pre-clinical pediatric dentistry - psau · pre-clinical pediatric dentistry dsv 342 pain perception...

PRE-CLINICAL PEDIATRIC DENTISTRY

DSV 342 Pain perception control and LA

(Pinkham, Ch.7, Pg 108, Ch.28,Pg 447) 9

update 5/5/2012

Professor Othman Al-Ajlouni Salman Bin Abdul Aziz University

Tuesday 8/5/2012 9:00 -10:00 am

Sunday, November 09, 2014 1 Professor Othman Al-Ajlouni

PAIN PERCEPTION CONTROL • General anesthesia

• Local anesthesia:

Mechanisms of action

Local anesthetic agents

Local anesthetic properties

toxicity

• Analgesics

Nonnarcotic analgesics

Narcotic analgesic

Sunday, November 09, 2014 Professor Othman Al-Ajlouni 2

PAIN PERCEPTION CONTROL

General anesthesia

unconscious through depression of CNS.

Very young, precooperative, mentally retarded.

Anesthesiologist


PAIN PERCEPTION CONTROL • Local anesthesia:

Mechanisms of action: primary effect is to penetrate

nerve cell membrane and block receptor sites that control the influx of Na associated with membrane depolarization.

Local anesthetic agents.

Small nerve fibers > susceptible to the onset of LA>large fibers.

Sensations modalities blocked firstly pain, cold, warmth, touch,

and pressure.

LA agents are weak chemical bases.

Salts added as uncharged free-base form (lipid soluble) to

penetrate nerve cell membrane.


PAIN PERCEPTION CONTROL Local anesthetic agents:

ESTERS: cocaine, benzoic acid ester derivatives:

benzocaine,

procaine(Novocain),

tetracaine(Pontocaine), and

chloroprocaine(Nesacaine)

Allergic reactions

AMIDES: lidocaine synthesis, diethylaminoacetic acid derivatives:

mepivacaine(Carbocaine),

prilocaine(Citanest),

bupivaine(Marcaine), and

etidocaine(Duranest).

Free from allergic reactions Sunday, November 09, 2014 Professor Othman Al-Ajlouni 5

PAIN PERCEPTION CONTROL Local anesthetic properties

Potency

Onset Time

Duration

Regional Technique

Other Factors:Dose, Vasoconstricors,


PAIN PERCEPTION CONTROL Toxicity

Toxic reactions due to: Overdose, accidental intravascular injection, idiosyncratic response, allergic reaction, or interactive effects with other agents.

Maximal safe dose (mg\kg):

Central nervous system reactions

Cardiovascular system reactions


GENEREC NAME

BRAND NAME

TYPE CONCENTRATION

VASOCONSTRICTOR

MAX. REC. DOSE (MG\KG)

ABSOLUTE MAX.(MG\KG)

AV. DURATION PUPLAL TISSUE (MIN)

AV.DURATION SOFT TISSUE(HR)

PROXYCAINE WITH PROCAINE

RAVOCAINE ESTER 0.4% 1;20.000 6.6 400 30-60 23

LIDOCAINE XYLOCAINE AMIDE 2% 1;100.000 EPINEPHRINE

4.4 300 60 3-5

MEPIVACAINE CARBOCAINE AMIDE 3% AND 2%

1;20.000 LEVONORDEFRIN (NEO-COBERFIN)

4.4 300 60 2% 60-90 3%

2-3 3% 3-5 2%

PRILOCAINE CITANEST AMIDE 4% 6.0 400 10 (INFIL) 1\12-2

PRILOCAINE FORTE

CITANEST FORTE

AMIDE 4% 1;200.000 EPINEPHRINE

6.0 400 60-90 3-8


LA IN CHILDREN • HIGHER CARDIAC OUTPUT

• HIGHER BASAL METABOLIC RATE

• HIGHER DEGREE OF TISSUE PERFUSUION

• LA AGENTS ABSORBED MORE RAPIDLY

• DETOXIFY CHEMICALS SLOWER RATE THAN ADULTS DUE TO LESS MATURE LIVER ENZYME SYSTEM

• MORE SUSCEPTLE TO TOXICITY AT LOWER DRUG LEVEL THAN ADULT DUE TO IMMATURE CENTRAL NERVOUS AND CARDIOVASCULAR SYSTEMS

FOR THESE REASONS;

