DS
Uploaded byDr. Nameeda K. S.
PPTX, PDF5,025 views

Local anesthesia in children

Local anaesthesia and exodontia in children is discussed. Key points include: 1. Local anaesthesia works by reversibly interrupting nerve conduction. The most accepted theory is that local anaesthetics bind to sodium channels on nerves, preventing sodium entry and conduction. 2. Techniques for anaesthetizing primary teeth include inferior alveolar nerve block, mental nerve block, infiltration and supraperiosteal injections. 3. Landmarks and techniques may need modification for paediatric patients due to anatomical differences compared to adults.

Embed presentation

Downloaded 66 times
Local Anaesthesia and Exodontia in Children Dr Nameeda K S
Contents Local anaesthesia 1. Classification 2. Composition 3. Mechanism of action 4. Theories 5. ASA Classification 6. Techniques for anesthesization Maxillary and Mandibular primary teeth 7. Complications 8.Dosage consideration 2 ◆ AAPD guidelines ◆ Recent techniques for pain less
Local Anaesthesia ◆ It is defined as a transient loss of sensation to a painful or potentially painful stimulus, resulting from a reversible interruption of peripheral conduction along a specific neural pathway to its central integration and perception in the brain. ◆ Local anaesthesia has been defined as loss of sensation in a circumscribed area of the body caused by a depression of excitation in nerve endings or an inhibition in the conduction process of peripheral nerves. 3 Covino BG, Vassallo HG: local anesthetics: mechanisms of acion and clinical use, New York, 1976, Grune and Stratton.
History 4 Earliest pain relief (Incas) – Cocoa shrub , mood elevator- Introduced by Europeans to South America 1855 – Gaedicke extracted alkaloid Erythroxylin 1860 – Dr. Scherzer - cocaine from this alkaloid 1844 – Francis Rynd (Dublin) - Acetate of morphine + Creosote -- Skin incision (marks birth of LA) Sigmund Freud and Carl Koller- Cocaine for eye operation William Steward Halsted - Cocaine for inferior dental nerve block 1886 – BDJ - William Alfred Hunt et al - Cocaine - dental anesthetic documented 1901 – E Mayers- Vasoconstrictor + cocaine 1905- 13 lives claimed – addiction Alfred Einhorn & E Uhlfelder(Sweden) Synthesized Procaine hydrochloride- sterilizable, non-addictive, non-toxic 1943 Nils Lofgren(Sweden) Synthesized - Anilide called Lignocaine Lignocaine – amide linked synthetic derivative 1946 – Lignocaine introduced in Dental practice 1948 – Lignocaine; published in BDJ – Lofgren Sweden – Birth place of newer LA agents •Bupivacaine •Ropivacaine History
Ideal properties ◆ Non irritating to the tissues ◆ Not cause permanent alteration of nerve structure ◆ Low systemic toxicity ◆ Effective as injectable or on topical application ◆ Time of onset as short as possible ◆ Duration of action  Long enough to complete the procedure  Short enough to prevent extended recovery 5
Bennett’s additions (1974) ◆ Potent enough to give complete anesthesia without harmfully concentrating the solution ◆ Free from allergic reactions ◆ Stable in solution & readily undergo biotransformation in the body ◆ Either sterile or capable of being sterilized 6 Bennett CR; Monheim’s local anesthesia and pain control in dental practice, ed 5, St Louis 1974, Mosby
Classification- based on origin 7 Natural Cocaine. Synthetic nitrogenous compound Paraaminobenzoicacid Procaine Benzocaine Acetanilide Lignocaine Quinoline Cinchocoline Non Nitrogenous compounds Benzyl alcohol Miscellaneous Clove oil , Phenol .
Based on intermediate group 8
Based on biological site and mode of action 9
10 • Ultra short acting • <30min - lignocaine • Short acting • 45-90min – min 2% lignocaine with 1:200000 epinephriine • Medium acting • 90-150min – 2%lignocaine with Vc or 4% prilocaine with 1:200000 epinephhrine • Long acting • >180 min - 5% Bupivacaine with 1:200000 epinephrine Injectable • Soluble – cocaine • Insoluble - benzocaine Surface
Composition  Local anesthetic drug –Lignocaine  Vasopressor drug - Adrenaline.  Antioxidant - Sodium Metabisulfite/ Capryl hydrocuprienotoxin  Fungicide - Thymol  Preservative – Methylparaben.  For isotonicity – Normal Saline .  Vehicle – Distilled water to equal the desired amount. 11  Decreased absorption of LA  Increased local concentration of LA  Decreased blood levels and toxicity  Increased potency and duration of action  Decreased bleeding at site of injection
Mode of Action 12 Local anaesthetics slow the rate of depolarization of the nerve potential such that the threshold potential is not reached. As a result, an action potential cannot be propagated in the presence of local anaesthetic and conduction blockade results A. Altering the basic RMP of nerve B. Altering the threshold potential C. Decreasing the rate of depolarization D. Prolonging rate of repolarization
THEORIES OF ACTION OF L.A ◆ Acetylcholine theory ◆ Dettbarn-1967 ◆ Involved in nerve conduction in addition to its role as a neurotransmitter at nerve synapses  No such evidence ◆ Calcium displacement theory ◆ Goldman-1966 ◆ L.A causes nerve block by displacement of Ca from some membrane site that controls entry of Na  Varying conc. of Ca in nerve not seen 13
14 ◆ Surface charge theory ◆ Wei-1969 ◆ Action by binding to nerve membrane and changing its electric potential. ◆ Cationic molecules aligned at membrane water interface –surface electric potential more positively charged ◆ Demerits- RMP not altered by LA. ◆ LA act on nerve channel rather than surface –cannot explain how uncharged LA molecule causes nerve blockage. ◆ Membrane expansion theory ◆ Lee-1976 ◆ LA lipid soluble – enters nerve membrane and changes its configuration. There by reduced space for sodium to enter and thus cause inhibition. ◆ Explains how non ionised drug causes- blockade, nerve membrane do expand and become more fluid when exposed to LA . ◆ No evidence to tell that the whole blockade is due to this phenomenon.
Specific receptor theory ◆ Strichartz-1987 ◆ LA act by binding to specific receptors- sodium channel-on external/ axoplasmic surface. ◆ Once it binds there is no permeability of sodium- no conduction. ◆ LA molecule replace calcium molecule at calcium gate – thus prevent sodium entry. ◆ This is by far the most accepted theory. 15
16
Order of nerve fibre blockade 17
Armamentarium ◆ Syringe ◆ Needle ◆ Cartridge 18
Types of Injection Procedures A. Nerve block: depositing the LA solution within close proximity to a main nerve trunk. B. Field block: depositing a in proximity to the larger nerve branches. C. Local infiltration: small terminal nerve endings are anaesthetized. 19
Anaesthetic Techniques In Paediatric Patients 20
21
Anesthetization of mandibular teeth and soft tissue . CLASSIFICATION OF INFERIOR ALVEOLAR NERVE BLOCK 22 Intraoral Open mouth Direct technique Modified direct technique (by Charles Hopkins) Angelo Sargenti technique Direct thrust technique Modified direct thrust technique (by Dr. Borris Levill) Brownlee’s modification of direct thrust technique Indirect technique Fischer 123 technique Clarke and Holmes technique Anterior ramus technique Curved needle technique Closed mouth Vazirani-Akinosi technique Extra oral Technique by Kurt Thoma
23 Common anatomical landmarks 1. Mucobuccal fold 2. Internal oblique ridge 3. External oblique ridge 4. Retromolar triangle 5. Pterygomandibular ligament 6. Pterygomandibular space 7. Buccal sucking pad 8. Anterior border of ramus of mandible
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 paediatric patient. ◆ The injection must be made slightly lower and more posteriorly than for an adult patient ◆ The depth of insertion should be 15 mm approx. and around I ml of solution must be deposited. 24 Before 6 years 6- 12 years After 12 years
Landmarks 1. Coronoid notch 2. Pterygomandibular raphe 3. Occlusal plane of the mandibular posterior teeth. 25 ◆ 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 treatment, extraction, pulp therapy and if can’t apply mental block due to infection
26 Operator position for right handed- For right IANB- 8 O clock facing the patient For left IANB- 10 O clock facing the same side as patient Patient position- Supine or semi supine position
Techniques for paediatric patients 1. Inverted triangle concept (by Mathewson) 2. Thumb concept (by Wright) 3. Lingula technique 27
Inverted triangle concept (by Mathewson)  Anterior border of ramus is palpated with finger or thumb in its greatest curvature  Imaginary triangle is formed by anterior border of ramus internal pterygoid muscle vault of palate (apex lying inferiorly)  An imaginary longitudinal line dividing the tip of finger/thumb as it rests in coronoid notch  Passes medially over depressed area just above apex  Solution is injected at midpoint of the line 28
