Use of Local Anesthesia for Pediatric Dental Patients

BEST PRACTICES: USE OF LOCAL ANESTHESIA

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 385

Purpose

e American Academy of Pediatric Dentistry (AAPD)

intends this document to help practitioners make decisions

regarding use of local anesthesia to control pain in infants,

children, adolescents, and individuals with special health care

needs during the delivery of oral health care.

Methods

Recommendations on use of local anesthesia were developed

by the Council on Clinical Aairs, adopted in 2005

, and last

revised in 2020.

This update is based upon a literature search

of the Pubmed

/MEDLINE database using the terms: local

anesthesia AND dentistry AND systematic review, topical

anesthesia AND dentistry, buffered anesthesia AND dentistry.

Two hundred forty-eight articles matched these criteria. Addi-

tionally, Handbook of Local Anesthesia, 7th Edition

contributed

significantly to this revision. When data did not appear suffi-

cient or were inconclusive, recommendations were based upon

expert and/or consensus opinion by experienced researchers

and clinicians.

Background

Local anesthesia is the temporary loss of sensation in one part

of the body produced by a topically-applied or injected agent.

Local anesthetics act within neural bers to inhibit the rapid

ionic inux of sodium necessary for neuron impulse generation

and propagation.

4,5

is helps prevent sensation of pain during

procedures, which can foster a trusting relationship between

the patient and dentist, allay fear and anxiety, and promote a

positive dental attitude. Inadequate pain control during dental

procedures has the potential for signicant physical and psy-

chological consequences.

Many local anesthetic agents are

available to facilitate management of pain in the dental patient.

e two general types of local anesthetic chemical formula-

tions are: (1) esters (e.g., procaine, benzocaine, tetracaine) and

(2) amides (e.g., lidocaine, mepivicaine, prilocaine, articaine).

e technique of local anesthetic administration is an im-

portant consideration in pediatric patient behavior guidance.

8,9

Age-appropriate nonthreatening terminology, distraction, topi-

cal anesthetics, proper injection technique, and pharmacologic

management can help the patient have a positive experience

during administration of local anesthetics.

8,10(p184)

In pediatric

dentistry, appropriate dosage (based on body weight) will

minimize the chance of toxicity.

11(pg294)

Knowledge of gross

and neuroanatomy of the head and neck allows for proper

placement of the anesthetic solution and helps minimize

complications (e.g., hematoma, trismus, intravascular injec-

tion).

12(pg308)

A comprehensive understanding of the patient’s

Use of Local Anesthesia for Pediatric Dental

Patients

Latest Revision

2023

How to Cite: American Academy of Pediatric Dentistry. Use of

local anesthesia for pediatric dental patients. The Reference Manual

of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric

Dentistry; 2023:385-92.

Abstract

This best practice presents recommendations regarding use of local anesthesia to control pain for pediatric dental patients. Considerations

in the use of topical and local anesthetics include: the patient’s medical history, developmental status, age, and weight; planned procedures;

needle selection; and safety concerns such as risk for methemoglobinemia and systemic effects of anesthetic agents. Guidance is offered

on the documentation of local anesthesia administration including anesthetic selection, dose administered, injection type and location, and

postoperative instructions. Potential complications such as toxicity, paresthesia, allergy, and postoperative self-induced soft tissue injury are

discussed. Additional recommendations address alternative methods of local anesthesia delivery, concurrent use with sedation or general

anesthesia, and use during pregnancy. Pain management is an important component of oral health care and can result in a more positive

patient experience during pediatric dental procedures

This document was developed through a collaborative effort of the American Academy of Pediatric Dentistry Councils on Clinical Affairs and

Scientiﬁc Affairs to offer updated information and recommendations on using local anesthetics in the management of dental pain for

pediatric patients and persons with special health care needs.

