pain control for child and adolescent

1. Pain control for child and
adolescent
Presented by:
N Chaudhary

2. Outline:
 Introduction
 Topical anesthetics & jet
injection
 Local anesthesia by conventional
injection
 Mandibular teeth and soft tissue
 Inferior Alveolar Nerve Block
 Lingual Nerve Block
 Long Buccal Nerve Block
 Infiltration for Mandibular
Primary Molars + Mandibular
Incisors
 Gow-Gates Mandibular Block
Technique
 Maxillary primary and
permanent incisors and canines
 Supraperiosteal Technique (Local
Infiltration)
 Maxillary primary molars and
premolars
 Maxillary permanent molars
 The palatal tissues
 Nasopalatine Nerve Block
 Greater Palatine Injection

3.  Supplemental injection
techniques
 Infraorbital and Mental Nerve
Block
 Intraligamentary, Intraosseous,
Interseptal, and Intrapulpal
Injection
 Computer-controlled local
anesthetic delivery system (Wand)
 Complications after a local
anesthetic
 Anesthetic Toxicity
 Trauma to Soft Tissue
 Reversal of dental anesthesia
analgesics

4. Introduction
 Control of pain during dental procedures is one of the
most important aspects of child behavior guidance in the
dental office.
 Dental procedures can be carried out more effectively.
 The injection in local anesthesia injection delivery
produces the greatest negative response in children. Thus,
efforts should be continued to help child cope with it.

5. Topical Anesthetics
 May reduce the slight discomfort associated with the
insertion of the needle before the injection of the local
anesthetic.
 Some present a disadvantage if they have:
 Disagreeable taste
 the additional time required to apply them may increase the
child’s anxiety.
 Available in gel, liquid, ointment, and pressurized spray
forms. However, liquid, gel, or ointment preparations
seem to be preferred by most dentists.

6.  Numerous anesthetic agents have been used in topical
anesthetic preparations:
Ethyl aminobenzoate
Butacaine sulfate
Lidocaine
Tetracaine
 Ethyl aminobenzoate (benzocaine) liquid, ointment, or gel
preparations are mostly preferred for its more rapid onset,
longer duration of anesthesia and not produce systemic toxicity.
 The mucosa is dried with gauze, and a small amount of the
topical anesthetic agent is applied by a cotton-tipped applicator
to the tissue with a cotton swab for around 30 sec..

7. Jet Injection
 is used instead of topical anesthetics by some dentists.
 based on the principle that small quantities of liquids
forced through very small openings under high pressure
can penetrate mucous membrane or skin without causing
excessive tissue trauma.
 The method is quick and essentially painless, although the
suddenness of the injection may produce momentary
anxiety in the patient.

8.  The Syrijet Mark II is
One jet injection device
that holds a standard 1.8-
mL cartridge of local
anesthetic solution. It can
be adjusted to expel 0.05
to 0.2 mL of solution
under 2000 psi pressure.
 A more recently developed
jet injection device
delivers a dose of dry
powdered anesthetic to the
oral mucosa.

9. Conventional injection
Regardless of the size of the needle used, it is generally
agreed that the anesthetic solution should be injected slowly,
and that the dentist should watch the patient closely for any
evidence of an unexpected reaction.
25-gauge 27-gauge 30-gauge

10. Anesthetization of
mandibular teeth and soft
tissue

11. conventional mandibular 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.

12. infiltration anesthesia for
mandibular primary molars
Infiltration/Intrapapillary has same effectiveness as
inferior alveolar block/long buccal infiltration in mandibular
primary molars for pulpotomy treatment and stainless steel
crowns in children 3 to 9 years of age .

13. infiltration for mandibular
incisors
The solution is deposited labial to the incisors on the
same and the opposite side of the midline as an adjunct to an
inferior alveolar nerve block when total anesthesia of the
quadrant is desired.

14. gow-gates mandibular block
technique
 This approach uses external anatomic landmarks to align
the needle so that anesthetic solution is deposited at the
base of the neck of the mandibular condyle:
the tragus of the ear
the corner of the mouth.

15. anesthetization of maxillary teeth
and soft tissue

16. supra-periosteal technique (local
infiltration)
The apices of the
maxillary primary anterior
teeth are essentially at the
level of the mucobuccal
fold, thus injection should be
injection should be close to
the bone and adjacent to the
apex of the tooth.

