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International Journal of Paediatric Dentistry 2002; 12: 80 – 89

Administering local anaesthesia to paediatric dental patients – current status and prospects for the future

Blackwell Science Ltd

D. RAM & B. PERETZ Department of Paediatric Dentistry, The Hebrew University Hadassah School of Dental Medicine, Jerusalem, Israel

Summary. Fear-related behaviours have long been recognized as the most difficult aspect of patient management and can be a barrier to good care. Anxiety is one of the major issues in the dental treatment of children, and the injection is the most anxietyprovoking procedure for both children and adults. There is a constant search for ways to avoid the invasive, and often painful, nature of the injection, and to find more comfortable and pleasant means for anaesthesia before dental procedures. Objective. The purpose of the present review is to summarize relevant data on topics connected with the administration of local anaesthesia. Methods. The review will survey the current available methods, viz. electronic anaesthesia, lidocaine patch, computerized anaesthesia (the Wand), and the syrijet as well as the conventional injection, used for paediatric patients. Conclusions. Usually new techniques for locally anaesthetizing dental patients are tested on adults. However, despite recent research in the field, the injection remains the method of choice. It is necessary to continue to conduct studies using new techniques on adults and children, so that a more acceptable technique can be found. Keywords: anaesthetic agents, children, local anaesthesia, techniques

Introduction Pain control is an important part of dentistry and particularly of paediatric dentistry. Fear-related behaviour has long been recognized as the most difficult aspect of patient management and can be a barrier to good care [1]. While patients’ fears may be acquired through vicarious experiences and threatening information, direct experience is the most common source of dental fear. It is ironic that local anaesthesia allows virtually pain-free treatment, yet is associated with many anxious thoughts and misconceptions in young patients [1]. Administering local anaesthetic injection may not only provoke anxiety in patients, but also in the dentist. In a study in California, Dower et al. [2] found

that 16% of the dentists polled, identified giving an injection to children as the most anxiety-provoking task. Another study has shown that, at least sometimes, the idea of giving injections may have been a reason for some dentists to reconsider dentistry as a career [3]. Administering local anaesthesia by injection is still the most common method used in dentistry. However, there is a constant search for ways to avoid the invasive and often painful nature of the injection, and to find a more comfortable and pleasant means of producing local anaesthesia before dental procedures. The purpose of the present review is to summarize relevant data on topics involved in the administration of local anaesthesia, and on the current available methods used for paediatric dental patients. Commonly used local anaesthetic agents

Correspondence: Professor B. Peretz, Department of Pediatric Dentistry, The Hebrew University Hadassah School of Dental Medicine, P.O. Box 12272, Jerusalem, Israel. E-mail: [email protected]

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Chemically, the local anaesthetic agents in common clinical use today may be divided into two broad © 2002 BSPD and IAPD

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groups: (1) agents containing an ester linkage, and (2) agents containing an amide linkage. The most commonly used local anaesthetics for paediatric dentistry are the amide-type agents: lidocaine HCl 2% with 1 : 100 000 epinephrine, mepivacaine HCl 2% with 1 : 20 000 levonordfrine, mepivacaine HCl 3%, prilocaine HCl 4%, and prilocaine HCl 4% with 1 : 200 000 epinephrine [4]. These agents are preferred because of their reduced allergenic characteristics and their greater potency at lower concentrations. Local anaesthetic carpules also contain preservatives, organic salts, and may contain vasoconstrictors. Preservatives like methylparabene may be one of the sources of allergic reactions. Vasoconstrictors are used to constrict blood vessels, counteract the vasodilatory effects of the local anaesthetic, prolong the duration of the anaesthetic, reduce systemic absorption and toxicity and to provide a bloodless field for surgical procedures [5]. The use of a vasoconstrictor will allow the maximum total dose of the anaesthetic agent to be increased by nearly 40% [6,7]. Many agents have been employed as vasoconstrictors with local anaesthetics, but none has proved to be as clinically effective as epinephrine. The maximum dose of lidocaine and mepivacaine with vasoconstrictors recommended for children is 4·4 mg/kg [8]. The average duration of pulpal anaesthesia is 60 min for 2% lidocaine 1 : 100 000 epinephrine, 50 min for 2% mepivacaine 1 : 20 000 levonordefrin, and 25 min for 3% mepivacaine. On the other hand, for soft tissues, the duration of the anaesthesia is 170 min for 2% lidocaine 1 : 100 000 epinephrine, 130 min for 2% mepivacaine 1 : 20 000 levonordefrin, and 90 min for 3% mepivacaine [9]. Attempts have been made to find agents that reduce the duration of soft tissue anaesthesia [10]. However, no such reduction has been observed, thus the authors recommend that 2% lidocaine with 1 : 100 000 epinephrine be used when performing local anaesthesia in young children. Mechanism of action of local anaesthetic agents A stimulus, activating specific receptors at nerve endings, produces nerve impulses, or action potentials, causing pain. The nerve impulses travel along the nerve fibres via a mechanism that involves ion transport across the neuronal membrane. The primary

