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The Takeaway

Two recent studies provide strong, evidence-based support that dental malpractice defense attorneys can use to counter plaintiffs’ claims that using articaine as a local anesthetic increases the risk of nerve damage in dental procedures.

Introduction

In dentistry, local anesthesia is the primary technique used to control pain in a variety of procedures, including tooth extractions and implant placement. In lawsuits filed against dentists for alleged nerve injuries, plaintiffs frequently argue that the use of articaine (brand name Orabloc) as a local anesthetic increases the risk of nerve damage compared to the use of lidocaine. Dentists and oral surgeons have differing views on this, creating a classic battle-of-the-experts in dental malpractice cases.

Plaintiffs’ Contentions

For context, in Canada and several European countries, articaine is the most frequently used anesthetic agent. In the U.S., 2% lidocaine injections are the most widely used local anesthetic. However, 4% articaine provides more profound anesthetic success than lidocaine for infiltrations. Plaintiffs’ experts often cite studies completed in 1995 and 2010 that associate the use of articaine with higher instances of paresthesia (i.e., tingling), which is a recognized symptom of traumatic nerve damage. Plaintiffs’ attorneys in dental negligence claims use these studies to argue a causal link between the use of articaine/Orabloc and inferior alveolar and/or lingual nerve injuries. The classic argument used is: (1) defendant dentist knew or should have known that the use of articaine carried an increased risk of nerve injury, and (2) had the defendant used lidocaine, there would have been no injury to the Plaintiff.

Defense Strategies

To defend these claims, defense experts often rely on more recent studies that investigate whether articaine is more neurotoxic than lidocaine at clinical levels. These studies conclude that articaine did not produce a prolonged block of neuronal responsiveness or increased toxicity in comparison to lidocaine.

For example, in 2018, The University of Pennsylvania School of Dental Medicine conducted an in vitro study to determine the effects of 2% lidocaine and 4% articaine on cell viability and neurotoxicity. (The investigators used the pure powder forms of each drug.) The results of the study, published in Anesthesia Progress: The Journal of Sedation and Anesthesiology in Dentistry,[1] concluded that articaine does not produce a prolonged loss of responsiveness or cell death to neural cells as compared with lidocaine.

In 2021, the Journal of Oral and Maxillofacial Surgery (a peer-reviewed journal) published the results of a study[2] that sought to respond, with more extensive evidence, to the question around the increased risk of hypesthesia (i.e. loss of sensation) with the use of articaine. Two independent reviewers compiled information from multiple databases regarding cases of patients undergoing lower third molar extractions. Of the 886 extractions that met the criteria of the study, 436 used 4% articaine and 430 used other local anesthetics, 295 of which were 2% lidocaine. The study noted that no previous research indicated with a high level of evidence that the use of articaine carried an increased risk of hypesthesia in lower third molar surgery. They further noted that no causal relationship had been found between the anesthetic agent and neurological damage. The investigators’ meta-analysis concluded there was no statistically significant increased risk of hypesthesia with the use of articaine compared with other local anesthetics. Additionally, the presence of permanent hypesthesia was not confirmed in any case.

Conclusion

Having well-qualified defense experts explain these newer studies can provide the foundation for arguing that a dental practitioner’s use of articaine is not, in and of itself, negligent. Moreover, these studies present consistent evidence-based data to support a defense that articaine does not carry an increased risk of nerve damage.

[1] “Effects of Lidocaine and Articaine on Neuronal Survival and Recovery,” Anesthesia Progress. 2018 Summer; 65(2): 82–8; PMCID: PMC6022788

[2] “Does the Use of Articane Increase the Risk of Hypesthesia in Lower Third Molars Surgery? A Systemic Review and Meta-Analysis,” Journal of Oral Maxillofacial Surgery. 2021 Jan; 79(1): 64-74.