E. Salomon, S. Mazzoleni, S. Sivolella, F.

Cocilovo,
D. Gregori, M.R. Giuca, R. Ferro
Dental Unit Regional Centre for Study, Prevention
and Therapy of Dental Diseases
Veneto Region, Cittadella Hospital , Health District no. 15
Ospedale- Cittadella (PD) - Italy.

with no differences between males and females. After

this age that success rate dramatically drops.
Keywords Community paediatric dentistry;
Restorative dentistry/dental materials; Pain control;
Sedation.

e-mail: salomon_elena@libero.it

Introduction

Age limit for infiltration

anaesthesia
for the conservative
treatment
of mandibular first
molars. A clinical
study on a paediatric
population
abstract
Aim The aims of this study were to assess the age limit
for infiltration anaesthesia as an effective technique in
treating carious lesions of first permanent molars in
the paediatric age and if differences exist between
males and females.
Materials anf methods A total of 51 teeth from
48 different patients aged between 6 and 14 years
were included in the study. The anaesthetic solution
used was 1.8 ml of 2% mepivacaine with 1:100000
epinephrine. The effectiveness of anaesthesia was
assessed by electrical pulp test after 3, 5, 7 and 10
minutes.
Results In 56.9% of the treated cases a single
mandibular infiltration was sufficient to induce
complete pulpal anaesthesia of the tooth to be treated.
Under 10 years of age, the infiltration technique
was effective in 85.2% of cases. The success rate
of anaesthesia also decreased significantly and not
linearly in function of age. The success of infiltration
anaesthesia was not related to gender.
Conclusion Mandibular infiltration anaesthesia is a
successful technique for most patients under 10 years
(success rate: 85.2%) especially for the younger ones,

259

It is now widely accepted that, particularly in

paediatric dentistry, one of the most important aspects
in managing the cooperation of patients is pain
control [Aminabi et al., 2009]. To date tooth decay is
a disese which requires a widespread care among the
population, in particular in the socially disadvantaged
classes [Ferro et al., 2010; Ferro et al., 2012].
The most commonly used local anaesthetic techniques
are inferior alveolar nerve block (IANB) and buccal
infiltration. Truncal anaesthesia may, however, affect
childrens cooperation and has some disadvantages
[Hallonsten et al., 2004; including longer duration of
anaesthesia, a higher frequency of self-induced injuries
such as biting of the lip or tongue and a degree of
difficulty that makes the injection stressful for both
the clinician and patient [Yassen, 2010]. The usual
technique of IANB is also associated with additional
risks and complications such as nerve or vascular injury,
intravascular injection, muscle injuries and myofascial
pain, more frequently than other local anaesthetic
techniques [Lustig and Zusman, 1999; Manfredini et al.,
2011]. On the other hand, pulpal anaesthesia through
buccal infiltration can be reached only if the anesthetic
solution is able to spread from the periosteum to the
apexes of the teeth through the thickness of cortical
bone [Manani, 2003] and therefore its success depends
on the thickness and density of the alveolar cortical
bone [Lloyd Du Brul, 1988].
Due to the structure of mandibular cortical bone, the
effectiveness of infiltration anaesthesia for mandibular
molars has traditionally been considered unsuitable for
dental procedures in adults [Abdulwahab et al., 2009;
Hawkins and Moore, 2002]. In children bones are less
compact than in adults, and the mandibular cortex
is crossed by many canals; the anaesthetic solution
can spread more quickly and smoothly, helping the
effectiveness of the infiltration techniques [Council on
Clinical Affairs, 2005; Malamed, 2004].
Several studies evaluating the use of mandibular
infiltration as an alternative to inferior alveolar nerve
block in deciduous dentition concluded that the two
techniques do not differ significantly [Donohue et al.,
1993; Naidu et al., 2004; Oulis et al., 1996; Yassen,
2010].
Maki et al. [2000], demonstrated that the volume

Supplement to European Journal of Paediatric Dentistry vol. 13 issue 3 - October 2012

Salomon e. et al.