17. anesthetization of maxillary
primary molars and premolars
 the first primary molar has
thin overlying bone thus
infiltration will be
effective

18.  The second primary and
first permanent molars are
overlaid by thick bone of
zygomatic process, thus
posterior superior alveolar
(PSA) nerve block should
be obtained along with
infilteration

19. Anesthetization of maxillary
permanent molars
1
• Instructs the child to partially close the mouth to allow the cheek and lips
to be stretched laterally.
2
• Tip of index finger in concavity in mucobuccal fold (its nail adjacent the
mucosa and its ball in posterior surface of zygomatic process)
• Finger point at direction of needle during injection
3
• The puncture point is in the mucobuccal fold above and distal to the
distobuccal root of upper 6 or above upper 7, The needle is advanced
upward and distally, depositing the solution over the apices of the teeth.

20. anesthetization of the palatal
tissues
 very painful procedures
 To over come this issue first use:
After buccal
infiltration
interdental
(interpapillary)
infiltration

21. Nasopalatine nerve block
 Only when infiltration provide insufficient anesthesia
 Technique:
The path of insertion of the needle is alongside the incisive
papilla, just posterior to the central incisors.

22. greater (anterior) palatine
injection
 Technique ( for mixed and permanent dentition):
Before the injection is made, it is helpful to bisect an
imaginary line drawn from the gingival border of the most
posterior molar that has erupted to the midline. Approaching
from the opposite side of the mouth, the dentist makes the
injection along this imaginary line and distal to the last tooth

23.  Technique (only for the primary dentition):
the injection should be made approximately 10 mm
posterior to the distal surface of the second primary molar.

24. supplemental injection techniques
Infraorbital nerve block
Mental nerve block
Intraosseous injection
Interseptal injection
Intrapulpal injection

25. Infraorbital nerve block
 Preferred only when:
Removal impacted teeth (canines or first premolars)
Removal of large cysts
moderate inflammation or infection contraindicates use of
the infiltration
longer duration or a greater area of anesthesia is needed.

26. the mental nerve block
 Anesthetizes all mandibular teeth in the quadrant except
the permanent molars.
 Has a disadvantage over inferior alveolar nerve block
puts the syringe in clear view of the patient

27. periodontal ligament injection
(intraligamentary injection)
 Technique:
The needle is placed in the gingival sulcus, usually on the
mesial surface, and is advanced along the root surface until
resistance is met, then admnistrate anasthesia in PDL.
 Its advantages:
provides reliable pain control rapidly and easily.
provides pulpal anesthesia for 30 to 45 minutes

28. Peri-press syringes:
 designed specifically for the periodontal ligament
injection technique
 has a solid metal barrel and is calibrated to deliver 0.14
mL of anesthetic solution each time the trigger is
completely activated.
 two types of syringes designed specifically for
intraligamentary injections: gun-like and pen-like.

29. Intraosseous, interseptal , and
intrapulpal injection
The intrapulpal injection:obtains profound pulpal anesthesia
during direct pulp therapy when other local anesthesia
attempts have failed.
Intraosseous injection techniques:require the deposition of
local anesthetic solution in the porous alveolar bone. This
achieved by using mall, round bur or using reinforced
intraosseous needle .
Both used only when periodontal ligament space if infected.

30. Computer-controlled local
anesthetic
delivery system (wand)
 The system includes:
 a conventional local anesthetic needle
 a disposable wand-like syringe held by a pen grasp
 A microprocessor with a foot control
 an aspiration cycle for use when necessary.

31. complications after a local
anesthetic
Anesthetic toxicity
Trauma to soft tissue

32. anesthetic toxicity
 One way to compare the effectiveness of a dose and
its toxicity is to assess the amount of a substance
administered with respect to body weight.
 Or use an easy rule called “The rule of 25” which states
that for healthy patients, a dentist can safely use 1
cartridge of anesthetic for every 25 pounds of patient
weight

33. types and doses of local anesthesia
 Maximum Doses of Local Anesthetics in Children
Articaine: 7.0mg/kg, 3.2 mg/lb, 500 mg total
Lidocaine: 4.4 mg/kg, 2 mg/lb, 300 mg total
Mepivicaine: 4.4 mg/kg, 2 mg/lb, 300 mg total
Prilocaine: 6 mg/kg, 2.7 mg/lb, 400 mg total
Bupivicaine: 2 mg/kg, 0.9mg/lb, 90 mg total
Etidocaine: 8 mg/kg, 3.6mg/lb, 400 mg total

34. trauma to soft tissue
 Parents of children should be warned that the soft tissue
will be without sensation for 1 hour or more.
 may bite the lip, tongue, or inner surface of the cheek
resulting in formation traumatic ulcer

35. reversal of dental anesthesia
OraVerse
 Became the first pharmaceutical agent indicated for the
reversal of soft-tissue anesthesia
 Not recommended for use in children younger than 6
years of age or in those with weight below 15 kg