Guideline on Use of Local Anesthesia for Pediatric Dental Patients PDF

reference manual v 32 / no 6 10 / 11 Guideline on Use of Local Anesthesia for Pediatric Dental Patients Originating Council Council on Clinical Affairs Review Council Council on Clinical Affairs Adopted 2005 Revised 2009 Purpose...

reference manual v 32 / no 6 10 / 11 Guideline on Use of Local Anesthesia for Pediatric Dental Patients Originating Council Council on Clinical Affairs Review Council Council on Clinical Affairs Adopted 2005 Revised 2009 Purpose tion and helps minimize complications (eg, hematoma, trismus, The American Academy of Pediatric Dentistry (AAPD) intends intravascular injection). Familiarity with the patient’s medical this guideline to help practitioners make decisions when using history is essential to decrease the risk of aggravating a medical local anesthesia to control pain in infants, children, adoles- condition while rendering dental care. Appropriate medical con- cents, and individuals with special health care needs during the sultation should be obtained when needed. delivery of oral health care. Many local anesthetic agents are available to facilitate man- agement of pain in the dental patient. There are 2 general types Methods of local anesthetic chemical formulations: (1) esters (eg, procaine, This revision included a new systematic literature search of the benzocaine, tetracaine); and (2) amides (eg, lidocaine, mepiva- MEDLINE/Pubmed electronic database using the following caine, prilocaine, articaine).3 Local anesthetics are vasodilators; parameters: Terms: dental anesthesia, dental local anesthesia, they eventually are absorbed into the circulation, where their and topical anesthesia; Field: all fields; Limits: within the last systemic effect is related directly to their blood plasma level.4 10 years, humans, English, and clinical trials. One thousand one Vasoconstrictors are added to local anesthetics to constrict blood hundred thirty articles matched these criteria. Papers for review vessels in the area of injection. This lowers the rate of absorption were chosen from this list and from references within selected of the local anesthetic into the blood stream, thereby lowering articles. When data did not appear sufficient or were inconclu- the risk of toxicity and prolonging the anesthetic action in the sive, recommendations were based upon expert and/or consen- area.4 Epinephrine is contraindicated in patients with hyper- sus opinion by experienced researchers and clinicians. thyroidism.5 Its dose should be kept to a minimum in patients receiving tricylic antidepressants since dysrhythmias may occur. Background Levonordefrin and norepinephrine are absolutely contraindi- Local anesthesia is the temporary loss of sensation including pain cated in these patients.6 Patients with significant cardiovascular in one part of the body produced by a topically-applied or injected disease, thyroid dysfunction, diabetes, or sulfite sensitivity and agent without depressing the level of consciousness. Prevention those receiving monoamine oxidase inhibitors, tricyclic antide- of pain during dental procedures can nurture the relationship of pressants, or phenothiazines may require a medical consultation the patient and dentist, building trust, allaying fear and anxiety, to determine the need for a local anesthetic without vasocon- and promoting a positive dental attitude. The technique of lo- strictor.6,7 When halogenated gases (eg, halothane) are used for cal anesthetic administration is an important consideration in general anesthesia, the myocardium is sensitized to epinephrine. the behavior guidance of a pediatric patient. Age-appropriate Such situations dictate caution with use of a local anesthetic.6 “nonthreatening” terminology, distraction, topical anesthetics, Amide-type local anesthetics no longer are contraindicated in proper injection technique, and nitrous oxide/oxygen analgesia/ patients with a family history of malignant hyperthermia, an anxiolysis can