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effect of local anaesthetic agents is to penetrate the nerve cell membrane and block receptor sites that control the influx of sodium ions associated with membrane depolarization [8]. The rapid and predictable response to local anaesthetic agents in most patients may suggest that once a critical concentration of local anaesthetic reaches the nerve, impulse conduction through that nerve is blocked in an all-or-none fashion. This mistaken notion gives rise to other common clinical misconceptions such as: ‘If the lip and tongue are numb to the level of the midline, the tooth has to be numb’, or ‘If an explorer can be run through the buccal and lingual gingiva without pain, he’s obviously just imagining the tooth pain’ [9]. Most of what we know about the physiology of local anaesthetic block is derived from in-vitro experiments of isolated axon preparations. An axon bundle consists of many hundreds of axons which are surrounded by other bundles of axons. Each bundle is wrapped in a tough layer of connective tissue sheathing. The bundles are supplied by an intraneural vascular system and supported by additional connective tissue infrastructure. For the conduction of nerve impulses to be blocked, an adequate concentration of local anaesthetic must diffuse through all of these tissues before reaching the axonal membrane. At that point, if enough of the solution remains in an uncharged form it diffuses into the axon and acts on a sufficient number of axons until impulse conduction is blocked. The most important factor in this process is having a sufficient concentration of local anaesthetic deposited close to the neuronal membrane, enabling diffusion to the nerve [9]. When the child feels pain during a clinical procedure despite all signs of a successful block, it is often due to an insufficient number of axons within the nerve being blocked. This problem could be overcome by allowing enough time to elapse for anaesthesia to take place. A phenomenon, termed tachyphylaxis , implies that the nerve becomes resistant to subsequent injections, meaning that subsequent blocks in the same area are often less effective, and shorter in duration, than the original block. In order to avoid tachyphylaxis and to maintain profound anaesthesia , administration of an additional onequarter to one-half of the initial dose has been recommended when pulpal anaesthesia is expected to fade, even though the patient does not complain of pain [9].

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Safety of local anaesthetic agents and adverse reactions The inherent use of local anaesthetic injections allows practitioners to use them frequently with the confidence that adverse events are rare [11,12]. The most common reaction associated with local anaesthetics is a toxic reaction, resulting usually from an inadvertent intravenous injection of the anaesthetic solution. Overdose reactions are a particular risk when treating children because the toxic threshold is directly proportional to body-weight. Toxicity is dose dependent and occurs primarily in the cardiovascular and central nervous system. This toxic reaction could stimulate or depress the central nervous system. Stimulation of the central nervous system can cause a toxic vasoconstrictor reaction, and the signs and symptoms are: tachycardia, apprehension, sweating, and hyperactivity [13]. Depression of the central nervous system may follow leading to bradycardia, hypoxia and respiratory arrest. A recent study, on immediate complications in 1007 consecutive adult patients, demonstrated that local anaesthetic injections properly carried out appear to be safer today than they were in the past [14]. The study evaluated the prevalence of positive blood aspiration, blanching of the tissue and burning sensation on impingement of the nerve [14]. The findings demonstrated that in 2·9% of injections there was blood aspiration but without any complications, and in 2·5% the dentist touched the nerve, and the patient reported feeling an electric current sensation (mostly with inferior alveolar block). The most severe complication from an injection of local anaesthetic, syncope, occurred only in one case. According to our knowledge no similar study has been conducted in children. A possible reason for complications is overdose of local anaesthetic agent. Brent [15] reported on an 8-year-old girl who recovered after an overdose of local anaesthetic administered for the placement of sealants. Hersh et al. [16] reported on a 5-year-old girl who died after an overdose of local anaesthesia for multiple extractions. Allergic reactions to local anaesthesia are rare. The local anaesthetic agent with the highest incidence of allergic reactions is procain. Its antigenic component appears to be para-aminobenzoic acid (PABA), one of the metabolic breakdown products of procaine. Cross-reactivity has been reported between lidocaine and procaine [13]; this was traced

