1. General Anaesthesia for Dental Procedures
By: Dr. Mahmoud Al-mustafa
Associate Professor
Dept of Anaesthesia
Faculty of Medicine – The University of Jordan
24 December 2013

2. Sensations Peripheral:
Pain
Temperature
Touch
deep
light
Proprioception
Special senses
Central: Awareness:  Apprehension; Fear and Anxiety

3. Anaesthesia
In Surgery it implies : reversibly rendering the patient unconscious by drugs for the execution of a painful operative procedure - in a titrable and controlled way.

4. - Antidiuretic hormone
Surgery
Trauma  stress on the living body
Metabolic Response to stress
Neural Component  Autonomic system
- Sympathetic
- Parasympathetic
Endocrine Component  Hormonal System
- Growth Hormone
- Cortisol
- glucagon
- Antidiuretic hormone
- Renin – Aldosterone
- etc ……

5. Anaesthesia
Modulates the stress response by blocking the afferent limb of the response .
Pain and awareness are blocked by anesthetic drugs , but other afferent limb factors are not ( e.g. Hypovolemia, hypoxemia, etc)
 complete medical management of the patient – peri -operative Medical management

7. Anaesthesia Modern Anaesthesia is Composed of:
Hypnosis: Inducing Controlled Loss of
Awareness
Analgesia: Inducing Controlled Loss of Pain
(+/-) Muscle Relaxation( Controlled muscle Paralysis)

8. Hypnosis In Anaesthesia
*Hypnosis: The state of being asleep
Pharmacologically induced
A non-physiological very deep level of
sleep that deprives the patient from critical facullties.
Can and should be titrated according to the level of surgical stimulus

9. Analgesia * State of freedom from pain Analgesia vs. anaesthesia:
Analgesia can be brought about by local or regional techniques, or drugs with specific pain receptors action
( e.g. Opioids) without Loss of consciousness.

10. Muscle relaxation
Paralyzing the patient’s muscles by use of drugs that block the acetylcholine receptors at the Neuromuscular junction
Purposes:
Facilitation of airway management
Control of Ventilation
Facilitation of Surgery
Patient should be artificially ventilated !!

11. Stages of Anesthesia 2- Stage of uninhibited response (Excitement):
1- Stage of analgesia:
Diminished pain perception, verbal contact
maintained, laryngopharyngeal reflexes and
voluntary control Present
2- Stage of uninhibited response (Excitement):
Consciousness lost, verbal contact and voluntary
control lost  uncontrolled, exaggerated, withdrawal
type response to any stimulus
Protective laryngopharyngeal reflexes maintained !

12. Stages of Anesthesia (continued)
3- Stage of Surgical Anaesthesia:
Centers of the medulla become
progressively depressed (vomiting, striated
muscle tone, respiratory)
Autonomic reflexes depressed
It is the stage at which anaesthesia has depressed both the reticular activating system and perhaps selectively the pain synapses of the spinal cord and is the stage at which operations may be performed
Divided into Four planes according to the depth of anaesthesia and marked by cessation of breathing at its lower end.

13. Stages of Anesthesia (continued)
Stage 4: Stage of Respiratory Arrest
* Cessation of Respiration = Cardiac Arrest
* Anoxia
* Direct Cardiac effects : e.g. arrhythmias
* Danger of Death
* Should not be reached by anaesthetist

14. Anesthesia in Dentistry
1- Local Anaesthesia
2- Sedation
3- General Anaesthesia

15. Dental Procedures Requiring Sedation or General Anesthesia
1- Oral Surgery:
Removal of impacted teeth
Multiple Dental extractions
- Preprosthetic Surgery (Vestibuloplasties)
Insertion of Osteointegrated plants
Others….

