Guideline on Use of Local Anesthesia

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EjgedhZ 4HE !MERICAN !CADEMY OF 0EDIATRIC $ENTISTRY !!0$ INTENDS THIS GUIDELINE TO HELP PRACTITIONERS MAKE DECISIONS WHEN USING LOCAL ANESTHESIA TO CONTROL PAIN IN INFANTS CHILDREN ADOLES CENTS AND INDIVIDUALS WITH SPECIAL HEALTH CARE NEEDS DURING THE DELIVERY OF ORAL HEALTH CARE

BZi]dYh 4HIS REVISION INCLUDED A NEW SYSTEMATIC LITERATURE SEARCH OF THE -%$,).% 0UBMED ELECTRONIC DATABASE USING THE FOLLOWING PARAMETERS 4ERMS DENTAL ANESTHESIA DENTAL LOCAL ANESTHESIA

AND TOPICAL ANESTHESIA &IELD ALL lELDS ,IMITS WITHIN THE LAST YEARS HUMANS %NGLISH AND CLINICAL TRIALS /NE THOUSAND ONE HUNDRED THIRTY ARTICLES MATCHED THESE CRITERIA 0APERS FOR REVIEW WERE CHOSEN FROM THIS LIST AND FROM REFERENCES WITHIN SELECTED ARTICLES 7HEN DATA DID NOT APPEAR SUFlCIENT OR WERE INCONCLU SIVE RECOMMENDATIONS WERE BASED UPON EXPERT AND OR CONSEN SUS OPINION BY EXPERIENCED RESEARCHERS AND CLINICIANS

7VX`\gdjcY ,OCAL ANESTHESIA IS THE TEMPORARY LOSS OF SENSATION INCLUDING PAIN IN ONE PART OF THE BODY PRODUCED BY A TOPICALLY APPLIED OR INJECTED AGENT WITHOUT DEPRESSING THE LEVEL OF CONSCIOUSNESS 0REVENTION OF PAIN DURING DENTAL PROCEDURES CAN NURTURE THE RELATIONSHIP OF THE PATIENT AND DENTIST BUILDING TRUST ALLAYING FEAR AND ANXIETY

AND PROMOTING A POSITIVE DENTAL ATTITUDE 4HE TECHNIQUE OF LO CAL ANESTHETIC ADMINISTRATION IS AN IMPORTANT CONSIDERATION IN THE BEHAVIOR GUIDANCE OF A PEDIATRIC PATIENT !GE APPROPRIATE hNONTHREATENINGv TERMINOLOGY DISTRACTION TOPICAL ANESTHETICS

PROPER INJECTION TECHNIQUE AND NITROUS OXIDE OXYGEN ANALGESIA ANXIOLYSIS CAN HELP THE PATIENT HAVE A POSITIVE EXPERIENCE DURING ADMINISTRATION OF LOCAL ANESTHESIA )N PEDIATRIC DENTISTRY THE DENTAL PROFESSIONAL SHOULD BE AWARE OF PROPER DOSAGE BASED ON WEIGHT TO MINIMIZE THE CHANCE OF TOXICITY AND THE PROLONGED DURATION OF ANESTHESIA WHICH CAN LEAD TO ACCIDENTAL LIP OR TONGUE TRAUMA +NOWLEDGE OF THE GROSS AND NEUROANATOMY OF THE HEAD AND NECK ALLOWS FOR PROPER PLACEMENT OF THE ANESTHETIC SOLU

TION AND HELPS MINIMIZE COMPLICATIONS EG HEMATOMA TRISMUS

INTRAVASCULAR INJECTION &AMILIARITY WITH THE PATIENT S MEDICAL HISTORY IS ESSENTIAL TO DECREASE THE RISK OF AGGRAVATING A MEDICAL CONDITION WHILE RENDERING DENTAL CARE !PPROPRIATE MEDICAL CON SULTATION SHOULD BE OBTAINED WHEN NEEDED

-ANY LOCAL ANESTHETIC AGENTS ARE AVAILABLE TO FACILITATE MAN AGEMENT OF PAIN IN THE DENTAL PATIENT 4HERE ARE GENERAL TYPES OF LOCAL ANESTHETIC CHEMICAL FORMULATIONS ESTERS EG PROCAINE

