Anesthesia in pediatric dentistry – an overview

 Anestezia în stomatologia pediatrică – prezentare generală

First published: 12 aprilie 2022

Editorial Group: MEDICHUB MEDIA

DOI: 10.26416/Pedi.65.1.2022.6278


Pain is a sensory experience that each of us has undergone throughout our lives, a warning sign, an indication of dys­func­tion. Usually, the pain signals a present or imminent tissue injury, allowing the prevention or aggravation of the in­jury and having a protective role. There are no objective mea­sure­ments of pain; the physiological response of the tis­sues to acute injury and pain is similar regardless of whe­ther the source is surgery, trauma, burns or visceral da­mage. Al­most the entire oral and maxillofacial pathology re­lates to the trigeminal nerve; the fight against pain and ob­tai­ning anesthesia cannot be conceived without knowing its anatomy. The approach to a child in the dental office is dif­ferent from that of an adult patient. All children requiring den­tal treatment should be assessed before operation to de­termine the most appropriate form of pain and anxiety ma­nage­ment. The psychological component of analgesia is undeniable in dentistry in general and in pedodontics par­ti­cularly. There are several analgesia techniques and the choice of one or the other must be a well-motivated and as­sumed decision of the doctor, based on the evaluation of the child’s attitude, but also on the appreciation of the com­ple­xity and particularities of the therapeutic work to be performed. It is essential for the physician to know and master the techniques of anesthesia, the anesthetics, but also the accidents and/or complications that may occur. Per­for­ming analgesia in children requires the practitioner a certain experience, totally different from that imposed by the adult patient, given that this act, essential, will con­di­tion, to a large extent, the development of the current ses­sion, but also the future ones. Behavioral guidance or be­ha­vioral guidance accompanied by inhalation are the basic methods in the arsenal of modern sedatives available to the pedodontics. If the sedation methods in the dental of­fice used usually for the dental treatment of children could not be used or did not work, the next step is the dental treat­ment for children under venous conscious sedation or under conditions of general anesthesia in the hospital. Com­pletely uncooperative children often end up being treated with different types of deep sedation – conscious drug sedation or general anesthesia. Choosing or not these methods of analgesia remains at the discretion of the pa­tient/parents of the little patient, under the guidance of the dentist, without losing sight of the fact that nothing re­places the communication between doctor, patient and the parent. However, a successful treatment depends on the choice of the appropriate anesthetic technique and, even then, many children can only be managed with sedation or ge­neral anesthesia.

pain, anxiety management, analgesia, behavioral guidance


Durerea este o experienţă senzorială pe care fiecare dintre noi am trăit-o de-a lungul vieţii, un semnal de avertizare, un indice al unor disfuncţii. În mod obişnuit, durerea sem­na­lea­ză o leziune tisulară prezentă sau iminentă, permiţând prevenirea sau agravarea leziunii şi având un rol protector. Nu există măsurători obiective pentru durere; răspunsul fiziologic al ţesuturilor la injurie şi durere acută este similar indiferent dacă are drept sursă actul chirurgical, o traumă, o arsură sau o afectare viscerală. Aproape întreaga patologie orală şi maxilo-facială se leagă, într-o anumită măsură, de nervul trigemen, combaterea durerii şi obţinerea anesteziei la acest nivel neputând fi concepute fără cunoaşterea ana­to­miei acestuia. Abordarea unui copil în cabinetul sto­­ma­­to­­logic este diferită de cea a unui pacient adult. Toţi co­piii care necesită tratament stomatologic trebuie evaluaţi îna­in­te pentru a determina cea mai adecvată formă de ges­tio­na­re a durerii şi anxietăţii. Componenta psihologică a analgeziei este de netăgăduit în stomatologie în general şi în pedodonţie în mod particular; există mai multe tehnici de analgezie, iar alegerea uneia sau a alteia trebuie să fie o decizie bine motivată a medicului, având la bază eva­lua­rea atitudinii copilului, dar şi aprecierea complexităţii şi particularităţilor manoperei terapeutice de realizat. Este esen­ţial ca medicul să cunoască şi să stăpânească tehnicile de anestezie, substanţele anestezice, dar şi accidentele şi/sau com­pli­ca­ţiile ce pot surveni. Ghidarea comportamentală sau ghi­da­rea comportamentală însoţită de inhalosedare sunt me­to­de­le de bază din arsenalul de sedări moderne, aflat la dis­po­zi­ţia medicului pedodont. În situaţia în care metodele de se­da­re în cabinetul stomatologic folosite în mod uzual pentru tra­ta­men­tul dentar al copiilor nu au putut fi folosite sau nu au funcţionat, următorul pas este acela al tratamentului stomatologic pentru copiii sub sedare conştientă venoasă sau în condiţii de anestezie generală în spital. Copiii complet necooperanţi ajung de cele mai multe ori să fie trataţi cu diferite tipuri de sedare profundă – sedare conştientă me­di­ca­men­toasă sau anestezie generală. Alegerea sau nu a acestor me­to­de de analgezie rămâne la latitudinea pacientului/pă­rin­ţi­lor pacientului pediatric, sub îndrumarea medicului sto­ma­to­log, fără a scăpa niciun moment din vedere faptul că nimic nu înlocuieşte comunicarea dintre medic, pacient şi aparţinător. Cu toate acestea, succesul terapeutic depinde de alegerea tehnicii anestezice adecvate, însă chiar şi în aces­te condiţii mulţi pacienţi pediatrici pot fi trataţi numai în con­di­ţii de sedare sau anestezie generală.

