See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/336020264

Local Anesthetics in Pediatric Dental Practice

Article  in  Research Journal of Pharmacy and Technology · August 2019

DOI: 10.5958/0974-360X.2019.00700.5

CITATIONS READS
0 382

3 authors, including:

Vignesh R
Saveetha University
30 PUBLICATIONS   14 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Forensics in Pediatric Dentistry View project

Undergraduates guidance View project

All content following this page was uploaded by Vignesh R on 25 September 2019.

The user has requested enhancement of the downloaded file.

 Research J. Pharm. and Tech. 12(8): August 2019

ISSN 0974-3618 (Print) www.rjptonline.org

0974-360X (Online)

REVIEW ARTICLE
Local Anesthetics in Pediatric Dental Practice
Dr. Trophimus Gnanabagyan Jayakaran1*, Dr. Vignesh R2, Dr. Shankar P3
1
Senior Lecturer, Department of Pediatric and Preventive Dentistry, SRM Dental College,
Ramapuram, Chennai – 600089, Tamilnadu, India
2
Senior Lecturer, Department of Pediatric and Preventive Dentistry, Saveetha Dental College and Hospital,
Chennai -600077, Tamilnadu, India
3
Reader, Department of Pediatric and Preventive Dentistry, SRM Dental College,
Ramapuram, Chennai – 600089, Tamilnadu, India
*Corresponding Author E-mail: trophy.2000@gmail.com

ABSTRACT:
The administration of Local anesthesia is the greatest fear a child would encounter in the dental office. Hence it
is important that dentists obtain pain control with minimum discomfort to the child. This Review article provides
an overview about the various local anesthetic agents used in pediatric dental practice, dosage, complications and
the recent advances.

KEYWORDS: Local anesthesia, Lignocaine, WAND.

INTRODUCTION: How Local Anesthetics Work

Pain prevention in pediatric dentistry is crucial for a
child in achieving positive experience during the dental
visit, building trust and cooperation and making future
visits enjoyable. One of the main methods to prevent
pain is the administration of local anesthesia. [1,2]
Local anesthesia is the temporary loss of sensation
including pain in one part of the body produced by a
topically-applied or injected agent without depressing
the level of consciousness. Local anesthetics act within
the neural fibers to inhibit the ionic influx of sodium for
neuron impulse. [3,4]
The pediatric dental professional should be aware of
proper dosage (based on weight) to minimize the chance
of toxicity and the prolonged duration of anesthesia,
which can lead to accidental lip, tongue, or soft tissue
trauma. [5] Knowledge of gross and neuroanatomy of the
head and neck allows for proper placement of the
anesthetic solution and helps minimize complications.
Familiarity with the patient’s medical history is
mandatory to decrease the risk of aggravating a medical
condition while rendering dental care. Medical
consultation should be obtained as and when needed. [4,5]
Received on 24.05.2019 Modified on 28.06.2019
Accepted on 05.07.2019 © RJPT All right reserved
Research J. Pharm. and Tech 2019; 12(8): 4066-4070.
DOI: 10.5958/0974-360X.2019.00700.5
The primary action of local anesthetics in producing a
conduction block is to decrease the permeability of ion
channels to sodium ions (Na+). Local anesthetics
selectively inhibit the peak permeability of sodium,
whose value is normally about five to six times greater
than the minimum necessary for impulse conduction
(e.g., there is a safety factor for conduction
of 5× to 6×). [4]
Local anesthetics reduce this safety factor, decreasing
both the rate of rise of the action potential and its
conduction velocity. When the safety factor falls below
unity, conduction fails and nerve block occurs. Local
anesthetics produce a very slight, virtually insignificant
decrease in potassium (K+) conductance through the
nerve membrane. Calcium ions (Ca++), which exist in
bound form within the cell membrane, are thought to
exert a regulatory role on the movement of sodium ions
across the nerve membrane. Release of bound calcium
ions from the ion channel receptor site may be the
primary factor responsible for increased sodium
permeability of the nerve membrane. This represents the
first step in nerve membrane depolarization. Local
anesthetic molecules may act through competitive
antagonism with calcium for some site on the nerve
membrane. [4]