help the patient have a positive experience during abnormal elevation in body temperature during general anes- administration of local anesthesia.1,2 In pediatric dentistry, the thesia with inhalation anesthetics or succinylcholine.7,8 If a local dental professional should be aware of proper dosage (based on anesthetic is injected into an area of infection, its onset will be weight) to minimize the chance of toxicity and the prolonged delayed or even prevented.3 The inflammatory process in an area duration of anesthesia, which can lead to accidental lip or tongue of infection lowers the pH of the extracellular tissue from its trauma. Knowledge of the gross and neuroanatomy of the head normal value (7.4) to 5 to 6 or lower. This low pH inhibits anes- and neck allows for proper placement of the anesthetic solu- thetic action because little of the free base form of the anesthetic 156 CLINICAL GUIDELINES  American academy of pediatric dentistry is allowed to cross into the nerve sheath to prevent conduction of amide and ester agents and are at risk for side effects.15 The US nerve impulses.9 Inserting a needle into an active site of infection Food and Drug Administration does not regulate compound- also could lead to possible spread of the infection. ed topical anesthetics and recently issued warning about their use.17,18 Recommendations Recommendations: Topical anesthetics 1. Topical anesthetic may be used prior to the injection The application of topical anesthetic may help minimize dis- of a local anesthetic to reduce discomfort associated comfort caused during administration of local anesthesia. Topi- with needle penetration. cal anesthetic is effective on surface tissues (2-3 mm in depth) 2. The pharmacological properties of the topical agent to reduce painful needle penetration of the oral mucosa.10,11 A should be understood. variety of topical anesthetic agents are available in gel, liquid, 3. A metered spray is suggested if an aerosol preparation ointment, patch, and aerosol forms. is selected. The topical anesthetic benzocaine is manufactured in 4. Systemic absorption of the drugs in topical anesthetics concentrations up to 20%; lidocaine is available as a solution must be considered when calculating the total amount or ointment up to 5% and as a spray up to a 10% concentra- of anesthetic administered. tion.3 Benzocaine has a rapid onset. Benzocaine toxic (overdose) reactions are virtually unknown. Localized allergic reactions, The AAPD recommends further investigation regarding however, may occur after prolonged or repeated use.12 Topical the safety and efficacy of compounded topical anesthetics lidocaine has an exceptionally low incidence of allergic reactions and their applications for pediatric dental patients. but is absorbed systemically and can combine with an injected amide local anesthetic to increase the risk of overdose.13 Selection of syringes and needles Compounded topical anesthetics also are available.14,15 Two The American Dental Association (ADA) has established of the more common formulations contain 20% lidocaine, 4% standards for aspirating syringes for use in the administration tetracaine, and 2% phenylephrine or 10% lidocaine, 10% prilo- of local anesthesia.19,20 Needle selection should allow for pro- caine, 4% tetracaine, and 2% phenylephrine.15 Compounded found local anesthesia and adequate aspiration. Larger gauge topical anesthetics have been used in orthodontic procedures for needles provide for less deflection as the needle passes through placement of mini-screw implants to aid tooth movement,14,16 as soft tissues and for more reliable aspiration.21 The depth of in- well as in pediatric dentistry to anesthetize palatal tissues prior sertion varies not only by injection technique, but also by the to injection and for extraction of loose primary teeth without age and size of the patient. Dental needles are available in 3 the need for an injection. They contain high doses of both lengths: long (32 mm), short (20 mm), and ultrashort (10 mm). Table 1. injectable Local Anesthetics Duration in minutes3,23 Maxillary infiltration Mandibular block Maximum dosage23 Maximum total dosage23* Anesthetic Pulp Soft tissue Pulp Soft tissue mg/kg mg/lb (mg) Lidocaine 4.4 2.0 300 2% plain 5 5-10 2%+1:50,000 epinephrine 60 170 85 190 2%+1:100,000 epinephrine 60 170 85 190 Mepivacaine 4.4 2.0 300 3% plain 25 90 40 165 2%+1:100,000 epinephrine 60 170 85 190 2%+1:20,000 levonordefrin 50 130 75 185 Articaine 7.0 3.2 500 4%+1:100,000 epinephrine 60 190 90 230 Prilocaine 6.0 2.7 400 4% plain 20 105 55 190 4%+1:200,000 epinephrine 40 140 60 220 Bupivacaine 1.3 0.6 90 0.5%+1:200,000 epinephrine 40 340 240 440 * Total dosage should be based on child’s weight and should never exceed maximum total dosage. CLINICAL GUIDELINES 157 reference manual v 32 / no 6 10 / 11 Injectable local anesthetic agents Table 2. Dosage per Dental Cartridge 3 Local amide anesthetics available for dental usage Anesthetic mg/1.7 ml or include lidocaine, mepivacaine, articaine, prilocaine, Vasoconstrictor/1.7 ml 1.8 ml cartridge or 1.8 ml cartridge and bupivacaine (Tables 1 and 2). Absolute contra- Lidocaine indications for local anesthetics include a docu- 2% plain 34 or 36 N/A mented local anesthetic allergy.23 True allergy to 34 µg or 0.034 mg or an amide is exceedingly rare. Allergy to one amide 2%+1:50,000 epinephrine 34 or 36 does not rule out the use of another amide, but 36 µg or 0.036 mg 17 µg or 0.017 mg or allergy to one ester rules out use of another ester.3 2%+1:100,000 epinephrine 34 or 36 18 µg or 0.018 mg A bisulfate preservative is used in local anesthetics Mepivacaine containing epinephrine. For patients having an al- 3% plain 51 or 54 N/A lergy to bisulfates, use of a local anesthetic without a vasoconstrictor is indicated.12 Local anesthetics 17 µg or 0.017 mg or 2%+1:100,000 epinephrine 34 or 36 18 µg or 0.018 mg without vasoconstrictors should be used with cau- tion due to rapid systemic absorption which may 85 µg or 0.085 mg or 2%+1:20,000 levonordefrin 34 or 36 90 µg or 0.090 mg result in overdose.12 A long-acting local anesthetic (ie, bupivacaine) Articaine is not recommended for the child or the physically 17 µg or 0.017 mg or 4%+1:100,000 epinephrine 68 or 72 or mentally disabled patient due to its prolonged 18 µg or 0.018 mg effect, which increases the risk of soft tissue in- Prilocaine jury.23 Claims have been made that articaine can 4% plain 68 or 72 N/A diffuse through hard and soft tissue from a buccal 8.5 µg or 0.0085 mg or infiltration to provide lingual or palatal soft tissue 4%+1:200,000 epinephrine 68 or 72 9 µg or 0.009 mg anesthesia.23 Studies using articaine, lidocaine, and Bupivacaine prilocaine, however, did not substantiate these 8.5 µg or 0.0085 mg or claims.23,24 0.5%+1:200,000 epinephrine 8.5 or 9 9 µg or 0.009 mg Epinephrine decreases bleeding in the area of in- jection. Epinephrine concentrations of 1:50,000 may be indicated for infiltration in small doses into a surgical site to achieve hemostasis but are not in- Needle gauges range from size 23 to 30. Needle breakage is a dicated in children to control pain.12 Local an- rare occurrence. The primary cause of needle breakage is esthetics 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.12 A vasopressor- needle is already inserted.22 containing local anesthetic should be used when treatment Recommendations: extends to 2 or more quadrants in a single visit.12 1. For the administration of local dental anesthesia, den- An end product of prilocaine metabolism can induce tists should select aspirating syringes that meet ADA formation of methemoglobin, reducing the blood’s oxygen- standards. carrying capacity. In patients with subclinical methemoglo- 2. Short needles may be used for any injection in which binemia25 or with toxic doses (>6 mg/kg), prilocaine can the thickness of soft tissue is less than 20 mm. A long induce methemoglobinemia symptoms26 (eg, gray or slate needle may be used for a deeper injection into soft blue cyanosis of the lips, mucous membranes, and nails; tissue.21 Any 23- through 30-gauge needle may be used respiratory and circulatory distress).6 Prilocaine may be con- for intraoral injections, since blood can be aspirated traindicated in patients with methemoglobinemia, sickle cell through all of them. Aspiration can be more difficult, anemia, anemia, or symptoms of hypoxia or in patients re- however, when smaller gauge needles are used. An 21 extra-short, 30-gauge is appropriate for infiltration ceiving acetaminophen or phenacetin, since both medica- injections.21 tions elevate methemoglobin levels. 