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BEST PRACTICES: USE OF LOCAL ANESTHESIA
Use of Local Anesthesia fo Peiatic Dental
Patients
Latest Revision How to Cite: Aeican Acae of Peiatic Dentist Use of
22 local anesthesia fo eiatic ental atients The Refeence Manal
of Peiatic Dentist Chicao
Ill Aeican Acae of Peiatic
Dentist 22332
Abstract
This best practice presents recommendations regarding use of local anesthesia to control pain during pediatric dental procedures.
Considerations in the use of topical and local anesthetics include: the patient’s medical history, developmental status, age, and weight; planned
procedures; risk for methemoglobinemia; formulations of injectable anesthetic agents with and without vasoconstrictor as well as contra
indications for their use; and selection of syringes and needle length and gauge. uidance for documentation of local anesthesia addresses
anesthetic selection and dose administered in addition to injection type and location and postoperative instructions. otential complications
such as toicity, paresthesia, allergy, and postoperative selfinduced soft tissue injury are discussed. ecommendations also are provided for
alternative delivery methods, use with sedation or general anesthesia, and use during pregnancy. afety precautions emphasi e calculating
maimum dosage based on the patient’s weight, adjusting local anesthetic dosage when additional analgesic or sedative agents are used,
considering systemic absorption and the possibility of methemoglobinemia from topical anesthetic use, and bending of needles at the hub
increases risk for breakage. anagement of pain is an important component of oral health care and can result in a more positive
patient eperience.
This document was developed through a collaborative effort of the merican cademy of ediatric entistry Councils on Clinical ffairs
and cientific ffairs to offer updated information and recommendations on using local anesthetics in the management of dental pain for
pediatric patients and persons with special health care needs.
EYORDS ANALESICS ANESTHESIA
ENERAL ANESTHESIA
LOCAL DELIERY OF HEALTH CARE
METHEMOLOINEMIA
PAIN MANAEMENT
PEDIATRIC DENTISTRY
Purpose the rapid ionic influx of sodium necessary for neuron impulse
4,5
The American Academy of Pediatric Dentistry (AAPD) generation. This helps to prevent transmission of pain sensa-
intends this document to help practitioners make decisions tion during procedures, which can serve to build trust and
when using local anesthesia to control pain in infants, chil- foster the relationship of the patient and dentist, allay fear and
dren, adolescents, and individuals with special health care anxiety, and promote a positive dental attitude. The technique
needs during the delivery of oral health care. of local anesthetic administration is an important considera-
6
tion in pediatric patient behavior guidance. Age-appropriate
Methods nonthreatening terminology, distraction, topical anesthetics,
Recommendations on local anesthesia were developed by the proper injection technique, and pharmacologic managment
1 can help the patient have a positive experience during admin-
Council on Clinical Affairs and adopted in 2005 , and last
2 istration of local anesthesia.6,7 In pediatric dentistry, the dental
revised in 2015. This update is based upon a literature search
of the Pubmed /MEDLINE database using the terms: local professional should be aware of proper dosage (based on body
® weight) to minimize the chance of toxicity and the prolonged
anesthesia AND dentistry AND systematic review, topical
anesthesia AND dentistry, buffered anesthesia AND dentistry. duration of anesthesia, which can lead to self-inflicted tongue
3 8
Additionally, Handbook of Local Anesthesia, 7th edition con- or soft tissue trauma. Knowledge of gross and neuroanatomy
tributed significantly to this revision. When data did not of the head and neck allows for proper placement of the
appear sufficient or were inconclusive, recommendations were anesthetic solution and helps minimize complications (e.g.,
based upon expert and/or consensus opinion by experienced
researchers and clinicians.
