LA + Extractions in Children Flashcards
What are the contraindications for LA in children?
- immaturity
- mental or physical special needs
- treatment factors
- acute infection (ineffective LA)
What should be in your communication plan for delivering LA to children ?
- confident approach
- age appropriate language
- state expectations
- keep talking- specific verbal reinforcement, distraction, praise patient
What ways can you assess anaesthetia in children?
- ask child to point where it feels funny
- touch un-anaesthetised area and then anaesthetized area
- “is it sleepy here?” “how about here”
- sucking on lip
- rubbing face
What are some complications of delivering LA in children?
- drooling
- speech difficulty
- child upset by numb sensation
- soft tissue trauma
- needle breakage
- haematoma
What is the main cause of haematoma in LA delivery?
sub-optimal delivery e.g. grazing a blood vessel
more common in IDBs
What are the most commonly employed topical analgesics in the UK?
Lidocaine (Lignocaine)
benzocaine
What forms are topical anaesthetics provided in?
sprays
solutions
creams
ointments
Compare the concentration of the active ingredient in topical anaesthetic preparations to those present in local anaesthetic solutions. Why is this the case?
concentration of active ingredient is greater in topical preparations compared to LA solutions
uptake of the topical agent is rapid
Why should you avoud topical sprays?
- difficult to localise
- numbing of soft palate and some of oesophagus- uncomfortable feeling
Outline briefly a the method used to apply topical anaesthetic on a child?
- place topical on one end of the cotton wool roll, leave other end dry
- dry mucosa with dry end of cotton wool roll
- place topical on mucosa
What is the depth of the surface (mucosa) that topical anaethesia will anesthetise?
2-3mm
What is the success of the topical anaesthesia dependent on?
- dryness of area applied
- limited area application of the topical agent (application should be over a limited area)
- application of topical for a sufficient amount of time (2-3 minutes)- with pressure
Currently, in the UK articaine is not used for IDBs, why is this?
this is because there is a risk of permanent damage to the ID nerve
The power of analgesia for articaine is great
However, more recent evidence may permit the use of articaine for ID blocks
What is clarks rule for paediatric dosage of LA ?
Weight of patient (Kg)/70 x adult dose
(70 is the standard weight)
What is young’s rule for paediatric dosase of LA?
Age of child/ (age +12) x adult dose
What is the maximum dose of lidocaine that should be adminstered in children?
4.4mg/kg
What is the maximum dose of lidocaine that should be administered to a 68kg adult?
4.4 x 68 = 299.2/300 mg
How much lidocaine is present in a 2.2ml cartridge?
44mg
What is the maximum dose of lidocaine that should be administered to a 20kg child? Include the number of cartridges
4.4 x 20 = 88mg
(if one cartridge of 2.2ml contains 44mg) then only 2 cartridges should be used for a 20kg patient
What is the maximum safe paediatric dose for prilocaine (citanest)?
6.0mg/kg
What is the maximum safe dose of prilocaine that should be administered to a 20kg child? Include the number or cartridges
20 x 6.0 mg/kg= 120mg
(if there is 88mg in one prilocaine cartridge); 120/88 = 1/3 cartiridges of prilocaine can be used
What calculation can be used to estimate the body weight of a child?
(Age + 4) X 2
What other metnod can be used to determine maximum number of cartridges to administer paediatrically?
Nomogram
When can lower (than recommeneded/calculated) doses of LA be delivered?
- shorter stature
- under nourished
- medically compromised
When using a nomogram,if the age or max volume falls between the scale graduations what value should you use?
you should use the next LOWEST value on each scale
If a mixture of agents is used, what shoud you assume the whole volume is composed of?
you should assume the whole volume is composed of the most toxic agent
What should you include in your notes regarding LA delivery ?
- LA solution + vasoconstrictor
- drug concentration
- amount given in cartridges/mL
- site of injection, type of injection
- abnormal reactions
- warnings given
What is the extra caution for using bupivacaine in children?
there is an increased risk of soft tissue injury due to prolonged anaesthesia
What kinds of needles can be used for infiltration LA?
- extra short 30 gauge (10mm)
- short 30 gauge (20mm)
What kinds of needles are indicated for mandibular blocks?
long 27 gauge needle (35mm)
An infiltration of ____ ml of LA is sufficient for pulpal anaesthesia in mosth children. Why is this?
