Best clinical practice guidance for local analgesia in paediatric dentistry: an EAPD policy document

The Use of Local Anesthesia in Pediatric Dentistry: A Survey of Specialists' Current Practices in Children and Attitudes in Relation to Articaine

Aims

This study aimed to evaluate the clinical practices of local anesthesia in children. The study also sought to investigate pediatric dentists' views on articaine infiltration anesthesia and their willingness to use it to replace the inferior dental nerve block in primary molars.

Materials and Methods

A cross-sectional survey was emailed to 183 registered specialists. Descriptive statistics along with chi-square and Fisher's exact tests were used for data analysis.

Results

A total of 72 responses were received. The sample consisted of 62 (86.1%) females and 10 (13.8%) males with varying levels of experience. The vast majority of respondents (98.6%) used topical anesthesia in their practice with children. The most frequently used anesthetic agent was 2% lidocaine (72.2%) followed by 4% articaine (54.2%). The entire sample indicated that they frequently find difficulties in dose calculation for their child patient. Gender and level of experience did not significantly influence specialists' practice or their knowledge of local anesthesia. More than a third (31.9%) of participants were not happy to replace the block anesthesia with articaine infiltration for the treatment of lower primary molars. The most indicated reasons for this unwillingness were lack of effectiveness (11%) and inadequate scientific evidence (11%).

Conclusion

Most pediatric dentists used topical anesthesia with children. Lidocaine was the most commonly used injectable local anesthesia. Specialists' current practices of local anesthesia in children generally conformed well to good standards. However, inadequate knowledge regarding dose calculation was revealed. In addition, specialists' reluctance to use articaine infiltration instead of the block anesthesia was evident in the current population. Further studies, with larger sample size are encouraged.

Swiss paediatric dentists' preferences and experience on the use of articaine and other local/topical anaesthetics

PURPOSE

This study was conducted to explore the preference and experience of paediatric dentists based in Switzerland regarding the use of articaine and other local and topical anaesthesia.

METHODS

An 18-question survey was developed, piloted, and distributed to the members of the Swiss association of paediatric dentistry (n = 460). The following information were collected: most used local anaesthetic in different age groups, time needed to inject a full ampule, frequency of observed local and systemic side effects, application of topical anaesthetic prior to injection, time waited between application and the injection, and perceived effectiveness of topical anaesthetic. The dentists' responses were analysed with logistic regressions reporting odds ratios (OR) and 95% confidence intervals (CI) at 5%.

RESULTS

The response rate was 37% (n = 168) out of the 460 questionnaires sent, with the responders being predominantly female (67%) and 47-year-old on average. More than 80% of the dentists used articaine in all age groups. 45% of responders took longer than 60 s to inject a full ampule. Local and systemic side-effects were observed by 82% and 28% of respondents respectively, although the nature and the significance of those were not detailed due to the anonymous nature of the questionnaire. Significantly less local adverse effects were seen for older children (p = 0.04) and among dentists with more years of experience (p = 0.01). Most responders applied topical anaesthetic and half of them waited longer than 60 s before injection.

CONCLUSIONS

Articaine is a widely used local anaesthetic by the studied group of Swiss paediatric dentists regardless of patient's age. The use of topical anaesthetic before injection is a common practice with good perceived effectiveness.

Labels and descriptions of dental behaviour support techniques: A scoping review of clinical practice guidelines

INTRODUCTION

There is no agreed taxonomy of the techniques used to support patients to receive professional oral healthcare. This lack of specification leads to imprecision in describing, understanding, teaching and implementing behaviour support techniques in dentistry (DBS).

METHODS

This review aims to identify the labels and associated descriptors used by practitioners to describe DBS techniques, as a first step in developing a shared terminology for DBS techniques. Following registration of a protocol, a scoping review limited to Clinical Practice Guidelines only was undertaken to identify the labels and descriptors used to refer to DBS techniques.

RESULTS

From 5317 screened records, 30 were included, generating a list of 51 distinct DBS techniques. General anaesthesia was the most commonly reported DBS (n = 21). This review also explores what term is given to DBS techniques as a group (Behaviour management was most commonly used (n = 8)) and how these techniques were categorized (mainly distinguishing between pharmacological and non-pharmacological).