KEYWORDS: ANALGESICS; ANESTHESIA, GENERAL; ANESTHESIA, LOCAL; DELIVERY OF HEALTH CARE; METHEMOGLOBINEMIA; PAIN MANAGEMENT;

PEDIATRIC DENTISTRY

ABBREVIATIONS

AAPD: American Academy of Pediatric Dentistry. ADA: American

Dental Association. CNS: Central nervous system. FDA: U.S. Food

and Drug Administration. kg: Kilogram. LAST: Local anesthetic

systemic toxicity. mg: Milligram. mm: Millimeter. PDL: Periodontal

ligament.

BEST PRACTICES: USE OF LOCAL ANESTHESIA

386 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

medical history will decrease the risk of aggravating a medical

condition while rendering dental care. A medical consultation

may be indicated to obtain needed information.

Topical anesthetics

The application of a topical anesthetic may help minimize

discomfort caused during administration of local anesthesia.

Single drugs which are often used as topical anesthetics in

dentistry in clude 20 percent benzocaine, ve percent lidocaine,

and four percent tetracaine.

13(pg79)

Topical anesthetics are

effective on surface tissues (up to two to three millimeters

[mm] in depth) to reduce pain from needle penetration of

the oral mucosa.

13(pg76)

ese agents are available in gel, liquid,

ointment, patch, and aerosol forms. e concentration of local

anesthetics typically is higher in topical formulations than in

injectable solutions, and judicious application will reduce

potential for toxicity.

13(pg76)

Benzocaine and prilocaine both have

been associated with a risk of acquired methemoglobinemia,

and their use is contraindicated in patients with a history of

methemoglobinemia.

13(pg69),14,15(pg169)

Acquired methemoglobi-

nemia is a serious but rare condition that occurs when the

ferrous iron in the hemoglobin molecule is oxidized to the ferric

state. This molecule is known as methemoglobin, which is

incapable of carrying oxygen and results in a decreased avail-

ability of oxygen to the tissues.

Prilocaine is also relatively

contraindicated in patients at risk for methemoglobinemia

(e.g., patients with glucose-6-

phosphate dehydrogenase deciency,

sickle cell anemia, anemia; very

young patients) or patients with

symptoms of hypoxia.

13(pg71),16

Highly significant clinical concerns

have been reported in patients re-

ceiving the combination of

prilocaine-containing topical agents

and methemoglobin-inducing agents

(e.g., sulfonamides, acetaminophen,

phenytoin).

Additionally, the

United States Food and Drug

Administration (FDA) warns against

use of topical anesthetics (including

over-the-counter teething products)

containing benzocaine for children

younger than two years.

e FDA also has issued warnings

about the potential toxicity of com-

pounded topical anesthetics due to

the high concentration of individual

anesthetic components.

Com-

pounded topical anesthetics are

custom-made medications that may

bypass the FDA’s drug approval

process. Use of compound topical

anesthetics with unknown concen-

trations of local anesthetics carries a

risk of complications associated with overdose, including sei-

zures, arrhythmias, and death.

Selection of syringes and needles

The American Dental Association (ADA) has standards for

aspirating syringes for use in the administration of local anes-

thesia.

19,20

Needle gauges range from size 23 to 30, with the

lower numbers having the larger inner diameter. Needles with

lower gauge number (larger diameter) provide for less deection

as the needle passes through soft tissues and for more reliable

aspiration.

21(pg101)

The depth of insertion varies not only by

injection technique but also by the age and size of the patient.

Dental needles are available in three lengths: long (32 mm),

short (20 mm), and ultrashort (10 mm). Most needle fractures

occur during the administration of inferior alveolar nerve

block with 30-gauge needles.

Breakage can occur when a

needle is inserted to the hub

21(pg100)

, when the needle is weak-

ened due to bending before insertion into the soft tissues, or

by patient movement after the needle is inserted.

12(pg309),22,23

Injectable local anesthetic agents (Table)

Amide local anesthetics available for dental usage include li-

docaine, mepivacaine, articaine, prilocaine, and bupivacaine.

