3/19/2013

Anesthetic
Considerations
for
Dental Practice

A World Without Pain!

Edward P. Heinrichs, D.M.D.

University of Pittsburgh
School
of
Dental Medicine

CIPA
(Congenital Insensitivity to Pain with Anhidrosis)

Rare inherited disorder of the nervous system

which prevents the sensation of pain, heat,
and cold or any real nerve-related sensation.
Can feel pressure.
Anhidrosis body does not sweat

Hyperthermia

Mental Retardation

Infections
Teething

Self-mutilation

Infants rarely survive beyond age 3

Surviving infants do not often survive

beyond age 25

Lip & Tongue Scarring

Fractures
Eye Injuries

3/19/2013

Pain
A World Without Pain????

-Necessary
-Protective
-Can and Must be
Controlled

Public Speaking
Mice

Heights

Common Fears

Typical dental patient of 2013

Dentistry =

Pain

Anxiety
Flying

No fears
Going to the dentist

PAIN!!!!!!!!!!!!!

Phobias
Special Needs

LOCAL ANESTHESIA
in
DENTISTRY

3/19/2013

Emphasis on Pharmacologic
Techniques

How do we overcome pain

and anxiety in the dental office?

Safe and Effective

Behavioral Techniques

-Pharmacology
-Effect on Physiology
-Adverse Effects & Management

Hypnosis
Pharmacologic Approaches
(local anesthetics)

Science Based

Successful Dental
Practice

Spectrum of Pain Control

No
Meds

Nitrous
Oxide

Enteral
+

Nitrous

Gen
Anes

Local Anesthesia

Enteral

I.V.

Complications & Training

Delivery of Treatment

Successful Dental
Practice
(most important)

PLEASANT

Location
Surgical Skills & Outcomes
Interaction with Specialists
Interaction with Patients (Dr. & Staff)
Variety of Procedures Available
Educational Materials
Newsletters
Comfortable Atmosphere
Comfortable Treatment

(hospital or surgicenter)

Surgeon
Assisting Staff
Anesthesiologist

PAINLESS

3/19/2013

Roles of Each

SURGEON

Anesthesiologist

Surgical Procedure
Post-operative instructions
Post-operative prescriptions
Discharge
Follow-up call to patient?

Surgeon

ANESTHESIOLOGIST

Private Practice
Youre on your own

Review health History & vital signs

Determine level of anxiety
Decision on Pre-medication (anxiety)
Explain anesthetic procedure (consent)
Deliver appropriate anesthetic care
Continuous Monitoring & Recording of Data
Post-op Recovery, Instructions, Discharge
Follow-up call to patient?

What makes a good

Anesthesiologist?

Dentist
Anesthesiologist

Surgeon

YOU

Well educated
Well trained
Experienced
Confident
Ability to manage procedures, problems
and/or emergencies to the highest levels

3/19/2013

Patient
(never treat a stranger)

Local Anesthesia

Pharmacology
Toxic doses (one drug vs. two)
Agent (duration to match procedure)
Technique (Infiltration, block, wand, other)
Side-effects
Escort needed?

Health History
Vital Signs
Surgical History (anes & surg)
Bleeding, Infection, others
Anesthetic reactions and/or abnormalities
No history is significant

Chart Stamp
Date _______
Date _______

BP _____
BP _____

Pulse/O2 _______ Wt ____

Pulse/O2 _______ Wt ____
Meds:
Meds:
Allerg:
Allerg:
ROS
ROS:

3/19/2013

Mechanisms of Orofacial Pain & Analgesia

Mechanisms of
Orofacial Pain &
Analgesia

Peripheral Pain Mechanisms

Cutaneous Pain
Dentinal Pain
Inflammatory Pain
Central Pain Mechanisms
Rostral transmission of Pain
Endogenous Pain Suppression
Systems

Mechanisms of Orofacial Pain & Analgesia

Peripheral Pain
(mediated by nociceptors)

Skin, oral mucosa, pulp

A delta fibers
-fast conduction
- response to mechanical stimuli
- not chemical or thermal conductive
- responsible for first pain
- sharp pain

More C fibers than A delta fibers,

however, A delta fibers cover more
overall surface areas.

Skin, oral mucosa, pulp

C fibers
-slow conduction
- thermal, chemical, (mechanical)
- responsible for second pain
- dull, aching, burning (inflammatory)

The trigeminal system is the primary

conveyor of oral-facial pain.
Fifth cranial nerve
Largest of cranial nerves
Opthalmic, maxillary, and mandibular branches
Innervates face, anterior scalp, gingiva, oral
mucous membranes, teeth, anterior tongue,
nasal cavities, sinuses, jaw and tongue
musculature

3/19/2013

Trigeminal Nerve (5th)

Facial Nerve (7th)

taste sensation

Contributors to cutaneous
& orofacial pain
Vagus (10th)

Glossopharyngeal Nerve (9th)

larynx

posterior tongue, oronasal pharynx

Mechanisms of Orofacial Pain & Analgesia

Dental Pain (Peripheral)

Apical foramen of the adult bicuspid
700 - A delta fibers
1800 - C fibers
Pure pain transmission via thermal,
chemical, mechanical stimulation
Electro-pulp testing uses A delta fibers

Transmission of Pain
(pain perception)

Point of Origin

Local Anesthesia

Trigeminal Nucleus Caudalis in Medulla

Local
Anesthesia

Thalamus
Cerebral Cortex
(pain reaction)

END