ABBREVIATIONS
Background AAPD: Aeican Acae Peiatic Dentist ADA: Aeican Den
Local anesthesia is the temporary loss of sensation including tal Association CNS: Cental neos sste CVS: Caioascla
pain in one part of the body produced by a topically-applied sste FDA: US Foo an D Ainistation kg: illoa
or injected agent without depressing the level of conscious- lb: on mg: illia mm: illiete mL: illilite PDL:
Peioontal liaent
ness. Local anesthetics act within the neural fibers to inhibit
332 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
BEST PRACTICES: USE OF LOCAL ANESTHESIA
8,9
hematoma, trismus, intravascular injection). Familiarity with an abnormal elevation in body temperature during general
13
the patient’s medical history is essential to decrease the risk anesthesia with inhalation anesthetics or succinylcholine.
of aggravating a medical condition while rendering dental If a local anesthetic is injected into an area of infection, its
7,8
care. Medical consultation should be obtained as needed. onset will be delayed or even prevented. The inflammatory
Many local anesthetic agents are available to facilitate process in an area of infection lowers the pH of the extra-
management of pain in the dental patient. There are two gen- cellular tissue, inhibiting anesthetic action as little of the
eral types of local anesthetic chemical formulations: (1) esters active free base form of the anesthetic is allowed to cross into
8
(e.g., procaine, benzocaine, tetracaine); and (2) amides (e.g., the nerve sheath to prevent conduction of nerve impulses.
lidocaine, mepivacaine, prilocaine, articaine).10 Additionally, endocarditis prophylaxis (antibiotics) is not
Vasoconstrictors (e.g., epinephrine, levonordefrin, norepine- recommended for routine local anesthetic injections through
14
phrine) are added to local anesthetics to constrict blood vessels noninfected tissue in patients considered at risk.
in the area of injection. This lowers the rate of absorption of
the local anesthetic into the blood stream, thereby lowering Topical anesthetics
the risk of toxicity and prolonging the anesthetic action in the The application of a topical anesthetic may help minimize
11
area. Epinephrine is a relative contraindication in patients discomfort caused during administration of local anesthesia.
with hyperthyroidism, and dose of local anesthetics with Single drugs often used as topical anesthetics in dentistry in-
12
epinephrine should be limited. Patients with significant clude 20 percent benzocaine, five percent lidocaine, and four
cardiovascular disease, thyroid dysfunction, diabetes, or sulfite percent tetracaine.15 Topical anesthetics are effective on surface
sensitivity and those receiving monoamine oxidase inhibitors, tissues (up to two to three millimeters in depth) to reduce pain
4,15
tricyclic antidepressants, antipsychotic drugs, norepinephrine, from needle penetration of the oral mucosa. These agents
or phenothiazines may require a medical consultation to are available in gel, liquid, ointment, patch, and aerosol forms.
determine the need for a local anesthetic without vasoconstric- The U.S. Food and Drug Administration (FDA) has issued
13 16
tor. When halogenated gases are used for general anesthesia, warnings about the use of compounded topical anesthetics
the myocardium is sensitized to epinephrine, and such and the risk of methemoglobinemia.17 Compounded topical
13
situations dictate caution with use of a local anesthetic. anesthetics are custom-made medications that may bypass the
16
Amide-type local anesthetics no longer are contraindicated FDA’s drug approval process. These products may contain
in patients with a family history of malignant hyperthermia, very high combined levels of both amide and ester agents.
Exposure to high concentrations of
local anesthetics can lead to serious
32
Table. INECTALE LOCAL ANESTHETICS Aate fo Coté C et al adverse reactions, as indicated in the
16
FDA's warning. Acquired methemo-
Anesthetic Duration Maximum doseB mg anesthetic/ mg vasoconstrictor/ globinemia is a serious but rare condition
A
in minutes mg/kg mg/lb 1.7 mL cartridge 1.7 mL cartridge that occurs when the ferrous iron in
idocainec 90-200 4.4 2 the hemoglobin molecule is oxidized to
2%+1:50,000 epinephrine 34 0.034 mg the ferric state. This molecule is known
2%+1:100,000 epinephrine 34 0.017 mg as methemoglobin, which is incapable
18
of carrying oxygen. Risk of acquired
rticaine 60-230 7 3.2 methemoglobinemia has been associated
4%+1:100,000 epinephrine 68 0.017 mg primarily with two local anesthetics:
4%+1:200,000 epinephrine 68 0.0085 mg 13
prilocaine and benzocaine. Benzocaine
epivacaineD 120-240 4.4 2 is contraindicated in patients with a
3% plain 51 — history of methemoglobinemia and
2%+1:20,000 levonordefrin 34 0.085 mg should not be used in children younger
17
upivacaineE 180-600 1.3 0.6 than two years of age.