The pain is, according to the International Association for the Study of Pain (IASP), an unpleasant sensory and emotional sensation and experience, associated with an existing or potential tissue injury, or described as such (Merskey, 1986). This definition involves both sensitive (e.g., nociceptive) and emotional (e.g., suffering) factors; “current” and “potential” events are also formulated(1-3).

Pain is a sensory experience that each of us has undergone throughout our lives, a warning sign, an indi­ca­tion of dysfunction.

Usually, the pain signals a present or imminent tissue injury, allowing the prevention or aggravation of the injury and/or having a protective role. The transmission of nociceptive information can be modulated (increase or decrease of the threshold, sensitization) in the medullary dorsal horn, but also at other levels. The same nociceptive stimulus evokes different responses in the brain depending on whether the subject is in a state of alarm, awake, drowsy, in deep sleep or under the influence of drugs.

There are no objective measurements of pain. We can know that a person “has pain” only based on his state­ments or actions. These actions can be measured ob­jec­tively, but these measurements cannot assess the events that led to their occurrence.

Nociceptive impulses can, in theory, be measured, but they cannot define the degree of suffering or the personal response. The measurement of the response does not allow the identification of the stimulus and the stimulus cannot be measured. Pain initiates a complex neurohumoral response that initially helps maintain homeostasis in the presence of an injury or acute condition. If these lesions are excessive, the pain may become morbid. The physiological response of tissues to acute injury and pain is similar regardless of whether the source is surgery, trauma, burns or visceral damage(3).

Dentistry is filled with potential dangers to the young child. Fear of the unknown, surprise, pain, “shots” and physical restraint can all be debilitating to their developing psyche. The goal of pediatric management is to accomplish the necessary dental treatment and yet maintain the child’s comfort and cooperation. Unfortunately, these goals do not go together. Comfort is directly related to anxiety control, which can be achieved with or without drugs. However, a comfortable child is not necessary a cooperative one; oftentimes, cooperation will be gained only when levels of sedation are deepened, and the child becomes obtunded. Drug responses are varied and unpredictable and most sedatives cannot readily induce cooperation(4).

Children’s perception of pain is related to cognitive development. Before the age of 2 years old, a child is generally unable to distinguish between pressure and pain. Because of this, all forms of dental treatment will usually require general anesthesia for these younger children. Between the ages of 2 and 10 years old, a child may be able to understand the sensation of pain and differentiate it from other sensations such as pressure or vibration. Nevertheless, many dental procedures will still require general anesthesia in this age group. Children over the age of 10 years old are more likely to have the ability to think abstractly and respond appropriately to explanations. Children in this age group may therefore be able to cooperate with dental treatment performed under local anesthesia, with or without sedation. A child’s ability to cooperate with dentist and to accept the dental treatment is also influenced by other factors such as fear, family learning and previous experiences of pain(5,6).

Human dentition

When complete, the primary (deciduous) dentition consists of 20 teeth, while there are 32 permanent teeth. The most used dental identification system divides the dental arch into four quadrants. All primary central incisors are designated tooth “A” and followed posteriorly in alphabetical order, so that the primary second molars are designated tooth “E”. The permanent central incisors are designated tooth number 1 and are similarly followed posteriorly in numerical order to tooth number 8, which is the third molar or the “wisdom tooth” (Figures 1 and 2)(6).

Figure 1. Primary/deciduous dentition: A – incisor;  B – incisor; C – canine; D – molar; E – molar
Figure 1. Primary/deciduous dentition: A – incisor; B – incisor; C – canine; D – molar; E – molar
Figure 2. Permanent/succedaneous dentition: 1 – incisor; 2 – incisor; 3 – canine; 4, 5 – premolar; 6, 7, 8 – molar
Figure 2. Permanent/succedaneous dentition: 1 – incisor; 2 – incisor; 3 – canine; 4, 5 – premolar; 6, 7, 8 – molar

Anatomical and physiological considerations

There are many anatomical and physiological differences that influence pediatric anesthetic management. Pediatric patients have large heads, short necks, relatively large tongues, tonsils and adenoids, and narrow nasal passages that are readily blocked by secretions or edema.

