Comparison of Anesthetic Efficacy OF 2% Lidocaine Inferior Alveolar Nerve (IANB) Block Versus Primary Buccal Infilteration With 4% Articaine in Symptomatic Irreversible Pulpitis(SIP) IN Mandibular First Molars
Phase: NA
Conditions: Anesthetic Efficacy
Sponsor: Armed Forces Institute of Dentistry, Pakistan

Comparison of Anesthetic Efficacy OF 2% Lidocaine Inferior Alveolar Nerve (IANB) Block
Versus Primary Buccal Infilteration with 4% Articaine in Symptomatic Irreversible
Pulpitis(SIP) IN Mandibular First Molars

Comparison of Anesthetic Efficacy OF 2% Lidocaine Inferior Alveolar Nerve (IANB) Block
Versus Primary Buccal Infilteration with 4% Articaine in Symptomatic Irreversible
Pulpitis(SIP) IN Mandibular First Molars
UNIQUE PROTOCOL ID : SS-ENDO-IANBART-2025
Date of document : 07 .02. 2026
NCT Number : Not assigned yet
Resident name :
Dr Sadia Shehzadi
BDS ,FCPS II Resident Operative and Endodontics
Armed Forces Institute of Dentistry AFID CMH, Rwp
RTMC
:
2023-115-4828
Correspondence :
sadiashehzadi321@gmail.com
Phone number : 0334-2073051
Supervisor :
Major General Nadeem Ahmad Rana
BDS(Pb), MCPS ,FCPS
RTMC : DSG-S-083-216
Classified specialist in Operative dentistry
Commandant AFID, CMH Rawalpindi
Signatures of resident: _________
signatures of supervisor :_________
 

 
Introduction:
The inferior alveolar nerve block (IANB), commonly referred to as the
mandibular nerve block, is one of the most frequently employed techniques in dental practice
and a cornerstone for achieving regional anesthesia in the mandibular arch. Despite its
widespread use, the IANB is associated with a notable failure rate of 20–25%, even when
administered correctly (1). This high failure rate highlights the complexity of the technique,
which involves the precise deposition of local anesthetic solution into the pterygomandibular
space to block the inferior alveolar nerve before it enters the mandibular foramen. The
anatomical landmarks, such as the coronoid notch and pterygomandibular raphe, are
technique-sensitive and require a thorough understanding and skill for accurate localization
(2).
IANB is effective in anesthetizing the mandibular teeth, lower lip, buccal mucoperiosteum,
and anterior two-thirds of the tongue on the ipsilateral side. However, it is not without
complications. These range from trismus and hematoma formation to rare events such as
needle breakage and transient facial paralysis. Additionally, factors such as individual
variability in anatomy and the density of cortical bone contribute to its unpredictable efficacy.
This necessitates the exploration of alternative methods to achieve reliable anesthesia for
dental procedures (3).
Buccal infiltration (BI), a simpler and less technique-sensitive alternative, has garnered
interest in recent years. Articaine, a 4% local anesthetic solution, has demonstrated higher
success rates when used for buccal infiltration compared to the IANB with 2% lidocaine.
Anaesthetic success after buccal infiltration of 4% articaine was 76.9% compared to 62.8%
who received IANB of 2% lignocaine (4) For instance, Bartlett and Mansoor reported a 76.9%
success rate with articaine buccal infiltration versus a 62.8% success rate with lidocaine
IANB (5). In contrast, Komsic et al reported a 53.5% success rate with articaine buccal
infiltration compared to a 62.8% success rate with lidocaine IANB (6). Additionally, the
buccal cortical plate has been observed to have a mean thickness ranging from 1.4 mm to 2.3
mm, depending on anatomical location and population demographics, further influencing
anesthetic diffusion and efficacy. Articaine's superior efficacy is attributed to its ability to
penetrate the buccal cortical plate, which varies in density and porosity among individuals
and populations (7). However, its effectiveness may be influenced by anatomical factors such
as the thickness of the cortical bone, especially in the second molar region (8).
The majority of previous studies on this topic have focused on pediatric populations or
regions outside South Asia, yielding mixed results (9). There remains limited data on the
comparative efficacy of articaine BI and lidocaine IANB in adult patients with symptomatic
irreversible pulpitis in the mandibular molar region, particularly in the Pakistani population.

