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LOCAL AND

Semmelweis University Paedodontic and Orthodontic Clinic Anaesthesia

The aim is to carry out treatment without pain Anaesthesia

• Local Anaesthesia • Conscious sedation • General anaesthesia Methods:

• Temperature reduction

• Electronic dental anaesthesia (a minute electrical current to interfere with local nerve conduction. Electric stimulation closes the gate to pain transmission)

• Chemical agents (bondage of nerve endings is loose, reversible process)

Types:

• Infiltration

• Block injection

• Ganglion injection

Position of Mandibular Foramen Age <6 : below occlusal plane Age 6-12 years: at occlusal plane Age>12 : above occlusal plane Complications

• Needle breakage •Allergy • Pain on injection •Dermatological react. (urticaria, edema) • Burning •Bronchospasm (respiratory distress, • Paresthesia wheezing, cyanosis, perspiration, tachycardia,) • Trismus • Hematoma

0,3 ml 1:1000 epinephrine IM, antihistamin,O2, consultation Carpule syringe

• syringe is non-disposable equipment • it can be sterilized by autoclaving • positive aspirating syringe • cartridge can be placed directly into syringe • disposable needle can be screwed

Jet syringe • syringe without needle • noisy • does not produce reliable anaesthesia • post-operative pain and bleeding

Intraligamentary injection

• high pressure syringe with ultra-short needle • The anaesthetic is deposited via the periodontal ligament by the needle at degrees to the long axis of the tooth at the mesiobuccal aspect of the root • lips and tounge are not anaesthetized

General principles

 Explain to patient  what you are trying to do and why.  Use topical anaesthesia  lignocaine spray, oinments, flavoured benzocaine gel.  Use fine-gauge disposable needle.  Always have dental nurse to assist.  Hold mucosa taut.  Slow rate of injection.  Warn about post-op numbness. First choice of anaesthetic agent Amide type, intermediate action

• Lignocaine 2% (20 mg lign.ch.+0,01 mg epinehrine ch.)

• Ultracaine DS Forte 4% (40 mg articaine ch.+0,01 mg epinehrine ch.)

Second choice of anaesthetic agent

Amide type, long-lasting action

• Bupivacaine 0,5% (5mg bupiv.ch.+ 0,01 mg epinehrine ch.)

Dosage Depends upon body weight

L.: maximum dose 4,4 mg/kg U.: maximum dose 3,5 mg/kg(no under 4yrs) B.: maximum dose 1,3 mg/kg

Under 12 yrs 1 ml Over 12 yrs 2 ml

Contraindications

 Uncooperative patients  Patients with major bleeding diathesis  Infection around the injection site  Allergy

Conscious sedation

There is an extension of local anaesthesia technique using which produces, a state of depression of CNS enabling treatment to be carried out or local anaesthetic agent to be given.

Communication is maintained during treatment.

Conscious sedation Indications  The anxious child • The questioner: attempts to delay treatment. Firm but gentle handling is needed.Explain everything • The temper tantrum: ignore tantrum and try to complete treatment regardless

 General principles: • Show interest in child as a person • Do not deny patient’s fear • Explain why, how, when • Reward good behaviour • Get child involved in treatmentholding saliva ejector) (Mitchell and Mitchell Oxford Handbook)

Conscious sedation Relative analgesia is the most commonly used and safest form of sedation in dentistry. (Sytemic Agents: benzodiazepines, antihistaminics) The delivery of mixture of nitrous oxide and . • Start by delivering 1OO % oxygen via nasal mask • Then give 1O % nitrous oxide for 1min. • Increase to 2O % and 3O % (max.35%). • To give LA or to carry out treatment • Oxygenate patient for 2 min. • To sit in recovery room for 1O min.

Oral sedation

Diazepam: 1mg/kg (5mg) night before 1 tabl. and 1,5 h pre– treatment.

Midazolam: O,5mg/kg (7,5mg) night before 1 tabl. 1h prior to treatment.

Temazepam: O,3mg/kg (1Omg) 1h before treatment1-2 tabl.

Absorption time, the risk of sedation occurring too early or too late. Sexual fantasies, resistance, paradoxical stimulation can be under the influence of these drugs.

General anaesthesia: a temporary, controllable and reversible reduction of the sensitivity of the central nervous system, and its ability to respond to stimulus.  the sensitivity of different cells of CNS do not have the same inhibiting effect.

