Journal List > J Dent Anesth Pain Med > v.18(6) > 1110838

J Dent Anesth Pain Med. 2018 Dec;18(6):319-332. English.
Published online Dec 28, 2018.  https://doi.org/10.17245/jdapm.2018.18.6.319
Copyright © 2018 Journal of Dental Anesthesia and Pain Medicine
Efficacy of dental local anesthetics: A review
Nelly Badr,1 and Johan Aps2
1University of Washington, Seattle, USA.
2University of Western Australia, Division of Oral Diagnostics and Surgical Sciences, Perth, Australia.

Corresponding Author: Johan Aps, University of Western Australia, Dental School, Division of Oral Diagnostic and Surgical Sciences, M512, 17 Monash Avenue, Nedlands, WA 6009, Australia. Email: johan.apsdmfr@hotmail.com / Email: johan.aps@uwa.edu.au
Received Oct 18, 2018; Revised Nov 26, 2018; Accepted Nov 26, 2018.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.


Abstract

The objective of this review was to investigate the efficacy of dental local anesthetics, as it is well known among clinicians that local anesthesia may be challenging in some circumstances. Therefore, the focus of this review was on the efficacy of the products used in dental local anesthesia.

In a Pubmed database literature search conducted, a total of 8646 articles were found to be related to dental local anesthetics. After having applied the inclusion criteria (human research, performed in the last 10 years, written in English language, and focus on dental local anesthetics) and having assessed the quality of the papers, 30 were deemed eligible for inclusion in this review.

The conclusion of this review is that none of the dental local anesthetic amides provide 100% anesthesia. The problem appears to be more pronounced when mandibular teeth are attempted to be anaesthetized and especially if there is irreversible pulpitis involved. The authors conclude that this finding suggest exploration of more efficient techniques to administer dental local anesthesia, especially in the mandible, to establish a 100% efficacy, is needed.

Keywords: Amides; Local Anesthesia

INTRODUCTION

Local anesthesia in dentistry provides comfort for the patient, but also as much comfort for the clinician as the planned procedures can be carried out under the best possible conditions. From clinical experience and from the literature, it is clear that dental local anesthesia is not always as successful as anticipated [1, 2, 3, 4, 5, 6, 7, 8]. Especially mandibular block anesthesia can be difficult to achieve or challenging in some patients, even in the absence of a tooth with an acute pulpitis. Mandibular block failure rates differ from study to study and teach us that there is no 100% success [1, 2, 3, 7]. The efficacy of local anesthesia in the maxilla is much higher, based on clinical experience and publications. The main reason is probably the cortical plates of the mandible being thicker and denser and having less porosities that allow for a volume of local anesthetic to be diffused into the cancellous bone in case one attempts a buccal infiltration for instance, explains most of the difference with the maxilla. Another reason is the techniques that are used to achieve local anesthesia. In the maxilla, the most appropriate technique would be a buccal infiltration anesthesia close to the level of the apices of the teeth, while in the mandible, because of the reason mentioned above, local anesthesia is achieved mainly by attempting to deposit a volume of local anesthetic close to the mandibular nerve before it enters the mandible [6, 7, 9, 10]. Because of anatomical variations in localisation of the second branch of the trigeminal nerve with regard to the ramus of the mandible, the efficacy of local anesthesia is not 100% [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11].

The aim of this current review was to assess the peer-reviewed literature on the topic of dental local anesthetics to see if the efficacy of dental local anesthetics depends on the amide or a combination of amides used.

MATERIAL AND METHODS

Fig. 1 shows which search terms were used in the PubMed® database to identify relevant publications, how many publications were found per search term and how publications were finally triaged to be reviewed by both researchers. The inclusion criteria used, were that studies had to be related to human research, performed in the last 10 years, written in English language, and with a focus on dental local anesthetics. After having identified the search terms, the search was conducted between January 2017 and January 2018 by one researcher (NB). As can be derived from Fig. 1, an initial total of 8646 manuscripts were identified. After applying the selection criteria, 79 papers were subsequently read by both researchers, and then categorised in consensus in an Excel spread sheet (Microsoft®, Redmond, Washington, USA) to identify the type of study (e.g. randomised clinical trial), the amides investigated (e.g. articaine), the number of patients included in the study if it was a clinical trial, the country of origin and the year of publication and finally, the conclusion of the study. Both investigators read all 79 publications, and, in consensus, deemed 30 manuscripts eligible for the study's aim.