Thumb concept (by Wright) ◆ For right IAN block , middle of left thumbnail is positioned at coronoid notch and lightly over deep tendon of temporalis muscle ◆ Needle penetrates the tissue at middle of thumbnail carried between deep tendon of temporalis (laterally) and pterygomandibular raphe (medially) enter mandibular sulcus at the level of lingular notch 29
Lingula technique ◆ Mandibular foramen in children( lower level )than the occlusal level of the primary teeth ◆ Therefore injection has to be administered lower and posterior to the position ◆ Anterior and posterior edges of ramus are palpated for targeting lingual ◆ However success rate with lingula as a landmark is lower 30
Lilngual nerve block ◆ By bringing the syringe to the opposite side with the injection. ◆ If small amounts of la solution are injected during insertion and withdrawal of the needle during inferior alveolar nerve block – lingual nerve will be invariably anesthetised. 31
Long Buccal Nerve Block ◆ Site of injection ◆ Mucous membrane distal and buccal to the most distal molar tooth in the arch. ◆ Area Anesthetized ◆ Soft tissue and periosteum buccal to the mandibular molar teeth. ◆ For the removal of permanent mandibular molar or for placement of rubber dam on teeth in that region 32
Infiltration anaesthesia for primary mandibular molars ◆ Mandibular infiltration is an effective technique when performing a class I or II amalgam or an SSC restoration in a primary molar, both in primary and mixed dentition. ◆ When a pulpotomy was attempted, infiltration was effective in only 61% of the teeth evaluated as anesthetized upon probing, rubber dam placement, and preparation. Therefore, the technique cannot be considered to be reliable in the case of a pulpotomy ◆ Mandibular infiltration anaesthesia produces adequate anaesthesia in mandibular deciduous molars for most restorative procedures. 33 The effectiveness of mandibular infiltration compared to mandibular block anesthesia in treating primary molars in children Constantine J. Oulis, DDS, MS George P. Vadiakas, DDS, MS Aspa Vasilopoulou, DDS : Pediatric Dentistry - 18:4, 1996 American Academy ofPediatric Dentis
Mental Nerve Block ◆ Anatomy: The mental nerve is a continuation of the inferior alveolar nerve that innervates the lower lateral lip and the skin of the ipsilateral side of the mandible. It exits through the mental nerve foramen, which lies inferior to the second mandibular bicuspid. ◆ Landmark Technique: There are 2 approaches for the mental block: intraoral and extraoral. In the intraoral approach, the needle is inserted adjacent to the second mandibular premolar in a 45° angle toward the mental foramen. Anesthetic is infiltrated adjacent to the foramen, not in the foramen, which may result in ischemic nerve damage. In the extraoral approach, a similar trajectory is used with the needle, except the needle is inserted through the prepared skin superior to the mental foramen. The anesthetic is injected above and around the mental foramen, avoiding direct injection into the mental foramen. 34 Pediatric Nerve Blocks: An Evidence-Based Approach Sacha Duchicela,. Anthoney Lim, MD: Pediatric Emergency Medicine Practice, www.ebmedicine.net • October 2013.
◆ For right or left mental nerve block, a right handed operator should sit comfortably on front of the patient so the syringe may be placed into the mouth below the patient’s line if sight. 35
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. 36
Gow Gates Mandibular Block ◆ This approach uses external anatomic landmarks ( Intertragel notch) to align the needle. ◆ A nerve block procedure that anesthetizes the entire distribution of the fifth cranial nerve in the mandibular area. 37
38 Clinical evaluation of the Gow-Gates block in children. A. Yamada and J. T. Jasstak Anesth Prog. 1981 Jul-Aug; 28(4): 106–109
Anaesthetization of maxillary teeth and soft tissue ◆ Anesthetization of the primary anterior teeth – single tooth. ◆ Local infiltration or supraperiosteal technique- the needle is penetrated at the soft tissue at the mucobuccal fold. The solution is deposited slowly and slightly above and close to the apex of the tooth. 39
Anterior Superior Alveolar Nerve Block (ASA)- Infraorbital nerve block ◆ Indications ◆ More than two maxillay teeth ◆ Inflammation and infection ◆ When supraperiosteal injections are ineffective ◆ Contra indications ◆ Discrete treatment areas ◆ Hemostasis of localized areas 40 Pulp of the maxillary central incisor through the canine 72% of patients have premolars and mesiobuccal root of 1st molar anesthetized Buccal peiodontium and bone of these same teeth Lower eyelid, lateral aspects of the nose and upper lip
41 Landmarks: Infra orbital Notch, Mucobuccal fold, Infra orbital Foramen Feel the infra orbital notch moving your finger down the notch palpating the tissues gently; the outward bulge is the lower border of the orbit which is the roof of the infra orbital foramen; continue the finger inferiorly until a depression is felt which is the infra orbital foramen
Anesthetization of maxillary primary molars ◆ The maxillary primary molars are innervated by middle superior alveolar nerve. Whereas permanent molars are innervated by PSA nerve. ◆ Jorgensen demonstrated that there is plexus formation of MSA and PSA first the primary molar region. ◆ Buccal cortical plate at maxillary primary first molar – thin; where as in primary second molar thick. ◆ Hence the supraperiosteal injection is supplemented by a PSA – superior to the maxillary tuberosity. 42 Jorgensen NB – sedation, local and general anesthesia in dentistry: ed 3, Philadelphia, 1980, Lea and Febiger
Supraperiostial 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. ◆ Landmark: insertion 45 to Long acsses of the tooth 1. Mucobuccal fold. 2. Crown of the tooth. 3. Root contour of the tooth ◆ Areas Anesthetized 1. Pulp and root area of the tooth. 2. Buccal periosteum. 3. Connective tissue. 4. Mucous membrane 43 Contraindications Inflammation at site of injection Dense bone
Posterior Superior Alveolar Nerve Block (PSA) ◆ Highly successful nerve block with greater than 95% success. ◆ Effective for permanent maxillary molars and buccal periodontium-77 to 100%  Short dental needle is recommended to decrease the risk of hematoma formation.  Average depth of soft tissue penetration is 16 mm (short needle is 20 mm in length)  Mesiobuccal root of the maxillary 1st molar is not consistently innervated by the PSA nerve  Loetscher and associates- 28% of maxillary 1st molars’ mesiobuccal roots are innervated by the middle superior alveolar nerve (MSA). ◆ Areas Anesthetized ◆ Pulps of maxillary molars, buccal periosteum, bone overlying these tooth 44
45
Hematoma: ◆ if needle is over inserted too far posteriorly into the Pterygoid plexus of veins leads to this hematoma ◆ Visible intraoral hematoma develops within minutes; bleeds until the pressure of the extravascular blood equals that of the intravascular blood which can result in a large, unsightly hematoma ◆ The mandibular division of fifth cranial nerve is located lateral to PSA nerve. Deposition of local anaesthetic lateral to desired location may produce varying degree of mandibular anaesthesia 46
Middle Superior Alveolar Nerve Block 47
Palatal injections - 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. 48
Palatal injections - Nasoplatine Nerve Block ◆ Blocking the nasopalatine nerve anesthetizes the palatal tissues of the six anterior teeth. ◆ This technique is painful and is not routinely used before operative procedures. ( apply pressure to decrease pain). 49
Supplemental Injection Technique 1) 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. 50
Intrapulpal Injection: ◆ 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 51
Intraosseous Injection: ◆ Require the deposition of local anesthetic solution in the porous alveolar bone. ◆ By forcing a needle through the cortical plate and into the cancellous alveolar bone Or a small, round bur may be used to make an access in the bone for the needle. 52
ASA Classification for Paediatric dental patients- 1962 53 Class Status I Normal healthy patient II Patient with mild systemic disease.(eg. Controlled reactive airway disease) III Patient with severe systemic disease (eg. Child who is actively wheezing) IV Patient with severe systemic disease that is a constant threat to life (e.g. Child with status asthamaticus) V Moribund patient not expected to survive without an operation (e.g. Patient with severe cardiomyopathy requiring heart transplantation)
54