4066
 Research J. Pharm. and Tech. 12(8): August 2019

Local Anesthetic agents available:
Numerous local anesthetic agents are available to relieve
pain during the dental procedure. The most commonly
used local anesthetics for pediatric dentistry are the
amide type agents. Lidocaine hydrochloride (HCl) 2%
with 1:100,000 epinephrine is preferred because of their
low allergenic characteristics and their greater potency
at lower concentrations. [7] Vasoconstrictors are used to
constrict blood vessels, counteract the vasodilatory
effects of the local anesthetic, prolong its duration,
reduce systemic absorption and toxicity, and provide a
bloodless field for surgical procedures.[7,8] The use of the
vasoconstrictor will allow the maximum total dose of
the anesthetic agent to be increased by nearly 40%. [9,10]
Many agents have been employed as vasoconstrictors
with local anesthetics. But none has proved to be as
clinically effective as epinephrine. [9]
However epinephrine is contraindicated in patients with
hyperthyroidism. The dose should be kept to a minimum
in patients receiving tricylic antidepressants since
dysrhythmias may occur. [5] Levonordefrin and
norepinephrine are absolutely contraindicated in these
patients. Patients with significant cardiovascular disease,
thyroid dysfunction, diabetes, or sulfitesensitivity and
those receiving monoamine oxidase inhibitors, tricyclic
antidepressants, or phenothiazines may require a
medical consultation to determine the need for a local
anesthetic without vasoconstrictor. [5,11]
A long-acting local anesthetic (ie, bupivacaine) is not
recommended for the child or the physically or mentally
disabled patient due to its prolonged effect, which
increases the risk of soft tissue injury. Claims have been
made that articaine can diffuse through hard and soft
Table : 1 – Injectable Local Anesthetics [5]
tissue from a buccal infiltration to provide lingual or
palatal soft tissue anesthesia. [4]
Dose Calculation
Local amide anesthetics available for dental usage
include lidocaine, mepivacaine, articaine, prilocaine, and
bupivacaine (Table 1). Absolute contraindications for
local anesthetics include a documented local anesthetic
allergy. [11] True allergy to an amide is exceedingly rare.
Allergy to one amide does not rule out the use of another
amide, but allergy to one ester rules out use of another
ester.[12] A bisulfate preservative is used in local
anesthetics containing epinephrine. For patients having
an allergy to bisulfates, use of a local anesthetic without
a vasoconstrictor is indicated. [11]
The maximum dose of lidocaine and mepivacaine,
without vasoconstrictors, recommended for children is
4.4 mg/kg body weight (Table 2), and 7 mg/kg body
weight for lidocaine with vasoconstrictors. [4,13] (Table
2)
So, for a child weighing 25 kg, the maximum
permissible dosage of LA is 7 × 25 = 175 mg of LA.
As lidocaine is generally available as 2% solution, this is
2 gm in 100 ml of solution or 100 ml of solution will
have 2 gm of LA.
1 ml of solution has 2/ 100 =0.02 gm or 20 mg of LA
1.8 ml of solution (1 cartridge) will have – 20 × 1.8 = 36
mg of LA
If a total of 175 mg can be safely administered to a child
weighing 25 kg, it means 175/36 = 4.8 or 5 Cartridges of
Lidocaine with adrenaline (1.8 ml of solution) can be
safely administered.