Fig. 1
The decision process of the review explained, mentioning the number of papers collected, assessed and reviewed.
Click for larger imageDownload as PowerPoint slide

RESULTS

A total of 30 publications (Fig. 1) were considered relevant for the study: 7 reviews, and 23 clinical trials.

The details of the different studies and their conclusions can be found in Tables 1 and 2. These tables show data regarding the country of origin, the number of subjects involved, which amides were investigated and in the last column the final conclusions as stated in the respective papers. Table 3 tabulates the number of manuscripts that investigated which type of amide and which amide was found to be more or equally in efficacy to achieve local anesthesia. The numbers in the right hand side column refer to the manuscripts reference list.


Table 1
Review papers included in this current review, indicating reference, year of publication, type of amides involved, type of anesthesia involved and conclusion of the study
Click for larger imageClick for full tableDownload as Excel file


Table 2
In vivo and in vitro papers included in this current review, indicating reference, year of publication, type of amides involved, type of anesthesia involved and conclusion of the study
Click for larger imageClick for full tableDownload as Excel file


Table 3
Efficacy comparisons of amides in the literature (“>” indicating a higher efficacy and “=” indicating an equal efficacy).
Click for larger imageClick for full tableDownload as Excel file

Of the six amide products used in dental local anesthesia, 13 in vivo studies and 4 reviews found that articaine was the amide with the highest efficacy when compared to either lidocaine, mepivacaine, prilocaine or bupivacaine (see Table 1). Mepivacaine [12, 13] and bupivacaine [14, 15] as opposed to lidocaine, appeared to have a higher efficacy in one review [12, 14] and one in vivo study [13, 15], each.

Prilocaine, as opposed to lidocaine and bupivacaine, was found to have a higher efficacy in only one in vivo study [16]. Two in vivo studies claimed that ropivacaine had a high efficacy under different concentrations [17], without comparing it to another amide or when comparing it to lignocaine [18].

However, when duration of the local anesthetic effect was taken into account, mepivacaine was shown to work for a shorter duration compared to lidocaine [19].

Eleven studies [20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30] either found no significant differences between two types of amides or studied the volume of anesthetic and found its efficacy was significantly greater if higher volumes (more than one cartridge) were administered.

With regard to addition of vasoconstrictors epinephrine and clonidine, one in vivo study concluded that clonidine increased efficacy better than epinephrine, combined with lidocaine [31], while increasing the concentration of epinephrine, with articaine and lidocaine, did not significantly impact the anesthetic efficacy [14, 15]. Three in vivo studies showed that adding a sodium bicarbonate buffer to lidocaine [32, 33] and articaine [34], yielded no improvement in efficacy for either. One study [24] investigated the difference between mepivacaine combined with levonordefrin and lidocaine with epinephrine, and concluded that there were no significant differences between them with regard to efficacy.

Other in vivo studies incorporated drugs such as meperidine [35, 36] and mannitol [37] to lidocaine, and neither appeared to have a significant influence on anesthetic efficacy. Also, liposomal bupivacaine was assessed, but did not improve the efficacy either [38].

DISCUSSION

The authors noticed that the terms efficiency and efficacy are sometimes incorrectly interchanged. Efficacy is the correct term to be used when assessing the outcome of a product, for instance, or the ability to produce a desired result (e.g. 100% pulpal anesthesia), while efficiency is to be used to assess a process (e.g. how successful is mandibular block anesthesia?) or the state or the quality of being efficient. The mix up is understandable if English is not the native language of the authors, but it should be avoided at all times as it makes the search for papers for a review more complicated.