23 3. Needles should not be bent if they are to be inserted Recommendations: into soft tissue to a depth of >5 mm or inserted to 1. Selection of local anesthetic agents should be based their hub for injections to avoid needle breakage.21 upon: a. the patient’s medical history and mental/develop- mental status; 158 CLINICAL GUIDELINES  American academy of pediatric dentistry b. the anticipated duration of the dental procedure; and shivering, followed by overt seizure activity. Unconscious- c. the need for hemorrhage control; ness and respiratory arrest may occur.3 d. the planned administration of other agents (eg, The cardiovascular system (CVS) response to local anes- nitrous oxide, sedative agents, general anesthesia); thetic toxicity also is biphasic. The CVS is more resistant to local e. the practitioner’s knowledge of the anesthetic agent. anesthetics than the CNS.28 Initially, during CVS stimulation, 2. Use of vasoconstrictors in local anesthetics is recom- heart rate and blood pressure may increase. As plasma levels of mended to decrease the risk of toxicity of the anesthetic the anesthetic increase, however, vasodilatation occurs followed agent, especially when treatment extends to 2 or by depression of the myocardium with subsequent fall in blood more quadrants in a single visit. pressure. Bradycardia and cardiac arrest may follow. The car- 3. In cases of bisulfate allergy, use of a local anesthetic diodepressant effects of local anesthetics are not seen until there without a vasoconstrictor is indicated. A local anes- is a significantly elevated local anesthetic blood level.12 thetic without a vasoconstrictor also can be used for Local anesthetic toxicity can be prevented by careful in- shorter treatment needs but should be used with cau- jection technique, watchful observation of the patient, and tion to minimize the risk of toxicity of the anesthetic knowledge of the maximum dosage based on weight. Practi- agents. tioners should aspirate before every injection and inject slowly.12 4. The established maximum dosage for any anesthetic After the injection, the doctor, hygienist, or assistant should should not be exceeded. remain with the patient while the anesthetic begins to take ef- fect. Early recognition of a toxic response is critical for effective Documentation of local anesthesia management. When signs or symptoms of toxicity are noted, The 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.27 Following each tinued. Additional emergency management is based on the appointment, an entry is made in the record that accurately severity of the reaction.3,12 and objectively summarizes that visit. Appropriate documen- tation includes specific information relative to the adminis- Allergy to local anesthesia tration of local anesthesia. Allergic reactions are not dose dependant but are due to the patient’s heightened capacity to react to even a small dose. Al- Recommendations: lergies can manifest in a variety of ways, some of which include 1. Documentation must include the type and dosage of urticaria, dermatitis, angioedema, fever, photosensitivity, or local anesthetic. Dosage of vasoconstrictors, if any, anaphylaxis.12 Emergency management is dependent on the must be noted. (For example, 34 mg lido with rate and severity of the reaction. 