Local Complications of Local Anaesthesia & Recent Advancements in Localized Pain Control .pptx

LOCAL COMPLICATIONS
&
RECENT ADVANCEMENTS
in
LOCAL ANAESTHESIA.
by:
Dr. Mukesh Kumar Dey
MDS 2nd year student,
Dept. of Pedodontics and Preventive Dentistry.

CONTENTS
 Introduction.
 Types of Complications.
 Local Complications:
i. Needle breakage
ii. Prolonged anaesthesia
(paraesthesia)
iii. Facial nerve paralysis
iv. Ocular complications
v. Trismus
vi. Soft tissue injury
vii. Hematoma
viii. Pain on injection
ix. Burning on injection
x. Infection
xi. Oedema
xii. Sloughing of tissues
xiii. Post-anaesthetic intraoral
lesions
 Recent Advancements:
i. Topical Agents
ii. Injectable Agents
iii. Local Anaesthetic Delivery
Systems
iv. Non-pharmacological Means of
Pain Control

INTRODUCTION
 The administration of local anesthetics (LA) is essential
whenever potentially painful procedures are contemplated in
dentistry.
 Local anesthetics are extremely safe drugs when used as
recommended. However, whenever any drug, including a LA, is
used, the potential for unwanted and undesirable responses
exists.
 A number of potential complications are associated with the
administration of local anesthetic agents.

For purposes of convenience, these complications may be classified
into:
• Local:
that occur in the region of the injection.
• Systemic:
that affects the entire body, rather than a single
organ or body part.
TYPES OF COMPLICATIONS
Malamed SF. Handbook of Local Anaesthesia 7th edition 2020; 307-327.

LOCAL
COMPLICATIONS
of
LOCAL
ANAESTHETICS

i. Needle Breakage
 Since the introduction of non-
reusable, stainless steel dental LA
needles, needle breakage has
become an extremely rare
complication of dental LA injections.
 The exact cause of needle breakage
is rarely discernible.
 In most situations, needle fracture
occurs at the hub; never along the
shaft of the needle.

Most common site of
needle breakage.

 Needle breakage is not a significant problem if it
can be removed without surgical intervention.
 Ready access to a hemostat enables the clinician
or assistant to grasp the visible proximal end of
the needle fragment and remove it from the soft
tissue.
 However, problems arise when the needle has
been inserted to its hub and the soft tissue has
dimpled under pressure from the syringe, the
broken fragment will not be visible when the
syringe is withdrawn from the patient’s mouth.
 The needle fragment remaining in the tissue
poses a risk of serious damage being inflicted on
the soft tissues and surrounding structures (e.g.,
nerve, blood vessels) for as long as it remains.
Although it is an uncommon occurrence, needle
fragments can migrate.

Management:
 Management of the broken dental needle involves immediate referral of the
patient to an appropriate specialist such as an oral and maxillofacial surgeon
for evaluation and possible attempted retrieval.
 Conventional management involves locating the retained fragment through
panoramic and computed tomographic scanning.
 More recently, three-dimensional computed tomographic scanning has
been recommended to identify the location of the retained needle fragment.
 A surgeon in the operating theater then removes the retained needle fragment
with the patient under general anesthesia.

Lee J, Park MW, Kim MK, Kim SM, Seo KS. The surgical retrieval of a broken dental needle: A case report.
Journal of Dental Anesthesia and Pain Medicine 2015;15(2):99.

Prevention:
 Needle breakage is most likely with mandibular nerve blocks and if a needle
with a small diameter is used. Most cases of breakage have occurred with 30-
guage short needles.
 A long needle must be used so that at least 5 mm of the needle is outside the
mucosa to allow retrieval in the case of breakage.
 The patient should be advised against sudden movements. Also, extra caution
should be observed when inserting needles in younger, immature children or
in extremely phobic adult or child patients as they are more apt to make
sudden unexpected movements.
 Compared to that of the 27-guage needle, 30-guage needles are less effective
for pain relief during needle penetration.
 Furthermore, forceful or repeated pre-bending of the needle should be
avoided, and the needle should be changed if repeated injections are required.
Lee J, Park MW, Kim MK, Kim SM, Seo KS. The surgical retrieval of a broken dental needle: A case report. Journal of Dental
Anesthesia and Pain Medicine 2015;15(2):99.
Mathison M, Pepper T. Local Anesthesia Techniques in Dentistry and Oral Surgery. StatPearls Publishing 2023.

Acham S, Truschnegg A, Rugani P, Kirnbauer B, Reinbacher KE, Zemann W et al. Needle fracture as a complication of dental
local anesthesia: recommendations for prevention and a comprehensive treatment algorithm based on literature from the
past four decades. Clinical Oral Investigations 2019;23:1114.

ii. Prolonged Anaesthesia / Paraesthesia
 When anesthesia persists for days, weeks, or months, the potential for
the development of problems is increased.
 Paresthesia or persistent anesthesia is a disturbing yet often
unpreventable complication of LA administration. Paresthesia is one of
the most frequent causes of dental malpractice litigation.
 Paresthesia is defined as, “Persistent anesthesia (anesthesia well beyond the
expected duration), or altered sensation well beyond the expected duration
of anesthesia. In addition, the definition of paresthesia should include
hyperesthesia and dysesthesia, in which the patient experiences both pain
and numbness.”

Cause:
 Trauma to any nerve may lead to paresthesia, which is a common
complication of oral surgical procedures.
 Injection of a LA solution contaminated by alcohol or sterilizing
solution near a nerve produces irritation, resulting in oedema and
increased pressure in the region of the nerve, leading to paresthesia.
 Trauma to the nerve sheath can be produced by the needle during
injection.
Insertion of a needle into a foramen, as in the greater palatine nerve
block, also increases the likelihood of nerve injury.
 Hemorrhage into or around the neural sheath is another cause.
Bleeding increases pressure on the nerve, leading to paresthesia.

 Oedema following surgical procedures is another potential cause of
paresthesia, as the pressure of the edematous fluid compresses the
nerve.
 The LA solution itself may contribute to the development of paresthesia
after injection.
 Paresthesia has been reported to be more common with 4% solutions
such as articaine and prilocaine, compared to those of lower concentrations.
Associated Complications:
 Persistent anesthesia, rarely total, in most cases partial, and in most
cases transient, can lead to self-inflicted soft tissue injury.
 Biting or thermal or chemical insult can occur without a patient’s
awareness until the process has progressed to a serious degree. When
the lingual nerve is involved, the sense of taste (via the chorda tympani
nerve) may also be impaired.