Anesthetic Maxillary Infiltration Mandibular block Maximum Dosage Maximum

(Duration in Minutes) (Duration in Minutes) Total Dose
Pulp Soft Tissue Pulp Soft Tissue (mg/kg) (mg/lb) (mg)
Lidocaine 4.4 2.0 300
2% Plain 5 5-10
2% + 1:50,000 epinephrine 60 170 85 190
2% + 1:1,00,000 epinephrine 60 170 85 190
Mepivacaine 4.4 2.0 300
3% Plain 25 90 40 165
2% + 1:1,00,000 epineprine 60 170 85 190
2% + 1:20,000 levonordefrin 50 130 75 185
Articaine 7.0 3.2 500
4% + 1:1,00,000 epinephrine 60 190 90 230
4% + 1:2,00,000 epinephrine 45 180 60 240
Prilocaine 6.0 2.7 400
4% Plain 20 105 55 190
4% + 1:2,00,000 epinephrine 40 140 60 220
Bupivacaine 1.3 0.6 90
0.5% +1:2,00,000 epinephrine 40 340 240 440

4067
 Research J. Pharm. and Tech. 12(8): August 2019

Table 2: Maximum Dose – Lidocaine Without Adrenaline [30] Complications of Local Anesthesia:
Patient Weight (kg/lb) mg No. of cartidges There are numerous potential complications associated
10/23 44 1.2
15/34.5 66 1.8
with the administration of local anesthetics. These
20/46 88 2.4 complications may be separated into those that occur
25/57.5 100 2.7 locally in the region of injection and those that are
30/69 132 3.6 systemic.
40/92 176 4.8
50/115 220 6.1
60/138 264 7.3
The Local Complications include: [4]
70/161 300 8.3 1. Needle breakage
2. Prolonged anesthesia or paraesthesia
Rule of 10: 3. Facial nerve paralysis
Administering a painless inferior alveolar nerve block 4. Trismus
for a preschooler is one of the most difficult task for a 5. Soft tissue injury
dentist. There has been discussions whether to give a 6. Hematoma
local infiltration or an inferior alveolar nerve block to 7. Pain on injection
anesthetize the mandibular primary molars. Rule of 10 is 8. Burning on injection
a better approach to determine which injection is 9. Infection
appropriate. [14] The primary tooth to be anesthetized is 10. Edema
assigned a number from 1 to 5 according to its location 11. Sloughing of tissues
in the dental arch (central incisor = 1, second molar = 5). 12. Postanesthetic intraoral lesions
This number is added to the age of the child (in years),
and if the number is 10 or less, then an infiltration is The systemic complications include: [13]
more appropriate; if greater than 10, then an inferior 1. Toxicity due to overdose
alveolar nerve block is likely to be more effective. This 2. Allergy
simple approach works well in most cases. The only 3. Idiosyncrasy
instance where the rule would be contraindicated is 4. Syncope
where quadrant dentistry involving pulp treatment of 5. Drug interaction
both first and second molar. In this case local infiltration 6. Serum hepatitis
may not provide a sufficient depth of pulpal analgesia 7. Occupational dermatitis
and a mandibular block would be preferred. 8. Respiratory arrest
9. Cardiac arrest
Topical Anesthesia: 10. Hyperventilation
The primary goal in applying a topical anesthetic agent
is to minimize discomfort caused during administration Recommendations to reduce local anesthetic
of local anesthesia. It is effective on surface tissues (up complications: [5]
to two to three mm in depth) to reduce painful needle 1. Clinicians who utilize any type of local anesthetic in
penetration of the oral mucosa. [3,4] Topical anesthetic a pediatric dental patient should have appropriate
agents are available in gel, liquid, ointment, patch, and training, skills, availability of proper facilities,
aerosol forms. personnel, and equipment to manage any reasonably
foreseeable emergency.
The onset duration of lidocaine is 3-5 minutes. A recent 2. Care should be taken to ensure proper needle place-
study which compared the efficacy of commonly used ment during the intraoral administration of local
topical anesthetics demonstrated the superiority of 5% anesthetics. Clinicians should aspirate before every
EMLA cream (eutectic mixture of local anesthesia injection and inject slowly.
containing lidocaine and prilocaine) over all other 3. Following an injection, the doctor, hygienist, or as-
topical anesthetic agents. The topical anesthetic sistant should remain with the patient while the
benzocaine is manufactured in concentrations up to anesthetic begins to take effect.
20%; lidocaine is available as a solution or ointment up 4. Residual soft tissue anesthesia should be minimized
to 5% and as a spray up to 10% concentration. Localized in pediatric and special health care needs patients to
allergic reactions, however, may occur after prolonged decrease risk of self-inflicted postoperative injuries.
or repeated use. Topical lidocaine has an exceptionally 5. Clinicians should advise patients and their care-
low incidence of allergic reactions but is absorbed givers regarding behavioral precautions (eg, do not bite
systemically and can combine with an injected or suck on lip/cheek, do not ingest hot sub-stances) and
amide. [15] the possibility of soft tissue trauma while anesthesia
persists. Placing a cotton roll in the mucobuccal fold

