In paediatric dentistry, local analgesia offers virtually pain-free treatment, providing comfort for children and increasing their cooperation. To reduce plasma levels of the local analgesic and to enhance the analgesic effect, the use of a vasoconstrictor is recommended (Lipp et al.
1993; Meechan et al.
1994; Yagiela
1995), although, the vasoconstrictor may produce its own adverse side-effects (Meechan et al.
2001; Santos et al.
2007). To minimise those and to balance risk and benefit, a reduction of the vasoconstrictor in paediatric dentistry may be of value. Therefore, the aim of this non-intervention clinical study was an evaluation of efficacy, tolerance and safety of 4 % articaine with an adjunct of 1:400,000 epinephrine in dental treatment of children aged 4–17 years. For adult patients, our group could prove in a similar clinical setting that epinephrine-reduced articaine is safe and effective in short dental treatments (Daubländer et al.
2012). Though, to the best of our knowledge, this is the first study evaluating 4 % articaine with 1.400,000 epinephrine in paediatric dentistry. With a primary analgesia success rate of 93.5 % of cases, 99 % of all treatments were completed, although no self-reporting by the patients was included in the analysis. The latency of analgesia had a mean of 6 min. For latency with 4 % articaine with 1.200,000 epinephrine, a shorter time has been reported (Ram and Amir
2006). The influence of the vasoconstrictor concentration on analgesic diffusion due to a slower absorption rate may explain this difference (Lima-Junior et al.
2009; Kämmerer et al.
2012), although, this effect was not seen in infiltration analgesia (Moore et al.
2006). The volumes used in this study (mean = 1.1 ml) were generally very low; however, in smaller children, dosages up to 3.46 mg/kg of articaine were recorded. Those could be potentially dangerous when using a local analgesic without vasoconstrictor (Lipp et al.
1993; Meechan et al.
1994; Yagiela
1995). Altogether, we could demonstrate that with the low concentration of the vasoconstrictor used in the present study, efficacy as well as mean duration of analgesia was sufficient in nearly all cases. Efficacy and safety of 4 % articaine with the higher epinephrine concentrations of 1:100,000 and 1:200,000 in dental treatment of children have been studied before; showing a safe and efficient effect of the respective solution. There was also no higher incidence of adverse reactions following 4 % articaine with epinephrine 1:100,000 in children under the age of 4 years, although the manufacturer does not recommend this use (Wright et al.
1981,
1989; Dudkiewicz et al.
1987). A study on the pharmacokinetics of articaine with epinephrine 1:200,000 in children (3–12 years old) showed drug serum levels comparable to adults and no relevant differences between the 2 and 4 % solution. The maximum plasma levels were distinctly earlier and the plasma clearance increased in comparison to adult subjects (Jakobs et al.
1995).
A major disadvantage of local analgesia in children is the prolonged numbness after treatment, which may increase the chance of self-inflicted soft tissue lesions. The effect of numbness has been reported to be longer after articaine use than other local analgesics such as lidocaine (Ram and Amir
2006). As described by Adewumi et al. (
2008), younger children especially may primarily experience such side-effects. Nevertheless, due to the small number of such side-effects in the present study, this result may be seen controversial. We recommend further trials with narrower age limits, basing the studies on the younger age group.
Within the limitations of the present study (phone call 24 h later with an increased chance of recall bias), the mean duration of soft tissue analgesia was 2.19 h. Compared to adults using the same epinephrine-reduced articaine solution, the duration was approximately 20 min shorter in the paediatric population (Daubländer et al.
2012). Ram and Amir (
2006) reported for 4 % articaine with epinephrine 1:200,000 a mean duration of total soft tissue analgesia of 3.43 h. Accordingly, the reduction of vasoconstrictor results in a shorter time of numbness. This may explain the smaller number of soft tissue injuries in our study (0.4 %) compared to the 14 % reported by Adewumi et al. (
2008). Similar to prior studies, the duration of soft tissue numbness for local infiltration was shorter than the duration of nerve block injections (Malamed et al.
2000). We also found a weak but clinical relevant correlation with the injected volume when using infiltration.
After administration of 4 % articaine with different epinephrine concentrations (1:100,000 and 1:200,000), no severe adverse effects in children were observed. Both solutions were shown to be efficient and safe (Dudkiewicz et al.
1987; Wright et al.
1989). Therefore, our data concerning the safety of 4 % articaine with 1:400,000 epinephrine tested in 999 children with a low rate of minor side-effects reflect the already known risk–benefit profile of articaine solution.