local analgesia in children

8/3/2019 Local Analgesia in Children

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LOCAL ANALGESIA INCHILDREN


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IntroductionHaving the ability to give pain free injections is a

very obvious practice builder and is a very high

priority for anyone treating children.


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Equipment

Syringe

Aspirating syringe Needles

Disposable needles

For infiltrations

Short needles (2 cm 2.5 cm)

Fine needles (gauge 30)

For inferior dental nerve block

Long needles (3 cm)

Thicker needles (gauge 27)


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Local anaesthetic solutions

Local anaesthetics stabilizes nerve

membranes by affecting the influence

of stimulation on nerve conduction.


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Lignocaine Lignocaine 2% adrenaline 1:100,000

Safe (even in heart patients in doses kept withinreasonable limits,i.e; 3 or 4 cartridges).

Effective analgesia for 90 minutes.

Maximum safe dose in fit adults 500 mg (12 x 2ml cartridges)

For children, the rule of thumb with LA is < 5 years 1 cartridge

5 10 years 3 cartridges max

> 10 years 4 cartridges max


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Prilocaine Prilocaine 3% with felypressin 0.03 iu/ml

Effective analgesia for 90 minutes

Maximum safe dose for fit adults 600 mg (10 x 2ml cartridges)

Methaemoglobinaemia if in excess

For children, the rule of thumb with LA is < 5 years 1 cartridge

5 10 years 3 cartridges max

> 10 years 4 cartridges max


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Mepivacaine Mepivacaine HCL 3%

Quick onset of action

Duration of action short 15 30 minutes in maxilla

30 40 minutes in mandible

Max. safe dose 400mg (6 cartridges)


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Bupivacaine

Bupivacaine HCL 0.25%

Long acting, up to 6 hours

Max. safe dose for adults 2mg/kg

Contra-indicated in pregnancy


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Topical anaesthetic cream

Constituents in 1ml Lignocaine 50mg

Hyaluronidase 50 unitsin a water miscible base

Drawbacks : Taste

Long time for effect

x

Benzocaine (topical anaesthetic agent) is also used.


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Commonly Used LocalAnaesthetic Solution

Lignocaine 2%

with adrenaline 1: 80,000


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Side effects of adrenaline following

accidental I.V injection

1. Increased anxiety

2. Dyspnoea

3. Restlessness

4. Tachycardia

5. Tremors

6. Dizziness

7. Headache

Therefore always aspirate while injecting LA.


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Local Complications of LA1. Contaminated needle

2. Too rapid injection

3. Too large injected volume

4. Infected area

5. Laceration of the nerve (parasthesia for long time).

6. Laceration of an artery or a vein

7. Laceration of the periosteum (very well innervated, so painful later on).

8. Trismus

9. Facial paresis (if we go too far backwards).

10. Wounds in lips and cheeks (child may injure himself).


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General Complications of LA

1. Psychogenic complications - most common

2. Toxic complications - overdosage- lowered tolerance

3. Allergic complications - very rare

(allergy to lignocaine)

3. Drug interaction - rare(between adrenaline andtricyclic antidepressants)


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Giving injection to children1. Have a good history, especially about any previous LA experience.

2. Have patient in a relaxed reclined position.

3. Check, have a good line of vision and good access.

4. Dental syringe should be concealed.

5. Prepare mucosa with a topical anaesthetic agent.6. Stretch the mucosa and pull it on to the needle.

7. Prewarm the anaesthetic solution.

8. Inject the solution slowly.

9. Explain to the child what to expect.

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The position of mandibular foramen changes with age. It is

lower in children, goes up with age and in adults it is at the

level of occlusal plane.


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Types of Injections Infiltration Maxillary infiltration.

Mandibular infiltration in young children, upto 5 years of age.

Modified posterior superior alveolar nerve block

(maxillary molar nerve block).

Inferior dental nerve block

Intra-papillary injection

Periodontal ligament injection(intra-ligamentary anaesthesia)

Injection of LA with jet syringe

Electronic dental anaesthesia (EDA)


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Maxillary infiltration

1. Organise equipment and materials

2. Establish a good operating position

3. Inform the child

4. Apply topical analgesic

5. Prepare to give the injection

6. Give the injection

7. Withdraw the syringe and give postoperative instructions


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3. Inform the child




7. Withdraw the syringe and givepostoperative instructions

1. Organise equipment andmaterials

Equipment and materials should

be made ready before patiententers the surgery.

