Comparative Evaluation of Pain Control Using 4% Articaine Buccal Infiltration and 2% Lignocaine Inferior Alveolar Nerve Block for Pulpectomy in Primary Mandibular Second Molars in the Children of Age-group 6–10 Years: A Split-mouth Randomized Controlled Clinical Trial

Abstract

Aims

This study aims to evaluate pain control using 4% articaine buccal infiltration and 2% lignocaine inferior alveolar nerve block (IANB) for pulpectomy in primary mandibular second molars in children of age category of 6–10 years.

Background

In pediatric dentistry, one of the most significant aspects of child behavior management is pain control during injecting local anesthesia. This leads to building trust, allaying fear or anxiety, and promoting a positive dental attitude. IANB is the preferred technique for achieving pulpal anesthesia during the treatment of mandibular primary molars. About 2% lignocaine is the most commonly used anesthetic agent in dentistry. Administration of 2% lignocaine using IANB is difficult in pediatric patients, as it may lead to uncooperative behavior in child, whereas administration of 4% articaine through buccal infiltration is comparatively more feasible in child and also reduces the postoperative complications. Hence, this study aims to compare pain control using 2% lignocaine IANB and 4% articaine buccal infiltration.

Materials and methods

Children between 6 and 10 years were selected for the study. It was split-mouth randomized controlled clinical trial. About 40 primary mandibular second molars were randomized from 20 children. Two categories were as follows: (1) category A—4% articaine buccal infiltration was administered and then pulpectomy procedure was performed, and (2) category B—2% lignocaine IANB was administered and then pulpectomy procedure was performed.

Results

It indicated that 4% articaine buccal infiltration had a lower mean pain score than 2% lignocaine IANB using Wong–Baker's face pain scale for objective evaluation and comparing subjective mean pain scores using Modified Behavioral Pain Scale (MBPS) during pulpectomy procedure.

Conclusion

(1) Pulpectomy is possible by depositing 4% articaine buccal infiltration. Articaine is an effective local anesthetic and can be used as an alternative to lignocaine nerve block in children. (2) No significant adverse effects were observed after the use of 4% articaine.

Clinical significance

Articaine is an effective local anesthetic and can be used as an alternative to lignocaine in children. Delivering comfortable anesthesia is essential, as it increases both patient's trust and treatment acceptance while at the same time reducing personal stress level.

How to cite this article

Saple RP, Pustake BJ, Patil S, et al. Comparative Evaluation of Pain Control Using 4% Articaine Buccal Infiltration and 2% Lignocaine Inferior Alveolar Nerve Block for Pulpectomy in Primary Mandibular Second Molars in the Children of Age-group 6–10 Years: A Split-mouth Randomized Controlled Clinical Trial. Int J Clin Pediatr Dent 2025;18(5):491–499.

Introduction

Pain management during dental procedures is one of the most important components of managing a child's behavior in pediatric dentistry; administering local anesthetic is a crucial component of treatment. A child can receive treatment that is efficient, painless, and comfortable when local anesthesia is administered successfully. This fosters a positive dental attitude, reduces fear or anxiety, and builds trust. This is a crucial element since it influences how a pedodontist and their child patient interact.¹

One of the most challenging parts of treating a child patient can be administering dental injections, which are linked to anxiety and worried thoughts in young patients. As a result, it is critical to minimize discomfort and manage uncomfortable circumstances at every appointment, especially when reactions worsen after four or five injections.²

For many years, dental anxiety in children has been a cause for concern. Among dentistry, the local anesthetic injection causes the most anxiety among youngsters. Local anesthetics are frequently utilized during pediatric dental treatment to provide pain-free treatment, children's comfort, and cooperation because they are both the child's savior and a common cause of discomfort and anxiety in young patients following dental injections.³

For over 50 years, 2% lignocaine is the gold standard when compared with all available new local anesthetics, making it the most effective anesthetic agent for use in both kinds of dentistry.⁴

Articaine differs from other local anesthetic agents due to the presence of an aromatic ring, its degree of protein binding due to the presence of thiophene ring, and its effective tissue penetration. It has been observed to work extremely well, have good diffusion properties, and last a suitable amount of time because a vasoconstrictor was included. In the lipophilic portion of the molecule, a thiophene ring took the place of the benzene ring, and a sulfur atom was added to it for the first time in a local anesthetic.⁵

