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Articaine 30 Years Later
Articaine 30 Years Later
February 4, 2016
by Oral Health
Introduction
Local anesthesia forms the backbone of pain control techniques in dentistry.
Local anesthetics represent the safest (when used properly) and most effective
drugs for the prevention and management of perioperative and post-operative
pain.
The first known injection of a local anesthetic (1885) was an inferior alveolar
nerve block administered by the famed medical surgeon Dr. William Stewart
Halsted (1852–1922).1 The drugs injected were the combination of cocaine and
epinephrine. The dental profession quickly adopted local anesthesia as its
primary means of controlling pain eschewing general anesthesia that had been,
along with no anesthesia, the techniques of choice prior to 1885.
Carticaine, first prepared by Rusching and colleagues in 1969, had its generic
name changed to articaine when it entered clinical practice in Germany in
1976.4 Its use gradually spread, entering North America in Canada in 1983.5
The United Kingdom launched the drug in 1998, the United States in 2000, and
Australia in 2005. Articaine represents the first, and still only, local anesthetic
developed specifically for use in dentistry. Though articaine is classified as an
amide LA, articaine possesses chemical characteristics of both the amide and
ester groups (Fig. 1). It has become an extremely popular local anesthetic
wherever it has been made available. In 2014, articaine was the second most
used local anesthetic in the United States with a 34.86% market share
(lidocaine was first at 49.35%).6 In Australia 70% of dentists use articaine.7 In
2012, in Germany, where the drug was introduced in 1976, 97% of local
anesthetic use by dentists was articaine.8 Articaine is being used increasingly
by the medical profession.9
The elimination (beta) half-life of a drug is the time required to decrease its
blood (plasma) level or concentration by 50%. It is commonly stated that a drug
is ‘gone’ (eliminated) from the body in six half-lives (The blood level has actually
decreased by 98.25% at six-half lives).
The elimination half-lives of esters and amides are found in Table 1. Elimination
half-lives of esters is comparatively short to those of the amides. Procaine has a
half-life of 6 minutes, lidocaine approximately 90 minutes. It is important to
remember that the half-life of a drug has absolutely no relevance to the clinical
duration of action of that drug. A drug is clinically effective as long as it remains
in its target organ (e.g. inferior alveolar nerve) in a high enough (therapeutic)
concentration. The clinical action (e.g. ‘anesthesia’) of the drug ceases when it
diffuses out of the target organ into capillaries and veins. It is then that the
elimination half-life starts.
Given articaine’s ability to diffuse through the thick cortical plate of bone
following infiltration in the adult mandible, Kanaa et al looked at the ability of
articaine infiltration to increase the success rate of pulpal anesthesia following
an inferior alveolar nerve block (IANB) with 2% lidocaine with epinephrine
1:80,000.19 Patients received IANBs at each of two occasions (2.0 mL
lidocaine with epinephrine). Then they received either a buccal infiltration of 4%
articaine with epinephrine 1:100,000 or a ‘dummy’ injection in the buccal fold by
the mandibular 1st molar. The 1st molar and 1st premolar were pulp tested
every three minutes for 45 minutes. Results are shown in Figures 2 and 3. In
both teeth the additional articaine infiltration significantly increased the success
rate of pulpal anesthesia (55.6% to 91.7% for 1st molar; 66.7% to 88.9% for 1st
premolar). Though the study concluded at 45 minutes there was no indication
that pulpal anesthesia was waning at that time.19
In the United States the Food and Drug Administration classifies drugs by their
safety during pregnancy and nursing.20 The author is unaware of similar listings
by Health Canada (www.hc-sc.gc.ca).
Nursing: FDA categories for nursing infants are ‘S’ (Safe for nursing infant);
‘S?’ (Safety in nursing infants unknown); ‘S*’ (Potential for significant effects on
nursing infants) and ‘NS’ (Not safe for nursing infants).20 Lidocaine is the only
‘S’ local anesthetic. All others are ‘S?’ including epinephrine (in dental
concentrations). As nursing mothers are normally reluctant to expose their
infant to any drug that child does not need, it is not uncommon in the dental
environment to have a nursing mother in need of dental care ask their dentist,
‘Will the drug (e.g. lidocaine) be in the milk?” The answer will always be ‘Yes.’
