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Table21.1 Failure oflocal anesthetic inchildren.
Reference Samplesize Failure
Kuster and Rakes (1987) 4134 12.8%
Kaufman etal. (1991) 151 27%
Jones etal. (1995) 308 20.5%
Nakai etal. (2000) 361 11.6%
Naidu etal. (2004) 101 9%
16.2%
Rounded average 15%
● Articaine 4% with epinephrine 1:100 000 (10 μg/ml)
(A-
100) is recommended only for buccal infiltration in
anterior and posterior teeth in the maxilla and mandible
in special cases:
○ To achieve successful pulpal anesthesia in children,
which is difficult with the standard solution (e.g. anterior mandibular teeth with irreversible acute pulpitis).
○ To achieve anesthesia of primary mandibular molars
with periapical infiltration when mandibular block is
contraindicated (e.g. patients with hemophilia)
(Dudkiewicz etal.1987; Donohue etal.1993).
○ To reinforce mandibular block (with the standard
solution) in mandibular molars that are particularly
difficult to anesthetize (e.g. irreversible acute pulpitis).
● This solution of articaine has some disadvantages:
○ It is contraindicated in children aged under 4 years
because, although its safety has been demonstrated in
clinical trials (Wright etal.1989), it must be verified
with more data and clinical studies (Malamed
etal.2000,2001; Katyal2010).
○ There may be more cases of self- injury of the lips,
tongue, and buccal mucosa because of the longer
duration of soft tissue anesthesia (Adewuni etal.2008;
Chopra etal.2016; Annex 21).
Other anesthetic solutions can also be administered
(mepivacaine, prilocaine), although they are much less
effective (Annex 21). Solutions with long-
lasting anesthesia, such as bupivacaine, are contraindicated in children
aged under 12 years owing to the risk of self- injury (Laskin
etal.1977; Jensen etal.1981; Moore1984).
AnestheticTechniqueinChildren
Here, we would like to draw attention to the most relevant
aspects of the techniques applied with children:
1) Topical anesthetics in aerosolized form are not recom-
mended for children (especially children under 6-year
age) because they may lead to sudden uncooperative
behavior owing to the noise they make and a bad taste
as the anesthetic spreads through the mouth (Frasier
1967; Evers and Haegerstam1981), and thus yield poor
results (Chapter12 and Annex 19). The preferred form
is gel, ointment, cream, or paste (Annex 19).
2) In each technique, the quantity of solution adminis-
tered to children younger than 6–8
years is usually half
that administered to adults to avoid overdosage. For
example, if we were injecting the standard solution of
lidocaine 2% with epinephrine 1:100
000 (10 μg/ml) in
the conventional mandibular block technique (inferior
alveolar nerve block), then our approach would be as
follows:
In an adult weighing 52 kg and in another weighing
86
kg, we would inject 1 cartridge (i.e. 1.8 ml) to achieve
mandibular block. If we had to administer additional
injections in these adults, for example maxillary and
mandibular buccal infiltrations, the absolute maximum
dose would be 6.2 cartridges for the patient weighing
52
kg and 8.5 cartridges for the patient weighing 86 kg
(Annex 10).
In a 5- year- old child weighing 20 kg, we would inject
half a cartridge (i.e. 0.9
ml) to achieve mandibular block
(half the adult dose). If we had to administer additional
injections, for example maxillary and mandibular buccal infiltrations, the absolute maximum dose would be
2.5 cartridges (Annex 10).
3) The injection should not take long. When an injection
takes too long, the child becomes nervous and subjectively associates the injection with pain (Jones
etal.1995). This problem is partly resolved in little children because they receive half the dose and therefore
the injection takes half the time.
4) Vasovagal syncope is uncommon. The frequency of vas-
ovagal syncope in children aged under 14
years is very
low (1 per 2000=0.05%) because children react to emotional tension differently from adults; they do not
repress the fight-
or- flight response, but rather scream,
cry, throw a tantrum, or resist the injection, therefore a
vasovagal reaction does not occur (Kuster and
Udin 1985). In young adults, on the other hand,
one- third are thought to be susceptible to this type of
reaction (Yjipaavalniemi and Sane1981).
5) Self- injury may be more frequent. Self- injury is a problem
with children since after dental treatment the soft tissue
remains anesthetized and, in some cases, the patient may
bite and injure his/her lip, buccal mucosa, and tongue.