4068
 Research J. Pharm. and Tech. 12(8): August 2019
may help prevent injury, and lubricating the lips with
petroleum jelly helps prevent drying.
Failures in Local Anesthesia:
Numerous factors contribute to the failure of local
anesthesia. These may be related either to the patient or
the operator.
Operator‑dependent factors are:
i) Poor choice of local anesthetic solution
ii) Improper technique
Patient‑dependent factors are:
i) Anatomical variations
ii) Presence of infection
iii) Psychogenic factors (severe anxiety may influence
pain perception). [16,17]
Local Anesthesia and Infection:
If a local anesthetic is injected into an area of infection,
its onset will be delayed or even prevented. The
inflammatory process in an area of infection lowers the
pH of the extracellular tissue from its normal value (7.4)
to 5 or lower. This low pH inhibits anesthetic action
because little of the free base form of the anesthetic is
allowed to cross into the nerve sheath to prevent
conduction of nerve impulses. Inserting a needle into an
active site of infection could also lead to a possible
spread of the infection. [13]
Newer Techniques in Local Anesthesia:
The traditional aspirating syringe is still the most
common method by which local anesthetics are
administered. Newer techniques have been developed
that can help the dentist administer the local anesthetic
with minimum injection pain and adverse effects.
Computer Controlled Local Anesthetic Delivery
system (CCLADS):
In the mid‑1990s, work began on the development of
local anesthetic delivery systems that incorporated
computer technology to control the rate of flow of the
anesthetic solution through the needle. This concept is
now called computer‑controlled local anesthetic delivery
(CCLAD). [18] The first of these CCLAD devices, the
Wand™ (Milestone Scientific, Inc., Livingston, N.J.),
was introduced in 1997. Subsequent versions from same
manufacturers were named Wand Plus and then
CompuDent™, the current designation.
Wand/ CompuDent System:
The Wand system enables the operator to accurately
manipulate needle placement with fingertip accuracy
and deliver the LA with a foot‑activated control. It
consists of a disposable handpiece component and a
computer control unit. The handpiece is an ultralight
pen‑like handle which is linked to a conventional
4069
anesthetic cartridge with plastic micro tubing. A
growing number of clinical trials in medicine also
demonstrate measurable benefits of CCLAD
technology. [19,20]
Comfort control syringe
The Comfort Control Syringe has two main components:
A base unit and a syringe. Several functions of the unit‑
most importantly injection and aspiration‑ can be
controlled directly from the syringe, possibly making its
use easier to master for practitioners accustomed to the
traditional manual syringe. The Comfort Control
Syringe has five pre‑programmed speeds for different
injection techniques and can be used for all injection
techniques. [21] A comparison between the traditional
dental syringe and the Comfort Control Syringe revealed
no meaningful differences in ease of administration,
injection pain and efficacy, and acceptance by
patients.[22]
Jet Injectors
This technique is based on the principle of using a
mechanical energy source to create a release of pressure
sufficient to push a dose of liquid medication through a
very small orifice, creating a thin column of fluid with
enough force that it can penetrate soft tissue into the
subcutaneous tissue without a needle. Jet injectors are
believed to offer advantages over traditional needle
injectors by being fast and easy to use, with little or no
pain, less tissue damage, and faster drug absorption at
the injection site.[23] Studies in adults and children have
concluded that traditional infiltration was more
effective, acceptable, and preferred, compared with the
needleless injection. [24]
Vibrotactile Devices:
Inui and colleagues [25] have shown, however, that pain
reduction due to non‑noxious touch or vibration can
result from tactile‑induced pain inhibition within the
cerebral cortex itself and that the inhibition occurs
without any contribution at the spinal level, including
descending inhibitory actions on spinal neurons.
VibraJect
It is a small battery‑operated attachment that snaps on to
the standard dental syringe which delivers a
high‑frequency vibration to the needle that is strong
enough for the patient to feel.[23] Researches evaluating
the effectiveness of VibraJect, have shown mixed
results. Nanitsos et al.,[26] and Blair [27] have
recommended the use of VibraJect for painless injection.
In contrast, Yoshikawa et al.,[28] found no significant
pain reduction when VibraJect was applied with a
conventional dental syringe.
 Research J. Pharm. and Tech. 12(8): August 2019

