AnesthEssaysRes.2013JanApr7(1):49.

PMCID:PMC4173488

doi:10.4103/02591162.113977

Anupdateonlocalanesthesiaforpediatricdentalpatients
FaizalC.PeedikayilandAjoyVijayan1
DepartmentofPedodonticsandPreventiveDentistry,KannurDentalCollege,Kannur,KeralaState,India
1
DepartmentofOralandMaxillofacialSurgery,KannurDentalCollege,Kannur,KeralaState,India
Correspondingauthor:Dr.FaizalC.Peedikayil,DepartmentofPedodonticsandPreventiveDentistry,KannurDentalCollege,Kannur,KeralaState,
India.Email:drfaizalcp@gmail.com
Copyright:Anesthesia:EssaysandResearches
ThisisanopenaccessarticledistributedunderthetermsoftheCreativeCommonsAttributionNoncommercialShareAlike3.0Unported,whichpermits
unrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.

Abstract

Goto:

Paincontrolisanimportantpartofdentistry,particularlyinthemanagementofchildren.Behaviorguidance,and
doseandtechniqueofadministrationofthelocalanestheticareimportantconsiderationsinthesuccessfultreatment
ofapediatricpatient.Thepurposeofthepresentreviewistodiscusstherelevantdataontopicsinvolved,andon
thecurrentmethodsavailableintheadministrationoflocalanesthesiausedforpediatricdentalpatients.
Keywords:Localanesthesia,paincontrol,pedodontics
INTRODUCTION

Goto:

Fearrelatedbehaviorshavelongbeenrecognizedasthemostdifficultaspectofpatientmanagementandcanbea
barriertogoodcare.[1]Administeringlocalanesthesiabyinjectionisstillthemostcommonmethodusedin
dentistry.However,thereisaconstantsearchforwaystoavoidtheinvasiveandoftenpainfulnatureofthe
injection,andfindamorecomfortableandpleasantmeansofachievinglocalanesthesiabeforedentalprocedures.
[2,3]
Chemically,thelocalanestheticagentsincommonclinicalusetodaymaybedividedintotwobroadgroups:(A)
agentscontaininganesterlinkingand(B)agentscontaininganamide.Themostcommonlyusedlocalanesthetics
forpediatricdentistryaretheamidetypeagents.Lidocainehydrochloride(HCl)2%with1:100,000epinephrineis
preferredbecauseoftheirlowallergeniccharacteristicsandtheirgreaterpotencyatlowerconcentrations.[4]
Table1showsthedosageper1.8mLcartridgeoflidocaine.
Table1
Dosageperdentalcartridge
Localanestheticcarpulesalsocontainorganicsaltsandmaycontainvasoconstrictors.Vasoconstrictorsareusedto
constrictbloodvessels,counteractthevasodilatoryeffectsofthelocalanesthetic,prolongitsduration,reduce
systemicabsorptionandtoxicity,andprovideabloodlessfieldforsurgicalprocedures.[4,5]Theuseofthe
vasoconstrictorwillallowthemaximumtotaldoseoftheanestheticagenttobeincreasedbynearly40%.[6,7]
Manyagentshavebeenemployedasvasoconstrictorswithlocalanesthetics.Butnonehasprovedtobeasclinically
effectiveasepinephrine.[6]
Themaximumdoseoflidocaineandmepivacaine,withoutvasoconstrictors,recommendedforchildrenis4.4
mg/kgbodyweight,and7mg/kgbodyweightforlidocainewithvasoconstrictors.[8]
Theaveragedurationofpulpalanesthesiais60minutesfor20%lidocainewith1:100,000epinephrine,50minutes
for2%mepivacainewith1:20,000levonordefrin,and25minutesfor3%mepivacainewithoutvasoconstrictor.In

