Dr.

Ebtisam ELHamalawy

MFDS RSC (Edh.), MJDF RSC (Lon.), BDS (Misr

International University)
 Non opioids:
Acetoaminophen/ Codamol / co-methismol
metabolized in the liver, maximum 4g daily
 NSAIDs:
1. Asprin: mild anti-inflammatory, gastric irritation. CI: bleeding
dosorders, asthma, children
2. Ibuprofen: mild analgesic
CI: peptic ulcer, Asthma
3. Diflunisal: Anti-inflammatory analgesic CI: pregnancy, peptic
ulcer
 Opioids: tramadol act on the mu1 in the CNS moderate pain relief
CI: epilepsy, prophyria
 Sever pain: fentanyl , pethidine, morophine
 I : {Normal health patient}
 II: Mild systemic disease {well controlled
asthma/ hypertension / Epilepsy}
 III: sever systemic disease but not
incapacitating { uncontrolled diabetes /recent
myocardial infarction}
 IV: incapacitating disease constant threat to life
{unstable angina, recent cerbrovascular
accident}
 V: Patient not expected to live more than 24h
 ESTERS:

1. Cocaine
2. Ethyl aminobenzoate
3. Tetracaine

AMINDE:
1. Articaine
2. Bupivacaine
3. Etidocaine
4. Lidocaine
5. Mepivacaine
6. Prilocaine
 Indicated:
Pregnancy
 Contraindicated:
1. Prophria
2. Patients on suthamethonium since apnoea is
prolonged.
Indicated:
1.Patients on B-blockers

Contraindicated:
1.Prophyria
2. Heart block
3. Cholinestrase deficiency
 Indicated:
Prolonged analgesia
 Contraindicated:
1. Cardiac disease
2. Pregnancy { cause fetal hypoxia}
 Indicated:
Cardiovascular disesae
 Contraindicated:

prophyria
Pt on sulphonamides
Pt on antimalarial
G6PD
 CI:
1. Cardiac patients
2. Dry sockets
3. Pregnant patients
 CI:
PT predisposed to infective endocarditis

 Indicated: Bleeding tendency

1. Binding of LA molecule to this receptor site
2. Blockade of sodium channel
3. ↓in sodium conductance
4. ↓in rate of depolarization
5. Failure to achieve threshold potential level
6. Lack of development of propagated action
potentials
 Tonic-clonic seizure activity
 Generalised CNS depression
 Depressed blood pressure, heart rate and
respiratory depression
 MUST KNOW WHAT`s the maximum amount
of the medication to be given per kilogram of
the body weigh

 Lidonaine 4.4 mg /Kg

 Prilocaine 6 mg/Kg
 Articaine 7 mg/Kg
  EX: Lidocaine is 4.4mg/ kg maximum is (( 300
mg ))

  300 mg is the absolute maximum

For a 90 Kg patient { 4.4 x 90 = 396 mg which is
above the absolute maximum}. 
So for that patient the maximum amount of LA
you can administer is 300 mg

2% solution means there`s a 20 mg/ ml

A carpale holds 1.8 ml = 36 mg

 300/ 36 = 8.3 carpules

 Early features of overdose:
1. Circumoral parathesia
2. light headedness
3.Slurred speech
4. Localized muscle twitching
5. Visual hallucinations
 Amides: Liver
 Ester: plasmacholine esterase in the Blood
 Epinephrine: Reuptake in the noradrenergic
fibers. Enzyme catechol-o-transferase and
monoamine oxidase in the liver
 Lidocaine: 90 minutes
 Long acting LA : Bupivacaine/ etidocaine
 Short acting LA:
 Reduced after introduction of amides
 Dermatitis, bronchospasm, systemic
anaphylaxis
 Allergy to LA very rare
 More likely to be preservative
 Sodium metabisulfite
 Methylparaben
 Sodium chloride
 Latex allergy
 LA agent – conduction block
 Vasoconstrictor - ↓ed absorption of LA
 Sodium metabisulfite – antioxidant for
vasoconstrictor (epinephrine)
 Methylparaben – preservative, bacteriostatic
 Sodium chloride – isotonicity of solution
 Sterile water – diluent
 Dilution of 0.03 IU/ml with 3% prilocaine
 LIGNOCAINE 5%- SPRAY OR CREAM