Percentage method for calculating doses in children ◆ Rule of 10: ◆ Add patient’s age to the no .of the tooth being treated ◆ <10 – infiltration is sufficient or else regional block administration 55 Age (years) Mean weight (kg) Approximate percentage of adult dose 1 10 25 3 15 33 5 18 40 7 23 50 12 39 75 Adult 68 100
Dose Calculation 56
OraVerse: Reverses Numbness After Dental Procedures J. S. Prasanna J Maxillofac Oral Surg. 2012 Jun; 11(2): 212–219. ◆ OraVerse is a formulation of phentolamine mesylate that accelerates the return to normal sensation and function for patients after routine dental procedures. ◆ The maximum recommended dose of OraVerse is two cartridges in patients’ age 12 or greater, one cartridge in children age 6–11 years and weighing over 66 lbs, and one half cartridge in children 6–11 years and weighing 33– 66 lbs. OraVerse is not indicated in children less than 6 years of age or weighing less than 33 lbs. It is not recommended to use after invasive procedures such as endodontic treatment or surgery, where post-operative discomfort is anticipated 57
“Guideline on Use of Local Anesthesia for Pediatric Dental Patients AMERICAN ACADEMY OF PEDIATRIC DENTISTRY Adopted 2005 Revised 2009, 2015 58
Topical anesthetic ◆ Topical anesthetic is effective on surface tissues (up to two to three mm in depth) to reduce painful needle penetration of the oral mucosa. ◆ Topical anesthetic agents are available in gel, liquid, ointment, patch, and aerosol forms. ◆ The US Food and Drug Administration (FDA) has issued a warning about the use of compounded topical anesthetics and the risk of methemoglobinemia. ◆ Risk of acquired methe-moglobinemia has been associated primarily with two local anesthetics: prilocaine and benzocaine. There is no evidence of other local anesthetics contributing to the etiology of methemoglobinemia. ◆ Benzocaine, the most commonly used topical anesthetic, is available in concentrations up to 20 per-cent and comes in liquid, spray, and gel forms. 59
Recommendations- Topical anesthetics 1. Topical anesthetic may be used prior to the injection of a local anesthetic to reduce discomfort associated with needle penetration. 2. The pharmacological properties of the topical agent should be understood. 3. A metered spray is recommended if an aerosol preparation is selected. 4. Systemic absorption of the drugs in topical anesthetics must be considered when calculating the total amount of anesthetic administered 60
Selection of syringes and needles ◆ The American Dental Association (ADA) has long standing standards for aspirating syringes for use in the administration of local anesthesia. ◆ Dental needles are available in three lengths: long (32 mm), short (20 mm), and ultrashort (10 mm). Needle gauges range from size 23 to 30. 61 Recommendations: syringes 1. Any 23- through 30-gauge needle may be used for intraoral injections, since blood can be aspirated through all of them. Aspiration can be more difficult, however, when smaller gauge needles are used. An extra-short, 30-gauge is appropriate for certain infiltration injections. 2. Needles should not be bent if they are to be inserted into soft tissue to a depth of greater than five millimeters or inserted to their hub for injections to avoid needle breakage
62 Injectable local anesthetic agents- Recommendations: 1. Selection of local anesthetic agents should be based upon: — the patient’s medical history and mental/develop- mental status; — the anticipated duration of the dental procedure; — the need for hemorrhage control; — the planned administration of other agents (eg, nitrous oxide, sedative agents, general anesthesia) — the practitioner’s knowledge of the anesthetic agent. 2. Use of vasoconstrictors in local anesthetics is recommended to decrease the risk of toxicity of the anes- thetic agent, especially when treatment extends to two or more quadrants in a single visit. 3. In cases of bisulfate allergy, use of a local anesthetic without a vasoconstrictor is indicated. A local anes- thetic without a vasoconstrictor also can be used for shorter treatment needs but should be used with caution to minimize the risk of toxicity of the anesthetic agents. 4. The established maximum dosage for any anesthetic should not be exceeded. 5. Administration of local anesthetic should be based on the weight/body mass index (BMI) of the patient, not to exceed AAPD recommendations.
63
Documentation of local anesthesia- Recommendations 1. Documentation must include the type and dosage of local anesthetic. Dosage of vasoconstrictors, if any, must be noted. (For example, 34 mg lido with 0.017 mg epi or 34 mg lido with 1:100,000 epi). 2. Documentation may include the type of injection(s) given (eg, infiltration, block, intraosseous), needle selection, and patient’s reaction to the injection. 3. In patients for whom the maximum dosage of local anesthetic may be a concern, the weight should be documented preoperatively. 4. If the local anesthetic was administered in conjunc- tion with sedative drugs, the doses of all agents must be noted on a time-based record. 5. Documentation should include that post-injection instructions were reviewed with the patient and parent. 64
Recommendations to reduce local anesthetic complications 1. Practitioners who utilize any type of local anesthetic in a pediatric dental patient should have appropriate training and skills and have available the proper facilities, personnel, and equipment to manage any reasonably foreseeable emergency. 2. Care should be taken to ensure proper needle placement during the intraoral administration of local anesthetics. Practitioners should aspirate before every injection and inject slowly. 3. Following an injection, the doctor, hygienist, or assistant should remain with the patient while the anesthetic begins to take effect. 4. Residual soft tissue anesthesia should be minimized in pediatric and special health care needs patients to decrease risk of self-inflicted postoperative injuries. 5. Practitioners should advise patients and their care-givers regarding behavioral precautions (eg, do not bite or suck on lip/cheek, do not ingest hot sub-stances) and the possibility of soft tissue trauma while anesthesia persists. Placing a cotton roll in the mucobuccal fold may help prevent injury, and lubricating the lips with petroleum jelly helps prevent drying.6,7 Practitioners who use pheytolamine mesylate injectionsto reduce the duration of local anesthesia still should follow these recommendations. 65
Local Anesthesia and Pregnancy- recommendations 1. The use of local anesthesia during pregnancy generally is considered safe. Overall maternal oral health and the possibility of infection are important considerations. Benefits and risks should be considered. Local anesthesia without a vasoconstrictor should be considered. 2. Proper local anesthetic technique is a necessity. Aspiration to avoid intravascular injection, proper needle placement accuracy, and attention to dosages are critical. 3. Ester anesthetics should be avoided because of potential for allergenicity. . 4. Prilocaine should not be used due to risk of the foetus developing methhemoglobinemia 5. While lidocaine is considered the best choice of local anesthetic, mepivacaine and bupivacaine (both FDA Category C) can be used. 6. In second and third trimesters, proper positioning and heart rate monitoring are important to avoid postural hypotension. 7. During lactation, the use of local anesthetics without vasoconstrictors may be considered to avoid possible idiosyncratic reaction to the neonate, not to the vasoconstrictor but to the preservative used to stabilize the vasoconstrictor.66
Recent advances for pain control ◆ Jet syringe ◆ Vibra jet ◆ Dental vibe ◆ Wand ◆ Electronic dental anesthesia 67
LOCAL COMPLICATIONS ◆ Needle breakage ◆ Pain on injection ◆ Burning on injection ◆ Persistent anaesthesia or paresthesia ◆ Trismus ◆ Hematoma ◆ Sloughing of the tissue / soft tissue injury ◆ Facial nerve paralysis 68
SYSTEMIC COMPLICATIONS ◆ Toxicity ◆ Idiosyncracy ◆ Allergy ◆ Anaphylactoid reaction ◆ Syncope 69
References ◆Mcdonald and Avery’s Dentistry for the child and adolescent 10th edition . ◆Fundamentals of Pediatric Dentistry , 2nd revised edition , Mathewson/Primosch/Robertson. ◆Chaurasia BD.Human Anatomy- regional and applied dissection and clinical- vol 3, 4th edition, CBS publishers ◆C. Richard Bennett. Monheim’s local anaesthesia and pain control in dental practice Seventh Ed.1990. CBS Publishers, New Delhi. ◆Stanley Malamed. Handbook of Local Anaesthesia 6th edition. ◆D H Roberts, J H Sowray ‘local analgesia in dentistry” 2nd edition John Wright sons, limited publications. 1954 ◆Textbook of paediatric dentistry Nikhil Marwah edition 3. 70
Thank You 71