The anatomic structures in children are naturally smaller than those in an adult. There are three specific anatomic differences to be aware of in children(7):

1. The proximity of blood vessels in the maxillary tuberosity area, where infiltrating deeply with the needle may cause damage to the pterygoid venous plexus or posterior superior alveolar artery and resultant hematoma.

2. The mandibular ramus is shorter and is narrower anteroposterior; therefore, for an inferior alveolar nerve block, the extent of infiltration of the needle must be decreased.

3. The bone is not completely calcified, permitting expatiated diffusion of the local anesthetic agent.

Almost the entire oral and maxillofacial pathology is connected, to a certain extent, with the trigeminal nerve, and the fight against pain and obtaining anesthesia at this level cannot be conceived without knowing its anatomy. The trigeminal nerve is the fifth pair of cranial nerves; it is a mixed nerve but, from a sensory point of view, it is the most important receptor for pain in the face, viscerocranium and the cavities attached to it. From a motor point of view, the trigeminal nerve innervates the masticatory and lifting muscles of the mandible. It is the nerve that ensures almost exclusively the sensitivity of the viscerocranium and the face; it is the secretory neurovegetative nerve for the lacrimal, salivary and nasal-sinus mucosa glands, and it has a vasomotor and trophic role.

At the same time, the physiological differences between the child’s body and that of the adult are not insignificant at all; they condition, to an appreciable extent, the success of the anesthesia, but also the possibility of complications and their severity.

A higher metabolic rate in infants and children results in a proportionally greater alveolar ventilation than in adults. The functional residual capacity (FRC) – meaning the sum of the expiratory reserve volume and the residual volume – acts as a buffer to maintain arterial oxygenation during inspiration and expiration. In an adult, the ratio of alveolar ventilation to FRC is 1.5 to 1; in the infant, this ratio is 5 to 1; moreover, the supine position required for dental treatment further decreases the FRC by 20% to 30%. Since the metabolic demand for oxygen is 60% greater than in an adult and the alveolar ventilation to FRC ratio is so high, hypoxemia can develop rapidly in the pediatric patient(8).

It is important to ensure that children and adolescents receive safe and effective pain control. A range of techniques are available, comprising four overlapping categories: behavioral techniques, local anesthesia (LA), sedation and general anesthesia (GA).

Pediatric patients between the ages of 18 months old and 6 years old are some of the most difficult patients to manage in dentistry. They are often anxious and fearful due to lack of past experiences and are commonly influenced by parental feelings about dentistry(8). Coping skills are either underdeveloped or nonexistent and there is no incentive to cooperate. These are the reasons why treatment in pediatric dentistry, at least in children up to 7 years of age, is a challenge and cannot be conceived without behavioral guidance. There are a variety of behavioral management methods, but in principle we are talking about two major groups: pharmacological and nonpharmacological methods.

The pharmacological management of the pain and anxiety associated with pediatric dentistry includes:

(i) general anesthesia

(ii) sedation (i.v., transmucosal, oral, inhalation)

(iii) local anesthesia.

A. Local anesthesia (LA)

In most cases, the presentation to the dentist takes place after an acute painful episode. If the patient is a child, the diagnosis and treatment of pain will be difficult, due to the difficult/particular collaboration with the little patient.

Performing analgesia in children requires the practitioner a certain experience, totally different from that imposed by the adult patient, given that this act, essential, will condition, to a large extent, the development of the current session, but also of future ones. The psychological component of analgesia is undeniable in dentistry in general and in pedodontics particularly.

There are several analgesic techniques and the choice of one or the other must be a well-motivated and assumed decision of the doctor, based on the evaluation of the child’s attitude, but also on the appreciation of the complexity and particularities of the therapeutic work to be performed. It is essential for the doctor to know and master the techniques of anesthesia, the anesthetic substances, but also the accidents and/or complications that may occur.

Local or locoregional analgesia, the most frequently used, requires a good knowledge of anatomy and an environment conducive to its success(9-11).

Conventional techniques of local anesthesia

Dental procedures are often accompanied by pain and discomfort by the patient. This is the key reason for dental fear and anxiety in children. For this reason alone, the painless administration of anesthetic may be a crucial step in avoiding fearful and uncooperative patients. So, it depends upon the dentist to select an appropriate technique which can adequately anesthetize the tooth(12).

Several anesthesia techniques are described; as a general principle, local anesthesia acts directly on the receptors and nerve endings, the disappearance of sensitivity being strictly limited to the territory in which it is operated.

Injectable anesthetics are also given to the child, depending on age, weight and general health; it is not realistic nowadays not to anesthetize a child or to perform complex treatments only with topical anesthesia.