The mother immediately states that they do not want the drug. This becomes
problematic when the dental procedure is potentially painful. The concept of
“pump and discard’ successfully handles this situation. Following exposure to a
drug the nursing mother should pump and discard the milk for a period covering
six elimination half-lives of the drug administered. For all local anesthetics
except articaine this is a period of nine hours. The FDA states ‘When using
articaine, nursing mothers may choose to pump and discard breast milk for
approximately four hours (based on plasma half life) following an injection of
articaine (to minimize infant ingestion) and then resume breastfeeding.”
For simplicity’s sake, the term paresthesia will be used to encompass all forms
of nerve dysfunction. We will define paresthesia as a “persistent anesthesia or
altered sensation well beyond the expected duration of anesthesia.” Symptoms
can vary significantly, including sensations of numbness, swelling, tingling and
itching, tongue biting, drooling, loss of taste, and speech impediment.23,31-34
Prior to delving into this subject there are a number of ‘truisms’ regarding
anatomy, injections and local anesthetics that need to be considered.
This paper has become the most cited reference purporting to demonstrate that
4% LAs are associated with a greater risk of paresthesia. Virtually all papers
reporting increased risk of paresthesia from articaine ultimately cite this
reference as their initial source.
Articaine was introduced into Denmark in 2001 and by 2005 had garnered 35%
of the dental local anesthetic market.24 A 2006 paper by Hillerup and Jensen
reported that articaine was the drug most often associated with reports of
paresthesia by dentists to the Danish Medicines Agency (Laegemiddel
Styrelsen). The paper recommended that “Until factual information is available,
a preference of other formulations to Articaine 4% may be justified, especially
for mandibular block analgesia.”24 As a consequence of this paper the Danish
Dental Association recommended that articaine not be used by inferior alveolar
nerve block.
In October 2011 the Danish Medicines Agency followed up with this report: “The
Danish Medicines Agency’s database of side effects contain 160 reports on
adverse reactions from articaine that occurred from 2001-2005. The adverse
reactions are mainly sensory impairment and nerve damage. Since 2005, we
have seen a drop in the number of reports of new adverse reactions, up until 1
October 2011, we have received 2 reports on suspected adverse reactions from
articaine which occurred in 2011. In both cases, the patients have experienced
sensory impairment after treatment with articaine.”43
This is an example of two phenomena: (1) the Weber Effect and (2) the effect of
publicity, either negative or positive, on drug prescription and usage (Fig. 4).
Articaine was introduced into the United States in June 2000 and, as in most
countries, quickly became a popular dental local anesthetic. In 2014 articaine
was the 2nd most administered local anesthetic (34.86% market share) in
dentistry in the USA.6 A 2010 paper by Garisto et al reviewing 248 reports of
paresthesia to the United States FDAs Adverse Event Reporting System
(AERS) occurring following dental procedures over an 11-year period (1997 –
2008) concluded that “Reports involving 4% prilocaine and 4% articaine were
7.3 and 3.6 times, respectively, greater than expected on the basis of local
anesthetic use by U.S. dentists.”44 The relative risks of paresthesia from this
paper are shown in Table 8, compared with the same drugs in the 1995 Ontario
paper.
TABLE 8. Comparative incidence of paresthesia reported in USA and
Ontario.
Regarding articaine, it appears from the numbers in these two papers that the
risk of paresthesia is 9.4 times greater in Ontario than in the United States. The
overall risk of paresthesia from a dental local anesthetic injection in Ontario is
17.58 times greater.23,44
Regarding the AERS data base, the following is posted on its website:45 “AERS
data do have limitations. First, there is no certainty that the reported event was
actually due to the product. FDA does not require that a causal relationship
between the product and event be proven. Furthermore, FDA does not receive
all adverse event reports that occur with a product.” (authors note: it is
estimated that only about 10% of all adverse events are reported). “Many
factors can influence whether or not an event will be reported, such as the time
a product has been marketed (Weber Effect) and publicity about an event.
Therefore, AERS cannot be used to calculate the incidence of an adverse event
in the US population.”45
Resolution of paresthesia was reported in 108 of the 248 cases, with complete
resolution occurring between 1 day and 736 days. Confirmed resolution of the
paresthesia was reported in 34 of the 108 cases. Of these, 25 resolved in less
than 2 months with the remaining 9 resolving within 240 days.44 92.7% of the
reports involved the lingual nerve (89.0% lingual nerve alone, 3.7% both lingual
and IA nerves).44
Citing this paper, the 2012 edition of the Australian Dental Associations
Therapeutic Guidelines (Oral and Dental) stated: “Articaine has been claimed to
be more effective, but there are reports of an increased risk of neurotoxicity,
presenting as prolonged numbness in the areas of distribution, often with pain.
