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ISSN 0975-8437 INTERNATIONAL JOURNAL OF DENTAL CLINICS 2011:3(2):11-13

ORIGINAL RESEARCH ARTICLE

Topical Anesthetics: How Effective Are They


Preeti Dhawan, Gulshan Dhawan
Abstract
Background: Almost every dental procedure requires the use of needle insertion for the
administration of local anaesthetic agent. Aims: To compare the efficacy of various topical anaesthetic
agents with Eutectic Mixture of Local anesthetics (EMLA). Material and Methods: The sample population
consists of 120 children between the age group of 5-15 years were randomly divided into four groups, each
group comprising of 30 children. Four topical anesthetics i.e. EMLA 5%, Lignocaine 2%, Benzocaine 20%
and Placebo (Vaseline) were applied for five minutes before needle insertion. The effectiveness of the
topical anaesthetic agent was recorded by using Visual Analogue Scale (VAS), Lickerts’ scale and the
sound eye and motor scale (SEM). Results: When EMLA (Group I) was compared with other groups in
relation to Visual Analogue Scale, a highly significant difference in pain reduction (P<0.000001) was
found. No significant difference was found between Lignocaine (Group II) and Benzocaine (Group III).
Conclusion: EMLA showed a highly significant reduction in pain as compared to 2% Lignocaine and 20%
Benzocaine.
Key Words: Topical anesthetics; Eutectic mixture of local anesthetics; Visual Analogue Scale
Received on: 13/11/2010 Accepted on: 13/01/2010

Introduction
Pediatric dentistry frequently requires effectiveness of the topical anaesthetic agent was
Local anesthetics by Regional block or local recorded by using Visual Analogue Scale (VAS),
infiltration, which requires needle insertion. The Lickerts’ scale and the sound eye and motor
objective fears of the child during administration scale (SEM). Statistical analysis was done using
of local anaesthesia range from the sight of the SPSS v.10. The significance was calculated
needle to the pain associated with needle using students T test.
insertion. Topical anesthetics are thought to Results
function by blocking signal transmission in the The sample population consists of 120
terminal fibers of sensory nerves. Thus, their children between the age group of 5-15 years.
effects are thought to be limited to the control of The table 1 shows the pain and anxiety score
painful stimulation occurring in or just beneath with Visual analogue scale. EMLA (Group I)
the mucosa.(1) The main objective of this study shows, a highly significant difference in pain
was to compare the efficacy of various topical reduction (P<0.000001) as compared to other
anaesthetic agents with Eutectic Mixture of three groups. No significant difference was
Local anesthetics (EMLA) during needle found between Lignocaine (Group II) and
insertion in pediatric dental patients. Benzocaine (Group III).
Materials & Methods
The sample population consists of 120 Group 't' value 'p' value Significance
children between the age group of 5-15 years I-II 8.224 p < 0.000001 Highly significant
I – III 6.108 p < 0.000001 Highly significant
who reported to the outpatient department of I – IV 12.157 p < 0.000001 Highly significant
Pedodontics and Preventive Dentistry, who II – III 2.444 0.01759 Non-Significant
required the use of local anaesthesia for the II – IV 5.796 p < 0.000001 Highly significant
various dental procedures. Those children who III – IV 7.709 p < 0.000001 Highly significant
were having no other illness other than for which Table 1: analysis of variance for pain and anxiety with
different topical anesthetics with respect to visual analogue
they have reported and have no history of any scale
allergy to local anesthetics were selected for the The difference between various groups
study. The children were randomly assigned into with respect to VAS was found to be highly
four groups; consist of 30 children in each group. significant between Groups-I and IV (p <
Group I included children who were applied 0.000001) and non-significant between Groups-
EMLA, Group II was the Lignocaine group, II and III (p value is 0.01759). When comparison
Group III was Benzocaine group, Group IV was of means of pain score for different topical
the placebo group. After proper isolation, one of anesthetics was made with respect to Lickerts’
the four topical anesthetics was applied for five scale, EMLA (Group I) showed a highly
minutes before needle insertion. The significant p value (P<0.000001). The result was

