Administering local anaesthetics is one of the most common practices in a dental clinic. The achieved pain elimination plays especially an important role when treating children. Articaine has been considered superior to lidocaine due to its increased lipid-solubility and potency. However, its use in children younger than 4 years of age is still not recommended by the manufacturers. This study investigated the experience of paediatric dentists based in Switzerland regarding the use of articaine and other local/topical anaesthetics.

Articaine was—by far—the most used local anaesthetic by more than 80% of the participating Swiss paediatric dentists in all age groups (0–4, 4–12, and older than 12), compared to 3% who chose lidocaine. The fact that participating Swiss paediatric dentists widely use articaine in children younger than 4 years of age is especially interesting, as articaine is contraindicated in this group of children in Switzerland (Arzneimittel-Kompendium 2023). In Austria, however, a generic of articaine (Ultracain Dental forte) is approved for children older than one year. Anecdotally, two other generics of articaine (Ubistesin forte and Septanest mit Epinephrin) with the same concentrations of articaine and adrenaline as Ultracain Dental forte are only recommended in children older than 4 years of age due to the lack of data for younger children (Medizinmarktaufsicht 2023). This discrepancy in the age approval and labelling (“not recommended”, “lack of sufficient data”, “contraindicated”) between similar products in the same and neighbouring countries might be caused by bureaucratic formalities, and might be in part responsible for the fact that Swiss paediatric dentists use articaine in an—officially—contraindicated age group. This unsatisfactory aspect was also discussed in the latest policy document on best clinical practice for administering local anaesthesia in paediatric patients by the European Academy of Paediatric Dentistry (EAPD). The document has also drawn attention to other notable gaps in our current understanding in this particular area (e.g., dosage recommendations in relation to the dental treatment and evidence for the most effective and comfortable injection technique) (Kühnisch et al. 2017).Another reason of this wide use of articaine in younger children could be the lack of knowledge that a contraindication exists.

The here-reported wide use of articaine is in contrast with a couple of studies in the literature. In the United Kingdom, Ezzeldin et al. (2020) reported that only 19% of the members of the British society of paediatric dentistry chose articaine to be their first line anaesthetic, compared to 80% who chose lidocaine. However, articaine was still reported to be used by 62% of the paediatric dentists on daily and weekly basis. Of those using articaine, 87% reported refraining from using it in children younger than 4 years of age. In the United States, Brickhouse et al. (2008) reported that 10% of paediatric dentists chose articaine as their preferred anaesthetic in 2- to 3-year olds, compared to 82% who chose lidocaine. In 4- to 6-year-olds, the preference of articaine among paediatric dentists rose to 15%, compared to 78% who still preferred lidocaine. Alanazi et al. (2021) also reported that articaine was only used by 1.7% of Saudi dental practitioners when treating paediatric patients, compared to 92% who used lidocaine. Different marketing representations of each kind of anaesthetic and the kind of anaesthetic dentists used during their undergraduate studies might play a role in these contrasting findings (Ezzeldin et al. 2020). For instance, four out of six dentists who chose lidocaine as the most used anaesthetic in 0–4-year-olds in this study graduated from universities outside of Switzerland (United States, Germany, Greece).

Twenty-eight percent of participating Swiss paediatric dentists reported observing local side effects related to local anaesthetics 2 to 5 times annually, and 7% of them reported observing systemic side effects with the same frequency. Almost all of those reporting such frequency of observed side effects were articaine users in all age groups. However, and due to the considerably big difference between the numbers of articaine and lidocaine users in this study (137 vs. 6 in 0–4-year-old group, 158 vs. 6 in 4–12-year-old group, and 159 vs. 5 in > 12-year-old group), no statistically based conclusion can be made in favour of lidocaine (as the safer choice with less observed side effects). In fact, articaine might be considered–at least theoretically—systemically safer than lidocaine due to the presence of an ester side chain in its thiophene ring. The relative rapid inactivation of this chain in plasma results in the fact that articaine has a half-life of only 20 min compared to about 90 min in lidocaine. This shorter half-life is especially meaningful in lengthy appointments, where additional doses of anaesthetics might be necessary (Becker and Reed 2006). Among paediatric dentists in the UK, Ezzeldin et al. (2020) reported that the odds of side effects were greater when using lidocaine than when using articaine, considering the frequency of use. The reported side effects were prolonged paraesthesia and soft tissue trauma (84% in the lidocaine-user group vs. 15% in the articaine-user group). A higher proportion of participating Swiss paediatric dentists (approximately 70%) reported observing local side effects when using articaine on at least one occasion annually. In their systematic review, Klingberg et al. (2017) reported that no serious side or adverse effects were reported in the searched literature apart from soft tissue injuries such as lip or cheek biting, or pain related to injection site. Therefore, the relatively high percentage of participating Swiss paediatric dentists (28%) who reported observing systemic side effects was unexpected. Unfortunately, due to the anonymous nature of the questionnaire, further details regarding these observed systemic side effects could not be obtained. Ninety-three percent of participating Swiss paediatric dentists reported to always use a topical anaesthetic before injection. Similar result was reported by Kohli et al. (2001) where 89% of the paediatric dentists in the United States also reported to always use a topical anaesthetic. More percentage of Swiss paediatric dentists (48%) tended to wait for more than 60 s between topical anaesthetic and the injection than American peers (33%). Longer waiting times was found to be associated with more perceived effectiveness of topical anaesthetic in this study, which could be deemed logical as they would have more time to numb the injection site. This might explain the more percentage of Swiss paediatric dentists perceiving their application of topical anaesthetic as effective or very effective compared to the American peers (90% vs. 61%). Nevertheless, this explanation is rather speculative as many other factors could also play a role.

One potential limitation of this study is that the survey was distributed via email, which may have resulted in selection bias. Paediatric dentists who are more active or interested in research may be more likely to respond to the survey, potentially skewing the results. In Addition, self-reported data may not always be accurate or complete, as individuals may have different interpretations or memories of their experiences. Furthermore, the fact that the survey questions were close ended have limited the ability to collect more detailed and nuanced responses. At the same time, the attempt to fetch as much information as possible from a single survey might prolong the time necessary to answer all the questions and could affect the participation interest even more.