This document discusses local anesthesia techniques in pediatric dentistry. It begins by noting the importance of pain control for child behavior guidance. Anatomical differences between children and adults are described, including thinner bone and tissues in children, allowing for less needle penetration depth and smaller volumes of local anesthetic. Techniques for maxillary and mandibular anesthesia are outlined. Methods to minimize injection pain are provided, such as topical anesthetics, buffering or warming solutions, and vibration devices. The risks of toxicity, soft tissue trauma, allergic reactions and nerve damage are reviewed along with preventive measures. Reversal agents like OraVerse are also mentioned. Overall, the document provides an overview of best practices for safe and effective local

1. Local Anesthesia in Pediatric
Dentistry
By:
Khalid Khater – Kholoud Mamdouh – Hoda Hambouta

2. Introduction
• The most important aspects of
child behaviour guidance is pain
control
• The dentist may have to modify
the wording he uses with kids
• Responses become increasingly
negative over a series of four or
five injections

3. Outline:
• Pain management
during injection
• Block VS Infiltration
• Anatomical Differences
• Position
• Dosage
• Complications
• Recent
Articles

4. Anatomical Differences
Maxillary
Mandibular

5. Anatomical Differences
• maxillary and mandibular bone in
children is generally less dense
• injection techniques can usually be
completed with decreased depth of
needle penetration and a smaller
volume of local anaesthetic

6. Anatomical Differences
(Maxillary):
• The PSA nerve block is rarely
necessary because of the effectiveness
of infiltration in children
• In older children, the morphology of
the bone surrounding the apex of the
permanent first molar does not permit
effective infiltration of local anesthetic
because the zygomatic process lies
closer to the alveolar bone in children

7. Anatomical Differences
(Maxillary):
• Palatal anesthesia can be
achieved in children through
the nasopalatine and greater
(anterior) palatine nerve
blocks.
• If the child has only primary
dentition, the needle is inserted
approximately 10 mm posterior
to the distal surface of the
second primary molar

8. Palatal anesthesia
An intrapapillary injection can also be used to achieve palatal
anesthesia in young children

9. Anatomical Differences
(Mandibular)
• The mandibular foramen in
children lies distal and
more inferior to the
occlusal plane

10. Anatomical Differences
(Mandibular)
• The mandibular
foramen in
children lies distal
and more inferior
to the occlusal
plane

11. Anatomical Differences
(Mandibular)
• Because of the decreased
thickness of soft tissue (about
15 mm), a short needle may
be recommended for the IANB
in younger, smaller patients

12. Anatomical Differences
(Mandibular)
• The mental foramen is usually
located between the two primary
mandibular molars.
• A volume of 0.45 mL (one-fourth
of a cartridge) is suggested in
younger patients.
• The technique puts the syringe in
clear view of the patient

13. Position
Chair
Assistant
Dentist

14. Position
(Chair):
• Syringe out of Patient’s
vision
• Reduces the incidence of
syncope
• Sudden movements are
more easily controlled
Supine position

15. Position
(Assistant):
The dental assistant should position her
hands above the child’s hands to
intercept any unwanted movement
(Passively)
Syringe should always
passed and held in
blind spots

17. Position
(Dentist):
8 O’clock 10 O’clock

18. Ways of minimizing the pain
during injection

19. 1. Topical anesthesia
• Spray or ointment
• Effective on surface tissues (up to 2 to 3 mm
in depth) to reduce painful needle
penetration of the oral mucosa
• Dry with a guaze then apply with
pressure for 30 seconds just before
injection

20. 2. Intra-oral lidocaine patch
• Anaesthetic onset occurred within
5 min
• Patches can be kept in place for up
to 15 minutes, and may provide
anaesthesia for 60 minutes
• The patches were safe and well
tolerated

21. 3. Cryo-anaesthesia
• Pre-cooled Anaesthetic gel’s temperature was maintained using a standard
drug refrigerator at 4°C
• Help control pain by inducing local anesthesia around the treatment area
• Have also shown that it decreases edema and local blood flow.