thepresentlocalanestheticagentsused,thesofttissueanesthesiaismorethanthatofpulpalanesthesia.[5]Attempts
havebeenmadetofindagentsthatreducethedurationofsofttissueanesthesia.However,nosuchreductionhas
beenobservedthus,theauthorsrecommendthat2%lidocainewith1:100,000epinephrinebeusedwhen
administeringlocalanesthesiainyoungchildren.
Ifalocalanestheticisinjectedintoanareaofinfection,itsonsetwillbedelayedorevenprevented.[3]The
inflammatoryprocessinanareaofinfectionlowersthepHoftheextracellulartissuefromitsnormalvalue(7.4)to
56orlower.ThislowpHinhibitsanestheticactionbecauselittleofthefreebaseformoftheanestheticisallowed
tocrossintothenervesheathtopreventconductionofnerveimpulses.Insertinganeedleintoanactivesiteof
infectioncouldalsoleadtoapossiblespreadoftheinfection.[3,4,6,8,9]
Safetyoflocalanestheticagentsandadversereaction

Theinherentuseoflocalanestheticinjectionsallowspractitionerstousethemfrequentlywiththeconfidencethat
adverseeventsarerare.[10,11]Themostcommonreactionassociatedwithlocalanestheticsisatoxicreaction,
resultingusuallyfromaninadvertentintravenousinjectionoftheanestheticsolution.[8]Table2showstheadverse
reactiontocommonlyusedlocalanesthetics.
Table2
Adversereactionsofcommonlyusedlocalanesthetics

Overdosereactionsareaparticularriskintreatingchildren.[5,6]Thedosageofthelocalanestheticdependsonthe
physicalstatusofpatient,areatobeanesthetized,vascularityoforaltissues,andthetechniqueofadministration.It
isdifficulttorecommendamaximumdoseforchildrenbecausedosevarieswithfunctionsofageandweight.For
pediatricpatientslessthan10yearswhohaveleanbodymassandnormalbodydevelopment,themaximumdose
maybedeterminedbyapplicationofoneofthestandardformulas(Clarksrule).Inanycase,themaximumdose
shouldnotexceed7mg/kgbodyweightforlidocainewithepinephrineand4.4mg/kgforplainadrenaline.
Toxicityoccursprimarilyinthecardiovascularandcentralnervoussystemthistoxicreactioncouldstimulateor
depressthecentralnervoussystem.Stimulationofthecentralnervoussystemcancauseatoxicvasoconstrictor
reaction,andthesignsandsymptomsaretachycardia,apprehension,sweating,andhyperactivity.Depressionofthe
centralnervoussystemmayfollow,leadingtobradycardia,hypoxia,andrespiratoryarrest.[3,8,10,11,12]
Epinephrineiscontraindicatedinpatientswithhyperthyroidism.[5]Itsdoseshouldbekepttoaminimuminpatients
receivingtricylicantidepressantssincedysrhythmiasmayoccur.Levonordefrinandnorepinephrineareabsolutely
contraindicatedinthesepatients.Patientswithsignificantcardiovasculardisease,thyroiddysfunction,diabetes,or
sulfitesensitivity,andthosereceivingmonoamineoxidaseinhibitors,tricyclicantidepressants,orphenothiazines
mayrequireamedicalconsultationtodeterminetheneedforalocalanestheticwithoutavasoconstrictor[5,10,11]
Localanesthetictoxicitycanbepreventedbycarefulinjectiontechnique,watchfulobservationofthepatient,and
knowledgeofthemaximumdosagebasedonweight.Practitionersshouldaspiratebeforeeveryinjectionandinject
slowly.[11]Earlyrecognitionofatoxicresponseiscriticalforeffectivemanagement.Whensignsorsymptomsof
toxicityarenoted,administrationofthelocalanestheticagentshouldbediscontinued.Additionalemergency
managementisbasedontheseverityofthereaction.
Allergicreactionstolocalanesthesiaarerare.Thelocalanestheticagentwiththehighestincidenceofallergic
reactionsisprocaine.Itsantigeniccomponentappearstobeparaaminobenzoicacid(PABA).Crossreactivityhad
beenreportedbetweenlidocaineandprocaine.Allergiescanmanifestinavarietyofways,someofwhichinclude
urticaria,dermatitis,angioedema,fever,photosensitivity,oranaphylaxis.[8,11,12]Emergencymanagementis
dependentontherateandseverityofthereaction.[13]
Patients,withahistoryofallergytoalocalanesthetic,whocannotidentifythespecificagentused,presenta
problem.Thepatientshouldbereferredforevaluationandtesting,whichwillusuallyincludebothskintestingand
provocativedosetesting(PVT).Forpatientshavinganallergytobisulfates,useofalocalanestheticwithouta
vasoconstrictorisindicated.[8,13]Localanestheticswithoutvasoconstrictorsshouldbeusedwithcautiondueto
rapidsystemicabsorptionwhichmayresultinoverdose.[13,14]