CONCLUSIONS

This is the first attempt to generate a list of techniques that can be selected for patients and marks an initial step in future efforts at agreeing and categorizing these techniques into an accepted taxonomy, with all the benefits this brings to research, education, practice and patients.

Comparative study of articaine 4% versus lidocaine 2% in the local anesthesia of permanent mandibular first molars affected by MIH: a randomized controlled trial

PURPOSE

The current study compares articaine 4% with lidocaine 2% in terms of injection pain and effectiveness of anesthesia when treating permanent mandibular first molars (PMFMs) affected by molar incisor hypomineralization (MIH). In addition to comparing the complications of local anesthesia for both solutions.

METHODS

The sample included 20 children. Each child was randomly assigned to either articaine 4% or lidocaine 2% in their first session with the other solution being used at the subsequent session. Injection pain and the effectiveness of anesthesia were assessed using the Wong-Baker Faces® Pain Rating Scale and the Face, Legs, Activity, Cry, and Consolability (FLACC) scale. Parents were asked to report any complications of local anesthesia. The Wilcoxon-matched pairs signed-rank test was used to analyze the data.

RESULTS

Patients experienced greater pain when receiving articaine 4% injections according to both scales, differences were statistically significant when using the Wong-Baker Faces® Pain Rating scale (p < 0.05). Whereas, the FLACC scale did not show such differences (P > 0.05). Although there were no significant differences between the two solutions regarding the effectiveness of local anesthesia according to both scales (P > 0.05), articaine 4% was clinically found to be more effective than lidocaine 2%. No complications of local anesthesia were reported.

CONCLUSIONS

Articaine 4% injection was more painful than lidocaine 2%. However, both solutions were effective in anesthetizing PMFMs affected by MIH and without anesthetic complications in the studied sample.

TRIAL REGISTRATION

Clinical trial, NCT05200884, ( https://clinicaltrials.gov/ct2/show/NCT05200884 ).

Comparison of the effectiveness of intraligamentary anesthesia and inferior alveolar nerve block on mandibular molar teeth in pediatric patients: a randomized controlled clinical study

OBJECTIVES

The study aimed to compare the two local anesthetic techniques: inferior alveolar nerve block (IANB) and intraligamentary anesthesia (ILA) during the restorative treatment of mandibular first permanent molars in pediatric patients.

MATERIALS AND METHODS

In this randomized, controlled, cross-over, single-blind, split-mouth study, participants were divided into two groups: group 1, ILA in the first session and IANB in the second session, and group 2, IANB in the first session and ILA in the second session. The pain perception was analyzed using the visual analog scale (VAS) and Wong-Baker FACES pain rating scale (WBFPRS). Heart rate, arterial oxygen saturation (SpO₂), and postoperative complications were recorded. The data were analyzed with the Brunner-Langer model, Spearman correlation analysis, Fisher's exact t-test, chi-square, and McNemar tests.

RESULTS

Seventy-eight patients aged between 6 and 12 years were included. The session effect was not statistically significant in ILA (p = 0.762 and p = 0.411) for pain scores while it was significant in IANB (p < 0.001 for each score). There was no significant difference in the VAS, WBFPRS, heart rate, and SpO₂ between the anesthesia techniques (p = 0.454, p = 0.436, p = 0.406, p = 0.285, respectively). Postoperative complications increased in the IANB technique in the first session.

CONCLUSIONS

Intraligamentary anesthesia may be an alternative technique to IANB for the restorative treatment of mandibular first permanent molars in pediatric patients. In the first session, clinicians may choose the ILA instead of IANB.

CLINICAL RELEVANCE

In clinical procedures, administering anesthesia, which is effective, is less painful, and poses relatively low complication risk, has significant importance in sustaining children's cooperation with dental treatment.

Students' attitudes and knowledge on pain and pain management in paediatric dentistry-An observational study

INTRODUCTION

The dental and dental hygienist educational programs prepare students with knowledge on children's prophylactic pain treatment and pain management. Observing the students' understanding could help educational efforts to be more student oriented. The aim was to evaluate dental and dental hygienist students' knowledge and attitudes on pain prevention and pain management in children and adolescents, applying a multidimensional questionnaire previously used on general dental practitioners.

