Aim: To describe a small series of six cases of children who were diagnosed as uncooperative and referred to general anesthesia to complete their dental treatment. These children were actually exhibiting pain-related disruptive behaviors during previous dental treatments; we determined the reasons for ineffective anesthesia.
Background: One of the most common reasons for disruptive behaviors in children during operative dental treatment is the experiencing of pain during treatment. Disruptive behavior may lead to treatment under general anesthesia.
Case description: Parents of six uncooperative children referred to general anesthesia for dental treatment, arrived at our clinic, because they wanted a second opinion. The children were found to be nonresponsive to the common anesthetic technique and were treated by several approaches to increase the effectiveness of anesthesia. These included supplementary anesthesia to accessory innervation (in three cases), changing brands of anesthetic (in two cases), injecting the maximal dose at once to prevent tachyphylaxis, and waiting 5 minutes to achieve effectiveness of anesthesia (in one case). After achieving effective anesthesia, all the children fully cooperated during the operative treatment.
Conclusion: Ineffective anesthesia can lead to severe disruptive behavior when continuing the treatment irrespective to the sensation of pain. Several approaches were used to increase the effectiveness of anesthesia resulting in cooperation of the pediatric patients.
Clinical significance: Behavioral response to ineffective anesthesia may be diagnosed as uncooperativeness. Effort should be put to differentiate between ineffective anesthesia and uncooperative patient.
Allen KD, Kotil D, et al. Comparison of a computerized anesthesia device with a traditional syringe in preschool children. Pediatr Dent 2002 Jul–Aug;24(4):315–320.
Gibson RS, Allen K, et al. The Wand vs traditional injection: a comparison of pain related behaviors. Pediatr Dent 2000 Nov–Dec;22(6):458–462.
Versloot J, Veerkamp JS, et al. Children's coping with pain during dental care. Community Dent Oral Epidemiol 2004 Dec;32(6):456–461. DOI: 10.1111/j.1600-0528.2004.00187.x.
Nakai Y, Milgrom P, et al. Effectiveness of local anesthesia in pediatric dental practice. J Am Dent Assoc 2000 Dec;131(12):1699–1705. DOI: 10.14219/jada.archive.2000.0115.
Kaufman E, Weinstein P, et al. Difficulties in achieving local anesthesia. J Am Dent Assoc 1984 Feb;108(2):205–208. DOI: 10.14219/jada.archive.1984.0470.
Malamed SF. Neurophysiology. Handbook of local anesthesia, 5th ed., Elsevier Mosby Ino, 2004; p. 25.
Childers M, Reader A, et al. Anesthetic efficacy of the periodontal ligament injection after an inferior alveolar nerve block. J Endod 1996 Jun;22(6):317–320. DOI: 10.1016/S0099-2399(96)80267-6.
Parirokh M, Satvati SA, et al. Efficacy of combining a buccal infiltration with an inferior alveolar nerve block for mandibular molars with irreversible pulpitis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010 Mar;109(3):468–473. DOI: 10.1016/j.tripleo.2009.11.016.
Fan S. Anesthetic efficacy of inferior alveolar nerve block plus buccal infiltration or periodontal ligament injections with articaine in patients with irreversible pulpitis in the mandibular first molar. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009 Nov;108(5):e89–e93. DOI: 10.1016/j.tripleo.2009.06.012.
Hayden Jr J. The innervation of the maxillary first permanent and primary molars as determined by the deposition of local anesthetic solutions. A preliminary report. Acta Odontol Scand 1965 Apr;23(2):147–162. DOI: 10.3109/00016356509033571.
Meyer TN, Lemos LL, et al. Effectiveness of nasopalatine nerve block for anesthesia of maxillary central incisors after failure of the anterior superior alveolar nerve block technique. Braz Dent J 2007;18(1):69–73. DOI: 10.1590/S0103-64402007000100015.
Malamed ST. Technique for mandibular anesthesia. Handbook of local anesthesia, 5th ed, Elsevier Mosby, 2004; p. 227.
Walton RE, Abbott BJ. Periodontal ligament injection: a clinical evaluation. J Am Dent Assoc 1981 Oct;103(4):571–575. DOI: 10.14219/jada.archive.1981.0307.
