Copyright 2003, Elsevier Science (USA). All rights reserved. Chapter 37 Anesthesia and Pain Control in Dentistry Copyright 2003, Elsevier Science (USA)

Copyright 2003, Elsevier Science (USA). All rights reserved.

Chapter 37Anesthesia and Pain Control

in Dentistry

Chapter 37Anesthesia and Pain Control

in Dentistry

Copyright 2003, Elsevier Science (USA)

All rights reserved. No part of this product may be reproduced or transmitted in any form or by any means, electronic or mechanical, including input into or storage in any information system, without permission in writing from the publisher.

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Produced in the United States of America

ISBN 0-7216-9770-4


The practice of various psychological, physical, and chemical approaches to the prevention and treatment of preoperative, operative, and postoperative anxiety and pain.

Methods of pain control• Anesthetic agents • Inhalation sedation• Antianxiety agents • Intravenous sedation • General anesthesia

The practice of various psychological, physical, and chemical approaches to the prevention and treatment of preoperative, operative, and postoperative anxiety and pain.

Methods of pain control• Anesthetic agents • Inhalation sedation• Antianxiety agents • Intravenous sedation • General anesthesia

IntroductionIntroduction


The numbing of a specific site or area. Topical Anesthesia provides a

temporary numbing effect on nerve endings that are located on the surface of the oral mucosa.

Supplied as:• Ointments• Liquids• Sprays

The numbing of a specific site or area. Topical Anesthesia provides a

temporary numbing effect on nerve endings that are located on the surface of the oral mucosa.

Supplied as:• Ointments• Liquids• Sprays

Anesthetic AgentsAnesthetic Agents


Agents most frequently used for pain control in dentistry.

Criteria for use:• Be nonirritating to the tissues in the

area of the injection. • Produce minimal toxicity. • Be of rapid onset. • Provide profound anesthesia. • Be of sufficient duration. • Be completely reversible. • Be sterile.

Agents most frequently used for pain control in dentistry.

Criteria for use:• Be nonirritating to the tissues in the

area of the injection. • Produce minimal toxicity. • Be of rapid onset. • Provide profound anesthesia. • Be of sufficient duration. • Be completely reversible. • Be sterile.

Local AnesthesiaLocal Anesthesia


Local anesthesia temporarily blocks the normal generation and conduction action of the nerve impulses.

Local anesthesia is obtained by injecting the anesthetic agent near the nerve in the area intended for dental treatment.

Induction time is the length of time from the injection of the anesthetic solution to complete and effective conduction blockage.

Local anesthesia temporarily blocks the normal generation and conduction action of the nerve impulses.

Local anesthesia is obtained by injecting the anesthetic agent near the nerve in the area intended for dental treatment.

Induction time is the length of time from the injection of the anesthetic solution to complete and effective conduction blockage.

Method of ActionMethod of Action


Length of time from induction until the reversal process is complete.

Short-acting:• Local anesthetic agent lasts less than 30

minutes. Intermediate-acting:

• Local anesthetic agent lasts about 60 minutes.

Long-acting:• Local anesthetic agent lasts longer than

90 minutes.

Length of time from induction until the reversal process is complete.

Short-acting:• Local anesthetic agent lasts less than 30

minutes. Intermediate-acting:

• Local anesthetic agent lasts about 60 minutes.

Long-acting:• Local anesthetic agent lasts longer than

90 minutes.

DurationDuration


Criteria for use:• Prolongs the duration of an anesthetic

agent by decreasing the blood flow in the immediate area of the injection.

• Decreases bleeding in the area during surgical procedures.

Types:• Epinephrine • Levonordefrin • Norepinephrine

Criteria for use:• Prolongs the duration of an anesthetic

agent by decreasing the blood flow in the immediate area of the injection.

• Decreases bleeding in the area during surgical procedures.

