DENTAL ANESTHESIA COMPLICATIONS IN THE DENTAL CHAIR

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 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 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 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 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

Quantiflex Machine Nasal Mask Rubber Dam

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 Anesthesia Induction Inhalational (mask) induction N2O/O2 (>30%) + Halothane (3%) common, smooth Enflurane (>3%) less potent Isoflurane Respiratory irritation Sevoflurane New, smooth, less potent

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

Out-Patient Dental Anesthesia Maintenance 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 Anesthesia Recovery Left lateral position 100% O2 Suction Observation & monitoring Discharge criteria Instructions Analgesia (NSAIDs)

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

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

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

Out-Patient Dental Anesthesia Complications Allergic Reaction 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)

Out-Patient Dental Anesthesia Complications 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% O2 Cessation of anesthesia

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

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