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ISSN 0975-8437 INTERNATIONAL JOURNAL OF DENTAL CLINICS 2011:3(2):11-13

significant when Lignocaine (Group II) was respectively. However when these agents are
compared to Benzocaine (Group III) but no combined in eutectic form, the melting point of
significant difference was found between mixture is lowered to 17oC. This new physical
Lignocaine (Group II) and Placebo (Group IV) property allows the anaesthetic agents to form oil
table 2. at mouth temperature (37oC) and thus facilitates
increased absorption of local anaesthetic agents.
Between 't' value 'p' value Significance
Hence, the present study was undertaken to
comparatively evaluate the effectiveness of
I – II 14.441 p < 0.000001 Highly significant Eutectic Mixture of Local anesthetics (EMLA)
cream with the commonly available other topical
I – III 7.319 p < 0.000001 Highly significant anesthetics in reducing the pain associated with
intra-oral needle insertion.(3)
I – IV 15.092 p < 0.000001 Highly significant In the present study, the evaluation of
pain was done using the following three scales,
II – III 7.420 p < 0.000001 Highly significant Visual Analogue Scale, Lickerts’ scale and
Lickert's

Sound, Eye, Motor Scale. According to these


II – IV 1.621 p < 0.1 Non-significant
three scales, highly significant reduction in pain
III – IV 8.478 p < 0.000001 Highly significant scores was found (P<0.000001) when EMLA
Table2 intergroup comparison of mean values for Lickert's was compared with Lignocaine, Benzocaine and
Placebo. Topical anesthetics such as Lignocaine
The difference between various groups and Benzocaine have the same mechanism of
with respect to Lickert's scale was found to be action. These local anesthetic agents when
highly significant (p < 0.000001) between all the applied to the mucous membrane pass through
groups except between Gr-II and Gr-IV where p the epidermis and anaesthetize the superficial
value was 0.1 and the results were statistically nerve-endings. Thus, their effects are thought to
non-significant. Table 3 showed the comparison be limited to the control of painful stimulation
of means of pain for EMLA (Group I), occurring in or just beneath the mucosa.1 These
Lignocaine (Group II), Benzocaine (Group III) topical surface anesthetics are effective only on
and Placebo(Group IV) with respect to SEM surface tissue (2-3mm) and tissues deep to the
Scale. There was a highly significant reduction area of application are poorly anaesthetized.
in pain of EMLA (p<0.000001) with Lignocaine, Lignocaine is the most commonly used
Benzocaine and Placebo. The difference topical anaesthetic agent and according to
between various groups with respect to SEM Malamed, it is today, the gold standard against
scale was found to be highly significant. which all other topical anesthetics are compared.
However, it is not favorable, as regards to its
bio-adhesion, analgesic potential and taste
Between 't' value 'p' value Significance characteristics.(3) In our study, 20% Benzocaine
I – II 15.654 p < 0.000001 Highly significant was found to be better than 2% Lignocaine with
highly significant difference (p<0.000001)
I – III 7.225 p < 0.000001 Highly significant probably because Benzocaine can remain on the
I – IV 21.570 p < 0.000001 Highly significant region of application for a longer time and also
mucopain (20% Benzocaine) has a better
II – III 7.562 p < 0.000001 Highly significant
acceptable taste than 2% Lignocaine jelly. The
II – IV 8.381 p < 0.000001 Highly significant wide difference in the pain scores of EMLA with
SEM

III – IV 14.253 p < 0.000001 Highly significant other topical anesthetics may be due to different
mechanism of action of EMLA with Lignocaine
Table 3 intergroup comparison of the mean values for SEM and Benzocaine. (4) EMLA was introduced to be
used on skin mainly to reduce pain of venous
Discussion cannulation and to provide surface anaesthesia
In general, common topical anesthetics for the harvesting of skin grafts.
like Lignocaine and Benzocaine are effective Topically applied EMLA penetrates
only on surface tissue (2-3mm) and tissues deep through the epidermis to act on sensory nerve
to the area of application are poorly endings in the dermis in order to provide
anaesthetized.(2) E R Vickers and A. P Moorthy effective anaesthesia. EMLA blocks the Ad-
suggested that Lignocaine and Prilocaine bases fibers which transmit cold and pinprick sensation
have melting points of 69oC and 37oC and the C-fibers which transmits warmth and