 In some instances, paresthesia is not the clinical manifestation of
nerve injury.
 Hyperesthesia (i.e., an increased sensitivity to noxious stimuli) and
dysesthesia (a painful sensation occurring to usually non-noxious stimuli)
may also be noted.
Management:
 Most instances of paresthesia resolve within approximately 8 weeks
without treatment.
 Only when damage to the nerve is severe, will the paresthesia be
permanent, and this occurs only rarely.
 McCarthy and Orr have recommended the following time-honored
sequence in managing the patient with a persistent sensory deficit
after LA:

• Be reassuring:
Speak with the patient personally. Remember that if patients cannot
get through to speak to their doctor, they can always get the
doctor’s attention through litigation.
Explain that paresthesia is not uncommon after LA administration.
• Examine the patient in-person:
Determine the degree and extent of paresthesia.
Explain to the patient that paresthesia normally persists for at
least 2 months before resolution begins, and that it may last up to a
year or longer.
• Reschedule the patient for examination every 2 months for as long
as the sensory deficit persists.
• Dental treatment may continue, if both the doctor and the patient are
comfortable doing so, but administration of LA into the region of the
previously traumatized nerve should be avoided. Alternative LA
techniques should be used if possible.

Prevention:
 Strict adherence to the injection protocol and proper care and
handling of dental cartridges help minimize the risk of paresthesia.
Nevertheless, cases of paresthesia will still occur despite care taken
during the injection.
 Whenever a needle is inserted into soft tissues, anywhere in the body,
in an attempt to deposit a drug (e.g., local anesthetic) as close to a nerve
as possible without actually contacting it, it is simply a matter of time
before such contact does occur.
 As Pogrel et al. opined,
“It is reasonable to suggest that during a career, each dentist may
encounter at least one patient with an inferior alveolar nerve block
resulting in permanent nerve involvement. The mechanisms are
unknown and there is no known prevention or treatment.”
Pogrel MA, Thamby S. Permanent nerve involvement resulting from inferior alveolar nerve blocks. Journal of the American
Dental Association 2000;131:901–907.

iii. Facial Nerve Paralysis
 Paralysis of some of the terminal branches of facial nerve (CNVII) occurs
whenever an infraorbital nerve block is administered, or when maxillary
canines are infiltrated.
 Muscle droop is also observed when, occasionally, motor fibers are
anesthetized by inadvertent deposition of LA into their vicinity.
This may occur when anesthetic is introduced into the deep lobe of the
parotid gland, through which terminal portions of the facial nerve extend.

Cause:
 Transient CNVII paralysis is commonly
caused by the introduction of LA into the
capsule of the parotid gland, which is
located at the posterior border of the
mandibular ramus.
 Directing the needle posteriorly or
inadvertently deflecting it in a posterior
direction during an IANB, or over-
insertion during a Vazirani-Akinosi nerve
block, may place the tip of the needle
within the body of the parotid gland. If LA
is deposited, transient paralysis can result.

 Loss of motor function to the muscles of facial expression produced
by LA deposition is normally transitory. It lasts no longer than several
hours.
Usually, minimal or no sensory loss occurs.
 During this time the patient has unilateral paralysis and is unable to
use these muscles.
 The primary problem associated with transient facial nerve paralysis is
cosmetic: the person’s face appears lopsided.
No treatment is known, other than waiting for resolution of the
drug’s effect.
 A secondary problem is that the patient is unable to voluntarily close
one eye. The protective lid reflex of the eye is abolished. Winking and
blinking become impossible.
 The cornea, however, does retain its innervation; thus if it is irritated,
the corneal reflex is intact, and tears lubricate the eye.

Management:
 Reassure the patient. Explain that the situation is transient, lasting
several hours, and will resolve without residual effect. Mention that it is
produced by the normal action of LA drugs on the facial nerve.
 Contact lenses should be removed until muscular movement returns.
 An eye patch should be applied to the affected eye until muscle tone
returns. If resistance is offered by the patient, advise the patient to
manually close the affected eyelid periodically to keep the cornea
lubricated.
 Although no contraindication is known to reinjecting the patient to
achieve mandibular anesthesia, it may be prudent to forego further
dental care in the affected quadrant in that appointment.

Prevention:
 Transient facial nerve paralysis is almost always preventable by
adhering to protocol with the IANB and the Vazirani-Akinosi nerve
block techniques.
 A needle tip that comes in contact with bone (medial aspect of the
ramus) before depositing LA solution essentially precludes the
possibility that anesthetic will be deposited into the body of the
parotid gland during an IANB.
 If the needle deflects posteriorly during this nerve block and bone is not
contacted, the needle should be withdrawn almost entirely from the
soft tissues, the barrel of the syringe brought posteriorly (thereby
directing the needle tip more anteriorly), and the needle readvanced
until it contacts bone.
 Because no contact is made with bone during the Vazirani-Akinosi
nerve block, over-insertion of the needle, either absolute (>25 mm) or
relative (25 mm in younger patients), should be avoided, if possible.

iv. Ocular Complications
Ocular complications associated with intraoral LA administration, include:
 Amaurosis:
is a partial or complete loss of vision that occurs without
any visible changes to the eye.
 Blindness,
 Diplopia (double vision),
 Endophthalmitis:
is inflammation of the inner coats of the eye, resulting
from intraocular colonization of infectious agents with
exudation within intraocular fluids.
 Globe penetration,

 Horner syndrome (blepharoptosis, miosis, anhidrosis, hemifacial flushing,
conjunctival injection and enophthalmos)
 Impaired visual acuity (double vision)
 Mydriasis (dilation of the pupil)
 Ophthalmoplegia:
is the paralysis or weakness of the eye muscles. It can
affect one or more of the six muscles that hold the
eye in place and control its movements.
It can either be internal or external, partial or total.
 Ptosis:
also known as blepharoptosis, is a condition where the upper
eyelid droops or falls.
 Strabismus:
is a medical term for a condition where the eyes point in
different directions. It's also known as a squint.
It can either be convergent or divergent.

Anatomic Basis of Ocular Complications:
 Diffusion of the anesthetic drug through myofascial spaces or bony
openings, as in the case of the greater palatine canal approach.
 Inadvertent intravascular injection of the LA.
 Direct trauma of the periarterial sympathetic plexus. Such trauma sets
up a sympathetic impulse that travels to the orbit.
Management:
 Each case involving an ocular complication following intraoral LA
administration should be evaluated individually.
 It is recommended that consultation with an ophthalmologist be
obtained whenever there is uncertainty as to the cause.
 In conditions such as convergent strabismus or binocular diplopia, at
least until the anesthetic effect resolves, a “wait and observe” approach
is recommended.
 Supportive measures, such as patient reassurance and patching of the
affected eye.

v. Trismus
 Trismus is defined as,
“A prolonged, tetanic spasm of the jaw muscles by which the normal
opening of the mouth is restricted (locked jaw).”
Cause:
 Trauma to muscles or blood vessels in the infratemporal fossa is the most
common causative factor in trismus associated with dental injection of LA.
 LA solutions into which alcohol or cold sterilizing solutions have diffused,
produce irritation of tissues (e.g., muscle), potentially leading to trismus.
 Low-grade infection after injection can also cause trismus.