PRECISE LA TECHNIUE SHOULD BE USED

ASPIRATION TECHNIUES SHOULD BE PRACTICED

VASOCONSTRICTOR IS NECESSARY

KNOWLEDGE OF PROPERTIES OF LA AGENT IS ESSENTIAL

RECOMMENDED MAXIMAL SAFE DOSE OF LA SHOULD BE CALCULATED PRECISELY FOR EACH PT. AND MUST NEVER EXCEEDED.


PAIN PERCEPTION CONTROL • General anesthesia

• Local anesthesia:

Mechanisms of action

Local anesthetic agents

Local anesthetic properties

toxicity

• Analgesics

Nonnarcotic analgesics

Narcotic analgesic


LOCAL ANESTHESIA AND ORAL SURGERY IN CHILDREN

• Topical anesthesia.

• General considerations for local anesthesia.

• Operator technique

• Maxillary primary and permanent molar anesthesia.

• Maxillary primary and permanent incisor and canine anaesthesia.

• Palatal tissue anesthesia.

• Mandibular tooth anesthesia.

• Complications of local anesthesia.

• Alternative anesthesia systems



• Topical anesthesia:

is used to exclude the discomfort associated with needle insertion into mucosal membrane.

Benzocaine is good tasting and easy to control gel.

Use gel and apply to a very dry mucosal surface for at least 2 minutes.

Patch type (lidocaine patches) 46.1 mg lidocaine with minimum 10 minutes on a very dry mucosa.



• General considerations for local anesthesia: changes of Na receptors of neural membrane, LA block Na channels result in inhibition of neural excitability, reduces action potential transmission distal to the anesthetic block and fail to transmit information to the central nervous system (CNS).

• Failure due to operator error or anatomic aberrations.

• Local infection causing release of neuroactive substances (histamine, leukotrienes, kinins, and prostaglandins) and lowering pH.

• These changes reduce lipid solubility and interfere with its ability to penetrate the nervous tissue.

• Nerve block, Field block, Local infiltration


MAXIMUM RECOMMENDED DOSES OF LA FOR CHILDREN

PATIENT WEIGHT KG\LB 1KG=2.3LBS

MILLIGRAMS 36.4 mg\cartridge

NO.OF CARTRIDGES 1.8 ml\cartridge

10\23 44 1.2

15\34.5 66 1.8

20\46 88 2.4

25\57.5 100 2.7

30\69 132 3.6

40\92 176 4.8

50\115 220 6.1

60\138 264 7.3

70\161 300 8.3



Operator technique:

GOING TO SLEEP AFTER A LITTLE PINCH

COUNTERIRRITATION

DISTRACTION

SLOW RATE ADMINISTRATION 1 MINUTE AT LEAST

DENTAL ASSISSTANT

REFLEXIVE MOVEMENTS SHOULD BE ANTICIPATED

SHORT (20 MM) OR LONG (32 MM ), 27OR30 GAUGE NEEDLE



• Maxillary primary and permanent molar anesthesia:

POSTERIOR SUPERIOR ALVEOLAR NERVE (PERMENET MOLARS)

AND MIDLE SUPERIOR ALVEOLAR NERVE (MESIOBUCCAL ROOT OF 1ST PERMANENT MOLAR, PRIMARY MOLARS, AND PREMOLARS.


• 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 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.

Duration

• 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

Vasoconstrictor

• Ratio of vasoconstrictor to anesthetic solution:

• 1:20,000

• 1:50,000

• 1:100,000

• 1:200,000

Vasoconstrictor- 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.

Vasoconstrictor- 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.

Types 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.

Types 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.

Types of Local Anesthesia Injections- cont’d

Table 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.

Local Anesthesia Setup

• Injection into a blood vessel

• Infected area

• Localized toxic reaction

• Systemic toxic reaction

• Temporary numbness

• Paresthesia

Local 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.

Electronic Anesthesia

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