Anesthesia and pedodontics

Anesthesia and pedodontics

INTRODUCTION

Anesthesia must be justified and appropriate. The risk/benefit ratio must be assessed.
This act should be, as far as possible, physically and psychologically painless.

– An already established relationship of trust constitutes a major asset for its safe implementation.

GENERAL INFORMATION:

Anesthesia is defined as a reversible blockade of nerve conduction, unlike analgesia which increases the pain threshold.

Local anesthesia.

There are differences between children and adults which are:

anatomical:

-smaller bone structures (less needle penetration).

-less dense bone structures (faster diffusion of anesthesia.

-anatomical structures vary according to growth.

-thinner nerve fibers.

pharmacological:
- at the toxicity level,
- The maximum dose of anesthesia is calculated according to weight.
Material:

– There is no specific equipment. The use of single-use syringes provides a reassuring aspect.

Prerequisites for painless local anesthesia:

Prepare the child: (method “tell, show, do”); dry the mucous membrane;

Apply contact anesthesia for 2 minutes; dry the mucosa again

Apply pressure with your finger to the needle penetration area

Pull the lip and inject the anesthetic with a needle

Do not seek bone contact. Aspirate before injection.

Inject slowly

Bone density:

The bone cortex is more permeable, especially at the mandibular level in children under 5 years old.
Looser bone trabeculations promote diffusion of the anesthetic
Para-apical anesthesia is sufficient
After the eruption of the 6-year-old tooth, the external cortices become denser

b Anatomical differences

Maxillofacial growth modifies the anatomical landmarks used in locoregional anesthesia:

-2 years to 5 years, the mandibular foramen is located below the occlusal plane.

– 5 years to 8 years, this marker is located at the level of the occlusal plane.

It gradually rises to reach its final position towards

15 years old.

Avoid damaging the germ of the permanent tooth located in the inter-radicular space
Taking into account the divergence of the ravines of the baby teeth, the injection must be more distal compared to the permanent tooth.
Psychological approach to the child:
- Fear of dental care
- Anxiety
- The difficulties of cooperation

Psychological preparation adapted to the child’s age

l-Understanding our patient’s fears

Demystify our actions
Help him overcome this fear

Before the injection, regardless of age, the practitioner must prepare the young person for the procedure by using non-aggressive and positive terminology.

During the injection, in order not to alarm the child by stealthy maneuvers behind him, the syringe must be ready.

Three types of connection two families of AL:
AMINOESTER Bond Family of AMINOESTERS

Procaine-Benzocaine-Tecacaine

AMINOAMIDE bond Family of AMINOAMIDES

Lidocaine- Mepivacaine- Prilocaine- Articaine-

INJECTABLE ANESTHETICS

^°THE AMINO-AMIDES LIDOCAINE and ARTICAINE

Molecule of choice
His power is strong
Its average duration of action
Its short latency
Its toxicity is low

CONTACT ANESTHETICS
- Are used systematically in children
- The most suitable galenic form remains the GEL
- The most used molecule: LIDOCAINE
Choice of local anesthetics and anesthesia techniques:

-1 Local anesthetics

-The dose of anesthesia is expressed in milligrams per kilogram of body weight to avoid overdose, reduce the risks of toxicity and adverse effects.

-The maximum dosage must take into account the quantity of local anesthetics (surface and infiltration).

-The criteria for choosing the molecule are the same as for adults and the elimination capacity of the product is comparable to that of adults from the age of 6.

– Aminoamides are the family of choice for children although they do not have marketing authorization (MA) before the age of 4 years.

A- Amino-amides:

Lidocaine:
- vasodilator, hence a loss of effectiveness and a risk of overdose.
- Therefore, it is often used with a vasoconstrictor.

-Maximum dose:

– 2.2 mg/kg without exceeding the total dose of 300 mg. By

cartridge, 1.8ml of 2% Lidocaine (36mg).

-Vasoconstrictor: with or without vasoconstrictor.

– Anesthesia duration: Pulp: 5 to 10 min without vasoconstrictor and 60 min with. Soft tissue: 3-5 h

Mepivacaine:
without action on the vessels, it can be used without vasoconstrictor.
It is useful in case of allergy to bisulfites.

