|Year : 2015 | Volume
| Issue : 2 | Page : 96-100
Comparison and clinical efficacy of local anesthetic solution xylocaine with and without adrenaline [1:200000] in dental extraction
Anurag Saxena1, Syamantak Srivastava2, Amiya Agrawal1, Shipra Singh3, Harmurti Singh1, Anand Kumar1, Ruchika Khanna4, Ram K Srivastava1
1 Department of Oral and Maxillofacial Surgery, Career Post Graduate Institute of Dental Sciences, Lucknow, India
2 Department of Surgery, Subharati Medical College, Merrut, India
3 Department of Oral and Maxillofacial Surgery, Moti Lal Nehru Medical College, Allahabad, Uttar Pradesh, India
4 Department of Oral Medicine and Radiology, Shri Sukhmani Dental College, Punjab, India
|Date of Web Publication||2-Mar-2016|
17/12, Indira Nagar, Lucknow - 226 016, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Objective: The objective is to analyze most popularized xylocaine and to compare the adequacy of analgesia achieved and the effects of xylocaine hydrochloride 2% without adrenaline and xylocaine hydrochloride 2% with adrenaline (1:200,000), used as local anesthetics in dentistry for extraction of tooth.
Materials and Methods: Two hundred and fifty patients of varying age and sex, requiring at least extraction of two teeth, were picked from the outpatient department of oral and maxillofacial surgery. In each patient, two teeth were extracted under local anesthesia, one under xylocaine plain and other under xylocaine with adrenaline. Time of onset, depth, and duration of analgesia were recorded.
Conclusion: Lidocaine with epinephrine (1:200,000) local anesthesia efficacy in dental extractions is more effective than lidocaine without adrenaline in extraction of tooth, and the onset, duration, and depth of analgesia of xylocaine hydrochloride with adrenaline were good as compared to plain xylocaine (xylocaine without adrenaline). Thus, lignocaine as a local anesthetic may be an effective drug in dental extractions with the higher safety margin.
Keywords: Analgesia, extraction, inflamed, vasoconstrictor
|How to cite this article:|
Saxena A, Srivastava S, Agrawal A, Singh S, Singh H, Kumar A, Khanna R, Srivastava RK. Comparison and clinical efficacy of local anesthetic solution xylocaine with and without adrenaline [1:200000] in dental extraction. Saint Int Dent J 2015;1:96-100
|How to cite this URL:|
Saxena A, Srivastava S, Agrawal A, Singh S, Singh H, Kumar A, Khanna R, Srivastava RK. Comparison and clinical efficacy of local anesthetic solution xylocaine with and without adrenaline [1:200000] in dental extraction. Saint Int Dent J [serial online] 2015 [cited 2019 Jul 23];1:96-100. Available from: http://www.sidj.org/text.asp?2015/1/2/96/177934
The first important task for a dentist or maxillofacial surgeon is to allow a patient to be comfortable and pain-free during minor surgical procedures and various other dental procedures under local anesthetics is an essential part of the dentistry. The most commonly used block is inferior alveolar nerve block, and a local anesthetic solution is lignocaine with adrenaline for mandibular teeth extraction. However, past literature indicates failure rates of lignocaine are approximately ranging from 10% to 39%.
In general, surgical anesthesia requires the use of higher concentrations and doses. When a less intense block is demanded, the use of a lower concentration is intimated. The volume and concentration of the drug used for anesthetic effect will affect the spread and extent of anesthesia.
When lignocaine and adrenaline are used in combination, they prevent pain transmission passing from the area of injection to the brain and so it numbs the surgical area. This study signifies that painful procedures in oral and maxillofacial surgeries, such as minor surgical procedures or major surgeries, can be performed easily without causing pain and discomfort to patients. The numbness will constantly wear off following the surgical procedure under local anesthesia.
Extraction is the most common minor oral surgical procedure in oral and maxillofacial surgery. Painless tooth extraction using the local anesthetic agent is the requirement for the comfort of the patient. Lignocaine (xylocaine) is a commonly used drug to produce local anesthetic effect. Xylocaine, a local anesthetic agent, can be used as plain or with epinephrine (adrenaline) and is administered topically or by injection. It is used as the backbone ingredients for minor and major surgical procedures as local and regional anesthesia or analgesia for the oral surgical procedures. Dental extractions are associated with pain and require potent local anesthetics that can keep the patient comfortable during the procedure. Lignocaine is available for more than half a century and is still being widely used in clinical as well as the academic practice even with the advent of newer local anesthetic agents.
