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AnesthEssaysRes.2013JanApr7(1):49.doi:10.4103/02591162.113977

PMCID:PMC4173488

AnupdateonlocalanesthesiaforpediatricdentalpatientsFaizalC.PeedikayilandAjoyVijayan

DepartmentofPedodonticsandPreventiveDentistry,KannurDentalCollege,Kannur,KeralaState,IndiaDepartmentofOralandMaxillofacialSurgery,KannurDentalCollege,Kannur,KeralaState,IndiaCorrespondingauthor:Dr.FaizalC.Peedikayil,DepartmentofPedodonticsandPreventiveDentistry,KannurDentalCollege,Kannur,KeralaState,India.Email:drfaizalcp@gmail.com

Copyright:Anesthesia:EssaysandResearches

ThisisanopenaccessarticledistributedunderthetermsoftheCreativeCommonsAttributionNoncommercialShareAlike3.0Unported,whichpermitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.

Abstract

Paincontrolisanimportantpartofdentistry,particularlyinthemanagementofchildren.Behaviorguidance,anddoseandtechniqueofadministrationofthelocalanestheticareimportantconsiderationsinthesuccessfultreatmentofapediatricpatient.Thepurposeofthepresentreviewistodiscusstherelevantdataontopicsinvolved,andonthecurrentmethodsavailableintheadministrationoflocalanesthesiausedforpediatricdentalpatients.

Keywords:Localanesthesia,paincontrol,pedodontics

INTRODUCTION

Fearrelatedbehaviorshavelongbeenrecognizedasthemostdifficultaspectofpatientmanagementandcanbeabarriertogoodcare.[1]Administeringlocalanesthesiabyinjectionisstillthemostcommonmethodusedindentistry.However,thereisaconstantsearchforwaystoavoidtheinvasiveandoftenpainfulnatureoftheinjection,andfindamorecomfortableandpleasantmeansofachievinglocalanesthesiabeforedentalprocedures.[2,3]

Chemically,thelocalanestheticagentsincommonclinicalusetodaymaybedividedintotwobroadgroups:(A)agentscontaininganesterlinkingand(B)agentscontaininganamide.Themostcommonlyusedlocalanestheticsforpediatricdentistryaretheamidetypeagents.Lidocainehydrochloride(HCl)2%with1:100,000epinephrineispreferredbecauseoftheirlowallergeniccharacteristicsandtheirgreaterpotencyatlowerconcentrations.[4]Table1showsthedosageper1.8mLcartridgeoflidocaine.

Table1Dosageperdentalcartridge

Localanestheticcarpulesalsocontainorganicsaltsandmaycontainvasoconstrictors.Vasoconstrictorsareusedtoconstrictbloodvessels,counteractthevasodilatoryeffectsofthelocalanesthetic,prolongitsduration,reducesystemicabsorptionandtoxicity,andprovideabloodlessfieldforsurgicalprocedures.[4,5]Theuseofthevasoconstrictorwillallowthemaximumtotaldoseoftheanestheticagenttobeincreasedbynearly40%.[6,7]Manyagentshavebeenemployedasvasoconstrictorswithlocalanesthetics.Butnonehasprovedtobeasclinicallyeffectiveasepinephrine.[6]

Themaximumdoseoflidocaineandmepivacaine,withoutvasoconstrictors,recommendedforchildrenis4.4mg/kgbodyweight,and7mg/kgbodyweightforlidocainewithvasoconstrictors.[8]

Theaveragedurationofpulpalanesthesiais60minutesfor20%lidocainewith1:100,000epinephrine,50minutesfor2%mepivacainewith1:20,000levonordefrin,and25minutesfor3%mepivacainewithoutvasoconstrictor.In

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4173488/table/T1/http://www.ncbi.nlm.nih.gov/pubmed/?term=Vijayan%20A%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC4173488/table/T1/http://www.ncbi.nlm.nih.gov/pmc/about/copyright.htmlhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Peedikayil%20FC%5Bauth%5Dhttp://dx.doi.org/10.4103%2F0259-1162.113977http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4173488/table/T1/mailto:dev@null

thepresentlocalanestheticagentsused,thesofttissueanesthesiaismorethanthatofpulpalanesthesia.[5]Attemptshavebeenmadetofindagentsthatreducethedurationofsofttissueanesthesia.However,nosuchreductionhasbeenobservedthus,theauthorsrecommendthat2%lidocainewith1:100,000epinephrinebeusedwhenadministeringlocalanesthesiainyoungchildren.

