Local Anesthesia in Pediatric Dentistry

Local Anesthesia

The loss of sensation in a circumscribed area of the body due to depression of excitement in nerve endings or an inhibition of conduction process. (MALAMED,1980) LOCAL ANESTHETICS are the drugs that produce anesthesia in the region where it is applied or introduced.

Classification of local anesthetic agents

1.

Esters
ESTERS OF PARA-

ESTERS OF BENZOIC

ACID Butacaine Cocaine Ethyl aminobenzoate (benzocaine) Hexylcaine Piperocaine Tetracaine

AMINOBENZOIC ACID Chloroprocaine Procaine propoxycaine

2. Amides

3. Quinolones

Articaine Bupivacaine Dibucaine

centbucridine

Composition of local anesthetic solution

Local anesthetic agent: lignocaine hydrochloride 2% Vasoconstrictor : adrenaline 1:50,000 to 1:2,00,000 uses- delays the absorption of LA from the site a. provides blood less field b. prolongs the action c. reduces systemic toxicity Reducing agent: sodium metabisulphite - prevents oxidation of the solution Preservative: methyl paraben capryl hydrocuprino toxin, acts as antioxidant for vasoconstrictor Vehicle: ringers solution

Anesthetic agents suitable for the children

Lidocaine hydrochloride: 2% with

epinephrine 1:100,000

Mepivacaine hydrochloride: 2% with

Levonordefrin 1:20,000. it has more rapid onset and prolonged effect than Lidocaine Hcl.

Prilocaine hydrochloride: 4% with

epinephrine 1:200,000. it is a shorter acting agent. It should be used in sparing amounts as the metabolic product may promote the chance of developing methemoglobinemia.

Ideal requirements of the anesthetic agent

Must provide adequate anesthesia. Action must be reversible. Non-irritating to tissues. Low degree of systemic toxicity. Rapid onset and sufficient duration of action. Should not produce allergic reaction. Readily biotransformed. Able to be sterilized or be sterile.

Mode of action of local anesthesia

Local anesthesia is an alkaloid base that forms salts with acids. In solution the salt of the local anesthesia compound exists as both uncharged(free base) and positively charged molecule. The potential action depends on the ability of the anesthetic salt to liberate free base. Local anesthetics interfere with the conduction of action potentials along peripheral nerve fibers by impairing the functions of sodium ion channels. Recovery from nerve blockade is dependent on redistribution and metabolism of the anesthetic agent.

Mechanism of action of local anesthesia

Absorption, Metabolism & Excretion of anesthetic agent

Absorption Increased vascular area and without adrenaline: faster absorption Infection and low pH: slower absorption Metabolism 1. Ester group inactivated by hydrolysis in plasma by plasma cholinesterase. 2. Amide group Inactivated in the liver by the microsomal enzymes. Prilocarpine is most readily metabolised.

The renal clearance of amide agents of the agents inversely related to their protien binding capacity.

Excretion

The anesthetic agents are excreted from the kidney.

Duration of action
Duration of action is directly proportional to protien binding characteristics. Agents which are highly protien bound have the longest duration of action and vice versa. Onset and duration of action of 2% lignocaine 1:100,000 epinephrine Onset of action Infiltration: 2 minutes Block: 2 to 4 minutes Duration of action Infiltration: pulpal- 1 hour & soft tissue- 2 hrs Block: pulpal- 1 hrs & soft tissue- 3 to 5 hrs

Points to be kept in mind while administration of anesthesia in children

In children the bone in the maxilla and mandible are less dense and incompletely calcified. So diffusion of the LA agent through the layers of the bone is faster . The anatomic structures of the child are naturally smaller than those of adult, so the depth of penetration of the needle should be less. Penetrating too deeply at the area of tuberosity can produce hematoma of the pterygoid plexus or posterior superior alveolar artery is injured.

The depth of needle penetration must be reduced because the ramus of the mandible is shorter vertically and narrower anteroposteriorly. For the child the procedure is very much an emotional issue.

