Transcript Anesthesia and Pain Control in Dentistry Chapter 37

LECTURE 1
HISTORY OF SURGICAL DENTISTRY AND
MAXILLOFACIAL SURGERY, THEIR DEFINITION AND
TASK. PREPARATION OF THE PATIENT FOR
SURGERY. DEFINITION OF PAIN; REACTION OF THE
ORGANISM TO THE PAIN, THE OPERATING TRAUMA.
ANESTHESIA IN SURGICAL DENTISTRY.
GENERAL ANESTHESIA. INDICATIONS AND
CONTRAINDICATIONS, PREANESTHETIC
MEDICATION PRINCIPLES, NEUROLEPTANALGESIA.
COMPLICATIONS OF GENERAL ANESTHESIA, THEIR
TREATMENT AND PROPHYLAXIS. FUNDAMENTALS
OF CARDIOPULMONARY RESUSCITATION.
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Indications for Maxillofacial Surgery
 Extractions of decayed teeth that cannot be
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restored
Surgical removal of impacted teeth
Extraction of nonvital teeth
Preprosthetic surgery to smooth and contour
the alveolar ridge
Removal of teeth for orthodontic treatment
Removal of root fragments
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Indications for Maxillofacial Surgerycont’d
 Removal of cysts and tumors
 Biopsy
 Treatment of fractures of the mandible or
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maxilla
Surgery to alter the size or shape of the facial
bones
Surgery of the temporomandibular joint
Reconstructive surgery
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Indications for Maxillofacial Surgerycont’d
 Cleft lip and cleft palate repairs
 Salivary gland surgery
 Surgical implant procedures
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The Surgical Assistant
 Must have advanced knowledge and skill in:
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Patient assessment and monitoring
Specialized instruments
Surgical asepsis
Surgical procedures
Pain control techniques
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The Surgical Setting
 Dental Operatory
 Surgical Suite
 Operating Room
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What is Surgical Dentistry /Oral
Surgery?
The dental specialty of Surgical
Dentistry / Oral Surgery is concerned with
the diagnosis and surgical management of
pathological processes and anomalies in the
teeth or their supporting structures.
Most treatment can be completed on an
out-patient basis using local anæsthesia,
occasionally supplemented by sedation if
necessary.
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The Surgical Dentist / Oral Surgeon is trained in a number of
surgical procedures including the following:
the extraction of teeth and roots
the treatment of ectopic and impacted teeth
surgical endodontics
the re-implantation of teeth
surgical exposure of teeth (such as canines)
minor soft tissue surgery (such as biopsy techniques)
removal of intra-oral submandibular salivary calculi
management of dental trauma
closure of holes between the mouth and sinus
management of cuts to the mouth
dental implantology
minor orthodontic surgery (release of tongue-ties) and
pain and anxiety control, local anæsthesia and sedation
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The syllabus includes:
•diagnosis and management of oral disease
•surgical endodontics
•minor soft-tissue surgery
•management of dental trauma
•surgical placement of dental implants
•management of pain and anxiety by pharmacological and
non-pharmacological means
•control of cross-infection
•medico-legal aspects of surgical dentistry
Most Surgical Dentists / Oral Surgeons have trained in a
hospital-setting and often work part-time in hospital Oral
Surgery departments.
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Oral and maxillofacial surgery is surgery
to treat many diseases, injuries and defects
in the head, neck, face, jaws and the hard
and soft tissues of the oral (mouth) and
maxillofacial (jaws and face) region. It is
an internationally recognized surgical
specialty. In some countries, including the
United States, it is a recognized specialty of
dentistry; in others, including the UK, it is
recognized as a medical specialty.