Ifalocalanestheticisinjectedintoanareaofinfection,itsonsetwillbedelayedorevenprevented.[3]TheinflammatoryprocessinanareaofinfectionlowersthepHoftheextracellulartissuefromitsnormalvalue(7.4)to56orlower.ThislowpHinhibitsanestheticactionbecauselittleofthefreebaseformoftheanestheticisallowedtocrossintothenervesheathtopreventconductionofnerveimpulses.Insertinganeedleintoanactivesiteofinfectioncouldalsoleadtoapossiblespreadoftheinfection.[3,4,6,8,9]

Safetyoflocalanestheticagentsandadversereaction

Theinherentuseoflocalanestheticinjectionsallowspractitionerstousethemfrequentlywiththeconfidencethatadverseeventsarerare.[10,11]Themostcommonreactionassociatedwithlocalanestheticsisatoxicreaction,resultingusuallyfromaninadvertentintravenousinjectionoftheanestheticsolution.[8]Table2showstheadversereactiontocommonlyusedlocalanesthetics.

Table2Adversereactionsofcommonlyusedlocalanesthetics

Overdosereactionsareaparticularriskintreatingchildren.[5,6]Thedosageofthelocalanestheticdependsonthephysicalstatusofpatient,areatobeanesthetized,vascularityoforaltissues,andthetechniqueofadministration.Itisdifficulttorecommendamaximumdoseforchildrenbecausedosevarieswithfunctionsofageandweight.Forpediatricpatientslessthan10yearswhohaveleanbodymassandnormalbodydevelopment,themaximumdosemaybedeterminedbyapplicationofoneofthestandardformulas(Clarksrule).Inanycase,themaximumdoseshouldnotexceed7mg/kgbodyweightforlidocainewithepinephrineand4.4mg/kgforplainadrenaline.Toxicityoccursprimarilyinthecardiovascularandcentralnervoussystemthistoxicreactioncouldstimulateordepressthecentralnervoussystem.Stimulationofthecentralnervoussystemcancauseatoxicvasoconstrictorreaction,andthesignsandsymptomsaretachycardia,apprehension,sweating,andhyperactivity.Depressionofthecentralnervoussystemmayfollow,leadingtobradycardia,hypoxia,andrespiratoryarrest.[3,8,10,11,12]

Epinephrineiscontraindicatedinpatientswithhyperthyroidism.[5]Itsdoseshouldbekepttoaminimuminpatientsreceivingtricylicantidepressantssincedysrhythmiasmayoccur.Levonordefrinandnorepinephrineareabsolutelycontraindicatedinthesepatients.Patientswithsignificantcardiovasculardisease,thyroiddysfunction,diabetes,orsulfitesensitivity,andthosereceivingmonoamineoxidaseinhibitors,tricyclicantidepressants,orphenothiazinesmayrequireamedicalconsultationtodeterminetheneedforalocalanestheticwithoutavasoconstrictor[5,10,11]

Localanesthetictoxicitycanbepreventedbycarefulinjectiontechnique,watchfulobservationofthepatient,andknowledgeofthemaximumdosagebasedonweight.Practitionersshouldaspiratebeforeeveryinjectionandinjectslowly.[11]Earlyrecognitionofatoxicresponseiscriticalforeffectivemanagement.Whensignsorsymptomsoftoxicityarenoted,administrationofthelocalanestheticagentshouldbediscontinued.Additionalemergencymanagementisbasedontheseverityofthereaction.