BENZOCAINE TETRACAINE AND AMIDES EG LIDOCAINE MEPIVA CAINE PRILOCAINE ARTICAINE ,OCAL ANESTHETICS ARE VASODILATORS THEY EVENTUALLY ARE ABSORBED INTO THE CIRCULATION WHERE THEIR SYSTEMIC EFFECT IS RELATED DIRECTLY TO THEIR BLOOD PLASMA LEVEL 6ASOCONSTRICTORS ARE ADDED TO LOCAL ANESTHETICS TO CONSTRICT BLOOD VESSELS IN THE AREA OF INJECTION 4HIS LOWERS THE RATE OF ABSORPTION OF THE LOCAL ANESTHETIC INTO THE BLOOD STREAM THEREBY LOWERING THE RISK OF TOXICITY AND PROLONGING THE ANESTHETIC ACTION IN THE AREA %PINEPHRINE IS CONTRAINDICATED IN PATIENTS WITH HYPER THYROIDISM )TS DOSE SHOULD BE KEPT TO A MINIMUM IN PATIENTS RECEIVING TRICYLIC ANTIDEPRESSANTS SINCE DYSRHYTHMIAS MAY OCCUR ,EVONORDEFRIN AND NOREPINEPHRINE ARE ABSOLUTELY CONTRAINDI CATED IN THESE PATIENTS 0ATIENTS WITH SIGNIlCANT CARDIOVASCULAR DISEASE THYROID DYSFUNCTION DIABETES OR SULlTE SENSITIVITY AND THOSE RECEIVING MONOAMINE OXIDASE INHIBITORS TRICYCLIC ANTIDE PRESSANTS OR PHENOTHIAZINES MAY REQUIRE A MEDICAL CONSULTATION TO DETERMINE THE NEED FOR A LOCAL ANESTHETIC WITHOUT VASOCON STRICTOR 7HEN HALOGENATED GASES EG HALOTHANE ARE USED FOR GENERAL ANESTHESIA THE MYOCARDIUM IS SENSITIZED TO EPINEPHRINE 3UCH SITUATIONS DICTATE CAUTION WITH USE OF A LOCAL ANESTHETIC !MIDE TYPE LOCAL ANESTHETICS NO LONGER ARE CONTRAINDICATED IN PATIENTS WITH A FAMILY HISTORY OF MALIGNANT HYPERTHERMIA AN ABNORMAL ELEVATION IN BODY TEMPERATURE DURING GENERAL ANES THESIA WITH INHALATION ANESTHETICS OR SUCCINYLCHOLINE )F A LOCAL ANESTHETIC IS INJECTED INTO AN AREA OF INFECTION ITS ONSET WILL BE DELAYED OR EVEN PREVENTED 4HE INmAMMATORY PROCESS IN AN AREA OF INFECTION LOWERS THE P( OF THE EXTRACELLULAR TISSUE FROM ITS NORMAL VALUE TO TO OR LOWER 4HIS LOW P( INHIBITS ANES THETIC ACTION BECAUSE LITTLE OF THE FREE BASE FORM OF THE ANESTHETIC

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IS ALLOWED TO CROSS INTO THE NERVE SHEATH TO PREVENT CONDUCTION OF AMIDE AND ESTER AGENTS AND ARE AT RISK FOR SIDE EFFECTS 4HE 53 NERVE IMPULSES )NSERTING A NEEDLE INTO AN ACTIVE SITE OF INFECTION &OOD AND $RUG !DMINISTRATION DOES NOT REGULATE COMPOUND ALSO COULD LEAD TO POSSIBLE SPREAD OF THE INFECTION ED TOPICAL ANESTHETICS AND RECENTLY ISSUED WARNING ABOUT THEIR USE

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2ECOMMENDATIONS 4OPICAL ANESTHETICS

4OPICAL ANESTHETIC MAY BE USED PRIOR TO THE INJECTION 4HE APPLICATION OF TOPICAL ANESTHETIC MAY HELP MINIMIZE DIS

OF A LOCAL ANESTHETIC TO REDUCE DISCOMFORT ASSOCIATED COMFORT CAUSED DURING ADMINISTRATION OF LOCAL ANESTHESIA 4OPI

WITH NEEDLE PENETRATION CAL ANESTHETIC IS EFFECTIVE ON SURFACE TISSUES MM IN DEPTH 4HE PHARMACOLOGICAL PROPERTIES OF THE TOPICAL AGENT TO REDUCE PAINFUL NEEDLE PENETRATION OF THE ORAL MUCOSA !

SHOULD BE UNDERSTOOD VARIETY OF TOPICAL ANESTHETIC AGENTS ARE AVAILABLE IN GEL LIQUID

! METERED SPRAY IS SUGGESTED IF AN AEROSOL PREPARATION OINTMENT PATCH AND AEROSOL FORMS

IS SELECTED

4HE TOPICAL ANESTHETIC BENZOCAINE IS MANUFACTURED IN 3YSTEMIC ABSORPTION OF THE DRUGS IN TOPICAL ANESTHETICS CONCENTRATIONS UP TO LIDOCAINE IS AVAILABLE AS A SOLUTION MUST BE CONSIDERED WHEN CALCULATING THE TOTAL AMOUNT OR OINTMENT UP TO AND AS A SPRAY UP TO A CONCENTRA OF ANESTHETIC ADMINISTERED TION "ENZOCAINE HAS A RAPID ONSET "ENZOCAINE TOXIC OVERDOSE 4HE !!0$ RECOMMENDS FURTHER INVESTIGATION REGARDING REACTIONS ARE VIRTUALLY UNKNOWN ,OCALIZED ALLERGIC REACTIONS

THE SAFETY AND EFFICACY OF COMPOUNDED TOPICAL ANESTHETICS

HOWEVER MAY OCCUR AFTER PROLONGED OR REPEATED USE 4OPICAL AND THEIR APPLICATIONS FOR PEDIATRIC DENTAL PATIENTS LIDOCAINE HAS AN EXCEPTIONALLY LOW INCIDENCE OF ALLERGIC REACTIONS BUT IS ABSORBED SYSTEMICALLY AND CAN COMBINE WITH AN INJECTED AMIDE LOCAL ANESTHETIC TO INCREASE THE RISK OF OVERDOSE