The ideal tooth extraction is the painless removal of tooth or tooth root, with minimal trauma to the investing tissues. From time to time, multiple endeavors have been made to discover agents that eliminate pain during extraction. With the advent of local analgesic, it has become possible to achieve the relatively painless extraction. Now, local analgesics are the most frequently used drugs in dentistry. Various local analgesic drugs have been discovered such as Cocaine (1884), Procaine (1905), and Lignocaine (1943). Xylocaine is one of the known proprietary names of lignocaine that produces an effective, efficient local anesthetic effect.  Lignocaine is commonly used to anesthetize the mucosa and skin because of its rapid onset of action and long duration of sensory blockade.  Lidocaine is known to have an onset < 2 min, a duration of 1 to 2 h, and a maximum dose of 5 mg/kg, which improves to an onset <2 min, a duration of 2 to 6 h, and toxicity of 7 mg/kg with the addition of epinephrine. , The addition of epinephrine (adrenaline) to xylocaine increases the efficiency, duration of the analgesia, and reduces the risk of generalized toxicity. , Xylocaine fulfills all the ideal requirements of local analgesic drugs. However, there are certain contraindications to the use of xylocaine in cases of cardiovascular diseases, hypertension, and hyperthyroidism, etc.  This is also proved that xylocaine is not effective in the presence of inflamed tissue and pus in the immediate vicinity of the area to be injected with local analgesia. The addition of vasoconstrictor adrenaline prolongs the duration of the action of most local anesthetics. ,,, The inclusion of a vasoconstrictor increases the working duration and thus allowing completion of the extensive, time-consuming procedure in a pain-free state. Vasoconstrictors slow up the absorption of the anesthetic solutions by decreasing the blood flow and provide three advantages: Prolonged anesthesia, deeper anesthesia, and reduced systemic toxicity.  The effects of xylocaine hydrochloride with and without adrenaline in upper and lower jaws, anterior and posterior teeth are different. As a local analgesic, 2% lignocaine with adrenaline with concentration of 1:80,000 is the most suitable preparation for the extraction of teeth. However, it seldom has some disadvantages, the one is that the adrenaline may cause cardiovascular disturbances.
| Materials and Methods|| |
Two hundred and fifty patients of varying age and sex, requiring at least extraction of two teeth, were randomly selected from the Outpatient Department of Oral and Maxillofacial Surgery, were included in the present study. The protocol was approved by the Ethical Committee of Career Postgraduate Institute of Medical College and Research, and patients' consent form was also taken to perform this study. Each patient was subjected to detailed clinical history taking complete physical examination and necessary investigations, for example, blood sugar, the radiograph of tooth, and electrocardiogram, etc., whenever found necessary. In each patient, two teeth were extracted under anesthesia, one under xylocaine plain and other under xylocaine with adrenaline. Each patient was first subjected to intradermal skin sensitivity test for xylocaine. Xylocaine hydrochloride (2%) and adrenaline (1:200,000) were used for anesthetizing the teeth and surrounding structures. The drug was administered by nerve block techniques at different sites as required in a particular case. In those cases, where the use of adrenaline was not indicated, for example, hypertension, hyperthyroidism, and cardiac diseases, etc., xylocaine (2%) plain was used. In every case, 3 ml of local analgesic solution was used as a standard solution and adrenaline was used with the concentration of 1:200,000.
The time of onset for xylocaine was calculated from the time of injection of drugs to the development of analgesia. Both objective and subjective symptoms were analyzed, i.e., the feeling of heaviness or tingling sensation as well as the absence of pain when elicited by a blunt dental probe.
Duration of analgesia was noted from the period of onset of analgesia to the return of painful stimuli. The sensations were tested with a dental probe and the patient was enquired about the pain at every 5 min interval.
The depth of analgesia in xylocaine was evaluated by an instrument having a blunt probe attached to a spring. A point indicator attached to the probe was moved on a scale marked from 0 to 100 in four divisions. In patients, the probe was pressed slowly in the affected soft tissues until the patients felt pain, and the reading on the scale was noted.
The systemic effects, namely, pulse rate, blood pressure (systolic and diastolic), and respiratory rate were recorded. All these were recorded pre- and post-extraction. The data were recorded 15 min before injecting the xylocaine hydrochloride and after 10 min of completing the extraction of teeth.
Bleeding during extraction was graded as:
Patient's impression regarding the mode of analgesia - each patient was subjected to two tooth extractions, one under xylocaine hydrochloride plain and other under xylocaine hydrochloride with adrenaline. After tooth extraction, his/her reaction was observed by inquiry. He/she was asked to tell "which mode of analgesia you will prefer." His/her reply was recorded.
