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Use of Local Anesthesia for Pediatric Dental Patients

Purpose

The American Academy of Pediatric Dentistry (AAPD) intends this document to help practitioners make decisions when using local anesthesia to control pain in infants, children, adolescents, and individuals with special health care needs during the delivery of oral health care.

Methods

Recommendations on local anesthesia were developed by the Council on Clinical Affairs and adopted in 2005. This document is a revision of the previous version, last revised in 2009. This update is based upon a new systematic literature search of the Pubmed®/MEDLINE database using the terms: dental anesthesia, dental local anesthesia, and topical anesthesia; fields: all; limits: within the last 10 years, humans, English, clinical trials, birth through age eighteen. Five hundred six articles matched these criteria. Papers for review were chosen from this list and from references within selected articles. When data did not appear sufficient or were inconclusive, recommendations were based upon expert and/or consensus opinion by experienced researchers and clinicians.

Background

Local anesthesia is the temporary loss of sensation including pain in one part of the body produced by a topically-applied or injected agent without depressing the level of consciousness. Local anesthetics act within the neural fibers to inhibit the ionic influx of sodium for neuron impulse.1,2  This helps to prevent transmission of pain sensation during procedures which can serve to build trust and foster the relationship of the patient and dentist, allay fear and anxiety, and promote a positive dental attitude. The technique of local anesthetic administration is an important consideration in pediatric patient behavior guidance.3  Age-appropriate nonthreatening terminology, distraction, topical anesthetics, proper injection technique, and nitrous oxide/oxygen analgesia/anxiolysis can help the patient have a positive experience during administration of local anesthesia.3-5  In pediatric dentistry, the dental professional should be aware of proper dosage (based on weight) to minimize the chance of toxicity and the prolonged duration of anesthesia, which can lead to accidental lip, tongue, or soft tissue trauma.6  Knowledge of gross and neuroanatomy of the head and neck allows for proper placement of the anesthetic solution and helps minimize complications (e.g., hematoma, trismus, intravascular injection).6,7  Familiarity with the patient’s medical history is essential to decrease the risk of aggravating a medical condition while rendering dental care. Medical consultation should be obtained as needed.

Many local anesthetic agents are available to facilitate management of pain in the dental patient. There are two general types of local anesthetic chemical formulations: (1) esters (e.g., procaine, benzocaine, tetracaine); and (2) amides (e.g., lidocaine,mepivacaine, prilocaine, articaine).8  Local anesthetics are vasodilators; they eventually are absorbed into the circulation, where their systemic effect is related directly to their blood plasma level.9  Vasoconstrictors (e.g., epinephrine, levonordefrin, norepinephrine are added to local anesthetics to constrict blood vessels in the area of injection. This lowers the rate of absorption of the local anesthetic into the blood stream, thereby lowering the risk of toxicity and prolonging the anesthetic action in the area.9  Epinephrine is contraindicated in patients with hyperthyroidism.9  The dose should be kept to a minimum in patients receiving tricylic antidepressants since dysrhythmias may occur. Levonordefrin and norepinephrine are absolutely contraindicated in these patients.9  Patients with significant cardiovascular disease, thyroid dysfunction, diabetes, or sulfite sensitivity and those receiving monoamine oxidase inhibitors, tricyclic antidepressants, or phenothiazines may require a medical consultation to determine the need for a local anesthetic without vasoconstrictor.10,11  When halogenated gases are used for general anesthesia, the myocardium is sensitized to epinephrine. Such situations dictate caution with use of a local anesthetic.10

Amide-type local anesthetics no longer are contraindicated in patients with a family history of malignant hyperthermia, an abnormal elevation in body temperature during general anesthesia with inhalation anesthetics or succinylcholine.10

If a local anesthetic is injected into an area of infection, its onset will be delayed or even prevented.3-6  The inflammatory process in an area of infection lowers the pH of the extracellular tissue from its normal value (7.4) to six or lower. This low pH inhibits anesthetic action because little of the free base form of the anesthetic is allowed to cross into the nerve sheath to prevent conduction of nerve impulses.6

Recommendations

Topical anesthetics
 The application of a topical anesthetic may help minimize discomfort caused during administration of local anesthesia. Topical anesthetic is effective on surface tissues (up to two to three mm in depth) to reduce painful needle penetration of the oral mucosa.1,12  Topical anesthetic agents are available in gel, liquid, ointment, patch, and aerosol forms.

