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local anesthesia in dentistry 7 copmlicatin

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local anesthesia in dentistry 7 copmlicatin

  1. 1. In The Name Of GOD
  2. 2. ‫در‬ ‫موضعی‬ ‫حسی‬ ‫بی‬ ‫اصول‬ ‫دندانپزشکی‬ ‫مشکالت‬ ‫و‬ ‫عوارض‬ ‫نظری‬ ‫جراحی‬ ‫درس‬ ‫حسینی‬ ‫هادی‬ ‫سید‬ ‫دکتر‬ ‫صورت‬ ‫و‬ ‫فک‬ ‫جراحی‬ ‫متخصص‬ www.drhadihoseini.com ‫در‬ ‫اسالید‬ ‫دانلود‬: http://www.slideshare.net/hadidezyan
  3. 3. ‫موضعی‬ ‫حسی‬ ‫بی‬ ‫های‬ ‫دارو‬ ‫از‬ ‫استفاده‬ ‫در‬ ‫مشکالت‬ ‫و‬ ‫عوارض‬ ‫موضعی‬ ‫عوارض‬ ‫سیستمیک‬ ‫عوارض‬
  4. 4. Local Complications 1) Needle breakage 2) Prolonged Anesthesia or Paresthesia 3) Facial Nerve palsy 4) Trismus 5) Soft tissues injury 6) Hematoma : 7) Pain on injection 8) Burning on Injection 9) Infection : 10) Edema 11) Postanesthetic Intra-oral lesion: 12) Sloughing of tissue
  5. 5. Needle breakage Prevention • Do not use short needles for inferior alveolar nerve block in adults or larger children. • Do not use 30-gauge needles for inferior alveolar nerve block in adults or children. • Do not bend needles when inserting them into soft tissue. • Do not insert a needle into soft tissue to its hub, unless it is absolutely essential for the success of the injection. • Observe extra caution when inserting needles in younger children or in extremely phobic adult or child patients.
  6. 6. Prolonged Anesthesia or Paresthesia • Strict adherence to injection protocol • Most paresthesias resolve within approximately 8 weeks to 2 months without treatment. • Determine the degree and extent of paresthesia. • Explain to the patient that paresthesia • Record all findings • Second opinion • Examination every 2 months • It would be prudent to contact your liability insurance carrier should the paresthesia persist without evident improvement beyond 1 to 2 months.
  7. 7. Facial Nerve palsy • Reassure the patient • Contact lenses should be removed until muscular movement returns. • An eye patch should be applied to the affected eye until muscle tone returns • Record the incident on the patient's chart. • Although no contraindication is known to reanesthetizing the patient to achieve mandibular anesthesia, it may be prudent to forego further dental care at this appointment.
  8. 8. Trismus • Prescribe heat therapy, warm saline rinses, analgesics (Aspirin 325 mg) • If necessary, muscle relaxants to manage the initial phase of muscle spasm - Diazepam (approximately 10 mg bid) • Initiate physiotherapy • Antibiotics should be added to the treatment regimen described and continued for 7 full days • Patients report improvement within 48 to 72 hours
  9. 9. Soft tissues injury • Analgesics, antibiotics, lukewarn saline rinse, petroleum jelly • Cotton roll placed between lips and teeth, secured with dental floss, minimizes risk of accidental mechanical trauma to anesthetized tissues.
  10. 10. Hematoma • Hematoma is not always preventable. Whenever a needle is inserted into tissue, the risk of inadvertent puncturing of a blood vessel is present. • When swelling becomes evident during or immediately after a local anesthetic injection, direct pressure should be applied to the site of bleeding. • For most injections, the blood vessel is located between the surface of the mucous membrane and the bone; localized pressure should be applied for not less than 2 minutes. This effectively stops the bleeding. • Ice may be applied to the region immediately on recognition of a developing hematoma.