 Hemorrhage is another cause of trismus. Large volumes of extravascular
blood can produce tissue irritation, leading to muscle dysfunction as the
blood is slowly resorbed (over approximately 2 weeks).
 Multiple needle penetrations correlate with a greater incidence of post-
injection trismus.
 Excessive volumes of LA solution deposited into a restricted area produce
distention of tissues, which may lead to post-injection trismus.

 In the acute phase of trismus–
pain produced by hemorrhage leads to muscle spasm and
limitation of movement.
 The chronic phase–
• usually develops if treatment is not begun.
• Chronic hypomobility occurs secondary to organization of the
hematoma, with subsequent fibrosis and scar contracture.
• Infection may produce hypomobility through increased pain,
increased tissue reaction (irritation) and scarring.

Management:
 The patient must be scheduled for frequent check-ups and advised:
• heat therapy,
• warm saline rinses,
• analgesics, and
• muscle relaxants if necessary,
to manage the initial phase of muscle spasm.
 Analgesics: Orally administered aspirin(325mg) or ibuprofen(600mg) is usually
adequate in managing pain associated with trismus. Their anti-
inflammatory properties are also beneficial.
 Muscle relaxants such as Diazepam(~10mg) BID or benzodiazepine is used
for if deemed necessary.

 The patient should be advised to initiate physiotherapy consisting of:
• opening and closing the mouth, as well as
• lateral excursions of the mandible, for 5 minutes every 3 to 4 hours.
 Chewing gum (sugarless) is yet another means of providing lateral
movement of the TMJ.
 Avoid further dental treatment in the involved region until symptoms
resolve and the patient is more comfortable.
If continued dental care in the area is urgent, as with a painful infected
tooth, it may prove difficult to achieve effective pain control when
trismus is present.
 For severe pain or dysfunction, if no resolution is noted, the patient
should be referred to an oral and maxillofacial surgeon for evaluation.

vi. Soft Tissue Injury
 Trauma occurs most frequently in younger children,
in mentally or physically disabled children or
adults, and in older-old patients (>85 years).
 The primary reason is that soft tissue anesthesia
lasts significantly longer than does pulpal
anesthesia.
 Dental patients receiving LA during their treatment
are usually dismissed from the dental office with
residual soft tissue numbness.

Trauma to anesthetized tissues can lead to swelling and significant pain
when the anesthetic effects resolve.
A young child or a handicapped individual may have difficulty coping
with the situation, and this may lead to behavioral problems. The possibility
that infection will develop is remote in most instances.
Management:
is symptomatic:
 analgesics (e.g., age-appropriate dose of ibuprofen) for pain, as necessary;
 antibiotics as necessary, in the unlikely situation that infection results;
 lukewarm saline rinses to aid in decreasing any swelling that may be
present;
 petroleum jelly or other lubricant to cover a lip lesion and minimize
irritation.

Prevention:
 A cotton roll can be placed in the
buccal/labial fold between the lips and the
teeth if they are still anesthetized at the time of
discharge.
It is secured with dental floss wrapped
around the teeth (to prevent inadvertent
aspiration of the roll).
 Warn the patient and the guardian against
eating, drinking hot fluids, and biting of the
lips or tongue to test for anesthesia.
 A self-adherent warning sticker may be used
for children

 For all local anesthetics, the duration of:
soft tissue anesthesia > dentinal / osseous anesthesia.
 Use of phentolamine mesylate injections in patients over the age of six
years or at least 15 kilograms has been shown to reduce the duration of
effects of local anesthetic by about:
• 47 % in the maxilla and
• 67 % in the mandible.
 Use of phentolamine mesylate is not recommended for patients who
are younger than three years of age or weigh less than 15 kg.
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.

vii. Hematoma
 The effusion of blood into extravascular spaces can be
caused by inadvertent nicking of a blood vessel
(artery or vein) during administration of LA.
 A hematoma that develops due to nicking of an
artery usually increases rapidly in size until
management is instituted because of the significantly
greater pressure of blood within an artery.
 Nicking of a vein may or may not result in the
formation of a hematoma. Tissue density
surrounding the injured vessel is a determining
factor. The denser the surrounding tissues (e.g.,
palate), the less likely a hematoma is to develop.

Cause:
 Because of the density of tissue in the hard palate and its firm adherence
to bone, a hematoma rarely develops after a palatal injection. A rather
large hematoma may result from arterial or venous puncture after a PSA
nerve block or an IANB.
 The tissues surrounding these vessels more readily accommodate
significant volumes of blood. The blood effuses from vessels until
extravascular pressure exceeds intravascular pressure, or until clotting
occurs.
 Hematomas that occur after the IANB are usually visible only intraorally,
whereas those that occur after the PSA nerve block are visible extraorally.

 A hematoma rarely produces significant
problems, aside from the resulting “bruise,”
which may or may not be visible
extraorally.
 Possible complications of hematoma
include trismus and pain.
 Swelling and discoloration of the region
usually subside gradually, with complete
resolution occurring between 7 and 21
days.

Marques ALN, Figueroba SR, Mafra MAT, Groppo FC. Oedema and hematoma after local anesthesia via posterior superior
alveolar nerve block: a case report. J Dent Anesth Pain Med 2022;22(3):227-231.

Management:
 Immediate:
• When swelling becomes evident during or immediately after an LA
injection, direct pressure should be applied to the site of bleeding.
• No discoloration will be seen at the onset of a hematoma as the blood
is relatively deep within the soft tissues.
• For most injections the blood vessel is located between the surface of
the mucous membrane and the bone; localized pressure should be
applied for a minimum of 2 minutes. This effectively stops the
bleeding.

 Site of Pressure Application based on the Nerve Block used:
• Inferior Alveolar Nerve Block: The medial aspect of the ramus.
• Infraorbital Nerve Block: The skin directly over the infraorbital
foramen.
• Mental Nerve Block: The mental foramen, externally on the skin or
intraorally on the mucous membrane.
• Buccal Nerve Block or Any Palatal Injection: Pressure is applied at the
site of bleeding.

• Posterior Superior Alveolar Nerve Block: usually produces the largest and
most esthetically unappealing hematoma.
The hematoma is usually not recognized until a colorless swelling
appears on the side of the face around the TMJ area (usually a few
minutes after the injection is completed).
It progresses over a period of days, extending inferiorly and anteriorly
toward the lower anterior region of the cheek.
It is difficult to apply pressure to the site of bleeding in this situation
because of the location of the involved blood vessels, viz.:
o Posterior Superior Alveolar artery (the primary source of bleeding),
o Facial artery, and
o Pterygoid plexus of veins.

