Local Anesthesia in Pediatric Dentistry

Ye’ Myint Lwin

(4 th BDS 1/2020,UDMY)
Contents
Definition of LA
Classification
Composition
General structure of LA
Mode of Action
Metabolism
Maximum Recommended Doses
Types of Injection
Anesthesia of Mandibular Teeth and Soft Tissues
Anesthesia of Maxillary Teeth and Soft Tissues
Complications
Conclusion
 Definition of LA
Reversible loss of sensation in a circumscribed area of
the body caused by a depression of a excitation in
nerve ending or an inhibition of the conduction
process in peripheral nerves.
Classification
Based on Composition
1. Ester group
2. Amide group
3. Quinolone
Ester Group
1.Ester of benzoic acid
Cocaine
Butacaine
Tetracaine
Benzocaine

2.Ester of para-amino benzoic acid

Procaine
Chloroprocaine
Propoxycaine
Amide Group
Bupivacaine
Lidocaine
Prilocaine
Articaine
Mepivacaine

Quinolone
Centbucridine
 Classification
Based on mode of administration
Topical –it can be supplied in solution or ointment or
spray form. Commonly used to obtain
anesthesia of the mucosa prior to injection.
Benzocaine, Lignocaine
 Classification
Injectable – Lignocaine, Procaine.
 Classification
Based on Duration

Short acting- Procaine

Intermediate acting- Lidocaine

Long acting- Bupivacaine is not recommended for child

or physical or mentally disabled patient due to its
prolonged effect, which increases the risk of soft tissue
injury.
 Classification
Based on its Source

. Natural
. Synthetic

Except Cocaine all other are synthetic.

 Classification
Based on Potency

.Very potent – Etidocaine

.Moderately potent - Lidocaine

Composition
Local Anesthetic Agent
Vasoconstrictors
Reducing Agents
Preservatives
Fungicide
Isotonic Agent
Vehicle
1.Local Anesthetic Agent
Lignocaine hydrochloride 2% is most commonly used
local anesthetic agent.

2% lignocaine mean…

2mg in 100 ml
or
20mg in 1ml
• Uses- conduction blockade
2. Vasoconstrictors
Adrenaline in the concentration of 1:50000 to 1:200000
is commonly used.
1:200000 means…
1 gm in--------200000 ml
or
1 mg in---------200 ml (0.02 mg/ml)
Uses
• Delays absorption of LA from the site
• Provides blood less field
• Prolongs the action
• Reduces the systemic toxicity
3. Reducing Agent

S0dium metabisulphite is used to prevent the

oxidation of the vasoconstrictor.
4. Preservative
Methylparaben
It increases the self life of the anesthetic solution.
Acts as the bacteriostatic agent.

5. Fungicide
Thymol is used as fungicide
6. Isotonic Agent
Sodium chloride is used to make the solution isotonic
with the tissues and it makes the solution alkaline.

7. Vehicle
Modified ringer’s solution or distilled water is used as
vehicle.
It produces the volume of the solution and act as
dilutent.
General Structure of LA
A lipophilic group usually a benzene ring

A hydrophilic group usually a tertiary amine

These are connected by an intermediate chain that

includes an ester or amide linkage

LAs are weak bases.

 HOW

LOCAL ANESTHETICS

WORK
(mode of action)
 Theories
Different theories have been given to explain mode of
action of local anesthetic agent:
1. Acetylcholine Theory by Dett Barn in 1967.
2. Calcium Displacement Theory by Goldman in 1966.
3. Surface Charge Theory by Wei in 1969.
4. Membrane Expansion by Lee in 1976.
5. Specific Receptor
 Specific Receptor Theory
It says that the blocking of local anesthetic is due to
the blinding of the drug to a specific site inside the
nerve cell.
This decreases the permeability of nerve membrane to
sodium ions thus preventing the influx of sodium ions
into the nerve.
Thus the threshold potential of the nerve is increased
which causes the decrease conduction of the impulse.
Calcium ions are present in bound form within the
nerve cell membrane (sodium ion channel receptor
site)
LA molecules displaces these calcium ions from the
sodium channel receptor site

Binding of the LA molecule to this receptor site

Blockade of the sodium channel

decrease in sodium conductance

 Depression of the rate of depolarization

Failure to achieve the threshold potential level

Lack of development of propagated action

potential

CONDUCTION BLOCKADE
 Metabolism
Ester group
They are hydrolyzed in the plasma by the enzymes
pseudocholinesterase.
Allergic reactions that occur in response to ester
drugs are usually related to the metabolic product of
ester local anesthetic. i.e paraaminobenzoic acid
 Metabolism
Amide group
 There metabolism is more complex than that of
esters.
 Primary site of biotransformation is in liver.
 Hence the liver function and hepatic perfusion
significantly affect it.
Excretion
 The local anesthetic agent is excreted from kidney.
 Factors Affecting the Onset
pH and pKa of tissue
Protein binding of the local anesthetic
Use of vasoconstrictor
Site of deposition of LA
Nerve morphology
Concentration of anesthetic agent used
Anesthetic Agent Suitable for Children
Lidocaine hydrochloride 2% with
epinephrine 1:100,000
Mepivacaine hydrochloride 2% with
levonordefin 1:20,000
Prilocaine hydrochloride 4% with
epinephrine 1:2oo,000
 Potency of LA Agents
It depends on
1. Lipid solubility
2. Tissue diffusion characteristics
3. Intrinsic vasodilator activity