The U.S. Food and Drug Administration (FDA) has issued a warning about the use of compounded topical anesthetics and the risk of methemoglobinemia.13,14  Acquired methemoglobinemia is a serious but rare condition that occurs when the ferrous iron in the hemoglobin molecule is oxidized to the ferric state. This molecule is known as methemoglobin, which is incapable of carrying oxygen.15 Risk of acquired methemoglobinemia has been associated primarily with two local anesthetics: prilocaine and benzocaine. There is no evidence of other local anesthetics contributing to the etiology of methemoglobinemia.15

Prilocaine is available topically combined with lidocaine and in an injectable form. Benzocaine, the most commonly used topical anesthetic, is available in concentrations up to 20 percent and comes in liquid, spray, and gel forms. Benzocaine also is available over the counter in a variety of forms.15  It has a rapid onset. Benzocaine toxic (overdose) reactions have rarely been reported. Localized allergic reactions, however, may occur after prolonged or repeated use.16  Lidocaine is available as a topical solution or ointment up to five percent and as a spray up to 10 percent concentration.12,16  Topical lidocaine has an exceptionally low incidence of allergic reactions but is absorbed systemically and can combine with an injected amide local anesthetic to increase the risk of overdose.17

Compounded topical anesthetics also are available.1,18  Two of the more common formulations contain 20 percent lidocaine, four percent tetracaine, and two percent phenylephrine or 10 percent lidocaine, 10 percent prilocaine, four percent tetracaine, and two percent phenylephrine.18-20  Compounded topical anesthetics have been used in orthodontic procedures for gingival contouring and placement of mini-screw implants to aid tooth movement,1,18,20 as well as in pediatric dentistry to anesthetize palatal tissues prior to injection and for extraction of loose primary teeth without the need for an injection. They contain high doses of both amide and ester agents and are at risk for side effects similar to that of other topical anesthetics.1,13-15,18,19  The FDA does not regulate compounded topical anesthetics and recently issued warning about their use.17,18

Recommendations:

  1. Topical anesthetic may be used prior to the injection of a local anesthetic to reduce discomfort associated with needle penetration.
  2. The pharmacological properties of the topical agent should be understood.
  3. A metered spray is recommended if an aerosol preparation is selected.
  4. Systemic absorption of the drugs in topical anesthetics must be considered when calculating the total amount of anesthetic administered.

Selection of syringes and needles
The American Dental Association (ADA) has long standing standards for aspirating syringes for use in the administration of local anesthesia.21-23  Needle selection should allow for profound local anesthesia and adequate aspiration. Larger gauge needles provide for less deflection as the needle passes through soft tissues and for more reliable aspiration.22  The depth of insertion varies not only by injection technique, but also by the age and size of the patient. Dental needles are available in three lengths: long (32 mm), short (20 mm), and ultrashort (10 mm). Needle gauges range from size 23 to 30. Needle breakage is a rare occurrence. Breakage can occur when a needle is inserted to the hub, when the needle is weakened due to bending it before insertion into the soft tissues, or by patient movement after the needle is inserted.23,24

Recommendations:

  1. For the administration of local dental anesthesia, dentists should select aspirating syringes that meet ADA standards.
  2. Short needles may be used for any injection in which the thickness of soft tissue is less than 20 millime- ters. A long needle may be used for a deeper injection into soft tissue.23  Any 23- through 30- gauge needle may be used for intraoral injections, since blood can be aspirated through all of them. Aspiration can be more difficult, however, when smaller gauge needles are used.23,24  An extra-short, 30-gauge is appropriate for certain infiltration injections.23
  3. Needles should not be bent if they are to be in- serted into soft tissue to a depth of greater than five millimeters or inserted to their hub for injections to avoid needle breakage.23-25

