Child Management and Pain Control Flashcards
surface anaesthesia
anaesthesia of the surface tissue i.e. skin or mucous membrane
physical or pharmacological
uses of surface anaesthesia
to reduce pain of LA injection
to reduce discomfort of venepuncture
for superficial soft tissue manipulation
physical surface anaesthesia a.k.a
refrigeration anaesthesia
physical surface anaesthesia technique
By reducing the temperature
Ethyl chloride (rarely used as LA agent in children) - Can be useful for quick topical if pt not using EMLA correcting
Difficult to direct stream of liquid accurately
Inadvertent contact with vital teeth produces discomfort
Inflammable – kept in yellow flammable cupboard
pharmacological surface anaesthesia
topical anaesthesia
- intraoral topical agents
- topical anaesthesia for skin
- controlled release devices
- jet injectors
intraoral topical agents
Will anaesthetise 2-3mm depth of tissue
Success is technique dependent:
- Dry area (cotton wool roll)
- Apply over limited area (use a cotton wool roll)
- Apply for sufficient time: 2 mins
Different preparations:
- Lidocaine: 2% gel; 10% spray & 5% ointment
- Benzocaine: 20% gel (flavoured bubblegum, harder to find currently)
different preparations of intraoral topical anaesthesia
- Lidocaine: 2% gel; 10% spray & 5% ointment
- Benzocaine: 20% gel (flavoured bubblegum, harder to find currently)
what is important to remember when calculating the dose given of anaesthesia to a child
always take in the dose of topical anaesthesia as well as local anaesthesia
importance of intraoral topical anaesthesia in practice
These are key to LA in children (and anxious pt of all ages) but take care to follow correct approach and timings
intraoral topical uses
Pre-injection
Rubber dam clamp
Placing matrix band
Suture removal
Exfoliating primary teeth
Subgingival scaling
Incision of abscess
- Harder to apply other LAs
2 types of topical anaesthetic for skin
EMLA cream
ametop gel
EMLA cream
5% eutectic mixture of prilocaine (amide) and lidocaine (amide)
Needs to be applied for at least 45 minutes
Useful prior to general anaesthesia or intravenous sedation (veneflow)
ametop gel
Tetracaine (amethocaine) 4% gel (esther)
Faster onset than EMLA
Not as widely used as EMLA
type of topical controlled release devices
patches
topical patches
Incorporation of local anaesthetic into materials that adhere to the mucosa and allow slow release
Decreases the chance of the anaesthetic moving away from the application site
- helps keep topical injection at site
- dry cotton wool roll with topical can be distributed around mouth or swallowed – cause numb throat and patient may be less compliant
Under investigation
- Under development
- patches can be coloured to allow a bullseye which the operator can use to apply injection to correct site
advantages topical jet injectors (4)
Allows anaesthesia up to 1cm
Bleeding diatheses (susceptibility to bleeding e.g. haemophilia, VW) where deep injections are contraindicated - E.g. IV blocks – deep bleed, airway constriction etc
Sole means achieving LA depending on Tx
Prior to conventional techniques
disadvantages of topical jet injectors (4)
Could cause soft tissue damage if careless
Frightening sight and sound
Taste of solution
Expensive
2 types of non-pharmacological pain control
TENS (transcutaneous electrical nerve stimulation)
Hypnosis
TENS (transcutaneous electrical nerve stimulation)
blocks large myelinated nerve fibres and closes the gate to central transmission of smaller unmyelinated pain fibres
Controlled by patient (over 10yrs old)
- Early stages of labour
Uses: restorations, primary extractions, pre- LA (always need LA after)
hypnosis
An altered state of mind such that suggestions are accepted more readily and acted upon more powerfully
adjunct to LA by decrease pulse rate
- More powerful and work better
Decreases pulse rate, makes calmer
common LA solutions (4)
Lidocaine 2% with 1:80000 epinephrine/adrenaline (amide)
Lidocaine 2% plain (amide) (shorter acting as no vasoconstricter/adrenaline)
Prilocaine (Citanest®) 3% with felypressin (also known as octapressin) 0.03IU/ml (amide)
Articaine 4% (Septanest®) with 1:100 000 adrenaline (amide)
when might you use a LA without vasoconstrictor
Doesn’t stay in localised area for as long so is shorter acting - special need children
lidocaine
common local anaesthetic
anti-arrhythmic drug (supresses abnormal heart rhythms)
rapid onset of action
half life= 1.5-2hrs (time it takes to half concentration of drug in body – affected by vasoconstrictor)
suitable for infiltration, block, and surface anesthesia
addition of epinephrine (adrenaline) vasoconstricts arteries, reducing bleeding and also delays the resorption of lidocaine, almost doubling the duration of anaesthesia
4 contraindications of lidocaine
Heart block and no pace-maker
Allergy to LA (or to corn),
hypotension
impaired liver function
articaine
First produced in Germany 1969
Half life of 20 mins
Contains a thiophene ring instead of benzene
Additional ester group
Risk of systemic toxicity lower than others as it is hydrolised by blood quicker
More effective for mandibular infiltrations than lignocaine
- Usually for haemophiliacs where you are reluctant to do IDB
Lignocaine and articaine are equally effective as blocks.
