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Local Anesthetics in Pediatric Dental Practice

Article  in  Research Journal of Pharmacy and Technology · August 2019

DOI: 10.5958/0974-360X.2019.00700.5

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 Research J. Pharm. and Tech. 12(8): August 2019

ISSN 0974-3618 (Print) www.rjptonline.org

0974-360X (Online)

REVIEW ARTICLE
Local Anesthetics in Pediatric Dental Practice
Dr. Trophimus Gnanabagyan Jayakaran1*, Dr. Vignesh R2, Dr. Shankar P3
1
Senior Lecturer, Department of Pediatric and Preventive Dentistry, SRM Dental College,
Ramapuram, Chennai – 600089, Tamilnadu, India
2
Senior Lecturer, Department of Pediatric and Preventive Dentistry, Saveetha Dental College and Hospital,
Chennai -600077, Tamilnadu, India
3
Reader, Department of Pediatric and Preventive Dentistry, SRM Dental College,
Ramapuram, Chennai – 600089, Tamilnadu, India
*Corresponding Author E-mail: [email protected]

ABSTRACT:
The administration of Local anesthesia is the greatest fear a child would encounter in the dental office. Hence it
is important that dentists obtain pain control with minimum discomfort to the child. This Review article provides
an overview about the various local anesthetic agents used in pediatric dental practice, dosage, complications and
the recent advances.

KEYWORDS: Local anesthesia, Lignocaine, WAND.

INTRODUCTION: How Local Anesthetics Work

Pain prevention in pediatric dentistry is crucial for a The primary action of local anesthetics in producing a
child in achieving positive experience during the dental conduction block is to decrease the permeability of ion
visit, building trust and cooperation and making future channels to sodium ions (Na+). Local anesthetics
visits enjoyable. One of the main methods to prevent selectively inhibit the peak permeability of sodium,
pain is the administration of local anesthesia. [1,2] whose value is normally about five to six times greater
Local anesthesia is the temporary loss of sensation than the minimum necessary for impulse conduction
including pain in one part of the body produced by a (e.g., there is a safety factor for conduction
topically-applied or injected agent without depressing of 5× to 6×). [4]
the level of consciousness. Local anesthetics act within
the neural fibers to inhibit the ionic influx of sodium for Local anesthetics reduce this safety factor, decreasing
neuron impulse. [3,4] both the rate of rise of the action potential and its
conduction velocity. When the safety factor falls below
The pediatric dental professional should be aware of unity, conduction fails and nerve block occurs. Local
proper dosage (based on weight) to minimize the chance anesthetics produce a very slight, virtually insignificant
of toxicity and the prolonged duration of anesthesia, decrease in potassium (K+) conductance through the
which can lead to accidental lip, tongue, or soft tissue nerve membrane. Calcium ions (Ca++), which exist in
trauma. [5] Knowledge of gross and neuroanatomy of the bound form within the cell membrane, are thought to
head and neck allows for proper placement of the exert a regulatory role on the movement of sodium ions
anesthetic solution and helps minimize complications. across the nerve membrane. Release of bound calcium
Familiarity with the patient’s medical history is ions from the ion channel receptor site may be the
mandatory to decrease the risk of aggravating a medical primary factor responsible for increased sodium
condition while rendering dental care. Medical permeability of the nerve membrane. This represents the
consultation should be obtained as and when needed. [4,5] first step in nerve membrane depolarization. Local
anesthetic molecules may act through competitive
Received on 24.05.2019 Modified on 28.06.2019 antagonism with calcium for some site on the nerve
Accepted on 05.07.2019 © RJPT All right reserved membrane. [4]
Research J. Pharm. and Tech 2019; 12(8): 4066-4070.
DOI: 10.5958/0974-360X.2019.00700.5

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 Research J. Pharm. and Tech. 12(8): August 2019

