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

The difference between various groups

with respect to VAS was found to be highly
significant between Groups-I and IV (p <
0.000001) and non-significant between GroupsII and III (p value is 0.01759). When comparison
of means of pain score for different topical
anesthetics was made with respect to Lickerts
scale, EMLA (Group I) showed a highly
significant p value (P<0.000001). The result was

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

Lickert's

significant when Lignocaine (Group II) was

compared to Benzocaine (Group III) but no
significant difference was found between
Lignocaine (Group II) and Placebo (Group IV)
table 2.
Between

't' value 'p' value

Significance

I II

14.441

p < 0.000001 Highly significant

I III

7.319

p < 0.000001 Highly significant

I IV

15.092

p < 0.000001 Highly significant

II III

7.420

p < 0.000001 Highly significant

II IV

1.621

p < 0.1

III IV

8.478

p < 0.000001 Highly significant

Non-significant

Table2 intergroup comparison of mean values for Lickert's

The difference between various groups

with respect to Lickert's scale was found to be
highly significant (p < 0.000001) between all the
groups except between Gr-II and Gr-IV where p
value was 0.1 and the results were statistically
non-significant. Table 3 showed the comparison
of means of pain for EMLA (Group I),
Lignocaine (Group II), Benzocaine (Group III)
and Placebo(Group IV) with respect to SEM
Scale. There was a highly significant reduction
in pain of EMLA (p<0.000001) with Lignocaine,
Benzocaine and Placebo. The
difference
between various groups with respect to SEM
scale was found to be highly significant.

SEM

Between 't' value 'p' value

Significance

I II

15.654

p < 0.000001 Highly significant

I III

7.225

p < 0.000001 Highly significant

I IV

21.570

p < 0.000001 Highly significant

II III

7.562

p < 0.000001 Highly significant

II IV

8.381

p < 0.000001 Highly significant

III IV

14.253

p < 0.000001 Highly significant

Table 3 intergroup comparison of the mean values for SEM

Discussion
In general, common topical anesthetics
like Lignocaine and Benzocaine are effective
only on surface tissue (2-3mm) and tissues deep
to the area of application are poorly
anaesthetized.(2) E R Vickers and A. P Moorthy
suggested that Lignocaine and Prilocaine bases
have melting points of 69oC and 37oC

respectively. However when these agents are

combined in eutectic form, the melting point of
mixture is lowered to 17oC. This new physical
property allows the anaesthetic agents to form oil
at mouth temperature (37oC) and thus facilitates
increased absorption of local anaesthetic agents.
Hence, the present study was undertaken to
comparatively evaluate the effectiveness of
Eutectic Mixture of Local anesthetics (EMLA)
cream with the commonly available other topical
anesthetics in reducing the pain associated with
intra-oral needle insertion.(3)
In the present study, the evaluation of
pain was done using the following three scales,
Visual Analogue Scale, Lickerts scale and
Sound, Eye, Motor Scale. According to these
three scales, highly significant reduction in pain
scores was found (P<0.000001) when EMLA
was compared with Lignocaine, Benzocaine and
Placebo. Topical anesthetics such as Lignocaine
and Benzocaine have the same mechanism of
action. These local anesthetic agents when
applied to the mucous membrane pass through
the epidermis and anaesthetize the superficial
nerve-endings. Thus, their effects are thought to
be limited to the control of painful stimulation
occurring in or just beneath the mucosa.1 These
topical surface anesthetics are effective only on
surface tissue (2-3mm) and tissues deep to the
area of application are poorly anaesthetized.
Lignocaine is the most commonly used
topical anaesthetic agent and according to
Malamed, it is today, the gold standard against
which all other topical anesthetics are compared.
However, it is not favorable, as regards to its
bio-adhesion, analgesic
potential and taste
characteristics.(3) In our study, 20% Benzocaine
was found to be better than 2% Lignocaine with
highly significant difference (p<0.000001)
probably because Benzocaine can remain on the
region of application for a longer time and also
mucopain (20% Benzocaine) has a better
acceptable taste than 2% Lignocaine jelly. The
wide difference in the pain scores of EMLA with
other topical anesthetics may be due to different
mechanism of action of EMLA with Lignocaine
and Benzocaine. (4) EMLA was introduced to be
used on skin mainly to reduce pain of venous
cannulation and to provide surface anaesthesia
for the harvesting of skin grafts.
Topically applied EMLA penetrates
through the epidermis to act on sensory nerve
endings in the dermis in order to provide
effective anaesthesia. EMLA blocks the Adfibers which transmit cold and pinprick sensation
and the C-fibers which transmits warmth and