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Surgical procedures
Treatments may be performed on the craniomaxillofacial complex:
mouth, jaws, face, neck, skull, and include:
Dentoalveolar surgery (surgery to remove impacted teeth, difficult tooth
extractions, extractions on medically compromised patients, bone
grafting or preprosthetic surgery to provide better anatomy for the
placement of implants, dentures, or other dental prostheses)
Surgery to insert osseointegrated (bone fused) dental implants and
Maxillofacial implants for attaching craniofacial prostheses and bone
anchored hearing aids.
Cosmetic surgery of the head and neck: (rhytidectomy/facelift, browlift,
blepharoplasty/Asian blepharoplasty, otoplasty, rhinoplasty, septoplasty,
cheek augmentation, chin augmentation, genioplasty, oculoplastics, neck
liposuction, lip enhancement, injectable cosmetic treatments, botox,
chemical peel etc.)
Surgical treatment and/or splinting of sleep apnea, maxillomandibular
advancement, genioplasty
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Diagnosis and treatment of:
benign pathology (cysts, tumors etc.)
malignant pathology (oral & head and neck cancer) with (ablative
and reconstructive surgery, microsurgery)
cutaneous malignancy (skin cancer), lip reconstruction
congenital craniofacial malformations such as cleft lip and palate
and cranial vault malformations such as craniosynostosis,
(craniofacial surgery)
chronic facial pain disorders
temporomandibular joint (TMJ) disorders
Dysgnathia (incorrect bite), and orthognathic (literally "straight
bite") reconstructive surgery, orthognathic surgery,
maxillomandibular advancement, surgical correction of facial
asymmetry.
soft and hard tissue trauma of the oral and maxillofacial region
(jaw fractures, cheek bone fractures, nasal fractures, LeFort
fracture, skull fractures and eye socket fractures).
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How does a patient prepare for oral surgery?
Oral surgery can be a frightening experience, but proper
preparation can go far in making the procedure easier to anticipate.
The first step is to consult with the dentist or oral surgeon about the
procedure to understand what will be involved. The dentist will
give a brief description of how the procedure will be performed and
the medications used before, during and afterward. Patients
particularly nervous about the impending surgery may want to ask
about sedation options available.
The patient will be given a list of pre-operative instructions. It is
imperative to follow the instructions very carefully to ensure the
procedure will be safe and successful. Arrange for transportation to
and from the surgery, since certain medications may make it
impossible for the patient to drive himself. Take the necessary time
off work as recommended by the doctor.
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Objectives
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Patient data
Doctor – patient relationship
Anesthetic plan
Patient consent
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1.Review of patient data
 Medical record
 Interview history
History of underlying disease,
medication,
functional capacitance,
previous anesthetic history,
family history,
smoking and alcoholic use,
review of system,
psychological support
Airway evaluation
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1.Review of patient data
 Surgical condition
-Condition of disease, symptom of disease
-Surgical procedure
-Position of procedure
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2. Physical examination
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Vital signs
General appearance
HEENT
Respiratory system
CVS system
Abdomen
Extremities and spine
Neurologic system
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Airway evaluation
 History of difficult intubation
 Head and neck examination for airway
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evaluation
Face
Oral cavity : mouth opening
mandibular space
tongue
teeth
Mallampati classification
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Airway evaluation
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Mentothyroid distance : normal 6 cm.
Mentosternal distance : normal 15 cm
Mentohyoid distance : normal 3 FB
Neck movement: flexion and extension of
neck, history of radiation
Nasal cavity
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Thyromental distance
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Difficult intubation
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Mouth opening less than 3 cm.
Limitation of neck movement
Micrognatia
Macroglossia
Protusion of teeth
Short neck
Morbid obesity
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3.Laboratory data
 Value of testing
 Risk and costs benefits
 Preoperative testing: base on indication
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What is Pain?
The answer to this question seems obvious - pain is
pain, right? Pain is pain, but it's not all the same. The
International Association for the Study of Pain (IASP)
defines pain as “an unpleasant sensory and emotional
experience associated with actual or potential tissue
damage or described in terms of such damage.”
