This document discusses local anesthesia and pain control techniques for pediatric dentistry. It defines pain and anesthesia and covers various local anesthesia techniques including topical anesthesia, infiltration, nerve blocks, and supplemental injection techniques. It provides details on the contents of local anesthesia carpules, how local anesthetics are metabolized in the body, recommended dosages, and complications. The goal is to effectively manage pain for dental procedures in children.

1. LOCAL ANESTHESIA AND
PAIN CONTROL IN
PEDIATRIC DENTISTRY
By: Dr. Rahaf Najjar

2. - Definition of Pain and Anesthesia.
- Topical Anesthesia.
- Content of L.A Carpule.
- Metabolism of L.A.
- Anesthesia of Mandibular Teeth and Soft Tissue.
- Anesthesia of Maxillary Teeth and Palatal Tissue.
- Supplemental Injection Technique.
- Maximum Recommended Dose.
- Complications of L.A.
- New Techniques in L.A.

3. - Definition of Pain and Anesthesia.
- Topical Anesthesia.
- Content of L.A Carpule.
- Metabolism of L.A.
- Anesthesia of Mandibular Teeth and Soft Tissue.
- Anesthesia of Maxillary Teeth and Palatal Tissue.
- Supplemental Injection Technique.
- Maximum Recommended Dose.
- Complications of L.A.
- New Techniques in L.A.

4. Unpleasant sensational experience initiated by
noxious stimulus & transmitted over a specialized
neural network to CNS where it is interpreted.

5. Transient loss of sensation in a circumscribed area of
the body caused by :
Depression of
excitation in nerve
endings
Inhibition of the
conduction process in
peripheral nerves

6. - Definition of Pain and Anesthesia.
- Topical Anesthesia.
- Content of L.A Carpule.
- Metabolism of L.A.
- Anesthesia of Mandibular Teeth and Soft Tissue.
- Anesthesia of Maxillary Teeth and Palatal Tissue.
- Supplemental Injection Technique.
- Maximum Recommended Dose.
- Complications of L.A.
- New Techniques in L.A.

7. Available in different forms:
• Gel ( most effective type).
• Liquid
• Spray.

8. Technique:
• The mucosa at the site of the 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).

9. Advantages:
–Effective to a depth of 2-3 mm .
– Effective in reducing the discomfort of the
initial penetration of the needle into the
mucosa.
Disadvantages :
– Taste may be disagreeable to patient
–Length of application time may increase
apprehension in the pediatric patient.

10. • When applying topical anesthesia use the smallest
effective amount to avoid anesthetizing the
pharyngeal tissues ( cause gaging).
• Not known to produce systemic toxicity in adults
but can produce local allergic reactions.

11. - Definition of Pain and Anesthesia.
- Topical Anesthesia.
- Content of L.A Carpule.
- Metabolism of L.A.
- Anesthesia of Mandibular Teeth and Soft Tissue.
- Anesthesia of Maxillary Teeth and Palatal Tissue.
- Supplemental Injection Technique.
- Maximum Recommended Dose.
- Complications of L.A.
- New Techniques in L.A.

12. 1. Local anesthetic agent.
2. Vasoconstrictors.
3. Reducing agents.
4. Preservatives.
5. Fungicide.
6. Vehicle.

13. Reducing Agent
Sodium metabisulphite ( antioxidant).
Preservative
• Methylparaben.
• It increases the shelf life of the anesthetic solution.
• Acts as a bacteriostatic agent.

14. Fungicide
Thymol.
Vehicle
Modified Ringer’s solution / Distilled Water to give
volume.

15. Esters
–Esters of Benzoic Acid
Cocaine, Butacaine, Benzocaine, Tetracaine
–Esters of Para Aminobenzoic Acid
Procaine, Chloroprocaine, propoxycaine
Amides
Bupivacaine, lidocaine, articaine, prilocaine
Quinolones ( not used anaymore)
Centbucridine

16. - Lidocaine hydrochloride (Xylocain) 2 % is most
commonly used local anesthetic agent.
- 2% mean…….
2 g in 100 ml
or
20mg in 1 ml

17. Adrenaline in the concentration of 1:50000 to
1:200000 is commonly used.
Function of Vasoconstrictors
1. Delays absorption of LA from the site.
2. Provides blood less field.
3. Prolongs the action .
4. Reduces the systemic toxicity.

18. - Definition of Pain and Anesthesia.
- Topical Anesthesia.
- Content of L.A Carpule.
- Metabolism of L.A.
- Anesthesia of Mandibular Teeth and Soft Tissue.
- Anesthesia of Maxillary Teeth and Palatal Tissue.
- Supplemental Injection Technique.
- Maximum Recommended Dose.
- Complications of L.A.
- New Techniques in L.A.

19. Ester Group:
In the plasma by the enzymes pseudocholinesterase .
Amide Group:
In the liver.
Excretion of LA
From the kidney.

20. • Density and calcification of maxillary and mandibular bone.
• Anatomic structures.
• Penetration of the needle.
• Depth of needle penetration.
• Emotional aspect.

