LOCAL ANESHESIA IN AND PAIN CONTROL .2.pdf

LOCAL ANESHESIA IN AND PAIN CONTROL IN PEDIATRIC DENTISTRY.2 Presented by :dr mohira ezzeldin  Anesthesia of Mandibular Teeth and Soft Tissue Anatomy  Anesthesia of Mandibular Teeth and Soft Tissue: 1) Inferior Alveolar Nerve Block + Lingual Nerve Block: The sup...

LOCAL ANESHESIA IN AND PAIN CONTROL IN PEDIATRIC DENTISTRY.2 Presented by :dr mohira ezzeldin  Anesthesia of Mandibular Teeth and Soft Tissue Anatomy  Anesthesia of Mandibular Teeth and Soft Tissue: 1) Inferior Alveolar Nerve Block + Lingual Nerve Block: The supraperiosteal injection technique may sometimes be useful in anesthetizing primary incisors, but it is not as reliable for complete anesthesia of the mandibular primary or permanent molars.  Indication: 1.deep operative or surgical procedures for the mandibular primary or permanent teeth.. 2. Used for more than 1 tooth filling, extraction, pulp therapy and if can’t apply mental block due to infection.  The mandibular foramen is situated at a level lower than the occlusal plane of the primary teeth of the pediatric patient. –  The injection must be made slightly lower and more posteriorly than for an adult patient.  Landmarks  1. Coronoid notch  2. Pterygomandibular raphe  3. Occlusal plane of the mandibular posterior teeth.  Firm support during the injection procedure can be given when the ball of the middle finger is resting on the posterior border of the mandible.  The barrel of the syringe should be directed on a plane between the two primary molars on the opposite side of the arch.  It is advisable to inject a small amount of the solution as soon as the tissue is penetrated and to continue to inject minute quantities as the needle is directed toward the mandibular foramen.  Approximately 1 ml of the solution should be deposited around the inferior alveolar nerve  Area anesthetized  Mandibular teeth of the injected side.  Body of the mandible, inferior portion of the ramus.  Buccal mucoperiosteum, mucous membrane anterior to the mandibular 1st permanent molar.  Anterior 2/3rd of tongue and floor of the mouth.  Lingual soft tissue and periosteum.  2) Mental Nerve Block ( Lower E & D filling) 3.INFILTRATION ANESTHESIA FOR MANDIBULAR PRIMARY MOLARS  Indication:  for most restorative procedures  This can be done by injecting local anesthetic solution in the mucobuccal fold between the roots of primary mandibular molars. 4) Long Buccal Nerve Block Site of injection: Mucous membrane distal and buccal to the most distal molar tooth in the arch. Area Anesthetized: Soft tissue and periosteum buccal to the mandibular permanent molar teeth. 5) Infiltration For Mandibular Incisors:  The terminal ends of the inferior alveolar nerves cross over the mandibular midline slightly and provide conjoined innervation of the mandibular incisors. The labial bone overlying the mandibular incisors is usually thin enough for supraperiosteal anesthesia techniques to be effective INFILTRATION FOR MANDIBULAR INCISORS  The terminal ends of the inferior alveolar nerves cross over the mandibular midline slightly and provide conjoined innervation of the mandibular incisors.  Therefore a single inferior alveolar nerve block may not be adequate for operative or surgical procedures on the incisors, even on the side of the block anesthesia.  The labial cortical bone overlying the mandibular incisors is usually thin enough for supraperiosteal anesthesia techniques to be effective.  If only superficial caries excavation of mandibular incisors is needed or if the removal of a partially exfoliated primary incisor is planned, infiltration anesthesia alone may be adequate.  Incisor infiltration is most useful as an adjunct to an inferior alveolar nerve block when total anesthesia of the quadrant is desired.  In this case the infiltration injection is made close to the mid-line on the side of the block anesthesia, but the solution is deposited labial to the incisors on the opposite side of the midline. MANDIBULAR CONDUCTION ANESTHESIA (GOWGATES MANDIBULAR BLOCK TECHNIQUE  Introduced in 1973  This approach uses external anatomic landmarks to align the needle so that anesthetic solution is deposited at the base of the neck of the mandibular condyle.  This technique is a nerve block procedure that anesthetizes virtually the entire distribution of the fifth cranial nerve in the mandibular area, including the inferior alveolar, lingual, buccal, mental, incisive, auriculotemporal, and mylohyoid nerves. Thus with a single injection the entire right or left half of the mandibular teeth and soft tissues can be anesthetized, except possibly the mandibular incisors, which may receive partial innervation from the incisive nerves of the opposite side  The external landmarks are :  The tragus of the ear.  The corner of the mouth.  The needle is inserted just medial to the tendon of the temporal muscle and considerably superior to the insertion point for conventional mandibular block anesthesia.  The needle is also inclined upward and parallel to a line from the corner of the patient's mouth to the lower border of the tragus (intertragic notch).  The needle and the barrel of the syringe should be directed toward the injection site from the corner of the mouth on the opposite side SUPPLEMENTAL INJECTION TECHNIQUES 1) Periodontal Ligament Injection The periodontal ligament injection has been used for many years as an adjunctive method of obtaining more complete anesthesia when supraperiosteal or block techniques failed to provide adequate anesthesia.  Technique:  Simple.  Requires small quantities of anesthetic solution.  Produces anesthesia almost instantly.  The needle is placed in the gingival sulcus, usually on the mesial surface, and advanced along the root surface until resistance is met.  Then approximately 0.2 ml of anesthetic is deposited into the periodontal ligament.  For multirooted teeth, injections are made both mesially and distally. Considerable pressure is necessary to express the anesthetic solution. There are two types of syringes designed specifically for intraligamentary injections.  