- No - Grade I
- Mild - Grade II
- Moderate - Grade III
- Severe - Grade IV.
Data were summarized as mean ± standard deviation (SD). Groups were compared by Student's t-test. Proportions were compared by proportion Z-test. A two-tailed P < 0.05 was considered statistically significant.
| Results|| |
In the present study, 500 teeth were extracted under xylocaine hydrochloride, out of which 250 teeth were extracted under xylocaine with adrenaline and 250 teeth were extracted under plain xylocaine.
The distribution of cases according to the degree of mobility of tooth extracted under xylocaine hydrochloride plain and with adrenaline is summarized in [Table 1]. In plain group, most of the teeth (n = 240) were extracted with 2° mobility whereas with adrenaline group, most of the teeth (n = 230) were extracted with 1° mobility. Thus, most of the extractions under xylocaine hydrochloride (plain) were done with greater degree of mobility of teeth in comparison to xylocaine hydrochloride with adrenaline. Further, in both groups, the maximum failure was at 0° (plain: 40.0% and adrenaline: 14.3%). Overall, 10 (20.0%) failures were in plain group and 4 (8.0%) failures were in adrenaline group. However, the proportions of failures did not differ (P > 0.05) between the two groups, i.e., was found to be statistically the same.
|Table 1: Degree of mobility of the teeth extracted under xylocaine hydrochloride with adrenaline|
Click here to view
The time of onset of analgesia, duration of analgesia, and depth of analgesia of the two groups are shown graphically in [Table 1] [Table 2] [Table 3], respectively. The time of onset of analgesia, duration of analgesia, and depth of analgesia in the plain group ranged from 90 to 120 s, 55-65 min, and 55-65, respectively, with mean (±SD) of 104.30 ± 10.03 sec, 57.86 ± 9.15 min [Table 3], and 40.86 ± 0.90, respectively, whereas in adrenaline group, it ranged from 80 to 110 s, 110-145 min, and 62-80, respectively, with mean (±SD) of 95.69 ± 9.56 s, 133.30 ± 8.93 min [Table 4], and 73.57 ± 6.33, respectively. On comparing, t-test revealed significantly different and higher duration of analgesia (133.30 ± 8.93 vs. 57.86 ± 9.15, t = 41.72, P < 0.001) and depth of analgesia (73.57 ± 6.33 vs. 40.86 ± 0.90 [Table 5], t = 36.18, P < 0.001) in adrenaline group as compared to plain group. In contrast, mean time of onset of analgesia lowered significantly in adrenaline group as compared to plain group (95.69 ± 9.56 vs. 104.30 ± 10.03, t = 4.39, P < 0.001).
|Table 2: Degree of mobility of teeth extracted under xylocaine hydrochloride plain|
Click here to view
Finally, the patient's impression upon various modes of analgesia was also taken. Most of the patients (67.0%) agreed to xylocaine hydrochloride with adrenaline analgesia for the extraction of a third tooth, if required.
| Discussion|| |
It is essential to obtain complete analgesia for successful tooth extraction and also for various other dental procedures. A suitable anesthetic agent should be easily available, ideal, economical, easier in technique, and safer for the patient. A plenty of efforts and researchers have been done in the field of analgesia to ensure the points as mentioned above. However, all the available analgesic agents are yet far away from being an ideal. The ability to add vasoconstrictor drugs in local anesthetic solution is to potentiate the activity of local anesthetic agents has long been appreciated. To reduce the risk of adverse reactions, local anesthetic solutions must contain the minimum concentration of vasoconstrictors. ,, The use of local anesthetic with epinephrine is now a standard practice. Epinephrine is the most potent and efficient vasoconstricting drug in dental anesthetic solutions. Vasoconstrictors slow up the absorption of the anesthetic agents by decreasing the blood flow and provide longer and deeper analgesia. , It also reduces systemic toxicity. , In the present study, it was decided to evaluate the efficacy of epinephrine (adrenaline) in dental extractions and compare its effect with the xylocaine hydrochloride without adrenaline. To achieve a more detailed comparison of the two methods, various parameters such as the onset of analgesia, duration of analgesia, and depth of analgesia were used. The time of onset of analgesia in xylocaine hydrochloride plain was 104.28 s as compared to 95.69 s, with xylocaine hydrochloride and adrenaline group. It is obvious from these findings that the onset of analgesia with adrenaline is quite quick and is comparable to plain xylocaine hydrochloride. The duration of analgesia in plain xylocaine (57.85 min) was significantly less (P < 0.001) as compared to that of xylocaine hydrochloride with adrenaline group (133.30 min). Thus, the duration of analgesia can be very well prolonged by the addition of adrenaline with anesthetic solutions. The long duration of analgesia induced by adrenaline was desirable in surgical cases of long duration. The depth of analgesia in xylocaine plain group (40.85) was significantly less (P < 0.001) as compared to xylocaine with adrenaline group (73.57). These findings can be explained by the fact that the addition of vasoconstrictor in the anesthetic solution can increase the efficacy of local analgesic drugs. Xylocaine hydrochloride with adrenaline is more effective in the extraction of tooth than xylocaine hydrochloride plain. It is widely accepted that the addition of adrenaline to local anesthetic solutions prolongs the duration of anesthesia  and it has been stated that the depth of anesthesia is also improved.  Xylocaine hydrochloride with adrenaline was more effective because the local anesthetic agent remains at the site of injection more than the plain xylocaine. 