Cortex  loss of consciousness and memory  truncal ggl. and cells of cerebellum will be blocked  spinal cord and centers of medulla oblongata  paralysis of the respiration and circulation Indication of narcosis

. Anxiety O,1% . Disability 99,9%

• Mental handicap (mild, severe and Down sy.)

• Physical handicap (cerebral palsy– motor manifestation of cerebral damage, increased muscle tone)

• Sensory handicap (blindness, deafness)

Inhalational anaesthetics

Nitrous oxide  smell of sweetish  strong analgesic  weak narcotic  respiration and circulation are not influenced  non–toxic with adequate oxygen  side effect is rare

It is not proper for deep narcosis

Halothane  colourless pleasant–smelling  strong narcotic  weak analgesic  depress  respiration  circulation(RR,dysrythmias)  good relaxant  can be hepatotoxic on repeated administration Isoflurane Sevoflurane  non–pungent anaesthetic agent  less side effects (less cardiac problems)  rapid induction and recovery Narcosis

administration of oxygen+ nitrous oxide via mask٭ parasympathetic blocking agent ٭ sedative ٭ primary narcotic agent ٭ muscle relaxant ٭ combination of ٭

Narcosis

administration of oxygen+ nitrous oxide via mask٭ parasympathetic blocking agent Atropine ٭ sedative drug • reduces salivation,secretion ٭ primary narcotic agent • spasmolytic effect ٭ muscle relaxant • protects against vagal reflex ٭ combination of gases • stimulates respiration and CNS ٭ • anti-emetic effect Dose: O,O2 mg/kg

Narcosis

administration of oxygen+ nitrous oxide via mask٭ parasympathetic blocking agent ٭ sedative drug Midazolam ٭ primary narcotic agent • reduce the surgical stress effect ٭ muscle relaxant • reinforce of effect of narcosis ٭ combination of gases • decrease the incidence of ٭ unpleasant dreams • eliminate p–an. excitatory activity • reduce spasmophilia • anterograde amnesia Dose:O,2–O,4mg/kg Suspended by Flumazenil

Narcosis

administration of oxygen+ nitrous oxide via mask٭ parasympathetic blocking agent ٭ sedative drug ٭ primary narcotic agent Propofol ٭ muscle relaxant • smooth induction ٭ combination of gases • rapid recovery ٭ • cardiovascular depressant • depth of n.can be controlled • rare side effect • at sedative doses no effect on respiratory system Dose: 2,5 mg/kg

Narcosis

administration of oxygen+ nitrous oxide via mask٭ parasympathetic blocking agent ٭ sedative drug ٭ primary narcotic agent ٭ muscle relaxant ٭ combination of gases ٭

Contraidication of out–patient GA

∎ hyprtension

∎  brain pressure

∎ cardiovascular or respiratory disease

∎ severe liver or renal impairment

∎ uncotrolled anaemia, hypothyroidism,

∎ porphyria ∎ neurological disorders (multiple scler.)

∎ cervical spine pathology (spond.)

∎ allergy

∎ respiratory catarrh

∎ vaccination

∎ infectious disease

Personal and material conditions:

• anaesthetist, anaesthetic assistant, trained pedodontist and dental nurse • operating room • recovery room • anaesthesia apparatus • cardiac monitoring • blood pressure monitor • pulse oximeter • exhauster • resuscitating instruments: Ambu balloon, laryngoscope, tubes, positive pressure O₂ delivery system, vein cannula, gag. Emergency drugs

► Antihistamines ► Antihypoglycemics (Epinephrine) (5O% Dextrose) ► Anticonvulsant ► Vasopressors (Diazepam) (Ephedrine) ► Narcotic antagonist ► Analgesic (Naloxone) (Paracetamol) ► Steroid ► Advanced cardiac life (Hydrocortisone) support(Atropine)

Technical procedures:

► preliminary pediatric examination ► written consent ► establishment of treatment plan ► sequence of dental care ► empty stomach and bladder ► cannula entering vein sited and secured ► dental treatment with gag and evacuation

Condition of discharge from the clinic:

≻to give correct answer to his mental level and age

≻ ability to walk in a straight line

≻ no fever

≻ no nausea

≻ he can drink Thank you for your kind attention