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dull pain. EMLA also has a high water content

(which softens the stratum corneum, making it
more permeable) together with high proportion
of the lipophilic, un-ionized (basic) form of
anaesthetic, which makes EMLA membrane
permeable.7 The advantages of EMLA over
conventional topical anesthetics on the oral
mucous membrane may be due to following
reasons, a) It has a deeper depth of penetration
i.e
about 5 mm whereas other topical
anesthetics have a penetration depth of only 2-3
mm, b) It is able to diffuse effectively through
the keratinized tissue i.e gingival mucosa and
hard palate whereas other topical anesthetics can
act only on the non-keratinized tissue, c) -EMLA
is able to penetrate the buccal cortical plate more
effectively to block Ad and the unmyelinated Cfiber nociceptive afferents.
EMLA has an effective tissue
penetration. It is composed of oil-in-water
emulsion of Lignocaine and Prilocaine local
anesthetics. Rather than relying on an oil solvent
to dissolve the anesthetics, EMLA cream utilizes
the eutectic mixture of two compounds. Pure
Lignocaine and pure Prilocaine have melting
points above room temperature (67% and 37%
respectively) but a 1:1 mixture of the two has a
melting point of about 17oC and is thus,
normally liquid at room temperature. EMLA
cream is prepared by emulsifying this oily liquid
in water to give a final concentration of 25
mg/gm lignocaine and 25mg/gm prilocaine.
Although the final proportion of anaesthetic in
this cream is only 5%, which reduces the
possibility of toxicity, the oil droplets within the
emulsion are composed of 80% anaesthetic,
which provides a highly effective analgesic
concentration.
There are certain disadvantages
associated with EMLA cream viz it is difficult
for EMLA cream to remain in the region of
application for a long time because of the low
viscosity and it does not have very acceptable
taste.

It is recommended that EMLA

impregnated
intraoral patches impermeable to saliva if
available would be a major advantage for its use
intraorally and the bland taste of EMLA should
be modified if its use in pediatric dentistry is to
be perused.
Conclusion
In conclusion, it can be stated that
EMLA showed a highly significant reduction in
pain as compared to 2% Lignocaine and 20%
Benzocaine. EMLA can be of great help in
eliminating the pain of intraoral needle insertion
and its other advantages such as rapid
penetration on the skin and mucosa and plasma
concentrations not reaching the toxic levels
makes it the useful topical anaesthetic and should
be considered as a useful adjunct in the
management and treatment of pediatric patients
under local anaesthesia.
Authors Affiliations: 1. Dr Preeti Dhawan, M.D.S
Department of Pedodontics, Swami Devi Dayal Dental
College, 2. Dr. Gulshan Dhawan, Anesthesiologist,
M.D (Anaesthesia), Chandigarh, India.
References
1. DeNunzio M. Topical anesthetic as an adjunct to
local anesthesia during pulpectomies. Journal of
Endodontics1998;24(3):202-3.
2. Bernardi M, Secco F, Benech A. Anesthetic
efficacy of an eutectic mixture of lidocaine and
prilocaine (EMLA) on the oral mucosa:
prospective double-blind study with a placebo.
Minerva Stomatologica1999;48(1-2):39-43.
3. Vickers E, Punnia Moorthy A. A clinical
evaluation of three topical anaesthetic agents.
Australian Dental Journal1992;37(4):266-70.
4. Tulga F, Mutlu Z. Four types of topical
anaesthetic agents: evaluation of clinical
effectiveness. The Journal of Clinical Pediatric
Dentistry1999;23(3):217-20.
Address for correspondence
Dr Preeti Dhawan, M.D.S (Pedodontics)
Swami Devi Dayal Dental College,
Golpura Distt, Panchkula, India.
Ph:0091. 9896778118
E-mail: preetidhawan10@gmail.com

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

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