 EMLA – EUTECTTIC MIX LIGNOCAINE +

PRILOCAINE
 ESTER la’S
- hydrolized in the plasma by enzyme plasma
pseudocholinesterase
- Every 1 in 2800 persons have atypical form of
pseudocholinesterase causing an inability to
metabolise this class of LA’s
 AMIDE la’S
- primary site liver
- Prilocaine liver and some amount in lung
“A technique in which the use of a drug or drugs
produces a state of depression of the central
nervous system enabling treatment to be
carried out, but during which verbal contact
with the patient is maintained throughout the
period of sedation. The drugs and techniques
used to provide conscious sedation for dental
treatment should carry a margin of safety wide
enough to render loss of consciousness
unlikely”
 Children who undergo all other forms of seda-
tion should be fasted prior to the procedure as
follows:
• No solid food within 6 h
• No milk within 4 h
• No clear fluid within 2 h
 Contra-indications to nitrous oxide inhalation
sedation include:
• Common cold, tonsillitis, nasal blockage and
bleomycin chemotherapy
• Pre-co-operative children.
• First trimester of pregnancy
 Respiratory infection

 Vitamin B12 deficiency

 Can be used to facilitate dental extractions in
children.
 Is preferred to general anaesthesia for anxious
children undergoing elective orthodontic
(premolar) extractions.
 Is a cost effective alternative to general
anaesthesia.
 Is a weak analgesic, although this effect can be
influenced by the psychological preparation of
the patient.
 Inhalation Sedation with Nitrous Oxide Dedicated,
purpose-designed machines for the administration
of inhalation sedation for dentistry must be used.
 Such machines must conform to current British
Standards and be maintained according to
manufacturers’ guidance with regular,
documented servicing11.
 Gas cylinders must be stored safely
 Scavenging of waste gases must be active and
sufficient to fully conform to current COSHH
standards11,22,23.
 Pulse oximetry is not routinely required for
inhalation sedation.
 Failsafe Relative Analgesia machine
 Active waste gas scavenging machine
 Disposable indwelling needles and canulae
 Pulse oximetry
 Automatic sphygmomanometry
 No longer used as oral alternative to IV or
inhalation sedation
 Role in management of pre-appointment
anxiety
 Available as
 Tablet
 Gel-filled capsule
 Elixir for oral admin
 Flumazenil reverses all the effects of benzodi-
azepines.
 The duration of action of Flumazenil is 15–140
min and is dose dependent.
 The half-life of the antagonist is shorter than
midazolam, which may lead to resedation
 routine reversal is not recommended as part of
the conscious sedation technique.
 On the GABA receptor ---- Chlorine
channel---Hyperpolarization----- inhibition
of the Action potential
 Nitrous oxide gas has a sweet odour, which is pleasant to inhale
and non-irritant.
 Poor tissue solubility ensures its effect is characterized by rapid
onset and fast recovery
 Exposure to nitrous oxide can result in depression of vitamin B12
activity resulting in impaired synthesis of RNA.
o Titration technique
o Analgesic effect but LA still necessary
o Peak saturation 5 minutes similar recovery
o Rapid recovery
o Scavenging required
o Written post-op instructions and discharge
with escort
 Advantages
- non-irritant solution
- short half life (compared to diazepam)
- no clinically active metabolites
- ↑ed potency ( 2-3 times that of diazepam)
 No analgesia - LA required
 Respiratory depression
 Post-op supervision
 Allergy to benzodiazepines
 pregnancy/breast feeding

Psychiatric disease
 Needle phobias

 COPD
 Venepuncture – dorsum of hand or ACF
(antecuboital fossa)
 10mg in 5ml syringe
 Titrated dose – 2mg over 30 secs, then 1mg
every 30 secs until sedation adequate
 Top up if required
 Slurring of speech, slow response to
commands, lack of coordination
 Pulse-oximeter – O2 saturation and pulse rate
 Non-invasive BP
 Visual
- Colour
- Respiratory rate (chest)
 Pre-school Child:
Inhalation sedation
Oral sedation
Transmucosal sedation
 School age, Transitional Stage, Adults and other people

- Inhalation sedation
- oral sedation
- transmucosal sedation
- IV sedation (only in patients above age of 12)