LOCAL ANESHESIA IN AND PAIN CONTROL .1.pdf

LOCAL ANESHESIA IN AND PAIN CONTROL IN PEDIATRIC DENTISTRY 1 Presented by dr: mohira ezzeldin  One of the most important and challenging aspects of child behavior management is the control of pain.  Children who undergo early painful experiences during dental procedures a...

LOCAL ANESHESIA IN AND PAIN CONTROL IN PEDIATRIC DENTISTRY 1 Presented by dr: mohira ezzeldin  One of the most important and challenging aspects of child behavior management is the control of pain.  Children who undergo early painful experiences during dental procedures are likely to carry negative feelings toward dentistry into adulthood.  It is important that clinicians make every effort to minimize pain and discomfort during dental treatment Local Anesthesia( LA):  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.  Local anesthetics act within the neural fibers to inhibit the rapid ionic influx of sodium necessary for neuron impulse generation  This helps to prevent transmission of pain sensation during procedures, which can serve to build trust and foster the relationship of the patient and dentist, allay fear and anxiety, and promote a positive dental attitude.  The technique of local anesthetic administration is an important consideration in pediatric patient behavior guidance.  Local Anesthesia:  Content of L.A. Solution:  1. Local anesthetic agent.  2. Vasoconstrictors.  3. Reducing agents.  4. Preservatives.  5. Fungicide.  6. Vehicle.  Local anesthetic agent  (xylocaine, lignocaine 2% (20 mg/ml))  Vasoconstrictor  (adrenaline 1: 80,000 (0.012 mg) or Epinephrine)  Reducing Agent  Sodium metabisulphite 0.5 mg..  Preservative Methylparaben 0.1% (1mg). It increases the shelf life of the anesthetic solution. Acts as a bacteriostatic agent. Fungicide Thymol. Vehicle Modified Ringer’s solution / Distilled Water to give volume. There are two general types of local anesthetic chemical formulations:  (1) Esters (e.g., procaine, benzocaine, tetracaine);  (2) Amides (e.g., lidocaine, mepivacaine, prilocaine, articaine).1 Metabolism of LA:  Ester Group: They are hydrolyzed in the plasma by the enzymes pseudocholinesterase.  Amide Group: Primary site of biotransformation is in liver. Excretion: from kidney Successful local anesthesia is depend on:  Communication with the child  Good topical anesthesia ,allow adequate time for it to act  Slow injection of warm solution Topical anesthesia  Topical anesthetics reduce the slight discomfort that may be associated with the insertion of the needle before the injection of the local anesthetic.  The active agent is present in greater concentration in topical preparations than in local anesthetic solutions and uptake from the mucosa is rapid.  Variety of anesthetic agents have been used in topical anesthetic preparations, including:  Ethyl aminobenzoate.  Butacaine sulfate.  Cocaine.  Dyclonine.  Lidocaine.  Tetracaine.  The agents most commonly employed are lidocaine (lignocaine) and benzocaine..  Ethyl aminobenzoate (benzocaine) liquid, ointment, or gel preparations are probably best suited for topical anesthesia in dentistry.  They offer a more rapid onset and longer duration of anesthesia than other topical agents. Topical anesthetics are available in:  gel.  Liquid.  Ointment.  pressurized spray forms. Sprays are the least convenient as they are:  Difficult to direct.  Taste unpleasant.  Can lead to excess salivation if they inadvertently reach the tongue.  The quantity of anesthetic used is poorly controlled.( It is important to limit the amount of topical anesthetic used). The success of topical anaesthesia depends on the technique. Topical anesthetic agents can anaesthetize a 2–3mm depth of surface tissue when used properly. The following points should be noted when using intra-oral topical anesthetics: The area of application should be dried; The anesthetic should be applied over a limited area; The anesthetic should be applied for sufficient time.(1 to 2 minutes) Although the main use of topical anesthetics is as a pre-injection treatment, these agents have been used as the sole means of anaesthesia for some intra-oral procedures in children including the extraction of mobile primary teeth. During the application of the topical anesthetic, the dentist should prepare the child for the injection. The explanation should not necessarily be a detailed description but simply an indication that the tooth is going to be put to sleep so that the treatment can proceed without discomfort. Jet injectors  Jet injectors belong in a category somewhere between topical anaesthesia and LA.  These devices allow anaesthesia of the surface to a depth of over 1cm without the use of a needle.  They deliver a jet of solution through the tissue under high pressure. The jet injection instrument is based on the principle that small quantities of liquids forced through very small openings under high pressure can penetrate mucous membrane or skin without causing excessive tissue trauma. One jet injection device, the Syrijet Mark II holds a standard 1.8-ml cartridge of local anesthetic solution. It can be adjusted to expel 0.05 to 0.2 ml of solution under 2000 psi pressure Get injection used in:  children with bleeding diatheses.  Jet injection has been used both as the sole means of achieving LA and prior to conventional techniques  This method of anaesthesia has been used alone and in combination with sedation to allow the pain-free extraction of primary teeth  Disadvantage of get injector  Expensive equipment is required.  Soft tissue damage can be produced if a careless technique is employed.  The specialized syringes can be frightening to children because of both their Appearance and the sound produced during anaesthetic delivery.  