#OMPOUNDED TOPICAL ANESTHETICS ALSO ARE AVAILABLE 4WO OF THE MORE COMMON FORMULATIONS CONTAIN LIDOCAINE

TETRACAINE AND PHENYLEPHRINE OR LIDOCAINE PRI LOCAINE TETRACAINE AND PHENYLEPHRINE #OMPOUNDED TOPICAL ANESTHETICS HAVE BEEN USED IN ORTHODONTIC PROCEDURES FOR PLACEMENT OF MINI SCREW IMPLANTS TO AID TOOTH MOVEMENT

AS WELL AS IN PEDIATRIC DENTISTRY TO ANESTHETIZE PALATAL TISSUES PRIOR TO INJECTION AND FOR EXTRACTION OF LOOSE PRIMARY TEETH WITHOUT THE NEED FOR AN INJECTION 4HEY CONTAIN HIGH DOSES OF BOTH

3ELECTION OF SYRINGES AND NEEDLES 4HE !MERICAN $ENTAL !SSOCIATION !$! HAS ESTABLISHED STANDARDS FOR ASPIRATING SYRINGES FOR USE IN THE ADMINISTRATION OF LOCAL ANESTHESIA .EEDLE SELECTION SHOULD ALLOW FOR PRO FOUND LOCAL ANESTHESIA AND ADEQUATE ASPIRATION ,ARGER GAUGE NEEDLES PROVIDE FOR LESS DEmECTION AS THE NEEDLE PASSES THROUGH SOFT TISSUES AND FOR MORE RELIABLE ASPIRATION 4HE DEPTH OF IN SERTION VARIES NOT ONLY BY INJECTION TECHNIQUE BUT ALSO BY THE AGE AND SIZE OF THE PATIENT $ENTAL NEEDLES ARE AVAILABLE IN LENGTHS LONG MM SHORT MM AND ULTRASHORT MM

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-AXILLARY INFILTRATION !NESTHETIC

0ULP

3OFT TISSUE

-ANDIBULAR BLOCK

-AXIMUM DOSAGE

0ULP

MG KG

MG LB

MG

3OFT TISSUE

A^YdXV^cZ PLAIN

EPINEPHRINE

EPINEPHRINE

PLAIN

EPINEPHRINE

LEVONORDEFRIN

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6gi^XV^cZ

EPINEPHRINE

PLAIN

EPINEPHRINE

Eg^adXV^cZ

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EPINEPHRINE

4OTAL DOSAGE SHOULD BE BASED ON CHILD S WEIGHT AND SHOULD NEVER EXCEED MAXIMUM TOTAL DOSAGE

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-AXIMUM TOTAL DOSAGE

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)NJECTABLE LOCAL ANESTHETIC AGENTS ,OCAL AMIDE ANESTHETICS AVAILABLE FOR DENTAL USAGE INCLUDE LIDOCAINE MEPIVACAINE ARTICAINE PRILO MG ML /2 6ASOCONSTRICTOR ML !NESTHETIC ML CARTRIDGE /2 ML CARTRIDGE CAINE AND BUPIVACAINE 4ABLES AND !BSOLUTE CONTRAINDICATIONS FOR LOCAL ANESTHETICS INCLUDE A A^YdXV^cZ DOCUMENTED LOCAL ANESTHETIC ALLERGY 4RUE ALLERGY PLAIN /2 . !

TO AN AMIDE IS EXCEEDINGLY RARE !LLERGY TO ONE AM ยงG OR MG /2

EPINEPHRINE /2 IDE DOES NOT RULE OUT THE USE OF ANOTHER AMIDE BUT ยงG OR MG ALLERGY TO ONE ESTER RULES OUT USE OF ANOTHER ESTER ยงG OR MG /2

EPINEPHRINE /2 ! BISULFATE PRESERVATIVE IS USED IN LOCAL ANESTHET ยงG OR MG ICS CONTAINING EPINEPHRINE &OR PATIENTS HAVING BZe^kVXV^cZ AN ALLERGY TO BISULFATES USE OF A LOCAL ANESTHETIC PLAIN /2 . !

WITHOUT A VASOCONSTRICTOR IS INDICATED ,OCAL AN ยงG OR MG /2

EPINEPHRINE /2 ESTHETICS WITHOUT VASOCONSTRICTORS SHOULD BE USED ยงG OR MG WITH CAUTION DUE TO RAPID SYSTEMIC ABSORPTION ยงG OR MG /2

LEVONORDEFRIN /2 WHICH MAY RESULT IN OVERDOSE ยงG OR MG ! LONG ACTING LOCAL ANESTHETIC IE BUPIVACAINE 6gi^XV^cZ IS NOT RECOMMENDED FOR THE CHILD OR THE PHYSICALLY ยงG OR MG /2 OR MENTALLY DISABLED PATIENT DUE TO ITS PROLONGED

EPINEPHRINE /2 ยงG OR MG EFFECT WHICH INCREASES THE RISK OF SOFT TISSUE IN Eg^adXV^cZ JURY #LAIMS HAVE BEEN MADE THAT ARTICAINE CAN . !