0.017 mg epi or 34 mg lido with 1:100,000 epi).2 2. Documentation may include the type of injection(s) Paresthesia given (eg, infiltration, block, intraosseous), needle se- Paresthesia is persistent anesthesia beyond the expected dura- lection, and patient’s reaction to the injection. tion. Trauma to the nerve can produce paresthesia and, among 3. If 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.29 The patient may experience an “electric shock” be noted on a time-based record. in the involved nerve distribution area. Paresthesia also can be 4. In patients for whom the maximum dosage of local caused by hemorrhage in or around the nerve.30 Risk of per- anesthetic may be a concern, the weight should be manent paresthesia is 1:1,200,000 for 0.5%, 2%, and 3% local documented preoperatively. anesthetics and 1:500,000 for 4% local anesthetics.29 Reports 5. Documentation 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. Paresthesia unre- lated to surgery most often involves the tongue, followed by Local anesthetic complications the lip, and is more common with 4% solutions of articaine Toxicity (overdose) or prilocaine.30 Most cases resolve in 8 weeks.31 Most adverse drug reactions develop either during the injec- tion or within 5 to 10 minutes.12 Overdose of local anesthetic Postoperative soft tissue injury can result from high blood levels caused by a single inadvertent Self-induced soft tissue trauma is an unfortunate clinical com- intravascular injection or repeated injections.3 Local anesthetic plication of local anesthetic use in the oral cavity. Most 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 (CNS). Early subjective indications without complications, although bleeding and infection pos- of toxicity involve the CNS and include dizziness, anxiety, and sibly may result. The use of bilateral mandibular blocks does confusion. This may be followed by diplopia, tinnitis, drowsi- not increase the risk of soft tissue trauma when compared to ness, and circumoral numbness or tingling. Objective signs may unilateral mandibular blocks or ipsilateral maxillary infiltra- include muscle twitching, tremors, talkativeness, slowed speech, tion.32 In fact, the frequency of soft tissue trauma was much CLINICAL GUIDELINES 159 reference manual v 32 / no 6 10 / 11 higher than expected when only 1 side was anesthetized. Using control of the administration rate, pressure, and location of mandibular infiltration vs blocks is not of great value in pre- anesthetic solutions and/or result in successful and more con- vention of these injuries, since the duration of soft tissue an- trolled anesthesia. Endocarditis prophylaxis is recommended for esthesia may not be reduced significantly. In addition, for intraligamentary local anesthetic injections in patients at risk.37 some procedures, infiltration is not as effective as the mandi- Intraseptal injection for lingual anesthesia is a variation in bular block.33 technique after the buccal tissue is anesthetized. The needle is Caregivers responsible for postoperative supervision should inserted through the buccal tissue to anesthetize the lingual/ be given a realistic time for duration of numbness and informed palatal soft tissues. It can be used with the PDL injection to of the possibility of soft tissue trauma. Visual examples may gain lingual anesthesia when postoperative soft tissue trauma is help stress the importance of observation during the period of a concern.38 During pulpal therapy, administering local anes- numbness. For all local anesthetics, the duration of soft tissue thetic directly into the pulp may be indicated when other anesthesia is greater than dentinal or osseous anesthesia. Use of methods fail to anesthetize the tooth.38 phentolamine mesylate injections in patients over age 6 years or As with traditional methods of obtaining oral local anes- at least 15 kg has been shown to reduce the duration of effects thesia, the alternative methods generally are safe if the practi- of local anesthetic by about 47% in the maxilla and 67% in the tioner understands the principles for their use. Some of these mandible.34,35 However, there