Syringe should be placed on aclean surface and out of sightbecause sight of needle causesanxiety in children.


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3. Inform the child





2. Establish a good operatingposition Adjust the chair and headrest so

that the childs line of vision is at

least 450

from the horizontal.

Sit or stand facing the child at 8oclock position and adjust theheight of the chair so that theinjection site can be seen easilyand comfortably.

When injecting on the left side 11oclock position (behind thepatient) can also be used.


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3. Inform the child





3. Inform the child Tell the child that to clean decay

from the tooth it is best to makethe tooth go to sleep and that itwill wake up later.

Avoid the use of words likeneedle, injection, prick, hurt etc

.

The method of informing the childdepends upon the childs age and

psychological development andalso by the attitude to previousinjections.


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3. Inform the child





4. Apply topical analgesic Put topical analgesic cream on a

cotton roll or pellet. Let the child tosmell its fruity smell and tell thatthis will start to make the tooth go

to sleep. Dont put too muchcream on the pledget.

Retract the cheek with the lefthand and dry the tissue at themuco-buccal fold above the toothto be treated. Hold the topicalanalgesic against the tissue for 2

minutes. Distract the child duringthis period.

Jet injection also producesexcellent topical analgesia.


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3. Inform the child





5. Prepare to give the injection Remove the cotton roll or pellet

after 2 minutes and receive thesyringe from assistant in the righthand.

For injection in the maxillary leftquadrant, receive the syringe overthe childs left shoulder. Forinjection in the maxillary right side,the assistant should pass thesyringe from behind the patient,over the right shoulder.

The assistant should first carefullyplace the syringe in the dentistshand so that it can be usedimmediately, and then remove theneedle guard.


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3. Inform the child





6. Give the injection Pull the cheek outwards with the left

hand so that the mucous membrane ismade taught. Gently insert the tip of theneedle into the tissue, or draw thetaught tissue over the needle.

Inject a few drops of solution, pause fora few seconds, then advance theneedle carefully about 1 cm at 450 to thelong axis of the tooth.

Inject slowly (take about 30 sec). Informthe child that as the tooth goes to sleepit will feel funny and that it will wake up

later.

For 1st permanent molars, infiltrationsare given mesial and distal to the toothbecause of the dense zygomatic archover the 1st molar root apex.


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3. Inform the child





7. Withdraw the syringe andgive postoperativeinstructions After injecting the solution,

withdraw the needle and pass thesyringe to the assistant below thechilds field of vision.

Ask the child to rinse (fordistraction).

Warn the child and parent aboutthe danger of cheek or lip biting.

Praise the childs good behaviour.


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Mandibular infiltrationAll the steps are the same as

for maxillary infiltration except

step 5 and step 6.

These are:

5. Prepare to give the injection.

6. Give the injection.

5. Prepare to give the injection For left or right mandibular

infiltrations, receive the syringefrom assistant in the same way asfor left or right maxillary

infiltrations.6. Give the injection

Make the mucous membrane tautby pulling the cheek outwards.

Hold the syringe in a horizontalposition and take it carefully to thepatients mouth.

Position the tip of the needle atthe muco-buccal fold just belowthe tooth to be treated. Give theinjection as described undermaxillary infiltration.

Keep the syringe approximatelyparallel to the occlusal planerather than bringing it in line withthe long axis of the tooth.


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Modified posterior superior alveolar nerve block

(maxillary molar nerve block)1. Organize equipment and materials


3. Inform the child

4. Locate anatomical landmarks

Palpate the zygomatic process and note its relationship to the teeth. Note theposition of the distal root of the second molar (in a young child estimate thisposition).

Pass the finger posteriorly along the muco-buccal fold towards the maxillarytuberosity.




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7. Give the injection For injecting on the right side, retract the cheek with the left index or

middle finger and for injecting on the left side, retract with the leftthumb.

