Anesthesia In Dentistry

Anesthesia In Dentistry
Dentistry was often a painful and even a barbarous affair . Relieving pain is one of the important subject in dentistry . Many procedures could not be done properly unless pain is well controlled ; ex. Fillings , extraction , periodontal procedures , root canal treatment , minor or major surgeries , etc ..

Anesthesia In Dentistry (contd)

 Some important definitions

Anesthesia : The loss or abolition of all modalities of sensations which includes : Pain , touch , temperature , and pressure . General anesthesia : becomes unconscious . Achieved when the patient

Local anesthesia : The patient remain conscious but the anesthesia is localized to one part only .

Anesthesia In Dentistry (contd)

Infiltration anesthesia : Deposit of solution in the region to be anesthetized and permeates through the tissue to affect fine nerve endings . Block anesthesia : To anesthetize a region by blocking the conduction in the nerve trunk supplying the area . Topical or surface anesthesia : Local anesthetic applied on an intact mucous membrane to anesthetize the nerve endings .

Anesthesia In Dentistry (contd)

Paresthesia : Altered sensation occurred when : - A damaged sensory nerve is regenerating ; - Local anesthetic action starting to work or wearing off ; - Described as tingling sensation or pins and needles . Relative analgesic : A sedation technique in which the patient remains conscious but mental relaxation is induced by inhalation of a mixture of nitrous oxide , oxygen , and air . L.A. is used as adjacent when necessary . Sedatives : Produce sedation and relieve anxiety by acting on the CNS ( e.g. Valium (Diazepam) )

Neurophysiology
A Desirable properties of local anesthetics; B Fundamentals of impulse generation and transmission:
Nerve anatomy; Physiology of the peripheral nerves; Electrophysiology of nerve conduction; How local anesthetics work; Basic concepts of pain.
    

A Desirable properties of local anesthetics ;

Local anesthesia has been defined as a loss of sensation in a circumscribed area of the body caused by depression of excitation in nerve endings or an inhibition of the conduction process in peripheral nerves. There are many methods of inducing local anesthesia , some of which follow:
* Mechanical trauma; * Low temperature; * Anoxia; * Chemical irritants; * Neurolytic agents such as alcohol and phenol; * Chemical agents such as local anesthetics.

Electrophysiology of nerve conduction (contd)

In simple terms, local anesthetics act by preventing this entry of sodium ions and stopping propagation of electrical transmission by inhibiting nerve cell depolarization.

Pharmacology Of Local Anesthetics

- Local anesthesia is defined as a loss of sensation in circumscribed area of the body caused by a depression of excitation in nerve endings or an inhibition of the conduction process in peripheral nerves.
 Types of local anesthesia

a) Topical b) Infiltration c) Regional

Pharmacology Of Local Anesthetics

(contd)

Methods Of Inducing L.A.

a) Mechanical trauma b) Low temperature c) Chemical irritants d) Neurolytic agents such as alcohol or phenol e) Chemical agents as in L.A. - L.A. should prevent the conduction and generation of nerve impulse.

Local anesthetic
I Classification of anesthetic agents :
 Amides, Esters, constitute the major categories of local anesthetics;  The Ketone-linkage class of anesthesia has relatively little clinical importance and currently consists of a single topical agents.  The Lipophilic part is the largest portion of the molecule. Aromatic in structure, it is derived from benzoic acid or aniline.  The Hydrophilic part is an amino derivative of ethyl alcohol or acetic acid .

II Clinical Implications of pH and Local Anesthetic Activity (contd)

Most solutions of local anesthetics without vasoconstrictor have a pH between 5.5 and 7;

Local anesthetic solutions that contain a vasopressor (e.g., Epinephrine) are acidified by the manufacturer to retard oxidation of the vasoconstrictor, thereby prolonging the period of the drug effectiveness. Sodium bisulfite is commonly used, in a concentration between 0.05 % and 0.1 %; A 2 % solution of Lidocaine, with a pH of 6.8, is acidified to 4.2 by the addition of Sodium bisulfite.

 Solution Of Local Anesthetic

L.A. drug Vasopressor drug ------------preservative for vasopressor Sodium chloride Distilled water

Pharmacology Of Vasoconstrictors
After injection of local anesthetic ( L.A. ) into the tissue , blood vessels in the area dilate resulting in increased blood flow to the site ;

Pharmacology Of Vasoconstrictors (contd)

This increase perfusion leads to the following reactions :

a) Increased rate of absorption of the L.A. into the C.V.S. with its turn remove it from the injection site ; b) Higher plasma level of the L.A. , toxicity ; with increased risk of

c) Decreased duration of action and decreased depth of anesthesia ; d) Increased bleeding at the site of L.A. administration to increased perfusion .

Pharmacology Of Vasoconstrictors (contd)

- Vasoconstrictors are highly important additions to a local anesthetic solution , for the following reasons :

a) By constricting blood vessels ( B.V. ) , the vasoconstrictors

( V.C. ) decrease blood flow to the site of injection ; b) Absorption of the L.A. into C.V.S. is slowed , resulting in lower anesthetic blood level ; c) Lower anesthetic blood level decreases the risk of L.A. toxicity ; d) Higher volume of the L.A. agent remains around the nerve for longer periods , therefore increase the duration of action of L.A. e) Decrease bleeding at the site of administration and surgical site .