MATERIALS AND METHODS

Three hundred and four dental and dental hygienist students at Swedish universities were eligible for the survey. Written and oral information was given about the study's aim, methods, anonymity and voluntary participation. The multidimensional questionnaire included 47 closed questions.

RESULTS

The total responding rate was 65.4%; dental students 61.1% and dental hygienist students 92.8%. The total mean of knowledge and attitudes, beneficial for the treating of patient pain, varied between 57.1% and 83.3%. The biggest knowledge gap was identified regarding the items: Children under 2 years of age experience less pain than children over 2 years undergoing similar treatment(34.3%), The dentist is better suited than the parent to judge if a child is in pain (29.4%), and usually the child's pain experience diminishes when the parents are present (24.2%).

CONCLUSION

Dental and dental hygienist students reported vastly spread knowledge and attitudes regarding pain prophylactic and pain management in children and adolescents, as measured by a multidimensional questionnaire previously used on GDPs. Knowledge on students' understanding of the young patient's pain could help educational efforts to be more student oriented. The questionnaire must be further modified and more extensively tested to meet each participating students' program level.

Radiographic differences observed following apexification vs revascularization in necrotic immature molars and incisors: a follow-up study of 18 teeth

PURPOSE

To evaluate the effectiveness of apexification versus revascularization in the treatment of necrotic immature teeth and determine which strategy affords the greatest radiological success rate.

METHODS

An analysis was made of 18 teeth subjected to mineral trioxide aggregate (MTA) apical plugging and regenerative endodontic treatment, assessing healing of the apical lesions and the changes in root dimensions.

RESULTS

Significantly greater root growth was observed with revascularization in terms of the percentage change in length (12.75% at 6 months) and dentin thickness (34.57% at 6 months) (p < 0.05). There were no significant differences between the two treatments in terms of the apical healing scores after 6 months of follow-up (p > 0.05).

CONCLUSION

Apexification with an MTA apical plug and pulp regeneration are reliable treatments for non-vital immature teeth. The radiographic outcomes are comparable between the immature teeth subjected to MTA apexification versus those subjected to revascularization. The results of the present study indicate a greater increase in root length and width with regenerative endodontic treatment.

Using nitrous oxide inhalation sedation for classical conditioning - An evaluative study

Purpose

This study was undertaken to evaluate conscious sedation as a means of classical conditioning for managing paediatric dental patients.

Methods

A total of 20 healthy children (American Society of Anesthesiologists I) aged 5-9 years with positive and definitely positive Frankel behaviour rating scale were evaluated. In the first appointment (A₁) non-invasive treatment under nitrous oxide inhalation sedation was performed and oxygen saturation and pulse rate at 10%, 30% and 50% were recorded. In subsequent appointment (A₂") same treatment was executed under 100% oxygen and recordings were taken. Behaviour was assessed using comfort scale.

Results

No significant difference was observed in pulse rate, oxygen saturation and visual analogue scale whereas scores of comfort scale showed significant results.

Conclusion

Once behaviour modification to dental treatment is achieved, subsequent visit can be undertaken even without sedation, giving oxygen as a placebo where patient is sensitized to nasal hood resulting in positive dental behaviour.

Modified PDL anesthetic injection technique in the pediatric dental practice

Relevance. Effective pain relief is required for high-quality outpatient dental treatment in children. Infiltration and PDL local anesthetic injection techniques are easier and safer for young patients. Purpose – to determine the effectiveness and safety of the modified PDL anesthetic injection technique in the pediatric dental practice. Materials and methods. The study involved 100 children aged 4 to 7 years, in need of caries and pulpitis treatment in the primary dentition. 4% articaine solutions with 1: 200000 and 1: 400000 epinephrine were administered as a local anesthetic. The effectiveness of the treatment was determined by the visual analogue scale.Results. The study determined the high effectiveness and safety of the modified technique of PDL anesthetic injection of 4% articaine solution with epinephrine ratio 1:200 000 and 1:400 000 for the treatment of caries and pulpitis in 100 children aged 4-7 years.Conclusions. The conducted studies have demonstrated the high ffectiveness and safety of the modified PDL anesthetic injection technique of a 4% solution of articaine with epinephrine both at a concentration of 1:200 000 and 1:400 000.

