested groups, the difference was statistically nonsignificant (P > 0.05) after applying three factor repeated measure ANOVA. Oxygen saturation was also measured before and after administration of local anesthetic agents. However, the difference was not statistically significant (P > 0.05).
Table 2: Systolic blood pressure, diastolic blood pressure, heart rate, and oxygen saturation variations prior and postlocal anesthetic agent administration

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Systolic blood pressure

Systolic BP was measured before administration of local anesthetic agents. The difference was found to be statistically not significant after applying three factor repeated measure ANOVA adjusted for subject block and period or visit. Difference between Solution I and II; Solution II and III; Solution I and III is nonsignificant (P > 0.05) [Table 2].

Diastolic blood pressure

Diastolic BP was measured before and administration of local anesthetic agents. The difference was not found to be statistically significant after applying three factor repeated measure ANOVA adjusted for subject block and period or visit. Difference between Solution I and Solution II, Solution II and Solution III, Solution I and Solution III is nonsignificant (P > 0.05) [Table 2].

Heart rate

HR was measured before and administration of local anesthetic agents. The difference was found to be not statistically significant after applying three factor repeated measure ANOVA adjusted for subject block and period or visit. Difference between Solution I and Solution II, Solution II and Solution III, Solution I and Solution III is nonsignificant (P > 0.05) [Table 2].

Oxygen saturation

Oxygen saturation was measured before and administration of local anesthetic agents. Difference between Solution I and II, II and III, I and III is nonsignificant (P > 0.05) [Table 2].

Efficacy

Time taken for achieving maximum efficacy (using objective signs) was higher for buffered lignocaine (85.63 [±12.37] s), than for lignocaine (75.00 [±15.45] s) or articaine (79.38 [±18.55]). The difference was statistically significant between buffered lignocaine and lignocaine (P < 0.001) and buffered lignocaine and articaine (P = 0.026). The difference between the time taken for achieving maximum efficacy using subjective signs was found to be statistically significant between buffered lignocaine and lignocaine and buffered lignocaine and articaine (P < 0.05).


  Discussion Top


Life-threatening complications due to the sudden and dramatic increase in BP can occur during dental procedures. Although it is stated in the literature that local anesthetics with vasoconstrictors can be safely used during dental treatment, there are still some controversies about this subject.[9] Therefore, hemodynamic aspects, such as BP or HR, in hypertensive patients come into prominence. Monitoring hemodynamic changes while administering local anesthesia is essential to ensure safety of the patients, immediately identify situations of increased risk, establish an early diagnosis, prevent possible complications, and operate with increased safety.

Factors associated with increasing the hemodynamic are anxiety, pain during treatment and type of local anesthetic used. The anticipation of forthcoming dental treatment induces a physiologic stress response in patients that manifests in corticoid release, BP change and hemodynamic and cardiovascular reactions. Other than these physiological reason, presence of the vasoconstrictor, epinephrine in the local anesthetic solution and type of local anesthetic used also accounts for these changes.[10]

The association of emotional stress and fear with the enhanced sympathetic activity, of tachycardia with increased plasma concentrations of epinephrine or norepinephrine, or both are possible mechanism that may explain these effects.[11] Pain causes an alarm reaction manifested by hypothalamus oriented vasoconstriction and dilatation as well as the release of more epinephrine and norepinephrine, this results in increased HR and cardiac output.[12] In addition, pain may cause BP to rise due to the release of endogenous catecholamines which was also seen in our study. Several hemodynamic studies have been carried out in patients subjected to local anesthetic injection with a vasoconstrictor.[13],[14] While some have reported no significant changes in either BP (systolic and diastolic) or HR, others did and some authors have suggested that changes are dependent on the injected vasoconstrictor dose.[15]

In the present study, 46 out of 48 children had shown an increase in systolic BP after administration of Lignocaine, 42 after administration of Articaine, and 47 after administration of buffered lignocaine. The mean systolic and diastolic BP remained relatively constant in the current study, and no statistically significant differences were found between the three local anesthetic agents. The lack of significance may be due to limited dose of local anesthetic agent administered, whereas within the subjects the difference was found to be statistically significant. This may be attributed to children are more anxious towards local anesthetic injection. Lignocaine has an inherent vasodilating property, which in turn requires adrenaline. This has been shown to increase the BP and HR.[16]

There was mild elevation of HR and BP after administration of the three local anesthetics variants in almost all the participants. This is in agreement with other authors who reported no change in BP with the administration of adrenaline containing a local anesthetic.[17] In this study, the local anesthetic agents administered contained epinephrine as a vasoconstrictor, which would have maintained the BP and HR changes during the operation.

Another important factor associated with hemodynamic is height and weight of participant. This is extremely relevant in pediatric dentistry where there is a wide variation in weight and height between patients and thus not all patients should receive equal amounts of local anesthetic for the same procedure. Therefore, in the present study, a standard amount of local anesthetic solution (1.8 ml) was injected in all three groups.

