Local anesthesia for dental child

patient

Dr : Abdullah Sharaf
 Introduction
◻ Prevention and controlling of pain during dental treatment
is one of the most important parameters in the dentist’s
attempt to provide for his/her patients a complete and
quality-based dental treatment. Especially when the
patients are children, successfully achieving a high level of
cooperation, building trust, preventing the rise of dental
phobia, and establishing a positive attitude toward the
dental act are definitively connected with the minimization
of discomfort and even complete absence of pain while at
the dentist
◻ It is important at each visit to reduce discomfort to a minimum
and to control painful situations.
◻ Because there is usually some discomfort associated with the
procedure, use of a local anesthetic is generally indicated
when:
operative work is to be performed on the permanent teeth,
and in primary teeth.
The local anesthetic can prevent discomfort that may be
associated with placing a rubber dam clamp and cutting
tooth structure.
Even the youngest child treated in the dental office normally
presents no contraindications for the use of a local anesthetic.
 Local anesthesia

Transient loss of sensation in a circumscribed area of the

body caused by a depression of excitation in nerve
endings or an inhibition of the conduction process in
peripheral nerves.
 Equipment and Factors Relating to Local
Anesthesia
◻ Some of the equipment and factors that are
directly related to local anesthesia in pediatric
dentistry are as follows: the types of topical
anesthetics, the injector, the needles, the types of
local anesthetics, the vasopressors, the dosage
based on the choice of anesthetic, the injection rate
of the anesthetic, and the temperature of the
anesthetic solution
 METHODS OF LOCAL ANESTHESIA

There are several methods of achieving pain control with

local anesthetic agents. The various types of techniques used
for deposition of these agents, in dentistry are as follows:
1. Topical anesthesia
2. Infiltration anesthesia
3. Field block anesthesia
4. Nerve block anesthesia
 Topical Anesthesia

❑ Topical anesthetic is used to minimize the

discomfort caused during administration
of local anesthesia.
❑ Available in different forms:
Gel (e.g. benzocaine 20%), creams (e.g.
lidocaine 5%), or sprays (e.g. lidocaine
15%).
◻ Sprays are the least convenient as they are difficult
to direct.
◻ Some sprays taste unpleasant and can lead to
excess salivation if they inadvertently reach the
tongue.
◻ In addition, unless a metered dose is delivered, the
quantity of anaesthetic used is poorly controlled.
◻ In pediatric dentistry, gel is the simplest to use, since
its application on the desired part of the mucous
membrane can be controlled the easiest
Technique for topical anesthesia

◻ The mucosa at the site of the intended needle insertion is dried

with gauze.
◻ A small amount of the topical anesthetic agent is applied to
the tissue with a cotton swab.
◻ Topical anesthesia should be produced in 30 seconds.
◻ The dentist should prepare the child for the injection ( tell the
patient : the tooth is going to sleep so that the treatment can
proceed without discomfort).
◻ By topical anesthesia method small terminal nerves in the
surface area of the intact mucosa or the skin up to the depth of
about 2 mm are anesthetised by application a local anesthetic
agent directly to the area.
◻ In the UK the agents most commonly employed are lidocaine
and benzocaine.
Indications
i. Prior to the infiltration injection techniques or nerve
blocks for making the insertion of the needle painless