However, pain is a symptom that cannot be objectively
assessed. I can’t look at a patient and know precisely
what hurts, how badly, and what the pain feels like.
Pain, therefore, is whatever the person experiencing it
says it is.
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Introduction
 The practice of various psychological, physical,
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and chemical approaches to the prevention and
treatment of preoperative, operative, and
postoperative anxiety and pain.
Methods of pain control
• Anesthetic agents
• Inhalation sedation
• Antianxiety agents
• Intravenous sedation
• General anesthesia
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Anesthetic Agents
 The numbing of a specific site or area.
 Topical Anesthesia provides a temporary
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numbing effect on nerve endings that are
located on the surface of the oral mucosa.
Supplied as:
• Ointments
• Liquids
• Sprays
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Local Anesthesia
 Agents most frequently used for pain control in
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dentistry.
Criteria for use:
• Be nonirritating to the tissues in the area of
the injection.
• Produce minimal toxicity.
• Be of rapid onset.
• Provide profound anesthesia.
• Be of sufficient duration.
• Be completely reversible.
• Be sterile.
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Method of Action
 Local anesthesia temporarily blocks the normal
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generation and conduction action of the nerve
impulses.
Local anesthesia is obtained by injecting the
anesthetic agent near the nerve in the area
intended for dental treatment.
Induction time is the length of time from the
injection of the anesthetic solution to complete
and effective conduction blockage.
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Duration
 Length of time from induction until the reversal
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process is complete.
Short-acting:
• Local anesthetic agent lasts less than 30
minutes.
Intermediate-acting:
• Local anesthetic agent lasts about 60 minutes.
Long-acting:
• Local anesthetic agent lasts longer than 90
minutes.
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Vasoconstrictor
 Criteria for use:
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• Prolongs the duration of an anesthetic agent
by decreasing the blood flow in the immediate
area of the injection.
• Decreases bleeding in the area during surgical
procedures.
Types:
• Epinephrine
• Levonordefrin
• Norepinephrine
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Vasoconstrictor- cont’d
 Ratio of vasoconstrictor to anesthetic
solution:
• 1:20,000
• 1:50,000
• 1:100,000
• 1:200,000
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Vasoconstrictor- cont’d
 Contraindications for the use of
vasoconstrictors
• Unstable angina.
• Recent myocardial infarction.
• Recent coronary artery bypass surgery.
• Untreated or uncontrolled severe
hypertension.
• Untreated or uncontrolled congestive heart
failure.
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Types of Local Anesthesia Injections
 Infiltration is achieved by injecting the solution
directly into the tissue at the site of the dental
procedure.
• Most frequently used to anesthetize the
maxillary teeth.
• Used as a secondary injection to block
gingival tissues surrounding the mandibular
teeth.
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Types of Local Anesthesia Injections- cont’d
 Block anesthesia
• The solution is injected near a major nerve, and
the entire area served by that nerve is numbed.
• Type of injection required for most mandibular
teeth.
 Inferior alveolar nerve block
• Obtained by injecting the anesthetic solution near
the branch of the inferior alveolar nerve close to
the mandibular foramen.
• Type of injection for half of the lower jaw,
including the teeth, tongue, and lip.
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Types of Local Anesthesia Injections- cont’d
 Incisive nerve block
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• Injection given at the site of the mental
foramen.
• Used when the mandibular anterior teeth
or premolars require anesthesia.
Periodontal ligament
• Alternative infiltration anesthesia method by
which the anesthetic solution is injected
directly into the periodontal ligament and
surrounding tissues.
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Table 37-2 Local Anesthesia Setup: Anesthetic Syringe
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Local Anesthesia Setup
 Anesthetic carpule: Care and caution of use
• Cartridges should be stored at room temperature
and protected from direct sunlight.
• Never use a cartridge that has been frozen.
• Do not use a cartridge if it is cracked, chipped, or
damaged in any way.
• Never use a solution that is discolored or cloudy
or has passed the expiration date.