Agents that include epinephrine are formulated to an approx-

imate pH of 4.5 in order to prolong the shelf life of the

vasoconstrictor, but this may activate acid-sensing nociceptors

Abbreviations used in this table: kg=kilogram; lb=pound; mg=milligram; mL=milliliter.

Duration of anesthesia varies greatly depending on concentration, total dose, and site of administration; use

of epinephrine; and the patient’s age.

Use lowest total dose that provides eective anesthesia. Lower doses should be used in very vascular areas

or when providing local anesthesia without vasoconstrictor. Doses of amides should be decreased by 30 per-

cent in infants younger than six months. For improved safety, AAPD, in conjunction with the American

Academy of Pediatrics, recommends a dosing schedule for dental procedures that is more conservative that

the manufacturer’s recommended dose (MRD).

e table lists the long-established pediatric dental maximum dose of lidocaine as 4.4 mg/kg; however, the

MRD is 7 mg/kg.

Use in pediatric patients under four years of age is not recommended.

Use in patients under 12 years of age is not recommended.

Table. INJECTABLE LOCAL ANESTHETICS (Adapted from Coté CJ et al.

)

Anesthetic

Duration in

minutes

Maximum dose

mg anesthetic/

1.7 mL cartridge

mg vasoconstrictor/

1.7 mL cartridge

mg/kg

mg/lb

Lidocaine



90-200 4.4 2

2%+1:50,000 epinephrine

34 0.034 mg

2%+1:100,000 epinephrine

34 0.017 mg

Articaine

60-230

7 3.2

4%+1:100,000 epinephrine

68 0.017 mg

4%+1:200,000 epinephrine

68 0.0085 mg

Mepivacaine

120-240

4.4 2

3% plain 51 —

2%+1:20,000 levonordefrin 34 0.085 mg

Bupivacaine

180-600

1.3 0.6

0.5%+1:200,000 epinephrine 8.5 0.0085 mg

BEST PRACTICES: USE OF LOCAL ANESTHESIA

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 387

and lead to increased pain.

The higher acidity of local an-

esthetics with vasoconstrictor also may slow the onset of the

anesthetic while it transforms from its ionized to non-ionized

form in order to penetrate the lipid membrane of the nerve

sheath.

The effect of adjusting the pH of local anesthetics

with epinephrine in dentistry is of interest as a way to reduce

pain and time to onset of anesthesia. One systematic review

found that local anesthetic with epinephrine buffered with

sodium bicarbonate was 2.3 times more likely to achieve

anesthesia than nonbuffered agents for participants with a

clinical diagnosis of symptomatic irreversible pulpitis re-

quiring endodontic treatment.

Another systematic review

found that the pH adjustment was not eective in reducing

pain of intraoral injections, but buering did reduce the time

to onset of anesthesia when performing inferior alveolar nerve

blocks or injecting into inflamed tissues.

This review con-

cluded that the reduced time may not be clinically relevant

considering the time required to prepare the buered agent.

Similar results were found in children ages six to 12 years

old.

Additional research is needed regarding the effect of

buered local anesthetic on pain reduction in children.

28,29

Vasoconstrictors (e.g., epinephrine, levonordefrin, norepi-

nephrine) are added to local anesthetics to constrict blood

vessels in the area of injection. is lowers the rate of absorption

of the local anesthetic into the blood stream, thereby lower-

ing the risk of toxicity and prolonging the anesthetic action

in the area.

For patients with hyperthyroidism, cautious use

of epinephrine as a vasoconstrictor in local anesthetics is war-

ranted to decrease risk of tachycardia or hypertension.

15(pg148)

Patients with signicant cardiovascular disease

15(pg144)

, thyroid

dysfunction

15(pg148)

, diabetes

15(pg148)

, or sulte sensitivity

31(pg349)

and those receiving monoamine oxidase inhibitors

15(pg166)

tricyclic antidepressants

15(pg164)

, antipsychotic drugs

15(pg165)

norepinephrine, or phenothiazines

15(pp165,166)

may require a

medical consultation to determine the need for a local anesthetic

without vasoconstrictor.