-Maximum dose: 3mg/kg without exceeding the total dose of 300mg. Per cartridge, 1.8ml of Mepivacaine at 3% (54mg).

-Vasoconstrictor: without

– Anesthesia duration: Pulp: 20 to 40 min without vasoconstrictor and 60 min with. Soft tissue: 2-3 h

Articaine:

– Maximum dose: 5mg/kg without exceeding the total dose of 300mg. Per cartridge, 1.8ml of 4% articaine (72mg).

-Vasoconstrictor: with or without.

– Anesthesia duration: Pulp: 60 min with vasoconstrictor. Soft tissues: 3-6 h.

A vasoconstrictor, typically adrenaline, can be used from the age of 6 to 2 years in a 1/400,000 solution.
At 1/200000 for the older child.

2-Anesthesia techniques according to the patient’s age and the quality of the tooth’s supporting tissue:

A preoperative X-ray must be performed before any intraosseous, transcortical or osteocentral anesthesia, to contraindicate it in the event of destruction of the underlying bone or if the germ is on the injection path.

A-Surface or contact anesthesia, to reduce discomfort associated with needle penetration:

Use the Lidocaine gel and apply it with a cotton swab to the well-dried mucous membrane, without rubbing for about 2 minutes.
Absorption through the mucous membranes is rapid.
Respect the application time of at least 1 minute
Anesthesia is achieved to a depth of 2mm

B-Infiltration anesthesia:

Use room temperature anesthetic solution.

Penetrate the mucosa by directing the bevel towards the mucosa with stable support points.

The periapical:
- 6 months: Para-apical without vasoconstrictor
From 6 months to 3 years and from 3 years to 7/8 years: Para-apical with or without vasoconstrictor.

Over 8 years: Para-apical (maxillary and mandibular only in anterior and lateral sectors) and Troncular (posterior mandibular sector)
The local region:

It allows for the scheduling of treatments for multiple teeth. This technique numbs the mucous membranes, which can cause biting in young patients.

From 6 months to 3 years: without rotation, possible from 2 years if the alveolar bone is healthy.
From 3 years to 7/8 years, without rotation if the bone is healthy.

Over 8 years old, with rotation if the alveolar bone is healthy.

After treatment, warn the child and parents of the danger of

Bite .

C- Intraosseous anesthesia

Intraligamentous anesthesia

Its purpose is to deposit the anesthetic solution at the level of the desmodontal space to obtain anesthesia of the alveolus and the dental pulp.

Intraseptal anesthesia is not recommended as first-line treatment in children.

Intraosseous anesthesia: transcortical anesthesia

1-Principle: it is an injection of the anesthetic into the spongy bone surrounding the tooth after crossing the septum and the spongy bone to get closer to the apex of the teeth and allow its diffusion thanks to the intraosseous blood circulation.

Advantages:

– Immediate anesthesia.

-Bone, pulp and gingival anesthesia. No risk of

bite because there is no soft tissue anesthesia.

-Better effectiveness: less anesthetic required and 1 to 6 teeth anesthetized depending on the site and the quantity administered.

Contraindications and limitations:

Lack of bone due to:

– physiological bone resorption (linked to the eruption of permanent teeth);

-inflammatory/infectious bone resorption;

Permanent tooth germ on the needle path

(Ectopia or end of eruption);

Posterior area (difficult access).

Risks:

Transient and weak acceleration of the heart rate in some cases.

Needle breakage.

Injury to a dental root and the injection site is poorly

selected.

Potential necrosis of the papilla (rare in children).

Materials needed:
- Electronic assistance system for the injection of anesthetic without rotary perforation of the bone in children under 7-8 years old
- System with rotary perforation of the bone in children of

over 7-8 years old.

– Suitable intraligamentary needle: length 8-9mm and

diameter 0.30 (30G).

– Anesthetic with vasoconstrictor:

-Articaine or lidocaine, or even mepivacane;

-Adrenaline at 1/200000 preferable, 1/400000 possible.

