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A Survey of Local and Topical Anesthesia Use by Pediatric Dentists in the United States

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A Survey of Local and Topical Anesthesia Use by Pediatric Dentists in the United States Scientific Article A survey of local and topical anesthesia use by pediatric dentists in the United States Kavita Kohli DDS Peter Ngan DMD Richard Crout DMD, PhD Christopher C. Linscott DDS Dr. Kohli is an associate professor and interim director, Division of Pediatric Dentistry; Dr. Ngan is a professor and chair, Department of Orthodontics and Division of Pediatric Dentistry; Dr. Crout is a professor and director of research, Department of Periodontics, they are all at the West Virginia University - School of Dentistry, Health Sciences Center North, Morgantown, WV; Dr. Linscott is in private practice, Marietta, OH. Correspond with Dr. Kohli at [email protected] Abstract Purpose: The purpose of this survey is to evaluate current us- increase the chances of anesthetic overdose .7 Intravascular age of local and topical anesthesia by Pediatric Dentist to evaluate injection is one of the complications of local anesthetics in the current practices. children with the highest incidence seen associated with the Methods: Surveys were sent to 3051 pediatric dentists asking inferior alveolar nerve block.8 Anesthetic overdose reactions are about types of anesthetics, considerations in determining local an- related to the blood levels being above the overdose threshold esthetic dosage, time used to inject a cartridge and shortcomings of levels in the injected site. There are several factors that can topical preparations. Data were computed for percentage responses. predispose a patient to this overdose of anesthetic. The patient Results: The response rate was 55%. Only 49% used exact body factors include age, weight, other medications, sex, presence weight to determine local anesthetic dosage. The mostly commonly of other systemic disorders, genetics and mental attitude and used needles for infiltrations were 30-gauge short and blocks were environment. Drug factors that can contribute to the anesthetic 27-gauge short. Only 11% of the respondents were using ≥60 sec- overdose include vasoactivity, concentration, dose, route of onds to inject a full cartridge. Topical anesthetics were used by most, administration, rate of injection, vascularity of the injected area with the most commonly used brand being Hurricane‚. A third and presence of vasoconstrictors. Several of these factors can waited 60 seconds before injecting after the application of the topi- be eliminated without having to modify the procedure and they cal anesthetic. Most patients (89%) disliked the taste of topical include using the minimal drug concentration that would be anesthetics and adverse drug reactions were rarely seen. clinically adequate.9 Malamed recommends aspiration be per- Conclusions: The findings of this study demonstrate that Pe- formed prior to injection to prevent depositing a large amount diatric Dentists are most commonly using Lidocaine as the preferred of anesthetic into the circulatory system.10 The rate of the in- type of local anesthetic using 30 gauge short needle for infilterations jection is one of the most important factors to prevent drug and 27 gauge short needle for blocks. Most were taking anywhere overdose. A slow rate of injection taking 60 or more seconds from 11->60 seconds to inject a cartridge. Topical anesthetic was to inject a full cartridge of anesthetic can ensure that the anes- used by most and the preferred brand was Hurricane‚, however thetic is safe and clinically adequate.9 However, it is not known their perception of the effectiveness of topical anesthetics varied. what percentage of clinicians is utilizing this technique. There also appears to be a need to develop newer and better mode Topical anesthetics can also contribute to this drug over- of topical anesthetic delivery system in the pediatric dental popu- dose. Systemic toxic reactions associated with a topical lation. (Pediatr Dent 23:265-269, 2001) anesthetic are virtually unknown for the most commonly used topical anesthetic agents like benzocaine.10 Lidocaine-based topical anesthetics are basically vasodilators and are used in nesthetic injection is the dental procedure that produces stronger concentrations; they are rapidly absorbed into the sys- the greatest negative response in children.1 Pain and temic circulation when applied to the oral mucous membrane.11 anxiety can reduce the efficacy of anesthesia in pediat- It is recommended that the amide topical anesthetic be applied A 2 ric patients. This fear of anesthesia is often manifested as a sparingly only to the area of needle penetration to gauze-dried behavior management problem, with a few pediatric patients oral mucous membrane.10 The benzocaine (ester) topical an- lacking good coping skills and displaying hysterical behavior esthetics are less likely to cause an overdose as they are poorly in anticipation of discomfort.3 Anxiety is the most disturbing absorbed into the cardiovascular system, if at all.10 Malamed experience for children,4 a response that sometimes can only recommends that a sparing amount of amide topical anesthetic be controlled with techniques beyond local anesthesia.5 be used, but the ester topical anesthetic in small amounts can The proper use of local anesthetic has been reviewed exten- be used with minimal likelihood of overdose.11 sively in the literature.6 However, a recent national survey of Age and weight can be variables that are critical for the 7000 general dentists on the local anesthetic usage concluded safety of the pediatric population, it is imperative to reinforce that the present inferior alveolar nerve block techniques may the recommendations of Malamed to prevent anesthetic over- doses. 