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Local Anesthesia in Pediatric Dentistry: A Literature Review on Current

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REVIEW ARTICLE

Local Anesthesia in Pediatric Dentistry: A Literature Review

on Current Alternative Techniques and Approaches
Sainath R Elicherla1, Varada Sahithi2, Kanamarlapudi V Saikiran3, Mahesh Nunna4, Ramasubba R Challa5, Sivakumar Nuvvula6

A b s t r ac t​
Prevalence of pain and dental anxiety plays a crucial part in pediatric dentistry. These factors cause a delay in pursuing dental treatment, which
in turn increases early childhood caries. Anxiety and fear that arise before and during local anesthesia administration persist as barriers for
children experiencing dental treatment. Although local anesthesia plays a significant role in managing pain for children, researchers continue to
search for various comfortable methods to alleviate the pain during local anesthetic administration. Thus, the present overview aims to educate
pediatric dentists concerning newer local anesthetic delivery devices and several approaches in alleviating dental anxiety and pain in children.
Keywords: Children, Dental anxiety, Local anesthesia, Recent trends.
Journal of South Asian Association of Pediatric Dentistry (2021): 10.5005/jp-journals-10077-3076

I n t r o d u c t i o n​ 1,2,4–6
Department of Pediatric and Preventive Dentistry, Narayana
The International Association for the Study of Pain defines pain Dental College and Hospital, Nellore, Andhra Pradesh, India
3
as “an unpleasant sensory and emotional experience associated Department of Pediatric and Preventive Dentistry, SVS Institute of
with actual or potential tissue damage or described in terms of Dental Sciences, Mahabubnagar, Telangana, India
such damage”.1 Odontogenic pain related to dental caries, pulpal Corresponding Author: Sainath R Elicherla, Department of Pediatric
involvement, and dental trauma was reported favorably among and Preventive Dentistry, Narayana Dental College and Hospital,
children.2 It is one of the prime motives for pediatric patients to Nellore, Andhra Pradesh, India, Phone: +91 9440395427, e-mail:
attend dental care, especially emergency services.3 Management elicherlasai@gmail.com
of pain in pediatric dental care is a critical aspect of anxiety, How to cite this article: Elicherla SR, Sahithi V, Saikiran KV, et al. Local
often related to the induction of pain and exacerbates the pain Anesthesia in Pediatric Dentistry: A Literature Review on Current
perception. Consequently, these individuals experience higher Alternative Techniques and Approaches. J South Asian Assoc Pediatr
pain, which persists for a longer duration with exaggerated pain Dent 2021;4(2):148–154.
memory.4 Source of support: Nil
Thus, inadequate pain management helps stimulate negative Conflict of interest: None
responses and fear in children, which constitutes an obstacle for
dentists to instill a positive attitude in pediatric patients. Hence,
treating pediatric patients with minimal distress and pain has pediatric dentist on recent advances and several approaches to the
become a predominant objective for every pediatric dentist.5 The effective administration of local anesthesia and pain management.
anesthetic administration in children helps eradicate the pain
during dental treatment procedures. The word “Anesthesia” is an Aim and Objective
aggregate of words that includes (Greek) an-(“without”) and esthesis
The current literature review intends to compile substantial
(“sensation”). Malamed described local anesthesia as a reversible
evidence for pediatric dentists concerning the utilization of recent
loss of sensation in the encircled portion of the body caused by
local anesthetics, alternative methods, and techniques to diminish
a depression of excitation in nerve endings or inhibition of the
pain while administering anesthesia, thereby enhancing patient
conduction process in peripheral nerves.6
comfort.
The administration of a local anesthetic solution through
injection is the traditional method employed in alleviating dental
pain in children. Though this process successfully eliminates
A n e s t h e t i c D r u g s /A g e n ts​
pain during the procedure, anxiety and antagonistic behavior Topical Anesthetics Drugs/Agents
remain an issue for many children before and during anesthesia Topical anesthetic application benefits overcoming discomfort
administration.7,8 However, the pain encountered while receiving generated during the local anesthetic administration. It is active on
dental injections may hinder coping abilities during dental soft tissue surface of 2–3 mm in-depth and is accessible in various
treatment in subsequent visits.9 forms such as liquid, gel, aerosol, ointment, and patch.10,11 Topical
Thus, to overcome these shortcomings exploring new anesthetics reversibly block nerve conduction by acting on the
alternative and minimally invasive methods in local anesthetic dermis or mucosa’s free nerve endings at the administration site.
administration came into the limelight with better pain control, The conduction of nerve impulse gets hindered by reducing the
decreased injection pain, and enhanced quality of care for pediatric permeability of the nerve cell membrane to sodium ions, increasing
dentistry children. This review intends to update and educate the the excitability threshold.12