22. 4. Warming of local anaesthetic solution
Application of local anesthetic
at body temperature reduces
dental injection pain when
compared with local
anesthetics administered at
room temperature.
Gümüş H, Aydinbelge M. Evaluation of effect of warm local anesthetics on pain perception
during dental injections in children: a split-mouth randomized clinical trial. Clinical oral
investigations. 2020 Jul;24(7):2315-9

23. 5. Buffering of local anaesthetic solution
- By sodium bicarbonate in diff.
ratios
- This chemical reaction produces
CO2 that raises the pH of local
anaesthetic solution to 7.38 which
is closer to the body pH which is
7.4

24. 6. Vibration
Buzzy device or Dental vibe Vibraject

25. 6. Vibration

26. 7. Computer controlled Anaethesia
• Automatic delivery of local
anaesthetic solution at a
fixed pressure volume ratio
regardless of variations in
tissue resistance

28. 8. Jet injection
• Delivering anesthesetic solution :
• Without use of needle
• Without causing excessive tissue trauma
• Under high compressive forces.
• Produces surface anesthesia instantly
• Uses :
• instead of topical anesthetics
• Before rubber dam clamp placement

29. Nerve block VS Infiltration
In mandibular anesthesia in
pediatric dentistry

30. Inferior alveolar Nerve block in children
• Below 6 years : below the level of
occlusal plane
• 6-12 years : at the level of the
occlusal plane
• Above 12 years : above the level of
the occlusal plane

31. Infiltration VS Nerve block in mandibular anaesthesia
• Sharaf, 1997 demonstrated that Buccal infiltration anesthesia was found to
be as effective as block anesthesia in all situations, except when
pulpotomies were performed in the mandibular second primary molar, where
it proved to be unreliable regardless of age.
• Block anesthesia was significantly more painful than buccal infiltration
anesthesia, and behavior of children three through five years old sometimes
turned negative following the block injection.
Sharaf AA. Evaluation of mandibular infiltration versus block anesthesia in pediatric dentistry.
ASDC journal of dentistry for children. 1997 Jul 1;64(4):276-81.

32. Dosage

33. Dosage
The maximum safe
dosage of local
anesthetics, whether
topical or injected, is
generally increased when
used in combination with
a vasoconstrictor.
Vasoconstrictor
Constrict blood
vessels
Allow the
maximum total
dose of the
anesthetic agent to
be increased
Provide a
bloodless field for
surgical
procedures
Counteract the
vasodilatory
effects of the local
anesthetic
Prolong its
duration
Reduce systemic
absorption and
toxicity

34. Dosage
“The rule of 25” by Moore and Hersh states that for healthy patients, a dentist
can safely use 1 cartridge of anesthetic for every 25 pounds of patient weight.

35. Child: 20 kg? 4.4 x 20= 88 mg = 2.4
carpules
Adult: 70kg?
Children are more likely to experience toxic
reactions because of their lower body weight!
Dose Calculation:
MRD of 2 % Lidocaine with vasoconstrictor..
2% Lidocaine= 20 mg/ml
1 carpule= 1.8 ml
Amount of LA in 1 carpule= 20 x 1.8= 36 mg/carpule

36. Complications

37. Direct linear relationship between the
number of cartridges of local anesthetic
administered and the frequency of severe
reactions (maximum recommended dosage)
High drug serum concentration is absorbed
into the circulation. This serum concentration
is influenced by the dose, site, and method
of drug administration
1. ANESTHETIC TOXICITY

38. Signs and symptoms Biphasic reaction- excitation followed
by depression
Early: dizziness, anxiety, confusion
Later: diplopia, tinnitus, drowsiness

39. Preventive measures:
• Careful injection technique
• Maximum dosage based on weight
• Aspiration
• Recognition of a toxic response is critical for effective
management. Administration of the local anesthetic agent should
be discontinued.
• Additional emergency management is based on the severity of the
reaction.