Allergicreactionstolocalanesthesiaarerare.Thelocalanestheticagentwiththehighestincidenceofallergicreactionsisprocaine.Itsantigeniccomponentappearstobeparaaminobenzoicacid(PABA).Crossreactivityhadbeenreportedbetweenlidocaineandprocaine.Allergiescanmanifestinavarietyofways,someofwhichincludeurticaria,dermatitis,angioedema,fever,photosensitivity,oranaphylaxis.[8,11,12]Emergencymanagementisdependentontherateandseverityofthereaction.[13]

Patients,withahistoryofallergytoalocalanesthetic,whocannotidentifythespecificagentused,presentaproblem.Thepatientshouldbereferredforevaluationandtesting,whichwillusuallyincludebothskintestingandprovocativedosetesting(PVT).Forpatientshavinganallergytobisulfates,useofalocalanestheticwithoutavasoconstrictorisindicated.[8,13]Localanestheticswithoutvasoconstrictorsshouldbeusedwithcautionduetorapidsystemicabsorptionwhichmayresultinoverdose.[13,14]

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4173488/table/T2/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4173488/table/T2/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4173488/table/T2/

Techniquesforadministeringthelocalanesthetic

Controlofthechild'shead

Topicalanesthesia

Needlesizeandlength

Durationofinjection

Postoperativesofttissueinjury

Failureinlocalanesthesia

Alongactinglocalanesthetic(i.e.,bupivacaine)isnotrecommendedforthechildorthephysicallyormentallydisabledpatientduetoitsprolongedeffect,whichincreasestheriskofsofttissueinjury.[14]

Paresthesiaispersistentanesthesiabeyondtheexpecteddurationinjuriestotheinferioralveolarnerve(IAN)andlingualnerve(LN)canbecausedbylocalanalgesicblockinjections.Thenerveinjurymaybephysicalfromtheneedleorchemicalfromthelocalanestheticsolution.Thepatientmayexperienceanelectricshockintheinvolvednervedistributionarea.Paresthesiaalsocanbecausedbyhemorrhageinoraroundthenerve.Reportsofparesthesiaaremorecommonwitharticaineandprilocainethanexpected,fromtheirfrequencyofuse.Mostcasesresolveineightweeks.[8,15]

Patientmanagementwhileadministeringlocalanestheticinjections

Inchildren,behaviormanagementiscriticaltothesuccessofdentalprocedures.Arelaxedandcalmchildduringtheadministrationoflocalanesthesiaisimportantforthesuccessoftheclinicalprocessaswell.[2,3,4]Manytechniqueshavebeendescribedformanagingchildbehaviorinthedentaloffice,includingbothpharmacologicalandnonpharmacologicalmethods.[5]

Thereisnoperfecttechniquethatguaranteessuccessinanesthetizingallchildren.However,thereareafewkeyproceduresthataremutualtoalladministrationsthatmaybevaluabletothesuccessofalltechniques.

Onceachildhasgrabbedthesyringeorbumpedtheoperator'shandanddriventheneedleintothetissueofthebone,itmaybetoolatetorespond,andalastingimpressionhasbeenmadeinthechild'smindrelativetopainassociatedwiththelocalanestheticinjection.[4]Therefore,someauthorsrecommendthatthepractitionershouldhaveacontrolofthechild'sheadandagoodfingerrest,tocontrolthesyringeincasethechildmovesorresists.Thedentalassistantshouldbepreparedtorestrainthechild'shand,gentlybutfirmly.[16]

Theprimarygoalinusingtopicalanesthesiaistominimizethepainfulsensationofneedlepenetrationintothesofttissue.Thetopicalanestheticagentmustbeplacedondriedmucosaandleftinplaceforatleastoneminutetoachievemaximumeffect.Theonsetdurationoflidocaineis35minutes.Arecentstudywhichcomparedtheefficacyofcommonlyusedtopicalanestheticsdemonstratedthesuperiorityof5%EMLAcream(eutecticmixtureoflocalanesthesiacontaininglidocaineandprilocaine)overallothertopicalanestheticagents.Thetopicalanestheticbenzocaineismanufacturedinconcentrationsupto20%lidocaineisavailableasasolutionorointmentupto5%andasasprayupto10%concentration.Localizedallergicreactions,however,mayoccurafterprolongedorrepeateduse.Topicallidocainehasanexceptionallylowincidenceofallergicreactionsbutisabsorbedsystemicallyandcancombinewithaninjectedamide.[17]

