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Contraindications (Hersh etal.2016b; US Food and
Drug Asministration2019)
● General contraindications:
○ Allergy to any of the components of the solution –
ester local anesthetics, (tetracaine, benzocaine, procaine and para-
aminobenzoic acid), oxymetazoline,
and benzyl alcohol– is an absolute contraindication.
○ Children who weigh less than 40 kg (generally chil-
dren aged under 12
○ Epistaxis. Intranasal maxillary local anesthesia is not
years).
advised in patients with five or more nose bleeds
per month.
● Contraindications for oxymetazoline. It is important to
remember that the drug has a long half-
life (2 hours)
(Giannakopoulos etal.2012):
○ Uncontrolled hypertension. There is potential for a
hypertensive event due to the vasoconstrictive effects
of oxymetazoline. Nevertheless, the provider is advised
to monitor blood pressure.
○ Uncontrolled or active thyroid disease (Ciancio
etal.2013).
○ Interactions with the following medications may lead
to a hypertensive reaction (Chapter10):
■ Nonselective beta- adrenergic blocking agents
(Table10.4, Chapter10).
■ Tricyclic antidepressants (Table10.5, Chapter10).
■ Monoamine oxidase inhibitor antidepressants
(Table10.5, Chapter10).
○ Administration of other intranasal medications and/
or products containing oxymetazoline in the previous
24
hours.
● Contraindications for tetracaine:
○ History of congenital or idiopathic methemoglobine-
mia because although the literature suggests a lower
association with tetracaine, the risk still exists
(Levergne etal.2006; Guay2009).
Spray tip
Air bubble
Figure20.13 Parts of the prefilled sprayer. Redrawn,
with modifications, from Kovanaze
Barrel
Glass lid
®
instructions for use.
Finger
grip
Plunger
disinfectant, or used if dropped on the ground. It should
not be placed in a cartridge warmer (Highlights2016).
Preparation
● Remove two or three prefilled sprayers from the packet
using the finger grip. We remove two or three because this
is the quantity to be used during the session (see below).
● Check the expiration date (on both the carton and the
sprayer label). Check that the solution is clear and colorless. Note: The presence of a bubble is normal and does
not interfere with the product or dosing. Do not expel the
air bubble prior to dosing patient (Figure20.13).
● Install the finger grip. Snap the finger grip onto the top of
the sprayer barrel next to the glass lip (Figure20.14a,b).
● Remove the gray cap from the prefilled sprayer
(Figure20.14c). The device is now ready for use.
Technique
The technique for using Kovanaze® follows a wellestablished protocol for administration, which we describe
below (Ciancio et al. 2013, 2016; Hersh et al. 2016b;
Highlights2016):
Equipment
Kovanaze® comes in a prepackaged spray device (similar
to a syringe without the needle), known as a prefilled
sprayer or nasal spray (Figure20.13). The device consists
of 3% tetracaine hydrochloride (30 mg/ml) and 0.05%
oxymetazoline chloride (0.5 mg/ml) delivered as a single
0.2- ml dose. In other words, each intranasal spray contains 6 mg of tetracaine hydrochloride and 0.1 mg of oxymetazoline hydrochloride. Each sprayer is intended for a
single use and is not to be refilled (Hersh et al.2016a,b;
Saraghi and Hersh2017).
The sprayers should be stored in the refrigerator at
36–46 °F (2–8 °C) and in a dark place if possible. Devices
that have been at room temperature for 5 days should not
be used. The device should not be autoclaved, wiped with
● Patient position:
○ The patient must be sitting upright for administration
of Kovanaze®.
○ The patient’s nose should be perfectly clear and free
of mucus.
● Application of the first prefilled sprayer. The objective of
this stage is for the solution to reach the inferior meatus.
○ Positioning the prefilled sprayer. Place the white tip
inside the nostril on the same side as the planned dental procedure (ipsilateral):
■ As parallel as possible to the nasal floor, along the hor-
izontal plane (ala- tragus) at an angle of approximately
90° with respect to the line that joins thenasion and
the subnasale (vertical plane) (Figure20.15a).