The rationale for this study is to address the gap in the literature by evaluating the efficacy of
4% articaine buccal infiltration compared to 2% lidocaine IANB for pulpal anesthesia in
symptomatic mandibular first molar teeth in a sample of the Pakistani population. Unlike
prior research, which often relied on subjective assessments and overlooked confounding
factors such as anxiety and stress that lower pain thresholds, this study employs a
standardized methodology to objectively evaluate outcomes. ( Corah’s Dental anxiety scale
High and severe anxiety /phobic≥13 or ≥15 eliminated from study )Additionally, it aims to
assess the necessity for supplemental anesthesia, thus providing critical insights for
improving clinical protocols .
OBJECTIVE:
To compare the anesthetic efficacy of 2% lidocaine administered via inferior alveolar nerve
block (IANB) versus 4% articaine administered via primary buccal infiltration in achieving
pulpal anaesthesia for the treatment of mandibular first molars with symptomatic irreversible
pulpitis, measured by the success rate of pain elimination during endodontic procedures.
OPERATIONAL DEFINITIONS :
1. Anesthetic Efficacy
The ability of a local anesthetic technique to achieve successful pulpal
anesthesia, defined as the absence of pain during endodontic procedures
and two consecutive nonresponsive EPT readings at any time during 60
minutes period on mandibular first molars with symptomatic irreversible
pulpitis, as reported by the patient.
2. Inferior Alveolar Nerve Block (IANB)
A local anesthetic technique involving the deposition of 2% lidocaine
with epinephrine (1:80,000) near the mandibular foramen to anesthetize
the mandibular nerve, providing sensory blockade to mandibular teeth,
soft tissues, and tongue on the ipsilateral side.
3. Primary Buccal Infiltration
A local anesthetic technique involving the deposition of 4% articaine
with epinephrine (1:100,000) into the buccal mucosa near the apex of the
mandibular first molar, allowing the anesthetic to penetrate the cortical
bone and provide pulpal anesthesia.
4. Symptomatic Irreversible Pulpitis
A clinical condition characterized by spontaneous, lingering pain in a
mandibular first molar, confirmed by a positive response to thermal or
electric pulp testing, indicative of irreversible inflammation of the pulp.
NullHypothesis(H₀ ):
There is no difference in the anesthetic efficacy of 4% articaine primary buccal infiltration

and 2% lidocaine inferior alveolar nerve block in achieving successful pulpal anesthesia for
endodontic therapy in mandibular first molars with symptomatic irreversible pulpitis.
AlternateHypothesis(H₁ ):
4% articaine primary buccal infiltration demonstrates better anesthetic efficacy compared to
2% lidocaine inferior alveolar nerve block in achieving successful pulpal anesthesia for
endodontic therapy in mandibular first molars with symptomatic irreversible pulpitis.
MATERIAL AND METHODS
STUDY DESIGN: Single blinded Randomized Controlled Trial
SETTING: Operative Dentistry Department, AFID, CMH Rawalpindi
DURATION: 6 Months to 1 year after approval of Research Proposal
SAMPLE SIZE: By using WHO calculator, sample size is 330, having 165 in each group
with level of significance 5%, power of test 80%. Population proportion for group 1 (IANB)
is 62.8%.Population proportion for group II (BI) is 76.92% (4).
Group 1: n= 165
Patients
receiving 2% Lidocaine inferior Alveolar Nerve Block with 1:80,000
epinephrine using 0.4x42mm needle at the rate of 1.8ml per 60seconds
Group 2: n= 165
Patients receiving 4% Articaine with 1:100,000 Primary Buccal infiltration using
0.4x25mm needle at the rate of 1.8ml per 60seconds
SAMPLING TECHNIQUE: Consecutive non- random Sampling
SAMPLE SELECTION:
Permission will be taken from Ethical Research Committee of Armed Forces Institute of
Dentistry.
Inclusion criteria:

Systemically healthy patients classified as ASA I, aged 18–55 years.

Permanent mandibular first molar tooth requiring endodontic therapy.

Diagnosed with symptomatic irreversible pulpitis without swelling or sinus.

Normal periapical radiographic appearance (no evidence of periapical pathology).

Moderate pain as assessed by the Heft-Parker VAS (>54 mm and <114 mm).

Lingering pain or prolonged response to cold testing (lasting more than 10 seconds).

Positive response to electric pulp testing.

Outcome assessed must be pulpal anesthesia

Exclusion criteria:

Pregnant or lactating mothers.

Teeth with reversible pulpitis, previously treated, or with calcified canals.

