Local Anesthesia Techniques in Children (PDF)

LOCAL ANESTHESIA TECHNIQUES IN CHILDREN AND INDICATIONS OF TOOTH EXTRACTION  Local anesthesia is a method that suppresses conduction in peripheral nerves and reduces or completely stops sensation in nerve endings.  One of the most important issues in behavioral guidance in children is pai...

LOCAL ANESTHESIA TECHNIQUES IN CHILDREN AND INDICATIONS OF TOOTH EXTRACTION  Local anesthesia is a method that suppresses conduction in peripheral nerves and reduces or completely stops sensation in nerve endings.  One of the most important issues in behavioral guidance in children is pain control. If the child experiences pain in the dentist's chair, he or she may develop dental phobia in the future. Dental procedures can be performed more effectively if the child is relaxed and pain-free. Local anesthesia can provide a painless process for the child patient. Anesthesia in children is very important for the child's future cooperation. While a careful local anesthesia is painless and acceptable for the child, a painful local anesthesia experience will cause unhappiness and fear in the child and it will not be possible to treat. Before applying local anesthesia, it should be learned whether the child has previous anesthesia experience and how he feels about it. If the child does not have a bad experience before, the procedure is performed more easily. The pediatric patient should be prepared mentally and physically for anesthesia. The anesthesia procedure should be explained to the child in a language that children can understand.  Some anatomical differences in children cause anesthesia to be administered differently than in adults. 1-The anatomical structures in children are smaller than in adults. Therefore, the penetration depth of the needle should not be too great. 2- In the tuber region of the maxilla, the vascular structures are superficial. If the needle goes too deep, the pterygoid vein plexus or posterior superior alveolar artery may be damaged, resulting in a hematoma. 3-The mandibular ramus is vertically shorter and narrower in the anteroposterior direction. Therefore, the penetration depth of the needle should be reduced.  4- In children, the jaw bones are less calcified. This allows the local anesthetic agent to pass more quickly.5- Since the labial bone cortex in the upper jaw is very thin and vascularization is intense in children, local infiltration anesthesia is often sufficient. Intraoral Nerve Block Anesthesia Techniques Applied to the Upper Jaw Posterior Superior Alveolar Anesthesia (PSA) (Tüber Anesthesia): It is a technique used to provide anesthesia of the posterior superior alveolar branches of the maxillary nerve (N). With this anesthesia technique, the distobuccal and palatal roots of the upper 1st molar, all roots of the 2nd and 3rd molars, their periodontiums and buccal mucosa are blocked. When anesthesia of the PSA nerve is required in young children, the needle is directed towards the apical of the last erupted tooth on the side to be anesthetized and towards the distal of the zygomatic process. The jaw is inserted from front to back, from outside to inside, without losing bone contact, forming a 450 angle with the chewing plane. After advancing approximately 1 cm, the solution is slowly injected by aspirating.For PSA nerve block in children, short needles (approximately 20 mm) should be used to reduce the depth of needle penetration. In this way, an approach suitable for the smaller anatomical dimensions of the child patient is provided and the risk of hematoma formation is minimized. Complications of Local Anesthesia 1-Anesthetic ToxicityChildren are at a higher risk of developing toxic reactions due to anesthesia than adults.Reactions usually begin 5-10 minutes after injection. Local anesthetics administered in excessive doses cause agitation and then depression in the central nervous system and to a lesser extent in the cardiovascular system. Early symptoms in the central nervous system are dizziness, lightheadedness, anxiety, followed by diplopia (double vision), tinnitus, numbness or tingling around the mouth. Objective findings include muscle contraction, tremors, slowing and shaking of speech, and seizures. The patient may lose consciousness and respiratory arrest may develop. The first reaction seen in the cardiovascular system in anesthesia toxicity is increased heart rate and increased blood pressure. As the blood plasma level of the anesthetic increases, vasodilation first develops and blood pressure decreases. Bradycardia and cardiac arrest may develop.Local anesthesia toxicity can be prevented by using the correct injection technique. Clinicians should have a good knowledge of the maximum dose according to body weight. 2-Allergic ReactionsVery rare. Allergic reactions such as urticaria, dermatitis, angioedema, fever, photosensitivity and anaphylaxis may be observed. 3-ParesthesiaParesthesia is the anesthetic effect lasting longer than expected. It occurs due to trauma caused to the nerve during anesthesia. It can also occur due to bleeding in or around the nerve. It is most commonly seen on the tongue and lips. It heals within 8 weeks without the need for treatment. 