Based on this review, which covers the past 10 years, the findings suggest that articaine has been researched the most and that it also has the highest efficacy of the amides used in dental local anesthesia. The fact that articaine received so much attention is probably attributable to the fact that before the year 2000, articaine was not available in the USA, whereas in Europe it was already marketed in 1976. As can be derived from tables 1 and 2, 20 of the 31 papers included in our study were conducted in the USA. Although, it was not within the scope of this review paper, nevertheless, the authors are aware of the dubious reputation of articaine with regard to post-operative paresthesia and the discussion about it being manufactured as a 4% solution instead of 2% like lidocaine for dental local anesthesia [16, 39, 40]. It deserves to be emphasized, however, that in vitro laboratory studies on cell lines have shown that articaine is not the most neurotoxic amide used in dental local anesthesia. One in vitro study, conducted by Mallet et al., tested the toxicity of 6 local anesthetic products on human neuroblastoma cells and found that articaine is the least toxic amide [40], while another in vitro study, by Perez-Castro et al., conducted on a neuronal cell-line, concluded that bupivacaine is the most toxic amide [41]. These findings are in contrast to the reported potential adverse effects, published in two review articles, stating that articaine is harmful in high concentrations, such as 4% [39], and may cause paresthesia [40]. It has to be emphasized that in the latter review, it was found that also prilocaine can potentially cause paresthesia [40]. It is noteworthy that the clinical reports about paresthesia and apparent toxicity almost always involve mandibular block anesthesia. However, it seems strange to us that articaine, for instance, would have a high neurotoxic preference for the second branch of the trigeminal nerve only. Since that was not the aim of the present study, this issue will not be discussed further here, but it definitely deserves further in depth attention.

It is our impression that, after having read the papers regarding efficacy of dental local anesthetics, none of the amides studied and used in dentistry guarantee a 100% success, especially not in the mandible. Therefore, one could conclude that perhaps the technique of administration is inefficient and therefore the efficacy is poor. Intraosseous anesthesia could be the key to increase the efficacy of local anesthetics in the mandible.

CONCLUSIONS

From the consulted literature, it is clear that local anesthetics used in dentistry do not show a 100% efficacy, especially not if administered in the mandible or in cases of inflammation (acute irreversible pulpitis). The authors suggest that this opens perspectives to explore more successful ways of administering local anesthesia, in order for the local anesthetic to be more efficacious.

Notes

CONFLICT OF INTEREST:One of the authors (JA) is a key opinion leader for Dental Hi Tec®, the French manufacturer of SleeperOne® and Quicksleeper®.