This may be due to the higher concentration of the solution rather than to the
anaesthetic itself. Consequently, it is recommended that articaine should not be
used for regional blocks (e.g. inferior alveolar).28
The Weber Effect, named after the epidemiologist, Dr. JCP Weber46 is an
epidemiological phenomenon which states that the number of reported adverse
reactions for a drug rises until about the middle to end of the 2nd year of
marketing, peaks, and then steadily declines despite steadily increasing
prescribing rates.”
The validity of the Weber Effect has been challenged and demonstrated to be
verifiable.47 Hartnell and Wilson attempted to ‘validate or refute a widely
accepted epidemiological phenomenon known as the Weber effect by
replicating Weber’s original observation by using drugs (author’s note –
NSAIDs) that were marketed in the United States and using reports from a U.S.
database.” They concluded “The Weber effect was replicable.”47
Publicity affects drug prescribing and usage habits. Following the Danish Dental
Associations ‘recommendation’ to avoid the use of articaine by inferior alveolar
nerve block (IANB), its use in Denmark declined significantly (Fig. 4, red line).
In 2006 following the European Unions report stating there was no scientific
evidence of an increased risk of paresthesia from articaine, use of the drug
increased.
FIGURE 4. Articaine sales (red line) and adverse event reports (blue bars)
in Denmark, 2001-2010, reference #42.
The fact that the lingual nerve is stretched when the patient opens their mouth
for an IANB probably prevents the lingual nerve from ‘getting out of the way’ of
the needle. The resulting injury is more likely than not to be a result of
mechanical trauma to the lingual nerve from the metal needle. Stated in another
manner: “the lingual nerve is in the way.”
A 2003 paper by Pogrel et al attempted to explain why lingual nerve damage
was commonly seen as more profound.53 At the level at which the injection is
administered, the inferior alveolar nerve had 5 to 7 fascicles, whereas the
lingual nerve in that area usually had around three, but in a third of the cases
was actually unifascicular in the area where the IANB was given.53 (Fig. 5) If a
nerve with many fascicles (e.g. IANB) is damaged, only a small portion of the
sensory distribution would be affected. When a nerve with 1 to 3 fascicles (e.g.
lingual nerve) is damaged, the resulting area of sensory involvement will be
considerably larger.
All local anesthetics are neurotoxic. If all local anesthetics were equally
neurotoxic than the percentage of reported cases of paresthesia for the drug
should be equal to its market share. The resulting fraction ideally should be 1.0.
In a 2012 update reporting on 38 patients seen in his clinic between 2006 and
2011, Pogrel stated that “articaine is still causing permanent inferior alveolar
and lingual nerve damage (36%) which is proportionate to its market share
(37%).”37 “The number of cases caused by lidocaine, on the other hand,
appears to be only around 50% of its market share.” Prilocaine however by
causing 26% of all cases seen since 2005 with a market share of only 8% is
somewhat disproportionate to its market share.”37 Table 9 shows the results of
the two papers.
Is Articaine a More Effective Local Anesthetic and Does it Have
a Greater Risk of Paresthesia?
Editors Note:
Oral Health welcomes this original article from the well-respected Dr. Stanley
Malamed on articaine. In his review, Dr. Malamed discusses articaine and
paraesthesias. It is worth noting that the use of articaine and other 4% local
anaesthetic solutions for mandibular blocks has been an actively debated topic
for years. With regard to paraesthesias currently, the bulk of the literature
suggests a higher-than-expected incidence when higher concentration (4%)
local anaesthetic preparations are used. In the interest of presenting topics in a
balanced way, and acknowledging Dr. Malamed’s enthusiastic support for the
continued use of articaine for inferior alveolar nerve blocks in this article, our
readers may wish to also review articles by Dr. Dan Haas and Dr. Søren
Hillerup. Drs. Haas and Hillerup are two of the more notable additional authors
on the incidence of paraesthesias and some associated factors. Their viewpoint
represents a more guarded approach in the use of 4% solutions for mandibular
blocks.
Also at issue in this article is the use of articaine in pregnant women. Dr.
Malamed suggests that articaine, an FDA C-rated agent should be used instead
of B-rated lidocaine. The reason given is the shorter fetal exposure time to
articaine because of its faster metabolism. What is not clear is why exposing a
fetus to a potentially more harmful drug, even for a shorter time is
advantageous.
As always, how you choose to treat your patients is ultimately your decision.
At Oral Health, we would like these decisions to be based on the best
information available. We hope that you enjoyed Dr. Malamed’s article.
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