  11. 11. Pain on injection • Adhere to proper techniques of injection, both anatomic and psychological. • Use sharp needles. • Use topical anesthetic properly before injection. • Use sterile local anesthetic solutions. • Inject local anesthetics slowly. • Make certain that the temperature of the solution is correct • Buffered local anesthetics, at a pH of approximately 7.4, have been demonstrated to be more comfortable on administration
  12. 12. Burning on Injection • By buffering the local anesthetic solution to a pH of approximately 7.4 immediately before injection, it is possible to eliminate the burning sensation that some patients experience during injection of a local anesthetic solution containing a vasopressor. • Slowing the speed of injection also helps
  13. 13. Edema If edema occurs in any area where it compromises breathing, treatment consists of the following: • P (position): if unconscious, the patient is placed supine. • A-B-C (airway, breathing, circulation): basic life support is administered, as needed. • D (definitive treatment): emergency medical services (e.g., 9-1-1) is summoned. • Epinephrine is administered: 0.3 mg (0.3 mL of a 1:1000 epinephrine solution) (adult), 0.15 mg (0.15 mL of a 1:1000 epinephrine solution) (child [15 to 30 kg]), intramuscularly (IM) or 3 mL of a 1:10,000 epinephrine solution intravenously (IV- adult), every 5 minutes until respiratory distress resolves. • Histamine blocker is administered IM or IV. • Corticosteroid is administered IM or IV. • Preparation is made for cricothyrotomy if total airway obstruction appears to be developing. This is • extremely rare but is the reason for summoning emergency medical services early. • The patient's condition is thoroughly evaluated before his or her next appointment to determine the cause of the reaction.
  14. 14. Infection • Use sterile disposable needles. • Properly care for and handle needles. • Properly prepare the tissues before penetration. • Prescribe 29 (or 41, if 10 days) tablets of penicillin V (250-mg tablets). • Erythromycin may be substituted if the patient is allergic to penicillin.
  15. 15. Sloughing of tissue • Usually, no formal management is necessary for epithelial desquamation or sterile abscess. Be certain to reassure the patient of this fact. • For pain, analgesics such as aspirin or other NSAIDs and a topically applied ointment (Orabase) • The course of a sterile abscess may run 7 to 10 days
  16. 16. Postanesthetic Intra-oral lesion: • Primary management is symptomatic • No management is necessary if the pain is not severe • Topical anesthetic solutions (e.g., viscous lidocaine) • A mixture of equal amounts of diphenhydramine (Benadryl) and milk of magnesia rinsed in the mouth effectively coats the ulcerations and provides relief from pain. • Orabase, a protective paste, without Kenalog can provide a degree of pain relief. • A tannic acid preparation (Zilactin) can be applied topically to the lesions extraorally or intraorally (dry the tissues first).
  17. 17. Local Anesthetic Systemic Complications and Treatment