0.5-1ml
this is because the apices of the teeth are not very far from the mucosa this LA will diffuse quite easily
Why are mesial and distal infiltrations indicated for the maxillary first molar?
the presence of the zygomatic/malar buttress on the buccal aspect of the maxillary teeth
In the case of a localised infection, what LA delivery technique can be used to achieve analgesia of the posterior teeth?
Maxillary molar block techniwue
produces profound analgesis of maxillary primary/permanent molars
Maxillary molar block techniques results in the block of what nerves?
Posterior and middle superior alveolar nerve as they enter the posterior maxilla from the infratemporal fossa
Briefly describe how the maxillary molar block technique is administered
- palpate the maxillary zygomatic butress with index finger
- bolus of LA solution (1.5ml-2ml) is deposited in the mucosa distal to the zygomatic butress (site A)
- the analgesic solution is then massaged around the distal aspect of the maxilla into the infratemoral fossa with the index finger (site B)
this blocks the posterior superior dental nerves
Pain during anagelsia is reduced in what kinds of tissue?
loose compliant tissue
this is especially true for palatal infiltrations as they are more painful in non-compliant tissue
Describe a method that overcomes the pain of delivering palatal infiltrations in non-compliant tissue. What is a requirement before using this method/technique?
- injecting into looser tissue (interdental papilla) and advancingthe needle palatally i.e. advancing the local anaesthetic towards the palate via the buccal papillae
- a buccal infiltration must be given prior to this palatal infiltration technique
What is the benefit of the buccally approaching palatal infiltration?
palatal infiltration can be placed more comfortably
When is a buccally approaching palatal infiltration easier to achieve?
it simple to advance towards the palate when the teeth are spaced
How else can you lessen the discomfort of a palatal injection?
use pressure and topical anaesthesia
What does the rule of 10 refer to in the delivery of local anaesthesia?
if the age of the child + the number of the tooth (i.e. 5,6) is over10 then give an ID block
otherwise give a buccal and lingual infiltration
According to Donohue D Garcia-Gody (1993), what type of LA is more effective for pulpotomies and extractions?
block anaesthesia more effective
Where should you deposit you LA for an IDB in children?
- ID foramen below or at the occlusal plane of the decidious teeth
- ID foramen is larger as it is surrounded by a less prominent lingula
- depth of injection should be 1cm from the internal obliqye line of the mandible
Where is the mental foramen placed in children in comparision to adults?
the mental foramen sits anteriorly in children compared to more posteriorly in adults
When is intraligamentary anaesthesia usually delivered?
usually when IDB has failed
There is a theoretical risk of damage to the permanent successor with the use of intraligamentary anaesthesia. True or false
True
Describe how intraligamentary anaesthesia is delivered
small volume under high pressure is delivered into PDL and surrounding bone
What are the potential causes of the failure of LA?
- acute infection
- incorrect site
- insuffcient LA drug
- abnormal nerve supply- supply from mylohyoid implicated in failure of IDB
- patient immaturity- distinguishing between pain and pressure
What measures can be taken to reduce the incidence of self inflicted trauma following IDB injection?
POI
* Soft diet
* fluids- hot fluids
* CHX on swab to clean trauma
* protective paste
List other delivery systems of LA
- intraligamentary anaesthesia
- electronic anaesthesia
- intraoral lidocaine patch
- computerised LA- LA delivered slowly by a machine
- needleless LA
Why does LA need to be injected slowly?
the pressure build up from fluid is what causes the pain in LA delivery
What are factors for consideration for the extraction of primary teeth?
- behaviour problems
- size of teeth; roots form a proportionally greater part of the tooth
- shape- more bulbous crown/ roots are more splayed
- physiology- root resorption
- support- bone more elastic
- presence of permanent teeth- leave small fragment in situ, avoid blind elevation to prevent damage to permanent bud, take a radiograph for location assessment
What hand movements should you use for maxillary and mandibular anteriors?
clockwise and anticlockwise rotations
How can you go about the extraction of a buccally placed canine?
coupland elevator
What is the first and second movement for the extraction of upper primary molars?
palatal (to expand socket due to widely splayed roots)
continuous buccally directed force
(first movement is not an apical thurst to prevent damage to the permanent successor)
palatal movement permitted in paediatric extractions as bone is still elastic
What is the movement required for the extraction of lower primary molars?
- buccolingual expansion of the socket
Why should you restore all restorable teeth before extraction under GA if possible?
so if the restoration is unsuccessful you are able to extract the tooth under GA as well
Under GA, all teeth of doubtful prognosis should be extracted. True or false
Why is this?
True
to avoid repeated anaesthetic