Smith GN, Walton RE, et al. Clinical evaluation of periodontal ligament anesthesia using a pressure syringe. J Am Dent Assoc 1983 Dec;107(6):953–956. DOI: 10.14219/jada.archive.1983.0357.
Cohen HP, Cha BY, et al. Endodontic anesthesia in mandibular molars: a clinical study. J Endod 1993 July;19(7):370–373. DOI: 10.1016/S0099-2399(06)81366-X.
Nusstein J, Claffey E, et al. Anesthetic effectiveness of the supplemental intraligamentary injection, administered with a computer-controlled local anesthetic delivery system, in patients with irreversible pulpitis. J Endod 2005 May;31(5):354–358. DOI: 10.1097/01.DON.0000140565.88940.60.
Brannstrom M, Lindskog S, et al. Enamel hypoplasia in permanent teeth induced by periodontal ligament anesthesia of primary teeth. J Am Dent Assoc 1984 Nov;109:735–736. DOI: 10.14219/jada.archive.1984. 0172.
Ashkenazi M, Blumer S, et al. Effect of computerized delivery intraligamental injection in primary molars on their corresponding permanent tooth buds. Inter J Paediatr Dent 2010 July;20:270–275. DOI: 10.1111/j.1365-263X.2010.01049.x.
Ashkenazi M, Blumer S, et al. Post-operative pain and use of analgesic agents in children following intrasulcular anesthesia and various operative procedures. Br Dent J 2007 Mar;202:E13. DOI: 10.1038/bdj.2007.81.
Wright GZ, Starkey PE, et al. Local anesthesia in children. Managing children's behavior in the dental offices; 1983. pp. 126–139.
Fukayama H, Yoshikawa F, et al. Efficacy of anterior and middle superior alveolar (AMSA) anesthesia using a new injection system: the Wand. Quintessence Int 2003 July–Aug;34(7):537–541.
Rodd HD, Boissonade FM, et al. Pulpal status of hypomineralized permanent molars. Pediatr Dent 2007 Nov–Dec;29(6):514–520.
Fagrell TG, Lingström P, et al. Bacterial invasion of dentinal tubules beneath apparently intact but hypomineralized enamel in molar teeth with molar incisor hypomineralization. Int J Paediatr Dent 2008 Sep;18(5):333–340. DOI: 10.1111/j.1365-263X.2007.00908.x.
Versloot J, Veerkamp JS, et al. Pain behaviour and distress in children during two sequential dental visits: comparing a computerised anaesthesia delivery system and a traditional syringe. Br Dent J 2008 July 12;205(1):E2. DOI: 10.1038/sj.bdj.2008.414.
Ashkenazi M, Blumer S, et al. Effectiveness of various modes of computerized delivery of local anesthesia in primary maxillary molars. Pediatr Dent 2006 Jan–Feb;28(1):29–38.
Bele MH, Derle DV. Effect of sorbed water on disintegrant performance of four brands of Polacrilin Potassium NF. APS Pharm Sci Tech 2012 Mar;13(1):24–34. DOI: 10.1208/s12249-011-9717-8.
Feldmeyer L, Benden C, et al. Not all intravenous immunoglobulin preparations are equally well tolerated. Acta Derm Venereol 2010 Sep;90(5):494–497. DOI: 10.2340/00015555-0900.
Mittal G, Kumar N, et al. A radiometric study of factors affecting drug output of jet nebulizers. Indian J Pharm Sci 2010 Jan;72(1):31–38. DOI: 10.4103/0250-474X.62234.
Lamprecht G. In vitro determination of the release of alendronic acid from alendronate tablets of different brands during deglutition. J Pharm Sci 2009 Oct;98(10):3575–3581. DOI: 10.1002/jps.21639.
Datta P, Dasgupta A. Effect of Chinese medicines Chan Su and Danshen on EMIT 2000 and Randox digoxin immunoassays: wide variation in digoxin-like immunoreactivity and magnitude of interference in digoxin measurement by different brands of the same product. Ther Drug Monit 2002 Oct;24(5):637–644. DOI: 10.1097/00007691-200210000-00010.