© Jaypee Brothers Medical Publishers. 2021 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License
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appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons
Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
 Update on the Local Anesthesia in Pediatric Dentistry

Periodontal Anesthetic Kit during restorative procedures in adults.21 In contrast, Capetillo et

It comprises a 20% benzocaine solution, marketed as a needle-free al. reported that nasal spray afforded less pulpal anesthesia than
anesthetic kit. It constitutes a disposable plastic tip and syringe (3 infiltration with lidocaine, and undesirable effects are elicited like
mL), inserted deep within the gingival sulcus. It has an onset of nasal drainage, burning, pressure, severe respiratory depression,
action in 30 seconds, with nearly 15 minutes duration of action. seizures, convulsion, and disorientation.19,22
Generally, re-administration, infiltration, or periodontal ligament According to Ciancio et al., a more significant amount of nasal
anesthesia may be necessary for performing specific, more lengthy discomfort is seen in the combination of 3% tetracaine plus 0.05%
surgical procedures in adults.13 oxymetazoline group (25 vs 11%) than the tetracaine alone group
when it is administrated for restorative procedures for vital maxillary
Controlled Heat-aided Drug Delivery Patch teeth in adults. In contrast, the tetracaine alone group displayed
It comprises drug reservoir for a 1:1 eutectic mixture of tetracaine toothache, procedural pain, and congestion. These outcomes
base and 70 mg lignocaine, heat-generating medium, and medical supported that oxymetazoline’s addition to tetracaine can enhance
tape cover. The relevance of warm technology is that it eases the local anesthetic effect than administering tetracaine alone.23
transcutaneous delivery and analgesic effect of anesthetics.14
Once administered to the skin, heat passes from the patch to the I n j e c ta b l e L o c a l ​ A n e s t h e s ia
area, thereby increasing the skin temperature. The mixture of
Buffering the Local Anesthesia
activated carbon, iron powder, wood flour, and sodium chloride
generates this heat. The water is placed in a pouch made of filter Malamed described an approach where sodium bicarbonate’s
paper sandwiched between two polymer films; one film comprises addition immediately before anesthetic administration enhanced
pre-calculated size holes and another film with tiny holes covering the solution’s pH value. 24 Local anesthetics are weak bases to
the heat-generating chemical components. Air flows through the create a stable injectable anesthetic solution. Therefore, blending
gaps in the cover membrane at a constant pace into the heating with acid produces hydrochloride salt. Consequently, all local
mixture, thus generating heat when exposed to the environment anesthetic solutions are acidic before injection, which may provoke
by initiating a chemical reaction. This heating element can cause a a stinging or burning sensation during administration and post-
rise in temperature from 39 to 41°C temperature for 2 hours, which injection tissue injury. Hence, to bypass these, alkalinization of
hastens the transcutaneous drug distribution and its analgesic dental anesthetic cartridges is beneficial before injection, which
effect.15 hastens analgesia and lowers injection pain.25 For buffering the local
anesthesia, 8.4% sterile solution of sodium bicarbonate (NaHCO3)
Cetacaine is added to lidocaine with epinephrine as a neutralizing agent
It is a topical anesthetic solution comprising a unique triple action immediately before administration of local anesthetic injection.25
formula that blocks nerve impulse conduction and calcium ion
Advantages
binding and reduces potassium and sodium ion permeability. It
is designated for topical pain management across the mucous • Rapid onset aid in starting the procedure faster, which in turn
membranes, except the eyes.16 Dasarraju et al. stated that reduces treatment time.
cetacaine effectively achieves topical local anesthetic effect • Provides less painful injections.
compared to EMLA cream and 20% benzocaine gel in children. The • Produce profound, consistent anesthesia.
advantages of this agent are no need to dry the mucosal surface • Easy to use.
before applying cetacaine. Therefore, it is superior to benzocaine • Advantageous in the cases with abscess to get anesthetic action.
gel and EMLA cream. Hence, its usage is more beneficial in Interestingly, the disadvantages of buffering of local anesthesia
children, mainly where the isolation is difficult to achieve a were not reported in the literature to date. Goodchild and
desirable topical effect. The disadvantage of this agent is that even Donaldson suggested clinical implications of buffering the local
though it is available in liquid form, it cannot be administrated as anesthetics before injection, which is beneficial for patients who
an infiltrative anesthetic agent.17 have hassle in achieving profound anesthesia in clinical dentistry.26
Guo et al. from a meta-analysis stated that buffered lidocaine had
Nasal Route of Anesthesia decreased onset time and injection pain (visual analog scale) in
It is a novel method to accomplish local anesthesia for maxillary comparison with non-buffered lidocaine during inferior alveolar
teeth by deposition of an anesthetic agent from a metered nerve block.27 Afsal et al. reported that buffered lignocaine was
device’s nostrils.18 The hypothesis is that the anesthetic solution the most productive anesthetic agent during the administration
disperses through the nose’s mucous walls and affects the maxillary of inferior alveolar nerve block injection in 5- to 10-year-old
innervating teeth structures.19 It constitutes a mixture of 3% children.28 Aulestia-Viera et al. also reported another systematic
tetracaine hydrochloride and 0.05% oxymetazoline. In addition review and meta-analysis and stated that reduction in onset time
to its anesthetic properties, it furthermore deteriorates bleeding was not appreciated when alkalinized lidocaine was administered
risk, which occurs due to vasoconstriction of local blood vessels’ with terminal infiltration techniques in normal tissues; in contrast,
without a significant cardiovascular disturbance. This method the accelerated onset of time was illustrated for IAN blocks (–1.26
enables dental clinicians to manipulate in a conservative way minutes) and inflamed tissues (–1.37 minutes).29
necessitating pulpal anesthesia for maxillary incisors, canines,
premolars with >40 kg weight.20 Further research considering the Phentolamine Mesylate (Local Anesthesia Reversal
efficiency and safety in administering this method for pediatric Agent)
patients is necessary. Hersh et al. suggested that K305 (3% tetracaine The long span of soft-tissue anesthesia is often an unwanted
plus 0.05% oxymetazoline) was competent and well-tolerated outcome of local anesthesia in children. Self-inflicted soft-tissue