PLAIN /2 DIFFUSE THROUGH HARD AND SOFT TISSUE FROM A BUCCAL INlLTRATION TO PROVIDE LINGUAL OR PALATAL SOFT TISSUE ยงG OR MG /2

EPINEPHRINE /2 ยงG OR MG ANESTHESIA 3TUDIES USING ARTICAINE LIDOCAINE AND PRILOCAINE HOWEVER DID NOT SUBSTANTIATE THESE 7je^kVXV^cZ CLAIMS

ยงG OR MG /2

EPINEPHRINE /2 %PINEPHRINE DECREASES BLEEDING IN THE AREA OF ยงG OR MG INJECTION %PINEPHRINE CONCENTRATIONS OF

MAY BE INDICATED FOR INlLTRATION IN SMALL DOSES INTO A SURGICAL SITE TO ACHIEVE HEMOSTASIS BUT ARE .EEDLE GAUGES RANGE FROM SIZE TO .EEDLE BREAKAGE IS A NOT INDICATED IN CHILDREN TO CONTROL PAIN ,OCAL RARE OCCURRENCE 4HE PRIMARY CAUSE OF NEEDLE BREAKAGE IS ANESTHETICS THAT CONTAIN VASOPRESSORS HELP REDUCE TOXICITY WEAKENING THE NEEDLE DUE TO BENDING IT BEFORE INSERTION INTO BY SLOWING THE RATE OF ABSORPTION OF THE ANESTHETIC AND OR THE SOFT TISSUES ANOTHER CAUSE IS PATIENT MOVEMENT AFTER THE VASOPRESSOR INTO THE CARDIOVASCULAR SYSTEM ! VASOPRESSOR NEEDLE IS ALREADY INSERTED CONTAINING LOCAL ANESTHETIC SHOULD BE USED WHEN TREATMENT

2ECOMMENDATIONS EXTENDS TO OR MORE QUADRANTS IN A SINGLE VISIT

&OR THE ADMINISTRATION OF LOCAL DENTAL ANESTHESIA DEN !N END PRODUCT OF PRILOCAINE METABOLISM CAN INDUCE

TISTS SHOULD SELECT ASPIRATING SYRINGES THAT MEET !$! FORMATION OF METHEMOGLOBIN REDUCING THE BLOOD S OXYGEN

STANDARDS CARRYING CAPACITY )N PATIENTS WITH SUBCLINICAL METHEMOGLO

3HORT NEEDLES MAY BE USED FOR ANY INJECTION IN WHICH BINEMIA OR WITH TOXIC DOSES MG KG PRILOCAINE CAN

THE THICKNESS OF SOFT TISSUE IS LESS THAN MM ! LONG INDUCE METHEMOGLOBINEMIA SYMPTOMS EG GRAY OR SLATE

NEEDLE MAY BE USED FOR A DEEPER INJECTION INTO SOFT BLUE CYANOSIS OF THE LIPS MUCOUS MEMBRANES AND NAILS

TISSUE !NY THROUGH GAUGE NEEDLE MAY BE USED RESPIRATORY AND CIRCULATORY DISTRESS 0RILOCAINE MAY BE CON

FOR INTRAORAL INJECTIONS SINCE BLOOD CAN BE ASPIRATED TRAINDICATED IN PATIENTS WITH METHEMOGLOBINEMIA SICKLE CELL

THROUGH ALL OF THEM !SPIRATION CAN BE MORE DIFlCULT

HOWEVER WHEN SMALLER GAUGE NEEDLES ARE USED !N ANEMIA ANEMIA OR SYMPTOMS OF HYPOXIA OR IN PATIENTS RE SINCE BOTH MEDICA

EXTRA SHORT GAUGE IS APPROPRIATE FOR INlLTRATION CEIVING ACETAMINOPHEN OR PHENACETIN

TIONS ELEVATE METHEMOGLOBIN LEVELS

INJECTIONS

2ECOMMENDATIONS

.EEDLES SHOULD NOT BE BENT IF THEY ARE TO BE INSERTED 3ELECTION OF LOCAL ANESTHETIC AGENTS SHOULD BE BASED INTO SOFT TISSUE TO A DEPTH OF MM OR INSERTED TO

UPON

THEIR HUB FOR INJECTIONS TO AVOID NEEDLE BREAKAGE A THE PATIENT S MEDICAL HISTORY AND MENTAL DEVELOP MENTAL STATUS

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AND SHIVERING FOLLOWED BY OVERT SEIZURE ACTIVITY 5NCONSCIOUS NESS AND RESPIRATORY ARREST MAY OCCUR

4HE CARDIOVASCULAR SYSTEM #63 RESPONSE TO LOCAL ANES THETIC TOXICITY ALSO IS BIPHASIC 4HE #63 IS MORE RESISTANT TO LOCAL ANESTHETICS THAN THE #.3 )NITIALLY DURING #63 STIMULATION