A lot of the physiochemical characteristics of the most widely used local anesthetics, such as lignocaine, prilocaine, and mepivacaine, are shared by articaine; however, its aromatic ring and degree of protein binding are different. When treating mandibular primary molars, the preferred method for producing pulpal anesthesia is inferior alveolar nerve block (IANB). In dentistry, 2% lignocaine is the most often used anesthetic. Because anesthetic solutions only penetrate a small portion of the buccal cortical plate, IANBs are more successful than buccal infiltration with 2% lignocaine in producing profound anesthesia in mandibular molars.⁶

Administration of 2% lignocaine using IANB is difficult in pediatric patient as it may lead to uncooperative behavior in child, whereas administration of 4% articaine through buccal infiltration is comparatively more feasible in child and also reduces the postoperative complications.

Materials and Methods

Inclusion Criteria

• Children exhibiting cooperative behavior during treatment are categorized as class 3 or 4 on the Frankl Behavior Scale.⁶

• Presence of bilateral deep caries in primary mandibular second molars requiring pulp therapy.

Exclusion Criteria

• History of significant medical conditions.⁷

• Presence of abscess, sinus opening.

• Uncooperative patients.

Plan of the Study

• The parents and children were informed regarding the method.

• About 40 primary mandibular second molars of 20 children fulfilling inclusion criteria and who had deep carious lesions indicated for pulpectomy bilaterally were selected (Figs 1 to 3). In all patients, clinical examination was done and preoperative radiographs were taken.

• Split-mouth study was conducted using two anesthetic agents in the same child in two different appointments.

• Two categories were made—categories A and B.

• Topical anesthetic gel was applied for 1 minute (Figs 4A and 5A).

• Category A—4% articaine buccal infiltration was administered, and then pulpectomy procedure was performed.

• Category B—2% lignocaine nerve block was administered, and then pulpectomy procedure was performed.

• Both anesthetic agents were given using 2 mL syringe with 26 gauge × 1.5 length needle.

• According to randomization, in the first appointment, some patients received 0.45–0.60 mL of 4% articaine with 1:100000 epinephrine as buccal infiltration. The technique which was used was injection at the mucobuccal fold such that the solution got deposited slowly and close to the primary mandibular second molar (Fig. 5B).

• Some patients were administered 1–1.8 mL of 2% lignocaine with 1:1,00,000 epinephrine via an IANB. The technique involved placing the thumb on the occlusal surface of the molar, with its tip resting in the retromolar fossa. The syringe barrel was aligned along the plane between the two primary molars on the opposite side of the arch (Fig. 4B). It was recommended to inject a small amount of anesthetic solution immediately after tissue penetration following aspiration and to continue administering small increments as the needle advanced toward the mandibular foramen.

• After the injections and verbal instructions, pulpectomy procedure was taken place, and each child was requested to choose a facial expression that accurately reflected their pain experience using the Wong–Baker faces pain rating scale during pulp excavation, this was subjective evaluation (Figs 4C and 5C).

• The Modified Behavioral Pain Scale (MBPS), by Taddio et al., was utilized to objectively assess the patient's behavior during pulp excavation, focusing on facial expressions, movements, and crying (Figs 4D and 5D).

• At the second appointment, conducted after a minimum interval of 1 week, the alternative solution was applied, and the same procedure and evaluation were repeated. The occurrence of any untoward incidents, such as infection, headache, toothache, or self-inflicted soft tissue injuries such as lip or cheek biting, was determined by means of two phone calls made for follow-ups 1 week and 24 hours following the therapy.

Fig. 1:

Armamentarium for pulpectomy

Fig. 3:

Bilaterally deep occlusal caries of primary mandibular second molars which required pulpectomy

Figs 4A to D:

(A) Application of topical anesthesia; (B) Administration of 2% lignocaine IANB; (C) Evaluation of pain on subjective scale by patient during pulp excavation; and (D) Evaluation of pain on objective scale by operator during pulp excavation

Figs 5A to D:

(A) Application of topical anesthesia; (B) Administration of 4% articaine buccal infiltration; (C) Evaluation of pain on subjective scale by patient during pulp excavation; and (D) Evaluation of pain on objective scale by operator during pulp excavation