Injectable local anesthetic agents
 Local amide anesthetics available for dental usage include lidocaine, mepivacaine, articaine, prilocaine, and bupivacaine (Tables 1 and 2). Absolute contraindications for localanesthetics include a documented local anesthetic allergy.11,12  True allergy to an amide is exceedingly rare. Allergy to one amide does not rule out the use of another amide, but allergy to one ester rules out use of another ester.3  A bisulfate preservative is used in local anesthetics containing epinephrine. For patients having an allergy to bisulfates, use of a local anesthetic without a vasoconstrictor is indicated.11,16  Local anesthetics without vasoconstrictors should be used with caution due to rapid systemic absorption which may result in overdose.11,16

A long-acting local anesthetic (i.e., bupivacaine) is not recommended for the child or the physically or mentally disabled patient due to its prolonged effect, which increases the risk of soft tissue injury.12  Claims have been made that articaine can diffuse through hard and soft tissue from a buccal infiltration to provide lingual or palatal soft tissue anesthesia.12  Studies using articaine, lidocaine, and prilocaine, however, have not substantiated these claims.12

Epinephrine decreases bleeding in the area of injection. Epinephrine concentrations of 1:50,000 may be indicated for infiltration in small doses into a surgical site to achieve hemostasis but are not indicated in children to control pain.12  Local anesthetics that contain vasoconstrictors help reduce toxicity by slowing the rate of absorption of the anesthetic and/or vasoconstrictor into the cardiovascular system.8,11,12  A local anesthetic containing vasoconstrictor should be used when treatment extends to two or more quadrants in a single visit.12

An end product of prilocaine metabolism can induce formation of methemoglobin, reducing the blood’s oxygen-carrying capacity. In patients with subclinical methemoglobinemia15 or with toxic doses (i.e., greater than six mg/kg), prilocaine can induce methemoglobinemia symptoms15 (e.g., gray or slate blue cyanosis of the lips, mucous membranes, and nails; respiratory and circulatory distress).10  Prilocaine may be contraindicated in patients with methemoglobinemia, sickle cell anemia, anemia, or symptoms of hypoxia or in patients receiving acetaminophen or phenacetin, since both medications elevate methemoglobin levels.12

Recommendations:

  1. Selection of local anesthetic agents should be based upon:
    — the patient’s medical history and mental/develop- mental status;
    — the anticipated duration of the dental procedure;
    — the need for hemorrhage control;
    — the planned administration of other agents (e.g., nitrous oxide, sedative agents, general anesthesia); and
    — the practitioner’s knowledge of the anesthetic agent.
  2. Use of vasoconstrictors in local anesthetics is recommended to decrease the risk of toxicity of the anes- thetic agent, especially when treatment extends to two or more quadrants in a single visit. 
  3. In cases of bisulfate allergy, use of a local anesthetic without a vasoconstrictor is indicated. A local anes- thetic without a vasoconstrictor also can be used for shorter treatment needs but should be used with caution to minimize the risk of toxicity of the anesthetic agents.
  4. The established maximum dosage for any anesthetic should not be exceeded. 
  5. Administration of local anesthetic should be based on the weight/body mass index (BMI) of the patient, not to exceed AAPD recommendations found in Table 1.

Documentation of local anesthesia
The patient record is an essential component of the delivery of competent and quality oral health care.26  Following each appointment, an entry is made in the record that accurately and objectively summarizes that visit. Appropriate documentation includes specific information relative to the administration of local anesthesia.

Recommendations: 

  1. Documentation must include the type and dosage of local anesthetic. Dosage of vasoconstrictors, if any, must be noted. (For example, 34 mg lido with 0.017 mg epi or 34 mg lido with 1:100,000 epi).5
  2. Documentation may include the type of injection(s) given (e.g., infiltration, block, intraosseous), needle selection, and patient’s reaction to the injection.
  3. In patients for whom the maximum dosage of local anesthetic may be a concern, the weight should be documented preoperatively.
  4. If the local anesthetic was administered in conjunc- tion with sedative drugs, the doses of all agents must be noted on a time-based record.
  5. Documentation should include that post-injection instructions were reviewed with the patient and parent.

