Child Management and Pain Control

Question 1

surface anaesthesia

Answer 1

anaesthesia of the surface tissue i.e. skin or mucous membrane

physical or pharmacological

Question 2

uses of surface anaesthesia

Answer 2

to reduce pain of LA injection

to reduce discomfort of venepuncture

for superficial soft tissue manipulation

Question 3

physical surface anaesthesia a.k.a

Answer 3

refrigeration anaesthesia

Question 4

physical surface anaesthesia technique

Answer 4

By reducing the temperature

Ethyl chloride (rarely used as LA agent in children)
- Can be useful for quick topical if pt not using EMLA correcting 

Difficult to direct stream of liquid accurately

Inadvertent contact with vital teeth produces discomfort

Inflammable – kept in yellow flammable cupboard

Question 5

pharmacological surface anaesthesia

Answer 5

topical anaesthesia

• intraoral topical agents
• topical anaesthesia for skin
• controlled release devices
• jet injectors

Question 6

intraoral topical agents

Answer 6

Will anaesthetise 2-3mm depth of tissue

Success is technique dependent:

• Dry area (cotton wool roll)
• Apply over limited area (use a cotton wool roll)
• Apply for sufficient time: 2 mins

Different preparations:

• Lidocaine: 2% gel; 10% spray & 5% ointment
• Benzocaine: 20% gel (flavoured bubblegum, harder to find currently)

Question 7

different preparations of intraoral topical anaesthesia

Answer 7

• Lidocaine: 2% gel; 10% spray & 5% ointment

- Benzocaine: 20% gel (flavoured bubblegum, harder to find currently)

Question 8

what is important to remember when calculating the dose given of anaesthesia to a child

Answer 8

always take in the dose of topical anaesthesia as well as local anaesthesia

Question 9

importance of intraoral topical anaesthesia in practice

Answer 9

These are key to LA in children (and anxious pt of all ages) but take care to follow correct approach and timings

Question 10

intraoral topical uses

Answer 10

Pre-injection

Rubber dam clamp

Placing matrix band

Suture removal

Exfoliating primary teeth

Subgingival scaling

Incision of abscess
- Harder to apply other LAs

Question 11

2 types of topical anaesthetic for skin

Answer 11

EMLA cream

ametop gel

Question 12

EMLA cream

Answer 12

5% eutectic mixture of prilocaine (amide) and lidocaine (amide)

Needs to be applied for at least 45 minutes

Useful prior to general anaesthesia or intravenous sedation (veneflow)

Question 13

ametop gel

Answer 13

Tetracaine (amethocaine) 4% gel (esther)

Faster onset than EMLA

Not as widely used as EMLA

Question 14

type of topical controlled release devices

Answer 14

patches

Question 15

topical patches

Answer 15

Incorporation of local anaesthetic into materials that adhere to the mucosa and allow slow release

Decreases the chance of the anaesthetic moving away from the application site

• helps keep topical injection at site
• dry cotton wool roll with topical can be distributed around mouth or swallowed – cause numb throat and patient may be less compliant

Under investigation

• Under development
• patches can be coloured to allow a bullseye which the operator can use to apply injection to correct site

Question 16

advantages topical jet injectors (4)

Answer 16

Allows anaesthesia up to 1cm

Bleeding diatheses (susceptibility to bleeding e.g. haemophilia, VW) where deep injections are contraindicated
- E.g. IV blocks – deep bleed, airway constriction etc

Sole means achieving LA depending on Tx

Prior to conventional techniques

Question 17

disadvantages of topical jet injectors (4)

Answer 17

Could cause soft tissue damage if careless

Frightening sight and sound

Taste of solution

Expensive

Question 18

2 types of non-pharmacological pain control

Answer 18

TENS (transcutaneous electrical nerve stimulation)

Hypnosis

Question 19

TENS (transcutaneous electrical nerve stimulation)

Answer 19

blocks large myelinated nerve fibres and closes the gate to central transmission of smaller unmyelinated pain fibres