They are located posterior, superior, and medial to the maxillary
tuberosity.
Digital pressure can be applied to the soft tissues in the mucobuccal
fold as far distally as can be tolerated by the patient (without eliciting a
gag reflex).
Apply pressure in a medial and superior direction. If available, ice
should be applied extraorally to increase pressure on the site and help
to constrict the punctured vessel.

 Subsequent:
• The patient may be discharged once bleeding stops.
• The patient should be advised and informed about:
o possible soreness and limitation of movement. If either of these
develops, treatment must be initiated as described earlier.
o Discoloration will likely occur as a result of extravascular blood
elements; it is gradually resorbed over 7 to 21 days.
o not to apply heat to the area for at least 4 to 6 hours after the
incident.
o Ice may be applied to the region immediately on recognition of a
developing hematoma.
o Time is the most important element in managing a hematoma.
With or without treatment a hematoma will be present for 7 to
21 days.
• Avoid additional dental therapy in the region until symptoms and
signs resolve.

Prevention:
 Knowledge of the normal anatomy is important, although “normal anatomy may
differ from patient to patient”, must be kept in mind.
 Certain techniques are associated with a greater risk of a visible hematoma. The PSA
nerve block is the most common, followed by the mental/incisive nerve block and
the IANB.
 Modify the injection technique as dictated by the patient’s anatomy. For example, the
depth of penetration for a PSA nerve block may be decreased in a patient with
smaller facial characteristics.
 Use a short needle (27-gauge short needle is recommended) for the PSA nerve block to
decrease the risk of hematoma that is commonly a result of needle over-insertion.
 Minimize the number of needle penetrations into tissue. Never use a needle as a
probe in tissues.

viii. Pain upon Injection
 Pain on injection of LA can best be prevented through careful adherence
to the basic protocol of atraumatic injection.
Cause:
 Rapid deposition of the LA solution.
 Careless injection technique and a callous attitude.
 Using dull needle (sharpness is lost due to multiple insertions).
 Needles with barbs (from impaling bone) may produce pain as they are
withdrawn from tissue.

Pain on injection increases patient anxiety and may lead to sudden
unexpected movement, increasing the risk of:
• Needle breakage,
• Traumatic soft tissue injury (to the patient), or
• Needle-stick injury (to the administrator).
Management:
No management is necessary.
However, steps should be taken to prevent the recurrence of pain
associated with the injection of local anesthetics.

Prevention:
 Adhere to proper techniques of injection.
 Use:
• sharp needles.
• sterile LA solutions.
• topical anesthetic applied properly before injection.
 Inject LA slowly. Rate of injection:
 Ideally = 1.0 mL per minute;
 Recommended = 1.8 mL
or a 2.2-mL cartridge over 1 minute.
 Temperature of the solution: Too hot or too cold may be more uncomfortable
than one at room temperature.
 Buffered LA, at a pH of ~7.4, have been demonstrated to be more comfortable
on administration.

ix. Burning on Injection
 It is not uncommon.
 Several potential causes are known.
Cause:
 The primary cause of a mild burning sensation is the pH of the solution
being deposited into the soft tissues.
 Rapid injection of LA, especially in the denser, more adherent tissues
of the palate, produces a burning sensation.
 Contamination of LA cartridges with alcohol or other sterilizing
solutions upon storage.

 Cartridges stored in cartridge warmers are usually considered “too hot”
by the patient.
 Although usually transient, the sensation of burning on injection of LA
indicates that tissue irritation or damage is occurring.
• If caused by pH of the solution: it rapidly disappears as anesthesia
develops.
• Usually no residual sensitivity is noted when the anesthetic
action ends.

 When a burning sensation occurs as a result of rapid injection, a
contaminated solution, or an overly warm solution, the likelihood of
tissue damage is greater, and subsequent complications, such as post-
anesthetic trismus, oedema, or possible paresthesia, are reported.
Management:
 Because most instances are transient and do not lead to prolonged tissue
involvement, formal treatment is usually not indicated.
 In those few situations in which post-injection discomfort, oedema, or
paresthesia becomes evident, management of the specific problem is
indicated.

Prevention:
 By buffering the LA solution to a pH of ~7.4 immediately before
administration, it is possible to eliminate the burning sensation that some
patients experience during injection of an LA solution containing a
vasopressor.
 Slowing the speed of injection also helps.
 The cartridge of anesthetic should be stored at room temperature in
the container (blister pack or tin) in which it was shipped, or in a
suitable container without alcohol or other sterilizing agents.

x. Infection
It is an extremely rare occurrence since the introduction of single-use
sterile needles and glass cartridges.
Cause:
 The major cause of post-injection infection is contamination of the
needle before administration of the anesthetic.
 Contamination of a needle always occurs when the needle touches
mucous membrane in the oral cavity.
 Improper technique in the handling of LA equipment and improper
tissue preparation for injection are other possible causes of infection.

Contamination of needles or solutions may cause a low-grade
infection when the needle or solution is placed in deeper tissue.
This may lead to trismus if it is not recognized and proper
treatment is not initiated.
Management:
 Low-grade infection, which is rare, is seldom recognized immediately.

 Immediate treatment consists of those procedures used to manage
trismus.
 Trismus produced by factors other than infection normally responds
with resolution or reduction within several days.
 If signs and symptoms of trismus don’t begin to respond to
conservative therapy within 3 days,
the possibility of a low-grade infection should be entertained and a
7- to 10-day course of antibiotic therapy should be started.

Prevention:
 Use sterile disposable needles.
 Proper care and handling of needles. Take precautions to avoid
contamination of the needle through contact with non-sterile
surfaces.
 Proper care and handling of LA cartridges.
• Use a cartridge only once (one patient).
• Store cartridges aseptically in their original container,
covered at all times.
• Cleanse the diaphragm with a sterile disposable alcohol
wipe immediately before use if considered necessary.
 Properly prepare the tissues before injection.

xi. Oedema
Swelling of tissues is not a syndrome but it is a clinical sign of the
presence of some disorder.
Cause:
 Infection.
 Hemorrhage.
 Trauma during injection.
 Allergy: angioedema is a possible response to ester-type topical
anesthetics in allergic patients.
 Injection of irritating solutions (alcohol-containing cartridges or cold
sterilizing solution–containing cartridges).

 Hereditary angioedema is a condition characterized by the sudden onset
of “brawny” non-pitting oedema affecting the:
• face,
• extremities, and
• mucosal surfaces of the intestine and respiratory tract,
often without obvious precipitating factors.
Tissue manipulation within the oral cavity, including LA
administration, may precipitate an attack.
Lips, eyelids, and the tongue are often involved.
 Oedema related to LA administration is seldom of sufficient intensity to
produce problems such as airway obstruction.