Journal of South Asian Association of Pediatric Dentistry, Volume 4 Issue 2 (July–September 2021) 149
 Update on the Local Anesthesia in Pediatric Dentistry

trauma, altered facial appearance perception, impaired speech, and psi with this device. It can contribute to painless anesthesia and is
difficulty in chewing are some of the postoperative consequences ideal for nasopalatine and greater palatine injections. Furthermore,
of local analgesia. Phentolamine mesylate is an alpha-adrenergic mechanical adjustments can be possible for the depth of
antagonist, which enhances the clearance of local anesthetic penetration.39 Even though it has several advantages, Arapostathis
solution from the site of injection, diminishing the duration of et al. stated that children preferred traditional infiltration over the
action.30 It is a vasodilator and an adversary to the vasoconstrictor, jet-injector due to difficulty placing the device on gingival tissue
but not an anesthetic agent. 31 It produces faster diffusion of the area children experienced inadequate anesthesia.40
anesthetic agent into the vascular system away from the injection
site. It is available as a cartridge with a concentration of 0.4 mg/1.7 Single Tooth Anesthesia
mL. Dosage of this drug depends upon the number of cartridges This system employs an extra-short 30-G needle placed in the
of local anesthetic with vasoconstrictor administered. Usually, it gingival sulcus parallel to the tooth’s long axis. The number of
requires one cartridge of a reversal agent for every cartridge of the points for administering anesthesia differs for single- and multi-
local anesthetic administered.32 Phentolamine appears to be safe in rooted teeth, i.e., one point (distal) and two (distal and mesial)/three
3- to 5-year-old children with significantly enhanced lip sensation points, respectively. The needle has to be placed into the tissue
reversal than sham injections. 33 Disadvantage of this agent is that till it approaches the periodontal ligament to achieve adequate
it requires the second prick to deliver the drug to the respected anesthesia. Advantages of single tooth anesthesia (STA) include
site, which will hurt the child. lack of anticipatory anxiety (due to its pen-like design), lack of pain,
Grover et al. suggested that phentolamine mesylate no perioral tissue anesthetic effects (lips, tongue, and cheeks), and
administration improves patient care by offering significant no damages to the crown of permanent teeth.41 Garret-Bernardin
advantages like the accelerated safe return of normal functioning et al. stated that STA is an effective alternative to traditional
of oral soft tissues from 460 to 230 minutes and shortened the techniques due to less significant pain and discomfort in children.42
post-treatment duration.34 In a recent systematic review and meta- Al-Obaida et al. stated that STA increases the patients’ satisfaction
analysis performed by Vinnakota and Kamatham, the occurrence of and compliance due to its profound anesthetic effect in restorative
adverse events like facial swelling, increased blood pressure, and procedures among adolescence.43
reactions at the site of administration and paresthesia were more
significant. Phentolamine mesylate was administered as a reversing QuickSleeper [Computer-controlled Intraosseous
agent compared to controls. On segregating age-based studies, Anesthesia System]
there was a lower incidence of adverse events in children and In this technique, anesthesia is delivered with constant velocity
adolescents than in adults (odds ratio for children 0.68 and adults and pressure to reduce the anesthetic effect’s injection pain.18,44