As for the adult, but also for the child, if he didn’t have any contact with an anesthetic in the past, we will do an allergology test with the anesthetic substance that we intend to use.

The duration of the anesthetic block depends on several factors: individual variations in response to a drug, accuracy of the anesthetic puncture, tissue status at the puncture site (edema, vasodilation, pH), anatomical variations, type of anesthetic block (supra-/subperiosteal infiltration, peripheral trunk, intraosseous). Local anesthetics are used for invasive dental procedures like cavity preparations, deep scaling, surgical procedures, or vital pulp therapy.

  • Refrigeration anesthesia: very rarely used, in small intervals.

  • Topical local anesthesia: the application of the anesthetic is done pinning, soaking, spraying; spray anesthesia is more commonly used due to its ease and lack of risk.

  • Infiltration anesthesia: injection of the substance intratissue, in the tissue at the level of which it is intervened or around it; either direct infiltration anesthesia or modified techniques are performed, such as intraligamentary, bone or transcortical anesthesia. Direct infiltration anesthesia consists of injecting the anesthetic substance intramucosally, intradermally, into the submucosal or subcutaneous tissue; the injection is preceded by surface analgesia (topical).

  • The injection is slow, the recommended speed should not exceed 1 ml solution/min; it is checked, repeatedly, especially for trunk anesthesia, by repeated aspirations, the absence of penetration of a blood vessel.

  • Adult injectable anesthetics are also applicable to children, except for articaine which is contraindicated for children under 4 years of age.

  • The addition of the vasoconstrictor in the anesthetic solution allows to obtain a lasting analgesia, reducing, at the same time, the bleeding. Vasoconstrictor contraindications are rare: children under 3 years of age, unbalanced diabetes, or congenital heart disease with arrhythmias.

Plexus anesthesia: the easy traction of the gingival mucosa will reduce the painful sensation during the injection. In children, plexus anesthesia has a better effect on the mandible, especially on the temporary teeth. Anesthesia of the mandibular primary molars may usually be achieved by infiltration in children up to the age of 5 years old. A few studies(13) have evaluated the efficiency of mandibular infiltration as an alternative to mandibular block for the restoration of primary molars. No significant differences between infiltration and block were found. In addition, the amount of anesthesia was not considerably related to tooth location, age or type of anesthetic agent(13).

Peripheral trunk anesthesia:

  • It follows the deposition of the anesthetic in the neighborhood of a nerve trunk, at a distance from the tooth/teeth on which we want to intervene.

  • It is used either when the plexal anesthesia is not indicated or cannot be performed in the respective area, or when we want to anesthetize several teeth with a single anesthetic puncture.

  • In the case of anesthesia at Spix spine (peripheral truncal anesthesia of the inferior alveolar nerve), it requires a precise knowledge of the child’s specific anatomy; concretely, the smaller the child, the more divergent the mandibular arch, the Spix spine being found closer to the occlusal plane, the smaller the child.

The level of the foramen changes with the child’s age:

  • 4 years old and younger – the foramen is sometimes located below the plane of occlusion;

  • in children (4-10 years old), the foramen is located on the occlusal plane;

  • as the child matures, it moves to a higher position above the occlusal plane(14,15).

The intraligamentary injection is given into the periodontal ligament (PDL) using a syringe specially designed. Intraligamentary injections can also be given with a conventional needle. In this technique, the needle is introduced at the mesiobuccally and advanced for maximum penetration. Intraligamentary anesthesia has limitations, but it has been used to overcome failed conventional methods or as an adjunct(15). Intraligamentary injections produce significant bacteremia and hence they should not be given to a patient at risk of infective endocarditis unless appropriate antibiotic prophylaxis has been provided(16).

The intrapulpal method achieves anesthesia as a result of pressure. Saline is reported to be as effective as an anesthetic agent when injected intrapulpally. When a small access cavity is available into the pulp, a needle which fits securely into the pulp is used and a small amount (about 0.1 ml) of solution is injected under pressure. There will be an initial feeling of discomfort during this injection but, however, this is transient and anesthetic onset is rapid. When the exposure is large to allow a tight ne­edle to fit, the exposed pulp should be bathed in a little local anesthetic for about a minute before inserting the needle as apically as possible into the pulp chamber and depositing under pressure(17).

Alternative techniques of local anesthesia

Some of the most recent advances in anesthetic methods that provide alternative to conventional methods include the following techniques:

  • Computer-controlled local anesthetic drug delivery system (CCLAD’s)

  • Jet injectors

  • EMLA (eutectic mixtures of local anesthesia)

  • Topical anesthetic patches

  • Electronic dental anesthesia

  • Iontophoresis.