HEART RATE AND BLOOD PRESSURE MAY INCREASE !S PLASMA LEVELS OF THE ANESTHETIC INCREASE HOWEVER VASODILATATION OCCURS FOLLOWED

BY DEPRESSION OF THE MYOCARDIUM WITH SUBSEQUENT FALL IN BLOOD PRESSURE "RADYCARDIA AND CARDIAC ARREST MAY FOLLOW 4HE CAR DIODEPRESSANT EFFECTS OF LOCAL ANESTHETICS ARE NOT SEEN UNTIL THERE IS A SIGNIlCANTLY ELEVATED LOCAL ANESTHETIC BLOOD LEVEL

,OCAL ANESTHETIC TOXICITY CAN BE PREVENTED BY CAREFUL IN JECTION TECHNIQUE WATCHFUL OBSERVATION OF THE PATIENT AND KNOWLEDGE OF THE MAXIMUM DOSAGE BASED ON WEIGHT 0RACTI TIONERS SHOULD ASPIRATE BEFORE EVERY INJECTION AND INJECT SLOWLY !FTER THE INJECTION THE DOCTOR HYGIENIST OR ASSISTANT SHOULD REMAIN WITH THE PATIENT WHILE THE ANESTHETIC BEGINS TO TAKE EF FECT %ARLY RECOGNITION OF A TOXIC RESPONSE IS CRITICAL FOR EFFECTIVE MANAGEMENT 7HEN SIGNS OR SYMPTOMS OF TOXICITY ARE NOTED

$OCUMENTATION OF LOCAL ANESTHESIA 4HE PATIENT RECORD IS AN ESSENTIAL COMPONENT OF THE DELIVERY ADMINISTRATION OF THE LOCAL ANESTHETIC AGENT SHOULD BE DISCON OF COMPETENT AND QUALITY ORAL HEALTH CARE &OLLOWING EACH TINUED !DDITIONAL EMERGENCY MANAGEMENT IS BASED ON THE APPOINTMENT AN ENTRY IS MADE IN THE RECORD THAT ACCURATELY SEVERITY OF THE REACTION

AND OBJECTIVELY SUMMARIZES THAT VISIT !PPROPRIATE DOCUMEN TATION INCLUDES SPECIlC INFORMATION RELATIVE TO THE ADMINIS !LLERGY TO LOCAL ANESTHESIA !LLERGIC REACTIONS ARE NOT DOSE DEPENDANT BUT ARE DUE TO THE TRATION OF LOCAL ANESTHESIA PATIENT S HEIGHTENED CAPACITY TO REACT TO EVEN A SMALL DOSE !L