The unpleasant taste of the anaesthetic solution, which can accompany the use of this technique. although no needle is employed, the technique is not painless.  Local Anesthesia Armamentarium  1.) The Syringe  2.) The Needle  3.) The Cartridge  4.) Other Armamentarium - Topical Anesthetic (strongly recommended) - ointments, gels, pastes, sprays - Applicator sticks - Cotton gauze 64  Syringe Components  1.) Needle adapter  2.) Piston with harpoon  3.) Syringe barrel  4.) Finger grip  5.) Thumb ring 6  Needles:  A short (20mm)or long (32mm)27 or 30 gauge needle may be used for most intra oral injection in children.  An extrashort (10mm)30 gauge needle has been suggested for maxillary anterior injection. long needle are frequently suggested for inferior dental block anesthesia.  For most injections the bevel of the needle is oriented toward bone.  Local anesthesia (LA) . Maximum Recommended Doses: 4.4 mg/kg body weight  Dose Calculation:  2% lidocaine = 20 mg/ ml  1 carpule = 1.8ml  Amount of LA in 1 carpule = 20X 1.8 = 36mg/carpule.  Example: 20 Kg child can tolerate a maximum dose of 2% lidocaine with vasoconstrictor of LA ---------- 4.4 X 20= 88 mg = 2.4carpules.  It is important to note if a local anesthetic is injected into an area of infection, its onset will be delayed or even prevented  As local anesthetics and sedative agents both depress the CNS it is recommended that the dose of local anesthesia be adjusted downward when sedating children.  The dosage of local anesthetic does not need to be altered if nitrous oxide/oxygen analgesia/anxiolysis is administered alone.  For patients undergoing general anesthesia, the anesthesia care provider must be made aware of concomitant use of a local anesthetic containing epinephrine as epinephrine can produce dysrhythmias when used with halogenated hydrocarbons (e.g., halothane). Types of Injection Procedures : 1.Nerve block: depositing the LA solution within close proximity to a main nerve trunk. 2.Field block: depositing a in proximity to the larger nerve branches. 3.Local infiltration: small terminal nerve endings are anaesthetized.  TECHNIQUES  Patient Position :  Sitting upright can increase the chance of fainting, whilst at the other extreme(fully supine) the child may feel ill at ease. The upper body should be around 30° to the vertical. Techniques of local anaesthesia  There are no techniques of local anaesthetic administration that are unique to children; however, modifications to standard methods are sometimes required. Infiltration anaesthesia maxillary buccal infiltrations  Infiltration anaesthesia is the method of choice in the maxilla.  The infiltration of 0.5–1.0mL of local anaesthetic is sufficient for pulpal anaesthesia of most teeth in children.  The objective is to deposit LA solution as close as possible to the apex of tooth of interest ( supra-periostelly).  Landmark: insertion 45 to Long access of the tooth Areas Anesthetized  1. Pulp and root area of the tooth.  2. Buccal periosteum.  3. Connective tissue(buccally).  4. Mucous membrane(buccally).. Techniques  Assuming that the proper materials and equipment have been chosen, the following technique can be used to reduce the discomfort of buccal infiltration injections in the maxilla posterior to the canine. 1. Dry the mucosa and apply a topical anaesthetic for 1 to 2 minutes. 2. Wipe off excess topical anaesthetic. 3. Stretch the mucosa. 4. Distract the patient (stretching the mucosa and gentle pressure on the lip between finger and thumb can achieve this). 5. Insert the needle—if bone is contacted, withdraw slightly. 6. Aspirate; if positive, reposition the needle without withdrawing from the mucosa and when negative proceed. 7. Inject 0.5–1.0 mL supra-periosteally very slowly (15–30 seconds or via a computerized system).  If the rubber dam clamp impinges on the palatal tissue, injection of a drop or two of the anesthetic solution into the free marginal tissue lingual to the clamped tooth alleviates the discomfort Palatal anaesthesia  Anesthesia of the palatal tissues can be one of the more exquisitely painful procedures performed in dentistry.  INDICATION:  palatal anesthesia for a single anterior tooth removal.  Techniques  deposit anesthetic solution in the attached palatal gingiva adjacent to the tooth to be removed.  NASOPALATINE NERVE BLOCK  Will anesthetize the palatal tissues of the six anterior teeth.  Painful technique.(deposition of the anesthetic solution in advance of the needle)  The path of insertion of the needle is alongside the incisive papilla, just posterior to the central incisors. The needle is directed upward into the incisive canal.  In case of canine, inject a small amount of anesthetic adjacent to the lingual aspect of the canine to anesthetize overlapping branches of the greater palatine nerve.  If it is observed that the patient does not have profound anesthesia of anterior teeth during the operative procedures with the supra-periosteal technique, a nasopalatine injection is advisable  To reduce the discomfort of palatal injections approach the palatal mucosa via already anaesthetized buccal interdental papillae.  This is most readily achieved using an ultra-short (12mm) 30-gauge needle.  The needle inserted into the base of the interdental papilla at an angle of approximately 90° to the surface.  The needle is advanced palatally while injecting local anesthetic into the papilla. This is performed through both distal and mesial papillae.  Blanching should be seen around the palatal gingival margin.It can be supplemented by a painless gingival sulcus injection on the palatal side. GREATER (ANTERIOR) PALATINE INJECTION  Indication:  Maxillary primary molars or premolars extraction.  Palatal tissue surgery.  Technique:  Bisect an imaginary line drawn from the gingival border of the primary molar to the midline.approaching from the opposite side of the mouth(90 degree angle).