Local anesthetic complications
Toxicity (overdose)
Most adverse drug reactions develop either during the injection or within five to 10 minutes.15  Overdose of local anesthetic can result from high blood levels caused by a single inadvertent intravascular injection or repeated injections.3  Local anesthetic causes a biphasic reaction (excitation followed by depression) in the central nervous system (CNS). Early subjective indications of toxicity involve the CNS and include dizziness, anxiety, and confusion. This may be followed by diplopia, tinnitus, drowsiness, and circumoral numbness or tingling. Objective signs may include muscle twitching, tremors, talkativeness, slowed speech, and shivering, followed by overt seizure activity. Unconsciousness and respiratory arrest may occur.8

The cardiovascular system (CVS) response to local anesthetic toxicity also is biphasic. Initially, the CVS is subject to stimulation; heart rate and blood pressure may increase. As plasma levels of the anesthetic increase, however, vasodilatation occurs followed by depression of the myocardium with subsequent fall in blood pressure. Bradycardia and cardiac arrest may follow. The cardiodepressant effects of local anesthetics are not seen until there is a significantly elevated level in the blood.12

Local anesthetic toxicity can be prevented by careful injection technique, watchful observation of the patient, and knowledge of the maximum dosage based on weight. Practitioners should aspirate before every injection and inject slowly.12  After the injection, the doctor, hygienist, or assistant should remain with the patient while the anesthetic begins to take effect. Early recognition of a toxic response is critical for effective management. When signs or symptoms of toxicity are noted, administration of the local anesthetic agent should be discontinued. Additional emergency management is based on the severity of the reaction.1,12

Allergy to local anesthesia
Allergic reactions are not dose related but are due to the patient’s heightened capacity to react to even a small dose. Allergies can manifest in a variety of ways, some of which include urticaria, dermatitis, angioedema, fever, photosensitivity, or anaphylaxis.12,16  Emergency management is dependent on the rate and severity of the reaction.

Paresthesia
Paresthesia is persistent anesthesia beyond the expected duration. Trauma to the nerve can result in paresthesia and, among other etiologies, trauma can be caused by the needle during the injection.25  The patient may experience an electric shock in the involved nerve distribution area. Risk of permanent paresthesia has been estimated to be 1:1,200,000 for 0.5 percent, two percent, and three percent local anesthetics and 1:500,000 for four percent local anesthetics.25  Reports of paresthesia are more common with articaine and prilocaine than expected from their frequency of use. Paresthesia also can be caused by hemorrhage in or around the nerve.

Postoperative soft tissue injury
Self-induced soft tissue trauma is an unfortunate clinical complication of local anesthetic use in the oral cavity. Most lipand cheek-biting lesions of this nature are self-limiting and heal without complications, although bleeding and infection are possible.25  The use of bilateral mandibular blocks does not increase the risk of soft tissue trauma when compared to unilateral mandibular blocks or ipsilateral maxillary infiltration.25  Using mandibular infiltration versus blocks is not of great value in prevention of these injuries, since the duration of soft tissue anesthesia may not be reduced significantly.

Caregivers responsible for postoperative supervision should be given a realistic time for duration of numbness and informed of the possibility of soft tissue trauma. Visual examples may help stress the importance of observation during the period of numbness. For all local anesthetics, the duration of soft tissue anesthesia is greater than dentinal or osseous anesthesia. Use of phentolamine mesylate injections in patients over age six years or at least 15 kg has been shown to reduce the duration of effects of local anesthetic by about 47 percent in the maxilla and 67 percent in the mandible.27,28  However, there is no research demonstrating a relationship between reduction in soft tissue trauma and the use of shorter acting local anesthetics.7