Types Of Vasoconstrictors
( Sympathomimetic or Adrenergic ) drugs 1) Catecholamines : - Epinephrine - Nor-Epinephrine - Dopamine 2) Non-catecholamines - Amphetamine - Ephedrine 3) Felypressin ---Synthetic analogue hormone ) ( anti-diuretic

Adrenergic Receptors

Adrenergic receptors are found in most tissues of the body ; Ahlquist in 1948 recognized two types of adrenergic receptors , termed alpha and beta based on the inhibitory or excitatory actions of catecholamines on smooth muscle

Adrenergic Receptors (contd)

1) Alpha [ ] receptors : Activation of [ ] receptors by a sympathomimetic drug usually produces a response that includes the contraction of smooth muscle in blood vessels ( vasoconstriction ) . * * Alpha 1 : Excitatory Alpha 2 : Inhibitory

Adrenergic Receptors (contd)

2) Beta [ ] receptors : Smooth muscle relaxation , vasodilatation , bronchodilatation and cardiac stimulation . 1 : Found in the heart and small intestines and responsible for cardiac stimulation and lipolysis 2 : Found in the bronchi , vascular beds , and uterus and produces bronchodilation & vasodilation .

Dilutions of Vasoconstrictors
Concentration solution ; This means 1 : 10.000 1 : 100.000 1 : 80.000 1 : 200.000 ml 1 : 1000 means 1 gm / 1000 ml

1000 mg / 1000 ml 0.1 mg / ml 0.01 mg / ml 0.0125 mg / ml 0.005 mg / ml

1 mg / ml

5 micrograms /

Adrenergic Receptors (contd)

Epinephrine remains the most effective and most used vasoconstrictor in medicine and dentistry ; Nor-Epinephrine is not recommended , because it produces intense peripheral vasoconstriction with possible elevation of blood pressure , with nine times higher side effects than epinephrine .

Epinephrine { Adrenalin }
 Epinephrine as the acid salt is highly soluble in water ;  Slightly acid solutions are relatively stable if they are protected from air ;  Sodium bisulfite is usually added to epinephrine solutions to delay its deterioration ( through oxidation ) ;  Epinephrine is available as a synthetic and is also obtained from the adrenal medulla of animals ( approximately 80% of adrenal medullary secretions being epinephrine ) ;  Epinephrine acts directly on both effect predominate . - and -adrenergic receptors ;

Epinephrine { Adrenalin } (contd..)

Adrenalin has a number of systemic actions ; adrenaline affects : 1 ) The heart

 Increases the rate and force of contraction of the heart raising cardiac output ;  Increase in pulse rate ;  Rise in systolic and diastolic blood pressures ( standard dose has little effect ) ;  Increased myocardial oxygen consumption .

These actions lead to an overall decrease in cardiac efficiency

Epinephrine { Adrenalin } (contd..)

2 ) Effect on blood vessels - Vessels supplying the skin , mucous membranes , and kidneys contain primarily receptors ( epinephrine produces constriction in these vessels ) ; Blood vessels supplying the skeletal muscles contain both 2 and receptors , with 2 predominating . 2 adrenoreceptor stimulation produces vasodilatation by activation of Adenylate cyclase resulting in fall in diastolic pressure .

Epinephrine { Adrenalin } (contd..)

The injection of epinephrine directly into surgical sites leads to high tissue concentrations , a predominant -receptor stimulation , and hemostasis ; As epinephrine tissue levels decrease with time the primary action on blood vessels will revert to vasodilation , as 2 actions predominate . It is not uncommon , therefore , for some bleeding to be noted at about 6 hours following surgery .

Epinephrine { Adrenalin } (contd..)

3 ) Effect on the lungs

 B2 adrenoreceptor stimulation in the lungs leads to bronchiolar muscle relaxation ; It is important lifethreatening in case of bronchoconstriction (acute asthma ).

4 ) Effect on biological membranes

 In animal models , the adrenalineinduced hyperpolarization ( activation of a membrane-bound Na / K pump ) , has been shown to induce analgesia .

Epinephrine { Adrenalin } (contd..)

5 ) Effect on metabolism


Glucose concentration is increased due to an Alpha adrenergic inhibition of Insulin release .

6 ) Effect on wound healing



Interferes with wound healing : - The catecholamine reduces local tissue oxygen tension ; - Produces fibrinolysis . Sodium bisulfite is usually added to epinephrine solution to delay its deterioration.

Epinephrine { Adrenalin } (contd..)

Clinical applications Epinephrine

 Management of acute allergic reactions ;  Management of bronchospasm ;  Treatment of cardiac arrest ;  As a vasoconstrictor , for hemostasis ;  As a vasoconstrictor in local anesthetics , to decrease absorption into the cardiovascular system ;  As a vasoconstrictor in local anesthetics , to increase duration of action ;  To produce mydriasis .

Felypressin
-

( Octapressin )

Non-sympathomimetic amine ; Pronounced on venous than arteriolar microcirculation ; No effect on adrenergic nerve transmission , so safely given to : - Hyperthyroid patient ; - MAO inhibitor ; - Tricyclic antidepressants .

Felypressin

( Octapressin ) (contd..)

- Contra-indicated for pregnant women ;( oxytocic actions on the uterus ) ; Available in 0.03 IU / ml + 3 % Prilocaine

# : Few contraindications of Epinephrine ; instead we use Felypressin Patient with significant cardio-vascular disease ; Patient with thyroid dysfunction , diabetes , sulfite sensitivity ; Patient receiving MAO inhibitors , tricyclic antidepressant .