Types:• Epinephrine • Levonordefrin • Norepinephrine

VasoconstrictorVasoconstrictor


Ratio of vasoconstrictor to anesthetic solution:

• 1:20,000• 1:50,000• 1:100,000• 1:200,000

Ratio of vasoconstrictor to anesthetic solution:

• 1:20,000• 1:50,000• 1:100,000• 1:200,000

Vasoconstrictor cont’dVasoconstrictor cont’d


Contraindications for the use of vasoconstrictors • Unstable angina. • Recent myocardial infarction. • Recent coronary artery bypass surgery. • Untreated or uncontrolled severe

hypertension. • Untreated or uncontrolled congestive

heart failure.

Contraindications for the use of vasoconstrictors • Unstable angina. • Recent myocardial infarction. • Recent coronary artery bypass surgery. • Untreated or uncontrolled severe

hypertension. • Untreated or uncontrolled congestive

heart failure.

Vasoconstrictor cont’dVasoconstrictor cont’d


Infiltration is achieved by injecting the solution directly into the tissue at the site of the dental procedure.• Most frequently used to anesthetize the

maxillary teeth. • Used as a secondary injection to block

gingival tissues surrounding the mandibular teeth.

Infiltration is achieved by injecting the solution directly into the tissue at the site of the dental procedure.• Most frequently used to anesthetize the

maxillary teeth. • Used as a secondary injection to block

gingival tissues surrounding the mandibular teeth.

Types of Local Anesthesia InjectionsTypes of Local Anesthesia Injections


Block anesthesia• The solution is injected near a major nerve,

and the entire area served by that nerve is numbed.

• Type of injection required for most mandibular teeth.

Inferior alveolar nerve block • Obtained by injecting the anesthetic

solution near the branch of the inferior alveolar nerve close to the mandibular foramen.

• Type of injection for half of the lower jaw, including the teeth, tongue, and lip.

Block anesthesia• The solution is injected near a major nerve,

and the entire area served by that nerve is numbed.

• Type of injection required for most mandibular teeth.

Inferior alveolar nerve block • Obtained by injecting the anesthetic

solution near the branch of the inferior alveolar nerve close to the mandibular foramen.

• Type of injection for half of the lower jaw, including the teeth, tongue, and lip.

Types of Local Anesthesia Injections cont’dTypes of Local Anesthesia Injections cont’d


Incisive nerve block• Injection given at the site of the mental

foramen. • Used when the mandibular anterior

teeth or premolars require anesthesia. Periodontal ligament

• Alternative infiltration anesthesia method by which the anesthetic solution is injected directly into the periodontal ligament and surrounding tissues.

Incisive nerve block• Injection given at the site of the mental

foramen. • Used when the mandibular anterior

teeth or premolars require anesthesia. Periodontal ligament

• Alternative infiltration anesthesia method by which the anesthetic solution is injected directly into the periodontal ligament and surrounding tissues.

Types of Local Anesthesia Injections cont’dTypes of Local Anesthesia Injections cont’d


Table 37-2 Local Anesthesia Setup: Anesthetic SyringeTable 37-2 Local Anesthesia Setup: Anesthetic Syringe


Anesthetic carpule: Care and caution of use• Cartridges should be stored at room

temperature and protected from direct sunlight.

• Never use a cartridge that has been frozen. • Do not use a cartridge if it is cracked,

chipped, or damaged in any way. • Never use a solution that is discolored or

cloudy or has passed the expiration date. • Do not leave the syringe preloaded with

the needle attached for an extended period of time.

• Never save a cartridge for reuse.

Anesthetic carpule: Care and caution of use• Cartridges should be stored at room

temperature and protected from direct sunlight.

• Never use a cartridge that has been frozen. • Do not use a cartridge if it is cracked,

chipped, or damaged in any way. • Never use a solution that is discolored or

cloudy or has passed the expiration date. • Do not leave the syringe preloaded with

the needle attached for an extended period of time.

• Never save a cartridge for reuse.