ii. Prior to carrying out incision and drainage of abscesses

iii. Prior to removal of sutures

 Injectors and Needles
◻ The carpule syringe is the most commonly used syringe
in adult and pediatric dentistry.
◻ It is made of metal or plastic; mostly stainless steel can
be sterilized and features the ability to perform suction.
◻ Plastic devices seem to be preferred by children. When
using it in child patients, there are various innovative
ways in which syringes can be presented
Example of carpule syringe with suction ring
and plastic cover in the shape of a crocodile
◻ There are also other types of syringes which
combine with their needle counterparts, like the
intraligamental syringe, the injectors used for
controlled electronic administering on anesthesia
including intraosseous anesthesia, and even
needleless jet injectors
◻ In relation to needles, there are various types.
◻ They are available in size 32 – 40, 22 – 25, and 10
–13 mm (extra long, short, and extra short, respectively,
depending on the manufacturer)
◻ and 25, 27, and 30 G (Gauge, which corresponds to
0.025, 0.020, and 0.015 mm in lumen diameter).
◻ In pediatric dentistry, 30 and 27 G needles are the
most commonly used
◻ However, it is recommended that the needle used
for nerve block is not of the smallest diameter
(30 G), as using this type increases the danger of
the needle breaking.
◻ In relation to length, extra short 9–13 mm needles
are suggested for use in local infiltration anesthesia.
◻ while 22–25 mm needles are suggested when
performing inferior alveolar nerve block in child
patients
From top to bottom: 37 mm needle (extra long) with 25 G lumen. 22 mm
(short) and 27 G needle, recommended for inferior alveolar nerve block
in child patients. 22 mm (short) and 30 G lumen needle. 10 mm (extra
short) and 30 G needle, recommended for local infiltration anesthesia in
child patients. The arrows on the plastic piece of each needle indicate the
bevel side of the tip
 Types of Local Anesthetics – Dosage
◻ According to the European Academy of Paediatric
Dentistry guidelines, there is still a lack of information for
the use of local anesthetics in children aged under 4 years.
◻ Three local anesthetics are considered most appropriate in
child patients. All three are amide type, are safe, and are
effective and rarely cause allergic reactions.
◻ These are lidocaine, mepivacaine, and articaine
 Vasoconstrictors
◻ Epinephrine (adrenaline) is the main vasoconstrictor used
today in dental local anesthesia.
◻ The addition of a vasoconstrictor in anesthetic solutions
slows the rate of absorption by the tissues and thus
reduces the chance of occurrence of a toxic reaction
while at the same time increases the depth and duration
of anesthesia. The safe level of epinephrine in a solution
is considered to be 1:200,000, 1:100,000, or 1:400,000
 Rate or Speed of Injected Solution
◻ It is recommended that injection of the anesthetic is
done at a slow pace. This way, the chances of
anesthetic toxicity are reduced and allow time for
any unwanted systemic action to occur before the
entire solution is injected. At the same time, lower
pressure allows the anesthetic to remain close to the
injection point.
◻ The ideal speed of injection is 1 ml/min,
◻ Rapid injection of anesthetic causes some degree of
pain. Use of computer-controlled injectors may be a
way to help control the speed of injection and
therefore lower the intratissular pressure related to
injection
 Temperature of Injected Solution
◻ The temperature of the anesthetic does not seem to
correlate with pain experienced when it is above
15 °C.
◻ It is suggested that anesthetic solutions be
preserved at ambient temperature, somewhere
consequently not too hot or cold.
 Local Anesthesia Using Alternative Kinds
of Injectors
◻ These are appliances that differ from traditional
syringe anesthesia.
◻ The most common of these are: computer-controlled
administering of anesthesia (C-CLAD), computer-
controlled administering of anesthesia and needle
rotation, and needleless jet injector anesthesia
Various injectors for dental anesthesia. From left
to right: one with computer-controlled injection of
anesthetics and needle rotation (Quick Sleeper
5™), three injectors with computer controlled
injection of anesthetics (Sleeper One 5™, The
Wand – STA™, Dentapen™), and two manual
injectors: one with balanced weight distribution
(Citoject™) and a usual metal syringe. Note that
The Wand-STA™ is linked to its system with a
hose and Quick Sleeper™ and Sleeper One™
with a wire
 Types of Injection Procedures
1.Nerve block: depositing the local anesthesia solution within close
proximity to a main nerve trunk
2.Field block: depositing the local anesthesia solution in proximity
to the larger nerve branches
3.Local infiltration: small terminal nerve endings are anaesthetized

1 2 3
The selection of the type of anesthesia depends upon the
area and the type of surgery. In general, infiltration
anesthesia is adequate for a small isolated area, field
block is indicated when two or more teeth are being
treated, while a nerve block is indicated for dental or
surgical procedure in a quadrant of a jaw.
Anesthesia of Maxillary Teeth and Soft Tissue

1) Supraperiosteal Technique (Local Infiltration)

◻ Most frequently used for obtaining pulpal anesthesia in
maxillary teeth.
◻ Indicated whenever dental procedures are confined to
only one or two teeth.
Areas Anesthetized
1. Pulp and root area
of the tooth.
2. Buccal periosteum.
3. Connective tissue.
4. Mucous membrane.
2) Infraorbital nerve block

◻ It is given in case of swelling

and when infiltration has
failed.
◻ The infraorbital foramen in a
3 years old is about 5 mm
above the vestibular depth.
 3) Middle Superior Alveolar Nerve Block

✔ Innervates the premolars

and the mesiobuccal root
of the first permanent
molar.
 4)Posterior Superior Alveolar Nerve Block

▪ Innervates the posterior maxillary molars.

▪ They can be anesthetized as follows:
✔ Needle is inserted immediately behind the buttress of
the zygoma at the height of the vestibule.
✔ Tip of the needle must be in close proximity to the
periosteum.
✔ Foramen is approximately 8 mm from the insertion point
in a 3 year old and 11mm in a 14 year old.
 5) Palatal Anesthesia:
a) Nasopalatine Nerve Block:
◻ Nasopalatine nerve innervates the maxillary
anterior teeth.
◻ It is indicated when vestibular infiltration is
inadequate.
◻ About 0.2-0.3 ml of L.A is administered at
the entrance of the incisive foramen on the
incisive papilla.
◻ Blocking the nasopalatine nerve anesthetizes the
palatal tissues of the six anterior teeth.
◻ If the needle is carried into the canal, it is possible
to anesthetize the six anterior teeth completely.
However, this technique is painful and is not
routinely used before operative procedures.
◻ If the patient experiences incomplete anesthesia
after supraperiosteal injection above the apices of
the anterior teeth on the labial side, it may be
necessary to resort to the nasopalatine injection.
◻ The path of insertion of the needle is alongside the
incisive papilla, just posterior to the central incisors.
The needle is directed upward into the incisive
canal.
◻ The discomfort associated with the injection can be
reduced by deposition of the anesthetic solution in
advance of the needle.
b) Greater Palatine Nerve Block:
◻ Greater palatine nerve innervates
the maxillary posterior teeth in the
palatal aspect.
◻ Anesthetizes the mucoperiosteum of
the palate from the tuberosity to the
canine region and from the median
line to the gingival crest on the
injected side.
 Anesthesia of Mandibular Teeth and Soft Tissue:

1) Inferior alveolar nerve block

▪ Needle Used – 25 Gauge

▪ Nerves Anesthetized –

Inferior Alveolar Nerve (IAN)

Lingual Nerve
▪ Site Of Injection –

Region where the IAN enters the mandible through the Mandibular
Foramen
▪ Amount of solution deposited – 1 to 1.8 ml
◻ In general, when deep operative or surgical procedures
are undertaken for the mandibular primary or
permanent teeth, the inferior alveolar nerve must be
blocked.
◻ The supraperiosteal injection technique may sometimes
be useful in anesthetizing primary incisors, but it is not
as reliable for complete anesthesia of the mandibular
primary or permanent molars.
Technique
◻ Area of insertion – Mucous membrane on the medial side of the
mandibular ramus near the mandibular foramen.
◻ Target area – Inferior alveolar nerve as it passes downward
towards the mandibular foramen but before it enters the foramen
◻ The mandibular foramen is situated at a level lower than the
occlusal plane of the primary teeth of the pediatric patient.
◻ The injection must be made slightly lower and more posteriorly
than for an adult patient.

BELOW 6 YEARS 6 – 12 YEARS ABOVE 12 YEARS

 Area anesthetized
▪ Mandibular teeth of the injected side.
▪ Body of the mandible, inferior portion of the ramus.
▪ Buccal mucoperiosteum, mucous membrane anterior to the
mandibular 1st molar.
▪ Anterior 2/3rd of tongue and floor of the mouth.
▪ Lingual soft tissue and periosteum.
◻ Used for more than 1 tooth filling, extraction, pulp therapy
and if can’t apply mental block due to infection
 2) Mental Nerve Block

• Is effective in producing
anesthesia for the
premolars and anterior
teeth.
• The amount deposited is
0.5 to 1.0ml.
 3) Infiltration For Mandibular Incisors:

◻ The terminal ends of the inferior alveolar nerves cross over the
mandibular midline slightly and provide conjoined innervation of
the mandibular incisors.
◻ The labial bone overlying the mandibular incisors is usually thin
enough for supraperiosteal anesthesia techniques to be effective
 Supplemental Injection Technique:

Periodontal Ligament Injection

◻ The needle is placed in the gingival sulcus, and advanced along
the root surface until resistance is met. Then approximately 0.2 mL
of anesthetic is deposited into the periodontal ligament.
◻ Pressure is necessary ( by the injection) to express the anesthetic
solution.
◻ Since greater pressure is required to deposit the solution, there
are syringes specifically designed for this technique.
◻ They are of two types:
one of them is gun like
the other pen type.
Maximum amount of local anesthesia that can be given is:

◻ 4.4 mg/kg body weight: Lidocaine, Mepivacaine

◻ 6.0 mg/kg body weight: Prilocaine

◻ 7.0 mg/kg body weight: Articaine

 Maximum Recommended Doses:
✔ 4.4 mg/kg body weight with vasoconstrictor

❖ Dose Calculation:
2% lidocaine = 20 mg/ ml 1 carpule = 1.8ml
Amount of local anesthesia in 1 carpule = 20X 1.8 = 36mg/carpule.
Example:
20 Kg child can tolerate a maximum dose of 2% lidocaine with
vasoconstrictor of LA -----
4.4 X 20 = 88 mg = 2.4 carpules
 Complications of local anesthesia:

1) Systemic Complications
• Toxicity

• Syncope

• Allergic reaction

• Vasoconstrictors effects
 Manifestation Of Toxicity

• Cardiac Depression
Concentration of LA in Plasma

• Coma
• Convulsions
• Unconsciousness
• Muscular twitching
• Visual and auditory disturbances,
lightheadedness, numbness of tongue
Syncope

Signs and Symptoms:

▪ Child become pale and cold

▪ Pulse is rapid

▪ The pupils are dilated or constricted

▪ Drop of blood pressure

Allergic reaction:
▪ Uncommon.
▪ Manifestations: edema, eczema.
▪ Anaphylactic shock : more severe form of allergy
◻ Emergency.
Vasoconstrictors Effects

Patients with ischemic heart diseases and hypertension

are at high risk of toxicity if LA administrated
intravascularly.
 2) Localized complication

Needle breakage:
• Avoid bending needle;
minimize movement in
tissue; don't submerge
needle to the hub
Hematoma
Trauma of the nerve causing paresthesia.
Trismus
Soft tissue injury