More Related Content

PPTX
MANDIBULAR NERVE BLOCK in pediatric
byد.عبد الله الناصر
 
PPTX
Local Anesthesia - Paedodontics
byDr Reem Ayesha
 
PPTX
Local Anesthesia in Pediatric Dentistry.pptx
bymohamedAbdelbaset44
 
PPTX
LA in Pedodontics
byJean Michael
 
PPTX
Local anesthesia
byRahaf Sn
 
PDF
Local anesthesia in pediatric dentistry
byDr. Lilavanti vaghela
 
PPTX
Agents used for sedation in pediatric dentistry
byAya Adel
 
PPTX
Local anaesthesia for children (dentistry)
byjhansi mutyala
 
MANDIBULAR NERVE BLOCK in pediatric
byد.عبد الله الناصر
 
Local Anesthesia - Paedodontics
byDr Reem Ayesha
 
Local Anesthesia in Pediatric Dentistry.pptx
bymohamedAbdelbaset44
 
LA in Pedodontics
byJean Michael
 
Local anesthesia
byRahaf Sn
 
Local anesthesia in pediatric dentistry
byDr. Lilavanti vaghela
 
Agents used for sedation in pediatric dentistry
byAya Adel
 
Local anaesthesia for children (dentistry)
byjhansi mutyala
 

What's hot

PPT
Oral habits - pedodontics
byDr. Elvis David
 
PPTX
MANAGEMENT OF BRUXISM, LIP BITING AND MASOCHISTIC HABITS
byaanchalshruti
 
PPTX
Mandibular nerve blocks techniques
byANNOOR DENTAL COLLEGE,MUVATTUPUZHA
 
PPTX
healing of extraction socket power point presentation
byaggarwalaayushi98
 
PPTX
Local Anesthesia for pediatric dentistry
byRahaf Sn
 
PPTX
Local Anesthesia in Dentistry
byDr.Priyanka Sharma
 
PPTX
Local anaesthesia - Basics in dentistry
byDr.Prashant Karasu
 
PPT
Avulsion
byDr. Praveen Katepogu
 
PPT
Bevels and flares in dental restoration
byDr. Mayank Nahta
 
PPT
Pulp vitality test new
bysuraj nair
 
PPT
Posterior superior alveolar (psa) nerve block
byDr Chirag Ananth
 
PPTX
Chlorhexidine
byJanani Arvind
 
PPTX
Obturating materials for primary tooth
byjhansi mutyala
 
PPTX
Gingival crevicular fluid
byDr. Virshali Gupta
 
PPT
Recent Advances in local Anaesthesia in dentistry
byDr.Prashant Karasu
 
DOCX
ExtraOral Nerve Block Techniques
bySourendra Nath Basu
 
PPTX
Oral screen
bydayadayal
 
PPT
Space maintainer
bySaeed Bajafar
 
PPTX
Preventive resin restoration ppt
byAnu S
 
PPTX
Vestibuloplasty
byvrushupatel
 
Oral habits - pedodontics
byDr. Elvis David
 
MANAGEMENT OF BRUXISM, LIP BITING AND MASOCHISTIC HABITS
byaanchalshruti
 
Mandibular nerve blocks techniques
byANNOOR DENTAL COLLEGE,MUVATTUPUZHA
 
healing of extraction socket power point presentation
byaggarwalaayushi98
 
Local Anesthesia for pediatric dentistry
byRahaf Sn
 
Local Anesthesia in Dentistry
byDr.Priyanka Sharma
 
Local anaesthesia - Basics in dentistry
byDr.Prashant Karasu
 
Avulsion
byDr. Praveen Katepogu
 
Bevels and flares in dental restoration
byDr. Mayank Nahta
 
Pulp vitality test new
bysuraj nair
 
Posterior superior alveolar (psa) nerve block
byDr Chirag Ananth
 
Chlorhexidine
byJanani Arvind
 
Obturating materials for primary tooth
byjhansi mutyala
 
Gingival crevicular fluid
byDr. Virshali Gupta
 
Recent Advances in local Anaesthesia in dentistry
byDr.Prashant Karasu
 
ExtraOral Nerve Block Techniques
bySourendra Nath Basu
 
Oral screen
bydayadayal
 
Space maintainer
bySaeed Bajafar
 
Preventive resin restoration ppt
byAnu S
 
Vestibuloplasty
byvrushupatel
 

Similar to Local anesthesia in children

PPTX
Local Anesthesia in dentistry 76890.pptx
byDurveshPatil17
 
PPTX
Local anesthesia in dentistry : RECENT ADVANCES
byPooja Jayan
 
PPTX
Localans 140906145706-phpapp02-160924162017
byMaryam Arbab
 
PPTX
Local anaesthesia
byMohammed Haneef Farooq
 
PPTX
Local anesthesia IN PERIODONTICS DR.ANIZ.pptx
byPrasanthThalur
 
PPT
Maxillary injection techniques
byNishant Khurana
 
PDF
la-141122030742-conversion-gate01.pdf
byHaroonButt17
 
PPTX
3.local anesthesia in dentistry pptx presentation
byVaishnaviReddy529705
 
PDF
LOCAL ANESTHESIA IN ORAL AND MAXILLOFACIAL SURGERY
byARSHIYAGARG1
 
PPSX
Techniques for local anasthesia in dentistry
byMohammed Rhael
 
PPTX
local anaesthesia used in dentistery ppt
byhtetmyat553419
 
PPTX
LOCAL ANESTHESIA.pptx
byDrLasya
 
PPTX
An introduction to local anaesthesia in dentistry
byChristis Isseyegh
 
PPTX
LOCAL ANESTHESIA ITS TYPES/ CLASSIFICATION/ MECHANISM OF ACTION USES, PHARACO...
bySerat Rahman
 
PDF
Pain management in Restorative dentistry and Endodontics - fathima newpdf.pdf
byNAVANEETH KRISHNA
 
PPTX
جراحة الفم والاسنان المحاضره الثانيه .pptx
byAbodAldomini1
 
PPTX
local anesthesia: Uses, Types, Side effects and Safety
byPrachiRathi40
 
PPTX
Local Anesthesia
byHadi Munib
 
PPTX
basic techniques of dental local anesthesia.pptx
byMohammed kareem
 
PPTX
LOCAL ANESTHESIA.pptx
byalpeshbista1
 
Local Anesthesia in dentistry 76890.pptx
byDurveshPatil17
 
Local anesthesia in dentistry : RECENT ADVANCES
byPooja Jayan
 
Localans 140906145706-phpapp02-160924162017
byMaryam Arbab
 
Local anaesthesia
byMohammed Haneef Farooq
 
Local anesthesia IN PERIODONTICS DR.ANIZ.pptx
byPrasanthThalur
 
Maxillary injection techniques
byNishant Khurana
 
la-141122030742-conversion-gate01.pdf
byHaroonButt17
 
3.local anesthesia in dentistry pptx presentation
byVaishnaviReddy529705
 
LOCAL ANESTHESIA IN ORAL AND MAXILLOFACIAL SURGERY
byARSHIYAGARG1
 
Techniques for local anasthesia in dentistry
byMohammed Rhael
 
local anaesthesia used in dentistery ppt
byhtetmyat553419
 
LOCAL ANESTHESIA.pptx
byDrLasya
 
An introduction to local anaesthesia in dentistry
byChristis Isseyegh
 
LOCAL ANESTHESIA ITS TYPES/ CLASSIFICATION/ MECHANISM OF ACTION USES, PHARACO...
bySerat Rahman
 
Pain management in Restorative dentistry and Endodontics - fathima newpdf.pdf
byNAVANEETH KRISHNA
 
جراحة الفم والاسنان المحاضره الثانيه .pptx
byAbodAldomini1
 
local anesthesia: Uses, Types, Side effects and Safety
byPrachiRathi40
 
Local Anesthesia
byHadi Munib
 
basic techniques of dental local anesthesia.pptx
byMohammed kareem
 
LOCAL ANESTHESIA.pptx
byalpeshbista1
 

More from Dr. Nameeda K. S.