Thus, the main associated factors are as follows:
● Age. Owing to the child’s immaturity, the frequency
of self- injury increases with younger age (College
etal.2000; Adewuni etal.2008).
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● The duration of anesthesia in the soft tissues. Since
the frequency of self-
injury increases with the duration of anesthesia (Adewuni etal.2008), it is not recommended to use articaine 4% solution with
epinephrine 1:100
000 (10 μg/ml), even though it is
not contraindicated. As seen above, bupivacaine 0.5%
with epinephrine 1:200
000 is contraindicated.
Interestingly, bilateral mandibular block leads to self-
injury less frequently than unilateral mandibular block
(counterintuitive). This may be due to the following two
factors (College etal.2000):
● Bilateral mandibular block is performed in longer,
more extensive treatments, therefore the child’s soft
tissues are anesthetized for shorter periods after leaving the dentist’s office.
● The sensation of symmetrical soft tissue anesthesia
on both sides leaves the child less likely to explore the
mouth and bite him/herself.
The measures dentists can take to prevent these
lesions or at least reduce their frequency in children are
as follows:
● Explain to the parents that the child should not chew
or take very hot drinks while the lips remain anesthetized (tingling, numbness, dullness, tickling, or fat
lip). This point should be emphasized to both parents
and children.
● Place a cotton roll between the lips and the cheek.
Pediatric dentists use this trick with children for the
duration of soft tissue anesthesia. The child should be
reminded not to chew.
● Injection of phentolamine (OraVerse
®
) may prove useful in the areas where the anesthetic solution was
injected to reduce the duration of anesthesia in the
soft tissues after treatment (Tavares etal.2008; Zurfluh
etal.2015; Hersh etal.2017,2019) (see Chapter6).
6) Supplementary techniques. If the conventional tech-
niques is not sufficient and anesthesia fails, we can
turn to supplementary techniques (mainly periodontal
ligament [PDL] technique), but in children, we can
use supplementary techniques only in permanent teeth,
not in primary teeth, so as not to affect the buds of
the underlying permanent teeth (Brännström
etal.1984), although these abnormalities are minimal
(Chapter18). The exceptions to this contraindication
are as follows:
○ Children with severe coagulation abnormalities
(Spuller1988). The PDL technique is an alternative to
mandibular block.
○ Computer- controlled PDL injections (The Wand),
since pressure is controlled and there are no enamel
abnormalities (Ashkenazi etal.2010).
AnesthesiaofthePrimary
MandibularMolars
The primary mandibular molars can be anesthetized in
several ways:
1) Standard mandibular block. Children aged 6–8 years
receive half a cartridge (0.9
tion of lidocaine L-
100 or L- 80. After waiting 5 minutes,
ml) with the standard solu-
onset of soft tissue anesthesia in the lower lip (a sign
that the mandibular block is taking effect) should be
verified, thus indicating that the inferior alveolar nerve
has been anesthetized. Complementary buccal infiltration with a further half a cartridge of standard lidocaine
solution is recommended in the posterior mandibular
molars, which require good pulpal anesthesia.
It is important to note that complementary anesthesia is
applied after 5
minutes to avoid the risk of overlapping
anesthesia of the lower lip via mandibular block with
that of the infiltration and thus masking failure of
the block.
2) Buccal infiltration of the primary molars with the more
potent articaine solution (Afull cartridge (0.9–1.8
100) in half a cartridge to a
ml) to avoid using mandibular
block. This method has some advantages:
● As it is easier to administer, it could prove useful in
children who are more difficult to manage, such as
small children (McClure1968).
● As there is no anesthesia of the tongue, the risk of
self-
injury is reduced (Dudkiewicz etal.1987).
● It is a good option for hemophiliac patients, as we
have seen, since mandibular block is usually contraindicated in this population (Dudkiewicz et al. 1987;
Donohue etal.1993).
The disadvantage of this approach is that it may be
less effective than mandibular block, especially in the
second primary molar, possibly because the cortical
layer is thicker at this level and we use standard lidocaine solution as complementary buccal anesthesia
(Wright et al. 1991; Sharaf 1997), therefore articaine
solution with epinephrine 1:100
000 is preferred because
it is effective even in irreversible acute pulpitis (Veena
and Mytri2015; Chopra etal.2016).
3) Traditional mandibular block with the standard solu-
tion of lidocaine (L- 100 or L- 80). After verifying that the
lower lip has been anesthetized, we wait 5 minutes
before injecting complementary buccal anesthesia with
a potent solution such as articaine (A- 100) or lidocaine (L- 50).