Local Anesthetic agents available: tissue from a buccal infiltration to provide lingual or
Numerous local anesthetic agents are available to relieve palatal soft tissue anesthesia. [4]
pain during the dental procedure. The most commonly
used local anesthetics for pediatric dentistry are the Dose Calculation
amide type agents. Lidocaine hydrochloride (HCl) 2% Local amide anesthetics available for dental usage
with 1:100,000 epinephrine is preferred because of their include lidocaine, mepivacaine, articaine, prilocaine, and
low allergenic characteristics and their greater potency bupivacaine (Table 1). Absolute contraindications for
at lower concentrations. [7] Vasoconstrictors are used to local anesthetics include a documented local anesthetic
constrict blood vessels, counteract the vasodilatory allergy. [11] True allergy to an amide is exceedingly rare.
effects of the local anesthetic, prolong its duration, Allergy to one amide does not rule out the use of another
reduce systemic absorption and toxicity, and provide a amide, but allergy to one ester rules out use of another
bloodless field for surgical procedures.[7,8] The use of the ester.[12] A bisulfate preservative is used in local
vasoconstrictor will allow the maximum total dose of anesthetics containing epinephrine. For patients having
the anesthetic agent to be increased by nearly 40%. [9,10] an allergy to bisulfates, use of a local anesthetic without
Many agents have been employed as vasoconstrictors a vasoconstrictor is indicated. [11]
with local anesthetics. But none has proved to be as
clinically effective as epinephrine. [9] The maximum dose of lidocaine and mepivacaine,
without vasoconstrictors, recommended for children is
However epinephrine is contraindicated in patients with 4.4 mg/kg body weight (Table 2), and 7 mg/kg body
hyperthyroidism. The dose should be kept to a minimum weight for lidocaine with vasoconstrictors. [4,13] (Table
in patients receiving tricylic antidepressants since 2)
dysrhythmias may occur. [5] Levonordefrin and So, for a child weighing 25 kg, the maximum
norepinephrine are absolutely contraindicated in these permissible dosage of LA is 7 × 25 = 175 mg of LA.
patients. Patients with significant cardiovascular disease,
thyroid dysfunction, diabetes, or sulfitesensitivity and As lidocaine is generally available as 2% solution, this is
those receiving monoamine oxidase inhibitors, tricyclic 2 gm in 100 ml of solution or 100 ml of solution will
antidepressants, or phenothiazines may require a have 2 gm of LA.
medical consultation to determine the need for a local
anesthetic without vasoconstrictor. [5,11] 1 ml of solution has 2/ 100 =0.02 gm or 20 mg of LA
1.8 ml of solution (1 cartridge) will have – 20 × 1.8 = 36
A long-acting local anesthetic (ie, bupivacaine) is not mg of LA
recommended for the child or the physically or mentally
disabled patient due to its prolonged effect, which If a total of 175 mg can be safely administered to a child
increases the risk of soft tissue injury. Claims have been weighing 25 kg, it means 175/36 = 4.8 or 5 Cartridges of
made that articaine can diffuse through hard and soft Lidocaine with adrenaline (1.8 ml of solution) can be
safely administered.
Table : 1 – Injectable Local Anesthetics [5]

Anesthetic Maxillary Infiltration Mandibular block Maximum Dosage Maximum

(Duration in Minutes) (Duration in Minutes) Total Dose
Pulp Soft Tissue Pulp Soft Tissue (mg/kg) (mg/lb) (mg)
Lidocaine 4.4 2.0 300
2% Plain 5 5-10
2% + 1:50,000 epinephrine 60 170 85 190
2% + 1:1,00,000 epinephrine 60 170 85 190
Mepivacaine 4.4 2.0 300
3% Plain 25 90 40 165
2% + 1:1,00,000 epineprine 60 170 85 190
2% + 1:20,000 levonordefrin 50 130 75 185
Articaine 7.0 3.2 500
4% + 1:1,00,000 epinephrine 60 190 90 230
4% + 1:2,00,000 epinephrine 45 180 60 240
Prilocaine 6.0 2.7 400
4% Plain 20 105 55 190
4% + 1:2,00,000 epinephrine 40 140 60 220
Bupivacaine 1.3 0.6 90
0.5% +1:2,00,000 epinephrine 40 340 240 440