Gunlike  Penlike. They both have the additional disadvantage of being quite expensive compared to a good, conventional aspirating syringes. The penlike syringe would be preferred in pediatric dentistry, but unfortunately it is even more expensive than the gunlike instrument. Advantages of Periodontal Ligament Anesthesia: 1. It provides reliable pain control rapidly and easily. 2. It provides pulpal anesthesia for 30 to 45 minutes. 3. It is no more uncomfortable than other local anesthesia techniques. 4. It is completely painless if used adjunctively. 5. It requires very small quantities of anesthetic solution. 6. It does not require aspiration before injection. 7. It may be performed without removal of the rubber dam. 8. It may be useful in patients with bleeding disorders that contraindicate use of other injections. 9. It may be useful in young or disabled patients in whom the possibility of postoperative trauma to the lips or tongue is a concern.  Possible psychological disadvantages to use of the periodontal ligament injection technique, The technique provides the patient with an opportunity to see the syringe and to watch the administration of the anesthetic. The vary design of the syringe (which resembles a handgun) probably has some adverse psychological effects 2) Intrapulpal Injection  Indication:  Obtain profound pulpal anesthesia during pulp therapy when other local anesthesia attempts have failed.  Advantages:  Requires minimum volumes of LA solution  Immediate onset of action  Very few post operative complications  Disadvantage:  painful initially, although the onset of anesthesia is usually rapid. 3)Intraosseous Injection: Deposition of local anesthetic solution in the porous alveolar bone. By forcing a needle through the cortical plate and into the cancellous alveolar bone or a small, round bur may be used to make an access in the bone for the needle.  Indication:  Primary anesthesia.  Adjunctive anesthesia when other local injections have failed to produce adequate anesthesia..  This procedure is not difficult in children because they have less dense cortical bone than adults.  ' They do not seem to offer any advantages over the periodontal ligament injection except when use of the latter is contraindicated by infection in the periodontal ligament space. Alternative techniques for delivery of local anesthesia:  computer-controlled local anesthetic delivery: (CCLAD) is one the method to reduce patient pain during local anesthesia; it is a device that slowly administers anesthetics by using a computerized device to control the injection speed Complications OF LA: 1) Systemic Complications  Toxicity.  Allergic Reaction.  Syncope.  Vasoconstrictors effects. 2) Local Complications:  Soft tissue injury.  Broken needle.  Hematoma.  Trauma of the nerve causing Paresthesia.  Sloughing.  Trismus. . Allergic Reaction: Uncommon. Manifestations: edema, eczema or ertecharia. Potassium metabisulfate is used as a preservative in local anesthetics containing epinephrine. For patients having an allergy to bisulfates, use of a local anesthetic without a vasoconstrictor is indicated. Syncope:  Most common cause : Vasovagal attach  Signs and Symptoms: Child become pale and cold. Pulse is rapid. The pupils are dilated or constricted. Drop of blood pressure. TRAUMA TO SOFT TISSUE  Self-inflicted trauma may occur after local anaesthetic injections in children.  It may follow regional techniques in the mandible and infiltration anaesthesia in the maxilla.  The most common site is the lower lip but the tongue and upper lip can also be affected.  Parents of children who receive regional local anesthesia in the dental office should be warned that the soft tissue in the area will be without sensation for a period of 1 hour or more.  These children should be observed carefully so that they will not purposely or inadvertently bite the tissue..  The use of periodontal ligament techniques may reduce the frequency of this complication. However, it must be stressed that soft tissue anaesthesia is not completely avoided with this method in all cases.  HOW TO MANAGE LIP TRAUMA? History Taking  Take a complete medical and dental history  Ask about recent dental visits (within the past 3–5 days), particularly those that involved dental local anesthesia  Ask if lower or upper teeth were anesthetized Clinical Assessment  Determine if the traumatic lip ulcer is located on the same side of the mouth that was anesthetized  Check if the lip ulcer crosses the midline of the lip.  Traumatic lip ulcers can present unilaterally or bilaterally, depending on whether the child received a unilateral or bilateral mandibular nerve block and how the child bit his or her lip  Examine the patient to identify the presence of additional intraoral ulcers.  Traumatic lip ulcers can be accompanied by buccal mucosal (cheek) or tongue ulcers on the same side of mouth  Look for the five signs of infection: redness, pain, fever, swelling or edema, and generalized malaise.  Redness and localized edema are common findings in traumatic lip ulcers. If the other signs are also present, the lip may be secondarily infected  Localized edema should not be confused with a purulent infection Intervention  If a diagnosis of lip biting secondary to dental local anesthesia is made:  Treat the ulcer palliatively with over-the-counter analgesics  Prescribe chlorhexidine gluconate (0.12%) that is used daily to gently debride the ulcerated tissue.  No systemic antibiotics are indicated unless the lip becomes secondarily infected.  No surgical intervention (e.g., incision and drainage) is indicated. OraVerse  Is an alpha adrenergic blocker injection that reverses the effects of local anesthetic resulting in numbness in the lips and tongue after a dental procedure, and accelerates the return of normal function.  Indicated for adult and pediatric patients ages 3 years and older for the reversal of soft-tissue anesthesia.  OraVerse is administered using the same locations(s) and same technique(s) (infiltration or block injection) used for the administration of local anesthetic.  The most common adverse reaction with OraVerse (incidence ≥5% and > control) is injection-site pain.