References
1. Nakai Y, Milgrom P, Mancl L, Coldwell SE, Domoto PK, Ramsay DS. Effectiveness of local anesthesia in pediatric dental practice. J Am Dent Assoc 2000;131:1699–1705.
2. Milles M. The missed inferior alveolar block: A new look at an old problem. Anesth Prog 1984;31:87–90.
3. AlHindi M, Rashed B, AlOtaibi N. Failure rate of inferior alveolar nerve block among dental students and interns. Saudi Med J 2016;37:84–89.
4. Sanchis JM, Penarrocha M, Soler F. Bifid mandibular canal. J Oral Maxillofac Surg 2003;61:422–424.
5. Davoudi A, Rismanchian M, Akhavan A, Nosouhian S, Bajoghli F, Haghighat A, et al. A brief review on the efficacy of different possible and nonpharmacological techniques in eliminating discomfort of local anesthesia injection during dental procedures. Anesth Essays Res 2016;10:13–16.
6. Malamed SF. Techniques of maxillary anesthesia. In: Malamed SF, editor. Handbook of local anesthesia. 5th ed. St Louis, Missouri: Elsevier Mosby; 2004. pp. 189-225.
7. Malamed SF. Techniques of maxillary anesthesia. In: Malamed SF, editor. Handbook of local anesthesia. 5th ed. St Louis, Missouri: Elsevier Mosby; 2004. pp. 227-253.
8. van den Akker HP. Local complications. In: Baart JA, Brand HS, editors. Local anesthesia in dentistry. 1st ed. Oxford: Wiley-Blackwell; 2009. pp. 117-125.
9. Baart JA. Local anesthesia in the upper jaw. In: Baart JA, Brand HS, editors. Local anesthesia in dentistry. 1st ed. Oxford: Wiley-Blackwell; 2009. pp. 57-69.
10. Pogrel AM, Stevens RL, Bosack RC, Orr T. Complications with the use of local anesthetics. In: Bosack RC, Lieblich S, editors. Anesthesia complications in the dental office. 1st ed. Oxford: Wiley-Blackwell; 2014. pp. 207-218.
11. Baart JA. Local anesthesia in the upper jaw. In: Baart JA, Brand HS, editors. Local anesthesia in dentistry. 1st ed. Oxford: Wiley-Blackwell; 2009. pp. 71-86.
12. Su N, Liu Y, Yang X, Shi Z, Huang Y. Efficacy and safety of mepivacaine compared with lidocaine in local anaesthesia in dentistry: A meta-analysis of randomised controlled trials. Int Dent J 2014;64:96–107.
13. Visconti RP, Tortamano IP, Buscariolo IA. Comparison of the anesthetic efficacy of mepivacaine and lidocaine in patients with irreversible pulpitis: A double-blind randomized clinical trial. J Endod 2016;42:1314–1319.
14. Su N, Wang H, Zhang S, Liao S, Yang S, Huang Y. Efficacy and safety of bupivacaine versus lidocaine in dental treatments: A meta-analysis of randomised controlled trials. Int Dent J 2014;64:34–45.
15. Christensen J, Matzen LH, Vaeth M, Wenzel A, Schou S. Efficiency of bupivacaine versus lidocaine and methylprednisolone versus placebo to reduce postoperative pain and swelling after surgical removal of mandibular third molars: A randomized, double-blinded, crossover clinical trial. J Oral Maxillofac Surg 2013;71:1490–1499.
16. Piccinni C, Gissi DB, Gabusi A, Montebugnoli L, Poluzzi E. Paraesthesia after local anaesthetics: An analysis of reports to the fda adverse event reporting system. Basic Clin Pharmacol Toxicol 2015;117:52–56.
17. Brkovic BM, Zlatkovic M, Jovanovic D, Stojic D. Maxillary infiltration anaesthesia by ropivacaine for upper third molar surgery. Int J Oral Maxillofac Surg 2010;39:36–41.
18. Budharapu A, Sinha R, Uppada UK, Subramanya Kumar AV. Ropivacaine: A new local anaesthetic agent in maxillofacial surgery. Br J Oral Maxillofac Surg 2015;53:451–454.
19. Berberich G, Reader A, Drum M, Nusstein J, Beck M. A prospective, randomized, double-blind comparison of the anesthetic efficacy of two percent lidocaine with 1:100,000 and 1:50,000 epinephrine and three percent mepivacaine in the intraoral, infraorbital nerve block. J Endod 2009;35:1498–1504.
20. Poorni S, Veniashok B, Senthilkumar AD, Indira R, Ramachandran S. Anesthetic efficacy of four percent articaine for pulpal anesthesia by using inferior alveolar nerve block and buccal infiltration techniques in patients with irreversible pulpitis: A prospective randomized double-blind clinical trial. J Endod 2011;37:1603–1607.
21. Sampaio RM, Carnaval TG, Lanfredi CB, Horliana AC, Rocha RG, Tortamano IP. Comparison of the anesthetic efficacy between bupivacaine and lidocaine in patients with irreversible pulpitis of mandibular molar. J Endod 2012;38:594–597.