PPTX
Nmj part 1
byDr. Nameeda K. S.
 
PPTX
Part 2
byDr. Nameeda K. S.
 
PPTX
Inflammation part 1
byDr. Nameeda K. S.
 
PPTX
Rehabilitation
byDr. Nameeda K. S.
 
PPTX
Vitamin k and e
byDr. Nameeda K. S.
 
PPTX
Vitamin k and e
byDr. Nameeda K. S.
 
PPTX
Fluorosis index
byDr. Nameeda K. S.
 
Nmj part 1
byDr. Nameeda K. S.
 
Part 2
byDr. Nameeda K. S.
 
Inflammation part 1
byDr. Nameeda K. S.
 
Rehabilitation
byDr. Nameeda K. S.
 
Vitamin k and e
byDr. Nameeda K. S.
 
Vitamin k and e
byDr. Nameeda K. S.
 
Fluorosis index
byDr. Nameeda K. S.
 

Recently uploaded

PDF
Enhancing the Patient Journey in CIDP: Strategies for Improved Detection and ...
byi3 Health
 
PPTX
CATARACT SURGERY... KAL AAJ AUR KAL... THE PAST, THE PRESENT AND THE FUTURE.
byirfanrawal
 
PDF
appendix mucinous tumores.pdf jkljkljkljlkjkljlkjlk
byssuser947a1f
 
PPTX
1 Digestion of carbohydrates -digestion, absorption, clinical significance
byProf Viyatprajna Acharya
 
PDF
Smoking Impact Diagnostic Panel: Understanding Smoking's Hidden Impact on You...
byFelixRendon3
 
PDF
Bachelors in nursing science TOS Sem I KMU (1).pdf
byjesusebagahj73
 
PPTX
Basement membrane zone .pptx
bySaiDeshmukh23
 
PPTX
Hormonal IUS (Mirena®) Common Myths.pptx
byWafaa Benjamin
 
PPTX
An Age Reversal Update -- Bill Faloon --
byChurch Of Perpetual Life
 
PPTX
Social pharmacy :Nutrition and Health programme
byRupali kote
 
PPTX
ABCDE Assessment What and all comes under assessmnet
byMs. Yagya Koirala
 
PPTX
NDIS Accommodation in Redbank Plains.pptx
bysuperiorqualitycare
 
PPTX
Heat stroke General medicine Seminar .pptx
bypvmsiddharth
 
PPTX
Glasgow coma scale .pptx GCS by EYES response VERBAL response MOTOR response
byMAHEK KHAN
 
PDF
THERAPEUTIC PLASMA EXCHANGE BROCHURE.pdf
byDr Rashmi Sood
 
PDF
Ultrasound NT Scan: First Trimester Nuchal Translucency Screening Guide
byFelixRendon3
 
PPT
Anatomy of oesophagus physiology of the esophagus first attempt.ppt
byheadent
 
PPTX
Mental Status Examination | B.Sc Nursing 5th Semester | Mental Health Nursing I
bydhananjaydongare5
 
PPTX
1.3 inflamation, introduction to inflamation by Dr Lelaka.pptx
byjustin716667
 
PDF
Catalysts for Enhanced Patient CARE In Neuroendocrine Neoplasms: Clinical Ado...
byPVI, PeerView Institute for Medical Education
 
Enhancing the Patient Journey in CIDP: Strategies for Improved Detection and ...
byi3 Health
 
CATARACT SURGERY... KAL AAJ AUR KAL... THE PAST, THE PRESENT AND THE FUTURE.
byirfanrawal
 
appendix mucinous tumores.pdf jkljkljkljlkjkljlkjlk
byssuser947a1f
 
1 Digestion of carbohydrates -digestion, absorption, clinical significance
byProf Viyatprajna Acharya
 
Smoking Impact Diagnostic Panel: Understanding Smoking's Hidden Impact on You...
byFelixRendon3
 
Bachelors in nursing science TOS Sem I KMU (1).pdf
byjesusebagahj73
 
Basement membrane zone .pptx
bySaiDeshmukh23
 
Hormonal IUS (Mirena®) Common Myths.pptx
byWafaa Benjamin
 
An Age Reversal Update -- Bill Faloon --
byChurch Of Perpetual Life
 
Social pharmacy :Nutrition and Health programme
byRupali kote
 
ABCDE Assessment What and all comes under assessmnet
byMs. Yagya Koirala
 
NDIS Accommodation in Redbank Plains.pptx
bysuperiorqualitycare
 
Heat stroke General medicine Seminar .pptx
bypvmsiddharth
 
Glasgow coma scale .pptx GCS by EYES response VERBAL response MOTOR response
byMAHEK KHAN
 
THERAPEUTIC PLASMA EXCHANGE BROCHURE.pdf
byDr Rashmi Sood
 
Ultrasound NT Scan: First Trimester Nuchal Translucency Screening Guide
byFelixRendon3
 
Anatomy of oesophagus physiology of the esophagus first attempt.ppt
byheadent
 
Mental Status Examination | B.Sc Nursing 5th Semester | Mental Health Nursing I
bydhananjaydongare5
 
1.3 inflamation, introduction to inflamation by Dr Lelaka.pptx
byjustin716667
 
Catalysts for Enhanced Patient CARE In Neuroendocrine Neoplasms: Clinical Ado...
byPVI, PeerView Institute for Medical Education
 