and density of mandibular cortical bone increase

significantly with age; whereas cortical volume in 9
to 11-year-old children appears to be approximately
33-35% compared to that of adults, it increases up
to 83-87% between 15 and 17 years of age. Ono et
al. [2008] and Fayed et al. [2010] confirmed that the
mandibular cortical bone is less thick in adolescents
than in adults. Moreover Swasty et al. [2009] indicate
that mandibular cortical thickness is not fully mature
and does not reach its peak until the third decade of
life, and that the cortical bone thickness decreases
after the fifth decade.
Maki et al. [2000] and Fayed et al. [2010]
demonstrated that cortical bone develops differently
in females and males. While under 11 years of age
there are no differences with regard to gender, in
the following years in male subjects the cortical bone
develops more, both in volume and density, than in
females [Maki et al., 2000]. The increase of bones
thickness during the developmental age has not been
investigated so deeply up to now. The use of new
devices for radiographic examinations, such as conebeam volumetric tomography, will provide more
information with a high reduction of the radiation dose
compared to the traditional ones [Tomasi et al., 2010].
In a sample of 43 patients aged 13 to 48 years, mean
age 24.0 8.2 years, Ono et al. [2008] found that
mesially to the first lower molar the average cortical
bone thickness ranged from 1.59 to 2.66 mm.
The purpose of this study is to assess the age limit
for infiltration anaesthesia as an effective technique
in treating carious lesions of first permanent molars
in the paediatric age and the presence of differences
between males and females.

Materials and methods

The subjects included in this study were selected
with these following criteria.
Age between 6 and 14 years.
Presence of caries in mandibular first permanent
molars, which had not resulted in pulp necrosis or
irreversible pulpitis and the treatment of which required
the administration of local anaesthesia.
Cooperative behaviour.
A total of 51 teeth from 48 different patients (19
males and 29 females, mean age 10.2 2.3 years) were
included in the study. The efficacy of anaesthesia was
assessed by electrical pulp tester (Digitest Parkell); to
improve the conduction between the device and the
tooth, a small amount of water-soluble ultrasound gel
(Eco Supergel Ceracarta) was applied on the metal tip
of the device.
For delivery of local anaesthesia by buccal infiltration
the following were used: reusable, non self-aspiring
metal syringes, 30G 0.3 x 16 mm needles and 1.8 ml of

260

2% mepivacaine with 1:100000 epinephrine.

The pulp test firstly evaluated the initial vitality of
the affected tooth and the corresponding contralateral
tooth, to ensure that the instrument and the patients
responses were reliable. Infiltration anaesthesia was
performed at the level of the molar, and then the pulp
sensory threshold to the pulp test stimulation was
evaluated after 3, 5, 7 and 10 minutes. If the device
reached the maximum output intensity of electric
current (value 64 on display), without the patient
experiencing the stimulus, anaesthesia was considered
effective. If after 10 minutes, the pulp sensitivity
represented by the value of the pulp tester at which
the patient felt the stimulusremained unchanged or
nearly so, anaesthesia was considered unsuccessful.
On the contrary, if after 10 minutes the pulp sensory
threshold had significantly decreased (at least 80% on
the instrument scale, corresponding to value 51) the
operator waited 5 more minutes before taking further
control of pulpal sensitivity.
Descriptive analysis presenting percentages (absolute
numbers) for categorical variables and median (interquartile difference) for continuous variables was
performed. Variable distribution was compared among
successful and unsuccessful anaesthesia using chisquare test of Wilcoxon test whenever appropriate.
Association of probability of successful anaesthesia was
estimated using a logistic regression model and modeled
using restricted cubic spline. Non-linearity was assessed
using the AIC criterion. Residual sensitivity at time 3,
5, 7 and 10 minutes after anaesthesia was estimated
using a proportional hazard model and depicted using
a Kaplan-Meier function. All analyses were performed
in R System [R Development Core Team (2010). R: A
language and environment for statistical computing. R
Foundation for Statistical Computing, Vienna, Austria.
ISBN 3-900051-07-0, URL http://www.R-project.org/]
using Harrels Design libraries [Regression Modeling
Strategies by FE Harrell (Springer-Verlag, 2001)].

Results
In 29 cases out of 51 (56.9%) a single mandibular
infiltration was enough to induce complete pulpal
anaesthesia of the tooth to be treated.
Successful buccal anaesthesia did not vary according
to patients gender (Table 1).
Probability of a successful infiltration anaesthesia
decreases significantly and non-linearly (Fig. 1) as a
function of age (OR 0.02 95% C.I. 0.01-0.18); which
means that up to 10 years of age the gradual reduction
of the probability of success is small. This probability,
however, falls significantly in older subjects. If, in fact,
in the age group between 6 and 10 years the success
rate reaches 85.2% of cases, while in the age group
between 11 and 14 years it goes down to only 25%.