22. Mason R, Drum M, Reader A, Nusstein J, Beck M. A prospective, randomized, double-blind comparison of 2% lidocaine with 1:100,000 and 1:50,000 epinephrine and 3% mepivacaine for maxillary infiltrations. J Endod 2009;35:1173–1177.
23. Forloine A, Drum M, Reader A, Nusstein J, Beck M. A prospective, randomized, double-blind comparison of the anesthetic efficacy of two percent lidocaine with 1:100,000 epinephrine and three percent mepivacaine in the maxillary high tuberosity second division nerve block. J Endod 2010;36:1770–1777.
24. Lawaty I, Drum M, Reader A, Nusstein J. A prospective, randomized, double-blind comparison of 2% mepivacaine with 1 : 20,000 levonordefrin versus 2% lidocaine with 1 : 100,000 epinephrine for maxillary infiltrations. Anesth Prog 2010;57:139–144.
25. Krzeminski TF, Gilowski L, Wiench R, Plocica I, Kondzielnik P, Sielanczyk A. Comparison of ropivacaine and articaine with epinephrine for infiltration anaesthesia in dentistry - a randomized study. Int Endod J 2011;44:746–751.
26. Lammers E, Nusstein J, Reader A, Drum M, Beck M, Fowler S. Does the combination of 3% mepivacaine plain plus 2% lidocaine with epinephrine improve anesthesia and reduce the pain of anesthetic injection for the inferior alveolar nerve block? A prospective, randomized, double-blind study. J Endod 2014;40:1287–1292.
27. Sreekumar K, Bhargava D. Comparison of onset and duration of action of soft tissue and pulpal anesthesia with three volumes of 4% articaine with 1:100,000 epinephrine in maxillary infiltration anesthesia. Oral Maxillofac Surg 2011;15:195–199.
28. Kanaa MD, Whitworth JM, Meechan JG. A comparison of the efficacy of 4% articaine with 1:100,000 epinephrine and 2% lidocaine with 1:80,000 epinephrine in achieving pulpal anesthesia in maxillary teeth with irreversible pulpitis. J Endod 2012;38:279–282.
29. Martin M, Nusstein J, Drum M, Reader A, Beck M. Anesthetic efficacy of 1.8 ml versus 3.6 ml of 4% articaine with 1:100,000 epinephrine as a primary buccal infiltration of the mandibular first molar. J Endod 2011;37:588–592.
30. Brunetto PC, Ranali J, Ambrosano GM, de Oliveira PC, Groppo FC, Meechan JG, et al. Anesthetic efficacy of 3 volumes of lidocaine with epinephrine in maxillary infiltration anesthesia. Anesth Prog 2008;55:29–34.
31. Jain NK, John RR. Anesthetic efficacy of 4% articaine versus 2% lignocaine during the surgical removal of the third molar: A comparative prospective study. Anesth Essays Res 2016;10:356–361.
32. Whitcomb M, Drum M, Reader A, Nusstein J, Beck M. A prospective, randomized, double-blind study of the anesthetic efficacy of sodium bicarbonate buffered 2% lidocaine with 1:100,000 epinephrine in inferior alveolar nerve blocks. Anesth Prog 2010;57:59–66.
33. Schellenberg J, Drum M, Reader A, Nusstein J, Fowler S, Beck M. Effect of buffered 4% lidocaine on the success of the inferior alveolar nerve block in patients with symptomatic irreversible pulpitis: A prospective, randomized, double-blind study. J Endod 2015;41:791–796.
34. Shurtz R, Nusstein J, Reader A, Drum M, Fowler S, Beck M. Buffered 4% articaine as a primary buccal infiltration of the mandibular first molar: A prospective, randomized, double-blind study. J Endod 2015;41:1403–1407.
35. Goodman A, Reader A, Nusstein J, Beck M, Weaver J. Anesthetic efficacy of lidocaine/meperidine for inferior alveolar nerve blocks. Anesth Prog 2006;53:131–139.
36. Mohajeri L, Salehi F, Mehrvarzfar P, Arfaee H, Bohluli B, Hamedy R. Anesthetic efficacy of meperidine in teeth with symptomatic irreversible pulpitis. Anesth Prog 2015;62:14–19.
37. Cohen H, Reader A, Drum M, Nusstein J, Beck M. Anesthetic efficacy of a combination of 0.9 m mannitol plus 68.8 mg of lidocaine with 50 mug epinephrine in inferior alveolar nerve blocks: A prospective randomized, single blind study. Anesth Prog 2013;60:145–152.
38. Glenn B, Drum M, Reader A, Fowler S, Nusstein J, Beck M. Does liposomal bupivacaine (exparel) significantly reduce postoperative pain/numbness in symptomatic teeth with a diagnosis of necrosis? A prospective, randomized, double-blind trial. J Endod 2016;42:1301–1306.