Ashort(20mm)orlong(32mm)27or30gaugeneedlemaybeusedformostintraoralinjectionsinchildren.Anextrashort(10mm)30gaugeneedlehasbeensuggestedformaxillaryanteriorinjections.Longneedlesarefrequentlyrecommendedforinferiordentalnerveblockanesthesia.However,theclinicalexperienceofmanydentistshasshownthatshorterneedlesareadequateandsafeespeciallyfortheyoungdifficulttomanagedentalpatients.[3,12]

Injectionoflocalanestheticsshouldalwaysbemadeslowly,precededbyaspirationtoavoidintravascularinjectionandsystemicreactionstothelocalanestheticagentorthevasoconstrictor.[8,16]

Selfinducedsofttissuetraumaisanunfortunateclinicalcomplicationoflocalanestheticuseintheoralcavity.Mostlipandcheekbitinglesionsofthisnatureareselflimitingandhealwithoutcomplications,althoughbleedingandinfectionmaypossiblyresult.[18]

Caregiversresponsibleforpostoperativesupervisionshouldbegivenarealistictimefordurationofnumbnessandbeinformedofthepossibilityofsofttissuetrauma.

Anumberoffactorscontributetothefailureoflocalanesthesia.Thesemayberelatedeithertothepatientortheoperator.Operatordependentfactorsare(a)badchoiceoflocalanestheticsolutionand(b)poortechnique.

Patientdependentfactorsare(a)anatomicalvariations,(b)thepresenceofinfection,thatis,theacidicenvironment

preventsthelocalanestheticagentfromreachingandpenetratingthenerve,and(c)psychogenicfactors,thatis,severeanxietymayinfluencepainperception.[10,19,20]

Whenalocalanestheticfails,generally,itisbesttorepeattheinjectionthiswilloftenleadtosuccess.Inthecaseofrepeatblockinjections,itiseasiertopalpatebonylandmarksatthesecondattemptastheneedlecanbemaneuveredinthetissuespainfully.[19]

Conventionalmethodsofobtaininglocalanesthesia

Infiltrationisthechoicetoanaesthetizemaxillaryteethsuccessfully.Inthiscase,theneedleshouldpenetratethemucobuccalfoldandbeinsertedtothedepthoftheapicesofthebuccalrootsoftheteeth.Thesolutionisdepositedsupraperiosteallyandinfiltratesthroughthealveolarbonetoreachtherootapex,asthealveolarboneinchildrenismorepermeablethanitisinadults.Alittlelocalanestheticmaybesufficienttoproduceanesthesiaofteeth.[21]

Stretchingthemucosaoftheinjectionsiteandgentlypullingontotheobliquelyplacedbeveloftheneedleisrecommendedforbuccalinfiltrations.Insodoing,theinitialneedlepenetrationisshallow.Asmallamountofsolutionhastobeinjectedintothesuperficialmucosa.Afterafewseconds,theneedlecanbeslowlyadvanced12mmandafteranegativeaspiration,anothersmallamountofsolutioncanbedeposited.Thisshouldberepeateduntiltheremaininganestheticsolutioniscompletelyinjected.[21]

Anesthesiaofthemandibularprimarymolarsmayusuallybeachievedbyinfiltrationinchildrenuptotheageoffiveyears.Afewstudieshaveevaluatedtheeffectivenessofmandibularinfiltrationasapossiblealternativetomandibularblockfortherestorationofprimarymolars.Nosignificantdifferencesbetweeninfiltrationandblockwerefound.Inaddition,thequalityofanesthesiawasnotsignificantlyrelatedtotoothlocation,age,ortypeofanestheticagent.[22]