Alongactinglocalanesthetic(i.e.,bupivacaine)isnotrecommendedforthechildorthephysicallyormentally
disabledpatientduetoitsprolongedeffect,whichincreasestheriskofsofttissueinjury.[14]
Paresthesiaispersistentanesthesiabeyondtheexpecteddurationinjuriestotheinferioralveolarnerve(IAN)and
lingualnerve(LN)canbecausedbylocalanalgesicblockinjections.Thenerveinjurymaybephysicalfromthe
needleorchemicalfromthelocalanestheticsolution.Thepatientmayexperienceanelectricshockinthe
involvednervedistributionarea.Paresthesiaalsocanbecausedbyhemorrhageinoraroundthenerve.Reportsof
paresthesiaaremorecommonwitharticaineandprilocainethanexpected,fromtheirfrequencyofuse.Mostcases
resolveineightweeks.[8,15]
Patientmanagementwhileadministeringlocalanestheticinjections

Inchildren,behaviormanagementiscriticaltothesuccessofdentalprocedures.Arelaxedandcalmchildduring
theadministrationoflocalanesthesiaisimportantforthesuccessoftheclinicalprocessaswell.[2,3,4]Many
techniqueshavebeendescribedformanagingchildbehaviorinthedentaloffice,includingbothpharmacological
andnonpharmacologicalmethods.[5]
Techniquesforadministeringthelocalanesthetic Thereisnoperfecttechniquethatguaranteessuccessin

anesthetizingallchildren.However,thereareafewkeyproceduresthataremutualtoalladministrationsthatmay
bevaluabletothesuccessofalltechniques.
Onceachildhasgrabbedthesyringeorbumpedtheoperator'shandanddriventhe
needleintothetissueofthebone,itmaybetoolatetorespond,andalastingimpressionhasbeenmadeinthe
child'smindrelativetopainassociatedwiththelocalanestheticinjection.[4]Therefore,someauthorsrecommend
thatthepractitionershouldhaveacontrolofthechild'sheadandagoodfingerrest,tocontrolthesyringeincase
thechildmovesorresists.Thedentalassistantshouldbepreparedtorestrainthechild'shand,gentlybutfirmly.[16]
Controlofthechild'shead

Topicalanesthesia Theprimarygoalinusingtopicalanesthesiaistominimizethepainfulsensationofneedle