is no research demonstrating a techniques are desirable, especially in infants, children, adoles- relationship between reduction in soft tissue trauma and the cents, and special health care needs patients, since specific teeth use of shorter acting local anesthetics.36 may be anesthetized with less residual anesthesia (ie, avoid dis- Recommendations to reduce local anesthetic complications: comfort and potential self-mutilation of block anesthesia).38 1. Practitioners who utilize any type of local anesthetic The mandibular bone of a child usually is less dense than that in a pediatric dental patient shall possess appropriate of an adult, permitting more rapid and complete diffusion of training and skills and have available the proper the anesthetic.9 Mandibular buccal infiltration anesthesia is as facilities, personnel, and equipment to manage any effective as inferior nerve block anesthesia for some operative reasonably foreseeable emergency. procedures.9,33 In patients with bleeding disorders, the PDL in- 2. Care should be taken to ensure proper needle place- jection minimizes the potential for postoperative bleeding of ment during the intraoral administration of local soft tissue vessels.6 Intraosseus techniques may be contraindi- anesthetics. Practitioners should aspirate before every cated with primary teeth due to potential for damage to devel- injection and inject slowly. oping permanent teeth.30 Also, the use of the PDL injection 3. After the injection, the doctor, hygienist, or assistant or intraosseus methods is contraindicated in the presence of should remain with the patient while the anesthetic inflammation or infection at the injection site.38 begins to take effect. Recommendation: 4. Residual soft tissue anesthesia should be minimized in Alternative techniques for the delivery of local anesthesia pediatric and special health care needs patients to de- may be considered to minimize the dose of anesthetic used, crease risk of self-inflicted postoperative injuries. improve patient comfort, and/or improve successful dental 5. Practitioners should advise patients and their care- anesthesia. givers regarding behavioral precautions (eg, do not bite or suck on lip/cheek, do not ingest hot substances) Local anesthesia with sedation, general anesthesia, and/or and the possibility of soft tissue trauma while anesthe- nitrous oxide/oxygen analgesia/anxiolysis sia persists. Placing a cotton roll in the mucobuccal Drugs that have the same mechanism of action often will have fold may help prevent injury, and lubricating the lips additive effects when used together. Local anesthetics and with petroleum jelly helps prevent drying.36 Practi- sedative agents both depress the CNS. An increase in toxic tioners who use pheytolamine mesylate injections to reactions of local anesthetics when combined with opioids has reduce the duration of local anesthesia still should been demonstrated.39 Narcotics may decrease the amount of follow these recommendations. protein binding of local anesthetics and also elevate arterial carbon dioxide, both of which will increase CNS sensitivity to Supplemental injections to obtain local anesthesia convulsions. In addition, narcotics such as meperidine have The majority of local anesthesia procedures in pediatric dentistry convulsant properties when excessive doses are administered. involve traditional methods of infiltration or nerve block tech- It has been suggested that the dose of local anesthesia be ad- niques with a dental syringe, disposable cartridges, and needles justed downward when sedating children with opioids.39 as described so far. Several alternative techniques, however, are Using local anesthesia has been found to reduce the dos- available. These include computer-controlled local anesthetic age of inhalation anesthetics for patients undergoing general delivery, periodontal injection techniques (ie, periodontal liga- anesthesia.40 The anesthesia care provider needs to be aware of ment [PDL], intraligamentary, and