• American Academy of Pediatric Dentistry (AAPD). Clinical guideline on appropriate use of local anesthesia for pediatric dental patients. Chicago (IL): American Academy of Pediatric Dentistry (AAPD); 2005. 8 p. [41 references]

This is the current release of the guideline.

Topical Anesthetics

1. Topical anesthetic may be used prior to the injection of a local anesthetic to reduce discomfort associated with needle penetration.
2. The pharmacological properties of the topical agent should be understood.
3. A metered spray is suggested if an aerosol preparation is selected.
4. Systemic absorption of a lidocaine topical anesthetic must be considered when calculating the total amount of anesthetic administered.

Selection of Syringes and Needles

1. For the administration of local dental anesthesia, dentists should select aspirating syringes that meet the standards of the American Dental Association (ADA).
2. Short needles may be used for any injection in which the thickness of soft tissue is less than 20 mm and a long needle for a deeper injection into soft tissue (Malamed, "The needle," 2004). Any 23- through 30-gauge needle may be used for intraoral injections since blood can be aspirated through all of them; however, aspiration can be more difficult when smaller gauge needles are used (Malamed, "The needle," 2004). An extra-short, 30-gauge is appropriate for infiltration injections (Malamed, "The needle," 2004).
3. Needles should not be bent or inserted to their hub for injections to avoid needle breakage (Malamed, "The needle," 2004).

Injectable Local Anesthetic Agents

1. Selection of local anesthetic agents should be based upon:
   1. The patient's medical history and mental/developmental status
   2. The anticipated duration of the dental procedure
   3. The need for hemorrhage control
   4. The planned administration of other agents (e.g., nitrous oxide, sedative agents, general anesthesia)
   5. The practitioner's knowledge of the anesthetic agent
2. Use of vasoconstrictors in local anesthetics is recommended to decrease the risk of toxicity of the anesthetic agent.
3. In cases of bisulfate allergy, use of a local anesthetic without vasoconstrictor is indicated. Local anesthetic without vasoconstrictor also can be used for shorter treatment needs.
4. The established maximum dosage for any anesthetic should not be exceeded.

See Tables 1 and 2 in the original guideline document for injectable local anesthetics, their maximum dosages, and the dosage per dental cartridge.

Documentation of Local Anesthesia

1. Documentation must include the type and dosage of local anesthetic in milligrams. Vasoconstrictor, if any, must be noted either in milligrams or concentration (e.g., 36 mg lidocaine with 0.018 mg epinephrine or 36 mg lidocaine with 1:100,000 epinephrine) (Malamed, "Basic injection technique," 2004).
2. Documentation may include the type of injection(s) given (e.g., infiltration, block, intraosseous), needle selection, and patient's reaction to the injection.
3. Post-operative instructions (e.g., behavioral and dietary precautions) should be given to the patient and/or caregiver.
4. If the local anesthetic was administered in conjunction with sedative drugs, the doses of all agents must be noted on a time-based record.
5. In patients for whom the maximum dosage of local anesthetic may be a concern, the weight should be documented preoperatively.

Local Anesthetic Complications

1. Practitioners who utilize any type of local anesthetic in a pediatric dental patient shall possess appropriate training and skills and have available the proper facilities, personnel, and equipment to manage any reasonably foreseeable emergency.
2. Care should be taken to ensure proper needle placement during the intraoral administration of local anesthetics. Practitioners should aspirate before every injection and inject slowly.
3. After the injection, the doctor, hygienist, or assistant should remain with the patient while the anesthetic begins to take effect.
4. Residual soft tissue anesthesia should be minimized in pediatric and special health care needs patients to decrease risk of self-inflicted post-operative injuries.
5. Practitioners should advise patients and their caregivers regarding appropriate behavioral precautions and the possibility of soft tissue trauma following the administration of local anesthesia.

Supplemental Injections to Obtain Local Anesthesia

1. Alternative techniques for the delivery of local anesthesia may be considered to minimize the dose of anesthetic used, improve patient comfort, and/or improve successful dental anesthesia.

Local Anesthesia with Sedation, General Anesthesia, and/or Nitrous Oxide/Oxygen Analgesia/Anxiolysis

1. Particular attention should be paid to local anesthetic doses used in children. To avoid excessive doses for the patient who is going to be sedated, a maximum recommended dose based upon weight should be calculated.
2. The dosage of local anesthetic should not be altered if nitrous oxide/oxygen analgesia/anxiolysis is administered.
3. When general anesthesia is employed, local anesthesia may be used to reduce the maintenance dosage of the anesthetic drugs. The anesthesiologist should be informed of the type and dosage of the local anesthetic used. Recovery room personnel also should be informed.

None provided

All oral health policies and clinical guidelines are based on 2 sources of evidence: (1) the scientific literature; and (2) experts in the field.

• American Academy of Pediatric Dentistry (AAPD). Clinical guideline on appropriate use of local anesthesia for pediatric dental patients. Chicago (IL): American Academy of Pediatric Dentistry (AAPD); 2005. 8 p. [41 references]

Not applicable: The guideline was not adapted from another source.

2005

American Academy of Pediatric Dentistry - Professional Association

American Academy of Pediatric Dentistry

Council on Clinical Affairs

Not stated

Not stated

This is the current release of the guideline.

None available

This NGC summary was completed by ECRI on August 19, 2005. This summary was updated by ECRI on February 21, 2006 following the U.S. Food and Drug Administration (FDA) advisory on benzocaine sprays.

This summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.