LA in children Flashcards

1
Q

History of LA

A

1859 - cocaine isolated by Niemann
1880 - topical opthalmic anaesthetic, Koller
1884 - regional anaesthesia in oral cavity, Halstead
1905 - procaine synthesis
1943 - lidocaine
-1950s, 1960s, 1970s ‘modern anaesthetics’

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2
Q

Dental LAs

A

Two groups: amides and esters
Most are amides
Amides less allergenic than amides
Lidocaine - gold standard

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3
Q

How do anaesthetics work?

A

Chemical roadblock between the source of the pain and the brain
Electrical signals = action potentials
Local anaesthetics block the sodium channel –> nerve signals cannot be transmitted
Vasoconstrictor –> slows the removal of the anaesthetic from the vicinity of the nerve –> prolongs anaesthetic action

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4
Q

To use or not to use?

A

Avoid GA if possible, Poswillo report, 1990
‘LA is the mainstay of pain control during dental treatment’, GDC Standards 2005
Child - age, cooperation
Procedure - 1 filling or 8 fillings
Effects of painful experience? - 1 extraction fine, 2nd one will be scared
Primary teeth are ‘insensitive’ to pain - not true!

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5
Q

Possible contraindications

A
Lidocaine
 - known hypersensitivity
 - acute porphyrias
 - heart block
Adrenaline
 - cardiac arrhythmias
 - hyperthyroidism
Prilocaine
- known allergy
Bleeding disorders
 - infiltration techniques (more likely block will cause bleed)
Infection at injection site
 - consider block techniques
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6
Q

Topical anaesthetic

A
Xylonor gel (5% Lidocaine)
Paeds clinic - now used
Benzocaine gel (20%), 
bubble gum flavoured - used to be used
EMLA Cream 
(Eutectic mixture of local anaesthetics – 5% mixture lignocaine + prilocaine)
usually skin, pre-iv access
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7
Q

Local anaesthetic solutions

A

2%(20mg/ml) lidocaine with 1:80,000 adrenaline (2.2ml syringe)
- gold standard
- pulpal anaesthesia 45mins
- soft tissue anaesthesia 2-3hours
3%(30mg/ml) prilocaine (Citanest) with felypressin
- similar spectrum of activity
- also 4%(40mg/ml) plain solution

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8
Q

Articaine solution

A
4% articaine with 1:100,000 or 1:200,000 adrenaline
Septanest
Similar performance
Metabolism quicker 
Good for mandibular infiltrations?
Not to be used<4 years
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9
Q

Articaine contraindications

A

Contraindicated in patiens with know hypersensitivity to amide La or hypersensitivity to sodium metabisulfite
Intravascular injection is strictly contra-indicated and associated with convulsions
Anti-convulsant meds can be used

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10
Q

Maximum doses

A

Lidocaine: 4.4mg/kg
Prilocaine: 6.0mg/kg
Articaine: 7.0mg/kg (children 5mg/kg)
Bupivicaine (used for longer procedures, longer acting) 2.0mg/kg

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11
Q

How much does a child weigh?

A
body weight (kg) = (age +4) x 2
e.g. 3 year old 
(3 + 4) x 2 =14kg
1 year old = 10kg
5 year old = 20 kg etc.
BUT a lot of children are overweight! Try to weigh them
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12
Q

Maximum dose for 3 year old

A
Weight = 14kg
Max dose of lidocaine: 4.4mg/kg
Max dose for 3 year old = 4.4x14 = 62mg
2% lidocaine = 2 parts per 100 = 20 parts
per 1000 = 20mg/ml
1 cartridge = 2.2ml = 44mg
62mg/44mg = 1.4 cartridges
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13
Q

LA maximum dose

A

1 cartridge per 10kg of body weight
e.g. 1/10 cartridge per kg
3-year-old=14kg
14/10=1.4 cartridges

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14
Q

La armamentarium

A

SafetyPlus system
Sterile, single use, aspirating syringe system, designed to prevent needle stick injuries
No recapping necessary, conforms with guidelines
Bevel indicator to assist in orientating bevel to bone
Transparent barrel to allow visualisation of aspiration

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15
Q

Needle selectiong

A

Infiltration anaesthesia
- 30-gauge 2cm needle

Block anaesthesia
 - 27-gauge 3cm needle
 - ability to aspirate
Intraligamental anaesthesia
 - 30 gauge 1cm needle
*As length of needle increases, needle diameter decreases*
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16
Q

Behaviour management

A
*Communcation is the key to success*
Verbal and non-verbal commuication
TLC
Tell-show-do
Positive renforcement
Control
Distraction
Relaxation
17
Q

Communcation

A

‘Childrenese’
- magic jelly, sleepy juice
Explain what it does
Explain how it will feel
- hot and spicy, warm and cosy, tingly
When will it wake up
- the funny feeling should be gone before dinner
Don’t lie!!
Talk to the child throughout ( I’m pulling back your lip, on the count of three you’ll feel…)
Give lots of feedback about the child’s behaviour
Positive reinforcement (evidence - based)
Use distraction (can you taste the jungle juice?/deep breath)
Reassure (only if needed – that’s how its supposed to feel/taste etc.)
Counting/’dental aerobics’ (gives alternative focus)

18
Q

Should we show the LA syringe to the child?

A

Whatever the dentist feels comfortable with
If child desires to see syringe, studies show there is no detriment in showing it
Tell-show-do vs. distraction
Identify needle phobics prior to LA attempt
DO NOT LIE!!

