Chapter 37 – Anesthesia and Pain Control

Methods of Pain Control

 Anesthetic Agents  Intravenous (IV) Sedation

 Inhalation Sedation  General Anesthesia
 Antianxiety Agents

Topical Anesthesia

 Provides a temporary numbing effect on nerve endings located on the surface of the oral mucosa.
 Placed on mucosa for 3-5 minutes
 Supplied as: Ointments, Liquids, Sprays

Local Anesthesia

 The agent most frequently used for pain control in dentistry

 Characteristics/advantages

o Is nonirritating to the tissues in the area o Delivers profound anesthesia

of the injection o Duration of action is sufficient
o Is minimally toxic o Sterile
o Rapid on onset o Completely reversible

Local Anesthesia Mechanism of Action

 Temporary blocks the normal generation and conduction action of the nerve impulses
 Obtained by injecting the anesthetic agent near the nerve in the area intended for dental treatment
 Induction time:
o Length of time from the injection of the anesthetic solution to complete and effective conduction blockage

Duration

 Time from induction to completion of the reversal process

 Short acting:
o Local anesthetic agent lasting 60 to 180 minutes
 Intermediate:
o Local anesthetic agent lasting 120 to 240 minutes
 Long Acting:
o Local anesthetic agent lasting 240 to 540 minutes

Vasoconstrictors – *Prolongs or lengthens the duration of an anesthetic

 Indication for use:

o Prolongs the duration of an anesthetic agent by decreasing the blood flow in the immediate area of the
injection.
o Decreases bleeding in the area during surgical procedures
 Types:
o Epinephrine – most common
o Levonordefrin
o Neo-Cobefrin

Ratio of Anesthetic Solution to Vasoconstrictor

 1:20,000  1:100,000
 1:50,000  1:200,000
Contraindications to the Use of Vasoconstrictors

 Unstable angina  Untreated or uncontrolled severe hypertension

 Recent myocardial infarction  Untreated or uncontrolled congestive heart
 Recent coronary artery bypass surgery failure.

Injection Techniques

 Infiltration is achieved by injecting the solution directly into the tissue at the sit of the dental procedure.
o most frequently used to anesthetize the maxillary teeth
o Used as a secondary injection to block gingival tissues surrounding the mandibular teeth
 Block anesthesia is achieved by injecting near a major nerve, with the entire area served by that nerve being numbed.
o Type of injection required for most mandibular teeth

Anesthetic Cartridge

 Precautions:
o Cartridges should be stored at room temp. and protected from
direct sunlight.
o Never use a cartridge that has been frozen
o Do not use a cartridge if it is cracked, chipped, or damaged in any way.
o Never use a solution that is discolored or cloudy or has passed the expiration date.
o Do not leave the syringe preloaded with the needle attached for an extended period.
o Never save a cartridge for reuse.\

Needle

 Gauge (lumen size):

o Thickness or size of the needle o Small number=thicker needle

o Larger number=thinner needle

 Length:

o Short: 1 inch o Long: 1 5/8 inch

Local Anesthetic Cautions

 Injection into a blood vessel  Systemic toxic reaction

 Infected area  Temporary numbness
 Localize toxic reaction  Paresthesia
 Chapter 37
Inhalation Sedation
 Nitrous oxide/oxygen is a combination of gases inhaled to help eliminate fear and aid relaxation
 History:
o The use of nitrous oxide dates to 1844
o Dr. Horace Wells was the first to use nitrous oxide on patients
 Effects:
o Nitrous oxide/oxygen is non additive
o Onset is easy, side effects are minimal, and recovery is rapid
o Nitrous oxide/oxygen produces stage I anesthesia
o Nitrous oxide/oxygen dulls the perception of pain

Advantage of Using N2O/O2

 Administration is simple and easily managed  Side effects are minimal

 The services of anesthetist or other special  The patient is awake
personnel are not required  Recovery is rapid
 N20/02 has an excellent safety record  N2O/O2 can be used with patients of all ages

Contraindications to Use of N2O/O2

 Pregnancy: first trimester  Emphysema: increase O2

 Nasal obstruction: problems inhaling through the  Multiple sclerosis: breathing difficulties
nose  Emotional stability: altered perception of reality

