AMERICAN ACADEMY OF PEDIATRIC DENTISTRY

Guideline on Use of Local Anesthesia for Pediatric

Dental Patients
Originating Council
Council on Clinical Affairs

Review Council
Council on Clinical Affairs

Adopted
2005

Revised
2009, 2015

Purpose
The American Academy of Pediatric Dentistry (AAPD) intends this guideline 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
This guideline is an update of the 2009 revision. It is based
upon a new systematic literature search of the Pubmed electronic database using the following parameters: 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 (eg, hematoma, trismus, intravascular injection).6,7
Familiarity with the patients 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 (eg,
procaine, benzocaine, tetracaine); and (2) amides (eg, 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 (eg, 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

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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 US 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

Table 1. INJECTABLE LOCAL ANESTHETICS

Duration in minutes3,12
Maxillary infiltration
Anesthetic

Pulp

Soft tissue

Mandibular block
Pulp

Soft tissue

Lidocaine
2% plain

2%+1:50,000 epinephrine

60

170

85

190

2%+1:100,000 epinephrine

60

170

85

190

3% plain

25

90

40

165

2%+1:100,000 epinephrine

60

170

85

190

2%+1:20,000 levonordefrin

50

130

75

185

4%+1:100,000 epinephrine

60

190

90

230

4%+1:200,000 epinephrine

45

180

60

240

4% plain

20

105

55

190

4%+1:200,000 epinephrine

40

140

60

220

40

340

240

440

Articaine

Prilocaine

Bupivacaine

mg/kg

mg/lb

(mg)

4.4

2.0

300

4.4

2.0

300

7.0

3.2

500

6.0

2.7

400

1.3

0.6

90

Total dosage should be based on childs weight and should never exceed maximum total dosage.
Manufacturers package inserts and Malameds Handbook of Local Anesthesia, 6th edition recommend maximum dosage of 7 mg/kg.
As of August, 2011, 2% lidocaine without epinephrine is no longer available in dental cartridges in North America.12

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Maximum total dosage12*

5-10

Mepivacaine

0.5%+1:200,000 epinephrine

Maximum dosage12

AMERICAN ACADEMY OF 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.
Table 2. DOSAGE PER DENTAL CARTRIDGE 3,12
Anesthetic

mg/1.7 mL or
1.8 mL cartridge

Vasoconstrictor/1.7 mL
or 1.8 mL cartridge

Lidocaine
2% plain

34 or 36

2%+1:50,000 epinephrine

34 or 36

2%+1:100,000 epinephrine

34 or 36

N/A
34 g or 0.034 mg or
36 g or 0.036 mg
17 g or 0.017 mg or
18 g or 0.018 mg

Mepivacaine
3% plain

51 or 54

N/A

2%+1:100,000 epinephrine

34 or 36

17 g or 0.017 mg or
18 g or 0.018 mg

2%+1:20,000 levonordefrin

34 or 36

85 g or 0.085 mg or
90 g or 0.090 mg

Articaine
4%+1:100,000 epinephrine

68 or 72

4%+1:200,000 epinephrine

68 or 72

17 g or 0.017 mg or
18 g or 0.018 mg
8.5 g or 0.0085 mg or
9 g or 0.009 mg

Prilocaine
4% plain

68 or 72

N/A

4%+1:200,000 epinephrine

68 or 72

8.5 g or 0.0085 mg or
9 g or 0.009 mg

Bupivacaine
0.5%+1:200,000 epinephrine

8.5 or 9

8.5 g or 0.0085 mg or
9 g or 0.009 mg

Listed dosage on cartridges should be calculated 1.8 mL because anesthetic solution

dispensed per cartridge can vary between 1.7 to 1.76 mL.
As of August, 2011, 2% lidocaine without epinephrine is no longer available in dental
cartridges in North America.12

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 milli meters. 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 in jections, 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 inserted 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 local
anesthetics 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 (ie, 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

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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 bloods oxygen-carrying
capacity. In patients with subclinical methemoglobinemia15
or with toxic doses (ie, greater than six mg/kg), prilocaine can
induce methemoglobinemia symptoms15 (eg, 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 patients 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 (eg,
nitrous oxide, sedative agents, general anesthesia);
and
the practitioners knowledge of the anesthetic agent.
2. Use of vasoconstrictors in local anesthetics is recom mended 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 documenta-

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tion 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 (eg, infiltration, block, intraosseous), needle

selection, and patients 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 conjunction 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

AMERICAN ACADEMY OF PEDIATRIC DENTISTRY

Allergy to local anesthesia

Allergic reactions are not dose related but are due to the patients 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 (eg, 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 [ie,
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
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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 (eg, 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

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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
1. Ogle OE, Mahjoubi G. Local anesthesia: Agents, techni

ques, and complications. Dent Clin North Am 2012;

56(1):133-48
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.
5. Malamed SF. Basic injection technique. In: Handbook of
Local Anesthesia. 6th ed., St. Louis, Mo: Mosby; 2013:
157-68.
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.

AMERICAN ACADEMY OF PEDIATRIC DENTISTRY

8. Moore PA, Hersh EV. Local anesthetics: pharmacology

and toxicity. Dent Clin North Am 2010;54(4):587-99.
9. Malamed SF. Pharmacology of vasoconstrictors. In:
Handbook of Local Anesthesia. 6th ed., St. Louis, Mo:
Mosby; 2013:25-38.
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. US Dept. for Health and Human Services, Food and
Drug Administration, Center for Drug Evaluation and
Research. Guidance for FDA staff and industry: Marketed unapproved drugsCompliance 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. US 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/PostmarketDrugSafetyInformation
forPatientsandProviders/ucm054718.htm. Accessed
September 3, 2015.
15. Trapp L, Will J. Acquired methemoglobinemia revisited.
Dent Clin North Am 2010;549(4):665-75.
16. Malamed SF. Systemic complications. In: Handbook of
Local Anesthesia. 6th ed., St. Louis, Mo: Mosby; 2013:
311-40.
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.
19. Kravitz ND. The use of compound topical anesthetics:
A review. J Am Dent Assoc 2007;138(10):1333-9.
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.
27. Tavares M, Goodson MJ, Studen-Pavlovich D, et al. Reversal of soft-tissue local anesthesia with phentolamine
mesylate in pediatric patients. J Am Dent Assoc 2008;
139(8):1095-104.
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.
31. Wilson W, Taubert KA, Gevitz P, et al. Prevention of
infective endocarditis: Guidelines from the American
HeartAssociation. Circulation e-published April 19, 2007.
Available at: http://circ.ahajournals.org/cgi/reprint/
CIRCULATIONAHA.106.183095. Accessed August
27, 2015. Correction Circulation 2007;116:e376-e377.
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, DC: National
Maternal and Child Oral Health Resource Center. Available at: http://www.cdph.ca.gov/programs/MCAH
OralHealth/Documents/MCAH-OHP-OralHealth
PregnancyConsensus2011.pdf . Accessed September 3,
2015.

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