Mandibularblockisthelocalanesthesiatechniqueofchoicewhentreatingmandibularprimaryorpermanentmolars.Depthofanesthesiahasbeentheprimaryadvantageofthistechnique.Anesthesiaofallthemolars,premolars,andcaninesonthesamesideofinjectionallowsfortreatingmultipleteethofthesamequadrantatoneappointment.Fortheinferioralveolarblock,thechildisrequestedtoopenhismouthaswideaspossiblewhiletheoperatorpositionstheballofthethumbonthecoronoidnotchoftheanteriorborderoftheramus.Theneedleisinsertedbetweentheinternalobliqueridgeandthepterygomandibularraphe.[23]Thepositionoftheforamenchangeswiththechild'sage:Inayoungchild(4yearsoldandyounger)theforamenissometimeslocatedbelowtheplaneofocclusion.Inayoungchild,theforamenislocatedontheocclusalplane.Asthechildmatures,itmovestoahigherposition.[5,24]

Thebarrelofthesyringeoverliesthetwoprimarymandibularmolarsontheoppositesideofthearchandparalleltotheocclusalplane.Inthiscase,asmallamountofsolutionshouldbeinjectedand,afteranegativeaspirate,theneedleshouldadvanceuntilbonycontactismade,verygentlyandslowly.Whentheinferioralveolarnerveblockmaynotadequatelyanesthetizetheteeth,longbuccalanesthesiaisrequired.Thisisachievedbyinfiltratingafewdropsoftheanestheticintothebuccalsulcusjustposteriortothemolars.[5,22]

Theintraligamentaryinjectionisgivenintotheperiodontalligamentusingasyringespeciallydesignedforthepurpose.Intraligamentaryinjectionsalsocanbegivenwithaconventionalneedleandsyringe.Inthistechnique,theneedleisinsertedatthemesiobuccalaspectoftherootandadvancedinformaximumpenetration.Theneedledoesnotpenetratedeeplyontotheperiodontalligamentbutiswedgedatthecrestofthealveolarridge.A12mm30gaugeneedleisrecommended,andthebevelshouldfacethebone,althougheffectivenessisnotimpairedwithdifferentorientation.Intraligamentaryanesthesiahaslimitationsasaprincipalmethodofanesthesia,duetothevariableduration,buthasbeenusedtoovercomefailedconventionalmethodsorasanadjunct.[24]Intraligmentaryinjectionsproducesignificantbacteremiaandthereforeshouldnotbegiventoapatientattheriskofinfectiveendocarditisunlessappropriateantibioticprophylaxishasbeenprovided.[25]

Theintrapulpalmethodachievesanesthesiaasaresultofpressure.Salinehasbeenreportedtobeaseffectiveasananestheticsolutionwheninjectedintrapulpally.Whenasmallaccesscavityisavailableintothepulp,aneedlewhichfitssnuglyintothepulpisusedandasmallamount(about0.1mL)ofsolutionisinjectedunderpressure.Therewillbeaninitialfeelingofdiscomfortduringthisinjectionhowever,thisistransientandanestheticonsetisrapid.Whentheexposureistoolargetoallowasnugneedletofit,theexposedpulpshouldbebathedinalittle

Computerizedlocalanesthesia

Electronicdentalanesthesia

Intraorallidocainepatch

Jetinjection

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localanestheticforaboutaminutebeforeintroducingtheneedleasfarapicallyaspossibleintothepulpchamberandinjectingunderpressure.[26]

Intraligamentaryanesthesiahasaroletoplayinlocalanesthesiainmoderndentistrybutitdoesnotfulfilalltherequirementsforaprimarytechnique.Aswithtraditionalmethodsofobtainingorallocalanesthesia,thealternativemethodsgenerallyaresafeifthepractitionerunderstandstheprinciplesfortheiruse.Alternativetechniquesforthedeliveryoflocalanesthesiamaybeconsideredtominimizethedoseofanestheticused,improvepatientcomfort,and/orimprovesuccessfuldentalanesthesia.Someofthesetechniquesaredesirable,especiallyininfants,children,adolescents,andpatientswithspecialhealthcareneeds,sincespecificteethmaybeanesthetizedwithlessresidualanesthesia(i.e.,avoiddiscomfortandpotentialselfmutilationofblockanaesthesia).Themandibularboneofachildusuallyislessdensethanthatofanadult,permittingmorerapidandcompletediffusionoftheanesthetic.Mandibularbuccalinfiltrationanesthesiaisaseffectiveasinferiornerveblockanesthesiaforsomeoperativeprocedures.Inpatientswithbleedingdisorders,thePDLinjectionminimizesthepotentialforpostoperativebleedingofsofttissuevessels.Intraosseoustechniquesmaybecontraindicatedwithprimaryteethduetothepotentialfordamagetodevelopingpermanentteeth.Also,theuseoftheperiodontalligamentinjectionorintraosseousmethodsiscontraindicatedinthepresenceofinflammationorinfectionintheinjectionsite.[5,10,16,21,27]