Fig. 2:

Armamentarium for local anesthesia

Evaluation of Pain Control

Subjective Evaluation

Pain experienced by children was evaluated by Wong–Baker's face pain scale during pulp excavation of pulpectomy procedure for both the categories.⁸ This scale was employed to assess the pain perceived by kids through subjective evaluation. The children were shown six cartoon faces illustrating various emotions, from smiling to laughing to crying. Each face was assigned a numerical value ranging from 0 to 10. They were asked to choose the facial expression that best matched their level of discomfort during the pulpectomy procedure, with the following scoring system:

Objective Evaluation

The child's reactions during pulp excavation in pulpectomy procedures for both categories were observed and evaluated by the operator using the MBPS, as described by Taddio et al.⁹ This scale measured aspects such as facial expressions, body movements, and crying, with the scoring outlined.

Results

Subjective Evaluation

The results of subjective evaluation were as follows: in category A, subjective symptoms 4 (20%) have shown “no hurt,” while none among category B have shown that. Among category A, 10 (50%) have shown “hurts little bit,” while 6 (30%) from category B reported the same. Six (30%) subjects from category A and 10 (50%) from category B have shown “Hurts little more.” Four (20%) from category B have shown “hurts even more” and none from category A. There was a statistically significant difference present for distribution of subjective symptoms and two categories with p = 0.015* (Table 1).

Table 1:

Frequency distribution for subjective evaluation between two categories

Subjective evaluation
Categories		Frequency	Percentage	Valid percent	Cumulative percent	Fisher's exact test p-value
A	No hurt	4	20.0	20.0	20.0	0.015*
	Hurts little bit	10	50.0	50.0	70.0
	Hurts little more	6	30.0	30.0	100.0
	Total	20	100.0	100.0
B	Hurts little bit	6	30.0	30.0	30.0
	Hurts little more	10	50.0	50.0	80.0
	Hurts even more	4	20.0	20.0	100.0
	Total	20	100.0	100.0

*Statistically significant

The mean difference for mean subjective evaluation score between category A (2.20 ± 1.436) and elastic module (3.80 ± 1.436) was −1.600 which was found statistically significant with p = 0.001 with confidence interval (CI): −2.5200, −0.680 (Table 2).

Table 2:

Comparison of mean subjective evaluation between two categories by unpaired t-test

Categories A vs B	t	df	Sig. (two-tailed) p-value	Mean difference	Confidence interval (CI)
					Lower	Upper
2.20 ± 1.436	−3.523	38	0.001*	−1.600	−2.520	−0.680
3.80 ± 1.436

*Statistically significant

Objective Evaluation

The results of objective evaluation were as follows: total 13 (65%) subjects from category A have shown a total objective score 2, while 1 (5%) have shown score 3. Total objective score 4 was shown by 3 (15%) from category A and 1 (5%) from category B, while total score 6 was reflected by 1 (5%) from category A and 8 (40%) from category B. Among category B, 2 (10%) have shown a total score 7 while 4 (20%) have shown score 9. There was a statistically significant difference present for the distribution of total objective symptoms scores and two categories with p < 0.001* (Table 3).

Table 3:

Frequency distribution and percentage for objective evaluation between two categories

Total score
Categories/total score		Frequency	Percentage	Valid percent	Cumulative percent	Fisher's exact test p-value
A	2	13	65.0	65.0	65.0	<0.001*
	3	1	5.0	5.0	70.0
	4	3	15.0	15.0	85.0
	5	2	10.0	10.0	95.0
	6	1	5.0	5.0	100.0
	Total	20	100.0	100.0
B	4	1	5.0	5.0	5.0
	5	5	25.0	25.0	30.0
	6	8	40.0	40.0	70.0
	7	2	10.0	10.0	80.0
	9	4	20.0	20.0	100.0
	Total	20	100.0	100.0

*Statistically significant

The score for facial expression among category A, 14 (70%) have shown “neutral expression.” Six (30%) from category A and 16 (80%) from category B have shown “slightly negative expression (grimace).” Four (20%) from category B have shown “definitely negative expression (furrowed eyebrows, eyes closed tightly).” There was a statistically significant difference present for distribution of facial expression—objective symptoms and two categories with p < 0.001* (Tables 4 and 5).