Types of injection procedures

1.

Nerve block : the anesthetic agent is deposited near the main nerve trunk. Local infiltration: profusion of the drug at the terminal ends of the branches. Field block: refers to the placement of the solution around the principal terminal branches.

2.

3.

PARTS OF SYRINGE

Contraindications
Mentally retarded Chronic debilitating disease septicemia, diabetes, bacteremia Bleeding disorder Steroid therapy- adrenal crisis Anticoagulant therapy Liver or renal therapy Epilepsy Radiation therapy hyperthyroidism

Anesthesia for the Maxillary tissues

A. B.

Anesthesia for the Mandibular tissues

A. B. C.

C.
D. E. F. G.

Infiltration Posterior superior alveolar nerve block Middle superior alveolar nerve block Maxillary anterior region block Palatal infiltration Nasopalatine nerve block Greater palatine nerve block

Infiltration Inferior alveolar block Mental nerve block

Maxillary and Mandibular infiltration

The needle penetration for infiltration site on the labial aspect is determined by two anatomical landmarks; the mucobuccal fold and mucogingival junction . The needle penetration site is 2 to 3mm apical to the mucogingival junction and the depth nit more than 2 to 3mm deep. About 0.5ml of the solution is deposited at the site. in the mandible ,the solution is deposited in the buccal and lingual vestibule.

Maxillary anesthesia
Posterior superior alveolar nerve block

Innervates the posterior maxillary deciduous molars. Needle is inserted immediately behind the buttress of zygoma at the height of the vestibule. Tip of the needle must be in close proximity to the periosteum. Foramen is approximately 8mm from the insertion point in a 3 year old and 11mm in a14 year old.

Needle position for posterior superior alveolar nerve block

Middle superior alveolar nerve block

Innervates the premolars and the mesiobuccal root of the 1st molar. The method of anesthetization is similar to posterior superior alveolar nerve.

Maxillary anterior superior alveolar nerve block

depositing the solution in the apical region provides satisfactory anesthesia of the labial side of the maxillary anterior region in most cases.

Infraorbital nerve block

It is given in case of swelling and when infiltration has failed. The infraorbital foramina in a 3 years old is about 5mm above the vestibular depth.

Nasopalatine nerve block

Nasopalatine nerve innervates the maxillary anterior teeth. It is indicated when vestibular infiltration is inadequate. About 0.2 to 0.4ml of LA is administrated at the entrance of the incisive foramen on the incisive papilla.

Greater palatine nerve block

Greater palatine nerve innervates the maxillary posterior teeth in the palatal aspect. It is anesthetized at the region idway between the midline of the hard palate and the palatal surface of the posterior teeth.

Mandibular anesthesia
Inferior alveolar nerve block

Most common block used for anesthetizing the molars and premolars. In children the mandibular foramen is located near the posterior border of the ramus.. In a 3 year old child the foramen is about 5mm from the posterior border and 20mm from the anterior border. The foramen invariably aligns with the deepest concavity on the anterior border of the mandible.

Technique

The anterior border of the ramus is palpated, with the finger or thumb resting in its greater curvature. As the medial pterygoid ligament passes inferiorly and laterally to attach at the base of the mandible, a triangle is formed by the anterior border of the ramus,the medial pterygoid and latera pterygoid muscle. The apex of triangle is placed inferiorly. An imaginary longitudinal line dividing the tip of the thumb as it rests in the coronoid notch passes medialy over a depressed area just above the apex. The penetration site of the needle is the point of intersection.

