Local Anesthesia & Surgery in Children Flashcards
an unpleasant sensory and emotional experience associated
with actual or potential tissue damage ,or described in terms
of such damage
pain
most fundamental and important component (of pain), sound principles of behavior management
pain control
pain control is achieved by:
- psychological preparation
- skilled and sensible local anesthetic delivery technique
- sound knowledge of anatomical landmarks
when patient management problems occur
- painful injection experience
- no anesthesia during dental extraction
a loss of sensation in a circumscribed area of the body
caused by a depression of excitation in nerve endings or an
inhibition of the conduction process in peripheral nerves
local anesthesia
local anesthesia: ideal properties
- reversible
- non-irritating to tissue; produce no secondary local reaction
- no or minimal systemic toxicity
- sufficient potency
- rapid onset of action
- adequate shelf life
- provide complete regional anesthesia
- relatively free from producing allergic reaction
- stable in solution
amide vs ester: which and why?
- amide type
- rare adverse effects
most often used LA for pedo px
2% Lidocaine 1:100,000 epi
seldom used LA for pedo px
4% Articaine 1:100,000 epi
why Articaine is not used for pedo px
- more potent
- causes prolonged numbness, which can lead to soft tissue injury
T or F: LA agents are vasodilators and the use of vasoconstrictor is recommended
true
advantages of using a vasoconstrictor
- decrease probability of high plasma levels (avoid overdose)
- slowing LA agent into cardiovascular system (avoid toxicity)
- prolong effect of anesthesia
- decrease bleeding at the site of administration
contents of LA
- LA agent (amide, ester)
- vasoconstrictor (adrenaline)
- reducing agents (sodium metabisulphite)
- preservatives (methylparaben)
- fungicide (thymol)
- vehicle (modified ringer’s solution, distilled water)
2% Lidocaine: common concentration
20 mg/mL
1 carpule = ?
1.8 mL
amount of LA in 1 carpule
20 mg/mL x 1.8 mL = 36 mg/carpule
MSD/MAD
- 4.0 mg/kg body weight without epinephrine
- 7.0 mg/kg with epinephrine
MSD equation
patient kg x MAD/concentration of LA agent in carpule
applied before injecting LA solution
topical anesthesia
topical anesthesia: types
- gel
- liquid
- spray
advantage of using benzocaine-based topical anesthesia
- slowly absorbed
- less likely to cause any overdose complications
advantage of using gel-type topical anesthesia
more controlled regional application at a proposed injection site
method of applying aerosol formulation (sprays) topical anesthesia
using cotton tip on mucosa
depth where topical anesthesia is effective
2-3 mm
primary use of topical anesthesia
reducing discomfort of initial penetration of needle into the mucosa
disadvantage of using topical anesthesia
taste may be disagreeable
amount to use for topical anesthesia
pea size amount (0.1 ml = 20 mg)
points to note when using intraoral topical anesthesia
- area of application should be dried
- applied over limited area
- applied for sufficient time
topical anesthesia: drying methods
- 3 way syringe
- cotton
- suction
topical anesthesia: area efficacy
more effective on mucosa than attached gingiva
topical anesthesia: sufficient time for anesthetic effect to occur
1.5 - 5 mins
why is it not advisable to use topical anesthesia for 2.5 mins in practice?
cooperation of child might not be stable; if px is not cooperative, 1 min is enough
LA mechanism of action
because LA are weak bases, they are commonly combined with a strong acid (i.e. HCl) to improve water solubility, tissue diffusion, etc.
innervations: maxillary
- greater palatine n.
- anterior superior alveolar n.
- middle superior alveolar n.
innervations: mandibular
- inferior alveolar n.
- mental and incisive n.
- long buccal n.
- lingual n.