40. 2. TRAUMA TO
SOFT TISSUE
The child has chewed the area, and the result 24 hours later is an ulceration -
traumatic ulcer.
Parents of children who receive regional local anesthesia in the dental office
should be warned that the soft tissue in the area will be without sensation.
These children should be observed carefully so that they will not purposely or
inadvertently bite the tissue.
Secondary infections may develop

41. Preventive measures
1. Select a local anesthetic with a duration of action
that is appropriate for the length of the planned
procedure.
Short-duration local anesthetic solutions (e.g., 3%
mepivacaine, 4% prilocaine without a vasoconstrictor)
Long-duration local anesthetic bupivacaine (0.5%) with
epinephrine 1:200,000 is not recommended as it
increases the risk of soft tissue injury.
2. Advise the patient and accompanying adult about the
possibility of injury if the patient bites, sucks or chews
on the lips, tongue and cheek. They should delay eating
and avoid hot drinks until the effects of the anesthesia
are totally dissipated.
3. Reinforce the warning by placing a cotton roll or
rolled up gauze (“Bite on the ghost”) in the mucobuccal
fold if anesthesia symptoms persist.
4. The management of soft tissue trauma involves
reassuring the patient and parent (it’s okay if the tissue
turns white), allowing up to a week for the injury to
heal, and lubricating the area with petroleum jelly or
antibiotic ointment to prevent drying, cracking and pain.

42. REVERSAL OF DENTAL
ANESTHESIA
OraVerse
Phentolamine mesylate causes vasodilation at the
site where the anesthetic agent was injected; this
leads to higher absorption of local anesthetic and
thus reduces the duration of anesthesia.
• FDA approved its use in pediatric patients 3
years and older.
• Dosage form of OraVerse (phentolamine
mesylate) is 0.4 mg/1.7 ml solution per
cartridge. It is administered in an equal volume
to the LA, up to a maximum of 2 cartridges in
adults. OraVerse is administered at the same
location and by the same technique used
previously for the LA
• A RCT in 2021 by Emmanuella et al
concluded“Phentolamine mesylate was
efficacious in reducing the incidence of self-
inflicted soft-tissue ulceration and accelerated
the time of return to normal function after LA.”
Beshara ER, Sharaf AA, Wahba NA. EFFECT OF PHENTOLAMINE MESYLATE ON THE INCIDENCE OF SELF-INFLICTED SOFT TISSUE INJURY FOLLOWING
INFERIOR ALVEOLAR NERVE BLOCK ANESTHESIA IN CHILDREN:(RANDOMIZED CONTROLLED CLINICAL TRIAL). Alexandria Dental Journal.2021 Apr 1;46(1):153-60.

43. Laser Diode
Photobiomodulation therapy by 810-
nm diode laser can be proposed as a
non-invasive method in order to
reduce the duration of anesthesia in
pediatric patients.
Seraj B, Ghadimi S, Hakimiha N, Kharazifard MJ, Hosseini Z. Assessment of photobiomodulation therapy by an 8l0-nm diode laser on the reversal of soft tissue local
anesthesia in pediatric dentistry: a preliminary randomized clinical trial. Lasers in medical science. 2020 Mar;35(2):465-71.

44. 3. Allergy
• Rare.
• The local anesthetic agent with the highest
incidence of allergic reactions is procaine.
• Its antigenic component appears to be para-
aminobenzoic acid (PABA).
• Allergies can manifest in a variety of ways:
urticaria, dermatitis, angioedema, fever,
photosensitivity, or anaphylaxis.
• Emergency management is dependent on the rate
and severity of the reaction.

45. Needle breakage Edema and hematoma after local anesthesia via
posterior superior alveolar nerve block
4. Needle
breakage
5. Hematoma
6. Trauma of the
nerve resulting in
parasthesia
persistent
anesthesia beyond
the expected
duration

46. Pain Management
Local anesthesia
Non-
pharmacological
approach
Pharmacological
approach

47. Each child is unique and exists in the context of his family.

48. Parental Anxiety
Toxic Stress
Medical Experiences
Child abuse
Dental awareness
Anxiety/ Fear
Sleep deprivation
Injury
Illness
Expectations
Social isolation

49. Social
Psychological
Physical
Pain
Proper behavior guidance techniques lead
to pain free dental visits.
• Positive Approach
• Team Attitude
• Truthfulness
• Flexibility
• Multisensory Communication
• Active Listening
• Scheduling
• Reinforcement

50. Minimal Sedation

53. Thank You !