Chapter 37

Anesthesia and Pain Control in Dentistry

Copyright 2003, Elsevier Science (USA)
All rights reserved. No part of this product may be reproduced or transmitted in any form or by any means, electronic or mechanical, including input into or storage in any information system, without permission in writing from the publisher. PowerPoint presentation slides may be displayed and may be reproduced in print form for instructional purposes only, provided a proper copyright notice appears on the last page of each print-out. Produced in the United States of America ISBN 0-7216-9770-4

Copyright 2003, Elsevier Science (USA). All rights reserved.

Introduction

The practice of various psychological, physical,

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

Copyright 2003, Elsevier Science (USA). All rights reserved.

Anesthetic Agents
The numbing of a specific site or area. Topical Anesthesia provides a temporary
numbing effect on nerve endings that are located on the surface of the oral mucosa. Supplied as: Ointments Liquids Sprays

Copyright 2003, Elsevier Science (USA). All rights reserved.

Local Anesthesia
Agents most frequently used for pain control in

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.

Copyright 2003, Elsevier Science (USA). All rights reserved.

Method of Action
Local anesthesia temporarily blocks the normal
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.

Copyright 2003, Elsevier Science (USA). All rights reserved.

Duration

Length of time from induction until the reversal

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.

Copyright 2003, Elsevier Science (USA). All rights reserved.

Vasoconstrictor
Criteria for use:
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

Copyright 2003, Elsevier Science (USA). All rights reserved.

Vasoconstrictor- contd
Ratio of vasoconstrictor to anesthetic
solution: 1:20,000 1:50,000 1:100,000 1:200,000

Copyright 2003, Elsevier Science (USA). All rights reserved.

Vasoconstrictor- contd
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.

Copyright 2003, Elsevier Science (USA). All rights reserved.

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.

Copyright 2003, Elsevier Science (USA). All rights reserved.

Types of Local Anesthesia Injections- contd

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.

Copyright 2003, Elsevier Science (USA). All rights reserved.

Types of Local Anesthesia Injections- contd

Incisive nerve block
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.

Copyright 2003, Elsevier Science (USA). All rights reserved.

Table 37-2 Local Anesthesia Setup: Anesthetic Syringe

Copyright 2003, Elsevier Science (USA). All rights reserved.

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.

Copyright 2003, Elsevier Science (USA). All rights reserved.

Table 37-3 Disposable Needle

Copyright 2003, Elsevier Science (USA). All rights reserved.

Local Anesthetic Cautions

Injection into a blood vessel Infected area Localized toxic reaction Systemic toxic reaction Temporary numbness Paresthesia

Copyright 2003, Elsevier Science (USA). All rights reserved.

Electronic Anesthesia
A noninvasive method to block pain electronically by
using a low current of electricity through contact pads that target a specific electronic waveform directly to the nerve bundle at the root of the tooth. Benefits to the patient: No needles. No post-operative numbness or swelling. Chemical-free method of anesthesia. No risk of cross-contamination. Reduces fear and anxiety. Patients have control over their own comfort level.

Copyright 2003, Elsevier Science (USA). All rights reserved.

Inhalation Sedation
Nitrous oxide/oxygen (NO/O) is a
combination of these gases that the patient inhales to help eliminate fear and to help the patient relax. History Dates back to 1844. Dr. Horace Wells first used it on his patients. Effects Non addictive. Easy onset, minimal side effects, and rapid recovery. Produces stage I anesthesia. Dulls the perception of pain.
Copyright 2003, Elsevier Science (USA). All rights reserved.

Contraindication of Using N O/O

Pregnancy: First trimester Nasal obstruction: Problems inhaling
through the nose Emphysema: Increased O Multiple sclerosis: Breathing difficulties Emotional stability: Altered perception of reality

Copyright 2003, Elsevier Science (USA). All rights reserved.

Inhalation Sedation Equipment

Cylinders: Gases are dispensed in steel cylinders,
which are colored green for O and blue for NO. NO machines: Portable or part of the dental unit. Control valves: Control the flow of each gas. Flowmeter: Indicates the rate of flow of the gases. Reservoir bag: The two gases are combined in this bag and the patient draws on it for breathing.

