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J Am Dent Assoc, Vol 131, No 12, 1699-1705.
© 2000 American Dental Association
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RESEARCH

JADA Continuing Education

EFFECTIVENESS OF LOCAL ANESTHESIA IN PEDIATRIC DENTAL PRACTICE



YUKIE NAKAI, D.D.S., Ph.D., PETER MILGROM, D.D.S., LLOYD MANCL, Ph.D., SUSAN E. COLDWELL, Ph.D, PETER K. DOMOTO, D.D.S., M.P.H. and DOUGLAS S. RAMSAY, D.M.D., Ph.D.


   ABSTRACT
TOP
 ABSTRACT
SUBJECTS AND METHODS
 ANALYSIS
 RESULTS
 HYPOTHESIS TESTING
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Background. Pain control in dental treatment for children is very important. The purpose of this study is to describe the characteristics of local anesthetic use by pediatric dentists and to examine factors related to its effectiveness in children.

Methods. The authors observed 361 patients in 17 pediatric dental practices in Washington state while each child received restorative or surgical dental treatment. The authors recorded data concerning local anesthetic use and effectiveness. The children’s mean age was 87 months, and 181 (50.1 percent) of the patients were girls. A pediatric dentist observer rated each child’s anxiety before the initial injection of local anesthetic and the effectiveness of pain control during restorative treatment. The observing dentist asked the treating dentist about the effectiveness of pain control after completion of treatment.

Results. Forty-two of 361 children (11.6 percent) were observed to experience ineffective pain control. Fourteen of 17 dentists (82.4 percent) were observed to have at least one patient in whom pain control was ineffective. Lidocaine (2 percent with 1:100,000 epinephrine) was used by 15 of 17 dentists (88.2 percent) and in 312 of 361 cases (86.4 percent). The average amount of agent was one cartridge (36 milligrams of lidocaine). Children who were anxious, who had symptoms before treatment, and who underwent more invasive operative and endodontic procedures were more likely to experience ineffective pain control.

Conclusions. The data suggest that painful treatment is relatively frequent even in specialized pediatric practice. Variability in general practice is likely to be greater.

Clinical Implications. The incidence of ineffective pain control may be less if clinicians use methods to reduce anxiety and perioperative infection and symptoms.

Effective pain control is critical in dentistry. Painful treatment has been shown to be important in the etiology of dental fear. People who are hurt while receiving dental care as children are more likely to avoid dental care as adults.1,2 Much research has been carried out on the topic of pediatric local anesthesia, but the focus has been on comparing different injection techniques and concentrations of anesthetics. The Reference Manual of the American Academy of Pediatric Dentistry3 does not include a guideline on pain control, nor do the manual’s sections on behavioral management or sedation include mention of this topic. For example, Donohue and colleagues4 compared the block and infiltration techniques in the mandible and found no significant difference in their effectiveness. Oulis and colleagues5 found no significant difference between these two techniques when placing amalgams and stainless steel crowns, but they found that infiltrations were less effective than blocks for pulpotomies and extractions. Sharaf 6 reported similar findings. Wilson and colleagues7 compared the effectiveness of 1 percent lidocaine with that of 2 percent lidocaine and reported no significant difference. Nevertheless, little is known about the frequency of ineffective local anesthesia in community dental practice, of the techniques and drugs used in various procedures, or of problems encountered. Reviews of the adult anesthesia literature suggest that anesthetic failure is common and that possible causes include anatomical variation, inflammation, anxiety and injection techniques.8–11

Pain is a multidimensional phenomenon, and its treatment in children reflects both the nature of pain and attitudes toward and values regarding pain in children. For pediatric dentistry, a child’s age,7,12–14 sex,7,13,14 symptom15–19 and anxiety20–24 at injection; the initial dose of anesthetic administered25,26; the arch treated7,20; the operative procedure performed7,14; and the use of nitrous oxide/oxygen inhalational sedation and oral premedication27 all have been suggested to influence the effectiveness of pain control. These factors can be classified as dentist-dependent or child characteristics or behaviors. Milgrom and colleagues,28 in a study of general dentists who treat children, found that 10 percent of these dentists regularly performed procedures in children that can be painful, and that up to 67 percent did not believe that young children’s reports of pain can be meaningfully interpreted. The researchers also found an association between practitioners’ use of pain control procedures and beliefs about how to manage children’s behavior.