©INTERNATIONAL JOURNAL OF DENTAL CLINICS VOLUME 3 ISSUE 2 APRIL - JUNE 2011 12


ISSN 0975-8437 INTERNATIONAL JOURNAL OF DENTAL CLINICS 2011:3(2):11-13

dull pain. EMLA also has a high water content It is recommended that EMLA impregnated
(which softens the stratum corneum, making it intraoral patches impermeable to saliva if
more permeable) together with high proportion available would be a major advantage for its use
of the lipophilic, un-ionized (basic) form of intraorally and the bland taste of EMLA should
anaesthetic, which makes EMLA membrane be modified if its use in pediatric dentistry is to
permeable.7 The advantages of EMLA over be perused.
conventional topical anesthetics on the oral Conclusion
mucous membrane may be due to following In conclusion, it can be stated that
reasons, a) It has a deeper depth of penetration EMLA showed a highly significant reduction in
i.e about 5 mm whereas other topical pain as compared to 2% Lignocaine and 20%
anesthetics have a penetration depth of only 2-3 Benzocaine. EMLA can be of great help in
mm, b) It is able to diffuse effectively through eliminating the pain of intraoral needle insertion
the keratinized tissue i.e gingival mucosa and and its other advantages such as rapid
hard palate whereas other topical anesthetics can penetration on the skin and mucosa and plasma
act only on the non-keratinized tissue, c) -EMLA concentrations not reaching the toxic levels
is able to penetrate the buccal cortical plate more makes it the useful topical anaesthetic and should
effectively to block Ad and the unmyelinated C- be considered as a useful adjunct in the
fiber nociceptive afferents. management and treatment of pediatric patients
EMLA has an effective tissue under local anaesthesia.
penetration. It is composed of oil-in-water
emulsion of Lignocaine and Prilocaine local Authors Affiliations: 1. Dr Preeti Dhawan, M.D.S
anesthetics. Rather than relying on an oil solvent Department of Pedodontics, Swami Devi Dayal Dental
to dissolve the anesthetics, EMLA cream utilizes College, 2. Dr. Gulshan Dhawan, Anesthesiologist,
M.D (Anaesthesia), Chandigarh, India.
the eutectic mixture of two compounds. Pure
References
Lignocaine and pure Prilocaine have melting 1. DeNunzio M. Topical anesthetic as an adjunct to
points above room temperature (67% and 37% local anesthesia during pulpectomies. Journal of
respectively) but a 1:1 mixture of the two has a Endodontics1998;24(3):202-3.
melting point of about 17oC and is thus, 2. Bernardi M, Secco F, Benech A. Anesthetic
normally liquid at room temperature. EMLA efficacy of an eutectic mixture of lidocaine and
cream is prepared by emulsifying this oily liquid prilocaine (EMLA) on the oral mucosa:
in water to give a final concentration of 25 prospective double-blind study with a placebo.
mg/gm lignocaine and 25mg/gm prilocaine. Minerva Stomatologica1999;48(1-2):39-43.
3. Vickers E, Punnia Moorthy A. A clinical
Although the final proportion of anaesthetic in evaluation of three topical anaesthetic agents.
this cream is only 5%, which reduces the Australian Dental Journal1992;37(4):266-70.
possibility of toxicity, the oil droplets within the 4. Tulga F, Mutlu Z. Four types of topical
emulsion are composed of 80% anaesthetic, anaesthetic agents: evaluation of clinical
which provides a highly effective analgesic effectiveness. The Journal of Clinical Pediatric
concentration. Dentistry1999;23(3):217-20.
There are certain disadvantages
associated with EMLA cream viz it is difficult Address for correspondence
for EMLA cream to remain in the region of Dr Preeti Dhawan, M.D.S (Pedodontics)
Swami Devi Dayal Dental College,
application for a long time because of the low Golpura Distt, Panchkula, India.
viscosity and it does not have very acceptable Ph:0091. 9896778118
taste. E-mail: [email protected]

Source of Support: Nil, Conflict of Interest: None Declared

©INTERNATIONAL JOURNAL OF DENTAL CLINICS VOLUME 3 ISSUE 2 APRIL - JUNE 2011 13

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