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Table 2: Maximum Dose – Lidocaine Without Adrenaline [30] Complications of Local Anesthesia:
Patient Weight (kg/lb) mg No. of cartidges There are numerous potential complications associated
10/23 44 1.2
15/34.5 66 1.8
with the administration of local anesthetics. These
20/46 88 2.4 complications may be separated into those that occur
25/57.5 100 2.7 locally in the region of injection and those that are
30/69 132 3.6 systemic.
40/92 176 4.8
50/115 220 6.1
60/138 264 7.3
The Local Complications include: [4]
70/161 300 8.3 1. Needle breakage
2. Prolonged anesthesia or paraesthesia
Rule of 10: 3. Facial nerve paralysis
Administering a painless inferior alveolar nerve block 4. Trismus
for a preschooler is one of the most difficult task for a 5. Soft tissue injury
dentist. There has been discussions whether to give a 6. Hematoma
local infiltration or an inferior alveolar nerve block to 7. Pain on injection
anesthetize the mandibular primary molars. Rule of 10 is 8. Burning on injection
a better approach to determine which injection is 9. Infection
appropriate. [14] The primary tooth to be anesthetized is 10. Edema
assigned a number from 1 to 5 according to its location 11. Sloughing of tissues
in the dental arch (central incisor = 1, second molar = 5). 12. Postanesthetic intraoral lesions
This number is added to the age of the child (in years),
and if the number is 10 or less, then an infiltration is The systemic complications include: [13]
more appropriate; if greater than 10, then an inferior 1. Toxicity due to overdose
alveolar nerve block is likely to be more effective. This 2. Allergy
simple approach works well in most cases. The only 3. Idiosyncrasy
instance where the rule would be contraindicated is 4. Syncope
where quadrant dentistry involving pulp treatment of 5. Drug interaction
both first and second molar. In this case local infiltration 6. Serum hepatitis
may not provide a sufficient depth of pulpal analgesia 7. Occupational dermatitis
and a mandibular block would be preferred. 8. Respiratory arrest
9. Cardiac arrest
Topical Anesthesia: 10. Hyperventilation
The primary goal in applying a topical anesthetic agent
is to minimize discomfort caused during administration Recommendations to reduce local anesthetic
of local anesthesia. It is effective on surface tissues (up complications: [5]
to two to three mm in depth) to reduce painful needle 1. Clinicians who utilize any type of local anesthetic in
penetration of the oral mucosa. [3,4] Topical anesthetic a pediatric dental patient should have appropriate
agents are available in gel, liquid, ointment, patch, and training, skills, availability of proper facilities,
aerosol forms. personnel, and equipment to manage any reasonably
foreseeable emergency.
The onset duration of lidocaine is 3-5 minutes. A recent 2. Care should be taken to ensure proper needle place-
study which compared the efficacy of commonly used ment during the intraoral administration of local
topical anesthetics demonstrated the superiority of 5% anesthetics. Clinicians should aspirate before every
EMLA cream (eutectic mixture of local anesthesia injection and inject slowly.
containing lidocaine and prilocaine) over all other 3. Following an injection, the doctor, hygienist, or as-
topical anesthetic agents. The topical anesthetic sistant should remain with the patient while the
benzocaine is manufactured in concentrations up to anesthetic begins to take effect.
20%; lidocaine is available as a solution or ointment up 4. Residual soft tissue anesthesia should be minimized
to 5% and as a spray up to 10% concentration. Localized in pediatric and special health care needs patients to
allergic reactions, however, may occur after prolonged decrease risk of self-inflicted postoperative injuries.
or repeated use. Topical lidocaine has an exceptionally 5. Clinicians should advise patients and their care-
low incidence of allergic reactions but is absorbed givers regarding behavioral precautions (eg, do not bite
systemically and can combine with an injected or suck on lip/cheek, do not ingest hot sub-stances) and
amide. [15] the possibility of soft tissue trauma while anesthesia
persists. Placing a cotton roll in the mucobuccal fold

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 Research J. Pharm. and Tech. 12(8): August 2019

may help prevent injury, and lubricating the lips with anesthetic cartridge with plastic micro tubing. A
petroleum jelly helps prevent drying. growing number of clinical trials in medicine also
demonstrate measurable benefits of CCLAD
Failures in Local Anesthesia: technology. [19,20]
Numerous factors contribute to the failure of local
anesthesia. These may be related either to the patient or Comfort control syringe
the operator. The Comfort Control Syringe has two main components:
A base unit and a syringe. Several functions of the unit‑
Operator‑dependent factors are: most importantly injection and aspiration‑ can be
i) Poor choice of local anesthetic solution controlled directly from the syringe, possibly making its
ii) Improper technique use easier to master for practitioners accustomed to the
Patient‑dependent factors are: traditional manual syringe. The Comfort Control
i) Anatomical variations Syringe has five pre‑programmed speeds for different
ii) Presence of infection injection techniques and can be used for all injection
iii) Psychogenic factors (severe anxiety may influence techniques. [21] A comparison between the traditional
pain perception). [16,17] dental syringe and the Comfort Control Syringe revealed
no meaningful differences in ease of administration,
Local Anesthesia and Infection: injection pain and efficacy, and acceptance by
If a local anesthetic is injected into an area of infection, patients.[22]
its onset will be delayed or even prevented. The
inflammatory process in an area of infection lowers the Jet Injectors
pH of the extracellular tissue from its normal value (7.4) This technique is based on the principle of using a
to 5 or lower. This low pH inhibits anesthetic action mechanical energy source to create a release of pressure
because little of the free base form of the anesthetic is sufficient to push a dose of liquid medication through a
allowed to cross into the nerve sheath to prevent very small orifice, creating a thin column of fluid with
conduction of nerve impulses. Inserting a needle into an enough force that it can penetrate soft tissue into the
active site of infection could also lead to a possible subcutaneous tissue without a needle. Jet injectors are
spread of the infection. [13] believed to offer advantages over traditional needle
injectors by being fast and easy to use, with little or no
Newer Techniques in Local Anesthesia: pain, less tissue damage, and faster drug absorption at
The traditional aspirating syringe is still the most the injection site.[23] Studies in adults and children have
common method by which local anesthetics are concluded that traditional infiltration was more
administered. Newer techniques have been developed effective, acceptable, and preferred, compared with the
that can help the dentist administer the local anesthetic needleless injection. [24]
with minimum injection pain and adverse effects.
Vibrotactile Devices:
Computer Controlled Local Anesthetic Delivery Inui and colleagues [25] have shown, however, that pain
system (CCLADS): reduction due to non‑noxious touch or vibration can
In the mid‑1990s, work began on the development of result from tactile‑induced pain inhibition within the
local anesthetic delivery systems that incorporated cerebral cortex itself and that the inhibition occurs
computer technology to control the rate of flow of the without any contribution at the spinal level, including
anesthetic solution through the needle. This concept is descending inhibitory actions on spinal neurons.
now called computer‑controlled local anesthetic delivery
(CCLAD). [18] The first of these CCLAD devices, the VibraJect
Wand™ (Milestone Scientific, Inc., Livingston, N.J.), It is a small battery‑operated attachment that snaps on to
was introduced in 1997. Subsequent versions from same the standard dental syringe which delivers a
manufacturers were named Wand Plus and then high‑frequency vibration to the needle that is strong
CompuDent™, the current designation. enough for the patient to feel.[23] Researches evaluating
the effectiveness of VibraJect, have shown mixed
Wand/ CompuDent System: results. Nanitsos et al.,[26] and Blair [27] have
The Wand system enables the operator to accurately recommended the use of VibraJect for painless injection.
manipulate needle placement with fingertip accuracy In contrast, Yoshikawa et al.,[28] found no significant
and deliver the LA with a foot‑activated control. It pain reduction when VibraJect was applied with a
consists of a disposable handpiece component and a conventional dental syringe.
computer control unit. The handpiece is an ultralight
pen‑like handle which is linked to a conventional
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 Research J. Pharm. and Tech. 12(8): August 2019