Lignocaine drug of choice for block, as 4% solutions carry higher risk of non-surgical paraesthesia
contraindication of articaine
avoid in sickle cell patients (and other haemoglobinopathies)
4 effects of adrenaline
Avoid intra-arterial injection by careful technique
- aspirate prior to deposition to ensure not in BV
Adrenaline binds to alpha-receptors in the peripheral vasculature
- causing vasocontriction
Adrenaline binding with B1-adrenergic receptors in the heart wall.
- causes tachycardia (heart rate >100 bpm), due to
Increased HR in combination with peripheral constriction can lead to increased blood pressure.
However, it has been reported that there is no need to avoid adrenaline containing local (which is less effective) unless BP> 200mmHg (systolic) and/or (diastolic) >115mmHg
what should you consider when giving LA to pt with HBP
Have caution with patients on diuretics (“water tablet” used to decrease BP by flushing salt out of body
- use adrenaline free LA to avoid risk of reduction in potassium concentration) Meechan 92
Beta-Blocker (used to decrease blood pressure)
- less problematic
3 techniques of LA in children
infiltration
intraligamentary
regional block
LA needle sizes
long
- ID block
short (regular)
- infiltration
ultra-short
- infiltration of intra-papilllary
long LA needle use
ID block
short LA needle use
infiltration
ultra-short LA needle block
infiltration or intra-papillary
LA infiltration uses (5)
Anaesthesia in primary teeth
Anaesthesia in maxillary permanent teeth
Anaesthesia in mandibular permanent anterior teeth
Prior to intrapapillary and then intraligamental anaesthesia in posterior permanent teeth
Prior to intrapapillary and palatal/lingual anaesthesia
Not mandibular molars – unless articaine infiltration in haemophiliac
when is LA infiltration not used
mandibular molars – unless articaine infiltration in haemophiliac
LA infiltration technique
Dry mucosa
Topical anaesthetic (2 mins)
Wipe off excess topical anaesthetic
Stretch mucosa until taught (make more comfortable)
Distract patient (gentle pressure or rubbing on lip can do this, talking, singing)
Insert needle (ultra short or normal 30 gauge) Aspirate
Inject supraperiosteal as close as possible to apices of teeth
- Painful when on bone
lingual/palatal anaesthesia technique
Ultra-short 90 degrees to surface
- Already put in infiltration – so numb of area ahead before you inject
Approach via anesthetised buccal interdental papilla
Advance when see palatal blanching
- Otherwise uncomfortable
LA intraligamentary uses (2)
to supplement infiltrations
may eliminate need for block
intraligamentary technique
Can be tender in child due to pressure
- get specialised syringes
Interosseous via cancellous space via PDL
0.2ml per root – beware excess dose
More successful with a vasoconstrictor
Ultra short 32 gauge needle
30 degree to long axis of tooth in mesiobuccal gingival sulcus
- advance until resistance
Specialised syringe measured dose
Conventional syringe – 0.2ml is width of bung (hard to do)
syringes used for intraligamentary technique LA
Normal syringe with ultra short needle or Custom made syringes
- Peripass syringe – less pressure
the wand
Method specialised intraligamental LA and conventional blocks
Uses computerised flow of local anaesthetic
- Computer can guide you if on bone
Can be used as a method of intraligamental LA for single tooth anaesthesia
- E.g. special need children – avoid biting on numb soft tissue
Can also be used for infiltration and block anaesthesia
issue for the wand
not safety plus syringe system
- cap goes at side of machine
- cannot resheath it like normal conventional needle
- use one hand to deposit and then place back in cap
inferior alveolar and lingual nerve block in children
Mandibular foramen (smaller children)
- below occlusal plane
lower than in adults
Approach direct from primary molars of opposite side
Lateral to the pterygomandibular raphe and medial to ascending ramus
mental block technique (long buccal, mental and incisive nerve s)
Advance needle in buccal sulcus toward region between apices of 1st and 2nd primary molars.