■ Parallel toward the septum (midline) of the nasal
cavity (Figure20.15b).
t.me/Dr_Mouayyad_AlbtousH
Cap Finger grip
(a)
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(b)
Remove the cap Spray tip
(c)
Figure20.14 The finger grips and the prefilled sprayer are
separate (a). Snap the finger grip onto the top of the sprayer
barrel next to the glass lip (b) and remove the gray cap from the
prefilled sprayer (c). Redrawn, with modifications, from
Kovanaze
®
instructions for use.
○ Kovanaze® must be sprayed rapidly, therefore push
hard and fast on the plunger rod (expel the spray in
0.5
second or less) to create a mist or a plume that can
reach and anesthetize the nerves, and wait 4–5 minutes.
Install finger grip
● If patient reports discomfort, administer a third nasal
spray, at the same angle as the second spray (45°) (total
18
mg of tetracaine and 0.3 mg of oxymetazoline), and
wait an additional 10
minutes (total 18–20 minutes).
Note: The third spray is contraindicated in children and
adolescents (12–18 years) (total of only 12 mg of tetracaine
and 0.2
contraindicated in children weighing less than 40
erally children aged under 12
mg of oxymetazoline). At present, Kovanaze® is
kg (gen-
years).
● If the third nasal spray has failed (or the second in chil-
dren and adolescents), we can then use a rescue strategy
based on standard local anesthesia administered via buc-
cal infiltration.
Efficacy ofthe Technique
Clinical success has been evaluated in dental restorative
procedures (drilling and filling), where the drill is operated
at high speed to penetrate dentin. Table20.9 shows the success rate to be 85%, although this tends to be greater in incisors and canines (95–100%) than in premolars (60–75%)
(Ciancio etal.2016; Hersh etal.2016b). However, rigorous
assessment with an electric pulp tester shows that pulpal
anesthesia is achieved in 30%. This is also higher in the incisors and premolars (Capetillo etal.2019). The success of
the technique is low in comparison with buccal infiltration
with the standard solution of lidocaine 2% with epinephrine 1:100 000, which has success rates of 90–95% (Capetillo
etal.2019; Annex 21). Consequently, the use of this technique is limited in more invasive procedures such as extractions and endodontic dentistry.
Capetillo reported that these poor results could be
explained, at least in part, by the fact that the buccal cortical plate of the first premolar apices is only 0.7–1.8 mm
thick (Capetillo etal.2019). Therefore, during an infiltration, the local anesthetic is delivered very close to the apices of the teeth; in contrast, the apices are 8–9 mm from the
sinus floor (Jang etal.2017).
381
Note: Pushing slowly will create a stream (liquid) and
not a mist.
● Application of the second prefilled spray. The objective
here is for the solution to reach the middle meatus. After
waiting the necessary time, repeat the maneuver with
the other nasal spray, although this time at 45° to the line
that joins the nasion with the subnasale (vertical plane)
(Figure20.16a,b) and wait an additional 4–5 minutes.
● After waiting 8–10 minutes in total, we apply the test
drill into the dentin to ascertain whether the patient
responds. If the patient does not respond (no pain), then
continue with the procedure.
Complications Specific tothis Technique
Around 70% of patients experience an adverse effect,
although, fortunately, these are mild and usually resolve in
a few hours (Table20.10). This section is intended to guide
dentists with respect to the most important and frequent
signs and symptoms (data shown as rounded percentages),
as follows:
● Local complications:
○ Increased secretion of the nasal mucosa (rhinorrhea)
in 50%. Nasal dryness is rare (5% of cases).
t.me/Dr_Mouayyad_AlbtousH
Appr
ontal plane)
(b)
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382
Nasion
oximately
90°
Septum (midline)
Ver tical plane
Inferior meatus
Tragus
Inferior meatus
Subnasal
(a)
Ala-Tragus plane
(Horiz
Figure20.15 Spray position for first spray (approximately horizontal, 90°) (a) and parallel toward the septum (middle) of the nasal
cavity (b). Source: Redrawn, with modifications, from Kovanaze
○ Nasal congestion in 40% of cases with nasal discomfort,
stuffy nose, sensation of pressure, and even– albeit more
rarely– rhinalgia and nose bleed (epistaxis), both in 5%
of cases.
