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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 ...

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          BEST PRACTICES:   USE OF LOCAL ANESTHESIA
          Use of Local Anesthesia fo Peiatic Dental 
          Patients
          Latest Revision                                                    How  to  Cite:  Aeican  Acae  of  Peiatic  Dentist  Use  of   
          22                                                               local  anesthesia  fo  „eiatic  ental  „atients  The  Refeence  Man€al   
                                                                             of  Peiatic  Dentist  Chica‚o…  Ill†  Aeican  Acae  of  Peiatic   
                                                                             Dentist‡  22ˆ†332 ‰
            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 toicity, 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  
            maimum 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 eperience. 
            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.
            ŠEY‹ORDS†   ANALŒESICS‡ ANESTHESIA… ŒENERAL‡ ANESTHESIA… LOCAL‡ DELIŽERY OF HEALTH CARE… METHEMOŒLO‘INEMIA… PAIN MANAŒEMENT…   
                                      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: Aeican Acae Peiatic Dentist ADA: Aeican Den  
          Local anesthesia is the temporary loss of sensation including       tal  Association  CNS: Cental ne­o€s sste  CVS:  Caio­asc€la 
          pain in one part of the body produced by a topically-applied        sste  FDA:  US  Foo  an  D€‚  Ainistation  kg:  ƒillo‚a   
          or injected agent without depressing the level of conscious-        lb:  „o€n  mg:  illi‚a  mm:  illiete  mL:  illilite  PDL:   
                                                                              Peioontal  li‚aent
          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.       IN’ECTA‘LE LOCAL ANESTHETICS “Aa„te 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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...Best practices use of local anesthesia fo peiatic dental patients latest revision how to cite aeican acae dentist eiatic ental atients the refeence manal chicao ill abstract this practice presents recommendations regarding control pain during pediatric procedures considerations in topical and anesthetics include patient s medical history developmental status age weight planned risk for methemoglobinemia formulations injectable anesthetic agents with without vasoconstrictor as well contra indications their selection syringes needle length gauge uidance documentation addresses dose administered addition injection type location postoperative instructions otential complications such toicity paresthesia allergy selfinduced soft tissue injury are discussed ecommendations also provided alternative delivery methods sedation or general pregnancy afety precautions emphasi e calculating maimum dosage based on adjusting when additional analgesic sedative used considering systemic absorption possib...

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