DENTAL ANESTHESIA COMPLICATIONS IN THE DENTAL CHAIR

1. DENTAL ANESTHESIACOMPLICATIONS IN THE DENTAL CHAIR

3. 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

4. Out-Patient Dental Anesthesia • Dental Chair Anesthesia • Out-Patient dental extraction • Children (4-10 years): high incidence of URTI • Steadily decreased

5. Out-patient Dental AnesthesiaPatient Selection (&Indications) • ASA grade I&II • Disability (mental& physical) Review: coexisting disease current medications • Fearful adults rather sedation • Procedure short not so extensive

6. Out-Patient Dental AnesthesiaContraindications • 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

7. Out-Patient Dental AnesthesiaEquipment (Up to the standards of in-patient GA) • Dental Chair • Anesthetic equipment • Monitoring • Resuscitation equipment

8. Dental Chair • Adjustable: horizontal (supine) Head down • Manual release • Adjustable head rest • Hospital out-patient:operating table

9. Anesthesia Equipment • Continuous flow anesthesia machine • Quantiflex (Relative Analgesia) • Mouth props, packs, gags, nasopharyngeal airway, rubber dam • Separate suction unit • Scavenging system

10. Nasal Mask Rubber Dam Quantiflex Machine

11. Monitoring • Pulse • ECG • NIBP • Pulse Oximetry • Capnography

12. Resuscitation Equipment • Full range of tracheal tubes& accessories • Two working laryngoscope • IV agents: Succinylcholine& atropine • Emergency drugs • Defibrillator • Training: B&ALS

13. Out-Patient Dental AnesthesiaInduction • Inhalational (mask) induction N2O/O2 (>30%) + Halothane (3%) common, smooth Enflurane (>3%) less potent Isoflurane Respiratory irritation Sevoflurane New, smooth, less potent

14. Out-Patient Dental AnesthesiaInduction • Intravenous Induction AdvantagesAvoidance of face mask Less salivation Less atmospheric pollution Disadvantages CV depression Drugs MethohexitoneLow incidence of nausea &vomiting Good recovery Pain on injection, involuntary movements, hiccups & respiratory depression Propofol

15. Out-Patient Dental AnesthesiaMaintenance • 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

16. Out-Patient Dental AnesthesiaRecovery • Left lateral position • 100% O2 • Suction Observation & monitoring • Discharge criteria • Instructions • Analgesia (NSAIDs)

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

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

19. Out-Patient Dental AnesthesiaComplications • 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)

20. Out-Patient Dental AnesthesiaComplications • 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)

21. Out-Patient Dental AnesthesiaComplications • Allergic Reaction Manifestations - Hypotension, tachycardia, arrhythmias - Bronchospasm,cough, dyspnea, pulmonary oedema, laryngeal oedema, hypoxia - Urticaria, facial oedema, pruritus

22. Out-Patient Dental AnesthesiaComplications • 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)

23. Out-Patient Dental AnesthesiaComplications • 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

24. Out-Patient Dental AnesthesiaComplications Miscellaneous • Nasal trauma, epistaxis • Diffusion hypoxia • Continued bleeding Postoperative • Sore throat • Nausea & vomiting • Pain & swelling

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