Local anesthesia in children

  • 1.
    Local Anaesthesia and Exodontiain Children Dr Nameeda K S
  • 2.
    Contents Local anaesthesia 1. Classification 2.Composition 3. Mechanism of action 4. Theories 5. ASA Classification 6. Techniques for anesthesization Maxillary and Mandibular primary teeth 7. Complications 8.Dosage consideration 2 ◆ AAPD guidelines ◆ Recent techniques for pain less
  • 3.
    Local Anaesthesia ◆ Itis defined as a transient loss of sensation to a painful or potentially painful stimulus, resulting from a reversible interruption of peripheral conduction along a specific neural pathway to its central integration and perception in the brain. ◆ Local anaesthesia has been defined as loss of sensation in a circumscribed area of the body caused by a depression of excitation in nerve endings or an inhibition in the conduction process of peripheral nerves. 3 Covino BG, Vassallo HG: local anesthetics: mechanisms of acion and clinical use, New York, 1976, Grune and Stratton.
  • 4.
    History 4 Earliest pain relief(Incas) – Cocoa shrub , mood elevator- Introduced by Europeans to South America 1855 – Gaedicke extracted alkaloid Erythroxylin 1860 – Dr. Scherzer - cocaine from this alkaloid 1844 – Francis Rynd (Dublin) - Acetate of morphine + Creosote -- Skin incision (marks birth of LA) Sigmund Freud and Carl Koller- Cocaine for eye operation William Steward Halsted - Cocaine for inferior dental nerve block 1886 – BDJ - William Alfred Hunt et al - Cocaine - dental anesthetic documented 1901 – E Mayers- Vasoconstrictor + cocaine 1905- 13 lives claimed – addiction Alfred Einhorn & E Uhlfelder(Sweden) Synthesized Procaine hydrochloride- sterilizable, non-addictive, non-toxic 1943 Nils Lofgren(Sweden) Synthesized - Anilide called Lignocaine Lignocaine – amide linked synthetic derivative 1946 – Lignocaine introduced in Dental practice 1948 – Lignocaine; published in BDJ – Lofgren Sweden – Birth place of newer LA agents •Bupivacaine •Ropivacaine History
  • 5.
    Ideal properties ◆ Nonirritating to the tissues ◆ Not cause permanent alteration of nerve structure ◆ Low systemic toxicity ◆ Effective as injectable or on topical application ◆ Time of onset as short as possible ◆ Duration of action  Long enough to complete the procedure  Short enough to prevent extended recovery 5
  • 6.
    Bennett’s additions (1974) ◆Potent enough to give complete anesthesia without harmfully concentrating the solution ◆ Free from allergic reactions ◆ Stable in solution & readily undergo biotransformation in the body ◆ Either sterile or capable of being sterilized 6 Bennett CR; Monheim’s local anesthesia and pain control in dental practice, ed 5, St Louis 1974, Mosby
  • 7.
    Classification- based onorigin 7 Natural Cocaine. Synthetic nitrogenous compound Paraaminobenzoicacid Procaine Benzocaine Acetanilide Lignocaine Quinoline Cinchocoline Non Nitrogenous compounds Benzyl alcohol Miscellaneous Clove oil , Phenol .
  • 8.
  • 9.
  • 10.
    10 • Ultra shortacting • <30min - lignocaine • Short acting • 45-90min – min 2% lignocaine with 1:200000 epinephriine • Medium acting • 90-150min – 2%lignocaine with Vc or 4% prilocaine with 1:200000 epinephhrine • Long acting • >180 min - 5% Bupivacaine with 1:200000 epinephrine Injectable • Soluble – cocaine • Insoluble - benzocaine Surface
  • 11.
    Composition  Local anestheticdrug –Lignocaine  Vasopressor drug - Adrenaline.  Antioxidant - Sodium Metabisulfite/ Capryl hydrocuprienotoxin  Fungicide - Thymol  Preservative – Methylparaben.  For isotonicity – Normal Saline .  Vehicle – Distilled water to equal the desired amount. 11  Decreased absorption of LA  Increased local concentration of LA  Decreased blood levels and toxicity  Increased potency and duration of action  Decreased bleeding at site of injection
  • 12.
    Mode of Action 12 Localanaesthetics slow the rate of depolarization of the nerve potential such that the threshold potential is not reached. As a result, an action potential cannot be propagated in the presence of local anaesthetic and conduction blockade results A. Altering the basic RMP of nerve B. Altering the threshold potential C. Decreasing the rate of depolarization D. Prolonging rate of repolarization
  • 13.
    THEORIES OF ACTIONOF L.A ◆ Acetylcholine theory ◆ Dettbarn-1967 ◆ Involved in nerve conduction in addition to its role as a neurotransmitter at nerve synapses  No such evidence ◆ Calcium displacement theory ◆ Goldman-1966 ◆ L.A causes nerve block by displacement of Ca from some membrane site that controls entry of Na  Varying conc. of Ca in nerve not seen 13
  • 14.
    14 ◆ Surface chargetheory ◆ Wei-1969 ◆ Action by binding to nerve membrane and changing its electric potential. ◆ Cationic molecules aligned at membrane water interface –surface electric potential more positively charged ◆ Demerits- RMP not altered by LA. ◆ LA act on nerve channel rather than surface –cannot explain how uncharged LA molecule causes nerve blockage. ◆ Membrane expansion theory ◆ Lee-1976 ◆ LA lipid soluble – enters nerve membrane and changes its configuration. There by reduced space for sodium to enter and thus cause inhibition. ◆ Explains how non ionised drug causes- blockade, nerve membrane do expand and become more fluid when exposed to LA . ◆ No evidence to tell that the whole blockade is due to this phenomenon.
  • 15.
    Specific receptor theory ◆Strichartz-1987 ◆ LA act by binding to specific receptors- sodium channel-on external/ axoplasmic surface. ◆ Once it binds there is no permeability of sodium- no conduction. ◆ LA molecule replace calcium molecule at calcium gate – thus prevent sodium entry. ◆ This is by far the most accepted theory. 15
  • 16.
  • 17.
    Order of nervefibre blockade 17
  • 18.
  • 19.
    Types of InjectionProcedures A. Nerve block: depositing the LA solution within close proximity to a main nerve trunk. B. Field block: depositing a in proximity to the larger nerve branches. C. Local infiltration: small terminal nerve endings are anaesthetized. 19
  • 20.
  • 21.
  • 22.
    Anesthetization of mandibularteeth and soft tissue . CLASSIFICATION OF INFERIOR ALVEOLAR NERVE BLOCK 22 Intraoral Open mouth Direct technique Modified direct technique (by Charles Hopkins) Angelo Sargenti technique Direct thrust technique Modified direct thrust technique (by Dr. Borris Levill) Brownlee’s modification of direct thrust technique Indirect technique Fischer 123 technique Clarke and Holmes technique Anterior ramus technique Curved needle technique Closed mouth Vazirani-Akinosi technique Extra oral Technique by Kurt Thoma
  • 23.
    23 Common anatomical landmarks 1.Mucobuccal fold 2. Internal oblique ridge 3. External oblique ridge 4. Retromolar triangle 5. Pterygomandibular ligament 6. Pterygomandibular space 7. Buccal sucking pad 8. Anterior border of ramus of mandible
  • 24.
    Inferior Alveolar NerveBlock + Lingual Nerve Block ◆ The mandibular foramen is situated at a level lower than the occlusal plane of the primary teeth of the paediatric patient. ◆ The injection must be made slightly lower and more posteriorly than for an adult patient ◆ The depth of insertion should be 15 mm approx. and around I ml of solution must be deposited. 24 Before 6 years 6- 12 years After 12 years
  • 25.
    Landmarks 1. Coronoid notch 2.Pterygomandibular raphe 3. Occlusal plane of the mandibular posterior teeth. 25 ◆ 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 treatment, extraction, pulp therapy and if can’t apply mental block due to infection
  • 26.
    26 Operator position forright handed- For right IANB- 8 O clock facing the patient For left IANB- 10 O clock facing the same side as patient Patient position- Supine or semi supine position
  • 27.
    Techniques for paediatricpatients 1. Inverted triangle concept (by Mathewson) 2. Thumb concept (by Wright) 3. Lingula technique 27
  • 28.
    Inverted triangle concept(by Mathewson)  Anterior border of ramus is palpated with finger or thumb in its greatest curvature  Imaginary triangle is formed by anterior border of ramus internal pterygoid muscle vault of palate (apex lying inferiorly)  An imaginary longitudinal line dividing the tip of finger/thumb as it rests in coronoid notch  Passes medially over depressed area just above apex  Solution is injected at midpoint of the line 28
  • 29.
    Thumb concept (byWright) ◆ For right IAN block , middle of left thumbnail is positioned at coronoid notch and lightly over deep tendon of temporalis muscle ◆ Needle penetrates the tissue at middle of thumbnail carried between deep tendon of temporalis (laterally) and pterygomandibular raphe (medially) enter mandibular sulcus at the level of lingular notch 29
  • 30.