16. Dental Procedures Requiring Sedation or General Anesthesia (CONTINUED)
2- Restorative Dentistry:
Multiple dental restorative procedures
(e.g. Rampant Caries)
- Procedures performed on Mentally Retarded Patients

17. Dental Procedures Requiring Sedation or General Anesthesia (CONTINUED)
3-Temporomandibular Joint:
Arthroscopy
- Arthroplasty

18. Dental Procedures Requiring Sedation or General Anesthesia (CONTINUED)
4- Maxillofacial Surgery:
- Trauma
- Tumor
- Reconstructive

19. Dental Procedures Requiring Sedation or General Anesthesia (CONTINUED)
5- Special patient Groups:
Young Children esp. some with systemic Diseases (hemophilia,CHD)
Mentally retarded
Patients with poorly controlled Seizure activity
- Those with an oral septic focus

20. Problems Related to Dental Anaesthesia
1- In / Outpatient selectivity
2- Competition for the Airway by both Dentist and Anaesthetist
3- Patients are often children
4- Mentally handicapped patients

21. Conduct of Anaesthesia
1- Pre-Operative Assessment
2- Intra-Operative Management
3- Post-Operative Management

22. Pre-Operative Assessment
- History :medical,surgical,Anaesthetic,& Allergy
- Medical Examination
- Investigations: as per case
- Informed Consent: signed by patient or
guardian

23. Risk classification ASA I : A normal Healthy patient 0.06-0.08%
ASA II : A patient with mild systemic disease %
ASA III: A patient with severe systemic disease %
ASA IV: A patient with severe systemic disease
that is a constant threat to life %
ASA V: Moribund patient who is not expected to
survive without the operation %
ASA VI: A declared brain dead patient whose
organs are being removed for donor purposes
“E” For Emergency surgery

24. Intra-Operative Management
1- Establishing Monitoring:
Heart Rate, Blood Pressure, Electrocardiogram, Pulse Oxymetry,
End Tidal CO2 Monitoring
2- Induction of Anesthesia :
- Hypnosis => - Intravenous Drugs: (e.g. Sodium Thiopentone ,
Propofol, Etomidate, Ketamine ……)
- Analgesia => - Nitrous Oxide gas
- Opioid Drugs: Morphine, Pethidine,
Fentanyl, Alfentanyl, Sufentanyl,
Remifentanyl ….
- Muscle Relaxation =>
- short Acting: Suxamethonium( used for rapid sequince induction)
- Intermediate acting: Atracurium, Cis- atracurium, Vecuronium, Rocuronium,
- Long Acting: d-tudocurarine, Pancuronium

25. Monitoring

26. End Tidal CO2
Value less than arterial CO2 3-5 mmHg

27. Intraoperative Management continued
3- Maintenance of Anaesthesia =>
- Intravenous drug infusion for short acting
drugs
- Inhalational Agents for Hypnosis:
(e.g. Halthane,Sevoflurane,Isoflurane , Enflurane,desflorane, Nitrous Oxide, etc.. )
- Intermittent doses for intermediate or long acting muscle relaxants and analgesics

28. Intraoperative Management continued
4- Securing the Airway :
* Using a Cuffed Endotracheal Tube
- Orally
- Nasally: Better surgical access
* Throat pack
* Meticulous Suctioning

29. Endotracheal Tube

31. laryngeal mask airway

32. Intraoperative Management continued
5- Securing Ventilation
- Spontaneous Breathing
- Manual ventilation
- Using a mechanical Ventilator
6- Surgery Starts
* Continuous Monitoring for
- A,B,C
- Adequate Anaesthesia
-Necessary medical management

34. Intra-operative Issues
Loose Teeth
Surgical Debris
Bleeding
Secretions
Use of Throat Pack
Endocarditis Prophylaxis

35. Post–Operative Management
1- Emergence from Anesthesia
* Patient in Left Lateral Position
* Turn Anaesthetics off
* Reversal of residual Muscle relaxation
Anti-dote drug: e.g. Neostigmine
* Extubation of the airways
2- Sending patient to Recovery Room
3- Recovery Room Nursing:
Monitoring and Management
4- Assessment of Patient before Discharge
By anaesthetist

36. Recovery Room Issues Recovery Room Issues:
- Nursing in Lateral position
- Management of complications : Pain, Nausea, Vomiting, Hypoxia, etc
- Assessment by Anaesthetist before Discharge
- prescribing oral analgesic drugs if patient is sent home
- Advice NOT to Drive or operate machinery for 24 hours at least
- making sure that there is somebody to escort
patient home

37. Thank You