toxicity will not occur, and, second, the soft tissue anaesthesia resolves at the end of
the procedure. This reduces the chances of self-inflicted trauma. Hypnosis can be used
as an adjunct to local anaesthesia in children by decreasing the pulse rate and the
incidence of crying. It appears to be most effective in young children.
5.4 LOCAL ANAESTHETIC SOLUTIONS
A number of local anaesthetic solutions are now available that can provide
anaesthesia lasting from 10 min to over 6 h. There are few, if any, indications for the
use of the so-called 'long-acting' agents in children. The gold standard is lidocaine
(lignocaine) with epinephrine (adrenaline). Unless there is a true allergy to lidocaine
then 2% lidocaine with 1 : 80,000 epinephrine is the solution of choice in the United
Kingdom. 'Short-acting' agents such as plain lidocaine are seldom employed as the
sole agent because, although pulpal anaesthesia may be short-lived, soft tissue effects
can still last over an hour or so. More importantly, the efficacy of plain solutions is
much less than those containing a vasoconstrictor.
5.5 TECHNIQUES OF LOCAL ANAESTHESIA
5.5.0 Introduction
There are no techniques of local anaesthetic administration that are unique to children;
however, modifications to standard methods are sometimes required. As far as
positioning the child is concerned the upper body should be around 30 degrees to the
vertical. Sitting upright can increase the chances of a faint, while at the other extreme
(fully supine) the child may feel ill at ease. When there is a choice of sites at which to
administer the first local anaesthetic injection the primary maxillary molar area should
be chosen. This is the region that is most easily anaesthetized with the least
discomfort.
5.5.1 Infiltration anaesthesia
Infiltration anaesthesia is the method of choice in the maxilla. The infiltration of 0.5-
1.0 ml of local anaesthetic is sufficient for pulpal anaesthesia of most teeth in
children. The objective is to deposit local anaesthetic solution as close as possible to
the apex of the tooth of interest⎯however, the presence of bone prevents direct
apposition. As the apices of most teeth are closer to the buccal side, a buccal approach
is employed and the needle is directed towards the apex after insertion through
reflected mucosa. Direct deposition under periosteum can be painful, therefore a
compromise is made and the solution is delivered supraperiosteally. The one area
where pulpal anaesthesia can prove troublesome in the child's maxilla is the upper
first permanent molar region where the proximity of the zygomatic buttress can
inhibit the spread of solution to the apical area (see further). In the mandible, the use
of buccal infiltration anaesthesia will often produce pulpal anaesthesia of the primary
teeth; however, it is usually unreliable when operating on the permanent dentition
with the exception of the lower incisor teeth. The most dependable form of
anaesthesia in the posterior mandible is inferior alveolar nerve block anaesthesia.
5.5.2 Regional block anaesthesia