Definition
Local anesthesia is defined as a loss of sensation in a circumscribed area of the body caused by depression of excitation in nerve endings or inhibition of the conduction process in peripheral nerves.
Important feature of LA
Loss of sensation without inducing a loss of consciousness
Desirable properties of Local anesthesia
It should not be irritating
It should not cause any permanent alteration of nerve structure
Its systemic toxicity should be low
Time of onset of anaesthesia should be short
It must be effective regardless of whether it is injected into the tissue or is applied locally to mucous membrane
The duration of action must be long enough to permit the completion of procedure.
It should have potency sufficient to give complete anesthesia without the use of harmful concentrated solutions
It should be relatively free from producing allergic reactions
It should be stable in solution and should readily undergo biotransformation in the body
It should be sterile or capable of being sterilized by heat without deterioration
Anterior Superior Alveolar Nerve Block
Infraorbital nerve block
Simple technique and Safe
Indications
Dental procedures involving more than 2 maxillary teeth and their overlying buccal tissues
When supraperiosteal injection are ineffective
Contraindications
Discrete treatment areas
Hemostasis of localized areas
Nerves anesthetized
1) Anterior superior alveolar nerve
2) Middle superior alveolar nerve
3) Infraorbital nerve
A) Inferior palpebral
B) Lateral nasal
C) superior labial
Areas Anesthetized
Pulps of max. central incisor through the canine on the injected side
Pulps of max. premolar and mesiobuccal root of the 1st molar
Buccal periodontium and bone
Lower eye, lat. Aspect of nose, upper lip
Target Area – Infraorbital Foramen
Landmarks
Mucobuccal fold
Infraorbital Notch
Infraorbital Foramen
Technique
2 Extra oral
Intra oral
Intraoral Technique
Infraorbital ridge is palpated and 1cm inferior to it, the infraorbital foramen is palpated with middle finger.
The needle is inserted at the apex of the canine fossa or along the long axis of the first premolar
Extra oral Technique
Infraorbital rim is palpated and infraorbital depression is felt 1cm inferior to it
A needle is inserted cutaneously near the foramen
Middle Superior Alveolar Nerve Block
Indications
Dental procedures involving only max. premolars
Where ASA nerve block fails to provide pulpal anesthesia distal to max. canine
Contraindications
Infection or Inflammation
Nerves Anesthetized
Middle superior alveolar nerve and terminal branches
Areas Anesthetized
Pulps of max. premolars, mesiobuccal root of max.1st molar
Buccal periodontal tissues and bone
Target area
Maxillary bone above the apex of max. 2nd premolar
Posterior Superior Alveolar Nerve Block
Tuberosity Block
Target area
PSA nerve – posterior, superior, and medial to the posterior border of maxilla.
Inferior Alveolar Nerve Block
This lecture explain the basic of root canal preparation in endodontic treatment. It is not meant to be a comprehensive lecture, rather an preliminary one
This lecture explain the basic of root canal preparation in endodontic treatment. It is not meant to be a comprehensive lecture, rather an preliminary one
Zygoma: Strong buttress of lateral midface lying between zygomatic process of frontal bone and maxilla.
The high incidence of zygomatic complex fracture relates to its prominent position within the facial skeleton.
Local aneasthesia techniques which are to be performed extraorally when the conventional intraoral approches for local anaesthesia cant be performed.
Very useful for dental Practioners
Zygoma: Strong buttress of lateral midface lying between zygomatic process of frontal bone and maxilla.
The high incidence of zygomatic complex fracture relates to its prominent position within the facial skeleton.
Local aneasthesia techniques which are to be performed extraorally when the conventional intraoral approches for local anaesthesia cant be performed.
Very useful for dental Practioners
Classification
Mechanism of action
Duration of action
Absorption and distribution
Mode of action
Theories of action of L.A
Pharmacokinetics of local anaesthetics
Routes of administration
Metabolism or biotransformation
Individual agents
Vasoconstrictors
Systemic effects
Toxicity
Advantages
Disadvantages
Maximum allowable dose
Local anaesthetics in community trust services
Indian Dental Academy: will be one of the most relevant and exciting training center with best faculty and flexible training programs for dental professionals who wish to advance in their dental practice,Offers certified courses in Dental implants,Orthodontics,Endodontics,Cosmetic Dentistry, Prosthetic Dentistry, Periodontics and General Dentistry.