DentalVibe 15. Kravitz ND. The use of compound topical anesthetics: A review.
J Am Dent Assoc 2007;138:1333‑9.
This is a cordless, rechargeable, hand held device that
16. Boronat‑Lopez A, Penarrocha‑Diago M. Failure of locoregional
delivers soothing, pulsed, percussive micro‑oscillations anesthesia in dental practice. Review of the literature. Med Oral
to the site where an injection is being administered. Its Pathol Oral Circ Bucal 2006;11:E510‑3.
U‑shaped vibrating tip attached to a microprocessor 17. Wong MK, Jacobsen PL. Reasons for local anesthesia failures. J
Am Dent Assoc 1992;123:69‑73.
‑controlled Vibra‑Pulse motor gently stimulates the
18. Proceedings of the 1st Annual Computer‑Controlled Local
sensory receptors at the injection site, effectively closing AnesthesiaDelivery (C‑CLAD) System meeting. Introductory
the neural pain gate, blocking the painful sensation of remarks. New Orleans, Louisiana, USA: 2008.
injections. It also lights the injection area and has an 19. Tan PY, Vukasin P, Chin ID, Ciona CJ, Orteqa AE, Anthone GJ.
The Wand local anesthetic delivery system: A more pleasant
attachment to retract the lip or cheek.[29]
experience for anal anesthesia. Dis Colon Rectum
2001;44:686‑9.
Accupal 20. Anderson ZN, Podnos SM, Shirley‑King R. Patient satisfaction
The Accupal (Hot Springs, AR, USA) is a cordless during the administration of local anesthesia using a computer
controlled local anesthetic delivery system. Dermatol Nurs
device that uses both vibration and pressure to
2003;15:329‑30, 392.
precondition the oral mucosa. Accupal provides pressure 21. Clark TM, Yagiela JA. Advanced techniques and
and vibrates the injection site 360° proximal to the armamentarium for dental local anesthesia. Dent Clin North Am
needle penetration, which shuts the “pain gate,” 2010;54:757‑68.
22. Grace EG, Barnes DM, Reid BC, Flores M, George DL.
according to the manufacturer. After placing the device
Computerized local dental anesthetic systems: Patient and dentist
at the injection site and applying moderate pressure, the satisfaction. J Dent 2003;31:9‑12.
unit light up the area and begins to vibrate. The needle is 23. Ogle OE, Mahjoubi G. Advances in local anesthesia in dentistry.
placed through a hole in the head of the disposable tip, Dent Clin North Am 2011;55:481‑99.
24. Dabarakis NN, AlexanderV, Tsirlis AT, Parissis NA, Nikolaos
which is attached to the motor. [29]
M. Needle‑less local anesthesia: Clinical evaluation of the
effectiveness of jet anesthesia Injex in local anesthesia in
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