Newtechniquesforobtaininglocalanesthesia

TheWandsystemconsistsofadisposablehandpiececomponentandacomputercontrolunit.Thehandpieceisanultralightpenlikehandlewhichislinkedtoaconventionalanestheticcartridgewithplasticmicrotubing.

Thecoretechnologyisanautomaticdeliveryoflocalanestheticsolutionatafixedpressurevolumeratioisregardlessofvariationsintissueresistance.Thisresultsinacontrolled,highlyeffective,andcomfortableinjectioneveninresilienttissuessuchasthepalateandperiodontalligament.WhiletheWandhasbeenshowntoreducethepainassociatedwiththedeliveryoftheanestheticsolution,thetimeinvolvedintheprocedureappearstonegatetheeffectivenessofthedeviceareviewofcomputercontrolleddeliverydevicesaswellasotheralternativeanesthesiadeliverymethodsfoundthattheyeachpresentadversesideeffectsandgenerallyaremoreexpensivethanconventionalmethods.[28,29]

Theconceptofelectronicdentalanesthesia(EDA)involvestheapplicationofelectriccurrentthatloadsthenervestimulationpathwaytotheextentthatpainstimulusisblocked.AreviewoftheliteratureshowsasignificantreductioninpainobservedduringallthedentalproceduresconductedunderTENS(TENS:Transcutaneouselectricalnervestimulator).Thus,TENSshouldbeconsideredasausefuladjunctinthetreatmentofpediatricpatientsduringvariousminordentalprocedures.[29,30]

TherearemedicalcontraindicationstotheuseofEDA:Patientswithapacemakerorcochlearimplant,heartdisease,seizuredisorders,orcerebrovasculardisease,headtumor,neurologicaldisordersinvolvingtheheadandneck(e.g.,Bell'spalsy,trigeminalandpostherpeticneuralgia,multiplesclerosis,orTourette'ssyndrome),skinlesionsorabrasionsontheface,andpatientswithabnormalbruisingorbleedingdisorder.[31]

Theseareanestheticpatchescontainingalidocainebasethatisdispendedthroughabioadhesivematrixandapplieddirectlytotheoralmucosa.Thesepatchesareavailablein10and20%concentrations,eachcontainingapproximately23and416mgoflidocaineandcanreducethepainofinsertionofneedle.[29,32]

Thisinstrumentwasdevelopedtoachievelocalanesthesiafordentalprocedureswithouttheuseofaneedle.Thisisaccomplishedbydeliveringtheanestheticsolutionunderhighcompressiveforces.Anumberofuncontrolledstudiesofneedlelessdeviceshaveexaminedadultandchildpatients,typicallyfocusingontheanestheticpropertiesofthedeviceused.Inthesestudies,thepercentageofpatientswhoobtainedsufficientanesthesiawiththedevicesrangedfromabout50toabout90%.[33]Traditionalinfiltrationwasmoreeffective,acceptable,andpreferred,comparedwiththeneedlelessinjection.[34]

CONCLUSION

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Localanesthesiaformsthebackboneofpaincontroltechniquesindentistryandhasamajorroleindentistryforchildren.Thereisaconstantsearchforwaystoavoidtheinvasiveandoftenpainfulnatureoftheinjection,andtofindamorecomfortableandpleasantmeansofachievinglocalanesthesiabeforedentalprocedures.Despitetherecentinnovations,theinjectionremainsthemethodofchoiceinprovidinglocalanesthesia.

FootnotesSourceofSupport:Nil

ConflictofInterest:Nonedeclared.

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