0.5%+1:200,000 epinephrine 8.5 0.0085 mg Selection of syringes and needles
The American Dental Association
A Duration of anesthesia varies greatly depending on concentration, total dose, and site of administration; use (ADA) has long standing standards
of epinephrine; and the patient’s age. for aspirating syringes for use in the
B Use lowest total dose that provides effective anesthesia. Lower doses should be used in very vascular areas. 19-21
Doses should be decreased by 30 percent in infants younger than six months. For improved safety, AAPD, administration of local anesthesia.
in conjunction with the American Academy of Pediatrics, recommends a dosing schedule for dental pro- Needle selection should allow for pro-
cedures that is more conservative that the manufacturer’s recommended dose (MRD). found local anesthesia and adequate
C The table lists the long-established pediatric dental maximum dose of lidocaine as 4.4 mg/kg; however, 19,20
the MRD is 7 mg/kg. aspiration. Needle gauges range
D Use in pediatric patients under four years of age is not recommended. from size 23 to 30, with the lower
E
The prolonged anesthesia of bupivacaine can increase risk of self-inflicted soft tissue injury. numbers having the larger inner diameter.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 333
BEST PRACTICES: USE OF LOCAL ANESTHESIA
Needles with lower number provide for less deflection as reduction on the onset time with inferior alveolar injections
29
the needle passes through soft tissues and for more reliable for pulpitis. This review concluded that the reduced time
20
aspiration. The depth of insertion varies not only by of onset may not be clinically relevant considering the time
29
injection technique but also by the age and size of the patient. required to prepare the buffered agent. Similar results were
30
Dental needles are available in three lengths: long (32 found in children ages six to 12 years old.
millimeters [mm]), short (20 mm), and ultrashort (10 mm).
Most needle fractures occur during the administration of Documentation of local anesthesia
22
inferior alveolar nerve block with 30-gauge needles. Breakage The patient record is an essential component of the delivery
31
can occur when a needle is inserted to the hub, when the of competent and quality oral health care. Following each
needle is weakened due to bending it before insertion into appointment, an entry is made in the record that accurately
the soft tissues, or by patient movement after the needle is and objectively summarizes that visit. Appropriate documen-
inserted.21-23 tation includes specific information relative to the administra-
tion of local anesthesia. This would include, at a minimum,
31
Injectable local anesthetic agents the type and dosage of local anesthetic administered.
Local amide anesthetics available for dental usage include Documentation also may include the type of injection(s)
lidocaine, mepivacaine, articaine, prilocaine, and bupivacaine administered (e.g., infiltration, block, intraosseous), needle
(Table). Absolute contraindications for local anesthetics in- selection, and patient’s reaction to the injection. For example,
15
clude a documented local anesthetic allergy. True allergy to local anesthesia administration might be recorded as: mandibu-
15
an amide is exceedingly rare. Allergy to one amide does not lar block with 27-short; 34 milligrams (mg) 2% lidocaine with
rule out the use of another amide, but allergy to one ester 0.017 mg epinephrine [or 1/100,000 epinephrine]; tolerated
15
rules out use of another ester. Potassium metabisulfate is used procedure well. In patients for whom the maximum dosage of
as a preservative in local anesthetics containing epinephrine. local anesthetic may be a concern (e.g., young patients, those
For patients having an allergy to bisulfates, use of a local undergoing sedation), the body weight should be documented
anesthetic without a vasoconstrictor is indicated.24 Local anes- preoperatively. Because there may be enhanced sedative effects
thetics without vasoconstrictors can undergo rapid systemic when local anesthetics are administered in conjunction with
24
absorption which may result in overdose. sedative drugs, recording doses of all agents on a time-based
32
While the prolonged effect of a long-acting local anesthetic record can help ensure patient safety. Local anesthesia docu-
(i.e., bupivacaine) can be beneficial for post-operative pain in mentation also should include that post-injection instructions
adults, the concomitant increased risk of self-inflicted injury were reviewed with the patient and parent.