to the presence of a germicide, methylparaben, which is used in small amounts as a preservative and is chemically similar to PABA. True allergic reactions to local anaesthetics commonly used in dentistry (amides) are rare. Patients, with a history of allergy to local anaesthetic, who cannot identify the specific agent used, present a problem. The patient should be referred for evaluation and testing, which will usually include both skin testing and provocative dose testing (PVT) [13]. Patient management while administering local anaesthetic injections In children, behaviour management is critical to the success of paediatric dental procedures. A relaxed and calm child during the administration of local anaesthesia is important for the success of the clinical process as well. Many techniques have been described for managing child behaviour in the dental office, including both pharmacological and nonpharmacological methods. The child who requires dental treatment is, frequently, not capable of cooperative behaviour. The challenge facing clinicians is to provide an environment that allows technically complex dental treatment, starting with the injection of local anaesthetic, to be delivered without inflicting adverse psychological or physical harm to the child or others. Behavioural / non-pharmacological approach Non-pharmacological methods may include Tell Show Do, desensitization, modelling, reframing, distraction, and hypnosis [17–19]. These techniques are effective in reducing the pain and anxiety associated with dental procedures. With regard to hypnosis, it has been found to have a positive impact on paediatric patients and may serve as a good adjunct to the delivery of a local anaesthetic [20]. Pharmacological approach Although non-pharmacological behavioural techniques are preferred to manage children, these techniques are sometimes not effective alone in overcoming the anxiety of extremely fearful, very young, uncooperative children. In such situations, non-pharmacological techniques may need to be supplemented with pharmacological intervention to calm or sedate the child [9].

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Pharmacological management involves a broad spectrum of agents administered in a variety of ways (e.g. oral, parenteral, and inhalation routes).

shown that shorter needles are adequate and safe especially for the young, difficult to manage child [4].

Techniques for administering local anaesthetic

Duration of injection

There is no perfect technique that guarantees success in anaesthetizing all children. However, there are a few key procedures that are mutual to all administrations that may be valuable to the success of all techniques.

Injection of local anaesthetics should always be made slowly, preceded by aspiration to avoid intravascular injection and systemic reactions to the local anaesthetic agent or the vasoconstrictor [4,23]. One study has found that there was no evidence to suggest that varying the time to administer 1·8 mL of local anaesthetic between 36 and 161 s affects the behaviour of the children or the success of the anaesthesia [24]. Jones et al. [25] found an inverse correlation between subjective injection pain and injection duration, viz. that slow injections are less painful. In addition, they found that inferior dental nerve blocks were rated significantly more painful than buccal infiltrations.

Control of the child’s head Once a child has grabbed the syringe or bumped the operator’s hand and driven the needle into the tissue or the bone, it may be too late to respond, and a lasting impression has been made in the child’s mind relative to the pain associated with local anaesthetic injection [21]. Therefore, some authors recommend that the practitioner should have a control of the child’s head, and a good finger rest, to control the syringe in case the child moves or resists. The dental assistant should be prepared to restrain the child’s hands, gently but firmly. Topical anaesthesia The primary goal in using a topical anaesthesia is to minimize the painful sensation of needle penetration into the soft tissue. Topical anaesthetic agent must be placed on dried mucosa and left in place for at least 1 min to achieve maximum effect [19]. Onset duration of lignocaine is 3–5 min, of tetracaine is about 60 s, and of benzocaine is about 30 s. A recent study which compared the efficacy of commonly used topical anaesthetics demonstrated the superiority of 5% EMLA cream (eutactic mixture of local anaesthesia containing lidocaine and prilocaine) to all other topical anaesthetic agents [22].