penetrationintothesofttissue.Thetopicalanestheticagentmustbeplacedondriedmucosaandleftinplaceforat
leastoneminutetoachievemaximumeffect.Theonsetdurationoflidocaineis35minutes.Arecentstudywhich
comparedtheefficacyofcommonlyusedtopicalanestheticsdemonstratedthesuperiorityof5%EMLAcream
(eutecticmixtureoflocalanesthesiacontaininglidocaineandprilocaine)overallothertopicalanestheticagents.
Thetopicalanestheticbenzocaineismanufacturedinconcentrationsupto20%lidocaineisavailableasasolution
orointmentupto5%andasasprayupto10%concentration.Localizedallergicreactions,however,mayoccur
afterprolongedorrepeateduse.Topicallidocainehasanexceptionallylowincidenceofallergicreactionsbutis
absorbedsystemicallyandcancombinewithaninjectedamide.[17]
Ashort(20mm)orlong(32mm)27or30gaugeneedlemaybeusedformostintraoral
injectionsinchildren.Anextrashort(10mm)30gaugeneedlehasbeensuggestedformaxillaryanteriorinjections.
Longneedlesarefrequentlyrecommendedforinferiordentalnerveblockanesthesia.However,theclinical
experienceofmanydentistshasshownthatshorterneedlesareadequateandsafeespeciallyfortheyoungdifficult
tomanagedentalpatients.[3,12]
Needlesizeandlength

Injectionoflocalanestheticsshouldalwaysbemadeslowly,precededbyaspirationtoavoid
intravascularinjectionandsystemicreactionstothelocalanestheticagentorthevasoconstrictor.[8,16]
Durationofinjection

Postoperativesofttissueinjury Selfinducedsofttissuetraumaisanunfortunateclinicalcomplicationoflocal

anestheticuseintheoralcavity.Mostlipandcheekbitinglesionsofthisnatureareselflimitingandhealwithout
complications,althoughbleedingandinfectionmaypossiblyresult.[18]
Caregiversresponsibleforpostoperativesupervisionshouldbegivenarealistictimefordurationofnumbnessand
beinformedofthepossibilityofsofttissuetrauma.
Failureinlocalanesthesia Anumberoffactorscontributetothefailureoflocalanesthesia.Thesemayberelated

eithertothepatientortheoperator.Operatordependentfactorsare(a)badchoiceoflocalanestheticsolutionand
(b)poortechnique.
Patientdependentfactorsare(a)anatomicalvariations,(b)thepresenceofinfection,thatis,theacidicenvironment

preventsthelocalanestheticagentfromreachingandpenetratingthenerve,and(c)psychogenicfactors,thatis,
severeanxietymayinfluencepainperception.[10,19,20]
Whenalocalanestheticfails,generally,itisbesttorepeattheinjectionthiswilloftenleadtosuccess.Inthecaseof
repeatblockinjections,itiseasiertopalpatebonylandmarksatthesecondattemptastheneedlecanbe
maneuveredinthetissuespainfully.[19]
Conventionalmethodsofobtaininglocalanesthesia

