Anesthesia for dental procedures Dr S Parthasarathy MD

Anesthesia for dental procedures Dr. S. Parthasarathy MD, DA, DNB, Dip Diab. MD , DCA, Dip software based statistics, Ph. D (physiology)

Anesthesia started with dentistry Horace wells administered himself nitrous oxide – his colleague extracted his tooth in 1844 In 1846, morton did it again !!

Usually not called for !! • • Children Mentally retarded adults Dental phobia Acute pus Radiotherapy previous –( LA Vs GA) Allergy to local anesthetics Major surgeries (difficult dental extractions or for dental releasing surgeries)

Contraindications !! • Serious medical disease ? ? Can we do as an outpatient ? ? Eg. CHF, anticoagulants, • Swelling of the neck • Anesthetist – inexperienced

Three types of anesthesia • Dental chair anaesthesia, • Day care anaesthesia • In-patient anaesthesia.

Problems in dental chair Venous return decrease ? Venous embolism Unprotected airway Aspiration of blood or mucus Adrenaline in local anaesthetic can cause arrhythmias in presence of halothane • Higher incidence of arrhythmias due to stimulation of 5 th cranial nerve • • •

Problems in dental chair • Nasal bleeding if nasal airway is used to deliver the anaesthetic • Fainting due to cerebral hypoxia • Difficulty in initiating CPCR once cardiac arrest occurs • Foreign body obstruction of the airway by needles or dentures, necessitating removal by bronchoscopy • BABA FACE - pnemonic

• Preoperative work up √ • Equipments √ • Nasal airway

ECO mask – goldman mask Intermittent machines , haloxair ? ?

Haloxair unit

Newer set ups

SAFE short acting fast emergence • Bowel bladder evacuation • Inj. Atropine • Sevoflurane induction – previously halothane • Nitrous oxygen 65 – 35 + sevo – 50% fio 2 - better • Action in a few seconds • Recover !! SAFE agents !!

Older children • Propofol is definite • Thio and keta ? ? are other options • Suction – two machines IV sedation with MAC – OK !? Drooping of upper eye lid over pupil – patient is under !!- verrill sign Transparent neonatal mask

Position on induction !! Maximal time

Airways • • Nasal masks Nasal airways - mouth packs !! Mouth gag on the opposite side The surgeon finishes the procedure in a few seconds Allow to breathe through nose If adenoids , nasal airway is a must Intubate ? ? Devonshire Mckesson prop

Usually nasotracheal • Difficult access as in impacted tooth, macroglossia, short neck • Excessive uncontrolled bleeding Inpatients ? • maxillofacial or major dental surgery • Mentally handicapped • Obstruction of nasal passages, large adenoids where nasal mask is not effective

Semi sitting position problems ? ?

Intraoperative problem • There is a possibility of surgical emphysema or mediastinal emphysema following use of air turbine dental drills. • Stop nitrous oxide. • Diagnose a rare pneumothorax, • IPPV - ? • ICD - !

Intraoperative problems • • • Arrhythmias – adrenaline, halo , V th nerve Aspiration Laryngospasm Mouth breathing Fainting – oxygen, Iv fluids, stop manipulation Single click switch back to supine position Labile patients !!

• Arrest • Collapse • Anaphylaxis Think of dental chair

Use of the LMA for Dental Anaesthesia • Young (1991) has discussed the experience of using the regular nonreinforced LMA for dental work, usually for extractions and fillings in children. • Use of the LMA is said to be easier for the anesthetist than a nasal mask. • Throat pack – ok Reinforced LMA – good- less interference with dentist • Airway problems – more common – surgeons move all bones !! – manipulate and adjust mild – it becomes acceptable

Recovery • • Tooth sockets may continue to bleed. Complete awake Reflexes Packs Left lateral remove Suction 30 minutes atleast oxygen Nil oral for 3 -4 hours

EJOA – precision delivery of local anesthetic

Nerve blocks • Posterior Superior Alveolar Nerve Block • Middle superior alveolar nerve block • Anterior superior alveolar nerve block • Inferior alveolar nerve block

Middle superior alveolar nerve block • Mucobuccal fold above second premolar • 5 mm depth – 1 ml

posterior superior alveolar nerve block • height of the mucobuccal fold above and distal to distobuccal root of the last molar present in the arch • Upward (superiorly at a 45 degree angle to the occlusal plane). Inward (medially toward the midline at a 45 degree angle to the occlusal plane). • Backward (posteriorly at a 45 degree angle to the long axis of the molar) to a depth of 10 -14 mm.

Canine eminence ( infra orbital nerve block ) • Anterior superior alveolar nerve block

Inferior alveolar nerve block • anesthetic solution at the retromolar triangle which is a triangular area located near to the distal side of the lower third molar.

• Hypnosis • Acupuncture • Had roles but now ? ?

Post operative pain • Extraction of baby teeth is not especially painful. • The main problem is the psychological trauma of waking up uncomfortable in a strange place. • Para or syr. Ibuprofen sufficient

Poswilla report 1990 • IV sedation single drug with nitrous (LA) – patient talking • Operator and anesthetist – different • All monitors including defibrillator • Experienced

Summary • • • Three types Dental chair dangers Indications Contraindications LA alone , IVS with MAC, Nasal airway – 50 % O 2 LMA Intubate SAFE agents Recovery Nerve blocks Poswilla report

Thank you all There is no minor anesthetic technique Same vigilance