This short chapter examines the special case of children undergoing dental local anesthesia treatment. For all of the techniques addressed in this book, we have provided data on the methodological and anatomical variations and specific details that must be taken into account when treating children. Here, we bring together the most important aspects of this patient group, even though most have been addressed elsewhere in the book.

The Problem with Children and Adolescents

Control of pain during dental treatment in children and adolescents is essential, not only to be able to carry out the procedure, but also because trauma at this age determines the patient’s attitude to dental treatment in the future. It is in this age group that patients develop high levels of anxiety and phobias that lead them to avoid treatment in the future (McClure 1968; Molin and Seeman 1970; Lautch 1971; Cohen et al. 1982; Berggren and Meynert 1984; Rankin and Harris 1984).

Table 21.1 shows that pain is poorly controlled in 15% of children. The problem is even more serious because dentists tend to think that pain is poorly controlled in fewer cases than actually occurs (Nakai et al. 2000). Various circumstances favor failure of dental local anesthesia in children and adolescents, as follows:

1. Preschool age (<5–6 years) (Wright et al. 1991; Sharaf 1997; Tyrer 1999; Lind‐Strömberg 2001). Children in this age group are unable to understand the need to cooperate with the dentist (Pinkham and Schroeder 1975), even though their bones are more porous and thus facilitate diffusion of the anesthetic solution.
2. High levels of anxiety. Treatment fails in 55% of patients who experience excess anxiety (Nakai et al. 2000). Remember that seeing the syringe and needle and feeling the needle prick are the most anxiety‐inducing aspects of treatment (Lautch 1971; Gale 1972; Meldman 1972; Berggren and Meynert 1984; Scott et al. 1984; LeClaire et al. 1988).
3. Probability of failure of local anesthesia. This can reach 20% in patients who have previously experienced symptoms of pain (Nakai et al. 2000).

Local Anesthetic Solutions

The most commonly used anesthetic solutions in children and adolescents are as follows:

• Standard lidocaine 2% with epinephrine 1:100 000 (10 μg/ml) or 1:80 000 (12.5 μg/ml) (L‐100 or L‐80) is the solution most commonly used to achieve pulpal anesthesia in children, both for mandibular block and for maxillary and mandibular buccal infiltration. There are various reasons for this choice:
  • As children’s bones are smaller and more porous, the standard solution is very well diffused and successful pulpal anesthesia is achieved.
  • The standard solution makes it possible to administer a greater volume of the solution in milliliters depending on the child’s weight, since the maximum limits are greater than with most anesthetic solutions used in dentistry (Annex 10). This makes the approach much safer.
• Lidocaine 2% with epinephrine 1:50 000 (20 μg/ml) (L‐50), which contains twice the amount of epinephrine as the standard solution, is used to complement buccal infiltration of lidocaine 2% with epinephrine 1:100 000 (10 μg/ml) when pulpal anesthesia is not achieved (Gruber 1950). It is important to remember the criterion of not mixing two anesthetics at the same site (see Chapter 5). In this case, the anesthetic is the same; only the concentration of epinephrine varies. As this is double and thus more potent, pulpal anesthesia is more efficacious (Annex 21).
  

  Reference	Sample size	Failure
  Kuster and Rakes (1987)	4134	12.8%
  Kaufman et al. (1991)	151	27%
  Jones et al. (1995)	308	20.5%
  Nakai et al. (2000)	361	11.6%
  Naidu et al. (2004)	101	9%
  		16.2%
  Rounded average		15%

• Articaine 4% with epinephrine 1:100 000 (10 μg/ml) (A‐100) is recommended only for buccal infiltration in anterior and posterior teeth in the maxilla and mandible in special cases:
  • To achieve successful pulpal anesthesia in children, which is difficult with the standard solution (e.g. anterior mandibular teeth with irreversible acute pulpitis).
  • To achieve anesthesia of primary mandibular molars with periapical infiltration when mandibular block is contraindicated (e.g. patients with hemophilia) (Dudkiewicz et al. 1987; Donohue et al. 1993).
  • To reinforce mandibular block (with the standard solution) in mandibular molars that are particularly difficult to anesthetize (e.g. irreversible acute pulpitis).

  This solution of articaine has some disadvantages:

  • It is contraindicated in children aged under 4 years because, although its safety has been demonstrated in clinical trials (Wright et al. 1989), it must be verified with more data and clinical studies (Malamed et al. 2000, 2001; Katyal 2010).
  • There may be more cases of self‐injury of the lips, tongue, and buccal mucosa because of the longer duration of soft tissue anesthesia (Adewuni et al. 2008; Chopra et al. 2016; Annex 21).

Other anesthetic solutions can also be administered (mepivacaine, prilocaine), although they are much less effective (Annex 21). Solutions with long‐lasting anesthesia, such as bupivacaine, are contraindicated in children aged under 12 years owing to the risk of self‐injury (Laskin et al. 1977; Jensen et al. 1981; Moore 1984).

Anesthetic Technique in Children

Here, we would like to draw attention to the most relevant aspects of the techniques applied with children:

1. Topical anesthetics in aerosolized form are not recommended for children (especially children under 6‐year age) because they may lead to sudden uncooperative behavior owing to the noise they make and a bad taste as the anesthetic spreads through the mouth (Frasier 1967; Evers and Haegerstam 1981), and thus yield poor results (Chapter 12 and Annex 19). The preferred form is gel, ointment, cream, or paste (Annex 19).
2. In each technique, the quantity of solution administered to children younger than 6–8 years is usually half that administered to adults to avoid overdosage. For example, if we were injecting the standard solution of lidocaine 2% with epinephrine 1:100 000 (10 μg/ml) in the conventional mandibular block technique (inferior alveolar nerve block), then our approach would be as follows:

   In an adult weighing 52 kg and in another weighing 86 kg, we would inject 1 cartridge (i.e. 1.8 ml) to achieve mandibular block. If we had to administer additional injections in these adults, for example maxillary and mandibular buccal infiltrations, the absolute maximum dose would be 6.2 cartridges for the patient weighing 52 kg and 8.5 cartridges for the patient weighing 86 kg (Annex 10).

   In a 5‐year‐old child weighing 20 kg, we would inject half a cartridge (i.e. 0.9 ml) to achieve mandibular block (half the adult dose). If we had to administer additional injections, for example maxillary and mandibular buccal infiltrations, the absolute maximum dose would be 2.5 cartridges (Annex 10).

3. The injection should not take long. When an injection takes too long, the child becomes nervous and subjectively associates the injection with pain (Jones et al. 1995). This problem is partly resolved in little children because they receive half the dose and therefore the injection takes half the time.
4. Vasovagal syncope is uncommon. The frequency of vasovagal syncope in children aged under 14 years is very low (1 per 2000 = 0.05%) because children react to emotional tension differently from adults; they do not repress the fight‐or‐flight response, but rather scream, cry, throw a tantrum, or resist the injection, therefore a vasovagal reaction does not occur (Kuster and Udin 1985). In young adults, on the other hand, one‐third are thought to be susceptible to this type of reaction (Yjipaavalniemi and Sane 1981).
5. Self‐injury may be more frequent. Self‐injury is a problem with children since after dental treatment the soft tissue remains anesthetized and, in some cases, the patient may bite and injure his/her lip, buccal mucosa, and tongue. Thus, the main associated factors are as follows:
   • Age. Owing to the child’s immaturity, the frequency of self‐injury increases with younger age (College et al. 2000; Adewuni et al. 2008
     Only gold members can continue reading. Log In or Register to continue