Patient's impression regarding the mode of analgesia was also recorded after he/she had experienced extraction by both the techniques, 20% of the patients were prepared to get it by any method, but 67% prefer xylocaine hydrochloride with adrenaline.
Lignocaine (xylocaine) has come into popular use and has been reported not to be a vasoconstrictor as are most other local anesthetic agents.  The use of epinephrine (adrenaline) with lignocaine (xylocaine) seems to prolong the duration of local anesthesia, depth of analgesia, and onset of action. The use of 2% lignocaine with 1:200,000 adrenaline provides satisfactory analgesia for routine dental extractions and minor oral surgical procedures. The use of plain lignocaine does not provide sufficient analgesia for these procedures. It is recommended that when the use of adrenaline is contraindicated, alternative local anesthetic agents such as mepivacaine can be used.
van den Berg and Montoya-Pelaez 2001  stated that all the four anesthetic agents provide adequate anesthetic effect during cataract extraction lasting approximately 95-100 min after peribulbar anesthesia injection. Lidocaine 2% with epinephrine demonstrated most rapid onset and required least number of injections to establish block. A hyaluronidase effect was evident only after 15 min in the bup 0.5% hyalase and lido/bup/hyalase groups. Bup 0.5% plain was overall the least satisfactory, and the greatest supplementation rate occurred with lido/bup/hyalase, suggesting that either lido 2% epi or bup 0.5% hyalase is most suitable of the agents tested for this type of surgery.
Kambalimath in 2014  stated that 4% articaine offers better clinical performance than 2% lidocaine, particularly in terms of latency and duration of the anesthetic effect. However, no statistically significant differences in anesthetic efficacy were recorded between the two solutions.
The administration of local anesthetic solution xylocaine without a vasoconstrictor (adrenaline) turned more patients to complain of pain and discomfort in oral and maxillofacial procedures related extraction, etc. Xylocaine alone showed poor and inadequate pain control, but when merged with epinephrine, this identical anesthetic agent rendered a more intense blocking of large- and small-diameter nerve fibers.  Lidocaine is available in various others forms also such as injection, cream, gel, and spray and in various concentrations of 0.5%, 1%, 2%, 5%, and 10%. 
Kumar et al.  stated various adjuncts have been utilized with lignocaine to decrement tourniquet pain and prolong postoperative analgesia and its efficacy during dental extraction and various other restorative procedures in dentistry. An obligatory part of the dental process is to sanction a patient to feel comfortable and pain-free during operational and remedial dental procedures. The most popular local anesthetic injection for lower teeth is the inferior alveolar nerve block.
| Conclusion|| |
It is clear from the study that onset, duration, and depth of analgesia, i.e., local anesthetic effects in extraction by xylocaine hydrochloride with adrenaline were good as compared to plain xylocaine. The patient's impression regarding mode of analgesia was more satisfactory under xylocaine hydrochloride with adrenaline. Nowadays, the two medications are often used as a mixture to provide theoretically the longer action of bupivacaine and the faster onset of lidocaine. Till this study, no analytical benefit was estimated in comparing lidocaine with epinephrine, bupivacaine with epinephrine, and mixtures of the aforementioned local anesthetics with consideration to the onset of response using commercially available formulations for an intradermal field block. While a statistical difference was witnessed in continuation of effect, the clinical benefit was restricted and individual physicians should practice other clinically relevant factors to determine the composition of their local anesthetic.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Reeve LW. Modern pharmacodynamic concepts of local anesthesia. Dent Clin North Am 1970;14:783-804.