21. Nerve block:
Depositing the LA solution within close proximity to a
main nerve trunk.

22. Field block:
Depositing a in proximity to the larger nerve
branches.

23. Local infiltration:
Small terminal nerve endings are anaesthetized.

24. - Definition of Pain and Anesthesia.
- Topical Anesthesia.
- Content of L.A Carpule.
- Metabolism of L.A.
- Anesthesia of Mandibular Teeth and Soft Tissue.
- Anesthesia of Maxillary Teeth and Palatal Tissue.
- Supplemental Injection Technique.
- Maximum Recommended Dose.
- Complications of L.A.
- New Techniques in L.A.

25. BELOW 6 YEARS 6 – 12 YEARS ABOVE 12 YEARS
- 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.

26. 1. Coronoid notch
2. Pterygomandibular raphe
3. Occlusal plane of the mandibular posterior
teeth

27. Anesthetized Area
• 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.

28. Indications
• For more than 1 tooth filling, extraction, pulp
therapy
• If can’t apply mental block due to infection.
Contraindications
• Infection/inflammation at injection site.
• Patients at risk for self injury (eg. children).
• Patients with bleeding disorder.

30. Site of injection
Mucous membrane distal and buccal to the most
distal molar tooth in the arch.

31. Area Anesthetized
Soft tissue and periosteum buccal to the mandibular
molar teeth.

32. The terminal ends of the inferior alveolar nerves
cross over the mandibular midline slightly and
provide conjoined innervation of the mandibular
incisors.

33. • The labial bone overlying the mandibular incisors is
usually thin enough for supraperiosteal anesthesia
techniques to be effective.

34. A method of providing a guide as to whether an
infiltration or a block injection of LA is appropriate
for a child requiring treatment to a mandibular tooth.

35. • The primary tooth to be anaesthetized is assigned a
number from 1 to 5 according to its location in the
dental arch .
+
• This number is added to the age of the child (in
years)

36. If the number is ≥10 then an infiltration anaesthesia
is most appropriate
If <10, then an inferior dental nerve block is likely to
be more effective.
Only for pulpotomies & fillings.

37. Example:
3 years old patient going to have pulpotomy on # 75 ,
the proper LA technique is
infiltration
6 years old patient going to have filling on # 84, the
proper LA technique is
infiltration
4 years old patient going to have extraction of # 75,
the proper LA technique is
IANB

38. - Definition of Pain and Anesthesia.
- Topical Anesthesia.
- Content of L.A Carpule.
- Metabolism of L.A.
- Anesthesia of Mandibular Teeth and Soft Tissue.
- Anesthesia of Maxillary Teeth and Palatal Tissue.
- Supplemental Injection Technique.
- Maximum Recommended Dose.
- Complications of L.A.
- New Techniques in L.A.

39.  Most frequently used for obtaining pulpal
anesthesia in maxillary teeth.
 Indicated whenever dental procedures are confined
to only one or two teeth.

40. Landmark:
• insertion 45 to Long acsses of the tooth
• Mucobuccal fold.
• Crown of the tooth.
• Root contour of the tooth.

41. Areas Anesthetized
1. Pulp and root area of the tooth.
2. Buccal periosteum.
3. Connective tissue.
4. Mucous membrane

42. B) Nasoplatine Nerve Block:
• Blocking the nasopalatine nerve anesthetizes the
palatal tissues of the six anterior teeth.
• Painful technique and not routinely used in
operative procedures.

43. B) Greater Palatine Nerve Block:
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.

44. - Definition of Pain and Anesthesia.
- Topical Anesthesia.
- Content of L.A Carpule.
- Metabolism of L.A.
- Anesthesia of Mandibular Teeth and Soft Tissue.
- Anesthesia of Maxillary Teeth and Palatal Tissue.
- Supplemental Injection Technique.
- Maximum Recommended Dose.
- Complications of L.A.
- New Techniques in L.A.

45. • The needle is placed in the gingival sulcus, and
advanced along the root surface until resistance is
met.
• 0.2 mL of anesthetic is deposited into the
periodontal ligament.
• Pressure is necessary ( by the injection) to express
the anesthetic solution.

46. Advantages of Periodontal Ligament Anesthesia:
• Provides reliable pain control rapidly and easily.
• Provides pulpal anesthesia for 30 to 45 minutes.
• More comfortable than other local anesthesia
techniques.
• Completely painless if used adjunctively.
• Needs very small quantities of anesthetic solution.
• Does not require aspiration before injection.
• Performed without removal of the rubber dam.
• Useful in patients with bleeding disorders .
• Useful in young or disabled patients in whom the
possibility of postoperative trauma to the lips or
tongue is a concern.

47. Local anesthetic solution is delivered directly to the
pulp using a bent needle.
Advantages:
• Requires minimum volumes of LA solution
• Immediate onset of action
• Very few post operative complications

48. Require the deposition of local anesthetic solution in
the porous alveolar bone.

49. - Definition of Pain and Anesthesia.
- Topical Anesthesia.
- Content of L.A Carpule.
- Metabolism of L.A.
- Anesthesia of Mandibular Teeth and Soft Tissue.
- Anesthesia of Maxillary Teeth and Palatal Tissue.
- Supplemental Injection Technique.
- Maximum Recommended Dose.
- Complications of L.A.
- New Techniques in L.A.