Teeth with severe periodontal disease or periapical radiolucency.

Patients who have taken analgesics or anti-inflammatory drugs within 6 hours before
the treatment visit.

Patients on medications that could potentially interact with the anesthetic solution
(e.g., antihypertensives, anticoagulants).

History of allergy to 4% articaine, lidocaine, or epinephrine.

Systemic diseases, immunocompromised states, or significant anxiety/mental health
disorders.

History of vasovagal syncope on local anesthetic administration.
DATA COLLECTION:
Study will be conducted after the approval from Institutional Ethics Review Committee,
AFID and after obtaining informed consent from all participants (ANX “A”). (Attached at the end). A
total of 104 entitled patients reporting to Operative Dentistry Department, Armed Forces
Institute of Dentistry will be invited for participation in this study. The study population will
include patients presenting with symptomatic irreversible pulpitis in permanent mandibular
first molars, requiring endodontic therapy.
Demographic details (including name, age, gender, contact) will be obtained on data
collection forms. (Annex-B).
Before starting the treatment, each patient will receive an explanation regarding the Heft-
Parker Visual Analogue Scale (HP VAS) and will be asked to rate their baseline pain on a
self-reported questionnaire. Pain intensities will be categorized as no pain (0 mm), mild pain
(1–54 mm), moderate pain (55–114 mm), and severe pain (>114 mm). Corah’s Dental anxiety
scale High and severe anxiety /phobic≥13 or ≥15 eliminated from study . A 20% Benzocaine
gel will be applied topically at the injection site for 2 minutes using a cotton tip applicator,
ensuring that the application is uniform and does not anesthetize surrounding tissues. The
injection site and needle will be dried using a sterile gauze, and the tongue and buccal
surfaces of the lips will be isolated with cotton rolls to prevent inadvertent spread of the
topical anesthetic.
Patients will be randomly allocated to one of two groups using a computer-generated
randomization sequence to minimize selection bias. In Group 1, patients will receive an
inferior alveolar nerve block (IANB) using 1.8 mL of 2% lidocaine with 1:80,000 epinephrine
administered via the anterior technique in the pterygomandibular space. In Group 2, patients
will receive a primary buccal infiltration using 1.8 mL of 4% articaine with 1:100,000
epinephrine injected adjacent to the mandibular first molar, bisecting the approximate
location of the mesial and distal roots over a 1-minute period. All injections will be

administered by a single clinician to ensure standardization, and the same type of syringe and
needles (27G) will be used in both groups.
Fifteen minutes after injection, symptoms of soft tissue anesthesia will be evaluated. In
Group 1, lip numbness will be assessed to confirm successful anesthesia. If profound lip
numbness is not observed, the block will be considered unsuccessful, and the patient will be
excluded. In Group 2, anesthesia will be confirmed by probing the buccal soft tissue.
Following this confirmation, the affected teeth will be isolated with a rubber dam, and pulpal
anesthesia will be reassessed using an electric pulp tester (EPT). Patients will also rate their
pain levels using the HP VAS. If moderate or severe pain (VAS ≥55 mm) is reported,
supplemental anesthesia, such as intraligamentary or intrapulpal injections, will be
administered, and these cases will be documented as failures.
The endodontic procedure will then proceed with caries removal, access cavity preparation,
and canal instrumentation. At each stage of the procedure, the patient will be asked to rate
their pain or signal discomfort by raising their hand. The effectiveness of anesthesia will be
evaluated both objectively, based on the EPT reading, and subjectively, using the HP VAS.
Success will be defined as no response at the maximum EPT output of 80, and mild or no
pain (VAS <55 mm or <36% of the total VAS scale) during the procedure. Failure will be
recorded if the EPT reading is below 80, or the patient experiences moderate to severe pain
(VAS ≥55 mm or ≥36% of the total VAS scale) at any stage of the treatment.
By
ensuring
randomization,
blinding
the
outcome
assessor,
and
standardizing
the
administration of local anesthesia, this study aims to control potential confounding variables
and reduce bias. The success and failure of anesthesia will be assessed based on predefined
objective and subjective criteria, ensuring consistency and reliability of the outcomes.
PainAssessment
Pain intensities recorded on a self-report questionnaire using Heft-Parker VAS.
The scores are divided into 4 categories:
No pain: 0 mm (0%)
Mild pain: >0 mm to ≤54 mm (0–36% of the total VAS scale)
Moderate pain: >54 mm to <114 mm (36–76% of the total VAS scale)
Severe pain: ≥114 mm (>76% of the total VAS scale)
Pain perception was assessed at different stages of endodontic treatment using the Heft-
Parker Visual Analogue Scale (VAS). The evaluation was carried out before administration
of local anesthesia, 15 minutes later with electric pulp testing, during access cavity
preparation, on pulp chamber opening, and finally during root canal instrumentation. The
VAS scores, ranging from 0 to 170 mm, allowed classification of pain intensity as none, mild,
moderate, or severe, providing a standardized measure of patient discomfort throughout the
procedure.