- mylohyoid n.
points to be kept in mind regarding the difference between child and adult px
- density and calcification of max. and mand. bone
- anatomic structure
- depth of needle penetration
- emotional aspect
special considerations in anesthesizing
- acceptable behavior
- position of mandibular foramen
- needle scare
- computation for maximum safe dosage
special considerations: acceptable behavior
- crying is okay
- head should be still
- hands on the side
- legs should be lying straight
anatomic structure - mandibular canal: below 6 yrs old
below plane of occlusion
anatomic structure - mandibular canal: 6-12 yrs old
about even with plane of occlusion
anatomic structure - mandibular canal: 12 yrs old and above
palpate deepest curvature on the anterior border of ramus with thumb and bisect
needle scare: management
- learn proper handling of instruments
- use auxiliary or chairside assistant
- prepare patient emotionally and psychologically
commonly used needle in pedo px
short needle (22 mm); 27 gauge
goals of anesthesia
- minimize sensation of needle penetration in mucosa
- minimize sensation on pressure created during delivery of anesthetic solution
how to minimize sensation of pressure during delivery of anesthetic solution
- slow delivery (deliver 1 ml/min)
- distract the px (let them count)
best topical used before anesthesizing
Benzocaine 20% for 2 mins
anesthetic technique: mandibular teeth
- inferior alveolar nb
- lingual nb
- long buccal nb
IAN block: amount of LA
1/2 carpule
IAN block: needle used
30G (common), 27G for children over 12
Lingual NB: when used
injecting small amounts during IAN block and withdrawal of needle during IAN block
Lingual NB: amount of LA
1/4 carpule
Long Buccal NB: nerve supply anesthesized
- buccal gingiva
- accessory innervation
Long Buccal NB: amount of LA
1/4 carpule
Long Buccal NB: landmark
distal of 1st molar
anesthetic techniques: maxillary teeth
- infiltration technique
- palatal anesthesia
best and effective technique in maxillary anesthesizing
infiltration technique
infiltration technique: landmark
apices of max. molars
infiltration technique: amount of LA
1/2 carpule on buccal
more painful maxillary anesthetic technique
palatal anesthesia
why palatal anesthesia is more painful
- dense bone
- penetration of solution is difficult
technique used for palatal anesthesia
CHASE technique
interdental infiltration with slow injection to palatal aspect
CHASE technique
pulpotomy: techniques used
- buccal/labial infiltration
- block
pulpectomy: techniques used
- buccal/labial infiltration
- block
extraction: techniques used
- labial/palatal infiltration
- block
placement of clamps: techniques used
- buccal/interdental infiltration
- block
evaluation of anesthesia
- explorer test (before placing of clamps)
- run handpiece outside of mouth
- run handpiece inside mouth but not touching the tooth
- observe reaction
general techniques in anesthetic administration
- use of dental assistant
- use of topical anesthesia
- use of euphemisms
- distraction
euphemisms used in anesthetic administrations
- topical anesthesia: tooth jelly/sleepy juice
- needle prick: mosquito bite/pinch
- numbness: tooth will take a nap, feel fat
post op instructions after anes
- tell the child what to expect after anes
- assure px sensation will come back soon
complications of LA: general
- psychogenic (fainting/syncope)
- allergy
- toxicity
- cardiovascular effects
- CNS effects
- methemoglobinemia
- drug interactions
- infections (disposable needles)
complications of LA: early localized
- pain
- intravascular injections
- failure of LA
- motor nerve paralysis
- hematoma formation
complications of LA: early localized - pain
- needle penetration
- too rapid injection
- injection at inappropriate site
when motor nerve paralysis occurs
when deposition of LA solution is within parotid gland
complications of LA: late localized
- self-inflicted trauma
- oral ulceration
- long-lasting anesthesia
- trismus
- infection
T or F: Extraction of primary teeth is an integral part of any dental practice that includes children
true
main deterrent for a child to anticipate in any form of oral surgery
fear
suggested method for avoiding adverse psychological reactions to tooth extractions of children
child should be informed several days in advance of the appointment for tooth extraction
clinical exam and diagnosis for extraction
- mobility
- sensitivity to percussion
- lymphadenopathy
- soft tissue swelling
- reddening around affected area
important to put emphasis that no surgical procedure should be done without permission of guardian or parent
consent
questions answered for the basic understanding of consent
- what is to be done?