WATER
In 1981, the 34th Word Health Assembly in a resolution emphasized that safe drinking water is a basic element for “primary health care” which is the key to the attainment of “Health for All by the year 2000 AD.”
More recently, Millennium Development Goals included safe water and sanitation in the attainable goals.
In 1990, more than 1 billion people in developing world lacked access to safe drinking water and nearly 2 billion lacked an adequate system for disposing off their excreta.
POTABLE WATER
Also called as “Safe and Wholesome Water”
Defined as water that is
Free from pathogenic agents
Free from harmful chemical substances
Pleasant to taste, i.e., free from colour and odour; and
Usable for domestic purposes
Uses of water
Domestic use
Public purposes
Industrial purposes
Agricultural purposes
Power production
Carrying away wastes
Sources of Water
Rain
Surface water
Impounding reservoirs
Rivers and streams
Tanks, ponds and lakes
Sea water
Ground water
Shallow wells
Deep wells
Springs
WATER PURIFICATION
Storage
Filtration
Chlorination
Storage
a) Physical Action
b) Chemical Action
c) Biological Action
Filtration
98 – 99% of the bacteria are removed by filtration apart from other impurities.
Two types of filters are in use
The Biologic or Slow sand filters
Rapid or Mechanical filters
1. Slow Sand or Biologic Filters
Elements:
Supernatant (raw) water
A bed of graded sand
An under drainage system
A system of filter control values
Supernatant (raw) water
Depth – 1 – 1.5 metres
A bed of graded sand
Vital layer
Slimy growth covering the surface of the sand bed
“Schmutzdecke/ Zoogleal/ Biological layer”
Consists of thread like algae, plankton, diatoms and bacteria.
It extends 2-3 cms into the top portion of the sand bed.
Formation of vital layer - “Ripening” of the filter.
It is the “Heart” of the slow sand filter.
It removes organic matter,
Holds back bacteria
Oxidizes ammonical nitrogen into nitrates and
Helps in yielding bacteria free water.
An under drainage system
Filter box – Open rectangular box of 2.5 – 4 meters deep
A system of filter control values
To maintain a constant rate of filtration
Venturi meter – measure the bed resistance or loss of head
2) Rapid/Mechanical filters
Steps involved
Coagulation
Rapid mixing
Flocculation
Sedimentation
Filtration
Filter bed:
Each unit of filter bed has surface of about 80 to 90 sq. feet
Sand is the filtering medium.
Back washing
Rapid sand filters require frequent washing either daily or weekly depending upon the loss of head.
Washing is accomplished by reversing the flow of water through sand bed which is called “Backwashing”.
Helps in dislodging the impurities and cleaning up the sand bed.
Time - 15 to 20 minutes
Chlorination:
Chlorine kills pathogenic bacteria but has no effect on spores and certain viruses except in high doses.
It oxidizes Fe, Mn and HS;
It destroys taste and odour-producing constituents
It controls algae and slime organism
DENTAL AUXILIARY
Dental auxiliary is a person who is given responsibility by a dentist so that he or she can help the dentist render dental care, but who is not himself or herself qualified with a dental degree.
The duties undertaken by dental auxiliaries range from simple tasks such as sorting instruments to relatively complex procedures which form part of the treatment of patients.
DENTAL SURGERY ASSISTANT
Non-operating auxiliary who assists the dentist or dental hygienist in treating patients, but is not legally permitted to treat the patient independently.
Also known as Dental assistant, Chair side dental assistant, Dental nurse
DUTIES
Reception of the patient
Preparation of the patient for any treatment
Provision of all necessary facilities such as mouthwashes and napkins.
Sterilization, care and preparation of instruments.
Preparation and mixing of restorative materials including both filling and impression materials.
DENTAL SECRETARY/ RECEPTIONIST
Assists the dentist with his secretarial work and patient reception duties
DENTAL LABORATORY TECHNICIAN
Non–operating auxiliary who fulfils the prescriptions provided by dentists regarding the extra oral construction and repair of oral appliances and bridge-work.
Also known as Dental Mechanics
DUTIES
Casting of models from impressions made by the dentist
Fabrication of dentures, splints, orthodontic appliances, inlays, crowns and special trays.
DENTURIST
Dental laboratory technicians who are permitted to fabricate dentures directly for patients without a dentists’ prescription.
ADA defines denturism as fitting and dispensing of dentures illegally to the public.