1.58).35 Al-Khafaji et al. stated that phentolamine mesylate usage It comprises a handpiece and a control box; signals are sent to the
is safe and efficient in reversing soft tissue anesthesia, with 1.8 mL main control box through Bluetooth by pressing the pedal. Once
of 3% mepivacaine hydrochloride (without any vasoconstrictor).36 the circuit is completed, the handpiece drills and administers an
anesthetic solution into the intra-bony space or cancellous bone
Centbucridine to produce maximized anesthesia efficiency.45 Smaïl-Faugeron et
It is a quinolone derivative with a local anesthetic effect. The al. stated that the QuickSleeper® system eases dental practitioners
0.5% concentration of centbucridine can be used for adequate while dealing with children and adolescent patients as it is
infiltration anesthesia and also for nerve blocks. 37 However, the associated with less pain and anxiety.46
clinical trial results are not statistically significant, but descriptively, Smaïl-Faugeron et al. stated that QuickSleeper reduces pain
they are superior over lignocaine, having excellent anti-allergic compared to conventional infiltration in children as it is delivered
properties and antihistaminic properties. 37 Gune and Katre stated near the teeth in the cancellous bone; thereby, it has a limited soft-
that centbucridine was in line with lignocaine which is the gold tissue anesthetic effect. The authors also stated that QuickSleeper
standard and can be considered as a substitute for 12- to 14-year-old is useful in the treatment of MIH or severe pulpal inflammation.47
hypersensitivity patients to lignocaine or with another amide based Sixou et al. summarized that 58.9% of children with past dental
anesthetics and for individuals with cardiac and thyroid disorders anesthesia experience reported that this technique was more
where these vasoconstrictors are contraindicated.37 pleasant than the infiltration method as it delivers the drop by
drop anesthetic solution in the first 30 seconds.48 Carugo et al., in
L o c a l ​ A n e s t h e s ia D e l i v e ry D e v i c e s​ a systematic review, stated that computerized devices had been
demonstrated to reduce pain during anesthesia compared to
Jet-injection (Medjet-III) conventional techniques in children.49
The jet technology is a needleless injection that utilizes a
mechanical energy source to deliver pressure, enabling a thin Vibrotactile Devices
flow of anesthesia to infiltrate the soft tissues. It is presumed to Vibratory stimulation is the prospective technique used in pain
have benefits over traditional infiltration methods by displaying reduction. Many devices have been designed based on the “Gate-
a quick onset of soft tissue anesthesia, controlled distribution of control” theory, which states that the neural gate can be closed
the anesthetic dose, and high acceptance in instances of needle- while applying pressure and vibration, reducing itch and pain
phobia patients. The lack of a needle for administration advocates perception. The brain can only recognize one sensation from one
a positive psychological outcome. 38 This device can direct the area at a given time; thus, vibrating the cheek has been followed
anesthetic solution with a small orifice seven times less than the to distract the brain from the discomfort of the anesthetic shot.50
world’s smallest available needle. It can administer intradermal, Ungor et al. stated that vibrations were useful in reducing the pain
subcutaneous, and intramuscular volumes of 0.01–1 cm3 at 2,000 without causing anxiety upon injection.51