The needle is introduced into the oral cavity parallel with the occlusal plane of the mandibular posterior teeth. The needle depth is 8 to 10 mm from the mucosal surface. The amount deposited is 0.9 to 0.10 ml Lingual nerve is anterior and medial to the inferior alveolar nerve , so the needle has to be withdrawn and solution deposited half the distance from the inferior alveolar foramen. The amount deposited is 0.5 ml The buccal nerve can be anesthetised by infiltration in the buccal sulcus distal to the permanent teeth . The amount deposited is about 0.2ml

boundaries of pterygomandibular space : Anterior: pterygomandibular raphe & superior constrictor of pharynx Posterior: parotid gland Floor & medial: medial pterygoid muscle Lateral: ramus of the mandible Roof: lateral pterygoid muscle

Needle position in children

The lesser the height of the ramus in children can be compensated by inserting the needle a few millimeters nearer to the occlusal plane.
Position of the mandibular foramen
below occlusal plane

age Age < 6 years

Age 6-12 years

Age>12 years

at occlusal plane
above occlusal plane

Mental nerve block

It is effective in producing anesthesia for the premolars and anterior teeth. The amount deposited is 0.5 to 1.0 ml

Commonly made mistakes

waving the needle in front of the patient. The needle should be kept out of the direct vision of the child. Not getting supportive control of the patients head and hands. It is difficult and dangerous to administer anesthesia. Using long needles. Depth of penetration of a needle is very less compared to that in adults. Using inappropriate doses. Fast injection- care must be taken for slow administration of the solution. Not advising patients or parents regarding the post anesthesia side effects.

Factors responsible for successful administration of a Local Anesthetic agent in a pediatric patient
Able patient management. Concealment of the syringe. Appropriate use of a topical anesthetic agent. Effective exchange of the syringe between assistant and the operator. Appropriate anesthetic agent. Competency of the injection process.

complications

Due to solution: Toxicity, Idiosyncrasy, Allergy, Anaphylactic reaction, Infection, Local irritation Due to the needle:Trismus, Syncope, Edema, Broken needle,Infection, Hematoma, Sloughing and Bizarre neurological symptoms.

self inflicted injury: Numb feeling that is post operative complications such as lips, tongue or cheek biting leading to severe soreness and ulcerations.

ulcers on the lips due to biting following Inferior alveolar nerve block.

Wound on the cheek that occcurred due to continuous rubbing or scratching of the anesthetized area following Inferior alvolar nerve block.

Local complications
a) Needle breakage Most common cause is sudden unexpected movement. To prevent breakage: 1. Needles should not be inserted more than 2/3 their length, unless absolutely necessary. 2. Use large diameter needles. 3. do not bend needles as it weakens them. 4. Never force needle against resistance. Management Remain calm and instruct the patient not to move. Keep the patients mouth wide open and place a bite block. If the fragment is protuding ,remove it with cotton pliers. If it is within the deeper tissues refer to an oral surgeon.

b) Pain on injection May be due to careless injection technique Blunt needle Rapid deposition of the solution Prevention Adherence to proper technique Use of sharp needles Topical anesthetic Slow injection of the solution

c) Burning on injection It is due to difference between the pH of the solution being deposited and the tissues Contamination of the anesthetic with sterlizing solution Rapid injection Prevention Inject slowly (1ml/min) Store anesthetics at room temperature in the original container

d) Paresthesia Causes: Trauma to the nerve Injection of contaminated solutions Trauma t the nerve sheath by needle Hemorrhage due to ruptured vessel Most of the cases resolve within 8 weeks with no treatment but if it persists longer then refer to an oral surgeon.

e) Hematoma Causes: Inadvertently nicking a blood vessel , an artery or a vein during an injection. Management Direct pressure to be applied to the site. Cold packs applied to the area which acts as a vasoconstrictor It resolves in 7 to 14 days .

f) Trismus Causes: Trauma to muscles or blood vessels in infratemporal space following dental injections Contaminated cartridges Hemorrhage Needle insertion Excessive amount of anesthetic Management Moist heat application Analgesic and muscle relaxant Mouth opening and closing exercises for 5mins every 3 to 4 hours.