1. Computer-controlled local anesthetic delivery sys­tems(18-20)

In 1997, the first computer-controlled local anesthetic delivery system was introduced into dentistry. The Wand (recently renamed: The Wand/Component; Milestone Scientific, Inc., Livingston, NJ) was designed to improve the ergonomics and precision of the dental syringe. The system enables a dentist or hygienist to accurately manipulate needle placement with fingertip accuracy and deliver the local anesthetic with a foot-activated control. The lightweight handpiece is held in a pen like grasp that provides increased tactile sensation and control compared with the traditional syringe.

At present, two CCLADs are available:

  • The Wand/CompuDent system

  • Comfort Control Syringe.

2. Jet injector(21-23)

In 1947, Hingson and Hughes(21) introduced an instrument and a technique termed jet injection, which delivered anesthesia efficiently without the use of a needle. This approach soon aroused the interest among dentists.

The use of this instrument has proven to be successful in other areas, including insulin delivery, regional and digital blocks, anesthesia for incision of nondental abscess and aspiration biopsy of lymph nodes and repair of lacerations to the head and extremities and mass immunizations. In all cases, there was a marked preference by patients for the jet injection instrument over more conventional injection procedures. Jet injection is based on the principle that liquids forced through very small openings, called jets, at very high pressure can penetrate intact skin or mucous membrane(21).

3. EMLA (eutectic mixture of local anesthetics)(24-27) 

Eutectic is defined as a mixture of two or more compounds with the lowest melting point. EMLA cream (composed of lidocaine 2.5% and prilocaine 2.5%) is an emulsion in which the oil phase is a eutectic mixture of lidocaine and prilocaine in a ratio of 1:1 by weight. It was designed as a topical anesthetic able to provide surface anesthesia of intact skin (other topical anesthe­tics do not produce a clinical action on intact skin, only abraded skin) and therefore it is used primarily before painful procedures, such as venipuncture and other ne­edle insertions.

4. Topical anesthetic patches(28-30)

Anesthetic patches containing lidocaine base that is dispensed through a bio adhesive matrix and applied directly to the oral mucosa recently have been approved by the US Food and Drug Administration and are commercially available(28) (Dent patch lidocaine transoral delivery system, oven pharmaceuticals Inc.). These patches are available in 10 and 20 percent concentrations, each containing approximately 23 and 46 milligrams of lidocaine base per 2 square centimeters of patch, respectively. The lidocaine contained in the matrix diffuses directly through the mucosa while patch is affixed. The anesthesia is absorbed within five minutes. According to the manufacturer, the maximum effect is reached within 15 minutes and has a duration of 45 minutes.

5. Electronic dental anesthesia (EDA)

Computer anesthesia involves the very slow injection of an anesthetic substance and a very high degree of comfort for patients. DentaPen® is an innovative, electronic device that injects electronically, very slowly, with minimal pressure, a small amount of anesthetic, strictly targeting the tooth we intend to work on.

6. Iontophoresis

Iontophoresis has a wide range of application in dentistry, one of which is to produce a noninvasive technique of anesthesia. It can be used as a means of delivering local anesthetics to deeper tissues after topical application. It aids in the penetration of positively charged agents such as lignocaine and adrenaline to tissues under the influence of electrical charge(31-33). With the avoidance of needle, this technique could offer better patient management and dentist-patient relationship. There is a lack of recent studies regarding the application of iontophoresis in dentistry; however, further studies are necessary(12).

Good local analgesia requires highly skilled dental professionals to apply this knowledge coupled with a detailed understanding of the anatomical complexities to provide advanced pain management for the patients. Failure to achieve anesthesia can be a significant problem in the day-to-day practice of dentistry

The trend is changing as education, research and instrumentation reduce the cognitive and emotional barriers in the dentist’s and child’s perceptions of the local anesthesia experience. Child’s emotions surrounding injections are some of the most powerful feelings that dentists routinely encounter in daily dental practice. Alternative technique can add to the dentist’s skills in treating patients with comfort and efficiency.

Complications associated with the use of local anesthesia in pediatric dentistry

Local complications include failure of the block, infection, intravascular injection, hematoma, nerve damage, facial nerve palsy and needle fracture. There is also the risk of trauma to the anesthetized region of the face caused by biting and chewing, particularly in children who are very young, or who have developmental delay.

Systemic complications include dose-related toxicity of the local anesthetic agent and dose-independent hypersensitivity reactions. Children over 6 months of age absorb local anesthetic agents more rapidly than adults, and toxicity in children occurs at doses that are well below toxic levels in adults. Cardiovascular effects include arrhythmias and are due to the combined action of the local anesthetic agent and vasoconstrictor. Effects on the central nervous system include seizures, unconsciousness and respiratory arrest(6).

B. Sedation

Although there are no clear boundaries between them, the National Institute of Clinical Excellence defines three levels of sedation: minimal, moderate and deep sedation(34).

