essay 13 - anaesthesia in children- characteristics. Features of regional anaesthesia in oral and maxillofacial areas in inflammatory processes

Characteristics of anaesthesia in children

• children will undergo early painful experiences during dental procedures are likely to carry negative feelings towards dentistry into adulthood

• the best way to reduce pain during dental procedures in children is through injection of local anaesthetics

• the clinician should be aware of:

— anaesthetic overdose

— self induced traumatic injuries related to prolonged duration of soft tissue anaesthesia (tongue/lip biting)

— technique variations related to the smaller skulls and different anatomy in paediatric patients

describe the pharmacokinetics of local anaesthesia

• local anaesthetics bind to alpha 1 acid glycoproteins in plasma (AAG)

• neonates have 20-40% less AAG than adults. this can lead to higher serum levels of unbound local anaesthetic (high toxicity)

• infants have decreased clearance and a longer elimination of half life of local anaesthetic

describe the developmental and anatomic differences

• myelination is complete after 12 years of age. decrease myelination means increased penetration of local anaesthetics into the nerve fibres

• loose facial attachments in children around the nerves facilitates the spread of local anaesthetic. A regional block in children may spread further. the duration of nerve block may be shortened

describe the tell, Show, do technique

• verbal explanation of procedures= tell

• demonstration= show

• completion of procedure = do

• objectives; teach the patient and shape their response

• medication to decrease anxiety; diazepam 0.1mg/kg, orally, 30-40 mins before local anaesthesia

• assemble the syringe in view of patient in order to desensitise them, or out of their view to reduce psychological discomfort

administration

• control and limit movement (assistant restrains hands by asking children to play them on their belly button), communicate with patient (in a reassuring manner, and explain the process by storytelling, singing or counting)

basic injection technique

• stretching the tissue tight so that it is not loose or wrinkled

• insert needle 1-2mm into mucosa

• Bevel is orientated towards the bone

• inject several drops of anaesthetic before advancing the needle

• slowly advance the needle toward while injecting up to 1/4 carpule of anaesthetic

• aspirate and inject slowly

• continue to speak to patient throughout the injection process

• reward the patient immediately after successfully completing a segment of treatment

• observe for; blanching of skin, signs of allergic reaction, vasopressor reaction

list the specific injection techniques

• supraperiosteal injection (local infiltration)

• inferior alveolar nerve block

• posterior superior alveolar nerve block

• periodontal ligament injection (intraaligimentary injection)

describe the suprapariosteal injection

1. indications

• localised dental procedures in Maxilla or mandible ( especially in children <14-15 years)

• Pulpal anaesthesia of maxillary teeth, mandibular anterior teeth, Mandibular Primary molars (1-2 teeth)

2. advantages: effective in children due to thin porous bone

3. Contra indication: infection or acute inflammation at injection site

4. limitation: not suitable for large areas (REQUIRES MULTIPLE injections, risk of toxicity)

describe the suprapariosteal injection of mandibular molars

• effective for restorations, less effective than block anaesthesia for extractions or pulpotomies

• technique Technique: retract cheek → topical anaesthetic→ bevel toward bone → inject in mucobucal fold between roots → ½ carpule anaesthetic

describe the suprapariosteal injection of mandibular incisors

• Technique: retract cheek→ topical anaesthetic→ inject near mucogingival junction, across midline →1/2 carpule anesthetic

describe the suprapariosteal injection of the maxillary incisors and canines

• Technique: inject labially near apex → if needed, supplement palatal tissue anaesthesia via nasopalatine block or papillary infiltration

describe the suprapariosteal injection of maxillary molars and premolars

• areas anaesthetised: Pulp of Molars and premolars, buccal soft tissues and bone

• Technique: inject at height of muco buccal fold above root apices → ½ - 2/3 carpule anesthetic

• palatal anaesthesia: Achieved via local infiltration or Greater Palatine Nerve block

describe inferior alveolar nerve block

1. indications:

• procedures on multiple mandibular teeth

• the need for buccal or lingual soft tissue anaesthesia

2. children's atomical differences: Mandibular foramen is located lower and more anterior and young children → injection is made slightly lower and more posterior than in adults

3. contraindications: infection at injection site. high risk of self biting (young children, mentally handicapped)

describe periodontal ligament injection

1. uses:

• primary anaesthesia for 1-2 teeth

• supplemental anaesthesia to avoid soft tissue numbness

2. advantages:

• minimal soft tissue anaesthesia

• useful for bilateral treatment, bleeding disorders

3. contraindications: caution In primary Teeth were developing permanent successors (risk of enamel hypoplasia)

4. Technique: small volume (0.2ml) injected into Gingival sulcus along root surface

describe local anaesthetics for children - the preferred ones and doses

1. articaine (fast onset, low toxicity) - maximum dose: 5 mg/kg (example: 30kg child → max 150 mg → ~ 2 cartridges (each cartridge ~ 68 mg))

2. adrenaline usage (sander’s recommendation): some authors recommend avoiding adrenaline use in children <4-5 years

• 2 years = 0.2ml

• 3-4 years = 0.25 ml

• 5-6 years = 0.4 ml

• 7-9 years = 0.5 ml

• 10-14 years = 0.75 ml

• over 14 years = 1 ml

List The changes in the human body caused by acute inflammation

• intoxication

• dehydration

• compromised respiratory function

• impaired redox processes

• decrease PH - acidosis

• increase coagulation

• sensibilization - allergy

what are anaesthesia requirements in patients with acute inflammation

• not to suppress breathing

• not to violate the passibility of the upper Airways

• not to increase intoxication

• not to deteriorate general and local condition

• to provide adequate anaesthesia

describe local anaesthesia use during acute inflammation

• prefer technique is nerve block anaesthesia

• local anaesthesia in acute inflammation is with delayed onset and shorter duration

• it is recommended to use higher concentrations of local anaesthetics in maximum amounts

• the information causes nerve hyperalgesia (a low threshold stimulation results in pain)

• some authors believe that the nerve in the inflammatory area is in parabiosis (temporary inactive physiological condition)

• they use anaesthetics with lower concentrations for nerve deblocking; an anaesthetic with the usual concentration is applied after 20 - 30 mins

what is the preferred type of technique for anaesthesia in inflammatory Soft tissues

• infiltration anaesthesia is a preferable aesthetic technique in inflammatory soft tissues

• the needle is inserted into two points, and an anaesthetic agent is deposited along four imaginary lines that surround the area that has been anaesthetised (Hackenbruch’s rhomb)

to anaesthesia is performed according to Verlotski's rules

1. do not deposit anaesthetics into the inflammatory area (injection into the inflammatory tissues increases the pressure and causes strong pain; PH in inflammatory tissues is lower and because of that, the anaesthetic effect is unsatisfactory)

2. do not pass the needle through the inflammatory tissues (there is a risk of infections spreading into surrounding tissues)

3. insert the needle only to healthy tissues