DENTAL HEALTH EDUCATOR
A person who instructs in the prevention of dental disease and who may also be permitted to apply preventive agents intra-orally.
SCHOOL DENTAL NURSE
Who is permitted to diagnose dental disease and to plan and carry out certain specified preventive and treatment measure, including some operating procedures in the treatment of dental caries and periodontal disease in defined groups of people, usually school children.
FUNCTIONS
Prophylaxis
Topical fluoride application
Administration of local anesthetic
DENTAL THERAPIST
Permitted to carry out the prescription of a supervising dentist, certain specified preventive and treatment measures including the preparation of cavities and restoration of teeth
DUTIES
Vital pulpotomy
DENTAL HYGIENIST
Is an operating auxiliary licensed and registered to practice dental hygiene under the laws of the appropriate state, province, territory or nation.
DUTIES
Fluoride and sealant application
screening
EXPANDED FUNCTION DENTAL AUXILIARY
Who has received further training in duties related to the direct treatment of patients, though still working under the direct supervision of a dentist.
Undertake reversible procedures which could be either corrected or redone without harm to the patients health.
DUTIES
Placing and removing rubber dams, matrix bands and temporary restorations
CRITICAL EVALUATION OF DENTAL CARIES INDICES.pptxDrLasya
INDEX definition:
An Index can be defined as a numerical value describing the relative status of a population on a graduated scale with definite upper and lower limits, which is designed to permit and facilitate comparison with other populations classified by the same criteria and methods.
- Russell A. L
Ideal requisites of an index:
Clarity, simplicity, objectivity
Validity
Reliability
Quantifiability
Sensitivity
Acceptability
CLASSIFICATION OF INDICES
1) Direction in which the scores can fluctuate
a) Reversible – Measures conditions that can increase/ decrease on subsequent examinations
Eg: Loe and Silness Gingival Index
b) Irreversible – Measures conditions whose scores will not decrease on subsequent examinations
Eg: DMFT Index
2) The extent to which areas of oral cavity are measured
a) Full Mouth Index - Measures the patients’ entire periodontium or dentition.
Eg: Russell’s Periodontal Index
b) Simplified Index - Measures only a representative sample of the dental apparatus.
Eg: Greene & Vermillion’s Oral Hygiene Index-Simplified (OHI-S)
3) The entity they measure
a) Disease Index - ‘D’ portion of the DMFT
b) Symptom Index – Indices measuring gingival/ sulcular bleeding
c) Treatment Index - ‘F’ portion of the DMFT
4) The special categories
a) Simple Index - Measures the presence or absence of a condition.
Eg: Silness and Loe Plaque Index
b) Cumulative Index - Measures all the evidence of a condition, past and present.
Eg: DMFT Index for dental caries
INDICES FOR ASSESSING DENTAL CARIES
1. Decayed, Missing, Filled Teeth (DMFT) Index
2. Decayed, Missing, Filled Surfaces (DMFS) Index
3. Modified DMFT Index
4. Caries indices for primary dentition:
a. def index
b. dmf index
c. df index
d. Simplified index for dental caries experience
e. Dental Caries Severity Index for primary tooth (CSI)
5. Root caries index
6. Caries Severity Index
7. Dental Caries Severity Classification Scale (D1-D3)
8. Czechoslovakian caries Index
9. Stone’s Index
10. Caries susceptibility Index
11. D-M-F- surface percentage Index
12. Restorative Index
13. Moller’s Index
14. WHO Index for caries
15. Functional measure index
16. T- Health index (Tissue Health Index)
17. Dental health index
Recent Developments on Caries Indices:
1. Nyvad’s criteria
2. Significant Caries (SiC) Index
3. Specific Caries Index
4. ICDAS II
5. PUFA
6. Caries assessment spectrum and treatment (CAST) index
7. FDI World Dental Federation Caries Matrix
Different criteria for diagnosing pit and fissure caries:
1. Anglo-Saxon system (Liberal)
2. European system (Conservative)
SIGNIFICANT CARIES INDEX (SiC Index):
• Introduced in 2000 by Bratthall D, to identify group of individuals with the highest caries scores among population
Procedure:
Individuals are scored according to their DMFT values.
SiC Index is the mean DMFT of one third of the population with the highest caries scores is selected
The index is used as a complement to the mean DMFT
ART - Atraumatic Restorative Treatment.pptxDrLasya
DEFINITION
ART is defined as a minimally invasive care approach in preventing dental caries and stopping its further progression.