In pediatric dentistry, the aims of sedation include reducing fear and anxiety, augmenting pain control and minimizing movement. Children who cannot tolerate dental procedures with local anesthesia alone may be managed using a conscious sedation technique, defined as a controlled state of low consciousness that conserves protective and unconditioned reflexes, permits the continuance of a patient’s airway impartially and allows the patient to communicate appropriately to physical and verbal stimuli(34).

To achieve conscious sedation, sedative drugs may be administered via the inhalation, oral, transmucosal, or by i.v. routes. Inhalation sedation (relative analgesia) is achieved using a titrated mixture of up to 70% nitrous oxide in oxygen. This should be the first choice for pediatric dental patients who have a sufficient level of understanding to cooperate with the procedure, but are not able to tolerate local anesthesia alone.

Oral sedation is commonly achieved using midazolam, which can also be administered via transmucosal routes (e.g., nasal, sublingual). The standard technique for i.v. sedation is a titrated dose of a single agent (e.g., midazolam).

The use of advanced sedation techniques, involving the administration of ketamine, propofol and sevoflurane, has also been described for pediatric dentistry. Since these advanced techniques have a narrow margin of safety, the training required to administer these drugs requires careful consideration, together with the venue in which sedation is provided. Healthcare professionals providing sedation should be competent and experienced in delivering the sedation technique and able to manage any potential complications.

Advantages and benefits of intravenous se­da­tion:

  • Intravenous sedation involves avoiding general anesthesia, so the procedure is much safer!

  • Recovery time is very short.

  • The dose is adjusted according to the patient.

  • The effect of sedation is felt immediately.

  • There is no risk of drowning!

  • Consciousness is maintained throughout the intervention! This is a very important advantage, because the patient can cooperate with the doctor and follow his instructions.

  • The sedation alternatives are to perform the operation only with local anesthesia or general anesthesia.

Disadvantages and risks of sedation:

  • The procedure requires the use of an intravenous catheter, so there is a risk of hematoma

  • Amnesia is a common but positive side effect, as many patients do not want to remember what happened during the procedure.

  • The patient must leave accompanied and be supervised for a few hours after the intervention.

  • The anti-inflammatory drugs should be given and administered before the effect of local anesthesia decreases, to avoid the onset of pain.

C. General anesthesia (GA)

Often, the young age of the child, the inability to cooperate and the possible complications make it impossible to perform dental treatment in children even under inhalation with nitrous oxide or using sedative drug sedation and require dental treatment under general anesthesia.

The benefits of dental treatment under general anesthesia can be discussed only in the context in which it is performed in conditions of maximum safety for the child patient. This suppose that the intervention be carried out in a hospital, equipped with all the necessary equipment for an operating room, under the coordination of the intensive care department, which has the capacity to manage a treatment of this nature in all phases of its development.

General anesthesia may be required for pediatric dentistry in circumstances where:

  • the use of local anesthesia is either contraindicated, or inappropriate due to the presence of acute orofacial infection;

  • there has been previous failure of local anesthesia or sedation;

  • the patient is unable to cooperate with the proposed treatment due to immaturity, disability, or language difficulties;

  • the patient suffers from a psychological disorder such as severe anxiety;

  • extensive treatment is required.

When discussing the use of GA in child, some general considerations need to be considered:

  • the cooperative ability of the child;

  • the perceived anxiety and how the child has responded to similar procedures;

  • the degree of surgical trauma anticipated;

  • the complexity of the operative procedure;

  • the medical status of the child.

As for all episodes of pediatric anesthesia, the aim should be to ensure that the child is in the best possible physical and psychological condition to undergo the dental procedure. Children who require general anesthesia for dental treatment should receive the same standard of care as those who require general anesthesia for any other procedure. For most patients, dental extractions, restorations, or both, may be performed as day-case procedures. Inpatient care may be required for children with coexisting medical conditions such as cardiac disease or coagulation disorders. Other conditions requiring special consideration include anatomical or functional abnormalities of the airway, congenital syndromes or conditions associated with an increased anesthetic risk, such as the mucopolysaccharidoses(6).

Management of the uncooperative child

It is common for children to refuse general anesthesia for dental treatment. This refusal may reflect fear, anxiety, obstinacy, lack of understanding or the child’s genuine belief that the procedure is not in his best interest(35). The use of physical restraint in the management of an uncooperative child is considered as major infringement of the individual’s right to civil liberty and the decision to proceed with treatment should be based on the following guiding principles:

(i) first do no harm;

(ii) act in the best interests of the child;

(iii) respect the child’s right to refuse.

It is important to remember that, in most cases, the child will not die if the dental procedure is not performed at that time, although it is recognized that there are situations where the patient may suffer undue pain and distress if treatment is not provided as planned(36).