Pascuet E, Donnelly RF, Garceau D, Vaillancourt R. Buffered lidocaine hydrochloride solution with and without epinephrine: Stability in polypropylene syringes. Can J Hosp Pharm 2009;62:375-80.
Cousins MJ, Bridenbaugh PO. Neural Blockade in Clinical Anesthesia and Management of Pain. 4 th
ed. Philadelphia: Lippincott Williams & Wilkins; 2008.
Facts & Comparisons. Drug Facts and Comparisons 2011. 65 th
ed. St. Louis: Lippincott Williams & Wilkins; 2010.
Keesling GR, Hinds EC. Optimal concentration of epinephrine in lidocaine solutions. J Am Dent Assoc 1963;66:337-40.
Hoffman BB. Catecholamines, sympathomimetic drugs, and adrenergic receptor antagonists. In: Hardman JG, Limbird LE, Gilman AG, editors. Goodman and Gilman's The Pharmacological Basis of Therapeutics. 10 th
ed. New York, NY: McGraw-Hill; 2001.
Cassidy JP, Phero JC, Grau WH. Epinephrine: Systemic effects and varying concentrations in local anesthesia. Anesth Prog 1986c; 33:289-97.
Malamed S. Handbook of Local Anesthesia. 1 st
ed. St. Louis: CV Mosby Pub. Co.; 1980. p. 27-35.
Milam SB, Giovannitti JA Jr. Local anesthetics in dental practice. Dent Clin North Am 1984;28:493-508.
Roberts DN, Sowray JH. Local Analgesia in Dentistry. Bristol: John Wright & Sons, Ltd.; 1970.
Tófoli GR, Ramacciato JC, de Oliveira PC, Volpato MC, Groppo FC, Ranali J. Comparison of effectiveness of 4% articaine associated with 1: 100,000 or 1: 200,000 epinephrine in inferior alveolar nerve block. Anesth Prog 2003;50:164-8.
Jastak JT, Yagiela JA, Donaldson D. Local Anesthesia of the Oral Cavity. 3 rd
ed. Philadelphia: Saunders; 1995.
Yagiela JA. Adverse drug interactions in dental practice: Interactions associated with vasoconstrictors. Part V of a series. J Am Dent Assoc 1999;130:701-9.
Einhorn A. Text Book of Clinical Pharmacology in Dental Practice. Saint Louis: CV Mosby Company; 1974.
Stewart JH, Cole GW, Klein JA. Neutralized lidocaine with epinephrine for local anesthesia. J Dermatol Surg Oncol 1989;15:1081-3.
Cowan A. Local anaesthetics and vasoconstrictors. J Ir Dent Assoc 1974;20:156-62.
Aberg G. Studies on the duration of local anesthesia: A possible mechanism for the prolonging effect of "vasoconstrictors" on the duration of infiltration anesthesia. Int J Oral Surg 1980;9:144-7.
Roberts DH, Sowray LH. Local Analgesia in Dentistry. 2 nd
ed. Bristol: Wright PSG; 1979.
Howe GL, Whitehead FI. Local Anaesthesia in Dentistry. 2 nd
ed. Bristol: Wright PSG; 1981.
Monheim LM. Local Anesthetic and Pain Control in Dental Practice. 4 th
ed. St. Louis: Mosby Co; 1978. p. 162-6.
van den Berg AA, Montoya-Pelaez LF. Comparison of lignocaine 2% with adrenaline, bupivacaine 0.5% with or without hyaluronidase and a mixture of bupivacaine, lignocaine and hyaluronidase for peribulbar block analgesia. Acta Anaesthesiol Scand 2001;45:961-6.
Kambalimath DH, Dolas RS, Kambalimath HV, Agrawal SM. Efficacy of 4% Articaine and 2% Lidocaine: A clinical study. J Maxillofac Oral Surg 2013;12:3-10.
Davenport RE, Porcelli RJ, Iacono VJ, Bonura CF, Mallis GI, Baer PN. Effects of anesthetics containing epinephrine on catecholamine levels during periodontal surgery. J Periodontol 1990;61:553-8.
Nagata T, Mishima Y, Ito T, Sawada M, Hiraki T, Hamada N, et al.
Anesthetic management of a patient with deteriorated cardiac function following cardiopulmonary resuscitation. Kurume Med J 2010;57:81-4.
Kumar A, Khanna R, Srivastava RK, Ali I, Wadhwani P. Mannitol an adjuvant in local anaesthetic solution: Recent concept & changing trends (review). J Clin Diagn Res 2014;8:GE01-4.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]