For many years, lidocaine has been the local anesthetic most commonly employed by dentists. When combined with adrenaline, lidocaine, with its rapid onset and typical duration of 60 minutes for pulpal anesthesia and 3 to 5 hours for soft tissue anesthesia, has proven effective in maintaining adequate pain management, an essential tool for patient comfort and reducing fear and anxiety in typical patients. However, lidocaine has proven less effective in inducing profound anesthesia in patients in need of endodontic treatment, especially in teeth with symptomatic irreversible pulpitis.

Some studies have reported that articaine, which is metabolized differently from lidocaine more effectively achieves profound pulpal anesthesia in these patients. But other studies have found little difference in outcomes. Although several systematic reviews and meta-analyses of multiple studies have been undertaken, the results have been inconclusive, in part, perhaps, because the individual studies differ widely in types of teeth treated and method of administration. Nagendrababu et al from International Medical University, Malaysia, conducted an umbrella review—a relatively new methodology that analyzes the results from a group of systematic reviews—to determine whether 4% articaine should be preferred to 2% lidocaine combined with a vasoconstrictor when treating teeth with irreversible pulpitis. The authors hoped to resolve 4 questions about the 2 anesthetic solutions:

  • which one was the most effective local anesthetic solution
  • which one was associated with the least pain during injection
  • which one had the most rapid onset of pulpal anesthesia
  • which one had the fewest adverse events

Five systematic reviews with 35 individual meta-analyses published between 2011 and 2019 met their criteria for inclusion. All 5 reviews concluded that articaine was significantly more successful than lidocaine (Table 2). In the 3 reviews that performed a separate analysis for maxillary teeth using the infiltration technique, 2 found articaine outperformed lidocaine; all 4 of the reviews that performed a separate analysis for mandibular teeth found articaine had a better success rate, regardless of delivery method. Only 1 review analyzed the time to onset of anesthesia; articaine had a more rapid onset. The same review, the only one to analyze pain during injection and adverse effects, associated articaine with a lower pain score and fewer adverse effects.


The authors concluded that sufficient evidence shows that articaine outperforms lidocaine following inferior alveolar nerve blocks, infiltrations and supplemental injections during endodontic treatment of teeth with irreversible pulpitis. Limited available evidence suggests that articaine injections are less painful, have a more rapid onset of anesthesia and fewer adverse effects.

Nagendrababu V, Duncan HF, Whitworth J,  et al. Is articaine more effective than lido-caine in patients with irreversible pulpitis? An umbrella review. Int Endod J 2019; doi:10.1111/iej.13215.