DATA ANALYSIS:
The data will be analyzed using IBM SPSS Statistics version 23.0.
Descriptive statistics : Quantitative variables like age,Corah’s DAS , percentage, duration of
numbness and pain/VAS score will be expressed in terms of mean and standard deviation.
Qualitative variables such as gender, behaviour, efficacy, tooth number and side/quadrant
will be expressed in terms of frequency and percentage.
Both groups will be compared by using chi-square test. Effect modifiers such as age, gender,
side/quadrant tooth number, duration and behavior will be controlled through stratification
and Chi-square test will be applied accordingly. p ≤0.05will be considered significant .
References:
1. Jalalzadeh SM, Asgary S. Mandibular foramen position and its relationship to inferior
alveolar nerve block failure in patients with irreversible pulpitis: A cone-beam computed
tomography study. J Endod. 2022 Jun;48(6):719-26.
2. Ghorbanzadeh S, Sadighi A, Khademi A, Seif A, Arjomandzadegan M. Comparing
Gow-Gates and inferior alveolar nerve block techniques in achieving pulpal anesthesia
in mandibular molars with irreversible pulpitis: A double-blind randomized clinical trial.
J Dent Anesth Pain Med. 2023 Apr;23(2):127-34.
3. Jasim HH, Al-Sultan AM, Ismail HI. Efficacy of articaine versus lidocaine for inferior
alveolar nerve block in patients with mandibular molars with symptomatic irreversible
pulpitis: A meta-analysis. J Endod. 2021 Aug;47(8):1277-84.
4. Zain M, Rehman Khattak SU, Sikandar H, Shah SA, Fayyaz. Comparison of Anaesthetic
Efficacy of 4% Articaine Primary Buccal Infiltration Versus 2% Lidocaine Inferior
Alveolar Nerve Block in Symptomatic Mandibular First Molar Teeth. J Coll Physicians
Surg Pak. 2016 Jan;26(1):4-8. PMID: 26787022.

5. Gandhi SA, Das S, Das A, Agnihotri Y, Mohan RV, Dasu Subramanian VR. Anaesthetic
efficacy of lidocaine and articaine in inferior alveolar nerve block combined with buccal
infiltration in patients with irreversible pulpitis. J Pharm Bioallied Sci. 2021 Jun;13(Suppl
1):S731-S734 .
6. Komsic J, Vujkov S, Neskovic I, Blagojevic D, Tadic A, Petrovic B, et al. Comparative
evaluation of alveolar nerve block with 2% lidocaine-epinephrine and 4% articaine-
epinephrine buccal infiltration in mandibular premolar and molar region in children: A
double-blind, randomized trial. Children (Basel). 2025 Feb;12(2):215.
7. Shahi S, Nezafati S, Asgary S. Pulpal anesthesia with articaine vs. lidocaine for
mandibular molars with symptomatic irreversible pulpitis: A systematic review. Int
Endod J. 2023 Mar;56(3):300-10.
8. Ahmad N, Ullah H, Khan N. Frequency and factors affecting the failure of inferior
alveolar
nerve
block:
A
prospective
observational
study.
Cureus.
2023
May;15(5):e39012 .
9. Yu J, Liu S, Zhang X. Can buccal infiltration of articaine replace traditional inferior
alveolar nerve block for the treatment of mandibular molars in pediatric patients? A
systematic
review
and
meta-analysis.
Med
Oral
Patol
Oral
Cir
Bucal.
2021
Nov;26(6):e754-61 .