    Lingula technique ◆ Mandibularforamen in children( lower level )than the occlusal level of the primary teeth ◆ Therefore injection has to be administered lower and posterior to the position ◆ Anterior and posterior edges of ramus are palpated for targeting lingual ◆ However success rate with lingula as a landmark is lower 30
  • 31.
    Lilngual nerve block ◆By bringing the syringe to the opposite side with the injection. ◆ If small amounts of la solution are injected during insertion and withdrawal of the needle during inferior alveolar nerve block – lingual nerve will be invariably anesthetised. 31
  • 32.
    Long Buccal NerveBlock ◆ Site of injection ◆ Mucous membrane distal and buccal to the most distal molar tooth in the arch. ◆ Area Anesthetized ◆ Soft tissue and periosteum buccal to the mandibular molar teeth. ◆ For the removal of permanent mandibular molar or for placement of rubber dam on teeth in that region 32
  • 33.
    Infiltration anaesthesia forprimary mandibular molars ◆ Mandibular infiltration is an effective technique when performing a class I or II amalgam or an SSC restoration in a primary molar, both in primary and mixed dentition. ◆ When a pulpotomy was attempted, infiltration was effective in only 61% of the teeth evaluated as anesthetized upon probing, rubber dam placement, and preparation. Therefore, the technique cannot be considered to be reliable in the case of a pulpotomy ◆ Mandibular infiltration anaesthesia produces adequate anaesthesia in mandibular deciduous molars for most restorative procedures. 33 The effectiveness of mandibular infiltration compared to mandibular block anesthesia in treating primary molars in children Constantine J. Oulis, DDS, MS George P. Vadiakas, DDS, MS Aspa Vasilopoulou, DDS : Pediatric Dentistry - 18:4, 1996 American Academy ofPediatric Dentis
  • 34.
    Mental Nerve Block ◆Anatomy: The mental nerve is a continuation of the inferior alveolar nerve that innervates the lower lateral lip and the skin of the ipsilateral side of the mandible. It exits through the mental nerve foramen, which lies inferior to the second mandibular bicuspid. ◆ Landmark Technique: There are 2 approaches for the mental block: intraoral and extraoral. In the intraoral approach, the needle is inserted adjacent to the second mandibular premolar in a 45° angle toward the mental foramen. Anesthetic is infiltrated adjacent to the foramen, not in the foramen, which may result in ischemic nerve damage. In the extraoral approach, a similar trajectory is used with the needle, except the needle is inserted through the prepared skin superior to the mental foramen. The anesthetic is injected above and around the mental foramen, avoiding direct injection into the mental foramen. 34 Pediatric Nerve Blocks: An Evidence-Based Approach Sacha Duchicela,. Anthoney Lim, MD: Pediatric Emergency Medicine Practice, www.ebmedicine.net • October 2013.
  • 35.
    ◆ For rightor left mental nerve block, a right handed operator should sit comfortably on front of the patient so the syringe may be placed into the mouth below the patient’s line if sight. 35
  • 36.
    Infiltration For MandibularIncisors ◆ 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. 36
  • 37.
    Gow Gates MandibularBlock ◆ This approach uses external anatomic landmarks ( Intertragel notch) to align the needle. ◆ A nerve block procedure that anesthetizes the entire distribution of the fifth cranial nerve in the mandibular area. 37
  • 38.
    38 Clinical evaluation ofthe Gow-Gates block in children. A. Yamada and J. T. Jasstak Anesth Prog. 1981 Jul-Aug; 28(4): 106–109
  • 39.
    Anaesthetization of maxillaryteeth and soft tissue ◆ Anesthetization of the primary anterior teeth – single tooth. ◆ Local infiltration or supraperiosteal technique- the needle is penetrated at the soft tissue at the mucobuccal fold. The solution is deposited slowly and slightly above and close to the apex of the tooth. 39
  • 40.
    Anterior Superior AlveolarNerve Block (ASA)- Infraorbital nerve block ◆ Indications ◆ More than two maxillay teeth ◆ Inflammation and infection ◆ When supraperiosteal injections are ineffective ◆ Contra indications ◆ Discrete treatment areas ◆ Hemostasis of localized areas 40 Pulp of the maxillary central incisor through the canine 72% of patients have premolars and mesiobuccal root of 1st molar anesthetized Buccal peiodontium and bone of these same teeth Lower eyelid, lateral aspects of the nose and upper lip
  • 41.
    41 Landmarks: Infra orbital Notch, Mucobuccalfold, Infra orbital Foramen Feel the infra orbital notch moving your finger down the notch palpating the tissues gently; the outward bulge is the lower border of the orbit which is the roof of the infra orbital foramen; continue the finger inferiorly until a depression is felt which is the infra orbital foramen
  • 42.
    Anesthetization of maxillaryprimary molars ◆ The maxillary primary molars are innervated by middle superior alveolar nerve. Whereas permanent molars are innervated by PSA nerve. ◆ Jorgensen demonstrated that there is plexus formation of MSA and PSA first the primary molar region. ◆ Buccal cortical plate at maxillary primary first molar – thin; where as in primary second molar thick. ◆ Hence the supraperiosteal injection is supplemented by a PSA – superior to the maxillary tuberosity. 42 Jorgensen NB – sedation, local and general anesthesia in dentistry: ed 3, Philadelphia, 1980, Lea and Febiger
  • 43.
    Supraperiostial Technique (LocalInfiltration) ◆ Most frequently used for obtaining pulpal anesthesia in maxillary teeth. ◆ Indicated whenever dental procedures are confined to only one or two teeth. ◆ Landmark: insertion 45 to Long acsses of the tooth 1. Mucobuccal fold. 2. Crown of the tooth. 3. Root contour of the tooth ◆ Areas Anesthetized 1. Pulp and root area of the tooth. 2. Buccal periosteum. 3. Connective tissue. 4. Mucous membrane 43 Contraindications Inflammation at site of injection Dense bone
  • 44.
    Posterior Superior AlveolarNerve Block (PSA) ◆ Highly successful nerve block with greater than 95% success. ◆ Effective for permanent maxillary molars and buccal periodontium-77 to 100%  Short dental needle is recommended to decrease the risk of hematoma formation.  Average depth of soft tissue penetration is 16 mm (short needle is 20 mm in length)  Mesiobuccal root of the maxillary 1st molar is not consistently innervated by the PSA nerve  Loetscher and associates- 28% of maxillary 1st molars’ mesiobuccal roots are innervated by the middle superior alveolar nerve (MSA). ◆ Areas Anesthetized ◆ Pulps of maxillary molars, buccal periosteum, bone overlying these tooth 44
  • 45.
  • 46.
    Hematoma: ◆ if needleis over inserted too far posteriorly into the Pterygoid plexus of veins leads to this hematoma ◆ Visible intraoral hematoma develops within minutes; bleeds until the pressure of the extravascular blood equals that of the intravascular blood which can result in a large, unsightly hematoma ◆ The mandibular division of fifth cranial nerve is located lateral to PSA nerve. Deposition of local anaesthetic lateral to desired location may produce varying degree of mandibular anaesthesia 46
  • 47.
  • 48.
    Palatal injections -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. 48
  • 49.
    Palatal injections -Nasoplatine Nerve Block ◆ Blocking the nasopalatine nerve anesthetizes the palatal tissues of the six anterior teeth. ◆ This technique is painful and is not routinely used before operative procedures. ( apply pressure to decrease pain). 49
  • 50.
    Supplemental Injection Technique 1)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. 50
  • 51.
    Intrapulpal Injection: ◆ Localanesthetic 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 51
  • 52.
    Intraosseous Injection: ◆ Requirethe deposition of local anesthetic solution in the porous alveolar bone. ◆ By forcing a needle through the cortical plate and into the cancellous alveolar bone Or a small, round bur may be used to make an access in the bone for the needle. 52
  • 53.
    ASA Classification forPaediatric dental patients- 1962 53 Class Status I Normal healthy patient II Patient with mild systemic disease.(eg. Controlled reactive airway disease) III Patient with severe systemic disease (eg. Child who is actively wheezing) IV Patient with severe systemic disease that is a constant threat to life (e.g. Child with status asthamaticus) V Moribund patient not expected to survive without an operation (e.g. Patient with severe cardiomyopathy requiring heart transplantation)
  • 54.
  • 55.
    Percentage method forcalculating doses in children ◆ Rule of 10: ◆ Add patient’s age to the no .of the tooth being treated ◆ <10 – infiltration is sufficient or else regional block administration 55 Age (years) Mean weight (kg) Approximate percentage of adult dose 1 10 25 3 15 33 5 18 40 7 23 50 12 39 75 Adult 68 100