peridental injection), the concomitant use of a local anesthetic containing epineph- “needleless” systems, and intraseptal or intrapulpal injection. rine, as epinephrine can produce dysrhythmias when used with These techniques may improve comfort of injection by better halogenated hydrocarbons (eg, halothane).41 Local anesthesia 160 CLINICAL GUIDELINES  American academy of pediatric dentistry also has been reported to reduce pain in the postoperative 11. Rosivack RG, Koenigsberg SR, Maxwell KC. An analysis recovery period after general anesthesia.42 of the effectiveness of two topical anesthetics. Anesth Recommendations: Prog 1990;37(6):290-2. 1. Particular attention should be paid to local anesthetic 12. Malamed SF. Systemic complications. In: Handbook of doses used in children. To avoid excessive doses for the Local Anesthesia. 5 th ed. St. Louis, Mo: Mosby; 2004: patient who is going to be sedated, a maximum re- 311-25. commended dose based upon weight should be cal- 13. Malamed SF. Additional armamentarium. In: Handbook culated. of Local Anesthesia. 5th ed. St. Louis, Mo: Mosby; 2. The dosage of local anesthetic should not be altered 2004:120. if nitrous oxide/oxygen analgesia/anxiolysis is admi- 14. Graham JW. Profound, needle-free anesthesia in ortho- nistered. dontics. Clin Ortho 2006;40(12):723-4. 3. When general anesthesia is employed, local anesthesia 15. Kravitz ND. The use of compound topical anesthetics: A may be used to reduce the maintenance dosage of the review. J Am Dent Assoc 2007;138(10)1333-9. anesthetic drugs. The anesthesiologist should be in- 16. Kravits ND, Kusnoto B, Tsay TP, Hohlt WF. The use of formed of the type and dosage of the local anesthetic temporary anchorage devices for molar intrusion. J Am used. Recovery room personnel also should be in- Dent Assoc 2007;138(1):56-64. formed. 17. US Food and Drug Administration. FDA public health advisory: Life-threatening side effect with the use of skin References products containing numbing ingredients for cosmetic 1. Nathan JE, Venham LL, West MS, Werboff J. The ef- procedures. Available at: “http://www.fda.gov/cder/drug/ fects of nitrous oxide on anxious young pediatric patients advisory/topical_anesthetics.htm”. Accessed November across sequential visits: A double-blind study. ASDC J 15, 2008. Dent Child 1988;55(3):220-30. 18. US Dept for Health and Human Services, Food and Drug 2. Malamed SF. Basic injection technique in local anesthesia. Administration, Center for Drug Evaluation and Research. In: Handbook of Local Anesthesia. 5th ed. St. Louis, Mo: Guidance for FDA staff and industry: Marketed unap- Mosby; 2004:159-69. proved drugs–Compliance policy guide. Sec 440.100 3. Haas DA. An update on local anesthetics in dentistry. J Marketed new drugs without approved NDAs or ANDAs. Can Dent Assoc 2002;68(9):546-51. Available at “http://www.fda.gov/cder/guidance/6911fnl. 4. Malamed SF. Pharmacology of vasoconstrictors. In: pdf ”. Accessed November 15, 2008. Handbook of Local Anesthesia. 5 th ed. St. Louis, Mo: 19. American Dental Association Council on Dental Materi- Mosby; 2004:41-54. als and Devices. New American National Standards Insti- 5. Pérusse R, Goulet JP, Turcotte JY. Contraindications to tute/American Dental Association specification no. 34 for vasoconstrictors in dentistry: Part II. Hyperthyroidism, dental aspirating syringes. J Am Dent Assoc 1978;97(2): diabetes, sulfite sensitivity, cortico-dependant asthma, and 236-8. pheochromocytoma. Oral Surg Oral Med Oral Pathol 20. American Dental Association Council on Dental Materi- 1992;74(5):687-91. als, Instruments, and Equipment. Addendum to American 6. Malamed SF. Physical and psychological evaluation. In: National Standards Institute/American Dental Association Handbook of Local Anesthesia. 5 th ed. St. Louis, Mo: specification no. 34 for dental aspirating syringes. J Am Mosby; 2004:141-56. Dent Assoc 1982;104(1):69-70. 7. Goulet JP, Perusse R, Turcotte JY. Contraindications to 21. Malamed SF. The needle. In: Handbook of Local Anes- vasoconstrictors in dentistry: Part III. Pharmacologic in- thesia. 