Failure in local anaesthesia A number of factors contribute to failure of local anaesthesia. These may be related either to patient or the operator. Operator-dependent factors are: (1) bad choice of local anaesthetic solution and (2) poor technique. Patient-dependent factors are: (1) anatomical variations, (2) presence of infection, i.e. the acidic environment prevents the local anaesthetic agent reaching and penetrating the nerve, and (3) psychogenic factors, i.e. severe anxiety may influence pain perception [30–32]. When a local anaesthetic fails, generally, it is best to repeat the injection; this will often lead to success. In the case of repeat block injections it is easier to palpate bony landmarks at the second attempt as the needle can be manoeuvred in the tissues painlessly. Conventional methods of obtaining local anaesthesia

Needle size and length A short (20 mm) or long (32 mm) 27- or 30gauge needle may be used for most intraoral injections in children. An extra-short (10 mm) 30-gauge needle has been suggested for maxillary anterior injections [23]. Long needles are frequently recommended for inferior dental nerve block anaesthesia. However, many dentists’ clinical experience has

Infiltration Maxillary Infiltration is the choice to successfully anaesthetize maxillary teeth. In this case the needle should penetrate the mucobuccal fold and be inserted to the depth of the apices of the buccal roots of the teeth. The solution is deposited supraperiostally

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and infiltrates through the alveolar bone to reach the root apex. Since alveolar bone in children is more permeable than it is in adults, less local anaesthetic may suffice to produce anaesthesia of teeth [26]. Stretching the mucosa of the injection site, and gently pulling onto the obliquely placed bevel of the needle is recommended for buccal infiltrations. In so doing, initial needle penetration is shallow. A small amount of solution has to be injected into the superficial mucosa. After a few seconds the needle can be slowly advanced 1–2 mm and, after a negative aspiration, another small amount of solution can be deposited. This should be repeated until the remaining anaesthetic solution is completely injected [26]. Mandibular Some authors claim that anaesthesia of mandibular primary molars may usually be achieved by infiltration in children up to the age of 5 years [26]. Few studies have evaluated the effectiveness of mandibular infiltration as a possible alternative to mandibular block for the restoration of primary molars [28–30]. No significant differences between infiltration and block were found. In addition, the quality of anaesthesia was not significantly related to tooth location, age or type of anaesthetic agent. According to Oulis et al. [31], mandibular infiltration is an effective and reliable local anaesthesia technique for amalgam and stainless steel crown restorations in primary molars, but not reliable for pulpotomy in a primary molar, either in the primary or in the mixed dentition. Nerve block Mandibular block is the local anaesthesia technique of choice when treating mandibular primary or permanent molars. Depth of anaesthesia has been the primary advantage of this technique, while anaesthesia of all the molars, premolars and canines anaesthetized on the side injected allows for treating multiple teeth of the same quadrant at one appointment. For the inferior alveolar block, the child is requested to open his mouth as wide as possible, while the operator positions the ball of the thumb on the coronoid notch of the anterior border of the ramus, places the fingers on the posterior border of the ramus. The needle is inserted between the internal oblique ridge and the pterygomandibular raphe. The position of the foramen changes with the child’s age: in a young child (4 years old and younger), the foramen is