  • 56.
  • 57.
    OraVerse: Reverses NumbnessAfter Dental Procedures J. S. Prasanna J Maxillofac Oral Surg. 2012 Jun; 11(2): 212–219. ◆ OraVerse is a formulation of phentolamine mesylate that accelerates the return to normal sensation and function for patients after routine dental procedures. ◆ The maximum recommended dose of OraVerse is two cartridges in patients’ age 12 or greater, one cartridge in children age 6–11 years and weighing over 66 lbs, and one half cartridge in children 6–11 years and weighing 33– 66 lbs. OraVerse is not indicated in children less than 6 years of age or weighing less than 33 lbs. It is not recommended to use after invasive procedures such as endodontic treatment or surgery, where post-operative discomfort is anticipated 57
  • 58.
    “Guideline on Useof Local Anesthesia for Pediatric Dental Patients AMERICAN ACADEMY OF PEDIATRIC DENTISTRY Adopted 2005 Revised 2009, 2015 58
  • 59.
    Topical anesthetic ◆ Topicalanesthetic is effective on surface tissues (up to two to three mm in depth) to reduce painful needle penetration of the oral mucosa. ◆ Topical anesthetic agents are available in gel, liquid, ointment, patch, and aerosol forms. ◆ The US Food and Drug Administration (FDA) has issued a warning about the use of compounded topical anesthetics and the risk of methemoglobinemia. ◆ Risk of acquired methe-moglobinemia has been associated primarily with two local anesthetics: prilocaine and benzocaine. There is no evidence of other local anesthetics contributing to the etiology of methemoglobinemia. ◆ Benzocaine, the most commonly used topical anesthetic, is available in concentrations up to 20 per-cent and comes in liquid, spray, and gel forms. 59
  • 60.
    Recommendations- Topical anesthetics 1.Topical anesthetic may be used prior to the injection of a local anesthetic to reduce discomfort associated with needle penetration. 2. The pharmacological properties of the topical agent should be understood. 3. A metered spray is recommended if an aerosol preparation is selected. 4. Systemic absorption of the drugs in topical anesthetics must be considered when calculating the total amount of anesthetic administered 60
  • 61.
    Selection of syringesand needles ◆ The American Dental Association (ADA) has long standing standards for aspirating syringes for use in the administration of local anesthesia. ◆ Dental needles are available in three lengths: long (32 mm), short (20 mm), and ultrashort (10 mm). Needle gauges range from size 23 to 30. 61 Recommendations: syringes 1. Any 23- through 30-gauge needle may be used for intraoral injections, since blood can be aspirated through all of them. Aspiration can be more difficult, however, when smaller gauge needles are used. An extra-short, 30-gauge is appropriate for certain infiltration injections. 2. Needles should not be bent if they are to be inserted into soft tissue to a depth of greater than five millimeters or inserted to their hub for injections to avoid needle breakage
  • 62.
    62 Injectable local anestheticagents- Recommendations: 1. Selection of local anesthetic agents should be based upon: — the patient’s medical history and mental/develop- mental status; — the anticipated duration of the dental procedure; — the need for hemorrhage control; — the planned administration of other agents (eg, nitrous oxide, sedative agents, general anesthesia) — the practitioner’s knowledge of the anesthetic agent. 2. Use of vasoconstrictors in local anesthetics is recommended to decrease the risk of toxicity of the anes- thetic agent, especially when treatment extends to two or more quadrants in a single visit. 3. In cases of bisulfate allergy, use of a local anesthetic without a vasoconstrictor is indicated. A local anes- thetic without a vasoconstrictor also can be used for shorter treatment needs but should be used with caution to minimize the risk of toxicity of the anesthetic agents. 4. The established maximum dosage for any anesthetic should not be exceeded. 5. Administration of local anesthetic should be based on the weight/body mass index (BMI) of the patient, not to exceed AAPD recommendations.
  • 63.
  • 64.
    Documentation of localanesthesia- Recommendations 1. Documentation must include the type and dosage of local anesthetic. Dosage of vasoconstrictors, if any, must be noted. (For example, 34 mg lido with 0.017 mg epi or 34 mg lido with 1:100,000 epi). 2. Documentation may include the type of injection(s) given (eg, infiltration, block, intraosseous), needle selection, and patient’s reaction to the injection. 3. In patients for whom the maximum dosage of local anesthetic may be a concern, the weight should be documented preoperatively. 4. If the local anesthetic was administered in conjunc- tion with sedative drugs, the doses of all agents must be noted on a time-based record. 5. Documentation should include that post-injection instructions were reviewed with the patient and parent. 64
  • 65.
    Recommendations to reducelocal anesthetic complications 1. Practitioners who utilize any type of local anesthetic in a pediatric dental patient should have appropriate training and skills and have available the proper facilities, personnel, and equipment to manage any reasonably foreseeable emergency. 2. Care should be taken to ensure proper needle placement during the intraoral administration of local anesthetics. Practitioners should aspirate before every injection and inject slowly. 3. Following an injection, the doctor, hygienist, or assistant should remain with the patient while the anesthetic begins to take effect. 4. Residual soft tissue anesthesia should be minimized in pediatric and special health care needs patients to decrease risk of self-inflicted postoperative injuries. 5. Practitioners should advise patients and their care-givers regarding behavioral precautions (eg, do not bite or suck on lip/cheek, do not ingest hot sub-stances) and the possibility of soft tissue trauma while anesthesia persists. Placing a cotton roll in the mucobuccal fold may help prevent injury, and lubricating the lips with petroleum jelly helps prevent drying.6,7 Practitioners who use pheytolamine mesylate injectionsto reduce the duration of local anesthesia still should follow these recommendations. 65
  • 66.
    Local Anesthesia andPregnancy- recommendations 1. The use of local anesthesia during pregnancy generally is considered safe. Overall maternal oral health and the possibility of infection are important considerations. Benefits and risks should be considered. Local anesthesia without a vasoconstrictor should be considered. 2. Proper local anesthetic technique is a necessity. Aspiration to avoid intravascular injection, proper needle placement accuracy, and attention to dosages are critical. 3. Ester anesthetics should be avoided because of potential for allergenicity. . 4. Prilocaine should not be used due to risk of the foetus developing methhemoglobinemia 5. While lidocaine is considered the best choice of local anesthetic, mepivacaine and bupivacaine (both FDA Category C) can be used. 6. In second and third trimesters, proper positioning and heart rate monitoring are important to avoid postural hypotension. 7. During lactation, the use of local anesthetics without vasoconstrictors may be considered to avoid possible idiosyncratic reaction to the neonate, not to the vasoconstrictor but to the preservative used to stabilize the vasoconstrictor.66
  • 67.
    Recent advances forpain control ◆ Jet syringe ◆ Vibra jet ◆ Dental vibe ◆ Wand ◆ Electronic dental anesthesia 67
  • 68.
    LOCAL COMPLICATIONS ◆ Needlebreakage ◆ Pain on injection ◆ Burning on injection ◆ Persistent anaesthesia or paresthesia ◆ Trismus ◆ Hematoma ◆ Sloughing of the tissue / soft tissue injury ◆ Facial nerve paralysis 68
  • 69.
    SYSTEMIC COMPLICATIONS ◆ Toxicity ◆Idiosyncracy ◆ Allergy ◆ Anaphylactoid reaction ◆ Syncope 69
  • 70.
    References ◆Mcdonald and Avery’sDentistry for the child and adolescent 10th edition . ◆Fundamentals of Pediatric Dentistry , 2nd revised edition , Mathewson/Primosch/Robertson. ◆Chaurasia BD.Human Anatomy- regional and applied dissection and clinical- vol 3, 4th edition, CBS publishers ◆C. Richard Bennett. Monheim’s local anaesthesia and pain control in dental practice Seventh Ed.1990. CBS Publishers, New Delhi. ◆Stanley Malamed. Handbook of Local Anaesthesia 6th edition. ◆D H Roberts, J H Sowray ‘local analgesia in dentistry” 2nd edition John Wright sons, limited publications. 1954 ◆Textbook of paediatric dentistry Nikhil Marwah edition 3. 70
  • 71.