DentalVibe
This is a cordless, rechargeable, hand held device that
delivers soothing, pulsed, percussive micro‑oscillations
to the site where an injection is being administered. Its
U‑shaped vibrating tip attached to a microprocessor
‑controlled Vibra‑Pulse motor gently stimulates the
sensory receptors at the injection site, effectively closing
the neural pain gate, blocking the painful sensation of
injections. It also lights the injection area and has an
attachment to retract the lip or cheek.[29]
Accupal
The Accupal (Hot Springs, AR, USA) is a cordless
device that uses both vibration and pressure to
precondition the oral mucosa. Accupal provides pressure
and vibrates the injection site 360° proximal to the
needle penetration, which shuts the “pain gate,”
according to the manufacturer. After placing the device
at the injection site and applying moderate pressure, the
unit light up the area and begins to vibrate. The needle is
placed through a hole in the head of the disposable tip,
which is attached to the motor. [29]
REFERENCES:
1. Wright GZ, Weinberger SJ, Marti R, Plotzke O (1991) The
effectiveness of infiltration anesthesia in the mandibular primary
molar region. Pediatr Dent 13: 278-283.
2. Sharaf AA (1997) Evaluation of mandibular infiltration versus
block anesthesia in pediatric dentistry. ASDC J Dent Child 64:
276-281.
3. Ogle OE, Mahjoubi G. Local anesthesia: Agents, techni-ques,
and complications. Dent Clin North Am 2012;56(1):133-48.
4. Malamed SF. Handbook of Local Anesthesia. 6th ed., St. Louis,
Mo: Mosby; 2013
5. American Academy of Pediatric Dentistry: Guideline on Use of
Local Anesthesia for Pediatric Dental Patients. Clinical
Guidelines, reference manual 2015:37:6.
6. Moore PA, Hersh EV. Local anesthetics: pharmacology and
toxicity. Dent Clin North Am 2010;54(4):587-99.
7. Troutman KC. Pharmacologic Management of pain and anxiety
for pediatric patients, In: Wei SH, editor. Pediatric Dentistry
Total Patient Care, Philadelphia, PA: Lea and Febbiger; 1985. p.
156‑62.
8. Wilson SW, Dilley DC, Vann WF Jr, Anderson JA. Pain and
anxiety control (Partl: Pain perception control) In: Pickham J,
Casmassinno PS, Field HW, Mctigue DJ, Nowak A, editors.
Pediatric Dentistry, Infancy Through Adolescesce, 3rd ed,
Philadelphia, PA: WB Saunders; 1999.108‑15.
9. Scott DB, Jebson PJ, Braid DP, Prtengren B, Frish P. Factors
affecting plasma levels of lignocaine and prilocaine. Br J
Anaesth 1972;44:1040‑9.
10. Cannell H, Walters H, Beckett AH, Saunders A. Circulating
levels of lignocaine after peri‑oral injections. Br Dent J
1975;138:87‑93.
11. Becker DE, Reed KL. Essentials of local anesthetic
pharmacology. Anesth Prog 2006;53(3):98-109.
12. Dean JA, Avery DR, McDonald RE. Local anesthesia and pain