• Do not leave the syringe preloaded with the
needle attached for an extended period of time.
• Never save a cartridge for reuse.
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Local Anesthetic Cautions
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Injection into a blood vessel
Infected area
Localized toxic reaction
Systemic toxic reaction
Temporary numbness
Paresthesia
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General Anesthesia
 A controlled state of unconsciousness in which
there is a loss of protective reflexes, including
the ability to maintain an airway independently
and to respond appropriately to physical
stimulation or verbal command. This controlled
state in loss of consciousness, produces stage
III general anesthesia.
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Four Stages of Anesthesia
 Stage I: Analgesia is the stage at which a
patient is relaxed and fully conscious. The
patient is able to keep his or her mouth open
without assistance and is capable of following
directions. The patient will have a sense of
euphoria and a reduction in pain. Vital signs
are normal. Depending on the agent, the
patient can move into different levels of
analgesia.
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Four Stages of Anesthesia- cont’d
 Stage II: Excitement is the stage at which
a patient is less aware of his or her
immediate surroundings and can start to
become unconscious. The patient can
become excited and unmanageable. Nausea
and vomiting can occur. This is an
undesirable stage.
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Four Stages of Anesthesia- cont’d
 Stage III: General anesthesia is the stage
of anesthesia that begins when the patient
becomes calm after stage II. The patient feels
no pain or sensation. The patient will become
unconscious. This stage of anesthesia can be
met only under the guidance of an
anesthesiologist in a controlled environment
such as a hospital.
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Four Stages of Anesthesia- cont’d
 Stage IV: Respiratory failure or cardiac
arrest is the stage at which the lungs and
heart slow down or stop functioning. If this
stage is not reversed quickly, the patient will
die.
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General Anesthesia- cont’d
 Patient preparation
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• Preoperative physical examination.
• Laboratory tests.
• Patient or legal guardian must sign a consent
form.
Preoperative instructions
• Dentist will review the procedure, as well as
the risks.
• Must not have anything to drink or eat 8 to
12 hours before receiving general anesthesia.
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Main stages of resuscitation
A (Airway) – ensure open airway by preventing
the falling back of tongue, tracheal
intubation if possible
B (Breathing) – start artificial ventilation of
lungs
C (Circulation) – restore the circulation by
external cardiac massage
D (Differentiation, Drugs, Defibrilation) –
quickly perform differential diagnosis of
cardiac arrest, use different medication and
electric defibrillation in case of ventricular
fibrillation
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A (Airway)
ensure open
airway
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B (Breathing)
Tilt the head back
and listen for. If
not breathing
normally, pinch
nose and cover
the mouth with
yours and blow
until you see the
chest rise.
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C. Circulation
Restore the circulation, that is
start external cardiac massage
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ALGORITHM of Cardiopulmonary resuscitation
2 breaths (durationa 1 – 1.5 sec.)
palpation of pulse on carotid arteries (5 – 10 sec.)
1
person
in case of absence of pulse initiate
external cardiac massage
a
compression rate 80 – 100/min.
compression/breath = 15 : 2
2 breathsa in 4 – 7 sec.
4 cycles: 15 compression
and 2 breaths
2
persons
compression rate 80 – 100/min
compression/breath = 5 : 1
breath during 1 – 1.5 sec. after
each 5th compression
10 cycles: 5 compression
and 1 breath
check the pulse on carotid arteries (5 sec)
in case of absence of pulse continue resuscitation
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Drugs used in CPR
• Atropine – can be injected bolus, max 3 mg to
block vagal tone, which plays significant role in
some cases of cardiac arrest
• Adrenaline – large doses have been
withdrawn from the algorithm. The
recommended dose is 1 mg in each 3-5 min.
• Vasopresine – in some cases 40 U can
replace adrenaline
• Amiodarone - should be included in algorithm
• Lidocaine – should be used only in ventricular
fibrillation
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Thank you for
attention
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