Comparative evaluation of the anesthetic efficacy of 4% buffered articaine versus 2% un-buffered lidocaine for dental injections in children: a double-blind randomized parallel group control trial

Abstract

Background Effective pain control is central to the pediatric dental practice. Buffering local anesthetics with sodium bicarbonate raises the solution pH to physiological levels, theoretically accelerating the onset and reducing injection discomfort. Although buffered lidocaine has been studied in children, direct evidence comparing buffered 4% articaine with the most widely used clinical alternative (non-buffered 2% lidocaine) in a pediatric outpatient setting with a comprehensive outcome assessment remains scarce. This study aimed to compare buffered 4% articaine with 1:100,000 epinephrine and non-buffered 2% lidocaine with 1:100,000 epinephrine in children aged 6–12 years requiring single-tooth dental procedures and evaluate multiple clinically relevant outcomes, including pain, anesthetic onset, operator experience, and postoperative safety. Methods This parallel-group, double-blind, randomized controlled trial enrolled 100 healthy children (American Society of Anesthesiologists (ASA) Physical Status I, aged 6–12 years). The participants were randomly allocated in a 1:1 ratio to receive either buffered 4% articaine (n = 50) or non-buffered 2% lidocaine (n = 50). The primary outcomes were injection pain (visual analog scale [VAS] score), anesthetic onset time (s), and operator-rated difficulty (VAS). Secondary outcomes included intraoperative pain, duration of soft tissue anesthesia, cardiovascular response (heart rate), behavioral cooperation (Frankl scale), pulpal success, need for reinjection, lip or cheek biting, and delayed adverse events at one week. Results Buffered articaine produced significantly lower injection pain (2.25 ± 0.94 vs. 3.93 ± 0.90; P < 0.001), faster anesthetic onset (71.98 ± 15.24 vs. 115.28 ± 20.04 s; P < 0.001), lower operator difficulty scores (2.27 ± 0.99 vs. 4.22 ± 0.98; P < 0.001), and reduced procedure pain (2.15 ± 0.99 vs. 3.56 ± 1.05; P < 0.001). Soft tissue anesthesia lasted significantly longer with buffered articaine (159.02 ± 19.10 vs. 137.84 ± 17.54 min; P < 0.001). Heart rate elevation during the injection was significantly attenuated in the articaine group (P = 0.0003). Pulpal success rates were comparable (84% vs. 82%; P = 1.000), and no significant between-group differences were observed in the reinjection rate, lip or cheek biting, or delayed adverse events. Conclusion Buffered 4% articaine provides clinically superior injection comfort, faster onset, and better behavioral cooperation than non-buffered 2% lidocaine in the pediatric dental practice, with a comparable safety profile.