○ Throat irritation in 10% of cases, with itching, numb-
ness, burning sensation, and, more rarely, oropharyngeal pain.
®
instructions for use.
○ Increased tearing in 10% of cases.
○ Sneezing in 3%.
Note: Although most of these complications resolve in
minutes or hours, some series have shown epistaxis to persist for 24–48 hours and rhinorrhea and nasal congestion to
last a week (Capetillo etal.2019).
t.me/Dr_Mouayyad_AlbtousH
Nasion
Septum (midline)
Middle meatus
(b)
https://t.me/med1917
Ver tical plane
383
Tragus
Approximately
Middle meatus
Figure20.16 Spray position for second spray (approximately 45°) (a) and parallel toward the septum (midline) of the nasal cavity (b).
Redrawn, with modifications, from Kovanaze
45°
(a)
Subnasal
®
instructions for use.
Ala-tragus plane
(Horizontal plane)
Table20.9 Percentage of clinical success with Kovanaze
restorative procedures in the anterior maxillary teeth.
Reference Sample size Success
Ciancio etal. (2013) 30 83%
Ciancio etal. (2016) 44 84%
Hersh etal. (2016b) 100 88%
● General complications:
○ Headache (cephalea) in 15% of cases.
○ Cardiovascular abnormalities with increased systolic
and diastolic arterial pressure, as well as tachycardia
and bradycardia in 5–10% of cases.
®
Rounded 85%
t.me/Dr_Mouayyad_AlbtousH
in
It is interesting to note that, owing to its vasoconstrictive
effect, oxymetazoline enhances the anesthetic efficacy of
tetracaine but also increases local and general adverse
effects (Ciancio et al.2016), probably because of its long
half- life (2 hours) (Giannakopoulos etal.2012).
Advantages andDisadvantages
Advantages
1) This system can be used in patients who feel fear or
anxiety associated with intraoral injections and in
needle- phobic patients.
2) Elimination of adverse effects associated with injec-
tions. These include hematoma, needle breakage, paresthesia, and trismus.
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384
Table20.10 Complications specific to this technique (Kovanaze®) as recorded from five clinical trials (percentage of patients
affected).
Giannakopoulos
etal. (2012)
N=12 N=30 N=100 N=44 N=50
Patients affected 50% 37% 88% — 86%
Rhinorrhea 50% 13% 57% 39% 86%
Nasal dryness 8% —
Nasal congestion 33% 20% 24% 34% 80%
Rhinalgia —
Epistaxis 17% — 3% — 6%
Throat irritation 8% —
Sneezing — 3% 4% — —
Lacrimation — — 8% 16% —
Headache 25% — 9% 14% —
Arterial hypertension 8% 3% 8% 9% —
Tachycardia/bradycardia 8% — — 16% —
The terms used by the authors to define specific signs and symptoms often differ, with the result that there may be a certain degree of overlap
and differences in interpretation, for example nasal discomfort, nasal congestion, and sinus congestion (Ciancio etal.2016; Hersh etal.2016b).
Similarly, we cannot know whether the same patient presents more than one sign or symptom.
In addition, some signs and symptoms that presented very low frequencies have been eliminated and appear in a single series. Such is the
case, for example, of ringing ear (tinnitus) (Giannakopoulos etal.2012).
— 5% 7% —
Ciancio etal.
(2013)
4% — —
15% 14% —
Hersh etal.
(2016b)
Ciancio etal.
(2016)
Capetillo etal.
(2019)
3) The absence of an injection means that there is no risk
of transmitting infections via the blood (e.g. hepatitis B,
hepatitis C, and human immunodeficiency virus).