Controlled by patient (over 10yrs old)
- Early stages of labour

Uses: restorations, primary extractions, pre- LA (always need LA after)

Question 20

hypnosis

Answer 20

An altered state of mind such that suggestions are accepted more readily and acted upon more powerfully

adjunct to LA by decrease pulse rate
- More powerful and work better
Decreases pulse rate, makes calmer

Question 21

common LA solutions (4)

Answer 21

Lidocaine 2% with 1:80000 epinephrine/adrenaline (amide)

Lidocaine 2% plain (amide) (shorter acting as no vasoconstricter/adrenaline)

Prilocaine (Citanest®) 3% with felypressin (also known as octapressin) 0.03IU/ml (amide)

Articaine 4% (Septanest®) with 1:100 000 adrenaline (amide)

Question 22

when might you use a LA without vasoconstrictor

Answer 22

Doesn’t stay in localised area for as long so is shorter acting - special need children

Question 23

lidocaine

Answer 23

common local anaesthetic

anti-arrhythmic drug (supresses abnormal heart rhythms)

rapid onset of action

half life= 1.5-2hrs (time it takes to half concentration of drug in body – affected by vasoconstrictor)

suitable for infiltration, block, and surface anesthesia

addition of epinephrine (adrenaline) vasoconstricts arteries, reducing bleeding and also delays the resorption of lidocaine, almost doubling the duration of anaesthesia

Question 24

4 contraindications of lidocaine

Answer 24

Heart block and no pace-maker

Allergy to LA (or to corn),

hypotension

impaired liver function

Question 25

articaine

Answer 25

First produced in Germany 1969 Half life of 20 mins Contains a thiophene ring instead of benzene Additional ester group Risk of systemic toxicity lower than others as it is hydrolised by blood quicker More effective for mandibular infiltrations than lignocaine - Usually for haemophiliacs where you are reluctant to do IDB Lignocaine and articaine are equally effective as blocks. Lignocaine drug of choice for block, as 4% solutions carry higher risk of non-surgical paraesthesia

Question 26

contraindication of articaine

Answer 26

avoid in sickle cell patients (and other haemoglobinopathies)

Question 27

4 effects of adrenaline

Answer 27

Avoid intra-arterial injection by careful technique - aspirate prior to deposition to ensure not in BV Adrenaline binds to alpha-receptors in the peripheral vasculature - causing vasocontriction Adrenaline binding with B1-adrenergic receptors in the heart wall. - causes tachycardia (heart rate >100 bpm), due to Increased HR in combination with peripheral constriction can lead to increased blood pressure. However, it has been reported that there is no need to avoid adrenaline containing local (which is less effective) unless BP> 200mmHg (systolic) and/or (diastolic) >115mmHg

Question 28

what should you consider when giving LA to pt with HBP

Answer 28

Have caution with patients on diuretics (“water tablet” used to decrease BP by flushing salt out of body - use adrenaline free LA to avoid risk of reduction in potassium concentration) Meechan 92 Beta-Blocker (used to decrease blood pressure) - less problematic

Question 29

3 techniques of LA in children

Answer 29

infiltration intraligamentary regional block

Question 30

LA needle sizes

Answer 30

long - ID block short (regular) - infiltration ultra-short - infiltration of intra-papilllary

Question 31

long LA needle use

Answer 31

ID block

Question 32

short LA needle use

Answer 32

infiltration

Question 33

ultra-short LA needle block

Answer 33

infiltration or intra-papillary

Question 34

LA infiltration uses (5)

Answer 34

Anaesthesia in primary teeth Anaesthesia in maxillary permanent teeth Anaesthesia in mandibular permanent anterior teeth Prior to intrapapillary and then intraligamental anaesthesia in posterior permanent teeth Prior to intrapapillary and palatal/lingual anaesthesia Not mandibular molars – unless articaine infiltration in haemophiliac