It is important to note that in this case, when we apply
complementary buccal anesthesia with articaine, we
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392
follow the criterion of not mixing two local anesthetics at
the same site (see Chapter5). Thus, we use standard lidocaine solution in the pterygomandibular space and articaine in the buccal region. When complementary anesthesia
is with L-
50, we are using the same anesthetic, albeit at
greater potency, since it contains double the amount of epinephrine (Annex 21).
This option is used in cases where it is difficult to anesthetize the patient, such as in acute pulpitis, to guarantee
successful anesthesia, although we do not recommend it as
routine practice.
NeedlesandMandibularBlock
A survey in the United States indicated that 40% of pediatric dentists use 30G needles for mandibular block and that
almost 80% used short needles (Kohli etal. 2001). If we
review cases of needle breakage in mandibular block, we
can observe the following:
1) In more than 70% of cases, the needles used were inap-
propriate for the technique as they were 30G or short or
both (Annex 37).
● 30G needles (0.3 mm in diameter) are the finest, and
many dentists still think that these needles make
injection and anesthesia less painful than thicker
calibers (27G, 0.4
mm and 25G, 0.5 mm) (Smith1968;
Cooley and Robinson1979; Fuller etal.1979); however, clinical trials have not shown that 30G needles
are less painful than the other two, which are thicker
but more resistant to breakage (Table 11.3,
Chapter11).
● In mandibular block, short needles (≤25 mm) are eas-
ily inserted into the soft tissues as far as the hub,
which is the weakest part and the point at which the
needle breaks (Pietruszka et al. 1986; Bhatia and
Bounds 1998; Zelster et al. 2002; Ethunandan
etal.2007; Pogrel2009; Shah etal.2009).
2) In 30% of cases of needle breakage, the patients are
children (Annex 37): of note, children aged under
years account for 16% of the population in Spain
18
(INE2015) and for 23% of the population in the United
States (Census2015). This observation is closely associated with the possible lack of cooperation among children (around 20% of cases involved patients aged
<8
years [Annex 37]) and the habitual use of short 30G
needles for mandibular block by pediatric dentists
(Kohli etal.2001).
Chapter 22 provides a more careful analysis of needle
breakage. In conclusion, long 27G or 25G needles should be
used for mandibular block in children.
RemarksonBuccalInfiltration
● Many authors report that mandibular block is more
painful than buccal infiltration (Jones etal.1995; Oulis
et al. 1996; Sharaf1997; Chopra et al. 2016), although
other clinical trials have not found this to be the case
(Brownbill etal.1987). We believe that there is no differ-
ence if we follow the indications for mandibular block
shown in Chapter16.
● Many clinical studies have shown more soft tissue
anesthesia with mandibular block than with buccal infil-
tration and therefore a greater risk of self-
injury (Wright
et al. 1991; Donohue et al. 1993; Oulis et al. 1996).
However, it is also important to note that if A- 100 solution is used as complementary buccal anesthesia, then
the effect of the anesthetic takes longer to wear off in soft
tissues than with the standard solution (Annex 21).
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tissue local anesthesia with
Pavlovich, D. etal.
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Local Complications ofDental Local Anesthesia
397
Local complications caused by or associated with dental
local anesthesia can be classified according to onset
(Laskin 1984; Vega1998): (i) as immediate or accidental
complications, when they appear during treatment in the
office, or (ii) as late complications, or simply complications, when they appear after the patient has left the office.
Local complications are more frequent than general
complications, although, fortunately, the vast majority
resolve spontaneously without severe problems for the
patient and without leaving sequelae (Laskin 1984).
Table 22.1 shows these complications, their association
with onset (immediate or late), and their severity.
In 1997 (Vega1998) and during 2000–2010 (Pereaetal.2014), 4% of adverse effects (local or general) recorded
in Spain were associated with dental local anesthesia.
Perez
Persistent Post- injection Pain
Disappearance of local anesthesia effect is sometimes followed by slight discomfort at the injection site, which is
usually of little clinical relevance (Jorkjend and
Skoglund 1999); however, persistent moderatepain may be present and may last several days.