Infiltrationisthechoicetoanaesthetizemaxillaryteethsuccessfully.Inthiscase,theneedleshouldpenetratethe
mucobuccalfoldandbeinsertedtothedepthoftheapicesofthebuccalrootsoftheteeth.Thesolutionisdeposited
supraperiosteallyandinfiltratesthroughthealveolarbonetoreachtherootapex,asthealveolarboneinchildrenis
morepermeablethanitisinadults.Alittlelocalanestheticmaybesufficienttoproduceanesthesiaofteeth.[21]
Stretchingthemucosaoftheinjectionsiteandgentlypullingontotheobliquelyplacedbeveloftheneedleis
recommendedforbuccalinfiltrations.Insodoing,theinitialneedlepenetrationisshallow.Asmallamountof
solutionhastobeinjectedintothesuperficialmucosa.Afterafewseconds,theneedlecanbeslowlyadvanced12
mmandafteranegativeaspiration,anothersmallamountofsolutioncanbedeposited.Thisshouldberepeated
untiltheremaininganestheticsolutioniscompletelyinjected.[21]
Anesthesiaofthemandibularprimarymolarsmayusuallybeachievedbyinfiltrationinchildrenuptotheageof
fiveyears.Afewstudieshaveevaluatedtheeffectivenessofmandibularinfiltrationasapossiblealternativeto
mandibularblockfortherestorationofprimarymolars.Nosignificantdifferencesbetweeninfiltrationandblock
werefound.Inaddition,thequalityofanesthesiawasnotsignificantlyrelatedtotoothlocation,age,ortypeof
anestheticagent.[22]
Mandibularblockisthelocalanesthesiatechniqueofchoicewhentreatingmandibularprimaryorpermanent
molars.Depthofanesthesiahasbeentheprimaryadvantageofthistechnique.Anesthesiaofallthemolars,
premolars,andcaninesonthesamesideofinjectionallowsfortreatingmultipleteethofthesamequadrantatone
appointment.Fortheinferioralveolarblock,thechildisrequestedtoopenhismouthaswideaspossiblewhilethe
operatorpositionstheballofthethumbonthecoronoidnotchoftheanteriorborderoftheramus.Theneedleis
insertedbetweentheinternalobliqueridgeandthepterygomandibularraphe.[23]Thepositionoftheforamen
changeswiththechild'sage:Inayoungchild(4yearsoldandyounger)theforamenissometimeslocatedbelow
theplaneofocclusion.Inayoungchild,theforamenislocatedontheocclusalplane.Asthechildmatures,it
movestoahigherposition.[5,24]
Thebarrelofthesyringeoverliesthetwoprimarymandibularmolarsontheoppositesideofthearchandparallelto
theocclusalplane.Inthiscase,asmallamountofsolutionshouldbeinjectedand,afteranegativeaspirate,the
needleshouldadvanceuntilbonycontactismade,verygentlyandslowly.Whentheinferioralveolarnerveblock
maynotadequatelyanesthetizetheteeth,longbuccalanesthesiaisrequired.Thisisachievedbyinfiltratingafew
dropsoftheanestheticintothebuccalsulcusjustposteriortothemolars.[5,22]
Theintraligamentaryinjectionisgivenintotheperiodontalligamentusingasyringespeciallydesignedforthe
purpose.Intraligamentaryinjectionsalsocanbegivenwithaconventionalneedleandsyringe.Inthistechnique,the
needleisinsertedatthemesiobuccalaspectoftherootandadvancedinformaximumpenetration.Theneedledoes
notpenetratedeeplyontotheperiodontalligamentbutiswedgedatthecrestofthealveolarridge.A12mm30
gaugeneedleisrecommended,andthebevelshouldfacethebone,althougheffectivenessisnotimpairedwith
differentorientation.Intraligamentaryanesthesiahaslimitationsasaprincipalmethodofanesthesia,duetothe
variableduration,buthasbeenusedtoovercomefailedconventionalmethodsorasanadjunct.[24]Intraligmentary
injectionsproducesignificantbacteremiaandthereforeshouldnotbegiventoapatientattheriskofinfective
endocarditisunlessappropriateantibioticprophylaxishasbeenprovided.[25]
Theintrapulpalmethodachievesanesthesiaasaresultofpressure.Salinehasbeenreportedtobeaseffectiveasan
anestheticsolutionwheninjectedintrapulpally.Whenasmallaccesscavityisavailableintothepulp,aneedle
whichfitssnuglyintothepulpisusedandasmallamount(about0.1mL)ofsolutionisinjectedunderpressure.
Therewillbeaninitialfeelingofdiscomfortduringthisinjectionhowever,thisistransientandanestheticonsetis
rapid.Whentheexposureistoolargetoallowasnugneedletofit,theexposedpulpshouldbebathedinalittle