15(pg149)

e Malignant Hyperthermia

Association of the United States indicates that all local anes-

thetics, including those with vasoconstrictor, are safe for use in

patients susceptible to malignant hyperthermia.

32,33

When ha-

logenated gases are used for general anesthesia, however, the

myocardium is sensitized to epinephrine, and such situations

dictate caution with use of a local anesthetic.

15(pg165)

As with the

topical form, injectable prilocaine is relatively contraindicated

in patients with susceptibility to methemoglobinemia.

13(pg71)

While the prolonged effect of a long-acting local anesthetic

(i.e., bupivacaine) can be beneficial for postoperative pain

in adults, the concomitant increased risk of self-inicted injury

infers that it is contraindicated for children or intellectually

disabled patients.

11(pg298)

e mandibular cortical bone of a child is less dense than

that of an adult, permitting more rapid and complete diusion

of the injected anesthetic.

11(pg297)

Because of this increased per-

meability, mandibular buccal supraperiosteal inltration with

local anesthetic may be as eective as an inferior alveolar nerve

block for dental procedures (e.g., intracoronal restorations) on

mandibular primary teeth.

11(pg298)

Multiple systematic reviews

have compared inferior alveolar nerve blocks with lidocaine

to infiltration with articaine for restorative treatment, pulp

therapy, and extractions of both primary and permanent

molars in individuals under 18 years of age

34-39

; the evidence

regarding superiority is inconclusive. e ability of articaine to

diuse through hard and soft tissue from a buccal inltration

to provide lingual or palatal soft tissue anesthesia has been

reported as a potential advantage over lidocaine.

13(pg73),40

If a local anesthetic is injected into an area of infection, its

time to onset may be prolonged or anesthesia may be ineec-

tive.

11(pg289)

Infection lowers the pH of the extracellular tissue,

inhibiting diusion of the active free base form of the anesthetic

across the neural membrane, thereby stopping nerve impulse

conduction.

11(pg289)

Endocarditis prophylaxis (antibiotics) is not

recommended for routine local anesthetic injections through

noninfected tissue in patients considered at risk.

Documentation of local anesthesia

e patient record is an essential component of the delivery of

competent and quality oral health care.

Following each ap-

pointment, an entry is made in the record that accurately and

objectively summarizes that visit. Appropriate documentation

includes specic information relative to the administration of

local anesthetics. is would include, at a minimum, the type

and dosage of local anesthetic administered.

Documentation

also may include the type of injection(s) administered (e.g., in-

ltration, block, intraosseous), needle selection, and patient’s

reaction to the injection. For example, local anesthetic admin-

istration might be recorded as: mandibular block with 27-short;

34 milligrams (mg) two percent lidocaine with 0.017 mg

epinephrine (or 1/100,000 epinephrine); tolerated procedure

well. With patients for whom the maximum dosage of local

anesthetic may be a concern (e.g., young patients, those under-

going sedation), documenting the body weight and calculating

the maximum recommended total dose preoperatively can help

prevent overdosage. Because there may be enhanced sedative

eects when local anesthetics are administered in conjunction

with sedative drugs, recording doses of all agents on a time-

based record can help ensure patient safety.

Local anesthesia

documentation also includes a statement that post-injection

instructions were reviewed with the patient and parent.

Local anesthetic complications

Critical to the safety of all patients during the administration

of local anesthetics are the practitioner’s awareness of the risks

for complications and eorts to prevent them, recognition of

the signs and symptoms of an adverse event, and the ability

to provide time-critical interventions in case of a medical

emergency.

Local anesthetic systemic toxicity (LAST; overdose)

Younger pediatric patients are at greater risk for adverse drug

events.

31(pg332)

Most adverse drug reactions develop either during

the injection or within ve to 10 minutes.

LAST can result

BEST PRACTICES: USE OF LOCAL ANESTHESIA

388 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

from high blood levels caused by a single inadvertent intravas-

cular injection or repeated injections.