infers that it is contraindicated for the child or the physically
15
or intellectually disabled patient. Claims have been made Local anesthetic complications
that articaine can diffuse through hard and soft tissue from Toxicity (overdose)
a buccal infiltration to provide lingual or palatal soft tissue Younger pediatric patients are at greater risk for adverse drug
15 8
anesthesia. Systematic reviews comparing articaine versus li- events. Most adverse drug reactions develop either during the
18
docaine have concluded they present the same efficacy with injection or within five to 10 minutes. Local anesthetic sys-
25
no differences in patient-reported pain and that articaine temic toxicity can result from high blood levels caused by
is more effective in anesthetic success in mandibular first per- a single inadvertent intravascular injection or repeated injec-
26 6
manent molar areas as well as superior for inferior alveolar tions. Local anesthetic causes a biphasic reaction (excitation
27 33
nerve block in patient with irreversible pulpitis . followed by depression) in the central nervous system (CNS).
Prilocaine is contraindicated in patients with methe- The classic overdose reaction to local anesthetic is generalized
33
moglobinemia, sickle cell anemia, anemia, or symptoms of tonic-clinic convulsion. Early subjective indications of toxic-
hypoxia or in patients receiving acetaminophen or phenacetin, ity involve the CNS and include dizziness, anxiety, and confu-
since both medications elevate methemoglobin levels.15 sion. This may be followed by diplopia, tinnitus, drowsiness, and
The effect of adjusting the pH of local anesthetics in dentistry circumoral numbness or tingling. Objective signs may include
has become of interest because the acidic nature of local anes- muscle twitching, tremors, talkativeness, slowed speech, and
thetics (adjusted to approximately pH of 4.5 to prolong shelf shivering, followed by overt seizure activity. Unconsciousness
10
life) may cause pain during infiltration and delayed onset. One and respiratory arrest may occur.
systematic review found that local anesthesia buffered with so- The cardiovascular system (CVS) response to local anesthetic
dium bicarbonate was 2.3 times more likely to achieve success- toxicity also is biphasic. Initially, the CVS is subject to stimu-
ful anesthesia than nonbuffered local anesthesia for participants lation; heart rate and blood pressure may increase. As plasma
with a clinical diagnosis of symptomatic irreversible pulpitis levels of the anesthetic increase, however, vasodilatation occurs
28
requiring endodontic treatment. Another systematic review followed by depression of the myocardium with subsequent
found that the pH adjustment was not effective in reducing fall in blood pressure. Bradycardia and cardiac arrest may
pain of intraoral injections in normal or inflamed tissues or follow. The cardiodepressant effects of local anesthetics are not
reducing the time of anesthesia onset, but it had a slight seen until there is a significantly elevated level in the blood.15
33 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
BEST PRACTICES: USE OF LOCAL ANESTHESIA
Local anesthetic toxicity can be prevented by careful in- However, there is no research demonstrating a relationship
jection technique, watchful observation of the patient, and between reduction in soft tissue trauma and the use of shorter
knowledge of the maximum dosage based on body weight. It acting local anesthetics.
should be recognized that half the volume of a four percent
local anesthetic should be used compared to a two percent Alternative techniques for delivery of local anesthesia
solution with the same dosing recommendation. Practitioners Most local anesthesia procedures in pediatric dentistry involve
should aspirate before agent delivery during every injection and traditional methods of infiltration or nerve block techniques
15
inject slowly. Aspiration during injections decreases the risk with a dental syringe, disposable cartridges, and needles as
of an intravascular injection, and a slow injection technique described so far. Several alternative techniques, however, are
reduces tissue distortion and related discomfort. After the in- available. These include computer-controlled local anesthetic
jection, the doctor, hygienist, or assistant should remain with delivery, periodontal injection techniques, needleless systems,
the patient while the anesthetic begins to take effect. Early rec- and intraseptal or intrapulpal injection. Such techniques may
ognition of a toxic response is critical for effective management. improve comfort of injection by better control of the adminis-
When signs or symptoms of toxicity are noted, administration tration rate, pressure, and location of anesthetic solutions and
38,39
of the local anesthetic agent should be discontinued. Additional result in more successful and controlled anesthesia.