Table 4:

Comparison of mean objective evaluation score between two categories by unpaired t-test

Categories A vs B	t	df	Sig. (two-tailed) p-value	Mean difference	Confidence interval (CI)
					Lower	Upper
2.85 ± 1.309	−7.770	38	<0.001*	−3.500	−4.412	−2.588
6.35 ± 1.531

*Statistically significant

Table 5:

Association between facial expression—objective evaluation and two categories by Fisher's exact test

Category* facial expression cross-tabulation
			Facial expression			Total
			Neutral expression	Slightly negative expression (grimace)	Definitely negative expression (furrowed eyebrows, eyes closed tightly)
Categories	A	Count	14	6	0	20
		Category (%)	70.0	30.0	0.0	100.0
		Total (%)	35.0	15.0	0.0	50.0
	B	Count	0	16	4	20
		Category (%)	0.0	80.0	20.0	100.0
		Total (%)	0.0	40.0	10.0	50.0
Total		Count	14	22	4	40
		Category (%)	35.0	55.0	10.0	100.0
		Total (%)	35.0	55.0	10.0	100.0
Fisher's exact test p-value						<0.001*

*Statistically significant

The mean difference for mean facial expression objective symptoms evaluation score between category A (1.30 ± 0.470) and elastic module (2.20 ± 0.410) was −0.900 which was found statistically significant with p < 0.001 with CI: −1.183, −0.617 (Table 6).

Table 6:

Comparison of mean objective evaluation score—facial expression between two categories by unpaired t-test

Categories A vs B	t	df	Sig. (two-tailed) p-value	Mean difference	Confidence interval (CI)
					Lower	Upper
1.30 ± 0.470	−6.449	38	<0.001*	−0.900	−1.183	−0.617
2.20 ± 0.410

*Statistically significant

The score for cry among category A 17 (85%) and 6 (30%) from category B have shown “not crying.” Three (15%) from category A and 10 (50%) from category B have shown “moaning quietly, vocalizing gentle, or whimpering cry.” Four (20%) from category B have shown “full crying or sobbing.”

There was a statistically significant difference present for the distribution of cry—objective symptoms between two categories with p = 0.001* (Table 7).

Table 7:

Association between cry—objective evaluation and two categories by Fisher's exact test

Category* cry cross-tabulation
			Cry			Total
			Not crying	Moaning quietly, vocalizing gentle, or whimpering cry	Full crying or sobbing
Categories	A	Count	17	3	0	20
		Category (%)	85.0	15.0	0.0	100.0
		Total (%)	42.5	7.5	0.0	50.0
	B	Count	6	10	4	20
		Category (%)	30.0	50.0	20.0	100.0
		Total (%)	15.0	25.0	10.0	50.0
Total		Count	23	13	4	40
		Category (%)	57.5	32.5	10.0	100.0
		Total (%)	57.5	32.5	10.0	100.0
Fisher's exact test p-value						0.001*

*Statistically significant

The mean difference for mean cry objective symptom evaluation score between category A (1.15 ± 0.366) and elastic module (1.90 ± 0.718) was −0.750 which was found statistically significant with p < 0.001 with CI: −1.115, −0.385 (Table 8).

Table 8:

Comparison of mean objective evaluation score—cry between two categories by unpaired t-test

Categories A vs B	t	df	Sig. (two-tailed) p-value	Mean difference	Confidence interval (CI)
					Lower	Upper
1.15 ± 0.366	−4.160	38	<0.001*	−0.750	−1.115	−0.385
1.90 ± 0.718

*Statistically significant

The score for movements—objective symptoms among category A 16 (80%) have shown “usual movement and activity/resting and relaxed.” Four (20%) from category A and 14 (70%) from category B have shown “partial movement/attempt to avoid pain by withdrawing the limb where the puncture is done.” Six (30%) from category B have shown “agitation with complex/generalized movement involving the head torso or other limbs/rigidity.”

There was a statistically significant difference present for distribution of movements—objective symptoms and two categories with p < 0.001* (Table 9).