Complications associated with general anesthesia for dental treatment

Minor complications of general anesthesia for pedia­tric dentistry include postoperative headache, nausea, retching and vomiting, particularly in the presence of swallowed blood. Damage may occur to soft tissues or teeth adjacent to the operative site. Postoperative cough and sore throat may occur due to either tracheal intubation or irritation from the throat-pack. Major complications include complete respiratory obstruction from inhalation of foreign material. Airway obstruction may also occur due to the position of the throat pack or mouth-gag/prop, and also from the presence of blood or debris, particularly when the nasal mask is used for children in the sitting position. Injury to the neck may occur due to intraoperative positioning, as may dislocation of the temporomandibular joint. Although halothane is now rarely used to provide general anesthesia for pediatric dentistry, cardiac arrhythmias may still occur intraoperatively and may result in cardiac arrest. Contributing factors are thought to include high levels of endogenous catecholamines, stimulation of the trigeminal nerve and the use of epinephrine-containing local anesthetic agents(6).

The high cost of malpractice insurance for general anesthesia and regulation concerning the hospitalization of dental patients have motivated the dental professionals to seek alternative pain and anxiety control methods. Traditional forms of conscious sedation have certain limitations in pediatric patient, especially in the mentally handicapped. A technique described by Bennett(37), called dissociative sedation, offers a safe and reliable alternative to traditional conscious sedation and general anesthesia. Using ketamine as the primary sedative agent, this technique is marked by consciousness (assuming the patient is of normal intellect and sufficient age), cooperation, occasional robotic behavior(4), amnesia and analgesia. Unlike other drugs used for this purpose, ketamine does not depress the cardiorespiratory system, but will either maintain or slightly stimulate it. Respiratory depression does not occur, oxygen saturation remains adequate without supplemental oxygenation, and the airway is maintained, along with the ability to spontaneously cough, swallow and otherwise clear secretions or debris. The clinical experience with ketamine has been extensive and the drug has demonstrated a wide range of applications and an exceptional margin of safety. The addition of propofol has made a good technique even better(4). Even with its remarkable record of safety, efficacy and reliability, a physician administering ketamine should have in-depth anesthesia knowledge and skill and be proficient in treating airway complications.


The management of anxiety and pain is a very important aspect of pediatric dentistry and includes the use of general anesthesia, sedation and local anesthetic techniques. Adequate preoperative assessment is required to determine the most appropriate method of management, with the consideration of the child’s cognitive development and the proposed dental procedure.  


Conflict of interests: The authors declare no con­flict of interests.



  1. Treede RD. The International Association for the Study of Pain definition of pain: as valid in 2018 as in 1979, but in need of regularly updated footnotes. Pain Rep. 2018;3(2):e643. doi: 10.1097/PR9.0000000000000643.

  2. Cohen M, Quintner J, van Rysewyk S. Reconsidering the International Association for the Study of Pain definition of pain. Pain Rep. 2018;3(2):e634. DOI: 10.1097/PR9.0000000000000634. 

  3. Merskey H, Albe Fessard D, Bonica JJ, Carmon A, Dubner R, Kerr FWL, Lindblom U, Mumford JM, Nathan PW, Noordenbos W, Pagni CA, Renaer MJ, Sternbach RA, Sunderland S. Pain terms: a list with definitions and notes on usage. Recommended by the IASP subcommittee on taxonomy. PAIN. 1979;6:249–52. 

  4. Giovannitti JA Jr. Dental Anesthesia and Pediatric Dentistry. Anesth Prog. 1995;42:95-99.

  5. Courson F, Guillaume JL. L’anesthésie lors des actes chirurgicaux chez l’enfant. Actualités Odonto-Stomatologiques. 2006;237:7-18

  6. Adewale L. Anaesthesia for paediatric dentistry. Continuing Education in Anaesthesia. Critical Care & Pain. 2012;12(6):288-294.

  7. Malamed SF, Quinn CL. Injection techniques to anesthetize the difficult tooth. J Calif Dent Assoc. 26,1998,665–667.

  8. Steward DJ. Manual of Pediatric Anesthesia, New York, Churchill Livingstone, 1979: 5-13.

  9. Daubländer M. Anesthésie locale chez les enfants et adolescents. Rev Mens Suisse Odontostomatol. 2005;11:1105-1109.

  10. Mortier E, Droz D, Gerdolle D. L’anesthésie locale et régionale. Réalités Cliniques. 2001;12(1):35-46.

  11. Ram D, Peretz B. Administering local anaesthesia to paediatric dental patients – status and prospects for the future. Int J Paediatr Dent. 2002;12(2):80-89.

  12. Gunasekaran S, Babu G, Vijayan V. Local anaesthesia in pediatric dentistry – An overview. J Multi Dent Res. 2020;6(1):17–22.