5th ed. St. Louis, Mo: Mosby; 2004:99-107. teractions. Oral Surg Oral Med Oral Pathol 1992;74(5): 22. Malamed SF. Local complications. In: Handbook of 692-7. Local Anesthesia. 5 th ed. St. Louis, Mo: Mosby; 2004: 8. Gielen M, Viering W. 3-in-1 lumbar plexus block for 285-7. muscle biopsy in malignant hyperthermia patients: Amide 23. Malamed SF. Clinical action of specific agents. In: Hand- local anesthetics may be used safely. Acta Anaesthesiol book of Local Anesthesia. 5th ed. St Louis, Mo: Mosby; Scand 1986;30(7):581-3. 2004:55-81. 9. Malamed SF. Local anesthetic considerations in dental 24. Haas DA, Harper DG, Saso MA, Young ER. Lack of specialties. In: Handbook of Local Anesthesia. 5th ed. St. differential effect by Ultracaine (articaine) and Citanest Louis, Mo: Mosby; 2004:269, 274-5. (prilocaine) in infiltration anaesthesia. J Can Dent Assoc 10. Jeske AH, Blanton PL. Misconceptions involving dental 1991;57(3):217-23. local anesthesia. Part 2: Pharmacology. Tex Dent J 2002; 25. Bellamy MC, Hopkins PM, Hallsall PJ, Ellis FR. A study 119(4):310-4. into the incidence of methaemoglobinaemia after “three- in-one” block with procaine. Anaesthesia 1992;47(12): 1084-5. CLINICAL GUIDELINES 161 reference manual v 32 / no 6 10 / 11 26. Hardwick FK, Beaudreau RW. Methemoglobinemia in 36. Malamed SF. Anatomical considerations. In: Handbook renal transplant patient: Case report. Pediatr Dent 1995; of Local Anesthesia. 5th ed. St. Louis, Mo: Mosby; 2004; 17(7):460-3. 173-4 27. American Academy of Pediatric Dentistry. Guideline on 37. Wilson W, Taubert KA, Gevitz P, et al. Prevention of record-keeping. Pediatr Dent 2008;30(suppl):226-33. infective endocarditis: Guidelines from the American 28. Scott DB. Toxicity caused by local anesthetic drugs. Br J Heart Association. Circulation e-published April 19, Anaesth 1981;53(6):553-4. 2007. Available at: “http://circ.ahajournals.org/cgi/ 29. Haas DA. Local complications. In: Malamed SF, ed. reprint/CIRCULATIONAHA.106.183095)”. Accessed Handbook of Local Anesthesia. 5th ed. St Louis, Mo: March 30, 2008. Correction Circulation. 2007;116: Mosby; 2004:288-9. e376-e377. Available at: “htttp://circ.ahajournals.org/cgi/ 30. Haas DA, Lennon D. A 21-year retrospective study of content/full/116/15/1736”. Accessed May 23, 2008. reports of paresthesia following local anesthetic admin- 38. Malamed SF. Supplemental injection techniques. In: istration. J Can Dent Assoc 1995;61(4):319-20, 323-6, Handbook of Local Anesthesia. 5th ed. St Louis, Mo: 329-30. Mosby; 2004:256-68. 31. Nickel AA. A retrospective study of reports of paresthesia 39. Moore PA. Adverse drug reactions in dental practice: In- following local anesthetic administration. Anesth Prog teractions associated with local anesthetics, sedatives, and 1990;37(1):42-5. anxiolytics. J Am Dent Assoc 1999;130(4):541-4. 32. College C, Feigal R, Wandera A, Strange M. Bilateral 40. Barash PG, Cullen BF, Stoelting RK. Clinical Anesthesia. vs unilateral mandibular block anesthesia in a pediatric 2nd ed. Philadelphia, Pa: JB Lippincott Co; 1992:531. population. Pediatr Dent 2000;22(6):453-7. 41. Dionne RA, Phero JC, Becker DE. Management of Pain 33. Oulis C, Vadiakas G, Vasilopoulou A, The effectiveness and Anxiety in the Dental Office. Philadelphia, Pa: WB of mandibular infiltration compared to mandibular block Saunders; 2002:274-5. anesthesia in treating primary molars in children. Pediatr 42. Nick D, Thompson L, Anderson D, Trapp L. The use of Dent 1996;18(4):301-5. general anesthesia to facilitate dental treatment. Gen Dent 34. Tavares M, Goodson MJ, Studen-Pavlovich D, et al. 2003;51(5):464-8. Reversal of soft-tissue local anesthesia with phentolamine mesylate in pediatric patients. J Am Dent Assoc 2008; 139(8):1095-104. 35. Hersh EV, Moore PA, Papas AS, et al. Reversal of soft- tissue local anesthesia with phentolamine mesylate in adolescents and adults. J Am Dent Assoc 2008;139(8): 1080-93. 162 CLINICAL GUIDELINES