Local anesthesia and pain management in pediatric dentistry

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LOCAL ANESTHESIA AND
PAIN MANAGEMENT IN
PEDIATRIC DENTISTRY
Matt Fisher, DMD, MS
Albuquerque HIS Dental Clinic
June 5, 2013
Local Anesthesia
 The temporary loss of sensation, including
pain, produced by a topically-applied or
injected agent without depressing the level
of consciousness
Local Anesthesia in Children
 Prevention of pain during the dental
appointment should reduce fear and
anxiety, and promote a positive dental
attitude
 Attempting to get by without using local
anesthesia, when it is needed, is a common
mistake by the apprehensive dentist trying
to avoid confrontation with an equally
apprehensive child
Local Anesthetics
 Two general types:
 Esters
 Procaine (Novocaine®)
 Benzocaine
 Tetracaine
 Amides
 Lidocaine (Xylocaine®)
 Mepivacaine (Carbocaine®)
 Prilocaine (Citanest®)
 Articaine (Septocaine®)
 Bupivacaine (Marcaine®)
Local Anesthetics
 Local anesthetics are vasodilators and are
absorbed into the circulation
 Vasoconstrictors are added to constrict
blood vessels in the area of injection
 Decreases rate of absorption
 Decreases risk of toxicity
 Prolongs the anesthetic action in the area
Topical Anesthesia
 Used to minimize the discomfort of the
dental injection
 Should be used routinely with children
 Gels are preferred in children (liquids and
sprays are hard to control)
 Benzocaine is available in concentrations
up to 20 %, has a rapid onset, and toxic
reactions are virtually unknown
 Are absorbed systemically
Applying Topical Anesthetic
 Dry area where the topical will be applied
with a gauze
 Apply small amount of topical with a cotton
swab only to the area that the needle will be
penetrating
 Cover the cotton swab with the gauze and
leave in place for 30-60 seconds
 Use age-appropriate language to explain the
procedure, including sensation and taste
Injectable Local Anesthetics
 Vary from almost all other drugs in one very
significant way: with most other drugs
clinical effectiveness does not develop until
an adequate blood level of the drug is
reached. Local anesthetics, on the other
hand, have their effects terminated by
absorption into the circulatory system.
However, it is the blood level of the local
anesthetic which is the determining factor
of whether an overdose reaction will occur
Injectable Local Anesthetics
 Drug is injected at or near the nerve trunk
to produce a blockade of nerve impulses
into the CNS. It produces a loss of
sensation and sometimes a loss of motor
activity
Injectable Local Anesthetics
 Local anesthetic injected into an area of
infection will have a delayed onset and its
action may be prevented
 Infected areas have a pH of 4-6 (normal is
7.4) which inhibits the anesthetic from
crossing the nerve sheath
 Inserting a needle into an active site of
infection could lead to possible spread of
the infection
Injectable Local Anesthetics
 True allergy to local anesthetics is
extremely rare, but can occur
 A bisulfate preservative is used in
anesthetics containing epinephrine. If the
patient is allergic to bisulfates, anesthetics
without vasoconstrictor should be used
 Allergy to one amide does not rule out the
use of another amide
 Allergy to one ester does rule out the use of
another ester
Technique for Local Anesthetic Delivery
 Prepare the syringe away from patient’s
view
 Use age-appropriate, nonthreatening
language to describe what you are doing
(dripping warm sleepy juice next to your
tooth to help it fall asleep)
 Children are quick to pick up on your
anxiety and apprehension. Be relaxed and
calm
Technique for Local Anesthetic Delivery
 Use 30 gauge short needles when possible




(less force needed to penetrate and less
pain)
Use 27 gauge long needle for mandibular
blocks
Use intraseptal injections for palatal soft
tissue anesthesia
Don’t exceed maximum doses
The numb feeling can be very frightening to
children. Reassure them that this is exactly
what they are supposed to feel and that the
weird feeling will go away
Complications with Local Anesthetics
 Toxicity
 CNS
 CVS
 Allergy
 Paresthesia
 Post-operative soft tissue injury (cheek and
lip biting)
Effects of Toxicity on the CNS
 Biphasic reaction (excitation followed by
depression)
 Early: dizziness, anxiety, confusion
 Later: diplopia, tinnitis, drowsiness
 Objective signs: muscle twitching, tremors,
slowed speech, shivering, seizure activity,
unconsciousness, respiratory arrest
Effects of Toxicity on the CVS
 Biphasic reaction
 Initially stimulation (increased heart rate and
blood pressure)
 Followed by depression (decreased heart rate
and blood pressure, cardiac arrest)
 CVS response more resistant than CNS
Allergy to Local Anesthetic
 Reaction can vary greatly
 Urticaria
 Dermatitis
 Angioedema
 Fever
 Photosensitivity
 Anaphylaxis
Paresthesia
 Persistent anesthesia beyond the expected
duration
 Risk increases with local anesthetic
percentage
 Higher incidence with Articaine, Prilocaine
 Causes:
 Trauma to the nerve
 Hemorrhage in the area around the nerve
Post-operative Soft Tissue Injury
 Majority of cheek and lip biting lesions are
self-limiting and heal without
complications
 Secondary infections may develop
 Caregivers should be informed when local
anesthetics are used
 Location and duration of anesthesia
 Necessary precautions to take while numb
 OraVerse (phentolamine mesylate) not
recommended for children < 6 years old
Preventing Complications
 Know child’s weight
 Know maximum doses for every anesthetic
you intend to use
 Know how to calculate the number of
carpules you can safely use
 Have printed dosage guides available in the
clinic
 Obtain accurate medical history and verify
allergy information
Pain Management in
Pediatric Dentistry
 Pain is difficult to measure due to its
subjectivity, especially in children
 Majority of children respond well to
non-opioid analgesics (NSAIDS and
acetaminophen)
Pain Management in
Pediatric Dentistry
 Most cases of post-operative pain include
an inflammatory component so NSIADs
should be the first-line agents
 Acetaminophen lacks anti-inflammatory
properties but is a good alternative when
NSAIDs are contraindicated.
 Overdose of acetaminophen is common in
children
Children’s Motrin
 5-10 mg/kg every 8 hours
 Oral drops 40 mg/ml
 Oral suspension 100mg/5ml
 Chewables 50 and 100 mg
Children’s Tylenol (Acetaminophen)
 15 mg/kg every 4-6 hours
 Infant drops 80 mg/0.8ml
 80 mg chewables
 Available in multiple forms and dosages
(solution, elixer, suspension, syrup,
suppository)

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