150 Journal of South Asian Association of Pediatric Dentistry, Volume 4 Issue 2 (July–September 2021)
 Update on the Local Anesthesia in Pediatric Dentistry

Indications needle) and the guide sleeve component. The drill leads the guide
sleeve over the cortical plate, then separated and withdrawn. The
• It is indicated in children as distraction and pain reduction remaining guide sleeve is designed to admit a 27‐G needle to
created by vibrating massages. inject the anesthetic solution. The guide sleeve is detached after
• Indicated in cases where topical anesthesia is undesirable (due the IO injection is complete.52 The minimum onset time duration
to taste or allergy) or simply insufficient for relieving pain. for anesthesia was 5 minutes, the maximum time was 9 minutes.
The primary modifications in the application of the X-tip device
Contraindications
are:62
• Contraindicated in epileptic patients.
• The penetration need not be done through the attached gingiva.
• In severe neurological disorder patient.
• Care should be taken to detach the guide sleeve with a
• In the areas we need profound anesthesia, it can be used as an
hemostatic agent after administering the injection.
adjunct with an anesthetic method.
Dixit and Joshi reported a study to compare the IO anesthetic
VibraJet technique using X-tip with conventional infiltration technique for
It was introduced by Miltex Inc., York, PA, in 2002. 31 It is a battery- anesthetizing first permanent molars afflicted by molar incisor
operated device that can easily fit the standard dental syringe.52 hypomineralization in children. The authors stated that X-tip IO local
It produces higher-frequency vibration to the needle and for the anesthesia is a safe and effective technique in achieving profound
patient to feel when the knob is turned clockwise. Chaudhry et anesthesia for severe hypersensitivity MIH teeth in children with
al.53 and Nanitsos et al.54 concluded that children perceived less chronic pulpal inflammation.63
pain with VibraJect while administering local anesthetic injections
than the conventional techniques in both maxillary and mandibular IntraFlow
teeth, which requires local anesthesia procedures. In contrast, It contains a handpiece with a 24-G hollow perforator and disposable
Yoshikawa et al.55 and Saijo et al.56 reported that pain reduction transfuser. This device allows the operator to pierce the bone and
is not significant while VibraJect was attached with a traditional deposit the entire solution in one step near the attached gingiva.
dental syringe. It delivers the local anesthesia with a low speed, high torque, and
steady pressure into the bone. Once the bone penetrates, the
Dental Vibe transfuser directs the cartridge’s solution for infusion.62 Remmers et
This device comprises a rechargeable, cordless handheld al. stated that anesthesia was rapid and secure when administered
vibrotactile device. Dr Steven Goldberg designed this device in by the IntraFlow system than the traditional technique.64
2008. 57 It delivers injections with soothing percussive micro-
oscillations at the site of administration. It contains a U-shaped
vibrating tip connected to a microprocessor-controlled Vibra-
I o n to p h o r e s i s​
Pulse motor which quietly stimulates the injection site’s sensory It has a broad range of dentistry applications; one of its applications
receptors, thereby closing the pain gate and blocks the painful is a non-invasive procedure of anesthesia. This method can be used
sensation of injection prick. Tung et al.58 in 2018 and Sermet Elbay et for delivering local anesthesia to deeper oral tissues following
al.59 in 2016 concluded that the dental vibe reduces pain in pediatric topical application. This procedure assists in penetrating positively
patients receiving dental injections. charged lignocaine and adrenaline agents to deeper tissues with
an electrical influence.65 Due to the lack of needles, this technique
Accupal can enhance the dentist–patient relationship. Thongkukiatkun
It is a cordless device that employs vibration coupled with pressure et al. elicited that topical application of 20% lignocaine and
to condition the oral mucosa. Michael Zweifler invented this device. 0.1% epinephrine, through an iontophoretic current of 120 mA
Accupal delivers pressure, and it vibrates the injection site at 360° for the 90 seconds, is required to anesthetize exposed, normal
proximal to the needle infiltration that shuts the “pain gate”. After dentine.66 Cubayachi et al. stated that a combination of the drugs
placement of the device at the injection site, the unit vibrates by prilocaine hydrochloride and lidocaine hydrochloride appeared to
applying moderate pressure. The needle is positioned in a hole increase the mucosal accumulation after iontophoresis by 86- and
with the disposable tip head, and it is attached to the battery 12-fold, respectively (pH 7.0). Hence, applying iontophoresis to a
based motor.52 combination of drugs at pH 7.0 can assist in a needle-free approach
to promote the onset and extends buccal anesthesia duration.67
Intra-osseous Anesthesia
The first modern intra-osseous (IO) anesthesia technique requires N o n p h a r m aco lo g i c a l L o c a l P ai n
a motor-driven perforator to penetrate the bone and buccal M a n ag e m e n t​
gingiva. It allows the delivery of a local anesthetic agent directly
into the cancellous bone next to the anesthetized tooth.60 Idris et Laser Analgesia
al. concluded that supplemental IO injection significantly influences It is a noninvasive, nonthermogenic biomodulation of the dental
pulpal anesthesia in irreversible pulpitis conditions.61 Numerous pulp, which utilizes low-level laser therapy (LLLT). This LLLT does
systems are developed to attain IO anesthesia; commonly used not achieve profound anesthesia (a complete lack of sensation),
devices are X tip and IntraFlow. similar to infiltrative local anesthesia. It works on the principle by
modifying a neuronal cell membrane’s behavior, thereby causing
X-tip a temporary disruption in the Na-K pump, which results in loss of
The X‐tip anesthesia delivery system consists of an X‐tip that impulse transmission and in achieving the analgesic effect.68 Hence,
separates the device into two parts: the drill (a special hollow accepting laser dental treatment reduces anxiety in children and