Copyright 2003, Elsevier Science (USA). All rights reserved.

Inhalation Sedation Equipment- contd

Gas hose
Carries the gases from the reservoir bag to the mask or nosepiece. Masks: Supplied in sizes for adults and children The nosepiece through which the patient breathes the gases. Scavenger system Protection from the occupational risks of NO.

Copyright 2003, Elsevier Science (USA). All rights reserved.

Exposure to Nitrous Oxide

Used only for patient treatment. Never administered for recreational purposes. How to reduce NO hazards to dental
personnel Use a scavenger system. Use a patient mask that fits well. Discourage patients from talking. Vent gas outside the building. Routinely inspect equipment and hoses for leaks. Use an NO monitoring badge system.

Copyright 2003, Elsevier Science (USA). All rights reserved.

Patient Preparation for Inhalation Sedation

Review health history. Obtain base-line vital signs. Describe the procedure of administering the

gases. Describe the use of the mask and the importance of nasal breathing. Describe the sensations that the patient will experience. Reassure the patient.

Copyright 2003, Elsevier Science (USA). All rights reserved.

Assisting in the Administration of Inhalation Sedation

Start with pure oxygen while establishing the

patients tidal volume. Slowly titrate the nitrous oxide until the desired results are achieved. Patients should refrain from talking or mouth breathing. The NO/O analgesia should end with the administration of 100% O for 3 to 5 minutes. Obtain postoperative vital signs and compare them to the preoperative recordings.

Copyright 2003, Elsevier Science (USA). All rights reserved.

Antianxiety Agents
For the relief of anxiety. Sedatives Criteria for use:
Patients are very nervous about a procedure. Procedures are long or difficult. Mentally challenged patients. Very young children requiring extensive treatment.

Copyright 2003, Elsevier Science (USA). All rights reserved.

Sedatives
Commonly prescribed:
Secobarbital sodium (Seconal) Chlordiazepoxide HCl (Librium) Diazepam (Valium) Chloral hydrate (Noctec): For children

Copyright 2003, Elsevier Science (USA). All rights reserved.

Intravenous Sedation
Antianxiety drugs that are administered
intravenously continuously throughout a procedure at a slower pace, providing a deeper stage I analgesia.

Copyright 2003, Elsevier Science (USA). All rights reserved.

Intravenous Sedation- contd

Patient assessment
A health history, physical examination, and signed consent are performed. Baseline vital signs are taken and recorded. Oximetry and electrocardiogram are completed and recorded. Weight taken and recorded for dose determination.

Copyright 2003, Elsevier Science (USA). All rights reserved.

Intravenous Sedation- contd

Patient monitoring Physiologic measurements taken and recorded
every 15 minutes. Level of consciousness Respiratory function Oximetry Blood pressure Heart rate Cardiac rhythm

Copyright 2003, Elsevier Science (USA). All rights reserved.

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.

Copyright 2003, Elsevier Science (USA). All rights reserved.

General Anesthesia- contd

Pharmacologic make-up
Combination of gases NO/O Halothane or enflurane mixtures Intravenous agents such as thiopental sodium and methohexital sodium

Copyright 2003, Elsevier Science (USA). All rights reserved.

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.

Copyright 2003, Elsevier Science (USA). All rights reserved.

Four Stages of Anesthesia- contd

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.

Copyright 2003, Elsevier Science (USA). All rights reserved.

Four Stages of Anesthesia- contd

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.

Copyright 2003, Elsevier Science (USA). All rights reserved.

Four Stages of Anesthesia- contd

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.

Copyright 2003, Elsevier Science (USA). All rights reserved.

 Patient preparation

General Anesthesia- contd

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.

Copyright 2003, Elsevier Science (USA). All rights reserved.

Record Keeping for Sedation Methods

Always document the following measures and
observations: Review of patients medical history. Preoperative and postoperative vital signs. Patients tidal volume if using inhalation sedation. Time anesthesia began and ended. Peak concentration administered. Amount of postoperative time (in minutes) for patient recovery. Adverse events or patient complaints.

Copyright 2003, Elsevier Science (USA). All rights reserved.