Assessing Anesthetic Options for Nonsurgical Periodontal Therapy

Transcription

1 1301 Smile Way York, PA Clinical Education Assessing Anesthetic Options for Nonsurgical Periodontal Therapy Course Description: To deliver optimal patient care, pain management is an essential component of periodontal therapy procedures. Supported by science, this course will provide the dental professional with the information necessary to make an anesthetic choice based on each patient s needs. Course Objectives: Upon completion of the course the participant will be able to: Identify medical considerations for local anesthesia Review neurophysiology of drug interactions Discuss pharmacodynamics of local anesthetics Evaluate local anesthetic drugs to include; topical, injectable and non- injectable drugs Identify dental innervations techniques Identify local anesthetic complications Review signs and symptoms of anesthetic overdose Preview new anesthetic technologies COURSE OUTLINE 1. Assessment Considerations Medical history challenges Pain management concerns Pregnancy Fear Multiple medications Undiagnosed and undisclosed medical conditions Cardiovascular problems ASA Physical Status Classification ASA I o Normal, health patient ASA II o Mild, systemic disease ASA III o Severe systemic disease, not incapacitating may need alterations to LA ASA IV Severe systemic disease, constant threat to life may experience adverse events to LA, modifications necessary ASA V o Moribund, imminent death dental care is contraindicated ASA Medical Component Patient Assessment Evaluation Pre-anesthetic evaluation of patient 1

2 Prescription of the anesthetic plan Personal participation in technical aspects of regional anesthetic Remain physically available for treatment of emergencies Provide indicated post-anesthetic care Definition of Pain Unpleasant sensation necessary for survival Informs body of potentially dangerous changes Have a protective function Triggers reflex reaction to retract from painful stimulus If ignored could cause irreparable damage Classifications of Pain Nociceptive pain-sensory receptors that detect injury Neuropathic pain - nerve injury or dysfunction of the sensory nerves Pain disorders associated with psychogenic factors Considerations of the Fearful Patient Fear as a barrier Assessing and addressing strategies to manage fear Common psychogenic adverse events hyperventilation, syncopy Protocol for Stressful Patients Premedicate prior to appointment Short morning appointments Minimize waiting time and monitor vital signs Administer adequate pain control Post- operative pain and anxiety control Follow up treatment 2. Pregnancy Modifications and Considerations Pregnancy Guidelines for Perinatal Care Dental Anesthetic Drug Categories Category B: No evidence of risk in humans; either animal studies show risk Category C: Human studies are lacking and animal studies are either positive for fetal risk or lacking as well Category D: Positive evidence of risk 3. Multiple Medications and Potential Drug Interactions Medical and Dental History Patient s medical status Medications (Rx and OTC) Dietary and Herbal Supplements Previous history with dental anesthetics Street Drugs Methamphetamines, alcohol, marijuana PIL-Product/Patient Information Leaflet 2

3 4. Cardiovascular Concerns Cardiovascular Concerns ADA & AHA Guidelines for prevention of Infective Endocarditis Cardiovascular Accidents (CVA): Absolute contraindication within first 6 months Transient Ischemic Attacks (TIA): Absolute contraindications within first 6 months Myocardial Infarct Hypertension 5. Metabolic Considerations Metabolic Concerns Liver disease: Relative contraindication Kidney disease: Relative contraindication Uncontrolled diabetes: Relative contraindication Uncontrolled hyperthyroidism: Absolute contraindication Methemoglobinemia 3

4 6. Undiagnosed and Undisclosed Medical Conditions Undiagnosed and Undisclosed Medical Conditions Language barriers Hearing impaired Special needs Cultural barriers Informed consent 7. Pharmacodynamics of Local Anesthetics Block nerve impulses Blocks sodium channels in nerve membrane at cellular level If sodium channel is blocked, impulse is not transmitted Different LA drugs differ in side effects, dosages, & duration of action Electrophysiology of Pain Conduction Resting potential = -70mV (unstimulated nerve) Action potential - stimulus causes Na channel to open, allowing influx of Na+ ions into axoplasm Slow depolarization o Slow influx of Na+ inos thru channel causes electrical potential to become less negative o Threshold or Firing Potential = -60 to -50mV; Rapid depolarization begins Rapid depolarization o Rapid influx of Na+ thru channel so that electrical potential quickly reverses to +40mV; Action Potential is generated Repolarization occurs until resting potential is achieved (-60 to -90 mv) Action of Local Anesthetics: Block the action potential Specific Receptor Theory o Amide-type anesthetics o LA molecule diffuses thru nerve membrane and attaches to receptor site within Na channel blocking the Na+ ions from passing thru 8. Evolution and Chemical Formulations of Local Anesthetic Ester-type: o Metabolized in blood o Highly allergenic ; metabolite is PABA o Used only as topical Amide-type o Metabolized in liver & kidneys o Virtually non-allergenic o All injectables ; some topical formulations Specific Protein Receptor Theory Binds to receptor site in sodium channel Block entrance of sodium ions Act during depolarization phase 4