localanestheticforaboutaminutebeforeintroducingtheneedleasfarapicallyaspossibleintothepulpchamber
andinjectingunderpressure.[26]
Intraligamentaryanesthesiahasaroletoplayinlocalanesthesiainmoderndentistrybutitdoesnotfulfilallthe
requirementsforaprimarytechnique.Aswithtraditionalmethodsofobtainingorallocalanesthesia,thealternative
methodsgenerallyaresafeifthepractitionerunderstandstheprinciplesfortheiruse.Alternativetechniquesforthe
deliveryoflocalanesthesiamaybeconsideredtominimizethedoseofanestheticused,improvepatientcomfort,
and/orimprovesuccessfuldentalanesthesia.Someofthesetechniquesaredesirable,especiallyininfants,children,
adolescents,andpatientswithspecialhealthcareneeds,sincespecificteethmaybeanesthetizedwithlessresidual
anesthesia(i.e.,avoiddiscomfortandpotentialselfmutilationofblockanaesthesia).Themandibularboneofachild
usuallyislessdensethanthatofanadult,permittingmorerapidandcompletediffusionoftheanesthetic.
Mandibularbuccalinfiltrationanesthesiaisaseffectiveasinferiornerveblockanesthesiaforsomeoperative
procedures.Inpatientswithbleedingdisorders,thePDLinjectionminimizesthepotentialforpostoperative
bleedingofsofttissuevessels.Intraosseoustechniquesmaybecontraindicatedwithprimaryteethduetothe
potentialfordamagetodevelopingpermanentteeth.Also,theuseoftheperiodontalligamentinjectionor
intraosseousmethodsiscontraindicatedinthepresenceofinflammationorinfectionintheinjectionsite.
[5,10,16,21,27]
Newtechniquesforobtaininglocalanesthesia
Computerizedlocalanesthesia TheWandsystemconsistsofadisposablehandpiececomponentandacomputer

controlunit.Thehandpieceisanultralightpenlikehandlewhichislinkedtoaconventionalanestheticcartridge
withplasticmicrotubing.
Thecoretechnologyisanautomaticdeliveryoflocalanestheticsolutionatafixedpressurevolumeratiois
regardlessofvariationsintissueresistance.Thisresultsinacontrolled,highlyeffective,andcomfortableinjection
eveninresilienttissuessuchasthepalateandperiodontalligament.WhiletheWandhasbeenshowntoreduce
thepainassociatedwiththedeliveryoftheanestheticsolution,thetimeinvolvedintheprocedureappearstonegate
theeffectivenessofthedeviceareviewofcomputercontrolleddeliverydevicesaswellasotheralternative
anesthesiadeliverymethodsfoundthattheyeachpresentadversesideeffectsandgenerallyaremoreexpensive
thanconventionalmethods.[28,29]
Electronicdentalanesthesia Theconceptofelectronicdentalanesthesia(EDA)involvestheapplicationofelectric

currentthatloadsthenervestimulationpathwaytotheextentthatpainstimulusisblocked.Areviewofthe
literatureshowsasignificantreductioninpainobservedduringallthedentalproceduresconductedunderTENS
(TENS:Transcutaneouselectricalnervestimulator).Thus,TENSshouldbeconsideredasausefuladjunctinthe
treatmentofpediatricpatientsduringvariousminordentalprocedures.[29,30]
TherearemedicalcontraindicationstotheuseofEDA:Patientswithapacemakerorcochlearimplant,heart
disease,seizuredisorders,orcerebrovasculardisease,headtumor,neurologicaldisordersinvolvingtheheadand
neck(e.g.,Bell'spalsy,trigeminalandpostherpeticneuralgia,multiplesclerosis,orTourette'ssyndrome),skin
lesionsorabrasionsontheface,andpatientswithabnormalbruisingorbleedingdisorder.[31]
Theseareanestheticpatchescontainingalidocainebasethatisdispendedthrougha
bioadhesivematrixandapplieddirectlytotheoralmucosa.Thesepatchesareavailablein10and20%
concentrations,eachcontainingapproximately23and416mgoflidocaineandcanreducethepainofinsertionof
needle.[29,32]
Intraorallidocainepatch

Thisinstrumentwasdevelopedtoachievelocalanesthesiafordentalprocedureswithouttheuseofa
needle.Thisisaccomplishedbydeliveringtheanestheticsolutionunderhighcompressiveforces.Anumberof
uncontrolledstudiesofneedlelessdeviceshaveexaminedadultandchildpatients,typicallyfocusingonthe
anestheticpropertiesofthedeviceused.Inthesestudies,thepercentageofpatientswhoobtainedsufficient
anesthesiawiththedevicesrangedfromabout50toabout90%.[33]Traditionalinfiltrationwasmoreeffective,
acceptable,andpreferred,comparedwiththeneedlelessinjection.[34]
Jetinjection

