Anesthesia for dental procedures Dr. S. Parthasarathy MD, DA, DNB, Dip Diab.MD ,DCA, Dip software based statistics, PhD (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

Intermittent machines , haloxair ?? 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% fio2- better Action in a few seconds Recover !! SAFE agents !!

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

Position on induction !! Maximal time

Airways Intubate ?? 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 Devonshire Mckesson prop Intubate ??

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

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 Airway problems – more common – surgeons move all bones !! – manipulate and adjust mild – it becomes acceptable Reinforced LMA – good- less interference with dentist

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

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 10-14mm.

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 % O2 LMA Intubate SAFE agents Recovery Nerve blocks Poswilla report

There is no minor anesthetic technique Thank you all There is no minor anesthetic technique Same vigilance