Supplement to European Journal of Paediatric Dentistry vol. 13 issue 3 - October 2012

age limit for infiltration anaesthesia in first molars

Residual sensitivity

Effective anesthesia

(N=27)

(N=24)

Combined

p-value

Gender: m

51

44% (12)

33% ( 8)

39% (20)

0.417

Age

51

11.00/12.00/13.00

7.75/ 8.00/ 9.25

8.00/10.00/12.00

<0.001

Tooth: 46

51

48% (13)

50% (12)

49% (25)

0.895

initial

51

5.00/10.00/14.00

5.75/ 9.00/16.00

5.00/ 9.00/14.00

0.661

X3 minutes

49

10.00/17.00/25.00

25.50/37.00/43.25

16.00/25.00/37.00

<0.001

X5 minutes

51

11.00/19.00/34.50

50.75/60.50/64.00

19.00/38.00/59.00

<0.001

X7 minutes

41

12.5/27.0/43.5

64.0/64.0/64.0

19.0/47.0/64.0

<0.001

X10 minutes

16

40.25/45.50/52.25

64.00/64.00/64.00

40.75/48.00/53.25

0.02

tabLE 1 Success of infiltration anaesthesia according to observed patients characteristics. Data are percentages (absolute
numbers) for categorical variables and median (I quartile /median /III quartile) for continuous variables.

Effectiveness

1.0

0.8

-5

0.6

-10
6

10
Age

12

14

Adjusted to: Gender=f Tooth=36

fig. 1 Mean fracture resistance (and Standard Deviation) values

and modes of failure registered in the experimental groups.
Residual sensitivity after anaesthesia was at a median
level of 42 (37-64+ 95% CI) after 3 minutes , 61 (5564+ 95% CI) after 5 minutes and 64+ after 7 minutes
from anaesthesia (only 4% of the patients showed a
residual sensitivity after 10 minutes) (Fig. 2).

Discussion
The first permanent molar is the most cariessusceptible tooth in the young permanent dentition
[Mejre and Stenlund, 2000; Ong and Bleakley, 2010],
with lesions occurring generally within the first 3
years after its eruption. This study demonstrates the
possibility of using buccal infiltration instead of IANB
in paediatric patients for the treatment of caries of the

0.4

0.2

0.0
0

10

20

30

40

50

60

fig. 2 Residual sensitivity (continuous lines) and respective 95%

Confidence Intervals after 3 (dark red), 5 (red), 7 (orange) and 10
minutes after infiltration anesthesia.
mandibular first permanent molars.
As infiltration anaesthesia in patients aged between 6
and 10 years was successful in 85.2% of the cases, this
technique can be considered an effective procedure in
younger subjects (Fig. 1).
This outcome is related both to lower density and
thickness of cortical bone in this age group [Fayed et
al., 2010; Maki et al., 2000; Ono et al., 2008; Swasty
et al., 2009], and presumably to the process of root
growth, which in the case of first permanent molars is
completed at the age of 9-10.

Supplement to European Journal of Paediatric Dentistry vol. 13 issue 3 - October 2012

261

Salomon e. et al.

Therefore in children of this age group, the buccal

infiltration anaesthesia in the mandible could be
recommended not only for the deciduous dentition
[Donohue et al., 1993; Oulis et al., 1996; Yassen, 2010],
but also for the first permanent molars.
The significant decrease in the success rate (only
25%) of infiltration anaesthesia that occurs between 11
and 14 years could be related to thickening of cortical
bone in this area.
We expected differences in response between males
and females on the basis of the studies of some
authors, such as Maki et al. [2000] and Fayed et al.
[2010], demonstrating a different thickness and density
of cortical bone between gender; however, our study
did not present any differences in response between
males and females.

Conclusion
This is the first study to demonstrate that the
infiltration technique should be used as a possible
alternative to mandibular block anaesthesia in the
majority of carious lesions of the mandibular first
permanent molars in patients under 10 years of age.
This paper suggests buccal infiltration as an
alternative means to IANB for achieving anaesthesia
of the mandibular first permanent molar in young
children, being the former less stressful and offering
less complications and lower risks of affecting childrens
cooperation than the latter.

References
Abdulwahab M, Boynes S, Moore P, et al. The efficacy of six local anesthetic
formulations used for posterior mandibular buccal infiltration anesthesia. J
Am Dent Assoc 2009; 140:1018-1024.
Aminabadi NA, Farahani RMZ, Oskouei SG. Site-specificity of pain sensitivity
to intraoral anesthetic injection in chilgren. J Oral Sci 2009; 51:239-243.
Council on Clinical Affairs. Guideline on appropriate use of local anestesia
for pediatric dental patients. Reference Manual 2005-2006. American
Academy of Pediatric Dentistry, 2005.
Donohue D, Garciagodoy F, King DL, Barnwell GM. Evaluation of mandibular
infiltration versus block anesthesia in pediatric dentistry. Journal of
Dentistry of Children 1993; 60:104-106.
Fayed MMS, Pazera P, Katsaros C. Optimal sites for orthodontic mini-implant

262

placement assessed by cone beam computed tomography. Angle Orthod.