CONCLUSION

Goto:

Localanesthesiaformsthebackboneofpaincontroltechniquesindentistryandhasamajorroleindentistryfor
children.Thereisaconstantsearchforwaystoavoidtheinvasiveandoftenpainfulnatureoftheinjection,andto
findamorecomfortableandpleasantmeansofachievinglocalanesthesiabeforedentalprocedures.Despitethe
recentinnovations,theinjectionremainsthemethodofchoiceinprovidinglocalanesthesia.
Footnotes

Goto:

SourceofSupport:Nil
ConflictofInterest:Nonedeclared.

REFERENCES

Goto:

1.MilgromP,ColdwellSE,GetzT,WeinsteinP,RamsayDS.Fourdimensionsoffearofdentalinjections.JAm
DentAssoc.1997128:75666.[PubMed]
2.DowerJS,Jr,SimonJF,PeltierB,ChambersD.Patientswhomakeadentialmostanxiousaboutgiving
injections.JCalifornianDentAssoc.199523:3440.[PubMed]
3.SimonJF,PeltierB,ChanbersD,DowerJ.Dentiststroubledbytheadministrationofanestheticinjections:
Longtermstressandeffects.QuintInt.199425:6416.[PubMed]
4.TroutmanKC.PharmacologicManagementofpainandanzietyforpediatricpatients.In:WeiSH,editor.
PediatricDentistryTotalPatientCare.Philadelphia,PA:LeaandFebbiger1985.pp.15662.
5.WilsonSW,DilleyDC,VannWF,Jr,AndersonJA.Painandanxietycontrol(Partl:Painperceptioncontrol)In:
PickhamJ,CasmassinnoPS,FieldHW,MctigueDJ,NowakA,editors.PediatricDentistry,InfancyThrough
Adolescesce.3rded.Philadelphia,PA:WBSaunders1999.pp.10815.
6.ScottDB,JebsonPJ,BraidDP,PrtengrenB,FrishP.Factorsaffectingplasmalevelsoflignocaineand
prilocaine.BrJAnaesth.197244:10409.[PubMed]
7.CannellH,WaltersH,BeckettAH,SaundersA.Circulatinglevelsoflignocaineafterperioralinjections.Br
DentJ.1975138:8793.[PubMed]
8.MalamedSF.HandbookofLocalAnesthesia.5thed.St.Louis,Mo:Mosby2004.Localcomplicationspp.
2857.
9.HershEV,HermannDG,LampCI.Assessingthedurationofmandibularsofttissueanesthesia.JAmDent
Assoc.1995126:15316.[PubMed]
10.MalamedSF.HandbookofLocalAnesthesia.5thed.St.Louis,Mo:Mosby2004.Pharmacologyof
vasoconstrictorspp.4154.
11.JeskeAH,BlantonPL.Misconceptionsinvolvingdentallocalanesthesia.Part2:Pharmacology.TexDentJ.
2002119:3104.[PubMed]
12.HaasDA.Anupdateonlocalanestheticsindentistry.JCanDentAssoc.200268:54651.[PubMed]
13.ScottDB.Toxicitycausedbylocalanestheticdrugs.BrJAnaesth.198153:5534.[PubMed]
14.YagielaJA.Adversedruginteractionsindentalpractice:Interactionsassociatedwithvasoconstrictors.JAm
DentAssoc.1999130:7019.[PubMed]
15.HaasDA,LennonD.A21yearretrospectivestudyofreportsofparesthesiafollowinglocalanesthetic
administration.JCanDentAssoc.199561:319.[PubMed]
16.AmericanAcademyofPediatricDentistry(www.aapd.org)GuidelineonUseofLocalAnesthesiaforPediatric
DentalPatients.ClinicalGuidelines,referencemanual.2009.availablefrom
www.aapd.org/media/policies_guidelines/g_localanesthesia.pdf.
17.KravitzND.Theuseofcompoundtopicalanesthetics:Areview.JAmDentAssoc.2007138:13339.
[PubMed]