  13. Wright GZ, Weinberger SJ, Marti R, Plotzke O. The effectiveness of infiltration anesthesia in the mandibular primary molar region. Pediatric Dentistry. 1991;13(5):278–83.

  14. Wilson SW, Dilley DC, Vann WF, Anderson JA. Pain and anxiety control (Part I: Pain perception control). In: Pickham J, Casmassinno PS, Field HW, Mctigue DJ, Nowak A, editors. Pediatric Dentistry, Infancy Through Adolescesce. WB Saunders. 1999.

  15. Malamed SF. Handbook of Local Anesthesia. St. Louis, Mo: Mosby. 2013.

  16. Roberts GJ, Holzel HS, Sury MRJ, Simmons NA, Gardner P, Longhurst P. Dental Bacteremia in Children. Pediatric Cardiology. 1997;18(1):24–27.

  17. VanGheluwe J, Walton R. Intrapulpal injection Oral Medicine, Oral Pathology. Oral Radiology, and Endodontology. 1997;83(1):38–40. 2104(97)90088-3.

  18. Gibson RS, Allen K, Hutfless S, Beiraghi S. The Wand vs. traditional injection: a comparison of pain related behaviors. Pediatric Dentistry. 2000;22(6):458–62.

  19. Nicholson JW, Berry TG, Summitt JB, Yuan CH, Witten TM. Pain perception and utility: a comparison of the syringe and computerized local injection techniques. General Dentistry. 2001;49(2):167–73.

  20. Pashley EL, Nelson R, Pashley DH. Pressures Created by Dental Injections. Journal of Dental Research. 1981;60(10):1742–1748.

  21. Hingson RA, Hughes JG. Clinical Studies with Jet Injection. A New Method of Drug Administration. Anesthesia & Analgesia. 1947;26(6):221–251.

  22. Saravia ME, Bush JP. The needleless syringe: efficacy of anesthesia and patient preference in child dental patients. The Journal of Clinical Pediatric Dentistry. 1991;15(2):109.

  23. Munshi A, Hegde A, Bashir N. Clinical evaluation of the efficacy of anesthesia and patient preference using the needle-less jet syringe in pediatric dental practice. Journal of Clinical Pediatric Dentistry. 2002;25(2):131–136. 25.2.q6426p853266q575.

  24. Munshi A, Hegde A, Latha R. Use of EMLA®: is it an injection free alternative? Journal of Clinical Pediatric Dentistry. 2001;25(3):215–219. 25.3.hn62713500418728.

  25. Meechan JG. Intra-oral topical anaesthetics: a review. Journal of Dentistry. 2000;28(1):3–14. 1016/s0300-5712(99)00041-x.

  26. Meechan JG, Donaldson D. The intraoral use of EMLA cream in children: a clinical investigation. ASDC Journal of Dentistry for Children. 1994;61(4):260–262.

  27. Roghani S, Duperon DF, Barcohana N. Evaluating the efficacy of commonly used topical anesthetics. Pediatric Dentistry. 1999; 21:197– 200.

  28. Hersh EV, Houpt MI, Cooper SA, Feldman RS, Wolf MS, Levin MA. Analgesic efficacy and safety of an intraoral lidocaine patch. The Journal of the American Dental Association. 1996;127(11):1626–1634.

  29. Kreider KA, Stratmann RG, Milano M, Agostini FG, Munsell M. Reducing children’s injection pain: lidocaine patches versus topical benzocaine gel. Pediatric Dentistry. 2002;23(1):19–23.

  30. Noven pharmaceuticals. DentiPatch information.

  31. Wong JK. Injection I. Adjuncts to local anesthesia: separating fact from fiction. J Can Dent Assoc. 2001; 67:391–398.

  32. Lehtinen R. Efficiency of jet injection technique in production of local anesthesia. Proc Finn Dent Soc. 1979;75(1-2):13–14.

  33. Khan A, Yasir M, Asif M, Chauhan I, Singh AP, Sharma R, Singh P, et al. Iontophoretic drug delivery: history and applications. Journal of Applied Pharmaceutical Science. 2011;1(03):11–24.

  34. National Institute for Health and Clinical Excellence. Sedation for Diagnostic and Therapeutic Procedures in Children and Young People. (Clinical Guideline 112), 2010. Available at: uk/CG112 (accessed 3 July 2012)

  35. Walker H. The child who refuses to undergo anesthesia and surgery – a case scenario-based discussion of the ethical and legal issues. Paediatr Anaesth. 2009;19:1017–21.

  36. Nunn J, Foster M, Master S, et al. British Society of Paediatric Dentistry: a policy document on consent and the use of physical intervention in the dental care of children. Int J Paediatr Dent. 2008;18(Suppl. 1):39–46.

  37. Bennett CR. Dissociative sedation: a new concept. Compedium Contin Educ Dent. 1990; 11:36–38.

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