Given the little solid information on the effectiveness of pain control in pediatric dentistry, we undertook a study to add to the knowledge. We described the type and dose of local anesthetic and administration techniques used by pediatric specialists in Washington state and examined the relative significance of factors thought to be associated with pain control in children. On the basis of the literature, we hypothesized that effective pain control would be related to both dentist-dependent factors (initial dose of anesthetic administered, operative procedure, oral premedication and use of nitrous oxide/oxygen inhalational sedation) and children’s characteristics and behavior (age, sex, arch treated, anxiety level and the presence of symptoms before injection).


   SUBJECTS AND METHODS
TOP
 ABSTRACT
 SUBJECTS AND METHODS
ANALYSIS
 RESULTS
 HYPOTHESIS TESTING
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Subjects. As our focus was on both dentist- and child-related factors, we had two subsets of subjects.

Dentists. From the directory of the Washington State Academy of Pediatric Dentists (which contains 63 dentists), we randomly selected 36 pediatric dentists in private practice in Washington state, representing the major areas of the state and including dentists in communities with and without fluoridated water. We sent each a letter asking that he or she allow a pediatric dentist researcher to visit his or her practice to observe treatment and collect data on local anesthetic use. After adjusting for the dentists we were not able to reach, we had a total of 17 pediatric dentists (47.2 percent) who agreed to participate.

Children. Child subjects were 361 patients, each of whom was seen in one of the 17 practices for restorative treatment or oral surgery. An average of 21 children were seen per practice (range seven to 43 children). These were 180 boys (49.9 percent) and 181 girls (50.1 percent) between 26 and 155 months of age; the average age was 87 months (standard deviation = 29 months). This research was approved by the institutional review board at the University of Washington, and we obtained informed consent from the parents or guardians of all participants.

Measures. A single experienced pediatric dentist visited each dental clinic for a three- to four-day period and recorded the following on a simple checklist for each patient: age in months, sex, quadrants anesthetized, injection technique(s), initial dose and type of anesthetic injected for each area (to the nearest quarter-cartridge), use of topical anesthetic and/or nitrous oxide/oxygen inhalational sedation in combination with local anesthetic; and type of operative or surgical procedure performed.

The observer rated the child’s anxiety before the initial injection using the Frankl scale,29 which includes four categories: "definitely negative," "negative," "positive" and "definitely positive." Children rated in the two negative categories were considered anxious. The observer was calibrated with another experienced pediatric dentist researcher who had used this measure in a previous study. {kappa} statistics showed a high degree of interrater ({kappa} = 0.98) and intrarater reliability ({kappa} = 0.92).

During the restorative or oral surgical treatment, the dentist observer rated the effectiveness of pain control. He or she assessed the child’s response to stimulation during treatment using a measure, the SEM scale,30 that takes into account sound, eye and motor, or SEM, components of the patient’s response to stimulation. The scale consists of four levels: comfort, mild discomfort, moderately painful and painful (Table 1Go). When more than one patient was being treated at the same time, the observer focused on the child with the most severe dental condition to avoid errors in trying to record data in multiple operations. In seven of the 17 practices, one or two dental hygienists in addition to the dentist routinely administered local anesthetic. For cases in which the dental hygienist administered the local anesthetic, we included data with those of the dentist in the same practice because previous work has suggested that the quality of care provided by dentists and hygienists working in the same practice is correlated.31


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  		TABLE 1 RATINGS OF A CHILD’S PAIN ACCORDING TO THE SEM SCALE.*

 
After each treatment, the observer asked the treating dentist to provide the following information:

– Was oral premedication used for this patient?
– Did the patient or his or her parent report any symptom (pain or discomfort) in this area before treatment?
– What type of operative procedure was performed, and on which tooth or teeth?
– How would you rate the effectiveness of pain control with this patient—effective, partial or ineffective?

The treating dentist did not have access to the observer’s data. For the analysis, we dichotomized the pain control effectiveness measure into "effective" vs. "partial or ineffective."