sometimes located below the plane of occlusion [4]. In a young child, foramen is located on the occlusal plane. As the child matures [27], it moves to a higher position. The barrel of the syringe overlies the two primary mandibular molars on the opposite side of the arch and parallel to the occlusal plane. In this case, a small amount of solution should be injected and, after a negative aspirate, the needle should advance until bony contact is made, very gently and slowly. Long buccal anaesthesia When the inferior alveolar nerve block may not adequately anaesthetize the teeth, long buccal anaesthesia is required. This is achieved by infiltrating a few drops of anaesthetic into the buccal sulcus just posterior to the molars [4]. Intraligamentary anaesthesia The intraligamentary injection is given into the periodontal ligament using a syringe specially designed for the purpose. Intraligamentary injections can be given with a conventional needle and syringe, but the special syringes are preferable because they more easily produce the pressure that is required to inject into the periodontal ligament [4]. As a safety feature the barrel of the special syringe completely encloses the anaesthetic cartridge, in case the pressure should cause the glass to break. The syringes accept standard 1·8 or 2·2 mL cartridges of anaesthetic solution. In this technique the needle is inserted at the mesio-buccal aspect of the root and advanced until maximum penetration. The needle does not penetrate deeply into the periodontal ligament but is wedged at the crest of the alveolar ridge. A 12-mm 30-gauge needle is recommended, and the bevel should face the bone, although effectiveness is not impaired with different orientations [8]. One complete pull of the trigger delivers 0·2 mL of solution. The pressure under which the solution is injected produces vasoconstriction in the periodontal ligament and, to minimize the risk of tissue damage due to vasoconstriction, use of solutions containing adrenaline [35] is not recommended. According to Edwards et al. [36], hydrostatic pressure on the periodontal ligament has no direct effect on the production of anaesthesia, but the anaesthetic does. Intraligamentary anaesthesia has limitations as a principal method of anaesthesia, due to the variable

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duration, but has been used to overcome failed conventional methods or as an adjunct [37]. Intraligamentary injections produce a significant bacteraemia and therefore should not be given to patients at risk of infective endocarditis unless appropriate antibiotic prophylaxis has been provided [34]. No dose–response relationship between the local anaesthetic concentration and the efficacy of pulpal anaesthesia has been found [38]. However, the nature of vasoconstrictors added to the local anaesthetic, can affect the efficacy of pulpal anaesthesia when using the intraligamentary technique. Meechan [34] concluded that intraligamentary anaesthesia has a role to play in local anaesthesia in modern dentistry but it does not fulfil all the requirements for a primary technique. New techniques for obtaining local anaesthesia Electronic anaesthesia The concept of electronic dental anaesthesia (EDA) involves application of electric current that loads the nerve stimulation pathways to the extent that pain stimulus is blocked. This is known as the ‘gate control theory’, and was introduced by Melzack and Wall more than three decades ago [39]. The gate control theory states that activity generated by myelinated primary afferent fibres (the A fibres) inhibits the transmission of activity in small unmyelinated primary afferent pain fibres (the C fibres), acting via inhibitory circuits in the dorsal horn. This may be one of the explanations of how transcutaneous electrical nerve stimulation (TENS) produces anaesthesia. Another possible explanation is that the electrical stimulation causes the release of pituitary and hypothalamic opioid peptides into the systemic circulation or into the cerebrospinal fluid. Another theory is that serotonin, dopamine, and noradrenalin, are produced, and they may have roles in the effects of electrically produced analgesia. Drugs affecting these neurotransmitters have been shown to alter analgesia produced by the stimulation of opioids. The exact mechanism of TENS remains unknown and may be a combination of one or more of the theories. The most likely mechanism, however, is the activation of segmental inhibitory circuits in the spinal cord supplemented by descending inhibitory pathways. In a study conducted on 32 children aged 6–

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12 years, EDA has been found to be less effective than local anaesthesia in controlling pain during cavity preparation [40]. Reported pain scores for EDA were higher in permanent teeth and for deeper cavities. However, 63% of the children preferred EDA to local anaesthesia. Croll et al. [41] described the technique and reported on 45 cases. They recommended the use of this technique with cooperative children as young as 3 years of age, but not as a substitute for all other methods of pain modification and pain control. EDA should be viewed for use in children as an adjunctive option. The ability of a dental transcutaneous electronic nerve stimulator to control pain from injection of local anaesthesia was compared with the paincontrolling ability of topical anaesthesia [42]. Significantly less pain was reported for the injection of local anaesthetic solution, and the overall evaluation of the injection was more favourable when electronic anaesthesia was used. The patients preferred the electronic technique three to one over the topical anaesthetic. In a study conducted by Wilson et al. [43] on 30 sedated patients aged 24–48 months, the authors concluded that according to behavioural and physiological observations, EDA reduced the discomfort of the sedated children when receiving local anaesthesia. There are medical contraindications to the use of EDA: patients with a pacemaker or Cochlear implant, heart disease, seizure disorders or cerebrovascular disease, pregnancy, undiagnosed dental pain, brain tumour, neurological disorders involving the head and neck (e.g. Bell’s Palsy, trigeminal and postherpetic neuralgia, multiple sclerosis, or Tourette’s syndrome), skin lesions or abrasions on the face, patients with abnormal bruising or bleeding disorder. Intraoral lidocaine patch Anaesthetic patches containing lidocaine base that is dispensed through a bioadhesive matrix, and applied directly to the oral mucosa were approved by the U.S. Food and Drug Administration and are commercially available. These patches are available in 10 and 20% concentrations, each containing approximately 23 and 46 milligrams of lidocaine base per 2 cm2 of patch, respectively. In a study on adult patients, lidocaine patches achieved significantly better analgesia than the placebo within 2·5–