 Most instances of LA–related oedema result in pain and dysfunction of the
region.
 Angioneurotic oedema produced by a topical anesthetic in an allergic
individual, although exceedingly rare, can compromise the airway.
 Oedema of the tongue, pharynx, or larynx may develop, and is a
potentially life-threatening situation that requires vigorous management
(including activation of emergency medical services).
Management:
The management of oedema is aimed on reduction of the swelling as quickly
as possible and its cause.

 When produced by traumatic injection or by introduction of irritating solutions,
oedema is usually of minimal degree and resolves in several days without formal
therapy.
 After haemorrhage, oedema resolves more slowly (over 7 to 21 days) as extravasated
blood elements are resorbed into the vascular system.
If signs of haemorrhage are evident, management follows as previously
discussed for hematoma.
 Oedema produced by infection does not resolve spontaneously but may become
progressively more intense if untreated.
 If signs and symptoms of infection don’t appear to resolve within 3 days, antibiotic
therapy should be instituted as mentioned previously.

 Allergy-induced oedema is potentially life threatening. Its degree and location are
highly significant.
 If swelling develops in buccal soft tissues and there is absolutely no airway
involvement, treatment consists of immediate intramuscular injection (in the
vastus lateralis muscle) followed by a 3-day course of oral histamine blocker therapy
in children up to 30 kg.
 Consultation with an allergist to determine the precise cause of the oedema.
 If oedema occurs in any area where it compromises breathing, treatment consists of the
following:
• Position: if unconscious, the patient is placed supine.
• Airway→Breathing→Circulation: Basic Life Support is administered, as needed.

• Definitive treatment: emergency medical services are summoned.
• Epinephrine (im) is administered in the vastus lateralis every 5 minutes
until respiratory distress resolves.
• Histamine blocker and corticosteroid are administered
intramuscularly or intravenously.
• Preparation is made for cricothyrotomy if total airway obstruction
appears to be developing besides summoning emergency medical
services as quickly as possible.

• The patient’s condition is thoroughly evaluated before his/her next
appointment to determine the cause of the reaction.
Prevention:
 Proper care and handling of the LA armamentarium.
 Use of atraumatic injection technique.
 Complete an adequate medical evaluation of the patient before drug
administration.

xii. Sloughing of Tissues
Prolonged irritation or ischemia of gingival soft tissues may lead to a
number of unpleasant complications, including epithelial desquamation and
sterile abscess.
Cause:
 Epithelial Desquamation:
• Application of a topical anesthetic to the gingival tissues for a
prolonged period.
• Heightened sensitivity of the tissues to either topical or injectable
local anesthetic.

 Sterile Abscess:
• Secondary to prolonged ischemia resulting from the use of a LA
with a vasoconstrictor (usually nor-epinephrine).
• Usually develops on the hard palate.
 Pain, at times severe, may be a consequence of epithelial
desquamation or a sterile abscess.
 It is remotely possible that infection may develop in these areas.
Gogna, N., Hussain, S. & Al-Rawi, S. Case reports: Palatal mucosal necrosis after administration of a palatal infiltration.
British Dent Journal 2015;219:560–561.

Management:
 Usually no formal management is necessary for epithelial desquamation
or sterile abscess.
 Management may be symptomatic. For pain, analgesics, such as
aspirin or another non-steroidal anti-inflammatory drug and a
topically applied ointment (e.g., triamcinolone, Orabase), are
recommended to minimize irritation to the area.
 Epithelial desquamation resolves within a few days; the course of a
sterile abscess may run 7 to 10 days.

Prevention:
 Use topical anesthetics as recommended. Allow the solution to contact
the mucous membranes for 1 to 2 minutes to maximize its
effectiveness and minimize toxicity.
 When using vasoconstrictors for hemostasis, do not use overly
concentrated solutions.
 Epinephrine (1:50,000) may also produce this problem if repeated
injections of the solution occur whenever ischemia resolves, over a long
period (e.g., several hours).

xiii. Post-anaesthetic Intraoral Lesions
The primary initial symptom is pain, usually of a relatively intense nature.
Cause:
 Recurrent aphthous stomatitis (RAS) or herpes simplex can occur
intraorally after an LA injection or after any trauma to the intraoral
tissues.
 RAS is the most common oral mucosal disease known in humans.

 RAS is more frequently observed than herpes simplex, typically
developing on gingival tissues that are not attached to underlying
bone, such as the buccal vestibule.
 Herpes simplex can develop intraorally, although more commonly it is
observed extraorally.
 It is viral in origin and becomes manifest as small bumps on tissues
that are attached to underlying bone such as the soft tissue of the
hard palate.
 Trauma to tissues caused by a needle, an LA solution, a cotton swab, or
any other instrument.

The patient describes acute sensitivity in the ulcerated area and may
consider that the tissue has become infected as a result of the LA injection
they received.
However, the risk of a secondary infection developing in this situation is
minimal.
Management:
 Primary management is symptomatic. Pain is the major initial symptom,
developing approximately 2 days after injection.
 Reassure the patient that the situation is not caused by a bacterial infection
secondary to the LA injection, but is an exacerbation of a process that was
present, in latent form, in the tissues before injection.

 No management is necessary if the pain is not severe. However, if pain
causes the patient to complain, treatment can be instituted, usually with
various degrees of success.
 The objective is to keep the ulcerated areas covered/anesthetized. Topical
anesthetic solutions (e.g., viscous lidocaine) may be applied as needed to
the painful areas.
 A mixture of 1:1 diphenhydramine (Benadryl) and milk of magnesia
rinsed in the mouth effectively coats the ulcerations and provides relief
from pain. Orabase, a protective paste, without triamcinolone acetonide can
provide a degree of pain relief.

 Triamcinolone acetonide, a corticosteroid, is not recommended because
its anti-inflammatory actions increase the risk of viral or bacterial
involvement.
 A tannic acid preparation (Zilactin) can be applied topically to the lesions
extraorally or intraorally (dry the tissues first).
 The ulcerations usually last 7 to 10 days with or without treatment.

Prevention:
 Unfortunately there are no means of preventing these intraoral lesions
from developing in susceptible patients.
 Extraoral herpes simplex, on occasion, may be prevented or its clinical
manifestations minimized if it is treated in its prodromal phase.
 The prodrome consists of a mild burning or itching sensation at the site
where the virus is present.
 Antiviral agents, such as acyclovir, applied four times daily to the affected
area may effectively minimize the acute phase of this process.