Journal of South Asian Association of Pediatric Dentistry, Volume 4 Issue 2 (July–September 2021) 151
 Update on the Local Anesthesia in Pediatric Dentistry

adolescents.69 Chan et al. validated that Nd:YAG laser effectively shortened waiting time due to quicker and deeper cooling of action,
induced pulpal analgesia similar to that of 5% EMLA anesthetic and reduced children’s pain perception during needle insertion
cream and suggested that laser can be an innovative, non-invasive and deposition of solution.85 Bose et al. stated that precooling the
alternative for treating children with needle-phobic.70 Efthymiou et soft tissue area reduces the pain perception for infiltrations and
al. stated that photobiomodulation therapy using laser produces block anesthesia in children during regular dental procedures.86
adequate pulpal anesthesia in decayed permanent teeth during It is an easy, reliable, and cost-effective method.87 Tirupathi and
cavity preparation.71 Poli et al. suggested laser-induced analgesia Rajasekhar, in a systematic review, stated that precooling with ice
as a feasibly effective modality that affects pain perception and reduces pain than refrigerant spray before the local anesthetic
alters patients’ responses with minor anxiety levels due to its limited administration.88
invasiveness.72

Virtual Anesthesia C o n c lu s i o n​
The distraction techniques are the most extensively practiced Current techniques discussed in the present article to deliver local
behavioral techniques for alleviating dental anxiety. Currently, anesthesia play a vital role and appear to be a practical alternative
virtual reality (VR) devices are more engaging forms of distraction. to traditional methods. These newer techniques are being projected
Although it has certain limitations, several authors have stated that for their advantages and have a broad scope for their usage in
it decreases pain and increases patient satisfaction during medical pediatric dentistry. Usage of current techniques for effective and
procedures.73 Clinical trials on VR reported both subjective and pain-free local anesthetic administration produces a more pleasant
objective reduction of pain and anxiety during dental procedures experience for the dentist and children, resulting in more positive
in children.74 These observations recommend that VR can be used outcomes in maintaining a proper child–dentist relationship.
as an adjunctive tool in non-pharmacologic analgesia. Due to this
analgesic potential in VR, this is termed “virtual anesthesia”. Atzori References
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154 Journal of South Asian Association of Pediatric Dentistry, Volume 4 Issue 2 (July–September 2021)

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