4-Postoperative Soft Tissue Injury common problem in children is biting and chewing the lips, tongue and cheeks after anesthesia. The numbness in the soft tissue can last up to 4 hours. The patient and their guardian should be careful and not eat during this period until the numbness completely passes. If there is a trauma to the lip due to biting, the patient should be told that it is the result of biting the anesthetized area and that it will pass in up to 1 week. Vaseline can be applied to the area to prevent it from drying out. Orabase (corticosteroid pomade) can be used in such cases. "Xylocaine" solution or anesthetic creams prepared for the mouth can be applied to the area. Chlorhexadine mouthwashes (care should be taken for children over the age of 6) shorten the recovery period. 5- Injection of the wrong substance (NaOCl)NaOCl injection instead of local anesthetic or NaOCl solution overflowing from the root canals during endodontic treatment can cause severe pain and allergic reactions in the patient.In its treatment;Staying calm and gaining the patient's trust,Washing the area with pure water to dilute the solution,Recommending the application of cold water for the first 6 hours and then warm water,Giving antibiotics if there is a risk of infection,Always having antihistamines with you against allergic reactions,Applying corticosteroid ointment to reduce edema. When the root is broken during the extraction of a primary tooth: Root fractures are frequently encountered during the extraction of primary teeth. When the broken root piece is tried to be removed, the permanent tooth germ underneath may be damaged. However, leaving the broken root piece may increase the risk of postoperative infection and may cause a delay in the eruption of the permanent tooth. If the broken piece can be easily removed, it should be removed. If the broken piece is very small, located in a lower area in the socket, or very close to the permanent tooth germ, it should be left. Maximum recommended local anesthetic dose in children: 4.4mg/kg LA with adrenaline 7.5mg/kg La without adrenaline Example If 7.5mg/kg for 1kg in a 10kg child75mg for 10kg20mg= 1ml (2% lidocaine)75= 3.7ml maximum dose Anesthesia Application Protocol in Children The child patient is seated on the chair with the head and heart parallel to the ground and the feet slightly in the air. This position reduces the possibility of syncope in the child due to fear of needles.Any residue in the area where the needle will be applied is cleaned with gauze and the mucosa is dried.The lip is retracted enough to create a sufficient field of vision.Topical anesthetic is applied. Topical anesthetic should only be applied to the point where the needle will be inserted. Anesthetizing the soft palate and pharynx should be avoided. Wait for 1-2 minutes.The child should be kept under control so that he/she does not move while anesthesia is applied. The patient should be talked to in order to distract the child from the needle. The child should not see the needle until the last moment.The anesthetic dose should be adjusted well in the child patient. 2% lidocaine containing 1:100,000 epinephrine is the ideal local anesthetic for the child patient. Bupivacaine, which provides long-term soft tissue anesthesia, is not preferred in children. Tooth Extraction in ChildrenThe technique used for extraction in a child patient is similar to the technique used for adults. The biggest difference is the patient's management. The dentist should share the procedure with the patient and their parents. The child should be approached with the tell-show-do technique. The dentist should be sure to administer effective anesthesia. Because if the patient feels pain or soreness, it may be difficult to gain the child's trust to show the necessary behavior for the procedure to be completed.To prevent aspiration of the extracted tooth, the patient should be positioned in the chair so that the upper jaw does not form an angle greater than 45 degrees from the floor. PRIMARY TEETH EXTRACTION TECHNIQUES UPPER AND LOWER INCISORS The roots of the primary front group teeth are single-rooted and conical in shape. Therefore, they should be extracted with a rotational movement. During extraction, force should be avoided on the adjacent tooth. UPPER AND LOWER MOLARS The roots of primary molars are smaller in diameter and more divergent than permanent teeth. During extraction, damage to the permanent tooth germ in the region between the roots should be avoided. The extraction of primary molars is performed using slow and continuous palatal / lingual and buccal movements that provide expansion in the alveolar bone to reduce the risk of root fracture. During the extraction of lower primary teeth, the mandible should be supported to protect the TMJ from injury.The extraction area should not be curetted after the extraction of the primary tooth. This may cause damage to the permanent tooth below. The extraction socket should not be tightened. When the root is broken during the extraction of a primary tooth:Root fractures are frequently encountered during the extraction of primary teeth. When the broken root piece is tried to be removed, the permanent tooth germ underneath may be damaged. However, leaving the broken root piece may increase the risk of postoperative infection and may cause a delay in the eruption of the permanent tooth. If the broken piece can be easily removed, it should be removed. If the broken piece is very small, located in a lower area in the socket, or very close to the permanent tooth germ, it should be left SEDATION AND GENERAL ANESTHESIA The most important condition for a successful treatment in pediatric dentistry is to establish a good cooperation with the child patient. Fear and anxiety, which arise due to various reasons such as socio-cultural factors originating from parents or the