   ANALYSIS
TOP
 ABSTRACT
 SUBJECTS AND METHODS
 ANALYSIS
RESULTS
 HYPOTHESIS TESTING
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
One of the investigators (Y.N.) entered the data into a database in Excel 97 (Microsoft) and checked them for accuracy. We used the dentist observer’s rating of pain control, dichotomizing the ratings into ineffective pain control (ratings of "mild discomfort," "moderately painful" and "painful") and effective pain control ("comfort"). The observer rating and dentist rating had a high level of agreement ({kappa} = 0.82). To determine which dentist behaviors and child characteristics and behaviors were related to ineffective and effective pain control, we compared means for quantitative variables (child age, initial dose of local anesthetic) and group frequencies for categorical variables (sex, arch treated, symptom and anxiety before injection, use of oral premedication, use of nitrous oxide/oxygen inhalational sedation, operative procedure performed). We grouped pulpotomies and extractions for comparison with routine operative dental procedures because the former are considered more invasive.

Given that the unit of analysis is the child, but that the child is being treated in one of only 17 offices, it is unreasonable to expect responses within the same office to respond independently. To account for the intraoffice correlation, we performed the group comparisons using general estimating equations, or GEE, with an independence working correlation matrix.32,33 The GEE method accounts for the intraoffice correlation by adjusting the standard errors and significance levels (that is, P values) in the group comparisons using an empirical standard error estimator, which allows the correlation between responses within an office to be left unspecified. We estimated the intraoffice correlation in our analyses to be approximately zero (P = .0003). In addition to the group comparisons, we used multivariate logistic regression to assess simultaneously which of the dentists’ clinical behaviors and which of the children’s characteristics and behaviors were related to pain control. The dependent measure was the observer’s rating of effective or ineffective pain control, the independent measures were the dentists’ clinical behaviors and children’s characteristics and behaviors, and we performed the logistic regression using GEE to adjust the standard errors and significance levels for the intraoffice correlation. We performed all analyses using the PROC GENMOD feature of SAS/STAT software, Release 6.12 (SAS Institute Inc.).


   RESULTS
TOP
 ABSTRACT
 SUBJECTS AND METHODS
 ANALYSIS
 RESULTS
HYPOTHESIS TESTING
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Characteristics of dentists. The number of years of experience was similar between the pediatric dentists who participated (average 18 years, range two to 36 years) and those who refused or did not respond (average 19 years; range six to 38 years; t-test P = .82). The primary reason given for refusal was that the dentist did not perform a large volume of restorative treatments or oral surgery.

Description of local anesthetic use. In 169 of 361 patients (46.8 percent), treatment was performed in the maxilla; in 192, treatment was performed in the mandible. Extractions and pulpotomies were performed for 117 of 361 patients (32.4 percent), and 244 patients (67.5 percent) received restorations or stainless steel crowns. The vast majority of injections given for maxillary treatment were infiltrations (164 of 169, 97.0 percent). The frequency ordering of mandibular injections was as follows: alveolar block with long buccal nerve (64 of 192, 33.3 percent), infiltration alone (58 of 192, 30.2 percent), alveolar block alone (54 of 192, 28.1 percent), alveolar block with infiltration (15 of 192, 7.8 percent), and alveolar block with long buccal nerve plus infiltration (1 of 192, 0.5 percent). Most of the dentists used topical anesthetic in most of their cases: two of 17 dentists (11.8 percent) were observed not to use topical anesthetic in at least one case (range two to seven children per practice). Almost 90 percent of cases (312 of 361, 86.4 percent) and 15 of 17 dentists surveyed (88.2 percent) used 2 percent lidocaine with 1:100,000 epinephrine. Two dentists (11.8 percent) used 2 percent mepivacaine with levonordefrin in nine children, two (11.8 percent) used 3 percent mepivacaine plain in two children, and two dentists (11.8 percent) used 4 percent prilocaine with 1:200,000 epinephrine in 28 children. The average amount of each agent was one cartridge.