Systemic complications
a) Allergic reactions causes: The anesthetic drug itself basically esters. The antioxidant The preservative Maifestations Urticaria and angioedema Bronchospasm Generalised anaphylaxis Management Immediate skin reactions: 0.3ml 1:1000 epinephrine IM, antihistaminics Delayed skin reactions: IM antihistaminics Respiratory reactions: stop dental treatment, position patient in reclining position, administer oxygen via full face mask, IM epinephrine and antihistaminics

b) Vasovagal reactions due to stimulation of the parasympathetic nerve supply of the heart and vasodilator nerves of the skeletal muscles, there is reduced heart rate and arterial pressure, causing reduced blood flow to the brain. Syncope Nausea Sweating Pallor Deep breaths Apprehension Management: Patient placed in a semi reclined position, reassure, administer oxygen if needed and monitor vital signs

c) Overdose reactions Causes: The total dose administered is too large Rapid absorption from the site of injection Inadvertent administration of the anesthetic intravascularly it can be prevented by : 1. Use of an aspirating syringe 2. Use of needles not smaller than 25 gauge 3. Aspiration in at least two sites before injecting 4. Injecting slowly

Clinical manifestations of epinephrine or other vasopressor overdose Fear, anxiety Restlessness Headache Tremor Weakness, dizziness Pallor Respiratory difficulty Elevated heart rate Sharp elevation in blood pressure

Management

Terminate the dental procedure Maintain the airway and provide oxygen Recline the patient Monitor the vital signs Allow sufficient recovery time if the condition of the patient is severe, summon medical assistance.

Supplemental method to obtain Local anesthesia

Computer controlled local anesthetic delivery systems(CCLD) Provides controlled deposition of the solution. It enables the dentist in accurate placement of the needle while delivering the predetermined amount of solution through a foot activated control. Pain perceived by the patient is also reduced. The Wand/ CompuDent system, Comfort Control Syringe, Quick Sleeper and Anaeject are some of the CCLD systems available in the market.

The Wand is essentially a computer-controlled dental injection. The flow rate of the local anaesthetic is controlled by a computer. This means that the injection is guaranteed to be slow and steady and therefore comfortable. The handpiece device looks just like a ball point pen, it is so light and easy to handle. To start the computer, the dentist uses a footpedal connected to the computer tower. The computer does the rest. The cartridge holder, tube and wand handpiece are all single-use disposables.

The latest version of the Wand, called the STA system, has more colourful buttons to make it look even better The STA has two modes: 1. the first mode is the traditional wand technique. It now has three speeds so that the delivery can be made faster after the initial slow bit 2. The second mode is the Single Tooth Anaesthesia (STA) mode which uses a different needle, and has a visual gauge and emits little beeps to let the dentist know when theyve placed the needle correctly

Lidocaine patch (5%)

LIDODERM (lidocaine patch 5%) is comprised of an adhesive material containing 5% lidocaine, which is applied to a non-woven polyester felt backing and covered with a polyethylene terephthalate (PET) film release liner. The release liner is removed prior to application to the skin. The size of the patch is 10 cm 14 cm. Lidocaine is chemically designated as acetamide, 2(diethylamino)-N-(2,6-dimethylphenyl), has an octanol: water partition ratio of 43 at pH 7.4

Each adhesive patch contains 700 mg of lidocaine (50 mg per gram adhesive) in an aqueous base. It also contains the following inactive ingredients:dihydroxyaluminum aminoacetate disodium edetate gelatin, glycerin, kaolin methylparaben polyacrylic acid polyvinyl alcohol, propylene glycol Propylparaben sodium carboxymethylcellulose, sodium polyacrylate D-sorbitol, tartaric acid, and urea

references
Arathi rao, Principles and practice of Pedodontics, 2nd edition, page no. 377 to 397 Shobha tandon, 1st edition , page no. 461 to 470 Stanley F. Malamed , Handbook of Local Anesthesia, 4th edition, page no. 24 to 36 www.google.com www.wikipedia.com