1. General Anaesthesia for Dental Procedures
Dr Walid Zuabi
FCA RCSI
Consultant Anesthetist JUH

2. Anaesthesia
Terminology:
An-  No
Esthesia  Sensation

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

4. Anaesthesia
Implies reversibly rendering the patient unconscious by drugs for the execution of a painful operative procedure - in a titrated & controlled
way.

5. Surgery Trauma  stress Metabolic Response to stress:
Neural Component  Autonomic system
- Sympathetic
- Parasympathetic
Endocrine Component  Hormonal System
- Growth Hormone
- Cortisol
- glucagon
- Antidiuretic
- Renin & Aldosterone

6. Anaesthesia
Modulates the stress response by blocking the afferent limb of the response
Pain and awareness are blocked by anaesthetic drugs but other afferent limb factors are not/ Hypovolemia & hypoxemia
 Complete medical management of the patient: pre, intra & post-op management.

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

8. Hypnosis *Hypnosis: The state of being asleep.
Pharmacologically induced: non-physiological very deep level of
sleep that deprives the patient from his control.
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
( Opioids) without Loss of consciousness.

10. Muscle Relaxation
Paralyzing the patient’s skeletal muscles by use of drugs that block the acetylcholine receptors at the Neuromuscular junction
Purposes:
Facilitate airway management
Prevents aspiration
Control of Ventilation
Facilitate Surgery
Should patients be artificially ventilated!!

11. Stages of Anesthesia 2- Stage of uninhibited response (Excitement):
Divided into Four planes according to the depth and marked by cessation of breathing at its lower end.
1- Stage of analgesia:
Diminished pain perception while verbal contact & laryngopharyngeal reflexes and voluntary control Present
2- Stage of uninhibited response (Excitement):
LOC, verbal contact & voluntary control  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 this stage at which anaesthesia has depressed both the reticular activating system and selectively the pain synapses of the spinal cord and is the stage at which operations may be performed

13. Stages of Anesthesia (continued)
4- Stage of Respiratory Arrest
* Cessation of Respiration  Cardiac Arrest
* Anoxia
* Direct Cardiac effects: arrhythmias
* Danger of Death

14. Stages of Anesthesia 1- Stage of analgesia:
Diminished pain perception, verbal contact
maintained laryngopharyngeal reflexes and present
voluntary control.
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!
3- Stage of Surgical Anaesthesia:
4- Stage of Respiratory Arrest

15. In Dentistry
1- Local Anaesthesia
2- Sedation
3- General Anaesthesia

16. Dental Procedures Requiring General Anesthesia
1- Oral Surgery:
Removal of impacted teeth
Multiple extractions
- Preprosthetic Surgery
- Insertion of Osteointegrated implants

17. Dental Procedures Requiring General Anesthesia
2- Restorative Dentistry:
Multiple dental restorative procedures
- Procedures on special needs patients

18. Dental Procedures Requiring General Anesthesia
3-TMJ:
Arthroscopy
- Arthroplasty

19. Dental Procedures Requiring General Anesthesia
4- Maxillofacial Surgery:
- Trauma
- Tumors
- Reconstructive

20. Dental Procedures Requiring General Anesthesia
5- Special patient groups:
Young Children with systemic Diseases (hemophilia & CHD)
Patients with poor controlled Seizures
- Those with an oral septic focus

21. Summary of Fasting Recommendations

22. Summary of Fasting Recommendations
Clear liquids 2 Hrs

23. Summary of Fasting Recommendations
Clear liquids 2 Hrs
Solids 6 Hrs

24. Summary of Fasting Recommendations
Clear liquids 2 Hrs
Solids 6 Hrs
Nonhuman milk 6 Hrs

25. Summary of Fasting Recommendations
Clear liquids 2 Hrs
Solids 6 Hrs
Nonhuman milk 6 Hrs
Infant formula 6 Hrs

26. Summary of Fasting Recommendations
Clear liquids 2 Hrs
Solids 6 Hrs
Nonhuman milk 6 Hrs
Infant formula 6 Hrs
Light meal 6 Hrs

27. Summary of Fasting Recommendations
Clear liquids 2 Hrs
Solids 6 Hrs
Nonhuman milk 6 Hrs
Infant formula 6 Hrs
Light meal 6 Hrs
Breast milk 4 Hrs

28. Preoperative Pharmacologic Interventions
GI stimulants (metoclopramide)
Block of gastric acid secretion
H2 antagonists (cimetidine, ranitidine)
PPI (omeprazole, lansoprazole)
Antacids (sodium citrate)
Antiemetics (ondansetron)
Anticholinergics (atropine, glycopyrrolate)

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

30. Conduct of Anaesthesia
Pre-Operative Assessment
Intra-Operative Management
Post-Operative Care

31. Pre-Operative Assessment
- History: medical, surgical, anaesthetic & Allergy
- Physical Examination
- Investigations: accordingly.. INR or ECHO!
- Informed Consent: signed by patient or guardian

32. 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

33. Intra-Op Management 1- Establishing Monitoring:
Heart Rate, Blood Pressure, Electrocardiogram, Pulse Ox & ETCO2
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
- Intermediate: Atracurium, Cisatracurium,
Vecuronium, Rocuronium,
- Long Acting: d-tudocurarine, Pancuronium

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

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

36. Endotracheal Tube

39. Intraoperative Management continued
5- Securing Ventilation
- Spontaneous Breathing
- Manual ventilation
- Ventilator/ PPV
6- Surgery Starts
* Continuous Monitoring for
- A,B,C
- Adequate Anaesthesia
-Necessary management

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

41. Postop Management By anaesthetist 1- Emergence from Anesthesia
* Anaesthetics off
Recovery in Lateral Position
* * Reversal of residual Muscle relaxation
Anti-dote: Neostigmine with atropine
* Extubation
2- PACU:
Monitoring and Active Management
3- Assessment before Discharge
By anaesthetist

42. Recovery Room Issues - Nursing in Lateral position
- Management of complications: Pain, N&V, bleeding & hypoxia etc..
- Oral analgesia if sent home
- NOT to Drive or operate machinery for 24
hours AND making sure that there is somebody to escort patient home.

44. In summary Understanding the concept, limits & limitations.
The pharmacology of drugs used, when to & when not to use them.
Pts selection & preparation.
NPO
Recognizing troubles and managing them.
Postop care.