 The LAs currently available to the dental profession will, in almost all
situations, enable a patient to have dental treatment completed pain free.
• Articaine hydrochloride,
• Lidocaine hydrochloride,
• Prilocaine hydrochloride,
• Bupivacaine hydrochloride, and
• Mepivacaine hydrochloride
are excellent drugs that, when used properly; these are safe and highly
effective.
 As effective as LAs are, clinical situations still arise when it is difficult to
achieve adequate pain control.
CONCLUSION

 Moreover, most LA procedures in pediatric dentistry involve traditional
methods of infiltration or nerve block techniques with a dental syringe,
disposable cartridges, and needles as described so far.
 Several alternative techniques, including:
• needleless systems,
• periodontal injection techniques,
• computer-controlled local anesthetic delivery,
• intraseptal or intrapulpal injection
are now available.
 Such techniques may improve comfort of injection by better control of the
administration rate, pressure, and location of anesthetic solutions and
result in more successful and controlled anesthesia.
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.

RECENT
ADVANCEMENTS
in
LOCAL
ANAESTHETICS

Recent
Advancements
1. Topical Agents
2. Injectable Agents
3. Delivery Systems
4. Non-pharmacological means

 Cetacaine is the proprietary name of a preparation, composed of:
 It is commercially available as:
• Gel,
• Aerosol,
• Solution and
• Ointment,
1. TOPICAL ANAESTHETIC AGENTS
• Butamben 20 mg/mL
• Benzocaine 140 mg/mL
• Tetracaine hydrochloride 20 mg/mL
i. Cetacaine Topical Anaesthetic Liquid

 Topical pain control across mucous membranes, except in the eyes, can be
achieved using this formula.*
 Cetacaine shows better efficacy due to its:*
• reduced moisture sensitivity. and
• increased depth of surface anesthesia.
 Although it is available as spray and liquid, it cannot be administered as an
injection.*
 Dasarraju et al. (2020) found better topical anesthetic effects with
cetacaine compared to EMLA cream and 20% benzocaine gel in children
aged 7–11 years during palatal needle prick.**
*Remi RV, Anantharaj A, Praveen P, Prathibha RS, Sudhir R. Advances in pediatric dentistry: new approaches to pain control and anxiety
reduction in children - a narrative review. Journal of Dental Anesthesia and Pain Medicine 2023;23(6):303-315.
**Dasarraju RK, Nirmala SVSG. Comparative efficacy of three topical anesthetics on 7-11-year-old children: a randomized clinical study. Journal
of Dental Anesthesia and Pain Medicine 2020;20(1):29-37.

 *It contains clove oil3% (analgesic effect), chloramine1% (gelling agent), and papaya
extract (vehicle).
 Clove oil activates calcium and chloride channels in ganglion cells, resulting in an
analgesic effect.
 **Anantharaj et al. (2020) compared the topical anesthetic efficiency of precooling
with ice, clove–papaya based topical gel and benzocaine gel in pediatric patients.
The authors reported statistically insignificant differences among the topical
anesthetic efficiency of the three methods in pediatric patients. Moreover, the newly
introduced clove–papaya based topical anesthetic gel showed encouraging results,
and hence can be used as a potent topical anesthetic agent.
ii. Clove-papaya-based topical anesthetic gel
*Remi RV, Anantharaj A, Praveen P, Prathibha RS, Sudhir R. Advances in pediatric dentistry: new approaches to pain control and anxiety
**Anantharaj A, Mary SJ, Sudhir R, Bangalore JR, Praveen P; Rani SP. A comparative evaluation of pain perception following topical application
of benzocaine gel, clove-papaya based anesthetic gel and precooling of the injection site before intraoral injections in children. Journal of Indian
Society of Pedodontics and Preventive Dentistry 2020;38(2):184-189.

 It is quinolone derivative that produces a LA effect at a concentration of 0.5%.
 Goyal et al. (2013) reported that centbucridine and lignocaine showed similar time
of onset, depth of anesthesia, and cardiovascular effects following IANB
administration. The inherent vasoconstrictive nature of centbucridine results in a
significantly longer duration of anesthesia (2.5hrs) with no toxic reactions compared
to lignocaine (<2hrs).*
 Gune et al. (2020) recommended centbucridine as a substitute in 12-14 years old
medically compromised patients for whom lignocaine or adrenaline was
contraindicated.**
2. INJECTABLE ANAESTHETIC AGENTS
i. Centbucridine
*Goyal A, Jain G , Jain A, Ansari T, Bumb S. A new era of local anaesththetic agent: Centbucridine. Archives of CraniOroFacial Sciences
2013;1:40-43.
**Gune NS, Katre AN. Comparison of 0.5% centbucridine and 2% lignocaine as local anesthetic agents for dental procedures in children: a
randomised controlled trial. Indian Journal of Pediatrics 2020;87:268-274.

 The acidic nature of LA solutions can cause a burning sensation during
administration and post-injection tissue injury.
 Alkalinization of dental anesthetic cartridges using an 8.4% sterile solution of
sodium bicarbonate (NaHCO3) at the chairside immediately before injection
accelerates analgesia and reduces injection pain.
 Afsal et al. (2019) found that buffered lignocaine is the least painful and most
effective anesthetic agent during IAN block injections in 5–10-year-old patients.*
 Aulestia-Viera et al. (2018) in their study also concluded that buffered lidocaine has
shown an accelerated onset time for IAN blocks and less inflamed tissues compared
to normal tissues.**
ii. pH Buffering of Local Anesthetics
*Afsal MM, Khatri A, Kalra N, Tyagi R, Khandelwal D. Pain perception and efficacy of local analgesia using 2% lignocaine, buffered lignocaine,
and 4% articaine in pediatric dental procedures. Journal of Dental Anesthesia and Pain Medicine 2019;19(2):101-109.
**Aulestia-Viera PV, Braga MM, Borsatti MA. The effect of adjusting the pH of local anaesthetics in dentistry: a systematic review and meta-
analysis. International Endodontic Journal 2018;51(8):862-876.