19
Q

Desensitisation

A
Control, Trust, Relaxation
Visit 1: explain and teach relaxation techniques
Visit 2: needle uncovered outside mouth
Visit 3: needle on ginigivae
Visit 4: injection
20
Q

Anatomical considerations

A

Infiltration - nothing different
Blocks - ID foramen is further back and lower down - approach from D on other side
-halfway through between coronoid notch and pterygomandibular raphe

21
Q

LA delivery

A

Apply topical for sufficient length of time (1min)
Pull the mucosa taught
Establish a rest for the LA barrel
Rotation of the needle around its long axis may enable it to penetrate the mucosa more easily
Inject VERY SLOWLY, especially initially (keep talking)

22
Q

Infiltration anaesthesia

A

Pulpal analgesia – maxillary teeth but ? mandibular primary molars
Topical
Retract mucosa so taut
Gently advance needle and perforate mucosa
SLOW injection – 1ml/15-20 secs (ant. region)
Routine aspiration
Smooth withdrawl and protective sheath replaced

23
Q

Maxillary molars

A

Maxillary molar teeth

  • thick malar butress lower down
  • buccal aspect maxillary molar roots
  • infiltration injections
  • mesial and distal to roots = more permeable bone
24
Q

Maxillary molar block

A
Do not use in children
Infiltration not possible or failed
Primary and permanent molars
Post +/- middle superior dental nerves
Palpate max-zygomatic buttress
Deposit anaesthetic distal to buttress
Massage distal aspect of maxilla
Ask pt to occlude (coronoid process)
25
Q

Palatal anaesthesia (can use on adults as well)

A

Extraction or rubber dam placement
Classic techniques – painful
–>Intrapapillary injections
- Buccal infiltration
- Test papilla with probe
- Penetrate papilla to depth of 1-2mm
- Syringe barrel parallel to occlusal plane and perpendicular to line of arch
- Inject SLOWLY and gently advance
Continue until observe blanching of palate
Usually takes 20-30 secs
Repeat with the other papilla until blanching joins
Anaesthesia of complete gingival cuff achieved
Can progress to palatal infiltration
Also useful in mandible (<5years old)

26
Q

ID blocks

A

Inferior dental canal foramen
At level of the lower occlusal plane
Approx 6-9 years old
Topical, topical, topical!!
Open as wide as possible
Thumb palpates external oblique ridge
Tauten mucosa bet. pterygomandibular raphe and the external oblique ridge
Insert needle from opposite side of mouth
Barrel over 1st primary molar of other side
Needle enters midpoint between the external oblique ridge and pterygomandibular raphe at level of occlusal plane
Immediately deposit a small amount of anaesthetic solution
Gently advance with slow injection and aspiration
Bony resistance of internal surface of ramus
Withdraw 1mm and deposit the rest of the solution

27
Q

Infiltration alone vs ID block for pulpal anaesthesia?

A

Infiltration alone vs ID block for pulpal anaesthesia ?
‘RULE OF TEN’ (guide only!)
Count no. of tooth from midline and add tooth number
Answer is max age at which infiltration alone likely to give pulpal anaesthesia
-if (age of pt) + (tooth #) < 10 = infiltration
-(e.g. [4 yrs] + [LLD=4] = 8)
With articane rule of TWLEVE

28
Q

Intraligamental techniques

A

If routine infiltration or block techniques fail
Solution introduced via periodontium
Majority escapes through lamina dura into cancellous bone
? Potential damage to developing permanent teeth
? Contraindicated in patients at risk from bacteremia
Caution in acute periodontal inflammation/perio disease

29
Q

Intraligamental injections

A

‘Peripress’ system - high pressure, shielded barrels, protection
Intro needle into the interproximal perio sulcus at 50-60° angle to occlusal plane
Gently advance until bony resistance felt
Firm steady pressure to inject
‘back-pressure’
0.4-0.6ml mesial and distal
Immediate analgesia
Lips/tongue not anaesthtised

30
Q

Other delivery systems for LA

A

Computer-controlled delivery

Jet injection

31
Q

Computer-controlled delivery

A
  • e.g. The Wand
  • controls rate of admin
  • slow delivery via a line and needle
  • especially useful for direct palatal analgesia
32
Q

Jet injection

A
  • e.g. Injex
  • ‘needleless’
  • jet syringe injects LA solution under pressure through mucosa and bone
  • useful for soft tissue analgesia prior to traditional LA methods
33
Q

Operator safety

A
Directive 2010/32/EU - prevention from sharp injuries in the hospital and healthcare sector
Disposable
No recapping required
Safety plus syringe
Good positioning 
Calm approach
Hand rest
-up to 56% of dentists suffer at least one needle stick per year. Felix et al BDJ 1994
34
Q

Reason for failure of LA

A
Acute infection
Incorrect site
 -injection into muscle
 -intravascular injection
 -dense buccal bone
Insufficient local anaesthetic
Abnormal nerve supply
-anastomosis from aberrant or normal nerve fibres
Patient immaturity – (pychogenic pain)
35
Q

Pain on injection

A
Touching the nerve
 - ‘electric shock’
 - rapid analgesia
 - permanent damage rare
Subperiosteal injections
 - extremely painful and unnecessary
 - internal surface of ramus
 - avoid
36
Q

Post-injection problems

A
Lip, tongue and cheek trauma
Painful self-inflicted damage
Warn patient AND parent
Haematoma
Lacerated vein
Like a bruise
Resolution fairly rapid
Vasovagal syncope
Anxiety-driven
Early recognition and Mx