If you’ve ever heard me speak, you know that I often refer to children as “aliens”. Why? Is it because they sometimes look like aliens in early ultrasounds? No! Before I offend you, know that I love children and have the utmost respect for them. Simply put, I use the term “extraterrestrial” for exactly these reasons. I always want to remind myself and my students and the participants of my presentations that children are not just little adults. They have unique physical, emotional and developmental characteristics. Their pharmacokinetic and pharmacodynamic parameters can be very different from those of adults. The principles of adult pharmacotherapy are not easily extrapolated to “adapt” to the profile and needs of children.1
In this sense, children may be our most vulnerable patients with respect to potential drug interactions, adverse effects, toxicity, and contraindications. So, providing dental care to children can be especially difficult if we are not used to doing it, and it can almost feel like working with patients from another planet.
Preventing pain, anxiety and infection in children is definitely part of our practice. However, the careless use of dental pharmacotherapeutic agents for this purpose can be potentially disastrous in children. A working knowledge of current trends in pediatric dental pharmacology enables all dental practitioners to treat children better, consult pediatricians more effectively, and help educate parents and caregivers. In this two-part column, we will explore the pharmacokinetic and pharmacodynamic challenges we face in treating children, with a focus on the drugs most frequently used in our practice: local anesthetics, analgesics, and antibacterial agents. We’ll start with local anesthetics.
A higher risk of toxicity in children
If you have been practicing as a dental hygienist for some time, you know that it is common to use local anesthetics in your practice. And whether you work in a state that allows dental hygienists to administer anesthesia, you know that local anesthetics are generally considered safe when properly administered. Although it may seem at odds with what I said earlier, some of the basic principles of administering local anesthetics apply equally to children and adults. However, pediatric patients are at higher risk of toxicity and serious adverse effects with local anesthetics due to their reduced body weight and frequent use of sedatives.2
Often the cause of toxicity in children of local anesthetics is an overdose. This is especially true with higher concentration solutions, such as 4% articaine and prilocaine, as toxicity will be more likely with high doses. We must use the smallest effective dose of local anesthetic solutions in children; maximum recommended doses of local anesthetics should be calculated based on body weight and strictly adhered to, where possible.3The ease with which a pediatric patient can be overdosed with local anesthetics is compounded by the practice of multi-quadrant dentistry and the concurrent use of sedative drugs.4
Smaller volumes provide needed pain control
Younger patients do not need large volumes of local anesthetic agent to control pain.4Due to differences in anatomy, smaller volumes of local anesthetics provide the depth and duration of pain control usually needed to complete the planned dental treatment in younger patients.4Another factor is the presence of a vasoconstrictor.2All injectable local anesthetics have vasodilating properties. This may lead to faster vascular absorption, faster systemic absorption and potentially overdosage.2.4 It is strongly recommended that a vasoconstrictor be included in local anesthetic solutions used in children, especially when multiple quadrants are anesthetized in small pediatric patients, unless there is a compelling reason to exclude it.4
As such, a pediatric patient requiring extensive dental work should have a treatment plan that includes multiple appointments and single-quadrant dentistry, whenever possible, to avoid exceeding the maximum recommended dose of local anesthetic. .2However, many young children also need some form of pharmacological behavior management to help them endure and cooperate during long dental appointments.2
Beware of certain combinations
Local anesthetics and sedating agents can cause additive CNS depressive effects when used together.2Most overdose complications in children generally involve neurological and respiratory events before cardiovascular events.5Combining local anesthetics with opioids or antihistamines may further predispose children to seizures and adverse effects.6Additionally, it is standard practice to perform minimal conscious sedation on pediatric patients with nitrous oxide and oxygen and a benzodiazepine.2When administered with a local anesthetic, benzodiazepines increase the seizure threshold and may therefore mask early signs of local anesthetic overdose and directly lead to cardiovascular collapse.5
As dental practitioners, we need to be aware of the pharmacokinetic and pharmacodynamic differences associated with pediatric patients, and not simply treat them as “little adults”. Medications commonly used in dentistry can cause significant adverse effects and toxicity in children. In the second installment of this column, we will explore the pharmacokinetic and pharmacodynamic challenges we face in treating pediatric dental patients with analgesics and antibacterial agents.
Editor’s Note: This article originally appeared under the title “Children should be seen and heard!” in the January 2022 print edition of HDR.
- Harding AM. Pharmacological considerations in pediatric dentistry. Dent Clin North Am. 1994 Oct;38(4):733-753.
- Nicola W, Ouanounou A. Pharmacotherapy for the pediatric dental patient. Compend Contin Educ Dent. 2019 Jun;40(6):349-353.
- Moore PA. Prevent the toxicity of local anesthesia. J Am Dent Assoc. 1992 Oct;123(6):60-64.
- Malamed S. Manual of local anesthesia. Elsevier Mosby; 2004:272.
- Sekimoto K, Tobe M, Saito S. Local anesthetic toxicity: acute and chronic management. Acute medical surgery. 2017;4(2):152-160.
- Haas DA. An update on local anesthetics in dentistry. J Can Dent Assoc. 2002;68(9):546-551.