Very potent>>>>> Etidocaine

Moderately potent>> Lidocaine
 Maximum Recommended Doses
4.4 mg/kg body weight with adrenaline
7.5 mg/kg body weight without adrenaline

DOSE CALCULATION
%concentration(mg/ml) x ml/cartridge=total mg/cartridge
example : in a 10kg child
if 1kg = 4.4 mg
then 10kg = 44 mg
20 mg = 1 ml(2% lignocaine)
44 mg = 2.2 ml
So in a child of 10kg maximum recommended dose of LA
is 2.2ml.
Points to be kept in mind regarding
the differences between the child
and adult patient
Density and calcification of maxillary and mandibular
bone
Anatomic structures
Penetration of the needle
Depth of needle penetration
Emotional aspect
 Types of Injection
Nerve block- depositing the LA solution within close
proximity to a main nerve trunk thus preventing nerve
impulses from travelling centrally beyond that point
 Types of Injection
Field block- depositing in a proximity to the larger
nerve branches. Maxillary injections above the apex of
the tooth can be termed field blocks.
 Types of Injection
Local infiltration- small terminal nerve endings are
anesthetized. This technique is usually successful for
treatment of mandibular deciduous canines, incisors
and even in molars.
Anesthesia of Mandibular Teeth and Soft Tissues
1) Inferior alveolar nerve block + Lingual nerve block
- 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.
Landmarks
1. Coronoid notch
2. Pterygomandibular raphe
3. Occlusal plane of the mandibular posterior teeth
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 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
 Position of the patient- body of the mandible is parallel to
the floor.
 The operator stands to the right side of the patient with left
index finger palpates the mucobuccal fold.
 Aspirates slowly
 Needle depth--- 8-10 mm
 Amount deposited--- 0.9-1.0 ml
 Lingual nerve is anterior and medial to inferior alveolar
nerve
 So withdraw the needle about 1 mm and deposit the 0.5 ml
of LA
2) Mental Nerve Block
Lower E and D filling
3) Long Buccal Nerve Block
 Supplies the molar buccal gingivae and may provide
accessory innervation to the teeth.
 Site of injection- a small quantity of solution is deposited
in the mucobuccal fold at a point distal and buccal to the
most posterior molar.
 Area anesthetized- soft tissue and periosteum buccal to the
madibular molar teeth.
 Infiltration for Mandibular Incisors
 The terminal end of the inferior alveolar nerve 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.
 Anesthesia of Maxillary Teeth and Soft Tissues
 1.Supraperiosteal technique (Local Infiltration)
labial, buccal, palatal
In local infiltration, the nerve endings in the area of the
surgery are flooded with local anesthetic solution. The
incision is made through the same area in which solution has
been deposited.
Indicated whenever dental procedures are confined to only
one or two teeth.
Landmark: insertion 45 to long access of the tooth,
mucobuccal fold.
Areas anesthetized
-pulp and root area of the tooth
-buccal periosteum
-connective tissue
-mucous membrane
2) Anterior Superior Alveolar Nerve Block
 Anesthetizes the maxillary canine, central and lateral incisors and
mucosa above these teeth .
 3) Middle Superior Alveolar Nerve Block (not for children)
 Anesthetizes the maxillary premolars with occasional
overlap to the canine and first molar.
4) Posterior Superior Alveolar Nerve Block (not for children)
 Anesthetizes maxillary molar teeth. In this case, the first molar may
not be completely anesthetized. The PSA nerve block can be used in
conjunction with MSA/supraperiosteal block.
Palatal Anesthesia
a) Nasopalatine nerve block
Anesthetizes the palatal tissues of the six anterior teeth.
This technique is painful and not routinely used before
operative procedures.
b) Greater Palatine nerve block
Anesthetizes the posterior two thirds of the hard palate.
Supplemental Injection Techniques
 Periodontal ligament injection
 Intrapulpal injection (not used for deciduous teeth)
 Intraosseous injection (not used for deciduous teeth)
 Complications of LA
Generalized Complications
The most common psychogenic complication is fainting.
Management: sympathetic management and supine position
with legs slightly elevated.
Allergy
Very rare complication
Allergy can manifest in variety of forms ranging from a minor
localized reaction to emergency of anaphylactic shock.
If any suggestion that a child is allergic to LA they should be
referred local dermatology or clinical pharmacology department.
Taken advice for which alternative LA can be safely given to the
child.
 Toxicity
Overdosage of LA leading to toxicity is rarely a problem in adult
but can occur in children.
Doses which are well below toxic level in adult can produce
problem in children.
All the drugs, dosages should be related to body weight.
 CNS effect
 The CNS is not immune to local anesthetic effect.
 At low doses the effect is excitatory as CNS inhibitory fibers
are blocked.
 At high doses the effect is depressant and can lead to
unconsciousness and respiratory arrest.
 Fatalities due to LA overdose in children are generally the
result of central nervous tissue deoression.
 Methemoglobinaemia
 Prilocaine causes cyanosis due to methemoglobinaemia.