4) This system reduces the risk of accidental needlestick
injuries in clinicians.
Disadvantages
The technique has various disadvantages owing to the
characteristics of this new method, as previously seen:
1) The absence of deep pulpal anesthesia. Evaluation with
an electric pulp tester reveals pulpal anesthesia of 30%,
which is poor compared with buccal infiltration with the
standard solution (Capetillo etal.2019). Consequently,
the technique cannot be used in more invasive procedures such as oral surgery, extractions, endodontic
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LocalAnesthesiainChildren
389
This short chapter examines the special case of children
undergoing dental local anesthesia treatment. For all of the
techniques addressed in this book, we have provided data
on the methodological and anatomical variations and specific details that must be taken into account when treating
children. Here, we bring together the most important
aspects of this patient group, even though most have been
addressed elsewhere in the book.
TheProblemwithChildren
andAdolescents
Control of pain during dental treatment in children and
adolescents is essential, not only to be able to carry out the
procedure, but also because trauma at this age determines
the patient’s attitude to dental treatment in the future. It is in
this age group that patients develop high levels of anxiety
and phobias that lead them to avoid treatment in the future
(McClure 1968; Molin and Seeman 1970; Lautch 1971;
Cohen etal.1982; Berggren and Meynert1984; Rankin and
Harris1984).
Table21.1 shows that pain is poorly controlled in 15% of
children. The problem is even more serious because dentists tend to think that pain is poorly controlled in fewer
cases than actually occurs (Nakai etal.2000). Various circumstances favor failure of dental local anesthesia in children and adolescents, as follows:
1) Preschool age (<5–6 years) (Wright et al. 1991;
Sharaf1997; Tyrer1999; Lind- Strömberg2001). Children
in this age group are unable to understand the need to
cooperate with the dentist (Pinkham and Schroeder1975),
even though their bones are more porous and thus facilitate diffusion of the anesthetic solution.
2) High levels of anxiety. Treatment fails in 55% of patients
who experience excess anxiety (Nakai et al. 2000).
Remember that seeing the syringe and needle and feeling the needle prick are the most anxiety- inducing
aspects of treatment (Lautch 1971; Gale 1972;
Meldman 1972; Berggren and Meynert 1984; Scott
etal.1984; LeClaire etal.1988).
3) Probability of failure of local anesthesia. This can reach
20% in patients who have previously experienced symptoms of pain (Nakai etal.2000).
LocalAnestheticSolutions
The most commonly used anesthetic solutions in children
and adolescents are as follows:
● Standard lidocaine 2% with epinephrine 1:100 000 (10 μg/ml)
000 (12.5 μg/ml) (L- 100 or L- 80) is the solution
or 1:80
most commonly used to achieve pulpal anesthesia in
children, both for mandibular block and for maxillary
and mandibular buccal infiltration. There are various
reasons for this choice:
○ As children’s bones are smaller and more porous, the
standard solution is very well diffused and successful
pulpal anesthesia is achieved.
○ The standard solution makes it possible to administer
a greater volume of the solution in milliliters depending on the child’s weight, since the maximum limits
are greater than with most anesthetic solutions used in
dentistry (Annex 10). This makes the approach
much safer.
● Lidocaine 2% with epinephrine 1:50 000 (20 μg/ml)
(L- 50), which contains twice the amount of epinephrine
as the standard solution, is used to complement buccal
infiltration of lidocaine 2% with epinephrine 1:100 000
(10
μg/ml) when pulpal anesthesia is not achieved
(Gruber1950). It is important to remember the criterion
of not mixing two anesthetics at the same site (see
Chapter5). In this case, the anesthetic is the same; only
the concentration of epinephrine varies. As this is double and thus more potent, pulpal anesthesia is more efficacious (Annex 21).
Local Anesthesia in Dentistry: A Locoregional Approach, First Edition. Jesús Calatayud and Mana Saraghi.
© 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.
Companion website: www.wiley.com/go/Calatayud/local
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