 CCLAD technology delivers LA solutions at fixed flow rates, regardless of variations in
tissue resistance.
 Few of the most popular CCLAD systems include the:
i. Wand Single Tooth Anesthesia,
ii. QuickSleeper, and
iii. Comfort Control Syringe
 The syringe of the Wand is contained within the main unit, while the Quicksleeper and
Comfort Control Syringe have a base unit and a syringe.
3. LOCAL ANESTHETIC DELIVERY DEVICES
i. Computer-controlled local anesthesia delivery
Remi RV, Anantharaj A, Praveen P, Prathibha RS, Sudhir R. Advances in pediatric dentistry: new approaches to pain control and anxiety

 Castelo et al. (2023) assessed two CDS (i.e., the Wand STA and the
QuickSleeper) in children with deep caries in the deciduous dentition that
required invasive therapeutic procedures, using IAN block as the gold
standard in a randomized controlled split mouth clinical trial.
Authors at the end of the study confirmed the efficacy of intra-
ligamentary and intraosseous techniques administered using a CDS for
conducting invasive dental treatments in children, their advantages
compared with IAN block in terms of less pain generated by the anesthesia
injection and less postoperative morbidity, as well as the pediatric
patients’ preference for CDS versus conventional techniques.
Castelo AP, Mato EG, Aneiros IV, López LS, Rial MO, Pazos MTA et al. Evaluation of Intraligamentous and Intraosseous Computer-Controlled
Anesthetic Delivery Systems in Pediatric Dentistry: A Randomized Controlled Trial. Children 2023;10:01-12.

i. The Wand STA® is a computerized-controlled Single Tooth Anesthesia (STA) system
used to anesthetize the tooth being treated by intra-ligamentary injection.
 The STA technique prevents anticipatory anxiety and physical pain, the absence of
perioral tissue anesthesia, and the delivery of a controllable, lower dose of
anesthetic liquid.
 Mittal et al. (2015) reported significantly lower pain perception with palatal
infiltration using a Wand than during traditional palatal infiltration injection in 8-12
year-old children.*
 Garret-Bernardin et al. (2017) stated that the Wand computerized delivery system
provided less painful injections and was better tolerated among pediatric patients
than traditional syringes.**
*Mittal M, Kumar A, Srivastava D, Sharma P, Sharma S. Pain perception: computerized versus traditional local anesthesia in pediatric patients. J
Clin Pediatr Dent 2015;39:470-474.
**Garret-Bernardin A, Cantile T, D’Antò V, Galanakis A, Fauxpoint G, Ferrazzano GF et al. Pain Experience and behavior management in
pediatric dentistry: a comparison between traditional local anesthesia and the wand computerized delivery system. Pain Res Manag 2017;01-12.

ii. The QuickSleeper™ system delivers a computer-assisted
intraosseous (IO) injection, in which the volume and
speed of diffusion of the anesthetic agent into the cortical
bone are monitored by a wireless pedal.
 Less pain and soft-tissue anesthetic effects, along with the
non-threatening needle design of the Quicksleeper, can be
beneficial for anxious young patients.
 Smaïl-Faugeron et al. (2019) compared the pain caused by
conventional infiltration anesthesia (CIA) and IO anesthesia
(IOA) delivered by the computerized system, QuickSleeper™
in children. Authors at the end of this study concluded that
pain during the insertion of the needle and injection was
less with IOA relative to CIA in children.
Smaïl-Faugeron V, Muller-Bolla M, Sixou JL, Courson F. Evaluation of intraosseous computerized injection system (QuickSleeper™) vs
conventional infiltration anaesthesia in paediatric oral health care: A multicentre, single-blind, combined split-mouth and parallel-arm
randomized controlled trial. International Journal of Paediatric Dentistry 2019;29(5):573-584.

iii. The Comfort Control™ Syringe (CCS™) is an electronic, pre-
programmed delivery system for LA that dispenses the
anesthetic in a slower, more controlled and more consistent
manner than a traditional manual syringe.
 It has a special delivery system. which allows the injection to
begin at a slow rate to minimize the discomfort associated
with rapid injection.
 Langthasa et al. (2012) compared the pain perception by the
pediatric patients, while experiencing computerized injection
device, comfort control syringe (CCS) and the conventional
injection technique during dental clinical procedures. Authors
concluded that CCS provides less painful injections when
compared to the conventional injection technique in the
pediatric patients.
Langthasa M, Yeluri R, Jain AA, Munshi AK. Comparison of the pain perception in children using comfort control syringe and a conventional
injection technique during pediatric dental procedures. Journal of Indian Society of Pedodontics and Preventive Dentistry 2012;30:323-328.

 The liquid medication is pushed through a small
orifice under the pressure created by a
mechanical energy source to penetrate the
subcutaneous tissue without a needle.
 The jet injector shows a faster onset of soft tissue
anesthesia with less pain and tissue damage,
making it ideal for nasopalatine and greater
palatine injections.
 However, conventional needle anesthesia is
preferred for complicated surgical procedures or
extractions due to its longer duration of action and
better pain control.
ii. Jet Injection

 Patel et al. (2023) evaluated and compared the efficacy and preference
between needleless device INJEX and insulin syringe for anesthetizing
primary maxillary teeth in children aged 4–9 years.
Authors concluded that pain perception and preoperative anxiety
were significantly reduced while administrating LA using needleless
device INJEX due to its design, but its clinical efficacy was lower than
insulin syringe due to the small effective amount of anesthetic solution
delivered because of its spillage in the mucosa and its inability to completely
adapt to the tissue.
Patel M, Bhatt R, Mehta M, Patel C, Patel F, Makwani D. A comparative assessment of efficacy and preference between needleless device INJEX
and insulin syringe for anesthetizing primary maxillary teeth in children aged 4–9 years: A split-mouth crossover randomized clinical study.
Journal of Indian Society of Pedodontics and Preventive Dentistry 2023;41:149-155.

 LLLT suppresses painful sensations by temporarily disrupting the Na+-K+ pump
system and biomodulating the dental pulp.
 Profound anesthesia is not achieved due to the inability to suppress all sensations.
 Children show good acceptance and tolerance of erbium lasers for dental and soft
tissue treatments.
 Chan et al. (2012) reported the effective induction of pulpal analgesia using pulsed
Nd: YAG laser and suggested it as a non-invasive alternative for needle-phobic
children.*
 Uçar et al. (2022) also concluded that Topical anesthesia + LLLT with an f= 810nm
diode laser reduced injection pain in children aged 6-9 years who underwent
pulpotomy treatment, in their study.**
4. NON-PHARMACOLOGICAL MEANS OF PAIN CONTROL
i. Low-level LASER therapy
*Chan A, Armati P, Moorthy AP. Pulsed Nd: YAG laser induces pulpal analgesia: a randomized clinical trial. J Dent Res 2012; 91: 79S-84S.
**Uçar G, Şermet Elbay Ü, Elbay M. Effects of low level laser therapy on injection pain and anesthesia efficacy during local anesthesia in
children: a randomized clinical trial. Int J Paediatr Dent 2022; 32: 576-84.