 In this the ferrous iron of normal hemoglobin is converted

to the ferric form, which cannot combine with oxygen.
 Drug Interaction
 Apparently innocuous drug combination can interact and
cause significant problem in children.
 Example, an episode of methaemoglobinaemia has been
reported in a 3 months old child following the application
of EMLA.
 It was concluded in this case that prilocaine (in EMLA) had
interacted with sulfonamide that the child was already
receiving.
 Infections
The introduction of agent capable of producing a
generalized infection, such as Human
Immunodeficiency Virus (HIV) infection and
Hepatitis is a complication that should not occur when
appropriate cross-infection control measures are
employed.
 LOCALIZED COMPLICATIONS
Needle Breakage
Most common with IAN block and then with PSA block.
Causes – weakening of needle by bending
- unexpected movements by patients
- smaller gauge needles
Management
Fragment is visible use magill forceps or small hemostat.

Fragment no visible consult an oral surgeon.

 Paresthesia
It is defined as persistent anesthesia or altered sensation well
beyond the expected duration of anesthesia.
CAUSES
-trauma to any nerve or nerve sheath
-LA solution contaminated by alcohol
-hemorrhage
MANAGEMENT
-reassure the patient, explain that is not uncommon
-it normally persist fot at least 2 months and may last up to 1
year
-consultation with an oral surgeon or neurologist still the
sensory deficit is evident after 1 year
-dental treatment may continue
 Facial Nerve Paralysis
It occurs when anesthetic introduced into the deep lobe of parotid
gland.
It last no more than several hours
depending on the LA formulation,
volume injection and proximity to
facial nerve. Primary problem
associated is person’s face appears
lopsided, unable to voluntarily close
on eye.
MANAGEMENT
-reassure that the situation is transient
-contact lens should be removed
-an eye patch should be applied
-no contraindication for reanesthetizing the
patient
 Trismus
It is a prolonged tetanic spasm of the jaw muscle (locked jaw)
CAUSES
-most common is trauma to blood vessels or muscle
-LA solution contaminated with alcohol
-hemorrhage
-low grade infections after injection
-multiple needle penetrations
MANAGEMENT
-heat therapy, warm saline rinses
-analgesics, muscle relaxants, initiate physiotherapy
-complete recovery may take about six weeks
-surgical intervention to correct chronic
dysfunction
 Pain on Injection
CAUSES
-careless injection technique
-use of dull needles
-rapid deposition of LA
-needles with barbs
Problem—increase patient anxiety lead to sudden
movements , risk of needle breakage.
 Burning on Injection
CAUSES
-primary cause of mild burning sensation is pH of LA solution
-rapid injection of LA
-contamination of LA catridges
-solutions warmed to normal body temperature

No treatment because it is transient and do not lead to

prolonged tissue involvement.
 Edema
CAUSES
-trauma during injection
-infection
-allergy
-hemorrhage
-injection of irritating solutions
-hereditary angioedema
Problem—edema is intense enough to produce airway
obstruction.
Management
- edema caused by traumatic injection or irritating solution
it resolves in several days without treatment.
-after haemorrhage 7-14 days
-edema by infection does not resolve but may become more
progressively intense, antibiotic therapy should be instituted.
-allergy induced edema is potentially life threatening.
 Self Inflicted Injury
Lip biting
Tongue biting
Cheek biting
 Conclusion
 Local anesthetics are useful for a range of applications in
children and infants.
 When pain free reliable local anesthesia is achieved in
children confidence is gained by both the child and
operator, and a sound satisfactory professional relationship
is established.
 References
 Text book of Pediatric dentistry, 4th edition, Richard Welbury.
 Local Anesthesia for children, Dr. Mutyala Jhansi
 Local Anesthesia in pediatric, Dr. Abdullah Al Nasser
 Local Anesthesia for the child, Rahaf Najjar
 Blocks in Pediatric dentistry, Komal Tiwari
 Uses of LA for pediatric patients , 2015
 Oral nerve block questions and answers