5 9. Local Anesthetic Terminology 1. PIL Patient Information Leaflet 2. Concentration of Drug what is expressed in a cartridge, 2%, 3% or 4% 3. Volume 1.7ml which means (no less than) manufactures variation FDA requirement 4. Percentage expression of the relative amount of drug in a cartridge, 4% drug contains twice as much drug as a 2% drug 5. Relative contraindications those in which local anesthetic may be given with caution 6. Absolute contraindications situations which LA or vasoconstrictor drugs may not be administered safely 7. Absolute vasoconstrictor contraindications NO EPINEPHRINE 10. Vasoconstrictors Definition: A drug added to LA cartridges that constricts the blood vessels Benefits of Vasoconstrictors Constrict blood vessels Decrease risk of toxicity Prolong duration Provide hemostasis via infiltration Types of Vasoconstrictors Epinephrine 1:50,000, 1:100,000, 1:200,000 Levonordefrin synthetic 1:20,000 Fight or flight reactions Allergy to Epi is impossible Mimics allergy symptoms Maximum Dosage Recommendations Healthy patient 0.2mg per appointment Epi-sensitive or Cardiac Dose 0.04mg per appointment Sodium Bisulfite Preservative added to reduce oxidation of epi Contraindications sulfite allergy 11. Local Anesthetic Choices What type of anesthesia is needed? Topical Infiltration Field Block Nerve Block Anesthetic Decision Tree Topicals Compounded Anesthetics Non-injectables Injectables Short, intermediate, long acting 5

6 12. Topical Anesthetics Types of Topical Anesthetics 1. Benzocaine 20% 2. Lidocaine 5% 3. Benzocaine/Tetracaine products 4. Dyclonine Hydrochloride 5. Compounded Products Indications for Use: Topical anesthesia is a condition of temporary numbness caused by applying a substance directly to a surface of the body Applications Gels, sprays, liquids, ointments, pre-measured dose, patch, OTC products Compounding Pharmacy Drugs Anesthetics, mouth rinse, antibiotics, antifungals, cosmetic dental formulations Not FDA regulated Not tested for safety/efficacy FDA Modernization Act 1997 The compounding product must be individually prescribed for an identified patient Common Local Reactions Tissue sloughing Delayed hypersensitivity Redness Pain Burning at site Comparing Drugs Ask questions 13. Non-Injectable Anesthetic Eutectic Mixture Two drugs combined Periodontal Gel Eutectic Mixture of Lidocaine 2.5% + Prilocaine 2.5% Quicker uptake Longer duration Amide Classification Pregnancy B drug One approved FDA drug Indication for Use o Oraqix is indicated for adults who require localized anesthesia in periodontal pockets during SRP Oraqix Application Set appropriate expectations for patient Apply Oraqix to gingival margin of selected teeth Wait 30 seconds Insert blunt tip applicator subgingivally, walking thru pocket as Oraqix is dispensed, until the pocket is full Wait 30 seconds, Begin instrumentation Re-apply as necessary, up to maximum dosage of 5 cartridges per appointment Oraqix Dosage Oraqix can be used in combination with injectable anesthetic 6

7 Can be safely used in any combination, so as not to exceed the MRD of 5 cartridges per appointment alone or combined with another drug 14. Injectable Anesthetics Indications for Use Control and manage pain during dental procedures Types Lidocaine-Xylocaine-Octocaine Articaine-Articadent-Septocaine, Zorcaine Mepivacaine-Polocaine-Carbocaine Prilocaine-Citanest Bupivacaine-Marcaine Infection Changes area to low PH in acidic range LA may not be effective Questions to consider Duration of Procedure Extent of the treatment needed Generalized or Localized Need for Hemostasis Injectable Choices Short Acting: Pulpal duration<1 hour; Soft tissue <2-3 hours Mepivacaine 3% o Produces only slight vasodilatation; adequate duration without the addition of a vasoconstrictor Prilocaine 4% by infiltration o Epi-free alternative with when longer duration is desired Intermediate Acting: Pulpal duration >60 minutes; Soft tissue >3 hours Lidocaine 2% + Epi 1:100,000 o Gold Standard ~ utilized for convenience Lidocaine 2% + Epi 1:150,000 o Indicated for hemostasis during periodontal surgery Prilocaine 4% + Epi 1:200,000 o Maximum pulpal duration with least amount of vasoconstrictor Mepivacaine 2% + Levonordefrin 1:20,000 Articaine 4% + Epi 1:100,000 or 1:200,000 o Metabolizes faster Long Acting: Pulpal duration > minutes; Soft tissue > 4-9 hours Bupivacaine HCL.5% +Epi 1:200,000 Children and Articaine Under 4 years of age not investigated Remember the solution % Simple procedures 0.04% 7