31(pg334)

Local anesthetic

causes a biphasic reaction (excitation followed by depression)

in the central nervous system (CNS).

44(pg32)

e classic overdose

reaction to local anesthetic is generalized tonic-clinic convul-

sion.

44(pg33)

Early subjective indications of toxicity involve the

CNS and include dizziness, anxiety, and confusion. is may

be followed by diplopia, tinnitus, drowsiness, and circumoral

numbness or tingling. Objective signs may include muscle

twitching, tremors, talkativeness, slowed speech, and shivering,

followed by overt seizure activity. Loss of consciousness and

respiratory arrest may occur.

e cardiovascular system response to local anesthetic toxic-

ity also is biphasic. Initially, heart rate and blood pressure may

increase due to the injected epinephrine. As plasma levels of

the anesthetic increase, however, vasodilatation occurs followed

by depression of the myocardium and a subsequent fall in

blood pressure. Local anesthetics block voltage-gated sodium

channels that are responsible for the generation of cardiac

arrhythmias, and overdose may cause bradycardia and subse-

quent cardiac arrest. The cardiodepressant effects of local

anesthetics are not seen until there is a signicantly elevated

level in the blood.

31(pg342)

LAST can be prevented by careful injection technique,

watchful observation of the patient, and knowledge of the

maximum dosage based on body weight. is would include

aspirating after needle placement before agent delivery during

every injection and injecting slowly.

10(pg181)

Aspiration decreases

the risk of an intravascular injection, and a slow injection tech-

nique reduces tissue distortion and related discomfort. After

the injection, the clinical observation of the patient will enable

early recognition of a toxic response. When signs or symptoms

of toxicity are noted, administration of the local anesthetic

agent is discontinued and additional emergency management,

including patient rescue and activation of emergency medical

services, is based on the severity of the reaction.

Early treat-

ment with intravenous lipid emulsion therapy is a priority in

potentially serious cases of LAST.

Allergy to local anesthetics

Allergy to a local anesthetic, a rare nding, is an absolute con-

traindication for its use.

13(pg81)

Allergy to one amide does not

rule out the use of another amide, but allergy to one ester rules

out use of another ester.

31(pg347)

Patients may report an allergy

to local anesthetic agents even though they experienced a

reaction to the vasoconstrictor, a sensitivity to a preservative

(metabisulte) in agents containing epinephrine, administra-

tion of a toxic dose, or an intravascular injection. Documenta-

tion of the previous event and/or allergy testing can help the

practitioner proceed with procedural pain management. For

patients having an allergy to bisultes, use of a local anesthetic

without vasoconstrictor is indicated.

31(pg349)

Allergic reactions

are not dose related but are due to the patient’s heightened

capacity to react to even a small dose and can manifest in a

variety of ways, some of which include urticaria, dermatitis,

angioedema, fever, photosensitivity, or anaphylaxis.

31(pg354)

Emergency management is dependent on the rate and severity

of the reaction.

Paresthesia

Paresthesia is persistent anesthesia beyond the expected dura-

tion. Trauma to the nerve can result in paresthesia and, among

other etiologies, can be caused by the needle during the injec-

tion.

12(pg310)

Patients who initially experience an electric shock

sensation during injection may have persistent anesthesia.

12(pg312)

Paresthesia has been reported to be more common with four

percent solutions such as articaine and prilocaine compared to

those of lower concentrations.

46,47

Postoperative soft tissue injury

Self-induced soft tissue trauma (e.g., lip and cheek biting) is

an unfortunate clinical complication of local anesthetic use in

the oral cavity. Most lesions of this nature are self-limiting and

heal without complications, although bleeding and infection

are possible.

12(pg320)

e use of bilateral mandibular blocks may

increase the risk of soft tissue trauma when compared to uni-

lateral mandibular blocks or ipsilateral maxillary inltration.