- why is it being done?
- what complications can occur?
T or F: use of antibiotics in pediatric oral surgery is mandatory
false
conditions where antibiotics is not needed
- abscess well resorbed
- px is asymptomatic and in good general health
conditions where antibiotics can be considered
- fever
- periapical swelling
- adenopathy
- lymphadenitis
antibiotics is used as a prophylactic therapy for…
child with chronic debilitation (i.e. chronic heart disease)
T or F: radiographs are not important in pediatric tooth extractions
false
most frequent oral surgical procedure in children
extraction of 1 or more carious teeth
a good radiograph can determine:
- size and contour with primary roots
- presence of developing permanent tooth bud
- pathological root resorption and potential areas of root fracture during extraction
- extent of disease
indications for extraction
- unrestorable carious lesion
- necrotic pulp
- apical or furcation disease
- fractures of crown or roots
- acute and chronic pathologic involvement
- prolonged retention of primary teeth
- abnormal root resorption
- ankylosis
- impacted teeth
- supernumerary teeth
- iatrogenic reasons
- natal/neonatal primary tooth
- medically compromised children in w/c pulp therapy is contraindicated
reasons for removal of neonatal/natal teeth
- aspiration
- irritation (affects ventral part of tongue)
- pain during breastfeeding
importance of vitamin K in neonatal/natal tooth extractions
…
contraindications for extraction
- acute systemic infections
- acute oral infection
contraindications for extraction: acute systemic infections
- chronic heart disease
- congenital heart disease
- kidney disease
contraindications for extraction: acute oral infection
- cellulitis
- dentoalveolar abscess
- herpetic stomatitis
- bleeding disorders
- irradiated jaws
- malignancy
factors to consider during extraction
- age of child
- arch development
- amount of resorption of roots of primary teeth
- development of underlying permanent teeth
- presence or absence of successors
- behavior management
factors to consider during extraction: arch development
- preservation of primary canines
- serial extraction in interceptive orthodontics
factors to consider during extraction: amount of resorption of roots of primary teeth
- significant 2nd to 3rd degree mobility regardless of presence of succedaneous clinically
- less than 2/3 of succedaneous formed
cornerstones of the oral cavity
canines
primary tooth usually extracted last to give space for permanent teeth
first premolar
pediatric tooth extraction: armamentarium
- forceps (150, 151)
why forceps 16 is not used in primary molars
- cowhorn; beak is adapted on the bifurcation and this can affect succedaneous teeth of a primary molar
when do we suture in pediatric oral surgery?
when doing multiple exo (preserve interdental)
optimal movements for surgical procedure in pediatric dentistry
slow, smooth, graceful
important matters in facilitating good patient management in oral surgery
make sure that your px will:
- not feel any discomfort
- will not have murdered soft tissue
if a root is fractured
- be cautious in removing root tips so permanent tooth bud will not be jeopardized
- sometimes root tip is better left embedded; allow it to be exfoliated or resorbed
- parents should be advised that root tip remains; record properly in px notes and monitor periodically
pre-operative preparation: for parents
- parental consent before procedure
- instruct parent not to discuss with child what dentist will do
pre-operative preparation: for patients
- armamentarium should be kept behind chair
- never hold needle in front of child; always hide behind fingers/hand
- before giving LA, explain to child sensation of pinching or bite that can be felt
- explain to child the diff. between pressure and pain and sensation of numbness
patient position for administration of LA:
- max. occlusal plane at an angle between 60-90 degrees to the floor
- mandibular occlusal plane is parallel to floor
- supine position
post operative care
- bite on gauze for 30 mins
- do not use straw to drink for 24 hours
- do not spit
- use ice packs after surgery for the next 24 hours; keep on for 10 mins and off for 10 mins
- soft diet for 1st day
- appropriate warning to prevent trauma to cheeks and lips
- take pain medication as directed