Question 35

when is LA infiltration not used

Answer 35

mandibular molars – unless articaine infiltration in haemophiliac

Question 36

LA infiltration technique

Answer 36

Dry mucosa Topical anaesthetic (2 mins) Wipe off excess topical anaesthetic Stretch mucosa until taught (make more comfortable) Distract patient (gentle pressure or rubbing on lip can do this, talking, singing) ``` Insert needle (ultra short or normal 30 gauge) Aspirate ``` Inject supraperiosteal as close as possible to apices of teeth - Painful when on bone

Question 37

lingual/palatal anaesthesia technique

Answer 37

Ultra-short 90 degrees to surface - Already put in infiltration – so numb of area ahead before you inject Approach via anesthetised buccal interdental papilla Advance when see palatal blanching - Otherwise uncomfortable

Question 38

LA intraligamentary uses (2)

Answer 38

to supplement infiltrations may eliminate need for block

Question 39

intraligamentary technique

Answer 39

Can be tender in child due to pressure - get specialised syringes Interosseous via cancellous space via PDL 0.2ml per root – beware excess dose More successful with a vasoconstrictor Ultra short 32 gauge needle 30 degree to long axis of tooth in mesiobuccal gingival sulcus - advance until resistance Specialised syringe measured dose Conventional syringe – 0.2ml is width of bung (hard to do)

Question 40

syringes used for intraligamentary technique LA

Answer 40

Normal syringe with ultra short needle or Custom made syringes - Peripass syringe – less pressure

Question 41

the wand

Answer 41

Method specialised intraligamental LA and conventional blocks Uses computerised flow of local anaesthetic - Computer can guide you if on bone Can be used as a method of intraligamental LA for single tooth anaesthesia - E.g. special need children – avoid biting on numb soft tissue Can also be used for infiltration and block anaesthesia

Question 42

issue for the wand

Answer 42

not safety plus syringe system - cap goes at side of machine - cannot resheath it like normal conventional needle - use one hand to deposit and then place back in cap

Question 43

inferior alveolar and lingual nerve block in children

Answer 43

Mandibular foramen (smaller children) - below occlusal plane lower than in adults Approach direct from primary molars of opposite side Lateral to the pterygomandibular raphe and medial to ascending ramus

Question 44

mental block technique (long buccal, mental and incisive nerve s)

Answer 44

Advance needle in buccal sulcus toward region between apices of 1st and 2nd primary molars. Mental foramen faces anteriorly in children

Question 45

advantage of mental block

Answer 45

very good soft tissue anaesthesia

Question 46

disadvantage of mental block

Answer 46

Incisive nerve anaesthesia not as reliable as IDB Incisors may get crossover supply across midline so need a labial infiltration adjacent to tooth as well as this block

Question 47

nerves effected by mental block

Answer 47

long buccal mental incisive

Question 48

maxillary block technique

Answer 48

Direct block seldom used - Surgery in area e.g Supernumerary tooth, ectopic canine Greater palatine and nasopalatine blocks can be achieved by infiltrating LA through anaesthetised buccal papilla and ‘chasing’ the anaesthetic through to the palatal mucosa

Question 49

LA generalised compilations (5)

Answer 49

psychogenic (stress) allergy toxicity drug interactions infections

Question 50

allergy to LA

Answer 50

Anaphylaxis is very rare especially to amide group Metabisulphite (E223) preservative, antiseptic Latex – rubber bung cartridge Methyl parabens Preservative, (E218) found in blueberries

Question 51

LA toxicity effect (4)

Answer 51

cardiovascular - low levels: stimulant - high levels: circulatory collapse CNS - depressant leading to unconsciousness and respiratory arrest methaemoglobinaemia - cyanosis associated with lethargy and respiratory diseases reduced ability of RBC to release O2 to tissues - prilocaine, articaine, benzocaine