Table 9:

Association between movement—objective evaluation and two categories by Fisher's exact test

Category* movements cross-tabulation
			Movements			Total
			Usual movement and activity/resting and relaxed	Partial movement/attempt to avoid pain by withdrawing the limb where the puncture is done	Agitation with complex/generalized movement involving the head torso or other limbs/rigidity
Categories	A	Count	16	4	0	20
		Category (%)	80.0	20.0	0.0	100.0
		Total (%)	40.0	10.0	0.0	50.0
	B	Count	0	14	6	20
		Category (%)	0.0	70.0	30.0	100.0
		Total (%)	0.0	35.0	15.0	50.0
Total		Count	16	18	6	40
		Category (%)	40.0	45.0	15.0	100.0
		Total (%)	40.0	45.0	15.0	100.0
Fisher's exact test p-value						<0.001*

*Statistically significant

The mean difference for mean movements objective symptom evaluation score between category A (0.40 ± 0.821) and elastic module (2.30 ± 0.470) was −1.900 which was found statistically significant with p < 0.001 with CI: −2.328, −1.472 (Table 10).

Table 10:

Comparison of mean objective evaluation score—movement between two categories by unpaired t-test

Categories A vs B	t	df	Sig. (two-tailed) p-value	Mean difference	Confidence interval (CI)
					Lower	Upper
0.40 ± 0.821	−8.983	38	<0.001*	−1.900	−2.328	−1.472
2.30 ± 0.470

*Statistically significant

Occurrence of any Adverse Effects

In this study, no adverse reactions were observed after the administration of either 4% articaine containing 1:1,00,000 epinephrine or 2% lignocaine with 1:1,00,000 epinephrine. In both the categories that is in all 20 children that included 40 teeth no significant postanesthetic complications were observed clinically.

Discussion

One of the most crucial components of behavior management for children receiving dental care is pain control. It is mainly achieved using local anesthetic drugs through local anesthetic injections. Although injections trigger pain and anxiety in children, they are still used in the dental treatment for children's comfort, cooperation, and pain-free treatment.⁸ Unpleasant childhood experiences have made many adults phobic with regard to dental treatments.

The technique of local anesthesia administration is an important consideration in pediatric behavior guidance. Age-appropriate nonthreatening terminology, distraction, topical anesthetic, and proper injection techniques can help the children for having the positive experience during the administration of local anesthesia. Effective management of pediatric patients, particularly in reducing their anxiety and discomfort during restorative and surgical procedures, is largely dependent on achieving profound local anesthesia. Various techniques and methods are employed to minimize the discomfort associated with intraoral injections, including the use of topical anesthetics, transcutaneous electronic nerve stimulation, computerized injection systems, pressure application, and eutectic mixtures of local anesthetics. However, none of these methods have achieved universal acceptance. Nonetheless, it facilitates painless needle penetration into the surface tissue.^4,10

There are numerous local anesthetics available to help pediatric patients manage their pain. There are two general types of local anesthetic chemical formulation: (1) esters, for example, procaine, benzocaine, and tetracaine and (2) amides, for example, lignocaine, mepivacaine prilocaine, and articaine.¹¹

Compared to other local anesthetics, articaine is said to be able to diffuse into both soft and hard tissues more readily. The basis for articaine's extensive use and lower level of toxicity than lignocaine is the belief that it possesses better dispersion through soft tissue and bone, a quick onset, a strong anesthetic quality, and other desirable features. Because of its higher tissue penetration capabilities, articaine delivers full anesthesia by infiltration method.⁸

When treating mandibular primary molars, the preferred method for producing pulpal anesthesia is IANB. In dentistry, 2% lignocaine is the most often used anesthetic. Due to the poor anesthetic solution penetration through the buccal cortical plate, just buccal infiltration using 2% lignocaine is not as efficient as the IANB for obtaining profound anesthesia in mandibular molars.¹² This makes treating mandibular molars challenging in children.

In order to achieve mandibular molar anesthesia, buccal infiltration with articaine has been demonstrated to have a higher success rate than buccal infiltration with 2% lignocaine with epinephrine (1:1,00,000). Increased articaine diffusion or the concentration effect could be the reason for this improvement in efficacy.⁹ Infiltration with articaine has recently been found to be an efficient method of obtaining anesthesia for mandibular molars. Jung et al.13,14 discovered that buccal infiltration with articaine had a faster onset and equivalent efficacy.