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5 min after placement. Drug-related side-effects were minimal and venous blood levels of lidocaine were low, averaging 10– 14 times less than those achieved with a typical injection of lidocaine plus epinephrine [44]. Others have found that lidocaine patches were significantly more efficacious than matching placebo patches in reducing the pain associated with 25gauge needle insertions to the level of bone in the maxillary premolar region of adult patients [45]. Anaesthetic onset occurred within 5 min and was present for the entire 15-min period that the patches were in contact with the oral mucosa. In addition, the patches were safe and well tolerated by study participants. Computerized local anaesthesia A computerized local anaesthetic system has been developed as a possible solution to reduce the pain related to the local anaesthetic injection [46]. The core technology is an automatic delivery of local anaesthetic solution at a fixed pressure : volume ratio regardless of variations in tissue resistance. This results in a controlled, highly effective and comfortable injection even in resilient tissues such as the palate and periodontal ligament [47]. The Wand System (Milestone Scientific, Livingston, NJ, USA) consists of a disposable handpiece component and a computer control unit. The handpiece is an ultra-light pen-like handle which is linked to a conventional anaesthetic cartridge with plastic microtubing (Fig. 1). According to the manufacturer the handpiece should be rotated during the insertion of the needle to reduce the deflection of the needle. All techniques of local anaesthesia, such as maxillary and mandibular infiltration, mandibular block, intraligamentary, and anterior middle superior alveolar injection (AMSA) can be performed with the Wand system. The AMSA provides pulpal anaesthesia from the central incisor through the second premolar and the palatal tissue associated with these teeth with one needle penetration using three-quarters of a cartridge of anaesthetic. A bilateral AMSAI anaesthetizes 10 maxillary teeth extending from the second premolar to the contralateral second premolar and the associated palatal tissue. The AMSAI injection site is located at a point that bisects the maxillary first and second premolar and is midway between the crest of the free gingival margin and the mid-palatine suture. The needle is

Fig. 1. A computerized local anaesthetic device (Wand). The system consists of a computer control unit (A), a conventional anaesthetic cartridge (B) linked by a plastic microtubing (C) to a disposable pen-like handpiece component (D), and a foot control device (E).

orientated at a 45-degree angle with the bevel facing the palatal tissue as in the traditional technique. In a study conducted in children, Gibson et al. [52] concluded that, when compared with conventional palatal anaesthesia, the Wand injections can deliver proper anaesthetic, utilizing one palatal injection site, while significantly reducing the likelihood of disruptive behaviours during the initial moments of the injection. In a study of 80 adult patients who reported being anxious about receiving a dental injection it was found that levels of anxiety decreased significantly when the Wand System was used. Another conclusion was that there was an optimal flow rate of anaesthetic solution at which the perception of pain during an injection was minimized [48]. This optimal flow rate is best achieved with the Wand [44–49].