Local Anesthesia SetupLocal Anesthesia Setup


Table 37-3 Disposable NeedleTable 37-3 Disposable Needle


Injection into a blood vessel Infected area Localized toxic reaction Systemic toxic reaction Temporary numbness Paresthesia

Injection into a blood vessel Infected area Localized toxic reaction Systemic toxic reaction Temporary numbness Paresthesia

Local Anesthetic CautionsLocal Anesthetic Cautions


A noninvasive method to block pain electronically by using a low current of electricity through contact pads that target a specific electronic waveform directly to the nerve bundle at the root of the tooth.

Benefits to the patient:• No needles. • No post-operative numbness or swelling. • Chemical-free method of anesthesia. • No risk of cross-contamination. • Reduces fear and anxiety. • Patients have control over their own

comfort level.

A noninvasive method to block pain electronically by using a low current of electricity through contact pads that target a specific electronic waveform directly to the nerve bundle at the root of the tooth.

Benefits to the patient:• No needles. • No post-operative numbness or swelling. • Chemical-free method of anesthesia. • No risk of cross-contamination. • Reduces fear and anxiety. • Patients have control over their own

comfort level.

Electronic AnesthesiaElectronic Anesthesia


Nitrous oxide/oxygen (N²O/O²) is a combination of these gases that the patient inhales to help eliminate fear and to help the patient relax.

History• Dates back to 1844. • Dr. Horace Wells first used it on his

patients. Effects

• Non addictive.• Easy onset, minimal side effects, and rapid

recovery.• Produces stage I anesthesia. • Dulls the perception of pain.

Nitrous oxide/oxygen (N²O/O²) is a combination of these gases that the patient inhales to help eliminate fear and to help the patient relax.

History• Dates back to 1844. • Dr. Horace Wells first used it on his

patients. Effects

• Non addictive.• Easy onset, minimal side effects, and rapid

recovery.• Produces stage I anesthesia. • Dulls the perception of pain.

Inhalation SedationInhalation Sedation


Pregnancy: First trimester Nasal obstruction: Problems inhaling

through the nose Emphysema: Increased O²

Multiple sclerosis: Breathing difficulties

Emotional stability: Altered perception of reality

Pregnancy: First trimester Nasal obstruction: Problems inhaling

through the nose Emphysema: Increased O²

Multiple sclerosis: Breathing difficulties

Emotional stability: Altered perception of reality

Contraindication of Using N²O/O

²Contraindication of Using N

²O/O

²


Cylinders: Gases are dispensed in steel cylinders, which are colored green for O² and blue for N²O.

N²O machines: Portable or part of the dental unit.• Control valves: Control the flow of each

gas.• Flowmeter: Indicates the rate of flow of

the gases. • Reservoir bag: The two gases are

combined in this bag and the patient draws on it for breathing.

Cylinders: Gases are dispensed in steel cylinders, which are colored green for O² and blue for N²O.

N²O machines: Portable or part of the dental unit.• Control valves: Control the flow of each

gas.• Flowmeter: Indicates the rate of flow of

the gases. • Reservoir bag: The two gases are

combined in this bag and the patient draws on it for breathing.

Inhalation Sedation EquipmentInhalation Sedation Equipment


Gas hose • Carries the gases from the reservoir bag

to the mask or nosepiece. Masks: Supplied in sizes for adults and

children• The nosepiece through which the

patient breathes the gases. Scavenger system

• Protection from the occupational risks of N²O.

Gas hose • Carries the gases from the reservoir bag

to the mask or nosepiece. Masks: Supplied in sizes for adults and

children• The nosepiece through which the

patient breathes the gases. Scavenger system

• Protection from the occupational risks of N²O.

Inhalation Sedation Equipment cont’dInhalation Sedation Equipment cont’d


Used only for patient treatment. Never administered for recreational

purposes. How to reduce N²O hazards to dental

personnel • Use a scavenger system. • Use a patient mask that fits well.• Discourage patients from talking. • Vent gas outside the building. • Routinely inspect equipment and hoses

for leaks. • Use an N²O monitoring badge system.

Used only for patient treatment. Never administered for recreational

purposes. How to reduce N²O hazards to dental

personnel • Use a scavenger system. • Use a patient mask that fits well.• Discourage patients from talking. • Vent gas outside the building. • Routinely inspect equipment and hoses

for leaks. • Use an N²O monitoring badge system.