Intraosseous anesthesia osteocentral anesthesia.

Principle : injection of the anesthetic into the spongy bone surrounding the tooth after crossing the septum and the spongy bone to get closer to the apex of the teeth and allow its diffusion thanks to the intraosseous blood circulation.
Benefits :

-Immediate anesthesia.

-Bone, pulp and gum anesthesia. No risk of biting because there is no soft tissue anesthesia.

-Better effectiveness: less anesthetic required and one to six teeth anesthetized depending on the site and the quantity administered.

Contraindications and limitations

-Physiological bone resorptions;

-Bone resorptions linked to infection;

Risks

– Needle breakage;

-Damage to a dental root if the insertion point is poorly chosen;

-Transient and slight acceleration of the heart rate.

Comparison of osteocentral/transcortical anesthesia:
- Benefits :

-Less stress on the labial corner during the performance.

-Injection closer to the apex.

-Simpler approach for anesthesia of maxillary and mandibular molars.

– Disadvantages:

-More rotation to reach the spongy bone.

– No more risk of not finding the spongy bone if the axis is not good.

complications:

Complications can be local or general, immediate or delayed.

-Local:

– Immediate complications:

– Needle breakage is common at the block level

mandibular.

– Pain during the injection is due to an injection that is too

rapid or intravascular.

-Delayed local complications:

– BITE

-LOCAL ULCERATION

– ISCHEMIA

General complications : lipothymia and allergy.

Conscious sedation by inhalation of MEOPA (equimolar mixture of oxygen and nitrous oxide):

-MEOPA is indicated for children who are uncooperative during dental care. This medication allows for a state of conscious sedation, which increases the child’s cooperation and represents an interesting alternative to general anesthesia.

-MEOPA provides a surface analgesic effect, reduces the pain perception threshold, without however generating a real anesthetic effect, hence the need for local anesthesia.

Indications :

-Healthy child, phobic or anxious, for dental care requiring few sessions (3a4) or emergency care;

-Child with disabilities for care and check-ups;

-Very young child, even if the success rate is very low;

In the case of a child with severe systemic pathology, an anesthesia consultation may be recommended before indicating conscious sedation.

Contraindications:

Strict contraindications (CI) are rare due to the pharmacokinetics of MEOPA.
Most of them are linked to its diffusion properties within the rigid or extensible closed cavities of the human body: intracranial hypertension, gas embolism.
Others are linked to its metabolic consequences.
If the necessary care is numerous and/or complex, the benefit of a single treatment session under general anesthesia must be assessed.

Materials needed:

Bottle of MEOPA.
Nasal or nasobuccal mask adapted to the child’s face.
Single-use inhalation ^{system or one equipped with an antimicrobial filter.}
Exhaust ^{system expels air out of the room.}
Recommended monitoring: stopwatch.

Protocol:

Child reception:

^-Explain to the child the inhalation technique with the mask.

^{-Adopt a child-centered approach} throughout the treatment.

Induction of sedation:

It is done in 3 to 5 minutes.

– The expected sedative effect is muscle relaxation, and

sometimes a slight euphoria.

– Carrying out care

– Perform local anesthesia, if necessary.

-Perform conservative care under the operating field.

-Monitor the patient (verbal contact, heart rate).

-Exit from treatment:

– Stop inhalation and monitor the disappearance of the sedative effect: 3 to 5 min.

-Give postoperative instructions.

-Suggest follow-up.

General anesthesia:

General anesthesia is also indicated

Presence of multiple caries in a child with

Pathology such as:

Epileptic (multiplication of actions in the epileptic patient can trigger a crisis)
Patients with significant hemostasis disturbance
Organ transplant

– Patients waiting for chemotherapy or radiotherapy

– Disabled patients (motor disabilities, cerebral disabilities,

psychomotor handicapped

Conclusion

-The practitioner must do everything possible to prevent pain before, during and after treatment .

-Anesthesia techniques control intraoperative pain.

-Caring for a child in the dental office may require the use of sedation techniques or even general anesthesia.

– But awake care is recommended.