DENTAL ANESTHESIA

COMPLICATIONS IN THE DENTAL CHAIR

SAAD A. SHETA
Assistant Professor Consultant Anesthesia Dental College KSU

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 Procedure rather sedation 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 Anesthesia

Induction

Inhalational (mask) induction Intravenous Induction

Out-Patient Dental Anesthesia

Induction

Inhalational (mask) induction

N2O/O2 + Halothane Enflurane Isoflurane Sevoflurane

Common, smooth Less potent Respiratory irritation New, smooth, less potent

Out-Patient Dental Anesthesia

Induction Intravenous Induction
Advantages Avoidance of face mask Less salivation Less atmospheric pollution CV depression

Disadvantages Drugs Methohexitone

Low incidence of nausea & vomiting Good recovery Pain on injection, Involuntary movements, hiccups

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)

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 Sedation Deep Sedation General Anesthesia

Conscious Sedation

It is a controlled, pharmacologically Induced, minimally depressed level of consciousness that retains the patients 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

Sedation
Fundamental 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.

Sedation
Fundamental 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

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

Most complications occurred with polypharmacology in the hands of untrained personnel

Dental Chair Complications

Respiratory Complications Cardiovascular Complications Allergic Reaction Miscellaneous

 Respiratory Complications

Airway Obstruction Respiratory Depression

 Respiratory complications
Airway Obstruction
Causes Tongue Blood, debris Laryngeal spasm A-W Obstruction Hypoxia

Respiratory Depression
Narcotics Over-sedation Hypoventilation Hypercapnia Hypoxia Ventilation Reversal Agents

Clinical Picture

Management

Patent airway Oxygenation

Airway Obstruction

Most common cause: tongue and/or epiglottis

Open the Airway Position

Jaw thrust

Head tiltchin lift

Open the Airway Oropharyngeal Airway

Open the Airway Nasopharyngeal Airway

Open the Airway Endotracheal Intubation Aligning Axes of the Airway

Open the Airway Endotracheal Intubation Laryngoscopes

Open the Airway Endotracheal Intubation Visualization of the Cord

Open the Airway Laryngeal Mask Airway (LMA)

Open the Airway

Esophageal-Tracheal Combitube

Oxygenation
Adjunct Devices

Ventilation
Bag-Mask Ventilation

Key ventilation volume: enough to produce obvious chest rise

1 Person difficult, less effective

2 Persons easier, more effective

 Cardiovascular Complications

Hypotension Bradycardia Dysrhythmia Fainting

 Hypotension Induction of anesthesia Carotid sinus compression Over sadation

Bradycardia
Tooth extraction Halothane (nodal rhythm)

 Dysrhythmias Aetiology

(Tachy-arrhythmias)

(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)

Aetiology
limbic cortex-hypothalamus-reflex vasodilatation Increase parasympathetic activity-bradycardia

Management

Head 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

THANK YOU