Inhalation Sedation Equipment

 Cylinders:
o Gases are dispensed from steel cylinders, which are colored green for O2 and blue for N2O
 N2O machines are portable or part of the dental unit:
o Control valves control the flow of each gas
o A flowmeter indicates the rate of flow of the gases
o The two gases are combined in a reservoir bag, which the patient draws on for breathing
 Gas hose:
o Carries the gases from the reservoir bag to the mask or nose piece
 Masks: supplied in sizes for adults and children
o The nose piece through which the patient breathes the gases
 Scavenger system:
o Protection from the occupational risks of N2O

Exposure to Nitrous Oxide

 Used only for patient treatment

 Never administer for recreational purposes
 How to reduce N2O hazards to dental personnel:
o Use a scavenger system
o Use a patient mask that fits well
o Discourage the patient from talking
o Vent gas outside the building
o Routinely inspect equipment and hoses for leaks
o Use a monitoring-badge system to detect N2O
Patient Preparation for Inhalation Sedation

 Review the patients’ health history  Describe the use of the mask and the importance
 Obtain baseline vital signs of basal breathing
 Describe the procedure of administering the gases  Describe the sensations that the patient will
experience
 Reassure the patient

Assisting in the Administration of Inhalation Sedation

 Start with pure oxygen

 Slowly adjust the nitrous oxide until the desired results are achieved
 The patient 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 with the preoperative recordings

Antianxiety Agents

 Sedative is the drug of choice for physicians and dentists seeking the relieve anxiety in their patients
 Criteria for use:
o A patient is very nervous about a procedure
o A procedure is long or difficult
o The patient is mentally challenged
o The patient is a very young child requiring extensive treatment

Commonly Prescribed Sedatives

 Secobarbital sodium (Seconal)  Diazepam (valium)

 Chlordiazepoxide Hydrochloride (Librium)  Chloral Hydrate (Noctec): for children

IV Sedation

 Antianxiety drugs administered IV throughout a procedure at a slower pace, providing a deeper stage I analgesia.
 Patient assessment:
o A health history is taken, a physical examination performed, and signed consent obtained.
o Baseline vital signs are taken and recorded.
o Oximetry and electrocardiography are performed, and signed consent obtained
o The patient’s weight is taken and recorded for the determination of dosage
 Patient Monitoring
 Physiologic measurements are recorded every 15 minutes:

o Level or consciousness
o Respiratory function
o Oximetry
o Blood Pressure
o Heart Rate
o Cardiac Rhythm

General Anesthesia

 A controlled state of unconsciousness with a loss of protective reflexes- including the ability to maintain an airway
independently and to respond appropriately to physical stimulation or verbal command-that produces stage III general
anesthesia.

Four Stages of Anesthesia

  Stage I: analgesia
o At this stage the patient is relaxed and fully conscious
o The patient is able to keep his or her mouth open without assistance and is capable of following directions.
o The patient has a sense of euphoria and a reduction in pain
o Vital signs are normal
o The patient can move into different levels of analgesia
 Stage II: excitement
o At this stage the patient is less aware of his or her immediate surroundings
o The patient may become excited and unmanageable
o Nausea and vomiting may occur
o This is an undesirable stage
 Stage III: general anesthesia
o This stage of anesthesia begins when the patient becomes calm after stage II
o The patient feels no pain or sensation
o The patient will become unconscious
o 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
o At this stage the lungs and heart slow down or stop functioning.
o If this stage is not reversed quickly, the patient will die

General Anesthesia

 Patient preparation
o Preoperative physical exam
o Lab tests
o Signature of patient or legal guardian on a consent form
 Preoperative instructions
o The dentist will review the procedure, as well as the risks
o The patient must not have anything to drink or eat 8 to 12 hours before undergoing general anesthesia

Recordkeeping for Sedation Methods

 Always document the following measures and observations:

o Review of the patient’s medical history
o Preoperative and postoperative vital signs
o Patient tidal volume in inhalation sedation is being used
o Times at which anesthesia began and ended
o Peak concentration administered
o Postoperative time (in minutes) required for patient recovery
o Adverse events and patient complaints