Advising the patient/caregiver of a realistic duration of

numbness and postoperative precautions is necessary to decrease

the risk of self-induced soft tissue trauma. Visual examples may

help stress the importance of observation during the period of

numbness. For all local anesthetics, the duration of soft tissue

anesthesia is greater than dentinal or osseous anesthesia. Use

of phentolamine mesylate injections in patients over age six

years or at least 15 kilograms (kg) has been shown to reduce

the duration of eects of local anesthetic by about 47 percent

in the maxilla and 67 percent in the mandible.

49,50

Phento-

lamine mesylate reverses the vasoconstrictor via its antagonistic

eect at the α

receptor, allowing for vasodilation and rapid

metabolism of local anesthetic.

A relationship between reduc-

tion in soft tissue trauma and the use of shorter acting local

anesthetics has not been demonstrated.

11(pg296)

Use of phento-

lamine mesylate is not recommended for patients who are

younger than three years of age or weigh less than 15 kg (33

pounds).

Alternative techniques for delivery of local anesthesia

Most local anesthesia procedures in pediatric dentistry involve

traditional methods of inltration or nerve block techniques

with a dental syringe, disposable cartridges, and needles as

described so far. Several alternative techniques, including

computer-controlled local anesthetic delivery, periodontal

injection techniques, needleless systems, and intraseptal or

intrapulpal injection, are available. Such techniques may

improve comfort of injection by better control of the admin-

istration rate, pressure, and location of anesthetic solutions

and result in more successful and controlled anesthesia.

In patients with bleeding disorders, the periodontal liga-

ment (PDL) injection minimizes the potential for postoper-

ative bleeding of soft tissue vessels.

15(pg142)

e use of the PDL

BEST PRACTICES: USE OF LOCAL ANESTHESIA

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 389

injection or intraosseous methods is contraindicated in the

presence of inammation or infection at the injection site.

Local anesthesia with sedation and general anesthesia

Local anesthetics and sedative agents both depress the CNS.

erefore, it is recommended that the dose of local anesthetic

be adjusted downward when sedating children with opioids.

Reasons to use local anesthesia for dental procedures under

general anesthesia include concerns for increased future pain

sensitivity due to CNS priming

and reduction in postoper-

ative pain. In patients undergoing general anesthesia for dental

treatment including restorations and extractions, however, the

evidence for administration of local anesthesia intraoperatively

to reduce postoperative pain is equivocal.

56,57

Furthermore,

intraoperative use of local anesthesia may increase risk of post-

operative soft tissue trauma while the patient is numb.

Local anesthesia and pregnancy

Pregnancy causes many physiologic changes, including eects

on cardiovascular function and metabolism.

Consideration

should be given to the risks and benets of dental treatment to

the pregnant patient and fetus when choosing therapeutics.

Local anesthetics, including lidocaine, mepivacaine, and bu-

pivacaine, are safe for pregnant patients when the appropriate

dosage is used.

Because local anesthetics can pass through the

placental barrier, additional caution is indicated when the fe-

tus has known medical complications.

Epinephrine may cause

contraction of uterine blood vessels and limit blood ow to

the placenta.

erefore, caution is indicated in the use of local

anesthetics with vasoconstrictor for pregnant women, particu-

larly those with hypertensive conditions (e.g., preeclampsia).

e second trimester of pregnancy, when organogenesis of the

fetus is complete and comfortable positioning in the dental

chair may still be possible, may be the optimal time to complete

non-urgent dental treatment.

Lidocaine is considered safe for

use during breastfeeding.

62,63

Recommendations

Local anesthesia is an important consideration in behavior

guidance of pediatric dental patients. Inadequate pain control

during dental procedures has the potential for signicant phys-

ical and psychological consequences, including altering future

pain experiences for these children.

Agents used for preven-

tion of pediatric procedural pain have the potential for toxicity

and adverse reactions. Practitioners should adhere to the follow-

ing recommendations for use of local anesthetics for pediatric

dental patients.