Persistent postbuccal infiltration and affects approximately 1% of cases of
persistent pain (Table22.2). This is natural, given the low
degree of trauma involved in this technique at this level
(Kennedy etal.2001; Evans etal.2008), and the pain disappears spontaneously within 3
injection pain is much more frequent in mandibular block
and is thought to affect 5% of cases (Table22.2), possibly
because it is a much more traumatic technique. This complication usually resolves spontaneously within 3–4 days
(Dunbar et al. 1996; Ridenour et al. 2001; Mikesell
etal.2005).
injection pain is unusual in maxillary
days (Evans etal.2008). Post-
to- severe
Self- inflicted Injury
Anesthesia of the soft tissue persists after the dental treatment session, and some patients (mainly young children
and developmentally disabled patients) may bite and injure
their lips, jugal mucosa, and tongue.
The frequency of these lesions was unknown until
recently, not because they were uncommon, but because of
the few problems they generally cause. Pediatric dentists
estimate their frequency to be 5% or slightly greater (College
etal.2000; Ram and Amir2006), and studies based on case
series agree, reporting the frequency to be around 7%
(Table22.3). However, this percentage only refers to the
most severe cases, given that clinical studies focusing on
inflicted injury report a frequency of 13% (College
selfet al.2000; Adewuni et al. 2008), possibly because they
include small lesions such as redness or swelling that are
noticed by the dentist but not by parents (College
etal.2000). The lesions affect the lips (13%), buccal mucosa
(10%) (cheeks), and tongue (6%) (Adewuni etal.2008).
Once soft tissue anesthesia resolves, red and inflamed
lesions appear on the affected tissues and, in the more
severe cases, may become ulcerated and painful. The
lesions heal spontaneously in less than 2 weeks. We have
already seen that the cause is accidental biting of the anesthetized tissues. Occasional cases of burning by cigarette
smoke have been recorded in adults. The associated factors
are as follows:
1) Age. Smaller children are more likely to experience self-
inflicted injury because of their age (College etal.2000;
Adewuni etal.2008). The same applies to patients with
intellectual disability.
2) The duration of anesthesia in soft tissues. The longer
the duration, the greater the frequency of self- inflicted
injuries (Adewuni etal.2008).
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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398
Table22.1 Local complications ofdental local anesthesia:
severity andonset.
Severity Onset
Complication
1) Persistent pain + +
2) Self- inflicted injury + +
3) Facial blanching + +
4) Delay cutaneous lesion + +
5) Facial hematoma + + +
6) Nerve lesions + + + +
7) Trismus + + + +
8) Facial palsy + + + +
9) Ocular complications + + + +
10) Infections + +
11) Mucosal ulceration + + +
12) Breakage of needles + +
13) Breakage of cartridges + + +
14) Aural complications + + +
Table22.2 Moderate tosevere pain after maxillary buccal
infiltration andmandibular block.
Reference Sample size Persistent pain
Maxillary infiltration
Kennedy etal. (2001) 120 0%
Evans etal. (2008) 80 0%
Hersh etal. (2008) 122 2.5%
Mandibular block
Krafft and Hickel (1994) 12
Dunbar etal. (1996) 40 5%
Reitz etal. (1998) 38 0%
Ridenour etal. (2001) 30 14%
Mikesell etal. (2005) 57 5%
Mikesell etal. (2005) 57 21%
Goodman etal. (2006) 46 7%
Hersh etal. (2008) 122 5%
Willett etal. (2008) 25 8%
Mild Severe Immediate Late
≈ 1%
0.83%
104 0.32%
≈ 5%
7%
Table22.3 Percentage oflesions resulting frombiting after
dental local anesthesia.
Reference Age (years) Lesions
College etal. (2000) 2–18 13%
Malamed etal. (2001) <13 0.07%
Ram and Amir (2006) 5–13 5%
Adewuni etal. (2008) 2–14 13%
PeñarrochaHersh etal. (2017) 2–5 2%
Oltra etal. (2012) 11–55 4%
6.2%
≈ 5%
tissue anesthesia is shorter when the child leaves the
dentist’s office.
● The sensation of symmetrical paresthesia on both
sides means that the patient is less likely to explore
and bite the tissue.
The measures that dentists can take to prevent, or at
leastreduce, the probability of these lesions in children are
asfollows:
1) Explain to patients (especially children and their car-
egivers) that they cannot chew or have very hot drinks
while the lips continue to feel numb (tingling sensation,
numbness, dullness, swollen or fat lip).
● Adults should be advised not to smoke.
● Some patients claim that they can chew with the
other (nonanesthetized) side, although it must be
stressed that both sides tend to be used unconsciously
when chewing and that chewing may be more difficult than the patients perceive it to be.