2ECOMMENDATIONS LERGIES CAN MANIFEST IN A VARIETY OF WAYS SOME OF WHICH INCLUDE

$OCUMENTATION MUST INCLUDE THE TYPE AND DOSAGE OF URTICARIA DERMATITIS ANGIOEDEMA FEVER PHOTOSENSITIVITY OR

LOCAL ANESTHETIC $OSAGE OF VASOCONSTRICTORS IF ANY ANAPHYLAXIS %MERGENCY MANAGEMENT IS DEPENDENT ON THE

MUST BE NOTED &OR EXAMPLE MG LIDO WITH RATE AND SEVERITY OF THE REACTION

MG EPI OR MG LIDO WITH EPI

$OCUMENTATION MAY INCLUDE THE TYPE OF INJECTION S 0ARESTHESIA

GIVEN EG INlLTRATION BLOCK INTRAOSSEOUS NEEDLE SE 0ARESTHESIA IS PERSISTENT ANESTHESIA BEYOND THE EXPECTED DURA

LECTION AND PATIENT S REACTION TO THE INJECTION TION 4RAUMA TO THE NERVE CAN PRODUCE PARESTHESIA AND AMONG

)F THE LOCAL ANESTHETIC WAS ADMINISTERED IN CONJUNC OTHER ETIOLOGIES TRAUMA CAN BE CAUSED BY THE NEEDLE DURING

TION WITH SEDATIVE DRUGS THE DOSES OF ALL AGENTS MUST THE INJECTION 4HE PATIENT MAY EXPERIENCE AN hELECTRIC SHOCKv

BE NOTED ON A TIME BASED RECORD IN THE INVOLVED NERVE DISTRIBUTION AREA 0ARESTHESIA ALSO CAN BE

)N PATIENTS FOR WHOM THE MAXIMUM DOSAGE OF LOCAL CAUSED BY HEMORRHAGE IN OR AROUND THE NERVE 2ISK OF PER

ANESTHETIC MAY BE A CONCERN THE WEIGHT SHOULD BE MANENT PARESTHESIA IS

FOR

AND LOCAL

DOCUMENTED PREOPERATIVELY ANESTHETICS AND FOR LOCAL ANESTHETICS 2EPORTS

$OCUMENTATION SHOULD INCLUDE THAT POST INJECTION IN OF PARESTHESIA ARE MORE COMMON WITH ARTICAINE AND PRILOCAINE

STRUCTIONS WERE REVIEWED WITH THE PATIENT AND PARENT THAN EXPECTED FROM THEIR FREQUENCY OF USE 0ARESTHESIA UNRE LATED TO SURGERY MOST OFTEN INVOLVES THE TONGUE FOLLOWED BY ,OCAL ANESTHETIC COMPLICATIONS THE LIP AND IS MORE COMMON WITH SOLUTIONS OF ARTICAINE 4OXICITY OVERDOSE OR PRILOCAINE -OST CASES RESOLVE IN WEEKS -OST ADVERSE DRUG REACTIONS DEVELOP EITHER DURING THE INJEC TION OR WITHIN TO MINUTES /VERDOSE OF LOCAL ANESTHETIC 0OSTOPERATIVE SOFT TISSUE INJURY CAN RESULT FROM HIGH BLOOD LEVELS CAUSED BY A SINGLE INADVERTENT 3ELF INDUCED SOFT TISSUE TRAUMA IS AN UNFORTUNATE CLINICAL COM INTRAVASCULAR INJECTION OR REPEATED INJECTIONS ,OCAL ANESTHETIC PLICATION OF LOCAL ANESTHETIC USE IN THE ORAL CAVITY -OST LIP AND CAUSES A BIPHASIC REACTION EG EXCITATION FOLLOWED BY DEPRESSION CHEEK BITING LESIONS OF THIS NATURE ARE SELF LIMITING AND HEAL IN THE CENTRAL NERVOUS SYSTEM #.3 %ARLY SUBJECTIVE INDICATIONS WITHOUT COMPLICATIONS ALTHOUGH BLEEDING AND INFECTION POS OF TOXICITY INVOLVE THE #.3 AND INCLUDE DIZZINESS ANXIETY AND SIBLY MAY RESULT 4HE USE OF BILATERAL MANDIBULAR BLOCKS DOES CONFUSION 4HIS MAY BE FOLLOWED BY DIPLOPIA TINNITIS DROWSI NOT INCREASE THE RISK OF SOFT TISSUE TRAUMA WHEN COMPARED TO NESS AND CIRCUMORAL NUMBNESS OR TINGLING /BJECTIVE SIGNS MAY UNILATERAL MANDIBULAR BLOCKS OR IPSILATERAL MAXILLARY INlLTRA INCLUDE MUSCLE TWITCHING TREMORS TALKATIVENESS SLOWED SPEECH TION )N FACT THE FREQUENCY OF SOFT TISSUE TRAUMA WAS MUCH B THE ANTICIPATED DURATION OF THE DENTAL PROCEDURE C THE NEED FOR HEMORRHAGE CONTROL D THE PLANNED ADMINISTRATION OF OTHER AGENTS EG

NITROUS OXIDE SEDATIVE AGENTS GENERAL ANESTHESIA E THE PRACTITIONER S KNOWLEDGE OF THE ANESTHETIC AGENT

5SE OF VASOCONSTRICTORS IN LOCAL ANESTHETICS IS RECOM

MENDED TO DECREASE THE RISK OF TOXICITY OF THE ANESTHETIC

AGENT ESPECIALLY WHEN TREATMENT EXTENDS TO OR MORE QUADRANTS IN A SINGLE VISIT

)N CASES OF BISULFATE ALLERGY USE OF A LOCAL ANESTHETIC

WITHOUT A VASOCONSTRICTOR IS INDICATED ! LOCAL ANES

THETIC WITHOUT A VASOCONSTRICTOR ALSO CAN BE USED FOR

SHORTER TREATMENT NEEDS BUT SHOULD BE USED WITH CAU TION TO MINIMIZE THE RISK OF TOXICITY OF THE ANESTHETIC AGENTS

4HE ESTABLISHED MAXIMUM DOSAGE FOR ANY ANESTHETIC

SHOULD NOT BE EXCEEDED

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HIGHER THAN EXPECTED WHEN ONLY SIDE WAS ANESTHETIZED 5SING MANDIBULAR INlLTRATION VS BLOCKS IS NOT OF GREAT VALUE IN PRE VENTION OF THESE INJURIES SINCE THE DURATION OF SOFT TISSUE AN ESTHESIA MAY NOT BE REDUCED SIGNIlCANTLY )N ADDITION FOR SOME PROCEDURES INlLTRATION IS NOT AS EFFECTIVE AS THE MANDI BULAR BLOCK

#AREGIVERS RESPONSIBLE FOR POSTOPERATIVE SUPERVISION SHOULD BE GIVEN A REALISTIC TIME FOR DURATION OF NUMBNESS AND INFORMED OF THE POSSIBILITY OF SOFT TISSUE TRAUMA 6ISUAL EXAMPLES MAY HELP STRESS THE IMPORTANCE OF OBSERVATION DURING THE PERIOD OF NUMBNESS &OR ALL LOCAL ANESTHETICS THE DURATION OF SOFT TISSUE ANESTHESIA IS GREATER THAN DENTINAL OR OSSEOUS ANESTHESIA 5SE OF PHENTOLAMINE MESYLATE INJECTIONS IN PATIENTS OVER AGE YEARS OR AT LEAST KG HAS BEEN SHOWN TO REDUCE THE DURATION OF EFFECTS OF LOCAL ANESTHETIC BY ABOUT IN THE MAXILLA AND IN THE MANDIBLE (OWEVER THERE IS NO RESEARCH DEMONSTRATING A RELATIONSHIP BETWEEN REDUCTION IN SOFT TISSUE TRAUMA AND THE USE OF SHORTER ACTING LOCAL ANESTHETICS