Exposure to Nitrous OxideExposure to Nitrous Oxide


Review health history. Obtain base-line vital signs. Describe the procedure of administering

the gases. Describe the use of the mask and the

importance of nasal breathing. Describe the sensations that the patient

will experience. Reassure the patient.

Review health history. Obtain base-line vital signs. Describe the procedure of administering

the gases. Describe the use of the mask and the

importance of nasal breathing. Describe the sensations that the patient

will experience. Reassure the patient.

Patient Preparation for Inhalation SedationPatient Preparation for Inhalation Sedation


Start with pure oxygen while establishing the patient’s tidal volume.

Slowly titrate the nitrous oxide until the desired results are achieved.

Patients should refrain from talking or mouth breathing.

The N²O/O² analgesia should end with the administration of 100% O² for 3 to 5 minutes.

Obtain postoperative vital signs and compare them to the preoperative recordings.

Start with pure oxygen while establishing the patient’s tidal volume.

Slowly titrate the nitrous oxide until the desired results are achieved.

Patients should refrain from talking or mouth breathing.

The N²O/O² analgesia should end with the administration of 100% O² for 3 to 5 minutes.

Obtain postoperative vital signs and compare them to the preoperative recordings.

Assisting in the Administration ofInhalation SedationAssisting in the Administration ofInhalation Sedation


For the relief of anxiety. Sedatives Criteria for use:

• Patients are very nervous about a procedure.

• Procedures are long or difficult. • Mentally challenged patients. • Very young children requiring extensive

treatment.

For the relief of anxiety. Sedatives Criteria for use:

• Patients are very nervous about a procedure.

• Procedures are long or difficult. • Mentally challenged patients. • Very young children requiring extensive

treatment.

Antianxiety AgentsAntianxiety Agents


Commonly prescribed:• Secobarbital sodium (Seconal) • Chlordiazepoxide HCl (Librium) • Diazepam (Valium) • Chloral hydrate (Noctec): For children

Commonly prescribed:• Secobarbital sodium (Seconal) • Chlordiazepoxide HCl (Librium) • Diazepam (Valium) • Chloral hydrate (Noctec): For children

SedativesSedatives


Antianxiety drugs that are administered intravenously continuously throughout a procedure at a slower pace, providing a deeper stage I analgesia.

Antianxiety drugs that are administered intravenously continuously throughout a procedure at a slower pace, providing a deeper stage I analgesia.

Intravenous SedationIntravenous Sedation


Patient assessment • A health history, physical examination,

and signed consent are performed.• Baseline vital signs are taken and

recorded.• Oximetry and electrocardiogram are

completed and recorded.• Weight taken and recorded for dose

determination.

Patient assessment • A health history, physical examination,

and signed consent are performed.• Baseline vital signs are taken and

recorded.• Oximetry and electrocardiogram are

completed and recorded.• Weight taken and recorded for dose

determination.

Intravenous Sedation cont’dIntravenous Sedation cont’d


Patient monitoring Physiologic measurements taken and

recorded every 15 minutes.• Level of consciousness• Respiratory function• Oximetry• Blood pressure• Heart rate• Cardiac rhythm

Patient monitoring Physiologic measurements taken and

recorded every 15 minutes.• Level of consciousness• Respiratory function• Oximetry• Blood pressure• Heart rate• Cardiac rhythm

Intravenous Sedation cont’dIntravenous Sedation cont’d


A controlled state of unconsciousness in which there is a loss of protective reflexes, including the ability to maintain an airway independently and to respond appropriately to physical stimulation or verbal command. This controlled state in loss of consciousness, produces stage III general anesthesia.

A controlled state of unconsciousness in which there is a loss of protective reflexes, including the ability to maintain an airway independently and to respond appropriately to physical stimulation or verbal command. This controlled state in loss of consciousness, produces stage III general anesthesia.