Question 52

max safe dose of lidocaine 2% plain/with adrenaline

Answer 52

5mg/kg

Question 53

max safe dose of prilocaine 4% plain/3% with felypressin

Answer 53

8mg/kg

Question 54

max safe dose of mepivicaine 3% plain/2% with adrenaline

Answer 54

3mg/kg

Question 55

max safe dose of artiicaine 4% with adrenaline

Answer 55

7mg/kg

Question 56

max safe dose of 2% lidocaine in 20kg child

Answer 56

2% soln in 2.2ml cartridge contains 44mg Max safe dose is 4.4mg/kg or 1/10th cart /kg weight of a 5yr old child is 20kg 20kg x 4.4 = 88mg = 2 cartridges

Question 57

max safe dose of 3% prilocaine with felypressin in 20kg child

Answer 57

3% soln in 2.2ml cartridge contains 66mg Max safe dose is 6mg/kg (1/11th of a cartridge per kg weight) weight of a 5yr old child is 20kg 20kg x 6= 120mg so less than 2 cartridges (2 cartridges contain 132mg- so can only give 1 and 9/11ths of a cartridge)

Question 58

max safe dose of 4% articaine

Answer 58

4% soln in 1.8ml cartridge contains 72mg Max safe dose is 5mg/kg (1/15th cart/kg) Weight of 5 year old child is 20 kg 20kg x 5 = 100mg = 1 and 1/3 cartridge

Question 59

3 ways to prevent complication in LA administration

Answer 59

Aspiration Slow injection - Feels right – not depositing in wrong place, more comfortable for patient Dose limitation - Give the lowest dose needed for Tx - Half cartridge sufficient then just use that

Question 60

LA toxicity Treatment

Answer 60

``` Stop dental treatment Provide basic life support Call for medical assistance Protect patient from injury Monitor vital signs ```

Question 61

LA localised complications (6)

Answer 61

Self inflicted trauma – biting soft tissues Oral ulceration Long lasting anaesthesia Trismus Infection Developmental defects

Question 62

early localised complications to LA

Answer 62

Pain: - intraepithelial; subperiosteal; - nerve trunk; intravascular Intravascular injection: - arterial; venous Failure of LA: - anatomy; pathology; operator technique Motor nerve paralysis Haematoma formation

Question 63

4 contraindications to LA

Answer 63

in bleeding disorders avoid IDB allergy acute infection care in liver disease - amide dose reduction

Question 64

do nots in behaviour management

Answer 64

``` bribe coax shout bully threaten humiliate lose your patience with the patient allow child to have all their own way ```

Question 65

how to be empathetic to child

Answer 65

create an environment in which the child feels safe use a kind empathetic approach using directive guidance, and reinforcement to establish co-operation and obtain a rapport - praise specific behaviour – opening mouth wide, arms still - enforce specific behaviour allow the child some control (e.g. hand signal, take seriously) question for feeling (are you OK?)

Question 66

techniques is child behaviour management

Answer 66

Positive reinforcement Tell, show, do Acclimatisation Desensitisation Voice control Distraction Role modelling children often focus on negative words like 'pain; or 'hurt' - avoid them

Question 67

what is the safe max dose of ligocaine that can be given to child of 15kg

Answer 67

1.5 cartridges Calculate 1/10th cartridge per kg weight 4mg/kg --> 75mg for 30kg 44mg/cartridge 75/44 = 1.7045 (so 1.5 cartridges)

Question 68

what is a safe and effective way to anaesthetise a lower permanent molar in a 12 year old child with mild haemophilia A

Answer 68

Single tooth anaesthesia using the wand system and articaine with adrenaline - because nerve blocks should be avoided and buccal infiltration with lignocaine alone is less likely to be as effective

Question 69

what is the most common adverse effect when giving LA via an IA Nerve Block

Answer 69

Failure of local anaesthetic to anaesthetise the tooth sufficiently - Although in most cases this should be avoided with careful technique. It can be more difficult to effectively anaesthetise teeth with irreversible pulpitis, periapical abscess or hypomineralised sensitive molars

Question 70

what is the max safe dose of articaine that can be given to a 30kg child

Answer 70

2 cartridges 4.3ml is max safe dose – 1/15 cartridge/kg 7mg/kg --> 210mg for 30kg 88mg/cartridge 210/88 = 2.3863 (so B 2 cartridges)