1. Selection of local anesthetic agents should be based on

the patient’s medical history and mental/develop-

mental status, the anticipated duration of the dental

procedure, and the planned administration of other

agents (e.g., nitrous oxide, sedative agents, general

anesthesia).

2. Administration of local anesthetic should be based on

the body weight of the patient, not to exceed AAPD

recommendations in mg/kg found in Table. Practi-

tioners should use the lowest total dose that provides

eective anesthesia.

3. A topical anesthetic may be used prior to the in-

jection of a local anesthetic to reduce discomfort

associated with needle penetration. Systemic absorp-

tion of the drugs in topical anesthetics must be

considered when calculating the total amount of

anesthetic administered.

4. Documentation of local anesthetic administration

should include, at a minimum, the type and dosage

of agent. 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. The calculated maximum total dose for local anes-

thetics should be reduced when administered in

conjunction with other medications that depress the

CNS.

6. The calculated maximum total dose of amide local

anesthetics should be reduced by 30 percent in infants

younger than six months.

7. Postoperative instructions should include guidance

regarding the duration of local anesthesia and

strategies to reduce the risk of biting the lip, cheek,

or tongue.

8. Providers should have protocols for emergency man-

agement of patients exhibiting signs of LAST or an

allergic reaction.

Additional safety considerations

Careful selection, dosage, and technique are critical to the safe

administration of local anesthesia for pediatric patients. Im-

portant considerations include:

1. In the Table, the long-established maximum safe dose

for use of lidocaine with pediatric dental patients is

4.4 mg/kg; however, seven mg/kg is the manufacturer’s

recommended maximum dose. e maximum dose

for articaine as recommended by the manufacturer

is seven mg/kg. e lowest total dose that provides

eective anesthesia should be used, and lower total

doses should be used for injections into vascular areas.

For improved safety, AAPD, in conjunction with the

American Academy of Pediatrics, recommends a

dosing schedule for dental procedures that is more

conservative than the manufacturer’s recommended

dose.

2. Manufacturers do not recommend articaine use in

pediatric dental patients younger than four years. e

use of bupivacaine is not recommended in patients

younger than 12 years.

3. Compounded topical anesthetics may contain very

high combined levels of both amide and ester agents

which can lead to serious adverse reactions.

Considerations continued on the next page.

BEST PRACTICES: USE OF LOCAL ANESTHESIA

390 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

4. Use of benzocaine is contraindicated in patients with

a history of methemoglobinemia and in children

younger than two years of age. Prilocaine is also con-

traindicated in patients with a history of methemo-

globinemia and relatively contraindicated in those

who are susceptible to methemoglobinemia due to

medical history or concurrent use of other medications.

5. Needles are prone to breakage if bent prior to

injection or inserted to their hub.

6. Aspiration prior to injection and slow injection tech-

nique reduce the risk of adverse events related to

systemic administration of the local anesthetic.

References

1. American Academy of Pediatric Dentistry. Appropriate

use of local anesthesia for pediatric dental patients.

Pediatr Dent 2005;27(Suppl):101-6.

2. American Academy of Pediatric Dentistry. Use of local

anesthesia for pediatric dental patients. The Reference

Manual of Pediatric Dentistry. Chicago, Ill., USA:

American Academy of Pediatric Dentistry; 2020:318-23.

3. Malamed SF. Handbook of Local Anesthesia. 7th ed. St.

Louis, Mo.: Mosby; 2020.

4. Malamed SF. Neurophysiology. In: Handbook of Local

Anesthesia. 7th ed. St. Louis, Mo.: Mosby; 2020:14.

5. Ogle OE, Mahjoubi G. Local anesthesia: Agents, tech-

niques, and complications. Dent Clin North Am 2012;

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with special health care needs. The Reference Manual

of Pediatric Dentistry. Chicago, Ill., USA: American

Academy of Pediatric Dentistry; 2023:434-42.

7. Moore PA, Hersh EV. Local anesthetics: Pharmacology

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