50. For Lidocaine LA
4.4 mg/kg body weight with vasoconstrictor.
Dose Calculation:
2% lidocaine = 20 mg/ ml
1 carpule = 1.8ml
Amount of LA in 1 carpule = 20X 1.8 = 36mg/carpule.

51. For Articaine LA
7 mg/kg body weight with vasoconstrictor.
Dose Calculation:
4% Articaine = 40 mg/ ml
1 carpule = 1.8ml
Amount of LA in 1 carpule = 40X 1.8 = 72mg/carpule.

53. Example:
20 Kg child can tolerate a maximum dose of 2%
lidocaine with vasoconstrictor of LA ----------
4.4 X 20= 88 mg = 2.4carpules.
20 Kg child can tolerate a maximum dose of 4%
arcticaine with vasoconstrictor of LA ----------
7 X 20= 88 mg = 1.9 carpules

54. - Definition of Pain and Anesthesia.
- Topical Anesthesia.
- Content of L.A Carpule.
- Metabolism of L.A.
- Anesthesia of Mandibular Teeth and Soft Tissue.
- Anesthesia of Maxillary Teeth and Palatal Tissue.
- Supplemental Injection Technique.
- Maximum Recommended Dose.
- Complications of L.A.
- New Techniques in L.A.

55. • Toxicity.
• Syncope.
• Allergic Reaction.
• Vasoconstrictors effects.

56. Manifestation Of Toxicity
• Cardiac Depression
• Coma
• Convulsions
• Unconsciousness
• Muscular twitching
• Visual and auditory disturbances, light
headedness, numbness of tongue
ConcentrationofLAinPlasma

58. Most common cause : Vasovagal attach
Signs and Symptoms:
• Child become pale and cold .
• Pulse is rapid.
• The pupils are dilated or constricted.
• Drop of blood pressure.

59. • Uncommon.
• Edema, eczema or ertecharia.
• Anaphylactic shock : more sever form of allergy
(Med. Emergency)
• Management: 0.1- 0.5 ml of 1:1000 epinephrine
injection

60. Allergic reaction is caused by co-incidentalexposure
to other antigens such as:
• Preservatives ( methyl-p- hydroxybenzoate)
• Antioxidants ( bisulphate)
• Latex
• Local anesthetic drugs

62. Contraindications of using LA with vasoconstrictors:
• Unstable angina
• Myocardial infarction
• Untreated/ uncontrolled sever hypertension
• Recent coronary artery bypass surgery
• Uncontrolled diabetes
• Uncontrolled hyperthyroidism
• Tricyclic antidepressant ( TCA)

63. • Broken needle.
• Hematoma.
• Trauma of the nerve causing Paresthesia.
• Sloughing .
• Truisms.
• Soft tissue injury.

64. Phentolamine mesylate (OraVerse), a nonselective a-
adrenergic blocking drug, for the reversal of soft-
tissue anaesthesia and the associated functional
deficits resulting from an intraoral submucosal
injection of a local anaesthetic containing a
vasoconstrictor.

65. Mechanism of Action
• its increasing blood flow through the area into
which local anesthetic had previously been
deposited
• a pumping action produced by the rhythmic
contraction of skeletal muscles. The local anesthesia
drug would undergo a more rapid redistribution into
the capillaries and venules in the area.

66. - Definition of Pain and Anesthesia.
- Topical Anesthesia.
- Content of L.A Carpule.
- Metabolism of L.A.
- Anesthesia of Mandibular Teeth and Soft Tissue.
- Anesthesia of Maxillary Teeth and Palatal Tissue.
- Supplemental Injection Technique.
- Maximum Recommended Dose.
- Complications of L.A.
- New Techniques in L.A.

67. Needle Free

68. Administers local anesthetic at two specific rates of
delivery.
• The slow rate is 0.5ml/min
and
• Fast rate is 1.8ml/min .

69. • Mixture of Lidocaine & Prilocaine.
• Used for numbing the skin before inserting the
needle.
• It is designed to go through intact skin. (used
extraoral)
• Use in children under 6 months is contraindicated
due to the possibility for developing
methemoglobinemia.

70. • Contains 10% or 20% lidocaine.
• Placed for 15 minutes on the buccal mucosa of the
maxillary or mandibular premolar area, 2 mm
apical to the mucogingival junction.

71. • Uses the principle of Transcutaneous Electrical
Nerve Stimulation (TENS).
• Requires good patient co-operation.
• It increases salivary blood flow.

72. • Check the flow of LA solution.
• Use Anesthetic cartilage and siring at
• temperature close to room temperature.
• Proper positioning for the patient and doctor.
• Apply topical anesthesia.
• Always communicate with the pt.

73. • Keep syringe out of pt site.
• Don’t inject subperiosteally.
• Always aspirate in IANB.
• Slowly deposit LA solution.
• Bevel of the needle facing the bone.
• Never leave pt unattended.

74. THANK YOU