9 Received March 16, 2000 Revision Accepted December 22, 2000 Pediatric Dentistry – 23:3, 2001 American Academy of Pediatric Dentistry 265 Table 1. Local Anesthetic Results age of the times a topical anesthetic was used prior to the in- jection; the most commonly used preparation of topical 1. What type of local anesthetic drug do you use most often? anesthetics; waiting time after the application of topical anes- a. Lidocaine 83% thetic before injecting; if the practitioner considered the topical b. Mepivacaine 11% c. Bupivacaine 0% anesthetic effective; if the practitioner would consider a differ- d. Prilocaine 5% ent delivery system for the topical anesthetic; what his/her e. Other 1% patients most disliked about the topical anesthetic; what per- 2. What is the most important factor that you consider when centage of the patients had an adverse drug reaction to the you decide on dosage of the local anesthetic that you will topical anesthetic in the last year, and, if so, to briefly describe inject? the adverse drug reaction (Table 2). The survey also asked the a. exact age in years 2% clinicians to provide demographic data such as the size of the b. exact body weight 49% community and their year of graduation. Data was analyzed c. estimated size of the child 44% by computing the percentage response for each question. d. others : 5% 3. What gauge of needle do you use most often? Results a. infiltration : The return response rate of this survey was 55%. As for the 1. 25 gauge 4% demographic data, 27% of the respondents graduated between 2. 27 gauge 36% 3. 30 gauge 60% the years of 1987-1997, 30% graduated between the years of 4. other 0% 1977-1986, 31% graduated between the years of 1967-1977, b. blocks : and 12% had more than 30 years of practice experience. Thirty 1. 25 gauge 7% percent of the practitioners practiced in communities that had 2. 27 gauge 53% a population of 101,000-500,999; 21% practiced in commu- 3. 30 gauge 40% nities sized 51,000-500,999; 15% practiced in communities 4. other : 0% larger than 1,000,000; 12% practiced in communities of 4. What length of needle do you use most often? 600,000-1,000,000; and 11% practiced in communities of a. infiltration : 31,000-50,999. The remaining practiced in communities 1. long 3% 2. short 84% smaller than 31,000 people. 3. ultrashort 13% The responses for local anesthetic are tabulated in Table 1. 4. other : 0% Lidocaine was one of the most commonly used local anesthetic b. blocks : (83%), followed by mepivacaine (11%). Five percent reported 1. long 21% using prilocaine, and none reported using bupivacaine. One 2. short 78% percent of the respondents reported using diphenhydramine 3. ultrashort 1% 4. other : 0% as a local anesthetic agent. When questioned which criteria practitioners used to de- 5. How much time do you take to inject a full cartridge? termine the local anesthetic dosage, almost half of the a. ≤10 sec 2% b. 11-20 sec 25% respondents (49%) reported using the exact body weight when c. 21-30 sec 29% determining the dosage of local anesthetic for each pediatric d. 31-60 sec 33% patient. Estimated size of the patient was used by 44%, while e. ≥ 61 sec 11% 2% used the patient’s age, and 5% used other methods such as “all patients receive one cartridge”; “degree of difficulty of procedure”; “length of treatment”; “number of teeth needing There are several recommendations made by Malamed to be treated”; and “degree of carious involvement”. A few prac- when using local and topical anesthesia in the pediatric popu- titioners used no criteria to determine the dose, while a few used lation. It is not known what percentages of the practicing the dose needed to achieve profound anesthesia. A few respon- pediatric dentists are following these recommendations. There dents reported that the medical history of the patient or the is a need to assess the current practices in order to inform and type of treatment determined the dosage needed by the patient. educate the practitioners to prevent fatal anesthetic overdoses The commonly used gauge sizes by the practitioners showed in children. This survey will help make recommendations, if that 60% of the respondents preferred the use of a 30 gauge, any, on the need for a newer and better mode of topical anes- 36% used a 27 gauge and 4% used a 25 gauge for anesthetic thetic delivery systems in Pediatric Dentistry.
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