 The application of cold (refrigerant spray or ice) to a localized
body blocks the conduction of painful nerve impulses.
 Although cooling produces immediate anesthesia by acting on all
cells of the part, it has a very short duration (2–5 s), sufficient to
reduce the discomfort caused by needle insertion.
 Hindocha et al. (2019) reported that applying ice to the oral
mucosa before injection and 5% lidocaine gel had identical effects
on pain relief during needle insertion.*
 Tirupathi et al. (2020) stated that subjective and objective pain
during LA administration could be reduced in children by pre-
cooling the injection site.**
ii. Cryoanesthesia
*Hindocha N, Manhem F, Bäckryd E, Bågesund M. Ice versus lidocaine 5% gel for topical anaesthesia of oral mucosa - a randomized cross-over
study. BMC Anesthesiol 2019;19:227.
**Tirupathi SP, Rajasekhar S. Effect of precooling on pain during local anesthesia administration in children: a systematic review. J Dent Anesth
Pain Med 2020;20:119-127.

REFERENCES
 Malamed SF. Handbook of Local Anaesthesia 7th edition; 2020; 307-327.
 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.
 Lee J, Park MW, Kim MK, Kim SM, Seo KS. The surgical retrieval of a broken dental
needle: A case report. Journal of Dental Anesthesia and Pain Medicine 2015;15(2):99.
 Aquilanti L, Mascitti M, Togni L, Contaldo M, Rappelli G, Santarelli A. A Systematic
Review on Nerve-Related Adverse Effects following Mandibular Nerve Block Anesthesia.
Int J Environ Res Public Health. 2022 Jan 31;19(3):1627.
 Mathison M, Pepper T. Local Anesthesia Techniques in Dentistry and Oral Surgery.
StatPearls Publishing 2023.
 Acham S, Truschnegg A, Rugani P, Kirnbauer B, Reinbacher KE, Zemann W et al.
Needle fracture as a complication of dental local anesthesia: recommendations for
prevention and a comprehensive treatment algorithm based on literature from the past
four decades. Clinical Oral Investigations 2019;23:1114.

 Pogrel MA, Thamby S. Permanent nerve involvement resulting from inferior
alveolar nerve blocks. Journal of the American Dental Association 2000;131:901–
907.
 Marques ALN, Figueroba SR, Mafra MAT, Groppo FC. Oedema and hematoma after
local anesthesia via posterior superior alveolar nerve block: a case report. J Dent
Anesth Pain Med 2022;22(3):227-231.
 Gogna N, Hussain S, Al-Rawi S. Case reports: Palatal mucosal necrosis after
administration of a palatal infiltration. British Dent Journal 2015;219:560–561.
 Remi RV, Anantharaj A, Praveen P, Prathibha RS, Sudhir R. Advances in pediatric
dentistry: new approaches to pain control and anxiety reduction in children - a
narrative review. Journal of Dental Anesthesia and Pain Medicine 2023;23(6):303-
315.
 Dasarraju RK, Nirmala SVSG. Comparative efficacy of three topical anesthetics on
7-11-year-old children: a randomized clinical study. Journal of Dental Anesthesia and
Pain Medicine 2020;20(1):29-37.

 Anantharaj A, Mary SJ, Sudhir R, Bangalore JR, Praveen P; Rani SP. A comparative
evaluation of pain perception following topical application of benzocaine gel, clove-
papaya based anesthetic gel and precooling of the injection site before intraoral
injections in children. Journal of Indian Society of Pedodontics and Preventive Dentistry
2020;38(2):184-189.
 Goyal A, Jain G , Jain A, Ansari T, Bumb S. A new era of local anaesththetic agent:
Centbucridine. Archives of CraniOroFacial Sciences 2013;1:40-43.
 Gune NS, Katre AN. Comparison of 0.5% centbucridine and 2% lignocaine as local
anesthetic agents for dental procedures in children: a randomised controlled trial. Indian
Journal of Pediatrics 2020;87:268-274.
 Afsal MM, Khatri A, Kalra N, Tyagi R, Khandelwal D. Pain perception and efficacy of
local analgesia using 2% lignocaine, buffered lignocaine, and 4% articaine in pediatric
dental procedures. Journal of Dental Anesthesia and Pain Medicine 2019;19(2):101-109.
 Aulestia-Viera PV, Braga MM, Borsatti MA. The effect of adjusting the pH of local
anesthetics in dentistry: a systematic review and meta-analysis. International
Endodontic Journal 2018;51(8):862-876.

 Castelo AP, Mato EG, Aneiros IV, López LS, Rial MO, Pazos MTA et al. Evaluation of
Intraligamentous and Intraosseous Computer-Controlled Anesthetic Delivery Systems in
Pediatric Dentistry: A Randomized Controlled Trial. Children 2023;10:01-12.
 Mittal M, Kumar A, Srivastava D, Sharma P, Sharma S. Pain perception: computerized
versus traditional local anesthesia in pediatric patients. J Clin Pediatr Dent 2015;39:470-474.
 Garret-Bernardin A, Cantile T, D’Antò V, Galanakis A, Fauxpoint G, Ferrazzano GF et al.
Pain Experience and behavior management in pediatric dentistry: a comparison between
traditional local anesthesia and the wand computerized delivery system. Pain Res Manag
2017;01-12.
 Smaïl-Faugeron V, Muller-Bolla M, Sixou JL, Courson F. Evaluation of intraosseous
computerized injection system (QuickSleeper™) vs conventional infiltration anaesthesia in
paediatric oral health care: A multicentre, single-blind, combined split-mouth and parallel-arm
randomized controlled trial. International Journal of Paediatric Dentistry 2019;29(5):573-
584.
 Langthasa M, Yeluri R, Jain AA, Munshi AK. Comparison of the pain perception in children
using comfort control syringe and a conventional injection technique during pediatric dental
procedures. Journal of Indian Society of Pedodontics and Preventive Dentistry 2012;30:323-
328.

 Patel M, Bhatt R, Mehta M, Patel C, Patel F, Makwani D. A comparative assessment of
efficacy and preference between needleless device INJEX and insulin syringe for
anesthetizing primary maxillary teeth in children aged 4–9 years: A split-mouth
crossover randomized clinical study. Journal of Indian Society of Pedodontics and
Preventive Dentistry 2023;41:149-155.
 Chan A, Armati P, Moorthy AP. Pulsed Nd: YAG laser induces pulpal analgesia: a
randomized clinical trial. J Dent Res 2012;91:79S-84S.
 Uçar G, Şermet Elbay Ü, Elbay M. Effects of low level laser therapy on injection pain
and anesthesia efficacy during local anesthesia in children: a randomized clinical trial.
Int J Paediatr Dent 2022; 32: 576-584.
 Hindocha N, Manhem F, Bäckryd E, Bågesund M. Ice versus lidocaine 5% gel for
topical anaesthesia of oral mucosa - a randomized cross-over study. BMC Anesthesiol
2019;19:227.
 Tirupathi SP, Rajasekhar S. Effect of precooling on pain during local anesthesia
administration in children: a systematic review. J Dent Anesth Pain Med 2020;20:119-
127.

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