  18. 18. • Toxicity Caused by Direct Extension of the Usual Pharmacologic Effects of the Drug: 1) Side effects 2) Overdose reactions 3) Local toxic effects • Toxicity Caused by Alteration in the Recipient of the Drug: 1) A disease process (hepatic dysfunction, heart failure, renal dysfunction) 2) Emotional disturbances 3) Genetic aberrations (atypical plasma cholinesterase, malignant hyperthermia) 4) Idiosyncrasy • Toxicity Caused by Allergic Responses to the Drug Adverse drug reaction
  19. 19. Signs and Symptoms – Toxic Reaction to Local Anesthesia • Talkativeness • Slurred speech • Dizziness • Nausea • Depression • Euphoria • Excitement • Convulsions
  20. 20. ‫حسی‬ ‫بی‬ ‫داری‬ ‫اوردوز‬ ‫واکنش‬ Clinical signs and symptoms that develop as a result of an over-administration of a drug
  21. 21. Overdose Contributing Factors • Age • Weight • Other medications • Presence of disease • Genetics • Mental wellbeing
  22. 22. Drug Factors • Vasoactivity • Concentration • Dose • Route of administration • Rate of injection • Vascularity of the injection site • Presence of vasoconstrictors
  23. 23. ‫حسی‬ ‫بی‬ ‫اوردوز‬ ‫کلینیکی‬ ‫عالیم‬ LOW TO MODERATE OVERDOSE LEVELS: Confusion Talkativeness Apprehension Excitedness Slurred speech Generalized stutter Muscular twitching, tremor of face and extremities Elevated BP, heart rate and respiratory rate
  24. 24. ‫حسی‬ ‫بی‬ ‫اوردوز‬ ‫کلینیکی‬ ‫عالیم‬ MODERATE TO HIGH BLOOD LEVELS:  Generalized tonic clonic seizure, followed by  Generalized CNS depression  Depressed BP, heart rate and respiratory rate SYMPTOMS:  Headache  Light headedness  Auditory distrurbances  Dizziness  Blurred vision  Numbness of tongue and perioral tissues  Loss of consciousness
  25. 25. ‫سیستمیک‬ ‫عوارض‬ ‫کنترل‬ 1) Basic emergency management : A-B-C-D approach 2) Allergy : Medical history questionnaire is important. 3) Elective dental care 4) Emergency dental care: - Protocol no.1 : no treatment of an invasive nature - Protocol no.2 : use general anesthesia - Protocol no.3: Histamine blockers - Protocol no.4 : Electronic dental anesthesia/hypnosis
  26. 26. ‫خاص‬ ‫بیماران‬ ‫کنترل‬ • Uncooperative child The maximum safe dose of lidocaine for a child is 4.5 mg/kg per dental appointment. Local infiltration of anesthesia is sufficient for all dental treatment procedures in 90% of cases even in the mandible.
  27. 27. ‫خاص‬ ‫بیماران‬ ‫کنترل‬ • Handicapped Patient • retarded patients choose a shorter needle and/or a larger gauge needle which is less likely to be bent or broken. better to use general anesthesia
  28. 28. ‫خاص‬ ‫بیماران‬ ‫کنترل‬ Patients receiving anticoagulation or suffering from bleeding disorders  Oral procedures must be done at the beginning of the day & must be performed early in the week, allowing delayed re-bleeding episodes, usually occurring after 24-48 h, to be dealt with during the working weekdays.  Local anesthetic containing a vasoconstrictor should be administered by infiltration or by intraligamentary injection wherever practical. Regional nerve blocks should be avoided when possible.  Local vasoconstriction may be encouraged by infiltrating a small amount of local anesthetic containing adrenaline (epinephrine) close to the site of surgery.
  29. 29. ‫خاص‬ ‫بیماران‬ ‫کنترل‬ PREGNANCY • Lidocaine + vasoconstrictor: most common local anesthetic used in dentistry extensively used in pregnancy with no proven ill effects, Esters are better to be used. • Accidental intravascular injections of lidocaine pass through the placenta but the concentrations are too low to harm fetus.
