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LOCAL ANESTHESIA IN PEDIATRIC DENTISTRY

The student should be able to explain the composition, mechanism of action and
classification of local anesthesia, demonstrate different techniques of administration of local
anesthesia. They should be able to recognize the complications of local anesthesia for child
patient.
The student should be competent to apply rubber dam with operative procedures.

Refer:
Dentistry for the child & adolescent: McDonald, Avery, Dean; 8th Edition
Handbook of local anesthesia: Malamed
A manual of Peaediatric Dentistry: Andlaw & Rock
Kennedys Paediatric Operative Dentistry D.B.Kennedy, M.E.S.J. Curzon
Restorative techniques in pediatric dentistry- M.S. Duggal, M.E.S.J. Curzon
The Following topics are discussed in detail during the lecture:
LOCAL ANESTHESIA
Definition
Composition
Mechanism of Action
Anatomical differences in pediatric patient
Techniques of L.A application
Complications
Contra Indications
ISOLATION
Need for isolation in children:
Various means of Isolation:
Rubber Dam
Advantages
Contra indications
Armamentarium
Techniques
Precautions
Method of Application
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Local anesthesia produces a loss of sensation with out loss of consciousness as in genral
anesthesia. Mandatory in pediatric operative procedures as it is difficult to decide if the child
is restless after certain time- whether its due to pain / restlessness
Definition [ Malamed]
As a loss of sensation in a circumscribed area of the body caused by a depression of
excitation in nerve endings or an inhibition of the conduction process in peripheral nerves
Composition:
L.A agent: Lidocaine 2%, Mepivacaine, Prilocaine, Etidocaine, Bupivacaine
Vasoconstrictor:
Epinephrine, Levonordefrine, Phenylephrine 1:2500
L.A except cocaine has vasodilating action
Hence vasoconstrictors are used to:
Decreases the flow of blood to the site of injection
Slows the absorption of L.A into cardiovascular system
Lower L.A blood level decreases L.A toxicity
Higher amount of L.A remain around the nerve & increase the duration of action
Decreases the bleeding at the site of administration
Reducing agent:
Sodium meta bisulphate
Vasoconstrictors may oxidize as they are unstable on prolonged exposure to sunlight.
Preservative:
Caprylhydrocuprienotoxin, Methylparaben
Fungicide:
Thymol
Vehicle:
Modified Ringers solution
Minimize the discomfort during injection

Mechanism of Action:
Acetylcholine, Calcium displacement, Surface repulsion, Membrane expansion

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Specific Receptor theory: Strichartz 1987:. Action of the drug is direct; L.A agents act by
binding to specific receptors on the sodium channel & prevent the entry of sodium into the
cell.
Metabolism of amide L.A: Primary site of biotransformation of amide drug is liver. Rate of
biotransformation of drugs are similar.
Anatomical differences:
Cortical plates are less dense in children
Children less than 5 yrs- mandibular foramen lies 0.5 cm below the occlusal plane
Children about the age of 6 yrs foramen at the level of occlusal plane
Children more than 8-10 yrs foramen above the occlusal plane
Techniques:
Local Infiltration: 0.6- 1 ml, small terminal nerve endings
Field block: large terminal nerve branches
Nerve block: 1.8-2 ml, main nerve trunk
Intra ligamentary: 0.2 ml, given under high pressure, through the sulcus on mesial side
Intra Septal: 0.1ml, buccal mucosa, thru the inderdental papilla into interdental bone both
mesially & distally
Intra papillary: for palatal / lingual tissues
Intra pulpal: when other technique fail, needle bent & forced
Iontophoresis
Intra Oral Lignocaine patch
Jet Injection
Computer controlled injection system [Wand L.A system]
Electronic Dental anesthesia [Transcutaneous Electrical Nerve Stimulation]
Topical anesthesia [sprays, gels, EMLA]
Lignocaine- very bitter, but effective
Benzocaine- Longer duration of action & depth, acceptable taste