Recommendations to reduce local anesthetic complications: 

  1. Practitioners who utilize any type of local anesthetic in a pediatric dental patient should have appro- priate training and skills and have available the proper facilities, personnel, and equipment to manage any reasonably foreseeable emergency.
  2. Care should be taken to ensure proper needle placement during the intraoral administration of local anesthetics. Practitioners should aspirate before every injection and inject slowly.
  3. Following an injection, the doctor, hygienist, or assistant should remain with the patient while the anesthetic begins to take effect.
  4. Residual soft tissue anesthesia should be minimized in pediatric and special health care needs patients to decrease risk of self-inflicted postoperative injuries.
  5. Practitioners should advise patients and their caregivers regarding behavioral precautions (e.g., do not bite or suck on lip/cheek, do not ingest hot substances) and the possibility of soft tissue trauma while anesthesia persists. Placing a cotton roll in the mucobuccal fold may help prevent injury, and lubricating the lips with petroleum jelly helps prevent drying.6,7  Practitioners who use pheytolamine mesylate injections to reduce the duration of local anesthesia still should follow these recommendations.

Alternative techniques for delivery of local anesthesia
The majority of local anesthesia 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, however, are available. These include computer-controlled local anesthetic delivery, periodontal injection techniques [i.e., periodontal ligament (PDL), intraligamentary, and peridental injection], needleless systems, and intraseptal or intrapulpal injection. These techniques may improve comfort of injection by better control of the administration rate, pressure, and location of anesthetic solutions and/or result in successful and more controlled anesthesia.29,30  Endocarditis prophylaxis is recommended for intraligamentary local anesthetic injections in patients at risk.31

Intraseptal injection for lingual anesthesia is a variation in technique after the buccal tissue is anesthetized. The needle is inserted through the buccal tissue to anesthetize the lingual/ palatal soft tissues. It can be used with the PDL injection to gain lingual anesthesia when postoperative soft tissue trauma is a concern.29  During pulpal therapy, administering local anesthetic directly into the pulp may be indicated when other methods fail to anesthetize the tooth.29

As with traditional methods of obtaining oral local anesthesia, the alternative methods generally are safe if the practitioner understands the principles of their use. Some of these techniques are desirable, especially in infants, children, adolescents, and special health care needs patients, since specific teeth may be anesthetized with less residual anesthesia, avoiding discomfort and potential self-mutilation of block anesthesia.29  The mandibular bone of a child usually is less dense than that of an adult, permitting more rapid and complete diffusion of the anesthetic.6 Mandibular buccal infiltration anesthesia is as effective as inferior nerve block anesthesia for some operative procedures.6  In patients with bleeding disorders, the PDL injection minimizes the potential for postoperative bleeding of soft tissue vessels.10  The use of the PDL injection or intraosseous methods is contraindicated in the presence of inflammation or infection at the injection site.29

Recommendation:
 Alternative techniques for the delivery of local anesthesia may be considered to minimize the dose of anesthetic used, improve patient comfort, and/or improve successful dental anesthesia.

Local anesthesia with sedation, general anesthesia, and/or nitrous oxide/oxygen analgesia/anxiolysis
 Drugs that have the same mechanism of action often will have additive effects when used together. Local anesthetics and sedative agents both depress the CNS. It is recommended that the dose of local anesthesia be adjusted downward when sedating children with opioids.11  An increase in toxic reactions of local anesthetics when combined with opioids has been demonstrated.11 Narcotics may decrease the amount of protein binding of local anesthetics and also elevate arterial carbon dioxide, both of which will increase CNS sensitivity to convulsions. In addition, narcotics such as meperidine have convulsant properties when excessive doses are administered.