One of the main importance of this study compared to other studies taken place in children was the comparison of three different local anesthetic agents with similar concentration of epinephrine. Most studies on the hemodynamic effect of local anesthesia solution were done with vasoconstrictor solutions. However, these effects could not be due to the presence of vasoconstrictor but to the local anesthetic agent itself. The lack of control group in the present study consisting of plain anesthetic agents without epinephrine could be a probable limitation of this study. This study examined the effects of local anesthesia on patients requiring vital pulp therapy and extraction, while this may increase clinical importance, as the inflammation associated with pulpitis can acidify the surrounding tissues and thereby decrease the effectiveness of anesthetics, thereby reflecting changes in hemodynamic measurements. The anticipation of dental treatment induces a physiologic stress response in patients that manifest in release of endogenous catecholamines with resultant hemodynamic and cardiovascular changes.


  Conclusion Top


It may be concluded that the hemodynamic effects of the three local anesthetic solutions evaluated in this study were similar to each other, and they could be safely used in children aged 5–10 years. Buffered 2% lidocaine is as safe in children compared with the unbuffered form and articaine is safe as a local anesthetic and can be used as an alternative to lidocaine in children.

Ethical clearance

IRB Number:ECR-1129/Inst/DL/2018. Since there was an odd number of the visit in the study, orthogonal Latin square was used in which each column represented the order of anesthetic agents (A, B, C) given to each subject to achieve a balance [Figure 1].[6]
Figure 1: 3/3 balanced Latin square design

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Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bartlett G, Mansoor J. Articaine buccal infiltration vs lidocaine inferior dental block – A review of the literature. Br Dent J 2016;220:117-20.  Back to cited text no. 1
    
2.
Malamed SF. What's new in local anaesthesia? Anaesth Prog 1992;39:125.  Back to cited text no. 2
    
3.
Snoeck M. Articaine: A review of its use for local and regional anesthesia. Local Reg Anesth 2012;5:23-33.  Back to cited text no. 3
    
4.
Guimaraes CC, Lopes Motta RH, Bergamaschi CC, Araújo JO, Andrade NK, Figueiró MF, et al. Local anaesthetics combined with vasoconstrictors in patients with cardiovascular disease undergoing dental procedures: Systematic review and meta-analysis protocol. BMJ Open 2017;7:e014611.  Back to cited text no. 4
    
5.
Sharan S, Goswami M, Kaul R, Rahman B, Farooq S. Comparative evaluation of effectiveness of intraligamentary injection technique using articaine and lidocaine for extraction of primary mandibular posterior teeth. Int J Pedod Rehabil 2018;3:62-6.  Back to cited text no. 5
  [Full text]  
6.
Conway CM, Ellis DB, King NW. A comparison of the acute haemodynamic effects of thiopentone, methohexitone and propanidid in the dog. Br J Anaesth 1968;40:736-45.  Back to cited text no. 6
    
7.
Mikesell P, Nusstein J, Reader A, Beck M, Weaver J. A comparison of articaine and lidocaine for inferior alveolar nerve blocks. J Endod 2005;31:265-70.  Back to cited text no. 7
    
8.
Knoll-Köhler E, Frie A, Becker J, Ohlendorf D. Changes in plasma epinephrine concentration after dental infiltration anesthesia with different doses of epinephrine. J Dent Res 1989;68:1098-101.  Back to cited text no. 8
    
9.
Ezmek B, Arslan A, Delilbasi C, Sencift K. Comparison of hemodynamic effects of lidocaine, prilocaine and mepivacaine solutions without vasoconstrictor in hypertensive patients. J Appl Oral Sci 2010;18:354-9.  Back to cited text no. 9
    
10.
Brand HS, Gortzak RA, Palmer-Bouva CC, Abraham RE, Abraham-Inpijn L. Cardiovascular and neuroendocrine responses during acute stress induced by different types of dental treatment. Int Dent J 1995;45:45-8.  Back to cited text no. 10
    
11.
Brown RS, Rhodus NL. Epinephrine and local anesthesia revisited. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100:401-8.  Back to cited text no. 11
    
12.
Elad S, Admon D, Kedmi M, Naveh E, Benzki E, Ayalon S, 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;105:725-30.  Back to cited text no. 12
    
13.
Viana AM, Campos AC, Morlin MT, Chin VK. Plasma catecholamine concentrations and hemodynamic responses to vasoconstrictor during conventional or Gow-Gates mandibular anesthesia. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100:415-9.  Back to cited text no. 13
    
14.
Meechan JG, Parry G, Rattray DT, Thomason JM. Effects of dental local anaesthetics in cardiac transplant recipients. Br Dent J 2002;192:161-3.  Back to cited text no. 14
    
15.
Pérusse R, Goulet JP, Turcotte JY. Contraindications to vasoconstrictors in dentistry: Part I. Cardiovascular diseases. Oral Surg Oral Med Oral Pathol 1992;74:679-86.  Back to cited text no. 15
    
16.
Malamed SF, Gagnon S, Leblanc D. Efficacy of articaine: A new amide local anesthetic. J Am Dent Assoc 2000;131:635-42.  Back to cited text no. 16
    
17.
Guglielmo A, Reader A, Nist R, Beck M, Weaver J. Anesthetic efficacy and heart rate effects of the supplemental intraosseous injection of 2% mepivacaine with 1:20,000 levonordefrin. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:284-93.  Back to cited text no. 17
    


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