Place the tip of the finger or thumb on the tuberosity.

Now insert the needle between the tip of the retracting finger and thedistal surface of the zygomatic process, in line with the distal root ofthe second molar. Inject a few drops of solution.

Advance the needle upwards and backwards about 1.5 cm, towardsthe alveolar bone.

If no blood on aspiration, slowly inject 1.5 2 ml of solution.

While injecting, apply pressure to the alveolar mucosa with the finger

or thumb, As solution accumulates it causes a bulge in the tissuesanterior to the finger.

8.Withdraw the syringe and massage the solutiontowards the posterior superior alveolar foramen

Place a finger over the bulge at the injection site, ask the patient to

close the mouth a little, and push the solution upwards, backwardsand inwards towards the posterior superior alveolar foramen.


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Inferior dental nerve block

1. Organise equipment and materials As for maxillary infiltration.


Adjust the chair and headrest so that the childsline of vision is about 450 to the horizontal.

For injection of mandibular left quadrant, sit or stand

either behind the patient (11 oclock position) or facing

the patient (8 oclock position).

For injection of mandibular right quadrant, sit or standfacing the patient (8 oclock position).

3. Inform the child As for maxillary infiltration.


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Inferior dental nerve block continues

4. Locate the anatomical landmarks Palpate the internal oblique ridge of the anterior border

of the ramus, and note the pterygomandibular raphe andpterygomandibular triangle.

The injection site is within the pterygomandibular triangle

level with the occlusal surfaces of the molar teeth.

5. Apply topical analgesic Ask the child to open the mouth wide, dry the injection site

and apply the topical anaesthetic agent with a cotton role

or pledget held in tweezers.

Try to keep the topical anaesthetic cream in place for2 minutes without saliva contamination.

If this is not practicable, injection should be given sooner.


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Left side If you are positioned behind the patient, place the index or middle

finger of the left hand on the internal oblique ridge at the level of the

occlusal surfaces of the molar teeth, and support the mandible byplacing the thumb on the posterior border of the ramus.

If you are facing the patient, place the thumb on the internal obliqueridge and support the mandible posteriorly with the index finger.

Receive the syringe from assistant over the patients left shoulder.

Right side Place the thumb of the left hand on the internal oblique ridge and

support the mandible posteriorly with the index finger.

The assistant should pass the syringe behind the patient and hand itunder the dentists left arm, over the patients right shoulder.


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Indirect technique Direct the needle towards the injection site, holding the syringe

parallel to the occlusal plane and in line with the premolar and molarteeth.

Insert the needle just medial to the thumb or index finger positioned onthe internal oblique ridge, at the level of the occlusal surfaces of themolar teeth. In young children the position of the mandibular foramenis relatively low and is in line with the cervical margins of the teeth.

Immediately on penetrating the tissue, inject a few drops of solution.Slowly advance the needle about 1.5 cm, then, keeping the tip of theneedle in the same position, swing the syringe across the midline ofthe mouth, to lie over the opposite first primary molar or first premolarregion. Then advance the needle gently for about another 1 cm tocontact the bone.

Aspirate . If no blood is aspirated, inject about of the cartridgeslowly, over a period of 30 seconds. Then withdraw the syringe slowly.

If analgesia of lingual soft tissues is required, inject the remainder ofthe cartridge after withdrawing the syringe about half way.

Inform and reassure the child about the funny feeling.


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Direct technique

The technique is the same as the indirect technique except that theneedle is directed towards the injection site while holding the syringe

over the first primary molar or first premolar region of the oppositeside of the mandible.

8. Withdraw the syringe and give

postoperative instructions

As for maxillary infiltration.


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Intra-papillary injectionThe intra-papillary injection is used:

To produce analgesia of palatal or lingual tissues.

To avoid the need for painful injections directly into

palatal or lingual tissues.

Technique: . Give a submucosal injection buccally.

After about 1 minute, inject into the interdental papilla

mesial and distal to the tooth to be treated.

Pass the needle horizontally through the papilla

from buccal to palatal or lingual.

Inject a small volume of solution.