For patients undergoing general anesthesia, the anesthesia care provider needs to be aware of the concomitant use of a local anesthetic containing epinephrine, as epinephrine can produce dysrhythmias when used with halogenated hydrocarbons (e.g., halothane).1  Local anesthesia also has been reported to reduce pain in the postoperative recovery period after general anesthesia.32

Recommendations: 

  1. Particular attention should be paid to local anesthetic doses used in children (see Table 1). To avoid excessive doses for the patient who is going to be sedated, a maximum recommended dose based upon weight should be calculated.
  2. The dosage of local anesthetic need not be altered if nitrous oxide/oxygen analgesia/anxiolysis administered.
  3. When general anesthesia is employed, local anesthesia may be used to reduce the maintenance dosage of the anesthetic drugs. The anesthesiologist should be informed of the type and dosage of the local anesthetic used. Recovery room personnel also should be informed.

Local anesthesia and pregnancy
Special considerations are needed when using local anesthesia during pregnancy and the postpartum period, especially during lactation.33-35  Health and welfare of the mother, fetus, and neonate must always be a factor in treatment and use of local anesthesia. The use of local anesthesia during pregnancy is considered safe.36  Benefit and risks for mother and fetus must always be considered.33,36  During the first trimester, the impact on the mother and fetus must be considered in the choice of local anesthesia. Local anesthesia without a vasoconstrictor should be considered.33  Prilocaine should not be used due to risk of the fetus developing methhemoglobinemia.33  Patient positioning to avoid postural hypotension and proper dosage of anesthetic are important. For any treatment, judicious use of local anesthesia, especially vasoconstrictors, is important.33  The FDA has established a drug classification system based on their risks to pregnant women and their fetuses. In respect to the five categories (A, B, C, D, and X) established by the FDA, lidocaine is considered in Category B, the safest of the local anesthetics. The American Academy of Pediatrics considers lidocaine to be safe for use during breastfeeding.33-36

Recommendations:

  1. The use of local anesthesia during pregnancy generally is considered safe. Overall maternal oral health and the possibility of infection are important considerations. Benefits and risks should be considered. 
  2. Proper local anesthetic technique is a necessity. Aspiration to avoid intravascular injection, proper needle placement accuracy, and attention to dosages are critical.
  3. Ester anesthetics should be avoided because of potential for allergenicity.
  4. While lidocaine is considered the best choice of local anesthetic, mepivacaine and bupivacaine (both FDA Category C) can be used.
  5. In second and third trimesters, proper positioning and heart rate monitoring are important to avoid postural hypotension.
  6. During lactation, the use of local anesthetics without vasoconstrictors may be considered to avoid possible idiosyncratic reaction to the neonate, not to the vasoconstrictor but to the preservative used to stabilize the vasoconstrictor.

