Articaine buccal infiltration for mandibular first molars with irreversible pulpitis: is the evidence enough?

a commentary onSaatchi M, Mohammadi G, Iranmanesh P et al. Articaine buccal infiltration for mandibular first molars with symptomatic irreversible pulpitis: is it as effective as inferior alveolar nerve block with lidocaine? A systematic review and meta-analysis. Clin Oral Investig 2025; 29: 146. STUDY

designA systematic review and meta-analysis.

objectiveTo compare the anesthetic success rate of 4% articaine buccal infiltration (BI) with 2% lidocaine inferior alveolar nerve block (IANB) for lower first molars (LM1) presenting with symptomatic irreversible pulpitis. PATIENTS AND

methodsThis systematic review, registered in PROSPERO and conducted per PRISMA guidelines, included randomized clinical trials (RCTs) on adults (≥18 years) with symptomatic irreversible pulpitis in LM1, using a single cartridge (1.7-1.8 ml) of either articaine BI or lidocaine IANB as the primary injection. Studies were excluded if they were non-RCTs, used other anesthetics or techniques, included supplemental injections, used articaine BI as a secondary method, or did not report results specific to LM1. Anesthetic success was defined as patient-reported pain <4 on a visual analog scale (VAS) during cavity access or canal instrumentation. A comprehensive English-language search was conducted across five databases and gray literature sources, with manual searches of key journals and textbooks. Two independent reviewers handled screening and data extraction. Risk of bias was assessed with the Cochrane RoB2 tool. A fixed-effect meta-analysis estimated pooled risk ratios, with tests for heterogeneity and publication bias. Trial Sequential Analysis (TSA) was utilized to evaluate the robustness of the evidence, and the GRADE approach assessed certainty.

resultsFrom 780 initial records, five RCTs met the inclusion criteria after full screening. These trials included 405 patients aged 18-65, each comparing 4% articaine BI (1:100,000 epinephrine) against 2% lidocaine IANB (three with 1:100,000 and two with 1:200,000 epinephrine). No adverse effects were reported in three studies; the remaining two did not address safety. Risk of bias was low in three trials, with two showing some concerns due to unclear randomization and blinding. No publication bias was detected. Of the 405 first molars with irreversible pulpitis, 284 cases (70%) demonstrated successful pulpal anesthesia. The meta-analysis showed similar anesthetic success rates between articaine BI (72.2%) and lidocaine IANB (68.1%) [RR = 1.06, 95% CI: 0.93-1.20, I

conclusionModerate evidence indicates that 4% articaine BI offers anesthetic efficacy comparable to 2% lidocaine IANB for LM1 with symptomatic irreversible pulpitis. Although additional high-quality clinical trials are needed to validate these results, articaine BI may present a promising alternative to the traditional IANB technique in dental practice.