General Anesthesia General Anesthesia


Pharmacologic make-up• Combination of gases

• N²O/O²

• Halothane or enflurane mixtures• Intravenous agents such as thiopental

sodium and methohexital sodium

Pharmacologic make-up• Combination of gases

• N²O/O²

• Halothane or enflurane mixtures• Intravenous agents such as thiopental

sodium and methohexital sodium

General Anesthesia cont’d General Anesthesia cont’d


Stage I: Analgesia is the stage at which a patient is relaxed and fully conscious. The patient is able to keep his or her mouth open without assistance and is capable of following directions. The patient will have a sense of euphoria and a reduction in pain. Vital signs are normal. Depending on the agent, the patient can move into different levels of analgesia.

Stage I: Analgesia is the stage at which a patient is relaxed and fully conscious. The patient is able to keep his or her mouth open without assistance and is capable of following directions. The patient will have a sense of euphoria and a reduction in pain. Vital signs are normal. Depending on the agent, the patient can move into different levels of analgesia.

Four Stages of AnesthesiaFour Stages of Anesthesia


Stage II: Excitement is the stage at which a patient is less aware of his or her immediate surroundings and can start to become unconscious. The patient can become excited and unmanageable. Nausea and vomiting can occur. This is an undesirable stage.

Stage II: Excitement is the stage at which a patient is less aware of his or her immediate surroundings and can start to become unconscious. The patient can become excited and unmanageable. Nausea and vomiting can occur. This is an undesirable stage.

Four Stages of Anesthesia cont’dFour Stages of Anesthesia cont’d


Stage III: General anesthesia is the stage of anesthesia that begins when the patient becomes calm after stage II. The patient feels no pain or sensation. The patient will become unconscious. This stage of anesthesia can be met only under the guidance of an anesthesiologist in a controlled environment such as a hospital.

Stage III: General anesthesia is the stage of anesthesia that begins when the patient becomes calm after stage II. The patient feels no pain or sensation. The patient will become unconscious. This stage of anesthesia can be met only under the guidance of an anesthesiologist in a controlled environment such as a hospital.



Stage IV: Respiratory failure or cardiac arrest is the stage at which the lungs and heart slow down or stop functioning. If this stage is not reversed quickly, the patient will die.

Stage IV: Respiratory failure or cardiac arrest is the stage at which the lungs and heart slow down or stop functioning. If this stage is not reversed quickly, the patient will die.



Patient preparation• Preoperative physical examination.• Laboratory tests.• Patient or legal guardian must sign a

consent form. Preoperative instructions

• Dentist will review the procedure, as well as the risks.

• Must not have anything to drink or eat 8 to 12 hours before receiving general anesthesia.

Patient preparation• Preoperative physical examination.• Laboratory tests.• Patient or legal guardian must sign a

consent form. Preoperative instructions

• Dentist will review the procedure, as well as the risks.

• Must not have anything to drink or eat 8 to 12 hours before receiving general anesthesia.

General Anesthesia cont’d General Anesthesia cont’d


Always document the following measures and observations:• Review of patient’s medical history. • Preoperative and postoperative vital

signs. • Patient’s tidal volume if using inhalation

sedation. • Time anesthesia began and ended. • Peak concentration administered. • Amount of postoperative time (in

minutes) for patient recovery. • Adverse events or patient complaints.

Always document the following measures and observations:• Review of patient’s medical history. • Preoperative and postoperative vital

signs. • Patient’s tidal volume if using inhalation

sedation. • Time anesthesia began and ended. • Peak concentration administered. • Amount of postoperative time (in

minutes) for patient recovery. • Adverse events or patient complaints.

Record Keeping for Sedation MethodsRecord Keeping for Sedation Methods

Copyright 2003, Elsevier Science (USA). All rights reserved. Chapter 37 Anesthesia and Pain Control in Dentistry Copyright 2003, Elsevier Science (USA)

Documents

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topical anesthesia

profound anesthesia

elsevier science usa

dentistry copyright

anesthetic solution

nerve endings

nerve impulses