2010; 80:939-951.
Ferro R, Cecchin C, Besostri A, Olivieri A, Stellini E, Mazzoleni S.. Social
differences in tooth decay occurrence in a sample of children aged 3 to 5
in north-east Italy. Community Dent Health. 2010 Sep;27(3):163-6.
Ferro R, Besostri A, Olivieri A, Stellini E, Denotti G, Campus G. Caries
experience in 14-year-olds from Northeast Italy. Is socioeconomic-status
(SES) still a risk factor? Eur J Paediatr Dent 2012 Mar;13(1):46-52.
Hallonsten AL, Veerkamp J, Rlling I. Dolore, controllo del dolore e sedazione
nei bambini e negli adolescenti. In: Koch G, Poulsen S, Strohmenger L (ed).
Odontoiatria infantile, un approccio clinico. Milano: Edi.Ermes, 2004:105125.
Hawkins JM, Moore PA. Local anesthesia: advances in agents and techniques.
Dent Clin North Am 2002; 46(4):719-732, ix.
Lloyd Du Brul. Anatomia regionale ed applicata. In: Miani A, Ferrario VF (ed).
Anatomia Orale di Sicher. Milano: Edi.Ermes, 1988:499-501.
Lustig JP, Zusman SP. Immediate complications of local anesthetic administred
to 1007 consecutive patients. J Am Dent Assoc 1999; 130:496-499.
Maki K, Miller A, Okano T, Shibasaki Y. Changes in cortical bone mineralization
in the developing mandible: a three-dimensional quantitative computed
tomography study. J Bone Miner Res 2000; 15:700-709.
Malamed SF. Local anesthetic consideration in dental specialities. In:
Handbook of Local Anesthesia. St. Louis: Mosby, 2004: 274-275.
Manani G. Le anestesie non tronculari. In: Anestesia in odontostomatologia.
Napoli: Idelson-Gnocchi, 2003:381-403.
Manfredini D., Cocilovo F., Favero L., Ferronato G., Tonello S., GuardaNardini L. Surface electromyography of jaw muscles and kinesiographic
recordings: diagnostic accuracy for myofascial pain. J Oral Rehabil. 2011
Nov;38(11):791-9.
Mejre I, Stenlund H. Caries Rates for the mesial surface of the first permanent
molar and tge distal surface of the second primary molar from 6 to 12 years
of age in Sweden. Caries Res 2000; 34:454-461.
Naidu S, Loughlin P, Coldwell SE, Noonan CJ, Milgrom P. A Randomized
Controlled Trial Comparing Mandibular Local Anesthesia Techniques in
Children Receiving Nitrous Oxide-Oxigen Sedation. Anesth Prog 2004;
51:19-23.
Ong DC-V, Bleakley JE. Compromised first permanent molars: an orthodontic
perspective. Australian Dental Jurnal 2010; 55:2-14.
Ono A, Motoyoshi M, Shimizu N. Cortical bone thickness in the buccal
posterior region for orthodontic mini-implants. Int J Oral Maxillofac Surg
2008; 37:334-340.
Oulis CJ, Vadiakas GP, Vasilopoulou A. The effectiveness of mandibular
infiltration compared to mandibular block anesthesia in treating primary
molars in children. Pediatr Dent 1996; 18:301-305.
Swasty D, Lee JS, Huang JC, et al. Anthropometric analysis of the human
mandibular cortical bone as assessed by cone-beam computed
tomography. J Oral Maxillofac Surg 2009; 67:491-500.
Tomasi C, Bressan E, Corazza B, Mazzoleni S, Stellini E, Lith A. Reliability and
reproducibility of linear mandible measurements with the use of a conebeam computed tomography and two object inclinations. Dentomaxillofac
Radiol. 2011 May;40(4):244-50
Yassen GH. Evaluation of mandibular infiltration versus mandibular block
anaesthesia in treating primary canines in children. International Journal
of Paediatric Dentistry 2010; 20:43-49.

Supplement to European Journal of Paediatric Dentistry vol. 13 issue 3 - October 2012