DENTAL ANESTHESIA COMPLICATIONS IN THE DENTAL CHAIR Dental

DENTAL ANESTHESIA COMPLICATIONS IN THE DENTAL CHAIR

Dental Anesthesia n Out-Patient anesthesia (Dental Chair Anesthesia) n Day-Case anesthesia n In-Patient anesthesia Complete Dental rehabilitation Complicated oral surgery procedures Major Maxillofacial surgeries n In addition, Sedation Techniques

Out-Patient Dental Anesthesia n Dental Chair Anesthesia n Out-Patient dental extraction n Children (4 -10 years): high incidence of URTI n Steadily decreased

Out-patient Dental Anesthesia Patient Selection (&Indications) n ASA grade I&II n Disability (mental& physical) Review: coexisting disease current medications n Fearful adults rather sedation n Procedure short not so extensive

Out-Patient Dental Anesthesia Contraindications n Serious cardiopulmonary diseases n COPD n Diabetes or other endocrinological diseases n Neuromuscular disorders n Coagulopathies & Hemoglobinopathies n Marked oro-facial swelling (edema& trismus) n Potential difficult airways n Marked congenital heart defects n Extreme obesity n Drugs: MAOIs , Anticoagulant n Not fasting

Out-Patient Dental Anesthesia Equipment (Up to the standards of in-patient GA) n Dental Chair n Anesthetic equipment n Monitoring n Resuscitation equipment

Dental Chair n Adjustable: horizontal (supine) Head down n Manual release n Adjustable head rest n Hospital out-patient: operating table

Anesthesia Equipment n Continuous flow anesthesia machine n Quantiflex (Relative Analgesia) n Mouth props, packs, airway, rubber dam n Separate suction unit n Scavenging system gags, nasopharyngeal

Quantiflex Machine Nasal Mask Rubber Dam

Monitoring n Pulse n ECG n NIBP n Pulse Oximetry n Capnography

Resuscitation Equipment n Full range of tracheal tubes& accessories n Two working laryngoscope n IV agents: Succinylcholine& atropine n Emergency drugs n Defibrillator n Training: B&ALS

Out-Patient Dental Anesthesia Induction n Inhalational (mask) induction N 2 O/O 2 (>30%) + Halothane (3%) Enflurane (>3%) Isoflurane Sevoflurane common, smooth less potent Respiratory irritation New, smooth, less potent

Out-Patient Dental Anesthesia Induction n Intravenous Induction Advantages Avoidance of face mask Less salivation Less atmospheric pollution Disadvantages Drugs Methohexitone Propofol CV depression Low incidence of nausea &vomiting Good recovery Pain on injection, involuntary movements, hiccups & respiratory depression

Out-Patient Dental Anesthesia Maintenance n Inhalational agents/N 2 O n Nasal mask, mouth gag, pack n Maintain airway Posture (Supine Position) n Less hypotension n less bradycardia However n high risk of aspiration n Airway obstruction& n Decrease ERV

Out-Patient Dental Anesthesia Recovery n Left lateral position n 100% O 2 n Suction Observation & monitoring n Discharge criteria n Instructions n Analgesia (NSAIDs)

Out-Patient Dental Anesthesia Complications Respiratory Complications n Airway Obstruction (Tongue, Adenoid, Pack, debris…} n Respiratory arrest n Laryngeal spasm n Pulmonary aspiration

Out-Patient Dental Anesthesia Complications Cardiovascular Complications n Hypotension Induction of anesthesia Carotid sinus compression n Bradycardia Tooth extraction Halothane(nodal rhythm)

Out-Patient Dental Anesthesia Complications n Dysrhythmias (Tachy-arrhythmias) Aetiology (Tooth extraction) - High preoperative catecholamines - Light anesthesia - Airway obstruction & hypoxia - Halothane & local anesthesia - Local anesthesia with vasopressor Significance - Controversial - Significant with unexpected cardiac disease(viral myocarditis)

Out-Patient Dental Anesthesia Complications n Allergic Reaction Incidence - Very rare - More commonly (vaso-vagal, Toxic reaction, epinephrine) Aetiology - Ig E-mediated reaction - Easter-linked: p-amino benzoic acid - Amide-linked: preservatives (Paraben)

Out-Patient Dental Anesthesia Complications n Allergic Reaction Manifestations - Hypotension, tachycardia, arrhythmias - Bronchospasm, cough, dyspnea, pulmonary oedema, laryngeal oedema, hypoxia - Urticaria, facial oedema, pruritus

Out-Patient Dental Anesthesia Complications n Allergic Reaction Management - Discontinue drug - 100% O 2 - Epinephrine (0. 01 -0. 5 mg IV or IM) - Intubation - IV fluids (LRS 1 -2 liters) - Diphenhydramine - Hydrocortisone (up to 200 mg IV)

Out-Patient Dental Anesthesia Complications n Fainting Causes Previous factors (CV, allergic, . . ) Emotional factors (more common) Aetiology limbic cortex-hypothalamus-reflex vasodilatation Increase parasympathetic activity-bradycardia Management Head down-leg elevated 100% O 2 Cessation of anesthesia

Out-Patient Dental Anesthesia Complications Miscellaneous n Nasal trauma, epistaxis n Diffusion hypoxia n Continued bleeding Postoperative n Sore throat n Nausea & vomiting n Pain & swelling

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