- Jo E. Frencken, 2012
PRINCIPLES
Removing carious tooth tissue using hand instruments only
INDICATIONS
Only in small cavities (involving dentin)
In those cavities that are accessible to hand instruments.
Public health programs
CONTRA INDICATIONS
Presence of swelling (abscess) or fistula (opening from abscess region to the oral cavity) near the carious tooth.
Pulp exposure
Chronic inflammation of the pulp with pain in the tooth
There is an obvious carious cavity, but the opening is inaccessible to hand instruments
There are clear signs of a cavity for example in a proximal surface, but the cavity cannot be entered from the proximal or the occlusal direction.
Reasons for using hand Instruments:
With this technique, restorative care is made available to all population groups.
This technique is said to be tooth friendly as this conserves sound tooth tissues and causes less trauma to the teeth by requiring minimal cavity preparation.
Cost effective technique as this uses hand instruments in place of costly electrically driven dental equipment.
Use of local anesthesia for pain management is minimal there by reducing the psychological trauma to patients.
Hand instruments are easy clean and sterilize after every use, thus making infection control simplified
Reasons for using GIC
GIC sticks chemically both to enamel and dentine- the need to cut sound tooth tissue to prepare the cavity is reduced.
Fluoride is released from the restoration which will prevent and arrest caries.
Biocompatible cement as this restoration does not cause any irritation to pulp and gingiva, and has a co-efficient of thermal expansion similar to tooth structure.
Operators work posture:
Operator eye to patient tooth- 30 to 35 cms
Positions – Direct rear - 12 o’ clock
Right rear – 10 o’clock position
Assistant head - 10 to 15 cms higher than operator
Patient Position
Lying on back on flat surface
Head rest- firm foam or rubber ring
ADVANTAGES
Biological approach
Painless
Simplified infection control
No electrically driven and expensive dental equipment is needed
Technique is simple enough to train non-dental personnel or primary health care workers
Cost effective
Friendly procedure
Procedure:
1. Carious dentin can be removed with Spoon excavator
2. Fracture off unsupported thin enamel with Dental hatchet
3. Again clean the cavity with wet cotton rolls. Dry the tooth surface with dry cotton rolls
4. Apply dentin conditioner in the prepared tooth cavity
5. Mix the required amount of GIC
6. Restore the prepared cavity with mixed GIC with the help of blunt end of applier
7. Press the restorative material with gloved finger
8. Remove excess restorative material with sharp end of applier
9. Check the occlusion using articulating paper
CONCLUSION
ART is a combined preventive and curative oral care approach
CONTENTS
Plaque control
Types of Plaque control
Chemical Plaque Control
Goals of Chemical Plaque Control
Factors influencing effects of Chemical Plaque Control
Types of Chemical Plaque Control
1. Chlorhexidine Gluconate
2. Non prescription Essential oil rinses
3. Other Plaque Control Agents
a. Triclosan
b. Delmopinol
c. Metallic ions
d. Quarternary Ammonium Compounds
e. Enzymes
f. Antibiotics
Plaque control
“The removal of microbial plaque and the prevention of its accumulation on the teeth and adjacent gingival tissues”.
TYPES
Mechanical plaque control
Chemical plaque control
CHEMICAL PLAQUE CONTROL
Chemical plaque control should always be regarded as needs-related supplement to and not a substitute for mechanical plaque control.
Therefore, based on individual patients' predicted risk for oral disease, the choice of agent and frequency of use.
Goals of Chemical Plaque Control
1. To prevent plaque formation
2. To control plaque formation
3. To reduce, disrupt or remove existing plaque
4. To alter composition of plaque flora
5. To exert bactericidal or bacteriostatic effects on micro flora implicated in caries and periodontal disease
6. To alter surface energy of the tooth, in turn, affecting the plaque adherence
Factors Influencing Effects of Chemical Plaque Control
1. Substantivity
2. Penetrability
3. Selectivity
4. Solubility
5. Accessibility
Ideal requisites of an Antiplaque agent
Plaque and gingivitis
Pathogenic bacteria
Resistant bacteria
Compatible
Stains/ taste
Retentive property
Inexpensive and easy to use
CHLORHEXIDINE GLUCONATE:
Cationic bisbiguanide
Both antiplaque and antibacterial properties
Mechanism of action:
Substantivity
Bacteriostatic and bactericidal
5 hours – antibacterial, over 12 hours – bacterial count
80-90% reduction
Inhibits plaque by:
Preventing pellicle formation
Preventing adsorption of bacterial cell wall
Preventing binding of mature plaque
Adverse effects
Brownish staining
Taste sensation
Hypersensitivity
Stenosis of parotid duct
Indications of Chlorhexidine Gluconate
1. As an adjunct to mechanical oral hygiene
2. As root canal disinfectant
3. Following oral surgical procedures, including periodontal therapy, periodontal surgeries root planning, gingivectomy and after extraction.