Two hundred eighty-six of 361 children (79.2 percent) received nitrous oxide/oxygen inhalational sedation. Fifteen of 17 dentists (88.2 percent) used nitrous oxide/oxygen inhalational sedation in at least one case. Among these dentists, the proportion of children to whom they administered sedation in a given office ranged from 27.3 to 100 percent. The typical concentration used was 30 percent. Sixty-eight of 361 children (18.8 percent) received oral premedication before treatment. Nine of 17 (52.9 percent) dentists used premedication in at least one case. Among these dentists, the proportion of children to whom they administered pre-medication ranged from 12.5 to 95.2 percent. A wide range of sedative agents and combinations was used. In order of preference, from most to least frequent, the agents used were chloral hydrate and hydroxyzine, combinations of meperidine and promethazine or hydroxyzine, diazepam, hydroxyzine alone, or other benzodiazepines such as triazolam or midazolam. The dosages were not recorded.

Description of the children. Fifty-three of 361 children (14.7 percent) were symptomatic. Fifteen of 17 practices (88.2 percent) had at least one child who was symptomatic before treatment (range of symptomatic children within practices 3.1 to 47.1 percent). Thirty-seven of 361 children (10.2 percent) showed anxious behavior before receiving the initial injection. Fourteen of 17 practices (82.4 percent) had at least one case in which a child was anxious before treatment (range of anxious children within practices 4.4 to 25.0 percent).

Pain control effectiveness. Forty-two of 361 patients (11.6 percent) were observed to experience ineffective pain control. Fourteen of 17 dentists (82.4 percent) were observed to have at least one patient in whom pain control was ineffective. The proportion of cases per office with ineffective pain control ranged from 4.6 to 30.0 percent. Dentists reported that 30 of 361 patients (8.3 percent) experienced ineffective pain control. The proportion of cases per office in which the dentist reported ineffective pain control ranged from 3.1 to 20 percent.


   HYPOTHESIS TESTING
TOP
 ABSTRACT
 SUBJECTS AND METHODS
 ANALYSIS
 RESULTS
 HYPOTHESIS TESTING
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
The results from the group comparisons between children with ineffective and effective pain control support the hypotheses relating ineffective pain control to child anxiety, symptomatology and operative procedure (Table 2Go). Children who were anxious, those with symptoms before receiving the injection and those who underwent more invasive operative procedures (extractions or pulpotomies) were more likely to experience ineffective pain control. Our hypotheses regarding the dentist’s technique (initial dose of anesthetic and arch treated) were not supported. However, when we evaluated pain control in the mandible alone, we found a progressive improvement in pain control moving from infiltration alone (84.5 percent effective), block alone (87.0 percent effective), and block plus infiltration or long buccal nerve (92.5 percent effective).


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  		TABLE 2 FACTORS RELATED TO THE EFFECTIVENESS OF PAIN CONTROL IN PEDIATRIC DENTAL PRACTICE.

 
Although these differences are not statistically significant, it does suggest the possibility that injection technique could be related to effectiveness of pain control in the mandible. In a multivariate logistic regression analysis, which included all the factors, only child anxiety showed a statistically significant association with pain control (odds ratio = 16.6; P < .0001).


   DISCUSSION
TOP
 ABSTRACT
 SUBJECTS AND METHODS
 ANALYSIS
 RESULTS
 HYPOTHESIS TESTING
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
Our knowledge of problems with ineffective pain control derives from anecdotal practice reports and studies comparing various injection techniques.4–7,34–39 Some of these studies were based on small numbers of cases, and the children in the studies often are poorly characterized. In addition, these reports may be difficult to interpret because of the confounding of patient anxiety and pain. Nevertheless, the extent of ineffective pain control in children receiving local anesthetic reported in other studies ranges from 12.8 to 35 percent of cases,7,14,30,40 much greater than the results reported here.

In this study, we used the adult anesthesia literature to develop hypotheses that we evaluated in a child population. We surveyed a relatively large and representative group of pediatric specialists. The prevalence of ineffective pain control mirrors that reported in adults.8,20,41,42 Approximately one in 10 child patients was observed to have ineffective pain control. This rate was confirmed in analyses of the reports of the dentists themselves. It is interesting to note, however, that the dentists in this study appeared to underestimate the number of children who were poorly anesthetized.