2ECOMMENDATIONS TO REDUCE LOCAL ANESTHETIC COMPLICATIONS

0RACTITIONERS WHO UTILIZE ANY TYPE OF LOCAL ANESTHETIC

IN A PEDIATRIC DENTAL PATIENT SHALL POSSESS APPROPRIATE

TRAINING AND SKILLS AND HAVE AVAILABLE THE PROPER

FACILITIES PERSONNEL AND EQUIPMENT TO MANAGE ANY

REASONABLY FORESEEABLE EMERGENCY

#ARE SHOULD BE TAKEN TO ENSURE PROPER NEEDLE PLACE

MENT DURING THE INTRAORAL ADMINISTRATION OF LOCAL

ANESTHETICS 0RACTITIONERS SHOULD ASPIRATE BEFORE EVERY

INJECTION AND INJECT SLOWLY

!FTER THE INJECTION THE DOCTOR HYGIENIST OR ASSISTANT

SHOULD REMAIN WITH THE PATIENT WHILE THE ANESTHETIC

BEGINS TO TAKE EFFECT

2ESIDUAL SOFT TISSUE ANESTHESIA SHOULD BE MINIMIZED IN

PEDIATRIC AND SPECIAL HEALTH CARE NEEDS PATIENTS TO DE

CREASE RISK OF SELF INmICTED POSTOPERATIVE INJURIES

0RACTITIONERS SHOULD ADVISE PATIENTS AND THEIR CARE

GIVERS REGARDING BEHAVIORAL PRECAUTIONS EG DO NOT BITE

OR SUCK ON LIP CHEEK DO NOT INGEST HOT SUBSTANCES

AND THE POSSIBILITY OF SOFT TISSUE TRAUMA WHILE ANESTHE

SIA PERSISTS 0LACING A COTTON ROLL IN THE MUCOBUCCAL

FOLD MAY HELP PREVENT INJURY AND LUBRICATING THE LIPS

WITH PETROLEUM JELLY HELPS PREVENT DRYING 0RACTI

TIONERS WHO USE PHEYTOLAMINE MESYLATE INJECTIONS TO

REDUCE THE DURATION OF LOCAL ANESTHESIA STILL SHOULD

FOLLOW THESE RECOMMENDATIONS 3UPPLEMENTAL INJECTIONS TO OBTAIN LOCAL ANESTHESIA 4HE MAJORITY OF LOCAL ANESTHESIA PROCEDURES IN PEDIATRIC DENTISTRY INVOLVE TRADITIONAL METHODS OF INlLTRATION OR NERVE BLOCK TECH NIQUES WITH A DENTAL SYRINGE DISPOSABLE CARTRIDGES AND NEEDLES AS DESCRIBED SO FAR 3EVERAL ALTERNATIVE TECHNIQUES HOWEVER ARE AVAILABLE 4HESE INCLUDE COMPUTER CONTROLLED LOCAL ANESTHETIC DELIVERY PERIODONTAL INJECTION TECHNIQUES IE PERIODONTAL LIGA MENT ;0$,= INTRALIGAMENTARY AND PERIDENTAL INJECTION

hNEEDLELESSv SYSTEMS AND INTRASEPTAL OR INTRAPULPAL INJECTION 4HESE TECHNIQUES MAY IMPROVE COMFORT OF INJECTION BY BETTER

CONTROL OF THE ADMINISTRATION RATE PRESSURE AND LOCATION OF ANESTHETIC SOLUTIONS AND OR RESULT IN SUCCESSFUL AND MORE CON TROLLED ANESTHESIA %NDOCARDITIS PROPHYLAXIS IS RECOMMENDED FOR INTRALIGAMENTARY LOCAL ANESTHETIC INJECTIONS IN PATIENTS AT RISK

)NTRASEPTAL INJECTION FOR LINGUAL ANESTHESIA IS A VARIATION IN TECHNIQUE AFTER THE BUCCAL TISSUE IS ANESTHETIZED 4HE NEEDLE IS INSERTED THROUGH THE BUCCAL TISSUE TO ANESTHETIZE THE LINGUAL PALATAL SOFT TISSUES )T CAN BE USED WITH THE 0$, INJECTION TO GAIN LINGUAL ANESTHESIA WHEN POSTOPERATIVE SOFT TISSUE TRAUMA IS A CONCERN $URING PULPAL THERAPY ADMINISTERING LOCAL ANES THETIC DIRECTLY INTO THE PULP MAY BE INDICATED WHEN OTHER METHODS FAIL TO ANESTHETIZE THE TOOTH