Mental foramen faces anteriorly in children
advantage of mental block
very good soft tissue anaesthesia
disadvantage of mental block
Incisive nerve anaesthesia not as reliable as IDB
Incisors may get crossover supply across midline so need a labial infiltration adjacent to tooth as well as this block
nerves effected by mental block
long buccal
mental
incisive
maxillary block technique
Direct block seldom used
- Surgery in area e.g Supernumerary tooth, ectopic canine
Greater palatine and nasopalatine blocks can be achieved by infiltrating LA through anaesthetised buccal papilla and ‘chasing’ the anaesthetic through to the palatal mucosa
LA generalised compilations (5)
psychogenic (stress)
allergy
toxicity
drug interactions
infections
allergy to LA
Anaphylaxis is very rare especially to amide group
Metabisulphite (E223) preservative, antiseptic
Latex – rubber bung cartridge
Methyl parabens Preservative, (E218) found in blueberries
LA toxicity effect (4)
cardiovascular
- low levels: stimulant
- high levels: circulatory collapse
CNS
- depressant leading to unconsciousness and respiratory arrest
methaemoglobinaemia
- cyanosis associated with lethargy and respiratory diseases
reduced ability of RBC to release O2 to tissues
- prilocaine, articaine, benzocaine
max safe dose of lidocaine 2% plain/with adrenaline
5mg/kg
max safe dose of prilocaine 4% plain/3% with felypressin
8mg/kg
max safe dose of mepivicaine 3% plain/2% with adrenaline
3mg/kg
max safe dose of artiicaine 4% with adrenaline
7mg/kg
max safe dose of 2% lidocaine in 20kg child
2% soln in 2.2ml cartridge contains 44mg
Max safe dose is 4.4mg/kg or 1/10th cart /kg
weight of a 5yr old child is 20kg
20kg x 4.4 = 88mg = 2 cartridges
max safe dose of 3% prilocaine with felypressin in 20kg child
3% soln in 2.2ml cartridge contains 66mg
Max safe dose is 6mg/kg (1/11th of a cartridge per kg weight)
weight of a 5yr old child is 20kg
20kg x 6= 120mg so less than 2 cartridges (2 cartridges contain 132mg- so can only give 1 and 9/11ths of a cartridge)
max safe dose of 4% articaine
4% soln in 1.8ml cartridge contains 72mg
Max safe dose is 5mg/kg (1/15th cart/kg)
Weight of 5 year old child is 20 kg
20kg x 5 = 100mg = 1 and 1/3 cartridge
3 ways to prevent complication in LA administration
Aspiration
Slow injection
- Feels right – not depositing in wrong place, more comfortable for patient
Dose limitation
- Give the lowest dose needed for Tx
- Half cartridge sufficient then just use that
LA toxicity Treatment
Stop dental treatment Provide basic life support Call for medical assistance Protect patient from injury Monitor vital signs
LA localised complications (6)
Self inflicted trauma – biting soft tissues
Oral ulceration
Long lasting anaesthesia
Trismus
Infection
Developmental defects
early localised complications to LA
Pain:
- intraepithelial; subperiosteal;
- nerve trunk; intravascular
Intravascular injection:
- arterial; venous
Failure of LA:
- anatomy; pathology; operator technique
Motor nerve paralysis
Haematoma formation
4 contraindications to LA
in bleeding disorders avoid IDB
allergy
acute infection
care in liver disease - amide dose reduction
do nots in behaviour management
bribe coax shout bully threaten humiliate lose your patience with the patient allow child to have all their own way
how to be empathetic to child
create an environment in which the child feels safe
use a kind empathetic approach using directive guidance, and reinforcement to establish co-operation and obtain a rapport
- praise specific behaviour – opening mouth wide, arms still
- enforce specific behaviour
allow the child some control (e.g. hand signal, take seriously)
question for feeling (are you OK?)
techniques is child behaviour management
Positive reinforcement
Tell, show, do
Acclimatisation
Desensitisation
Voice control
Distraction
Role modelling
children often focus on negative words like ‘pain; or ‘hurt’
- avoid them
what is the safe max dose of ligocaine that can be given to child of 15kg
1.5 cartridges
Calculate 1/10th cartridge per kg weight
4mg/kg –> 75mg for 30kg
44mg/cartridge
75/44 = 1.7045 (so 1.5 cartridges)
what is a safe and effective way to anaesthetise a lower permanent molar in a 12 year old child with mild haemophilia A
Single tooth anaesthesia using the wand system and articaine with adrenaline
- because nerve blocks should be avoided and buccal infiltration with lignocaine alone is less likely to be as effective
what is the most common adverse effect when giving LA via an IA Nerve Block
Failure of local anaesthetic to anaesthetise the tooth sufficiently
- Although in most cases this should be avoided with careful technique. It can be more difficult to effectively anaesthetise teeth with irreversible pulpitis, periapical abscess or hypomineralised sensitive molars
what is the max safe dose of articaine that can be given to a 30kg child
2 cartridges
4.3ml is max safe dose – 1/15 cartridge/kg
7mg/kg –> 210mg for 30kg
88mg/cartridge
210/88 = 2.3863 (so B 2 cartridges)
