Local Anesthesia for Pediatric Patients

Initial increase in heart rate/BP, then vasodilatation and myocardial depression. [AAPD Guidelines 2023] “The cardiovascular system response to local anesthetic toxicity also is biphasic. Initially, heart rate and blood pressure may increase due to the injected epinephrine. As plasma levels of the anesthetic increase, however, vasodilatation occurs followed by depression of the myocardium.”

Dizziness, anxiety, confusion, followed by diplopia, tinnitus, drowsiness, circumoral numbness. [AAPD Guidelines 2023] “Early subjective indications of toxicity involve the CNS and include dizziness, anxiety, and confusion. This may be followed by diplopia, tinnitus, drowsiness, and circumoral numbness or tingling.”

Must include type and dosage of local anesthetic administered. [AAPD Guidelines 2023] “This would include, at a minimum, the type and dosage of local anesthetic administered.”

Should include specific details like injection type, needle size, amount, location. [AAPD Guidelines 2023] “For example, local anesthetic administration might be recorded as: mandibular block with 27-short; 34 milligrams (mg) two percent lidocaine with 0.017 mg epinephrine (or 1/100,000 epinephrine); tolerated procedure well.”

Not recommended for patients under 3 years or less than 15 kg. [AAPD Guidelines 2023] “Use of phentolamine mesylate is not recommended for patients who are younger than three years of age or weigh less than 15 kg (33 pounds).”

Generalized tonic-clonic convulsion. [AAPD Guidelines 2023] “The classic overdose reaction to local anesthetic is generalized tonic-clinic convulsion.”

Reduces duration of local anesthetic effects by reversing vasoconstrictor. [AAPD Guidelines 2023] “Use of phentolamine mesylate injections in patients over age six years or at least 15 kilograms (kg) has been shown to reduce the duration of effects of local anesthetic.”

Not recommended for routine injections through noninfected tissue in at-risk patients. [AAPD Guidelines 2023] “Endocarditis prophylaxis (antibiotics) is not recommended for routine local anesthetic injections through noninfected tissue in patients considered at risk.”

Maximum 0.04mg epinephrine (2 cartridges 1:100,000) per appointment. [AAPD Guidelines 2023, Table] “Maximum 0.04mg epinephrine (2 cartridges with 1:100,000) per appointment.”

May be as effective as blocks due to less dense mandibular bone. [AAPD Guidelines 2023] “Because of this increased permeability, mandibular buccal supraperiosteal infiltration with local anesthetic may be as effective as an inferior alveolar nerve block for dental procedures.”

True allergy is a rare finding and is absolute contraindication for use. [AAPD Guidelines 2023] “Allergy to a local anesthetic, a rare finding, is an absolute contraindication for its use.”

Second trimester, after organogenesis and before positioning difficulties. [AAPD Guidelines 2023] “The second trimester of pregnancy, when organogenesis of the fetus is complete and comfortable positioning in the dental chair may still be possible, may be the optimal time to complete non-urgent dental treatment.”

In presence of inflammation or infection at injection site. [AAPD Guidelines 2023] “The use of the PDL injection or intraosseous methods is contraindicated in the presence of inflammation or infection at the injection site.”

When needed information about medical condition impact on local anesthetic use is required. [Ref: AAPD Guidelines 2023]

Two types are: (1) esters (procaine, benzocaine, tetracaine) and (2) amides (lidocaine, mepivicaine, prilocaine, articaine). [Ref: AAPD Guidelines 2023]

Long (32mm), short (20mm), and ultrashort (10mm). [AAPD Guidelines 2023] “Dental needles are available in three lengths: long (32 mm), short (20 mm), and ultrashort (10 mm).”

Most needle fractures occur during inferior alveolar nerve block with 30-gauge needles. [AAPD Guidelines 2023] “Most needle fractures occur during the administration of inferior alveolar nerve block with 30-gauge needles.”

First trimester should be avoided for elective treatment. [AAPD Guidelines 2023] “The second trimester of pregnancy… may be the optimal time to complete non-urgent dental treatment.”

May cause uterine vessel contraction and limit placental blood flow. [AAPD Guidelines 2023] “Epinephrine may cause contraction of uterine blood vessels and limit blood flow to the placenta.”

Using 4.4mg/kg guideline, 15kg x 4.4 = 66mg max dose. Each cartridge contains 34mg. [AAPD Guidelines 2023] “The long-established pediatric dental maximum dose of lidocaine as 4.4 mg/kg… 34mg per cartridge.”