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Copyright 2003, Elsevier Science (USA). All rights reserved.
Chapter 37Anesthesia and Pain Control
in Dentistry
Chapter 37Anesthesia and Pain Control
in Dentistry
Copyright 2003, Elsevier Science (USA)
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Produced in the United States of America
ISBN 0-7216-9770-4
Copyright 2003, Elsevier Science (USA). All rights reserved.
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
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
IntroductionIntroduction
Copyright 2003, Elsevier Science (USA). All rights reserved.
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
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
Anesthetic AgentsAnesthetic Agents
Copyright 2003, Elsevier Science (USA). All rights reserved.
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.
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.
Local AnesthesiaLocal Anesthesia
Copyright 2003, Elsevier Science (USA). All rights reserved.
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.
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.
Method of ActionMethod of Action
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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.
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.
DurationDuration
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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
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
VasoconstrictorVasoconstrictor
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Ratio of vasoconstrictor to anesthetic solution:
• 1:20,000• 1:50,000• 1:100,000• 1:200,000
Ratio of vasoconstrictor to anesthetic solution:
• 1:20,000• 1:50,000• 1:100,000• 1:200,000
Vasoconstrictor cont’dVasoconstrictor cont’d
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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.
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.
Vasoconstrictor cont’dVasoconstrictor cont’d
Copyright 2003, Elsevier Science (USA). All rights reserved.
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.
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.
Types of Local Anesthesia InjectionsTypes of Local Anesthesia Injections
Copyright 2003, Elsevier Science (USA). All rights reserved.
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.
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.
Types of Local Anesthesia Injections cont’dTypes of Local Anesthesia Injections cont’d
Copyright 2003, Elsevier Science (USA). All rights reserved.
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.
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.
Types of Local Anesthesia Injections cont’dTypes of Local Anesthesia Injections cont’d
Copyright 2003, Elsevier Science (USA). All rights reserved.
Table 37-2 Local Anesthesia Setup: Anesthetic SyringeTable 37-2 Local Anesthesia Setup: Anesthetic Syringe
Copyright 2003, Elsevier Science (USA). All rights reserved.
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.
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.
Local Anesthesia SetupLocal Anesthesia Setup
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Table 37-3 Disposable NeedleTable 37-3 Disposable Needle
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Injection into a blood vessel Infected area Localized toxic reaction Systemic toxic reaction Temporary numbness Paresthesia
Injection into a blood vessel Infected area Localized toxic reaction Systemic toxic reaction Temporary numbness Paresthesia
Local Anesthetic CautionsLocal Anesthetic Cautions
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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.
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.
Electronic AnesthesiaElectronic Anesthesia
Copyright 2003, Elsevier Science (USA). All rights reserved.
Nitrous oxide/oxygen (N²O/O²) 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.
Nitrous oxide/oxygen (N²O/O²) 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.
Inhalation SedationInhalation Sedation
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Pregnancy: First trimester Nasal obstruction: Problems inhaling
through the nose Emphysema: Increased O²
Multiple sclerosis: Breathing difficulties
Emotional stability: Altered perception of reality
Pregnancy: First trimester Nasal obstruction: Problems inhaling
through the nose Emphysema: Increased O²
Multiple sclerosis: Breathing difficulties
Emotional stability: Altered perception of reality
Contraindication of Using N²O/O
²Contraindication of Using N
²O/O
²
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Cylinders: Gases are dispensed in steel cylinders, which are colored green for O² and blue for N²O.
N²O 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.
Cylinders: Gases are dispensed in steel cylinders, which are colored green for O² and blue for N²O.
N²O 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.
Inhalation Sedation EquipmentInhalation Sedation Equipment
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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 N²O.
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 N²O.
Inhalation Sedation Equipment cont’dInhalation Sedation Equipment cont’d
Copyright 2003, Elsevier Science (USA). All rights reserved.
Used only for patient treatment. Never administered for recreational
purposes. How to reduce N²O 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 N²O monitoring badge system.
Used only for patient treatment. Never administered for recreational
purposes. How to reduce N²O 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 N²O monitoring badge system.
Exposure to Nitrous OxideExposure to Nitrous Oxide
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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.
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.
Patient Preparation for Inhalation SedationPatient Preparation for Inhalation Sedation
Copyright 2003, Elsevier Science (USA). All rights reserved.
Start with pure oxygen while establishing the patient’s tidal volume.
Slowly titrate the nitrous oxide until the desired results are achieved.
Patients should refrain from talking or mouth breathing.
The N²O/O² analgesia should end with the administration of 100% O² for 3 to 5 minutes.
Obtain postoperative vital signs and compare them to the preoperative recordings.
Start with pure oxygen while establishing the patient’s tidal volume.
Slowly titrate the nitrous oxide until the desired results are achieved.
Patients should refrain from talking or mouth breathing.
The N²O/O² analgesia should end with the administration of 100% O² for 3 to 5 minutes.
Obtain postoperative vital signs and compare them to the preoperative recordings.
Assisting in the Administration ofInhalation SedationAssisting in the Administration ofInhalation Sedation
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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.
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.
Antianxiety AgentsAntianxiety Agents
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Commonly prescribed:• Secobarbital sodium (Seconal) • Chlordiazepoxide HCl (Librium) • Diazepam (Valium) • Chloral hydrate (Noctec): For children
Commonly prescribed:• Secobarbital sodium (Seconal) • Chlordiazepoxide HCl (Librium) • Diazepam (Valium) • Chloral hydrate (Noctec): For children
SedativesSedatives
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Antianxiety drugs that are administered intravenously continuously throughout a procedure at a slower pace, providing a deeper stage I analgesia.
Antianxiety drugs that are administered intravenously continuously throughout a procedure at a slower pace, providing a deeper stage I analgesia.
Intravenous SedationIntravenous Sedation
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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.
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.
Intravenous Sedation cont’dIntravenous Sedation cont’d
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Patient monitoring Physiologic measurements taken and
recorded every 15 minutes.• Level of consciousness• Respiratory function• Oximetry• Blood pressure• Heart rate• Cardiac rhythm
Patient monitoring Physiologic measurements taken and
recorded every 15 minutes.• Level of consciousness• Respiratory function• Oximetry• Blood pressure• Heart rate• Cardiac rhythm
Intravenous Sedation cont’dIntravenous Sedation cont’d
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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.
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.
General Anesthesia General Anesthesia
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Pharmacologic make-up• Combination of gases
• N²O/O²
• Halothane or enflurane mixtures• Intravenous agents such as thiopental
sodium and methohexital sodium
Pharmacologic make-up• Combination of gases
• N²O/O²
• Halothane or enflurane mixtures• Intravenous agents such as thiopental
sodium and methohexital sodium
General Anesthesia cont’d General Anesthesia cont’d
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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.
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.
Four Stages of AnesthesiaFour Stages of Anesthesia
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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.
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.
Four Stages of Anesthesia cont’dFour Stages of Anesthesia cont’d
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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.
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.
Four Stages of Anesthesia cont’dFour Stages of Anesthesia cont’d
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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.
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.
Four Stages of Anesthesia cont’dFour Stages of Anesthesia cont’d
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Patient preparation• 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.
Patient preparation• 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.
General Anesthesia cont’d General Anesthesia cont’d
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Always document the following measures and observations:• Review of patient’s medical history. • Preoperative and postoperative vital
signs. • Patient’s 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.
Always document the following measures and observations:• Review of patient’s medical history. • Preoperative and postoperative vital
signs. • Patient’s 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.
Record Keeping for Sedation MethodsRecord Keeping for Sedation Methods
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