References

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  2. Malamed SF. Neurophysiology. In: Handbook of Local Anesthesia. 6th ed., St. Louis, Mo.: Mosby; 2013:2-24. 
  3. Dean JA, Avery DR, McDonald RE. Local anesthesia and pain control for the child and adolescent. In: Dentistry for the Child and Adolescent. 9th ed. St Louis, Mo.: Mosby; 2011:241-52.
  4. Wilson S. Local anesthesia and oral surgery in children. In: Casamassimo PS, Fields HW, McTigue DJ, Nowak A, eds. Pediatric Dentistry Infancy Through Adolescence, 5th ed., St. Louis, Mo.: Elsevier; 2013:398-410.
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  6. Malamed SF. Anesthetic considerations in dental specialties. In: Handbook of Local Anesthesia. 6th ed. St. Louis, Mo.: Mosby; 2013:277-89.
  7. Malamed SF. Anatomic considerations. In: Handbook of Local Anesthesia. 6th ed. St. Louis, Mo.: Mosby; 2013:169-87.
  8. Moore PA, Hersh EV. Local anesthetics: pharmacology and toxicity. Dent Clin North Am 2010;54(4):587-99. 
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  10. Malamed SF. Physical and psychological evaluation. In: Handbook of Local Anesthesia. 6th ed. St. Louis, Mo.: Mosby; 2013:124-56. 
  11. . Becker DE, Reed KL. Essentials of local anesthetic pharmacology. Anesth Prog 2006;53(3):98-109. 
  12. Malamed SF. Clinical action of specific agents. In: Handbook of Local Anesthesia. 6th ed. St. Louis, Mo.: Mosby; 2013:52-75. 
  13. U.S. Department for Health and Human Services, Food and Drug Administration, Center for Drug Evaluation and Research. Guidance for FDA staff and industry: Marketed unapproved drugs–Compliance policy guide. Sec 440.100 Marketed new drugs without approved NDAs or ANDAs. Available at: “http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/ucm070290.pdf ”. Accessed September 3, 2015. 
  14. U.S. Food and Drug Administration. FDA public health advisory: Life-threatening side effect with the use of skin products containing numbing ingredients for cosmetic procedures. Available at: “http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/
    ucm054718.htm”. Accessed September 3, 2015.
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  17. Malamed SF. Additional armamentarium. In: Handbook of Local Anesthesia. 6th ed. St. Louis, Mo.: Mosby; 2013:110-2.
  18. Graham JW. Profound, needle-free anesthesia in orthodontics. Clin Ortho 2006;40(12):723-4.
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  20. Kravitz ND, Kusnoto B, Tsay TP, Hohlt WF. The use of temporary anchorage devices for molar intrusion. J Am Dent Assoc 2007;138(1):56-64.
  21. American Dental Association Council on Dental Materials and Devices. New American National Standards Institute/ American Dental Association specification no. 34 for dental aspirating syringes. J Am Dent Assoc 1978;97(2):236-8.
  22. American Dental Association Council on Dental Materials, Instruments, and Equipment. Addendum to American National Standards Institute/American Dental Association specification no. 34 for dental aspirating syringes. J Am Dent Assoc 1982;104(1):69-70.
  23. Malamed SF. The needle. In: Handbook of Local Anesthesia. 6th ed., St. Louis, Mo.: Mosby; 2013:92-100.
  24. Malamed SF, Reed KL, Poorsattar S. Needle breakage: incidence and prevention. Dent Clin North Am 2010;54(4):745.
  25. Malamed SF. Local complications. In: Handbook of Local Anesthesia. 6th ed. St. Louis, Mo.: Mosby; 2013:292-310.
  26. American Academy of Pediatric Dentistry. Guideline on record-keeping. Pediatr Dent 2015;37(suppl):307-14. 
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  28. Hersh EV, Moore PA, Papas AS, et al. Reversal of softtissue local anesthesia with phentolamine mesylate in adolescents and adults. J Am Dent Assoc 2008;139(8):1080-93.
  29. Malamed SF. Supplemental injection techniques. In: Handbook of Local Anesthesia. 6th ed., St Louis, Mo.: Mosby; 2013:253-76.
  30. Clark TM, Yagiela JA. Advanced techniques and armamentarium for dental local anesthesia. Dent Clin North Am 2010;54(4):757-68. 
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  32. Kaufman E, Epstein JB, Gorsky M, Jackson DL, Kadari A. Preemptive analgesia and local anesthesia as a supplement to general anesthesia: A review. Anes Progress 2005;52(1):29-38.
  33. Fayans EP, Stuart HR, Carsten D, Ly Q, Kim H. Local anesthetic use in the pregnant and postpartum patient. Dent Clin North Am 2010;54(4):697-713. 
  34. American Academy of Pediatrics Committee on Drugs. The transfer of drugs and other chemicals into human milk. Pediatrics 2001;108(3):776-89. Available at: “http: //pediatrics.aappublications.org/content/108/3/776.full.html”. Accessed September 3, 2015.
  35. Suresh L, Radfar L. Pregnancy and lactation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;97(6):672-82.
  36. Oral Health Care During Pregnancy Expert Workgroup 2012. Oral Health Care During Pregnancy: A National Summary of a Consensus Statement – Summary of an Expert Workgroup Meeting. Washington, D.C.: National Maternal and Child Oral Health Resource Center. Available at: “http://www.cdph.ca.gov/programs/MCAHOralHealth/Documents/MCAH-OHP-OralHealthPregnancyConsensus2011.pdf ”. Accessed September 3, 2015.