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Periodontal ligament injection

(intra-ligamentary injection)

The intraligamentary injection is given into the periodontal ligamentusing a special syringe. It can also be given with a conventionalsyringe using a short 30 gauge needle. Local anaesthesia withoutadrenaline is preferred.

Technique:1. Remove any calculus from the injection site and apply a disinfectant.

2. Introduce the needle into the gingival crevice, with the bevel of the needle

facing away from the tooth.

3. Move the needle apically until it becomes wedged between the tooth and thealveolar crest.

4. Squeeze the trigger slowly. If the needle is correctly placed there should be definiteresistance to injection and the tissues around the needle should blanch.

5. Inject slowly. The injection of 0.2 ml should take at least 20 seconds. A single rootshould not be injected more than 0.2 ml.

6. For a posterior tooth, give an injection around each root.


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Advantages

1. Can produce analgesia of a single tooth.

2. Controlled dose of anaesthetic possible.

3. No numbness of lip and tongue

4. Anaesthesia obtained immediately.

5. Duration of anaesthesia 45 55 minutes.

6. Avoids risk of injecting into a vessel.

7. Uses in children: Removal of loose deciduous teeth.

Removal of teeth in multiple quadrants.

Children with bleeding diathesis.


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Disadvantages1. Technique difficult.

2. Excessive pressures required may produce tissue damage.

3. Extrusion of mobile teeth.

4. Post operative pain.

5. Special syringe required.

6. Post operative resorption of teeth.

(67% success in children)


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Injection with jet syringeLocal analgesic solution may be injected into the oral tissues without using a needle, byusing an instrument that propels solution at high velocity through a fine orifice (jet syringe).Jet syringe inject solution to a depth of about 1 cm and deliver volumes between 0.05 and0.2 ml.

jet injection may be used for soft tissue analgesia prior to needle injection. It may also beused to produce analgesia for dental procedures for which infiltrations are normally used.

Technique:

1. Explain to the child.

2. Clean the injection site with antiseptic solution and then dry with cotton or gauze.

3. Place the nozzle of the jet syringe at the injection site. The nozzle should be at rightangle to the underlying tissue.

4. Warn the child that the spray is coming.

5. Hold the syringe immobile when injecting.

6. If analgesia is found to be inadequate during cavity preparation, give a second jetinjection or a needle injection.


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Advantages

1. Can produce anaesthesia of a single tooth.

2. Controlled dose of anaesthetic possible.

3. Minimal numbness of lip and tongue.

4. Avoids use of needles.


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Disadvantages

1. Injection point must be precise.

2. Technique important solution should enter tissue perpendicularly.

3. Penetration limited.

4. Bulky syringe.

5. Noisy.

6. Post operative pain, bruising.

7. Special syringe required.


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Electronic Dental Anaesthesia (EDA)

EDA consists of a high frequency low voltage current which is

passed between two electrodes positioned within the mouth. It

runs from small batteries.

Work in two ways:

1. By closing the gate,i.e; blocking the pain pathways as

described in the gate theory of pain control.

2. It causes biochemical changes within the blood which lead toincreased serotonin release.


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Advantages1. Quit onset of action.

2. No post operative effects.

3. Variable levels of action that the patient can control.

4. 80% success achieved.

5. Natural, i.e.; depends on endorfins produced by nerve cells.

6. Psychologically good for the patient to be able to control it.

7. Controls allow it to only be increased not decreased by the patient.

8. Runs from small batteries only, therefore no chance of current surge.

9. No prolonged post operative numbness.


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Disadvantages

1. Should not be used in patients with pacemakers, who suffer fromepilepsy, who are pregnant or who have had a CVA.

2. Need a co operative patient.

3. The patient needs quick reactions to respond appropriately.

4. Positioning the electrodes is difficult particularly where the sulci areshallow.

5. Water / saliva reduce the stickiness of the electrodes, therefore thecurrent may suddenly be lost as an electrode comes loose.

6. The amount of wires protruding makes it cumbersome.


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Local anaesthesia for all patients

The rule of thumb is:

1. Inject minimal amount of anaesthesia required.

2. Inject slowly to reduce discomfort and to prevent

anxiety and stress.

3. Always aspirate before injecting.


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Thank You

local analgesia in children

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