18.ChiD,KanellisM,HimadiE,AsselinME.Lipbitinginapediatricdentalpatientafterdentallocalanesthesia:
Acasereport.JPediatrNurs.200823:4903.[PMCfreearticle][PubMed]
19.BoronatLpezA,PearrochaDiagoM.Failureoflocoregionalanesthesiaindentalpractice.Reviewofthe
literature.MedOralPatholOralCircBucal.200611:E5103.[PubMed]
20.WongMK,JacobsenPL.Reasonsforlocalanesthesiafailures.JAmDentAssoc.1992123:6973.[PubMed]
21.OgleOE,MahjoubiG.LocalAnesthesia:Agents,Techniques,andComplications.DentClinNorthAm.
201256:13348.[PubMed]
22.WrightGZ,WeinbergerSJ,MartiR,PlotzkeO.Theeffectivenessofinfiltrationanesthesiainthemandibular
primarymolarregion.PediatrDent.199113:27883.[PubMed]
23.OulisC,VadiakasG,VasilopoulouA.Theeffectivenessofmandibularinfiltrationcomparedtomandibular
blockanesthesiaintreatingprimarymolarsinchildren.PediatrDent.199618:3015.[PubMed]
24.MalamedSF.HandbookofLocalAnesthesia.5thed.St.Louis,Mo:Mosby2004.Anatomicalconsiderations
pp.1734.
25.RobertsGJ,HolzelHS,SuryMR,SimmonsDentalbacteremiainchildren.PedCardiol.199718:247.
[PubMed]
26.VanGheluweMS,WaltonR.Intrapulpalinjection.Factorsrelatedtoeffectiveness.OralSurg.199783:3840.
[PubMed]
27.MeechanJG.Howtoovercomefailedlocalanaesthesia.BrDentJ.1999186:1520.[PubMed]
28.KoyuturkAE,AvsarA,SumerM.Efficacyofdentalpractitionersininjectiontechniques:Computerized
deviceandtraditionalsyringe.QuintessenceInt.200940:737.[PubMed]
29.BlantonPL,JeskeAH.Dentallocalanesthetics:Alternativedeliverymethods.JAmDentAssoc.
2003134:22834.[PubMed]
30.HarveyM,ElliottM.Transcutaneouselectricalnervestimulationforpainmanagementduringcavity
preparationsinpediatricpatient.ASDCJDentchild.199562:4951.[PubMed]
31.DhindsaA,PanditIK,SrivastavaN,GugnaniN.Comparativeevaluationoftheeffectivenessofelectronic
dentalanesthesiawith2%lignocaineinvariousminorpediatricdentalprocedures:Aclinicalstudy.ContempClin
Dent.20112:2730.[PMCfreearticle][PubMed]
32.HershEV,HouptMI,CooperSA,FeldmanRS,WolffMS,LevinLM.Analgesicefficacyandsafetyofan
intraorallidocainepatch.JAmDentAssoc.1996127:162634.[PubMed]
33.RamD,PeretzB.Administeringlocalanaesthesiatopaediatricdentalpatientscurrentstatusandprospectsfor
thefuture.IntJPaediatrDent.200212:809.[PubMed]
34.DabarakisNN,AlexanderV,TsirlisAT,ParissisNA,NikolaosM.Needlelesslocalanesthesia:Clinical
evaluationoftheeffectivenessofjetanesthesiaInjexinlocalanesthesiaindentistry.QuintessenceInt.
200738:5726.[PubMed]
ArticlesfromAnesthesia,EssaysandResearchesareprovidedherecourtesyofMedknowPublications