DENTAL ANESTHESIA

COMPLICATIONS IN THE DENTAL CHAIR

SAAD A. SHETA

Assistant Professor Consultant Anesthesia

Dental CollegeKSU

Dental Anesthesia

Out-Patient Anesthesia (Dental Chair Anesthesia)

Day-Case Anesthesia

In-Patient Anesthesia Complete Dental rehabilitation Complicated oral surgery procedures Major Maxillofacial surgeries

In addition, Sedation

Complications

Out-Patient Anesthesia (Dental Chair Anesthesia) Sedation Techniques

Out-Patient Dental Anesthesia

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

Out-patient Dental Anesthesia (Sedation)Patient Selection (&Indications)

• ASA grade I&II

• Disability (mental& physical) Review: coexisting disease

current medications

• Fearful adults rather sedation

• Procedure short not so extensive

Out-Patient Dental Anesthesia (Sedation)Contraindications

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

Out-Patient Dental Anesthesia (Sedation)Equipment (Up to the standards of in-patient GA)

Dental Chair Anesthetic Equipment Monitoring Resuscitation Equipment

Dental Chair

Adjustable: horizontal (supine)

Head down Manual release Adjustable head rest Hospital out-patient:operating table

Anesthesia Equipment

Continuous flow anesthesia machine Quantiflex (Relative Analgesia) Mouth props, packs, gags, nasopharyngeal airway,

rubber dam Separate suction unit Scavenging system

Monitoring

Pulse ECG NIBP Pulse Oximetry Capnography

Resuscitation Equipment

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

Out-Patient Dental AnesthesiaInduction

Inhalational (mask) induction Intravenous Induction

Out-Patient Dental AnesthesiaInduction

Inhalational (mask) induction

N2O/O2 +Halothane Common, smoothEnflurane Less potentIsoflurane Respiratory irritationSevoflurane New, smooth, less potent

Out-Patient Dental AnesthesiaInduction

Intravenous InductionAdvantages Avoidance of face mask

Less salivation Less atmospheric pollution

Disadvantages CV depression

DrugsMethohexitone Low incidence of nausea & vomiting

Good recovery

Pain on injection, Involuntary movements, hiccups

Propofol

Out-Patient Dental AnesthesiaMaintenance

Inhalational agents/N2O Nasal mask, mouth gag, pack Maintain airway

Posture (Supine Position) Less hypotension less bradycardia

However high risk of aspiration Airway obstruction& Decrease ERV

Out-Patient Dental AnesthesiaRecovery

Left lateral position 100% O2 Suction Observation & monitoring Discharge criteria Instructions Analgesia (NSAIDs)

Sedation

It is a technique where one or more drugs are used to

Depress the Central Nervous System of a patient thus reducing the awareness of the patient to his surrounding.

According to the degree of CNS depression:

Conscious SedationDeep SedationGeneral Anesthesia

Conscious Sedation

It is a controlled, pharmacologically Induced, minimally depressed level of consciousness that retains the patient’s ability to maintain a patent airway independently and continuously and respond appropriately to physical and/or verbal command

Deep Sedation

It is a controlled, pharmacologically induced state of depressed level of consciousness. from which the patient is not easily aroused and which may be accompanied

by a partial loss of protective reflexes,including the ability to maintain a patent airway independently and/or respond purposefully to physical stimulation or verbal commands

General Anesthesia

It is defined as:

unconsciousness

no response to pain

labile vital signs

GA is defined separately, however for the purpose of of describing management, the two phrases (GA & Deep Sedation) refer to one physiologic state

SedationFundamental Concepts

It is easy to drift from one state to another.

Patient state is considered in terms of the level of consciousness rather than the technique involved.

SedationFundamental Concepts

Sedation techniques are not pain-control techniques

One should guard against becoming comfortable with a single method. The treatment should fit the patient rather than the converse

Sedation Techniques

Non Titrable Technique

Oral Sedation Rectal Sedation Intramuscular Sedation Submucosal Sedation Intranasal Sedation

Titrable Technique

Inhalational Sedation Intravenous Sedation

Combination Of Two

Combination of Methods and Techniques

Most complications occurred with polypharmacology in the hands of untrained personnel

AUGMENTATION OF THE EFFECT + REDUCE THE DOSE OF STONGER DRUGS.

Dental Chair Complications

Respiratory Complications Cardiovascular Complications Allergic Reaction Miscellaneous

Respiratory Complications

Airway Obstruction Respiratory Depression

Respiratory complications

Airway ObstructionRespiratory Depression

Causes Tongue Blood, debris Laryngeal spasm

Narcotics Over-sedation

Clinical Picture A-W Obstruction Hypoxia

Hypoventilation Hypercapnia Hypoxia

Management Patent airway Oxygenation

Ventilation Reversal Agents

Airway ObstructionMost common cause: tongue and/or epiglottis

Open the AirwayPosition

Jaw thrust Head tilt–chin lift

Open the AirwayOropharyngeal Airway

Open the AirwayNasopharyngeal Airway

Open the AirwayEndotracheal Intubation “Aligning Axes of the Airway”

Open the AirwayEndotracheal Intubation “ Laryngoscopes ”

Open the AirwayEndotracheal Intubation “ Visualization of the Cord ”

Open the AirwayLaryngeal Mask Airway (LMA)

Open the AirwayEsophageal-Tracheal Combitube

OxygenationAdjunct Devices

Ventilation Bag-Mask Ventilation

Key ventilation volume: “enough to produce obvious chest rise”

1 Persondifficult, less effective

2 Personseasier, more effective

Cardiovascular Complications

Hypotension Bradycardia Dysrhythmia Fainting

Hypotension

Induction of anesthesia

Carotid sinus compression

Over sadation

Bradycardia

Tooth extraction

Halothane (nodal rhythm)

Dysrhythmias (Tachy-arrhythmias)

Aetiology (Tooth extraction)

High preoperative catecholamines Light anesthesia Airway obstruction & hypoxia Halothane & local anesthesia Local anesthesia with vasopressors

Significance Controversial Significant with unexpected cardiac disease(viral

myocarditis)

Fainting

Causes Previous factors (CV, allergic,..)Emotional factors (more common)

Aetiologylimbic cortex-hypothalamus-reflex vasodilatation

Increase parasympathetic activity-bradycardia

ManagementHead down-leg elevated

100% O2

Cessation of anesthesia

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)

Manifestations

Hypotension, tachycardia, arrhythmias

Bronchospasm, cough, dyspnea, pulmonary oedema, laryngeal oedema, hypoxia

Urticaria, facial oedema, pruritus

Management

Discontinue drug 100% O2 Epinephrine (0.01-0.5 mg IV or IM) Intubation IV fluids (LRS 1-2 liters) Diphenhydramine Hydrocortisone (up to 200mg IV)

Miscellaneous

Nasal Trauma, Epistaxis Pulmonary Aspiration Diffusion Hypoxia Continued Bleeding Post operative Sore Throat Post operative Nausea & vomiting Post operative Pain & swelling

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