● This must be emphasized to both children and
parents.
2) Place a cotton roll between the lips and cheek. This is a
commonly utilized practice in pediatric dentistry; the
cotton roll is left in place for as long as the soft tissue
anesthesia persists, reminding the patient not to chew
their lips or cheeks.
®
3) Phentolamine (OraVerse
) could prove very useful in
the areas where the anesthetic solution has been
injected to reduce numbness in the soft tissue after
treatment (Tavares etal.2008; Zurfluh etal.2015; Hersh
etal.2017) (Chapter6).
3) Bilateral mandibular block. Surprisingly, bilateral block
has a lower incidence of self- inflicted lesions than
unilateral block, possibly for two reasons (College
etal. 2000):
● Bilateral mandibular block is used in more extensive
and longer treatments, therefore duration of soft
Facial Blanching
Although the real frequency of this condition is unknown,
it is thought to be frequent and has been reported to
account for 1% of all cases of numbness caused by dental
local anesthetic (Lustig and Zusman1999).
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Blanching (ischemic paling) is characterized by blood
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loss during the injection or immediately after. It affects the
skin of the face (cheek) on the maxilla and disappears
spontaneously after 10–30
minutes without sequelae
(Kronman and Giunta 1987; Heasman and Reid 1995;
Aravena etal.2016).
Anesthetic Techniques Involved
● Mandibular block with the conventional or direct tech-
nique (Kronman and Giunta 1987; Heasman and
Reid1995; Webber etal. 2001; Uckan et al. 2006; Paul
et al. 2009; Aravena et al.2016), the Gow-
Gates technique (Dryden 1993) or the Laguardia–Akinosi technique (Donkor etal.1990).
● In the maxillary arch, the techniques involved are buccal
infiltration, posterior superior alveolar nerve block, the
high tuberosity technique (Kronman and Giunta1987;
Lustig and Zusman 1999), and the transpalatal (greater
palatine canal) approach (Mercuri1979).
399
Clinical Manifestations
Blanching appears on the same side of the face as the injection, with the following:
1) Facial blanching, which is characterized by the
following:
● Onset on the skin of the face below the lower eyelid
(infraorbital), malar or zygomatic region, side of the
nose, and above the nasolabial fold (cheek). It manifests as a continuous white patch (Figure 22.1)
or occasionally two patches (Kronman and
Giunta1987). Blanching is easily observed in persons
whose skin is not black (Mercuri 1979) and disappears spontaneously after 10–30 minutes (Kronman
and Giunta 1987; Heasman and Reid 1995; Paul
et al. 2009; Aravena et al. 2016; Kumaresan
etal.2018).
● The patch can sometimes extend intraorally to the
maxillary gingiva (Heasman and Reid1995; Aravena
etal.2016), hard palate (Dryden1993; Heasman and
Reid1995; Aravena etal.2016; Kumaresan etal.2018),
or even to the lower lip (Webber etal.2001).
● An asymptomatic sign (only observed by the dentist),
although the patient may initially feel numbness,
itching, a burning sensation, or even shooting pain, in
the affected area (Mercuri1979; Webber etal.2001;
Uckan etal.2006; Paul etal.2009; Aravena etal.2016;
Kumaresan etal.2018).
2) While rare, ocular complications (see section “Ocular
Complications”) of the have been described
(Dryden 1993; Webber et al. 2001; Chiappelli and
Figure22.1 Area affected by facial blanching.
Cajulis 2002; Uckan et al. 2006) and include the
following:
● Double vision (diplopia).
● Sensation of numbness, burning, or even pain in the
eye and periorbital area.
● Drooping of the upper eyelid (ptosis).
● Ischemic paling may extend to the eyelids and fore-
head (Webber etal.2001; Uckan etal.2006).
In these cases, ocular manifestations are the main
event, with blanching no more than an accompanying sign.
Causes andPathophysiology
Proposed Causes
1) Irritation of sympathetic fibers surrounded the arteries
(perivascular sympathetic plexus) by the tip of the needle at the injection site can cause reflex vasoconstriction along the terminal branches, in this case at the
level of the skin (this may occur internally, although
we do not see it). Since aspiration is negative in most
cases, this seems to be the most common explanation
(Laskin1984; Kronman and Giunta 1987; Lustig and
Zusman1999).
2) Epinephrine from the local intravascular anesthetic
injected is transported to the terminal peripheral
branches of the skin of the face (Kumaresan etal.2018).
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