control for the child and adolescent. In: Dentistry for the Child
and Adolescent. 9th ed., St Louis, Mo: Mosby; 2011:241-52.
13. Peedikayil FC, Vijayan A. An update on local anesthesia for
pediatric dental patients. Anesth Essays Res 2013;7:4-9.
14. Mathewson RJ, Primosch RE. Fundamentals of Pediatric
Dentistry (3rd Edn). Chicago, Quintessence, 1995
15. Kravitz ND. The use of compound topical anesthetics: A review.
J Am Dent Assoc 2007;138:1333‑9.
16. Boronat‑Lopez A, Penarrocha‑Diago M. Failure of locoregional
anesthesia in dental practice. Review of the literature. Med Oral
Pathol Oral Circ Bucal 2006;11:E510‑3.
17. Wong MK, Jacobsen PL. Reasons for local anesthesia failures. J
Am Dent Assoc 1992;123:69‑73.
18. Proceedings of the 1st Annual Computer‑Controlled Local
AnesthesiaDelivery (C‑CLAD) System meeting. Introductory
remarks. New Orleans, Louisiana, USA: 2008.
19. Tan PY, Vukasin P, Chin ID, Ciona CJ, Orteqa AE, Anthone GJ.
The Wand local anesthetic delivery system: A more pleasant
experience for anal anesthesia. Dis Colon Rectum
2001;44:686‑9.
20. Anderson ZN, Podnos SM, Shirley‑King R. Patient satisfaction
during the administration of local anesthesia using a computer
controlled local anesthetic delivery system. Dermatol Nurs
2003;15:329‑30, 392.
21. Clark TM, Yagiela JA. Advanced techniques and
armamentarium for dental local anesthesia. Dent Clin North Am
2010;54:757‑68.
22. Grace EG, Barnes DM, Reid BC, Flores M, George DL.
Computerized local dental anesthetic systems: Patient and dentist
satisfaction. J Dent 2003;31:9‑12.
23. Ogle OE, Mahjoubi G. Advances in local anesthesia in dentistry.
Dent Clin North Am 2011;55:481‑99.
24. Dabarakis NN, AlexanderV, Tsirlis AT, Parissis NA, Nikolaos
M. Needle‑less local anesthesia: Clinical evaluation of the
effectiveness of jet anesthesia Injex in local anesthesia in
dentistry. Quintessence Int 2007;38:572‑6.
25. Inui K, Tsuji T, Kakigi R. Temporal analysis of cortical
mechanisms for pain relief by tactile stimuli in humans. Cereb
Cortex 2006;16:355‑65.
26. Nanitsos E, Vartuli A, Forte A, Dennison PJ, Peck CC. The
effect of vibration on pain during local anaesthesia injections.
Aust Dent J 2009;54:94‑100.
27. Blair J. Vibraject from ITL dental. Dent Econ 2002;92:90.
28. Yoshikawa F, Ushito D, Ohe D, Shirasishi Y, Fukayama H,
Umino M. Vibrating dental local anesthesia attachment to reduce
injection pain. J Japanese Dent Soc Anesthesiology
2003;31:194‑5.
29. Saxena P, Gupta SK, Newaskar V, Chandra A. Advances in
dental local anesthesia techniques and devices: An update. Natl J
Maxillofac Surg 2013;4:19-24.
30. Muthu MS, Sivakumar N. Pediatric Dentistry: prinnciples and
practice. 2nd ed. New Delhi: Elsevier, 2011.

4070

View publication stats