8 15. Dental Innervation Trigeminal Nerve, V1, V2 and V3 o Opthalmic Branch (V1) Sensory o Maxillary Branch (V2) Sensory o Mandibular Branch (V3) Sensory and motor Injection Types Supraperiosteal o Local infiltration o Field block, aka infiltration Nerve Block Maxillary Injections Nerve Tissues anesthetized PSA Posterior Superior Alveolar Pulpal/buccal soft tissues of molars, except MB 1 st molar (30%) MSA Middle Superior Alveolar Pulpal/buccal soft tissues of premolars and MB root 1 st molar ASA Anterior Superior Alveolar Pulpal/buccal soft tissues of cuspid and incisors GP Greater Palatine Posterior portion of hard palate to midline NP Naso Palatine nerves bilaterally Anterior one third of hard palate IO Infraorbital, ASA and PSA Pulpal tissue of max central through canine. In 72% of patients pulpal tissues of max premolars and MB root of 1 st molar, buccal tissue and bone of same teeth, lower eyelid and lateral portion of nose and max lip AMSA ASA and MSA Pulpal tissue of max incisors, canines and premolars. Buccal Attached gingiva of same teeth, attached palatal tissues from Midline to free gingival margin on associated teeth Mandibular Injections Nerve Tissues anesthetized IA Inferior alveolar nerve and lingual nerve Mandibular teeth to the midline, buccal mucosa, lip, anterior Two thirds of tongue, lingual gingiva, floor of the mouth LB Buccal nerve Soft tissues and periosteum buccal to the mandibular molars M Mental Buccal tissues anterior to mental foramen to midline, skin of lip and chin I Mental and Incisive Pulpal tissues of premolars, canines & incisors; buccal Tissues anterior to mental foramen to midline, skin of lower lip And chin Failure of Anesthesia Anatomical variations Infection Individual reaction Intravascular/intramuscular injection Patient Anxiety 8

9 16. Local Anesthetic Complications Needle breakage Pain on injection Burning on injection Parathesia Trismus Hematoma Infection Edema Tissue sloughing Anesthetic Overdose = CNS toxicity Symptoms Include: o Lightheadedness, dizziness, headache o Visual disturbance o Sedation o Numbness or tingling of tongue o Impaired concentration o Dysarthria, Tinnitus, Metallic taste o Muscular twitching Epinephrine Overdoes Symptoms include: o Tension o Anxiety, apprehension o Nervousness o Tremors o Increased heart rate o Increased blood pressure o Throbbing headache o Hyperventilation Overdose Management Terminate procedure Reassure patient Position patient comfortably Monitor vital signs Administer oxygen Medical assistance if needed 17. New Horizons Local Anesthetic reversal agent Gate Control Theory Nasal Mist Buffering Agents 9

