Updated: Feb 27
Or we could call it....GIVING “SLEEPY JUICE” TO OUR PEDIACTIC PATIENTS
Is it just me or does anyone else take a deep breath and cross your fingers that you don’t have to give an injection to a kiddo?
There’s just a little something different about approaching injections with this population. Maybe it’s because, when I have a child in my chair who needs to get numb, they're already in pain and have anxiety. I don’t want to do anything to bring them more pain. I’d rather just give them a hug and teddy bear instead of a shot.
As with all of our patients our words and actions matter, but I think it's amplified 100 times when working with our younger patients. Thinking about the right way to approach the topic of giving an injection to kids is one key ingredient to anesthesia success. The other, is understanding anesthesia placement and dosage is different than our adult patients.
…. So, let’s look at some of the ways we can make this process easier on us and our patients.
By no means is this a comprehensive review of children and anesthesia just a few reminders I like to give myself and thought they would be helpful for you too.
AGE and WEIGHT:
Pediatric patients are at greater risk of local anesthetic overdose than practically any of our other patients. It’s sad but true.
One of the most important pieces of information we must consider to avoid overdose, is our patients age and weight. This is such a crucial step. In fact, every pediatric dental office I’ve ever talked with evaluates the patient’s weight when they arrive for treatment.
This vital information gives you the guidelines to calculate the correct dosage amount for specifically required for your young patients. There are a few different ways to figure this out. I like the American Academy of Pediatric Dentists dosage recommendations. These recommendations are lower than what we would traditionally give our adult patients
SEE CHART BELOW
Not only do we need to grab our calculator to figure out the dose for our patient, but we also need to be aware that children are more likely to have trauma’s post anesthesia as well. Kids are more likely to forget they are numb and will bite their lip. Also, they may chew their lip or cheek due to the weird tingling feeling as the anesthetic starts to wear off.
Using a minimal amount of anesthetic needed will protect our patient from an overdose but also reduce the amount of anesthesia time.
Make sure you select the appropriate anesthetic for the procedure. Sometimes a plain anesthetic can be the perfect option.
Oh, and don’t forget to have a conversation with our patient and their caregiver to remind them to be aware of the numb areas. I love those little stickers with the bear on the front saying "don't forget I'm still numb".
Since our patients have a developing skeletal system, anesthesia placement may be different. Especially for the mandibular area.
Using the infiltration technique in the buccal vestibule instead of a mandibular block can be just as successful. Several studies have shown that mandibular buccal infiltration specifically in the presence of only primary dentition is just as effective as a nerve block. The anesthetic type wasn’t as crucial either.
However, it has been noted that as the mandible develops and becomes thicker and the permanent molars begin to erupt, the use of 4% Articaine with epinephrine has a slight advantage.
In the event you do need to conduct a mandibular block the use of a long needle may not be required. This is due to the lack of mandibular growth and the reduced amount of soft tissue. So for patients under the age of 12 you may be able to use a short needle.
In regard to needle gauge and length selection, it all depends on which injection you are doing. If you are infiltrating using a short or even an extra short 27- or 30-gauge needle is appropriate. If you are doing a mandibular block a short needle will do the job. I do encourage you to select at 27- or even 25- gauge lumen. With proper topical the lumen size doesn’t create a difference in pain perception, but it can make a difference in the potential of needle deflection. This should be a factor of great consideration since we could encounter a patient who moves more, which can cause the needle to bend….AND…a bent needle can cause the anesthetic to deposit in the wrong location and increase the risk of needle breakage. Which is not a good thing!
TECHNIQUES: and BEHAVIOR MANAGEMENT
Using mandibular infiltration techniques is a great option for something a little less invasive. But what about other methods to create a positive injection process.
There is a lot of literature about how distraction techniques can create a positive experience for our patients. The use of virtual reality (VR) glasses was studied and resulted in a high acceptance rate by kids. How cool would that be to lay back and have VR glasses while getting your oral health taken care of. If you don’t happen to be in possession of that type of tech, clinicians have had success with the use of handheld games as well.
When my son was 6 years old and needed all 4 primary canines removed, he had a little bit of nitrous oxide and played the Gameboy the entire time. He didn’t even realize what was going on. Fast forward a few years there are several different options available including cellphone games.
The good old standby of tickling the kiddo’s earlobe, wiggling the lip or taping their nose can also be enough to get our patients thinking about something else.
Of course, with all these distraction techniques we cannot forget to keep the syringe out of the visual pathway. While that may not always be easy especially for the curious ones who are like little owls looking all around for the next item coming their way, we just have to do our best.
And yeah…if you have nitrous available to you, it does help. It’s not necessary but for some of the more challenging cases it can be the thing you need (just make sure you follow all those safety protocols too!).
Prior to giving the injection we need to prepare our patients for the process as well. It's key to understand your patients knowledge needs. For some children, knowing exactly what is happening is important. While others ignorance is bliss. I think we all know not to use the term "shots" with our patients. So using other terms for giving medicine is important. There are a variety of ways to explain the anesthesia process. I think the most popular is to say "we are giving your tooth a little sleepy juice" What ever you decide to say, make sure it is age appropriate.
OTHER DELIVER METHODS:
The use of the traditional syringe is still probably the most popular method of local anesthesia delivery but there are a couple of other ways to anesthetize those iddy biddy teeth.
Using a computer-controlled local anesthetic delivery (CCLAD) device can be helpful. There are several different kinds on the market like the WAND and DENTAPEN. This style of delivery devices have been shown to reduce anxiety and pain associated with injections. The premise is due to the slow and controlled delivery of the anesthetic. Also, because it doesn’t look like a traditional “shot” the perception to the patient could be a reason for the reduced anxiety.
As with any other patient make sure you consider your patients health history to evaluate for potential complications. I encourage you to use your best clinical judgement.
My hope is this little bit of information gives you the shot of confidence you need for our youngest patients.