The innervation of the maxillary first permanent and primary molars as determined by the deposition of local anesthetic solutions. A preliminary report

Pain-related Disruptive Behavior during Dental Treatment Interpreted as Uncooperative Behavior-Small Case Series

Aim

To describe a small series of six cases of children who were diagnosed as uncooperative and referred to general anesthesia to complete their dental treatment. These children were actually exhibiting pain-related disruptive behaviors during previous dental treatments; we determined the reasons for ineffective anesthesia.

Background

One of the most common reasons for disruptive behaviors in children during operative dental treatment is the experiencing of pain during treatment. Disruptive behavior may lead to treatment under general anesthesia.

Case description

Parents of six uncooperative children referred to general anesthesia for dental treatment, arrived at our clinic, because they wanted a second opinion. The children were found to be nonresponsive to the common anesthetic technique and were treated by several approaches to increase the effectiveness of anesthesia. These included supplementary anesthesia to accessory innervation (in three cases), changing brands of anesthetic (in two cases), injecting the maximal dose at once to prevent tachyphylaxis, and waiting 5 minutes to achieve effectiveness of anesthesia (in one case). After achieving effective anesthesia, all the children fully cooperated during the operative treatment.

Conclusion

Ineffective anesthesia can lead to severe disruptive behavior when continuing the treatment irrespective to the sensation of pain. Several approaches were used to increase the effectiveness of anesthesia resulting in cooperation of the pediatric patients.

Clinical significance

Behavioral response to ineffective anesthesia may be diagnosed as uncooperativeness. Effort should be put to differentiate between ineffective anesthesia and uncooperative patient.

How to cite this article

Malka A, Maya G. Pain-related Disruptive Behavior during Dental Treatment Interpreted as Uncooperative Behavior—Small Case Series. Int J Clin Pediatr Dent 2019;12(4):347–351.

Efficacy of intraligamentary anesthesia in maxillary first molar extraction

INTRODUCTION

Infiltration anesthesia (IA) is the method to anaesthetize maxillary teeth successfully. In contrast, intraligamentary anesthesia (ILA) has been used as supplementary anesthesia during tooth extraction, particularly when regional block anesthesia has failed. In this study, we compare the efficacy of and patient satisfaction with ILA vs IA when extracting maxillary first molar teeth.

METHODS

Forty patients were enrolled in this study and 80 maxillary first molars extracted. All patients served as their own control, with ILA as the experimental side and IA as the control side. The two techniques were compared for efficacy using a visual analog scale (VAS) and patient satisfaction compared using a verbal rating scale (VRS).

RESULTS

The mean VAS pain score for extraction using ILA was lower than that for IA (20.30±3.18 and 13.93±1.95 mm, respectively; P<0.001). For injection pain, the mean VAS pain score in the ILA side was higher than the IA side (42.28±4.51 and 31.73±3.1 mm, respectively; P<0.001). VRS results showed a higher number of patients who felt that pain during ILA was greater than expected compared with IA.

CONCLUSION

IA appears less painful during injection compared with ILA, and provides sufficient pain relief during extraction. However, ILA can be used when IA fails to achieve the desired pain suppression, as it provides higher extraction-pain relief.

Injection regimen for anesthesia of the maxillary first molar

This study evaluated whether a single or double injection is required to achieve first molar anesthesia. Subjects received posterosuperior alveolar nerve blocks. Presence or absence of anesthesia was evaluated with carbon dioxide dry ice pulp sensitivity testing. This was followed by mesial infiltration and a second pulp testing. The posterosuperior alveolar nerve block alone usually provided effective first molar anesthesia. A small percentage of subjects required an additional mesial infiltration to obtain anesthesia.

Patterns of innervation of the maxillary first molar: a dissection study

Human maxillae were dissected with the aim of tracing nerves from maxillary first molar root apices to their parent superior alveolar nerve branches. The contribution of the posterior, middle, and anterior superior alveolar nerves to the innervation of the first molar was assessed. The posterior superior alveolar nerve was found to contribute innervation 100% of the time; the middle superior alveolar nerve, when present, contributed innervation 28% of the time. The anterior superior alveolar nerve did not supply any innervation to the first molar.