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Complications:
Psychogenic: Numb feeling, Lip Biting, Pulling & Rubbing
Allergy
Toxicity: 4.4mg/kg body wt
Due to procedure:
Vasovagal syncope, Broken needle, Failure to achieve anesthesia, Facial paralysis, Trismus,
Infection, Developmental defect, Self inflicted trauma
Due to method:
Ballooning of tissue in intraepithelial due to lack of depression of solution
Pain in sub periosteal injections
Electric shock type of sensation when direct contact of needle to the nerve trunk
Anatomical variation:
Upper 1st molar- low zygomatic buttress
Accessory nerves: Max molar- G.palatine nerve
Mand molar- Cervical plexus
Mid line- Bilateral supply
Motor nerve paralysis, Solution deep in to parotids, Hematoma

Contra Indications:
Immaturity
Mental handicapped
Increased time required for treatment
Acute Infection
Allergy
Bleeding inferior alveolar nerve block
Endocarditis- Intra ligamentary
Incomplete root formation- Intra Ligamentary
Trismus- Inferior Alveolar nerve block
Epilepsy- TENS
Need for isolation in children:
Increased salivation
Excessive tongue movement
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Short span of attention hence short duration of treatment & better isolation
Danger of foreign body aspiration
Visibility
Improves the Properties of Restorative material
Behavior management
Various means of Isolation:
Fluid absorbent
Saliva ejectors
Rubber Dam
Matrices
Rubber Dam
Introduced by Barnun 1864
Advantages:
Saves time
Controls saliva: Maintains clean visible field, type of hemorrhage appreciated
Patient protection aspiration, swallowing
Clinician protection
Reduces the risk of cross contamination pulp therapy
Aids management: Retracts & protects soft tissue, tongue, lips
Increase efficacy- reduces rinsing, minimize patient conversation
Improves the properties of materials
Application of medicaments without dilution
Minimize mouth breathing during inhalation sedation procedure
Psychological benefit to patient
Contra indications:
Child with URT infection, nasal congestion, nasal obstruction
Presence of Fixed orthodontic appliance
Recently erupted teeth
Patient allergic to latex
Armamentarium:
Template U/L- Adult / Pedo
Marker
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Rubber dam sheet 6X6 / 5 X5 rolls/ sheets colors- Use dull side facing occlusally as
it is less reflective
Rubber dam punch
Rubber dam forceps
Clamps winged/ wingless/ serrated/ jaws inclined cervically/ endoilluminators
Rubber dam frame
Rubber dam napkin
Waxed dental floss
Scissors
Lubricants water soluble- soap slurry
Techniques:
Single tooth isolation- single surface restoration, single tooth pulp therapy
Isolation for Proximal carious tooth
Isolation for SS crown tooth preparation
Slit dam method
Quadrant isolation- most distal tooth is clamped & anterior most tooth to be ligated
Anterior teeth isolation- Dry Dam / heavy dam + ligature
Precautions:
Sheets: Patients allergic to latex- use latex free dam / napkins
Heavy- restorative/ anterior teeth & medium- endo as these can retract tissue better
than thin type
Punching: Holes too wide- thickness will be barrier for proximal placement
Holes too near- may create leakage of saliva
Incorrect punching moves the frame & sheet unnecessarily high obstructing airway
/ nose
Clamps: trial / error method- place & feel its secured
Use floss to tie to the bow; to retrieve in case of slipping
Fatigued bow mar result in non- stretching & poor retention
Forceps: Avoid traumatizing soft tissues; insert a finger to get the correct direction of
placement

Method of Application:
1. Clamp on tooth first. Rubber dam stretch over clamp & Frame placed. Good with
wingless clamp
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2. Clamp placed in punched rubber dam hole with wings engaged + stretched to frame.
Release tension of stretched dam by releasing at lower corner. This is placed on tooth
& then re-stretched to frame.
3. Clamp placed in punched rubber dam hole with wings not engaged. Once secured on
tooth, use plastic instrument to ease the sheet into wings. Then stretch the sheet on to
the frame.

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