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Liberman’s [50] impression of the WAND on paediatric dental patients, was that they found the method most comfortable, and it was a good tool for building positive dentist–patient relationships. Studies on the Wand system have mainly been conducted on adult patients, with only one study conducted on children. In this study a group of children who received a conventional injection were compared with other children who received local anaesthesia delivered with the Wand. No significant difference was found between pain perception following conventional injection and use of the Wand system [51]. Syrijet This instrument (National Keystone, Cherry Hill, NJ, USA) was developed to achieve local anaesthesia for dental procedures without the use of a needle [53]. This is accomplished by delivering the anaesthetic solution under high compressive forces. The method was tested on 34 children ranging in age between 5 and 15 years, on whom 45 dental procedures were completed. There was a statistically significant difference in favour of the instrument, with 25 children reporting a preference for it. The instrument was completely successful in providing anaesthesia in 36 of the 45 procedures. Conclusion Most advanced technologies for achieving local anaesthesia for dental patients have been shown and tested on adults. Thus, despite the recent innovations in the field, for the paediatric dental patient, the injection remains the method of choice. More studies using these new techniques on children are needed, so that more acceptable techniques for achieving local anaesthesia in children can be developed. Résumé. Les comportements lies à la peur sont connus depuis longtemps comme l’aspect le plus difficile de la gestion des patients et peuvent être une barrière à l’accomplissement de soins corrects. L’anxiété est une des composantes majeures des traitements dentaires chez l’enfant, et l’injection en est la procédure la plus génératrice pour les enfants comme pour les adultes. La recherché de moyens pour éviter la nature invasive et souvent douloureuse de l’injection est

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constante, de même que pour trouver les moyens les plus confortables et plaisants d’anesthésie avant les soins dentaires. L’objectif de cette revue est de résumer les données valables sur les sujets en lien avec l’administration d’anesthésie locale. Elle recouvrera les méthodes courantes reconnues utilisées chez l’enfant, viz., anesthésie électronique, patch de lidocaïne, anesthésie numérisée (the Wand), et le Syrijet, de même que l’injection conventionnelle. Habituellement, les nouvelles techniques sont testées chez l’adulte. Cependant, malgré des recherches récentes dans ce domaine, l’injection reste la méthode de choix. Il est nécessaire de continuer à mener des études utilisant les nouvelles techniques chez l’adulte et l’enfant, afin de trouver une technique plus acceptable. Zusammenfassung. Von Furcht beeinflusstes Verhalten ist seit Langem als schwierigster Aspekt der Patientenführung erkannt und kann eine Barriere für eine gute Versorgung sein. Ängstlichkeit ist ein wichtiger Gesichtspunkt bei der Zahnbehandlung von Kindern, dabei ist die Injektion die stärkste angsteinflößende Prozedur sowohl für Kinder als auch Erwachsene. Es wird beständig daran gearbeitet, die invasive und oft auch schmerzhafte Natur der Injektion zu vermeiden und komfortablere sowie angenehmere Methoden der Schmerzausschaltung zu finden. Ziel der vorliegenden Übersicht ist es, die wichtigsten Daten zur Verabreichung von Lokalanästhetika zusammenzufassen, nämlich elektronische Anästhesie, Lidocainpflaster, computergesteuerte Injektion (Wand), nadellose Injektion sowie die konventionelle Injektion für pädiatrische Patienten. Üblicherweise werden neue Methoden an Erwachsenen getestet. So bleibt trotz der jüngsten Entwicklungen die konventionelle Injektion weiter Methode der Wahl. Es ist erforderlich, die Studien zu neuen Techniken sowohl an Erwachsenen als auch an Kindern zu testen, um zu akzeptablen Ergebnissen zu kommen. Resumen. Las conductas relacionadas con el miedo han sido ampliamente reconocidas como el aspecto más difícil en el manejo del paciente y puede ser una barrera para un cuidado adecuado. La ansiedad es uno de los temas principales en el tratamiento de los niños, y la inyección es el procedimiento que más provoca ansiedad tanto en adultos como en niños.

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Existe una búsqueda constante de formas de evitar la naturaleza invasiva y con frecuencia dolorosa, de la inyección, y de encontrar medios más confortables y placenteros para la anestesia antes de los tratamientos dentales. El propósito de la presente revisión es resumir los datos relevantes sobre los tópicos relacionados con la administración de anestesia local. Se analizarán los métodos disponibles, tales como: anestesia electrónica, parches de lidocaina, anestesia computarizada (la varilla), y la syrijet, así como la inyección convencional, usada en pacientes pediatricos. Generalmente las nuevas técnicas para anestesia local son probadas en adultos. De todas formas, a pesar de las investigaciones recientes en el campo, la inyección permanece como el método de elección. Es necesario continuar con los estudios de conducta usando nuevos sistemas en adultos y en niños, para que puedan encontrarse técnicas más aceptables.

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