39. Hillerup S, Jensen RH, Ersboll BK. Trigeminal nerve injury associated with injection of local anesthetics: Needle lesion or neurotoxicity? J Am Dent Assoc 2011;142:531–539.
40. Garisto GA, Gaffen AS, Lawrence HP, Tenenbaum HC, Haas DA. Occurrence of paresthesia after dental local anesthetic administration in the united states. J Am Dent Assoc 2010;141:836–844.
41. Perez-Castro R, Patel S, Garavito-Aguilar ZV, Rosenberg A, Recio-Pinto E, Zhang J, et al. Cytotoxicity of local anesthetics in human neuronal cells. Anesth Analg 2009;108:997–1007.
42. Katyal V. The efficacy and safety of articaine versus lignocaine in dental treatments: A meta-analysis. J Dent 2010;38:307–317.
43. Kung J, McDonagh M, Sedgley CM. Does articaine provide an advantage over lidocaine in patients with symptomatic irreversible pulpitis? A systematic review and meta-analysis. J Endod 2015;41:1784–1794.
44. Su N, Li C, Wang H, Shen J, Liu W, Kou L. Efficacy and safety of articaine versus lidocaine for irreversible pulpitis treatment: A systematic review and meta-analysis of randomised controlled trials. Aust Endod J 2016;42:4–15.
45. Colombini BL, Modena KC, Calvo AM, Sakai VT, Giglio FP, Dionisio TJ, et al. Articaine and mepivacaine efficacy in postoperative analgesia for lower third molar removal: A double-blind, randomized, crossover study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:169–174.
46. Pellicer-Chover H, Cervera-Ballester J, Sanchis-Bielsa JM, Penarrocha-Diago MA, Penarrocha-Diago M, Garcia-Mira B. Comparative split-mouth study of the anesthetic efficacy of 4% articaine versus 0.5% bupivacaine in impacted mandibular third molar extraction. J Clin Exp Dent 2013;5:e66–e71.
47. Thakare A, Bhate K, Kathariya R. Comparison of 4% articaine and 0.5% bupivacaine anesthetic efficacy in orthodontic extractions: Prospective, randomized crossover study. Acta Anaesthesiol Taiwan 2014;52:59–63.
48. Ashraf H, Kazem M, Dianat O, Noghrehkar F. Efficacy of articaine versus lidocaine in block and infiltration anesthesia administered in teeth with irreversible pulpitis: A prospective, randomized, double-blind study. J Endod 2013;39:6–10.
49. Brkovic B, Gardasevic M, Roganovic J, Jovic N, Todorovic L, Stojic D. Lidocaine+clonidine for maxillary infiltration anaesthesia: Parameters of anaesthesia and vascular effects. Int J Oral Maxillofac Surg 2008;37:149–155.
50. Gazal G. Comparison of speed of action and injection discomfort of 4% articaine and 2% mepivacaine for pulpal anesthesia in mandibular teeth: A randomized, double-blind cross-over trial. Eur J Dent 2015;9:201–206.
51. Srinivasan N, Kavitha M, Loganathan CS, Padmini G. Comparison of anesthetic efficacy of 4% articaine and 2% lidocaine for maxillary buccal infiltration in patients with irreversible pulpitis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:133–136.
52. Nydegger B, Nusstein J, Reader A, Drum M, Beck M. Anesthetic comparisons of 4% concentrations of articaine, lidocaine, and prilocaine as primary buccal infiltrations of the mandibular first molar: A prospective randomized, double-blind study. J Endod 2014;40:1912–1916.
53. Rogers BS, Botero TM, McDonald NJ, Gardner RJ, Peters MC. Efficacy of articaine versus lidocaine as a supplemental buccal infiltration in mandibular molars with irreversible pulpitis: A prospective, randomized, double-blind study. J Endod 2014;40:753–758.
54. McEntire M, Nusstein J, Drum M, Reader A, Beck M. Anesthetic efficacy of 4% articaine with 1:100,000 epinephrine versus 4% articaine with 1:200,000 epinephrine as a primary buccal infiltration in the mandibular first molar. J Endod 2011;37:450–454.
55. Wali M, Drum M, Reader A, Nusstein J. Prospective, randomized single-blind study of the anesthetic efficacy of 1.8 and 3.6 milliliters of 2% lidocaine with 1:50,000 epinephrine for inferior alveolar nerve block. J Endod 2010;36:1459–1462.
56. Evans G, Nusstein J, Drum M, Reader A, Beck M. A prospective, randomized, double-blind comparison of articaine and lidocaine for maxillary infiltrations. J Endod 2008;34:389–393.
57. Boonsiriseth K, Chaimanakarn S, Chewpreecha P, Nonpassopon N, Khanijou M, Ping B, et al. 4% lidocaine versus 4% articaine for inferior alveolar nerve block in impacted lower third molar surgery. J Dent Anesth Pain Med 2017;17:29–35.