In our study, 20 children of age category from 6 to 10 years were selected who needed pulp therapy for mandibular second primary molars bilaterally. We selected this age category as this age category can understand the treatment procedures, can follow our commands, as well as point out his/her pain experience on the pain rating scale while going through pulpectomy procedures. This age category can show at most cooperative behavior. Pain threshold tends to decline, and pain management becomes more effective with increasing age. Limited literature was found among this age category; hence, we selected 6–10 years age category.

The technique that was used for buccal infiltration was injection at the puncture site at the mucobuccal fold so that the solution was deposited slowly and close to the primary mandibular second molar.

While blocking the inferior alveolar nerve with lignocaine injection, the thumb was placed on the occlusal surface of the molar with its tip resting in the retromolar fossa. On the opposing side of the arch, the syringe's barrel was aimed at the space between two primary molars. As soon as the tissue is penetrated following aspiration, it is best to inject a tiny amount of the solution. Keep injecting tiny amounts while the needle is aimed toward the mandibular foramen.

Pain experienced by children was evaluated using subjective scale and objective scale during the procedure in both appointments. Assessing pain in children can be highly challenging. The Wong–Baker faces pain scale was employed for subjective evaluation, demonstrating strong construct validity as a tool for self-reported pain assessment. Measuring the intensity of pain or discomfort in young children, particularly those of preschool age, can be complicated due to their developmental stage in cognition and language skills.

Khatri and Kalra¹⁴ stated through their study that children had more difficulty understanding the use of visual analog scale (VAS) than that of Wong–Baker faces pain rating scale. Although these scales provide a useful method of describing pain experience, they do not assess the multidimensional nature of pain.

For objective evaluation, we used MBPS suggested by Taddio et al. which was evaluated by the same operator in both categories.

Two categories (category A: 4% articaine buccal infiltration followed by pulpectomy and category B: 2% lignocaine IANB followed by pulpectomy) were compared for various subjective and objective symptoms by unpaired t-test.

Results of a total 20 subjects who were involved in this study with minimum age of 6 years and maximum age was 10 years with mean age 7.90 ± 1.518. Among 20 subjects who were involved in the study, 10 (50%) were male while 10 (50%) were female. In the present study, there was no significant difference among the categories regarding age or gender, which is in concordance with studies conducted by Ram and Amir.¹²

The results showed that lignocaine category (B) had a higher mean score for pain as compared to articaine category (A) mean score for pain on Wong–Baker faces pain scale as well as on MBPS for the anesthetic agents.

This indicates by subjective evaluation that articaine buccal infiltration had less pain score as compared to lignocaine nerve block. In the present study, 4% articaine showed better anesthetic efficacy as compared to 2% lignocaine according to subjective evaluation. This can be explained by the fact that articaine is unique among amide local anesthetics due to the presence of thiophene ring which increases its lipid solubility. Articaine's superior lipid solubility enhances its ability to penetrate nerve membranes, allowing it to diffuse more effectively through soft tissues compared to other local anesthetics. This results in higher intraneural concentrations, greater longitudinal spread, and improved conduction blockage. According to Borchard and Drouin¹⁵ study, ionic channels are blocked even in lower concentration with the thiophene derivative (articaine) compared to the benzene derivative (lignocaine).

Similar results were obtained in the study conducted by Daneswari et al.⁹ which included 30 patients (4–8 years) with an indication of pulp therapy in at least two primary mandibular second molars. They came to the conclusion that, given the growing popularity of novel delivery methods such as single-tooth analgesia, buccal infiltration with articaine offers a painless substitute that would enable dentists to refrain from using IANBs on young patients.

Conclusion

The results indicated that 4% articaine buccal infiltration had less mean pain score than 2% lignocaine using Wong–Baker face pain scale and comparable mean pain scores using MBPS during pulpectomy procedure.

The following conclusion can be drawn from the data obtained in our study:

• Routine use of IANB for pulpectomy procedures results in discomfort in children.

• No significant postanesthetic complication or adverse effects were observed clinically after the use of 4% articaine and 2% lignocaine anesthetic agents.

Clinical Significance

Articaine is an effective local anesthetic and can be used as an alternative to lignocaine in children. Delivering comfortable anesthesia is essential, as it increases both patient's trust and treatment acceptance while simultaneously reducing personal stress level.

Orcid

Ruchi P Saple https://orcid.org/0009-0001-9527-1289