Self-induced soft-tissue injuries following dental anesthesia in children with and without intellectual disability. A prospective study

PURPOSE

Self-induced soft-tissue injuries (SSI) are reported as local anesthesia complications, particularly in children. The purpose of the study was to evaluate the frequency of SSI following dental anesthesia in children with and without intellectual disability.

METHODS

241 children receiving dental treatments with local anesthesia were divided into 2 groups: A, children without intellectual disability (159 individuals, 299 injections); B, children with intellectual disability (82 individuals, 165 injections). Each group was divided into subgroups according to age, injection technique and dental treatment. Two days after the dental procedure, a phone survey was conducted to determine the presence of SSI.

RESULTS

The frequency of SSI in group B was 19%, with no differences in relation to gender and age. In group A the frequency of SSI was significantly lower (9%; p = 0.002; Chi-square test); the children in the ≤ 6 years-old subgroup experienced a higher frequency of SSI (p = 0.002). The lower arch was at major risk of SSI in both groups (p = 0.002). According to a multilevel approach group (p = 0.001) and injection technique (p = 0.0001) significantly influenced SSI; no influence of dental treatment is evidenced.

CONCLUSIONS

SSI are common complications of local anesthesia in young children and individuals with intellectual disability.

Comparison of the efficacy of a standard inferior alveolar nerve block versus articaine infiltration for invasive dental treatment in permanent mandibular molars in children: a pilot study

AIM

To determine whether there is a clinical difference between an inferior dental block (IDB) using 2% lidocaine and a buccal infiltration (BI) using 4% articaine, when anaesthetising mandibular first permanent molars in children.

METHODS

Patients aged 8-15 years who required invasive dental treatment on a lower molar tooth were randomised. The patient and dental operator were blind to the type of LA used. The patient used a visual analogue scale to record their experience of pain during injection and treatment.

RESULTS

Twenty six teeth were anaesthetised (13 articaine, 13 lidocaine). When using an IDB, all treatment was completed successfully. On one occasion, anaesthesia was deemed unsuccessful when using a BI of articaine. There was no statistical difference in the mean VAS for the perceived pain of injection or treatment.

CONCLUSION

This study showed that invasive dental treatment on a mandibular molar tooth can be completed successfully in children using a BI of articaine. In addition, the perceived pain of injection and treatment when using a BI of articaine is comparable to an IDB with lidocaine.

Evaluation of intraosseous computerized injection system (QuickSleeper™) vs conventional infiltration anaesthesia in paediatric oral health care: A multicentre, single-blind, combined split-mouth and parallel-arm randomized controlled trial

BACKGROUND

Conventional infiltration anaesthesia (CIA) is the most frequently used in paediatric oral health care. However, other techniques are available, such as intraosseous anaesthesia (IOA), that can beneficiate from newly developed technologies.

AIM

To compare the pain caused by CIA and IOA delivered by the computerized system (QuickSleeper™) in children.

DESIGN

We used an innovative design consisting in simultaneously conducting a multicentre split-mouth and parallel-arm randomized controlled trial (RCT) to allow for increased power. The primary outcome was pain reported by the patient on a visual analogue scale (0-10 cm) concerning the insertion of the needle and injection.

RESULTS

A total of 30 children were included in the split-mouth RCT and 128 in the parallel-arm RCT. We combined treatment effect estimates by using an inverse-variance weighting meta-analysis approach. Pain scores were significantly decreased with IOA vs CIA (mean difference -0.69 cm, 95% confidence intervals -1.13 to -0.25 cm). For each patient enrolled in the split-mouth RCT, about five were enrolled in the parallel-arm RCT, which allowed for not losing any eligible patients.

CONCLUSION

Pain during the insertion of the needle and injection was less with IOA vs CIA in children. The design of this study allowed for increasing statistical power and using all generated evidence. (ClinicalTrials.gov NCT02084433).