Annex- A
“COMPARISON
OF
ANESTHETIC
EFFICACY
OF
2%
LIDOCAINE
INFERIOR
ALVEOLAR
NERVE
(IANB)
BLOCK
VERSUS
PRIMARY
BUCCAL INFILTERATION WITH 4% ARTICAINE IN SYMPTOMATIC
MANDIBULAR FIRST MOLARS
Patient consent form:
I have
• Been informed and understood the procedure and protocol of the study.
• My question and queries were answered to my satisfaction.
• Been informed of the possible risks and side effects of the procedure being conducted.
• Understood that the project is for the purpose of research and will fulfill any treatment requirements
as well.
• Understand that the project may involve randomization of participants.
• Been informed that the confidentiality of the information will be maintained and safeguarded. Given
permission for medical practitioners, other health professionals, hospital or laboratories outside this
hospital, to release information concerning my dental problem and treatment which is needed for this
trial and understood that such information will remain confidential.
• Been assured that I am free to withdraw at any time without comment or penalty.
• Agreed to participate in the study project with my free will and wish.
Name and signature of participant: ___________________
Date: ___________________
Signature of Resident (Investigator): ___________________

(ANNEX- B )
DEPARTMENT OF OPERATIVE DENTISTRY
ARMED FORCES INSTITUTE OF DENTISTRY
RAWALPINDI
S. No.___ Hospital Registration No. _________
Gender: M/ F:
___
Age _________
Name _______________
Contact
No
_________
Tooth # ____
Duration ________
Corah’s
DAS :______
, Operator’s Name : _________ Anesthetic
agent___________ Group ________________ Duration for which
LA remained effective after the treatment __________
PainAssessment
Pain intensities recorded on a self-report questionnaire using Heft-Parker VAS.
The scores are divided into 4 categories:
No pain
0 mm
Mild pain
>0 mm and ≤54mm
Moderate pain >54 mm and < 114 mm
Severe Pain ≥114mm
Stage of Treatment
Heft-Parker VAS
Before LA administration
10-15 min later with EPT
Access cavity prep
Pulp chamber opening
Root canal instrumentation
Response at 10-15 mins with EPT : Responsive /Non responsive
Response at pulp chamber opening with EPT :Responsive / Non responsive
Efficacy of Local anesthetic agent : Yes/No

DEPARTMENT OF OPERATIVE DENTISTRY & ENDODONTICS
ARMED FORCES INSTITUTE OF DENTISTRY ( CMH RAWALPINDI )
NO DUPLICATION CERTIFICATE
It
is to certify that the study title COMPARISON OF ANESTHETIC EFFICACY OF 2%
LIDOCAINE INFERIOR ALVEOLAR NERVE (IANB) BLOCK VERSUS PRIMARY BUCCAL
INFILTERATION WITH 4% ARTICAINE IN SIP IN MANDIBULAR FIRST MOLARS is being
undertaken by Dr. Sadia Shehzadi RTMC No. DSG2023-115-4828 FCPS II resident of operative and
endodontics , has never been conducted at Armed Forces Institute of Dentistry (AFID) , CMH
Rawalpindi and there is no duplication of this study.
Major General Nadeem Ahmed Rana
BDS . MCPS .FCPS
Classified Specialist in operative and endodontics
Commandant AFID,CMH Rawalpindi
RTMC # DSG-S-083-216)
Supervisor Signature _______________
Resident signature _______________

To,
The Director R & RC,
College of Physicians and Surgeons Pakistan (CPSP) Regional Centre, Islamabad
Respected Sir,
Enclosed herewith please find the research proposal titled
‘’COMPARISON OF ANESTHETIC
EFFICACY OF 2% LIDOCAINE INFERIOR ALVEOLAR NERVE (IANB) BLOCK VERSUS
PRIMARY BUCCAL INFILTERATION WITH 4% ARTICAINE IN SIP IN
MANDIBULAR
FIRST MOLARS - a prerequisite for FCPS II in the subject of Operative dentistry and Endodontics.
Prepared by Dr.SADIA SHEHZADI RTMC Registration No: DSG-2023-115-4828
FCPS I Roll No: 910085
FCPS II Session of: July, 2023
Name of Supervisor: Major General Nadeem Ahmed Rana .
Qualification: BDS,MCPS, FCPS
Designation :
Classified Specialist in Operative and endodontics
Commandant AFID,CMH Rawalpindi
Name of Training Institute: Armed Forces Institute of Dentistry (AFID) , CMH Rawalpindi
Department: Operative and endodontics
Supervisor Signature: ________
Official stamp_______________
Dated : ________________
Yours sincerely
Dr.Sadia Shehzadi
Resident Operative dentistry &Endodontics
AFID,CMH Rawalpindi