emergency management, including patient rescue and activation The mandibular bone of a child usually is less dense than
of emergency medical services, is based on the severity of the that of an adult, permitting more rapid and complete diffusion
4 8
reaction. of the anesthetic. Mandibular buccal infiltration anesthesia is
as effective as inferior nerve block anesthesia for some oper-
Allergy to local anesthesia 8
ative procedures. In patients with bleeding disorders, the
Allergic reactions are not dose related but are due to the pa- periodontal ligament (PDL) injection minimizes the potential
tient’s heightened capacity to react to even a small dose and 13
for postoperative bleeding of soft tissue vessels. The use of the
can manifest in a variety of ways, some of which include PDL injection or intraosseous methods is contraindicated in
urticaria, dermatitis, angioedema, fever, photosensitivity, or 38
the presence of inflammation or infection at the injection site.
15,24
anaphylaxis. Emergency management is dependent on the
rate and severity of the reaction. Local anesthesia with sedation and general anesthesia
Local anesthetics and sedative agents both depress the CNS.
Paresthesia Therefore, it is recommended that the dose of local anes-
Paresthesia is persistent anesthesia beyond the expected dura- thesia be adjusted downward when sedating children with
tion. Trauma to the nerve can result in paresthesia and, 40
opioids.
among other etiologies, can be caused by the needle during For patients undergoing general anesthesia, the anesthesia
34
the injection. Patients who initially experience an electric shock care provider needs to be aware of the concomitant use of a
34
sensation during injection may have persistent anesthesia. local anesthetic containing epinephrine, as epinephrine can
Paresthesia has been reported to be more common with four produce dysrhythmias when used with halogenated hydrocar-
percent solutions such as articaine and prilocaine compared 4
bons (e.g., halothane). Local anesthesia has been reported to
to those of lower concentrations.35 reduce pain in the postoperative recovery period after general
41
anesthesia.
Postoperative soft tissue injury
Self-induced soft tissue trauma (lip and cheek biting) is an Local anesthesia and pregnancy
unfortunate clinical complication of local anesthetic use in The use of local anesthesia during pregnancy is considered
the oral cavity. Most lesions of this nature are self-limiting and 42
safe. The FDA has established a drug classification system
heal without complications, although bleeding and infection 43
based on their risks to pregnant women and their fetuses. In
34
are possible. The use of bilateral mandibular blocks does not respect to the five categories (A, B, C, D, and X) established
increase the risk of soft tissue trauma when compared to uni- by the FDA, lidocaine is considered in Category B, the safest
34 44
lateral mandibular blocks or ipsilateral maxillary infiltration. of the local anesthetics. Lidocaine is considered to be safe
Advising the patient/caregiver of a realistic duration of 45
for use during breastfeeding.
numbness and post-operative precautions is necessary to de-
crease risk of self-induced soft tissue trauma. Visual examples Recommendatons
may help stress the importance of observation during the 1. Selection of local anesthetic agents should be based
period of numbness. For all local anesthetics, the duration of on the patient’s medical history and mental/
soft tissue anesthesia is greater than dentinal or osseous anes- developmental status, the anticipated duration of the
thesia. Use of phentolamine mesylate injections in patients dental procedure, and the planned administration
over age six years or at least 15 kilograms (kg) has been shown of other agents (e.g., nitrous oxide, sedative agents,
to reduce the duration of effects of local anesthetic by about general anesthesia).
36,37
47 percent in the maxilla and 67 percent in the mandible.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 33
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