10 18. References 1. Ang-Lee, M.K., Moss, J., & Yuan, C. (2001). Herbal Medicines and Perioperative Care. Journal of the American Medical Association, 286(2), Ash-Bernal, R., Wise, R., & Wright, S. (2004). Acquired methemoglobinemia: a retrospective series of 138 cases at 2 teaching hospitals. Medicine, 83(5), Basset, K., DiMarco, A.C. (2007). Safety First. Dimensions of Dental Hygiene, 5(10), 20-22, Bassett, DiMarco, Naughton, (2010). Local Anesthesia for Dental Professionals (1st ed.) Boston, MA: Pearson Education, Inc. 5. Blanton, P.L., Jeske, A.H. (2003). ADA Council on Scientific Affairs; ADA Division of Science, Avoiding complications in local anesthesia induction: anatomical considerations. Journal of the American Dental Association. 134(7): Complications in Local Anesthesia Administration. (2006) Interview with Stanley Malamed. Dimensions of Dental Hygiene, 4(10): Eggleston, S., & Lush, L. (1996). Understanding allergic reactions to local anesthetics. Annuals of Pharmacotherapy, 30, Greer, F., & Shannon, M. (2005). Infant methemoglobinemia: the role of dietary nitrate in food and water. American Academy of Pediatrics Committee on Nutrition; American Academy of Pediatrics Committee on Environmental Health. Pediatrics, 116, Haas, D., & Lennon, D. (1995). A 21 year retrospective study of reports of paresthesia following local anesthetic administration. Canadian Dental Journal, 61, Han, Y. W., Fardini, Y. P., Chen, C. D., Iacampo, K. G., Peraino, V. A., Shamonki, J. M., et al. (2010). Term Stillbirth Caused by Oral Fusobacterium nucleatum. Obstetrics and Gynecology, 115, Hersh, E., Hermann, D., Lamp, C., Johnson, P., & MacAfee, K. (1995). Assessing the duration of mandibular soft tissue anesthesia. Journal of the American Dental Association, 126, Injectable Anesthetics. (2003) Journal of the American Dental Association, 134(5), Johansen, Orjan, (2004). Comparison of Articaine and Lidocaine Used as Dental Local Anesthetics, Section of Dental Pharmacology and Pharmacotherapy, Institute of Clinical Dentistry, University of Oslo. 13. Kanaa, M., Whitworth, J., Corbet, I., & Meechan, J. (2006). Articaine and lidocaine mandibular buccal infiltration anesthesia: a prospective randomized double-blind cross-over study. Journal of Endodotics, 32, Logothetis, D. (2012). Local Anesthesia for the Dental Hygienist (ed., Vol., pp.). St. Louis, 10

11 Missouri: Elsevier, Mosby 15. Malamed, S. (1993). Managing medical emergencies. Journal of the American Dental Association, 124(8), Malamed, Stanley F., (2004) Handbook of Local Anesthesia, Fifth Ed., St. Louis, Missouri: 10 DENTSPLY Professional 10/25/2013 Elsevier, Mosby 17. Markman, L. (2009). Teething: facts and fiction. Pediatric Review, 30, Moore, P., Boynes, S., & Hersch, E. (2006). The anesthetic efficacy of 4% articaine 1:200,000 epinephrine. Journal of the American Dental Association 137(11), Pogrel, M. (2009). Broken local anesthetic needles: a case series of 16 patients, with recommendations. Journal of the American Dental Association December, 140 (12) Rose, L. F., Mealey, B., Minsk, L., & Cohen, D. W. (2002). Oral care for patients with cardiovascular disease and stroke. Journal of the American Dental Association, 133(Supplement) 37S-44S. 21. Robertson, D., & Nusstein, J. E. (2007). The anesthetic efficacy of articaine in buccal infiltration of mandibular posterior teeth. Journal of the American Dental Association,138(8), Rubin, Rick J., DMD, MPA, Saad, Ali Y. DMD (2010), Dental Hygiene Local Anesthesia, Dental Board Busters, Williamsburg, VA, Braintree Publishing, LLC. 23. Rutherford, B., Zeller, J. R., & Thake, D. (2009). Local and Systemic Toxicity of Intraoral Submucosal Injections of Phentolamine Mesylate (OraVerse). Anesth Prog, Winter;56(56), Scofield, J. (2007). The Gravity of Methamphetamine Addiction. Dimensions of Dental Hygiene, 5(3), Smith, T., & Heaton, L. (2003). Fear of dental care: Are we making any progress? Journal of the American Dental Association, 134(8), Spolarich, A., & Andrews, L. (2007 Summer). An examination of the bleeding complications associated with herbal supplements, antiplatelet and anticoagulant medications. Journal of Dental Hygiene, 81(3), 67. Epublish July Whitcomb M, Drum M, Reader A, Nusstein J, Beck M, A Prospective, Randomized, Double-Blind Study of the Anesthetic Efficacy of Sodium Bicarbonate Buffered 2% Lidocaine With 1 : 100,000 Epinephrine in Inferior Alveolar Nerve Blocks, 28. Anesthesia Progress, Vol. 57, No. 2, P. 59 (2010)

12 30. Months.aspx2 Web Sites 29. American Association of Nurse Anesthetists: American Botanical Council: FDA Center for Food Safety and Applied Nutrition: Herbal Interactions, Mayo Clinic: NIH-National Center for Complementary and Alternative Medicine: American Heart Association: 12