Examining the hypotheses, we found that children experiencing ineffective pain control were anxious in greater proportion than children whose pain control was effective. Similarly, children who were symptomatic before treatment were more likely to experience ineffective pain control. Children who underwent extractions or pulpotomies were more likely to experience ineffective pain control than those who received restorative procedures. However, being anxious and being symptomatic were strongly related. Being symptomatic also was related to the type of operative procedure the patient underwent. Thus, in the multivariate analysis, the anxiety measure is the strongest predictor of poor pain control. These findings were true across dentists and regardless of whether treatment was in the mandible or maxilla. The initial volume of anesthetic also did not differ between outcomes. These results did not vary between different age groups or between boys and girls.

The frequency of using oral premedication and nitrous oxide/oxygen inhalational sedation varied among the pediatric dentists. Nevertheless, there was no difference in pain control effectiveness between groups of pediatric patients who received anxiolytic pre-medication or nitrous oxide and groups of patients who did not. This result seems incompatible with the finding that anxiety was the most important factor in the effectiveness of pain control; it may suggest that these pharmacological strategies to manage anxiety were ineffective. We know little about the child’s past experiences with dental care or the measures that were taken to prepare the child for the treatment. In the cases where nitrous oxide/oxygen inhalational sedation or oral premedication was used, the various doses and techniques themselves may have contributed to rather than helped solve the pain control problem.43

The dentists in this study appeared to underestimate the number of children who were poorly anesthetized.

These results are of interest because no pain control guidelines have been developed for pediatric dentistry and because previous research has focused primarily on technical issues, comparing various injection techniques such infiltrations and mandibular blocks.4–6 While our data suggest that these factors are important, especially when pulp treatments and surgery are envisioned, more attention needs to be focused on managing anxiety, perioperative infection and symptoms. Guidelines for pain control have been developed in other areas of pediatric medical care.44,45

Our observations need to be confirmed in other populations. Such studies should address one of the limitations of this study—the fact that while we used an observer to measure anxiety with an a priori definition, the same observer also evaluated the pain control outcome. One inevitably confounds the measurement of the other. Pain is a complex phenomenon; physical maturation, cognitive development and emotion all influence the ways in which pain is experienced and expressed. Children are able to reliably report painful experiences.46,47 Further studies should incorporate such well-validated measures of pain and anxiety. At the same time, clearer criteria should be used to validate children’s reports of symptoms.


   CONCLUSIONS
TOP
 ABSTRACT
 SUBJECTS AND METHODS
 ANALYSIS
 RESULTS
 HYPOTHESIS TESTING
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
Our research suggests that improved pain control strategies should be pursued in pediatric dentistry and applied in both specialized and general practice. These findings are important because they are derived from the observations of specialists. It is likely that pain control effectiveness may be more variable in general practice.28 This work is essential because poor pain control in children has been strongly predictive of fear and avoidance of dental care in adults.1,2 Unsuccessful attempts to provide treatment in children can result in poorer oral health later.2


   FOOTNOTES
 

When this article was written, Dr. Nakai was visiting assistant professor, Department of Pediatric Dentistry, University of Washington, Seattle. She now is assistant professor, Department of Pediatric Dentistry, Okayama University Dental School, Okayama, Japan.


Dr. Mancl is a research assistant professor, Department of Dental Public Health Sciences, University of Washington, Seattle.


Dr. Coldwell is an assistant professor, Departments of Pediatric Dentistry and Dental Public Health Sciences, University of Washington, Seattle.


Dr. Domoto is professor and the chairman, Department of Pediatric Dentistry, University of Washington, Seattle.


Dr. Ramsay is associate professor, Department of Pediatric Dentistry, and an associate professor, Department of Orthodontics, University of Washington, Seattle.


This research was supported by National Institutes of Health/National Institute of Dental and Craniofacial Research grants R13 DE12233 and DE00379; gifts from Astra Pain Control AB, Westborough, Mass., and Colgate Oral Pharmaceuticals, Piscataway, N.J.; and a stipend from Okayama University Dental School, Japan.


The authors thank all the pediatric dentists and child patients who participated in this study, without whose cooperation it would not have been possible.


Dr. Milgrom is a professor, Department of Dental Public Health Sciences, University of Washington, Box 357475, Seattle, WA 98195-7475, e-mail "dfrc@u.washington.edu". Address reprint requests to Dr. Milgrom.


   REFERENCES
TOP
 ABSTRACT
 SUBJECTS AND METHODS
 ANALYSIS
 RESULTS
 HYPOTHESIS TESTING
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 

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