!S WITH TRADITIONAL METHODS OF OBTAINING ORAL LOCAL ANES THESIA THE ALTERNATIVE METHODS GENERALLY ARE SAFE IF THE PRACTI TIONER UNDERSTANDS THE PRINCIPLES FOR THEIR USE 3OME OF THESE TECHNIQUES ARE DESIRABLE ESPECIALLY IN INFANTS CHILDREN ADOLES CENTS AND SPECIAL HEALTH CARE NEEDS PATIENTS SINCE SPECIlC TEETH MAY BE ANESTHETIZED WITH LESS RESIDUAL ANESTHESIA IE AVOID DIS COMFORT AND POTENTIAL SELF MUTILATION OF BLOCK ANESTHESIA 4HE MANDIBULAR BONE OF A CHILD USUALLY IS LESS DENSE THAN THAT OF AN ADULT PERMITTING MORE RAPID AND COMPLETE DIFFUSION OF THE ANESTHETIC -ANDIBULAR BUCCAL INlLTRATION ANESTHESIA IS AS EFFECTIVE AS INFERIOR NERVE BLOCK ANESTHESIA FOR SOME OPERATIVE PROCEDURES )N PATIENTS WITH BLEEDING DISORDERS THE 0$, IN JECTION MINIMIZES THE POTENTIAL FOR POSTOPERATIVE BLEEDING OF SOFT TISSUE VESSELS )NTRAOSSEUS TECHNIQUES MAY BE CONTRAINDI CATED WITH PRIMARY TEETH DUE TO POTENTIAL FOR DAMAGE TO DEVEL OPING PERMANENT TEETH !LSO THE USE OF THE 0$, INJECTION OR INTRAOSSEUS METHODS IS CONTRAINDICATED IN THE PRESENCE OF INmAMMATION OR INFECTION AT THE INJECTION SITE 2ECOMMENDATION !LTERNATIVE TECHNIQUES FOR THE DELIVERY OF LOCAL ANESTHESIA MAY BE CONSIDERED TO MINIMIZE THE DOSE OF ANESTHETIC USED

IMPROVE PATIENT COMFORT AND OR IMPROVE SUCCESSFUL DENTAL ANESTHESIA ,OCAL ANESTHESIA WITH SEDATION GENERAL ANESTHESIA AND OR NITROUS OXIDE OXYGEN ANALGESIA ANXIOLYSIS $RUGS THAT HAVE THE SAME MECHANISM OF ACTION OFTEN WILL HAVE ADDITIVE EFFECTS WHEN USED TOGETHER ,OCAL ANESTHETICS AND SEDA TIVE AGENTS BOTH DEPRESS THE #.3 !N INCREASE IN TOXIC REAC TIONS OF LOCAL ANESTHETICS WHEN COMBINED WITH OPIOIDS HAS BEEN DEMONSTRATED .ARCOTICS MAY DECREASE THE AMOUNT OF PRO TEIN BINDING OF LOCAL ANESTHETICS AND ALSO ELEVATE ARTERIAL CARBON DIOXIDE BOTH OF WHICH WILL INCREASE #.3 SENSITIVITY TO CONVUL SIONS )N ADDITION NARCOTICS SUCH AS MEPERIDINE HAVE CONVULSANT PROPERTIES WHEN EXCESSIVE DOSES ARE ADMINISTERED )T HAS BEEN SUGGESTED THAT THE DOSE OF LOCAL ANESTHESIA BE ADJUSTED DOWN WARD WHEN SEDATING CHILDREN WITH OPIOIDS

5SING LOCAL ANESTHESIA HAS BEEN FOUND TO REDUCE THE DOS AGE OF INHALATION ANESTHETICS FOR PATIENTS UNDERGOING GENERAL ANESTHESIA 4HE ANESTHESIA CARE PROVIDER NEEDS TO BE AWARE OF THE CONCOMITANT USE OF A LOCAL ANESTHETIC CONTAINING EPINEPH RINE AS EPINEPHRINE CAN PRODUCE DYSRHYTHMIAS WHEN USED WITH HALOGENATED HYDROCARBONS EG HALOTHANE ,OCAL ANESTHESIA

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ALSO HAS BEEN REPORTED TO REDUCE PAIN IN THE POSTOPERATIVE RECOVERY PERIOD AFTER GENERAL ANESTHESIA

2ECOMMENDATIONS

0ARTICULAR ATTENTION SHOULD BE PAID TO LOCAL ANESTHETIC

DOSES USED IN CHILDREN 4O AVOID EXCESSIVE DOSES FOR THE

PATIENT WHO IS GOING TO BE SEDATED A MAXIMUM RE

COMMENDED DOSE BASED UPON WEIGHT SHOULD BE CAL

CULATED

4HE DOSAGE OF LOCAL ANESTHETIC SHOULD NOT BE ALTERED

IF NITROUS OXIDE OXYGEN ANALGESIA ANXIOLYSIS IS ADMI

NISTERED

7HEN GENERAL ANESTHESIA IS EMPLOYED LOCAL ANESTHESIA

MAY BE USED TO REDUCE THE MAINTENANCE DOSAGE OF THE

ANESTHETIC DRUGS 4HE ANESTHESIOLOGIST SHOULD BE IN

FORMED OF THE TYPE AND DOSAGE OF THE LOCAL ANESTHETIC

USED 2ECOVERY ROOM PERSONNEL ALSO SHOULD BE IN

FORMED

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