  30. 30. FDA Category of Prescription Drugs Drug Category Use During Pregnancy Risk Lidocaine B Yes - Prilocaine B Yes - Mepivacaine C Use with caution- Consult physician Fetal bradycardia Bupivacaine C Use with caution- Consult physician Fetal bradycardia
  31. 31. ‫خاص‬ ‫بیماران‬ ‫کنترل‬ GERIATRIC PATIENT – When choosing an anesthetic, we are largely concerned with the effect of the anesthetic agent upon the patient's cardiovascular and respiratory systems. – increased tissue sensitivity to drugs acting on the CNS – Decreased hepatic size and blood flow may reduce hepatic metabolism of drugs – hypertension is common and can reduce renal function – Same prevention procedures used with children
  32. 32. ‫خاص‬ ‫بیماران‬ ‫کنترل‬ LIVER DISORDERS – Advanced liver diseases include: Liver cirrhosis - Jaundice - Potential complications: 1 . Impaired drug detoxication e.g. sedative, analgesics, general anesthesia. 2. Bleeding disorders ( decrease clotting factors, excess fibrinolysis, impaired vitamin K absorption). 3. Transmission of viral hepatitis. Management – Avoid LA metabolized in liver: Amides (Lidocaine, Mepicaine), esters should be used
  34. 34. ‫آلرژی‬ • Incidents of allergy are low • Often allergic reaction is to one of the ingredients within the cartridge, not the local anesthesia itself
  35. 35. • Hypersensitive state as a result of exposure to an allergen • Re-exposure can heighten the initial reaction
  36. 36. ‫آلرژی‬ ‫کلینیکی‬ ‫عالیم‬ • Fever • Angioedema • Urticaria • Dermatitis • Depression of blood-forming organs • Photosensitivity • Anaphylaxis
  37. 37. Angioedema
  38. 38. ‫کنیم‬ ‫جلوگیری‬ ‫آلرژی‬ ‫بروز‬ ‫از‬ ‫چگونه‬ • Take a thorough medical history • Dialogue the medical history with the patient
  39. 39. ‫رایج‬ ‫سواالت‬ • Allergic to any medications? • Have you ever had a reaction to local anesthesia? • If yes, describe what happened • Was treatment given? If so, what?
  40. 40. ‫موضعی‬ ‫های‬ ‫حسی‬ ‫بی‬ ‫به‬ ‫آلرژیک‬ ‫های‬ ‫واکنش‬ • Dermatitis • Bronchospasm • Systemic anaphylaxis • Hypersensitivity to esters (atypical pseudo cholinesterase, PABA)
  41. 41. ‫دارو‬ ‫گیرنده‬ ‫تغییرات‬ ‫بعلت‬ ‫حسی‬ ‫بی‬ ‫داروی‬ ‫سمیت‬ 1) Disease process 2) Emotional disturbances 3) Genetic aberrations 4) Idiosyncrasy
  42. 42. ‫نفرین‬ ‫اپی‬ ‫اوردوز‬ Very rare for patient to experience an epinephrine overdose
  43. 43. ‫عروقی‬ ‫کننده‬ ‫تنگ‬ ‫با‬ ‫اوردوز‬ ‫های‬ ‫نشانه‬ ‫و‬ ‫عالیم‬ • Fear, anxiety • Tenseness • Restlessness • Throbbing headache • Tremor • Perspiration • Weakness • Dizziness • Pallor • Respiratory difficulty • Palpitations
  44. 44. ‫عروقی‬ ‫کننده‬ ‫تنگ‬ ‫دوز‬ ‫اور‬ ‫در‬ ‫کنترل‬ • Terminate dental procedure • Sit patient upright in the dental chair • Reassure patient • Monitor blood pressure • Administer oxygen
  45. 45. ‫حسی‬ ‫بی‬ ‫مصرف‬ ‫های‬ ‫کنتراندیکاسیون‬ ‫عروقی‬ ‫کننده‬ ‫تنگ‬ ‫با‬ ‫موضعی‬ ‫های‬ • Uncontrolled hypertension • Myocardial infarction (within 6 months) • Unstable angina • Coronary artery bypass graft (> 3 months)
  46. 46. Asthma Patient • Thorough medical and dental history • Avoid use of anesthesia that contain epinephrine or levonordefrin because of sulfites (may cause wheezing) • Asthma patient that is steroid dependant may develop brochospasms • Establish rapport and calm environment
  47. 47. ‫خون‬ ‫فشار‬ • Stress and anxiety may raise the patient’s blood pressure (>160/100) • Thorough medical, dental and patient history • Norepinephrine and levonordefrin should not be used because of alpha1 stimulation (2% Mepivacaine with 1:20,000 levonordefrin) • Up to two cartridges of 2% lidocaine with 1:100,000 epinephrine is safe