environment, negative dental experiences experienced by the child, and the dentist's lack or inexperience in the methods of treating the child, are one of the most important problems in pediatric dentistry. Being able to control the behavior of the child patient and perform dental treatments is one of the most important duties of pedodontists. Psychological methods should be tried first in non-compliant child patients. However, in some cases, behavioral and psychopedagogical methods may be insufficient. In such cases, pharmacological applications are used. Pharmacosedation methods in pediatric dentistry are divided into two: sedation and general anesthesia. Although the two methods are not similar in terms of pharmacological agents and application, both methods are applied for the same purpose in dentistry. Considering the patient's treatment needs and fear and anxiety, general anesthesia is the method to be used in cases where sedation does not provide a solution. Sedation ist he state of anxiety being eliminated, reduced or not occurring at all. It is a period of anesthesia in which the patient is conscious but under the influence of medication. Protective reflexes are not eliminated in sedation, and the ability to respond to verbal commands continues. Another feature that is different from general anesthesia is that the patient who is sedated does not lose the ability to control his/her own airway. The purpose of sedation applied to the child patient for diagnosis and treatment procedures: To protect the patient's health, To minimize physical discomfort and pain, To control anxiety, minimize psychological trauma and provide amnesia. To control behavior and/or movement. To send the patient home in good health after the procedure. Indications for SedationMedical Indications: Mild systemic disorders: Sedation is used to eliminate the stress caused by dental procedures in individuals with simple systemic problems such as asthma, controlled hypertension and diabetes. Neuromuscular disorders: It is impossible to perform dental treatments without pharmacological assistance in patients with problems such as multiple sclerosis, spasticity, Parkinson's and uncontrolled epilepsy. Mild mental and psychiatric disorders: Problems such as Down syndrome and mild depression. B) Socio-psychological Indications: Mildly anxious: Many patients who are afraid of dentistry can overcome this fear with sedation methods.Children: Many children are anxious and afraid of dentistry and dentists.The patient or parents' desire.C) Dental Indications:In moderate and long-term surgical dental operations.In patients with trismus and excessive nausea reflex.In patients with a habit of fainting Contraindications for SedationSevere systemic diseases: myocardial infarction and uncontrolled diabetes, hypertension and epilepsy, Chronic obstructive airway diseases, Pregnancy, Syndromes involving muscle tissue such as myasthenia gravis, Patients using antidepressants, anticonvulsants and tranquilizers ,Obesity; overweight patients may experience problems with airway maintenance and breathing Patients with bleeding problems, If the patient has gastrointestinal obstruction Patients without an accompanying person, People who are not experienced and trained in sedation cannot administer sedation. Sedation is not administered unless emergency intervention and resuscitation materials available and without well experience. Types of Sedation Minimal or moderate sedation: A condition in which the patient can independently and continuously protect their airway, responding appropriately to physical stimuli and verbal commands, with a slight decrease in the level of consciousness. Even if the child's eyes are closed, they open them with a voice command directed to them. They respond with crying and startle reflexes to a painful stimulus such as local anesthesia. Routes of Administration of Minimal or Moderate Sedation in Dentistry: 1. Oral 2. Rectal 3. Topical 4. Sublingual (SL) 5. Intranasal (IN) 6. Transdermal (through the skin) 7. Subcutaneous (SC) 8. Intramuscular (IM) 9. Inhalation (pulmonary) 10. Intravenous (IV) Inhalation SedationThe nitrous oxide/oxygen (N2O/O2) sedation method is widely used in dentistry because it is safe, flexible, effective and has a wide range of uses. Protective reflexes of the pharynx and larynx continue in patients. Nitrous oxide is an anesthetic gas with a very mild odor, colorless, non- irritating and very slightly soluble in blood. It is fast-acting. The recovery period is short. Areas of Use of N2O/O2 Sedation in DentistryIn the first examination of patients who apply to the dental clinic with acute tooth or soft tissue pain, in order to increase the patient's pain threshold,In the removal of temporary prosthetic crowns and bridges applied to vital teeth,In the occlusal adjustment of crowns, bridges or vital teeth, so that the sound of the aerator or the vibration created by the bur can be better tolerated by patients,In the application of matrix bands and/or interdental wedges,In periodontal interventions; in the first periodontal examination, scaling, curettage, root planning, periodontal surgical procedures and emergency interventions of patients with acute necrotizing ulcerative gingivitis (ANUG),In oral and maxillofacial surgery, in the drainage of abscesses in long-term surgical procedures, in the treatment of postoperative complications and in the removal of stitches,In endodontic treatment; especially in the application of rubber dams, extirpation of the pulp and intrapulpal injection,