4. In patients with intermaxillary fixation, removable and fixed orthodontic appliance and prosthesis.
5. Effective plaque control among physically and mentally handicapped individuals.
6. Management of recurrent aphthous ulceration
NON PRESCRIPTION ESSENTIAL OIL RINSES:
Thymol
Eucalyptol
Menthol
Methyl salicylate
Other Plaque Control Agents:
Triclosan :
Phenol derivative
Synthetic, non-ionic, antimicrobial
Mycobacterium spores and candida species
Bacteriolysis
In combination with zinc citrate
Delay plaque maturation
Inhibit formation of prostaglandins and leukotrienes
Delmopinol:
Morpholino ethanol derivative
Pre-brushing mouthrinse
Adverse effects:
Numbness of Tongue
Staining of tooth and tongue staining
DEFINITIONS
Plaque
“A structured, resilient, yellow-grayish substance that adheres tenaciously to the intraoral hard surfaces including removable or fixed restorations.
Plaque control
“The removal of microbial plaque and the prevention of its accumulation on the teeth and adjacent gingival tissues”.
TYPES
Mechanical plaque control
Chemical plaque control
TOOTHBRUSHES
Tooth brush is designed to promote cleanliness of teeth and oral cavity.
- ADA’s Council on Dental Therapeutics
Objectives of Tooth brushing
Clean teeth and interdental areas
Prevent plaque formation
Disturb and remove plaque
Stimulate and massage gingiva
Clean tongue
TOOTHBRUSH
Parts:
Handle
Head
Tufts
Brushing plane
Shank
Types of tooth brushes
Manual
Powered
Sonic and ultrasonic
Ionic
MANUAL TOOTHBRUSHES
Toothbrush bristles
Stiffness varies:
Diameter of bristles
Length of bristles
Number of bristles in a tuft
Curvature of bristles
POWERED TOOTHBRUSHES
Automatic, mechanical or electric toothbrushes
Fredrick Tornberg – Mechanical toothbrush – 1885
First Powered toothbrush – 1939
The heads of these toothbrushes oscillate in a side-to-side motion or in a rotary motion – 40Hz
Indications
Young children
handicapped children
Individuals lacking manual dexterity
Orthodontic patients
Institutionalized patients
Patients with prosthodontic or endosseous implants
Patients on supportive periodontal therapy
Advantages:
Increase patient motivation
increased accessability
Helps the patient to brush for a required duration
No specific brushing technique
Uses less brushing force
Sonic and Ultrasonic Toothbrushes
High frequency vibrations (1.6 MHz)
DENTIFRICES
“A dentifrice is a substance used with a toothbrush for the purpose of cleaning the accessible surfaces of the teeth”.
ADA
1-1.25 inches in Length
5/16 - 3/8 inches in width
2 – 4 rows of bristles
5-12 tufts/ row
Functions
1. Minimizes plaque build up
2. Anti-caries action
3. Removal of stains
4. Mouth freshener
Sonic and Ultrasonic Toothbrushes
High frequency vibrations (1.6 MHz)
Ionic Toothbrushes
INTERDENTAL CLEANING AIDS
1. Dental floss
Multifilament – twisted or non twisted
Bonded/ Non bonded
Thick/ thin
Waxed/ non waxed
Functions
Disadvantages
Techniques:
1. The spool method
2. The circle or loop method
AIDS FOR GINGIVAL STIMULATION
Gingival massage
Increases
Keratinization
Blood flow
GCF
Water irrigation devices (Water pik)
Tongue scrapers:
“The process of removing debris from the surface of the tongue with some form of scraper designed for this purpose”.
Techniques :
Brushing
Tongue cleaning devices
DEFINITION
“Actions directed to preventing illness and promoting health to reduce the need for secondary or tertiary health care.
Mosby’s Medical dictionary, 8th edition, 2009
“The action of stopping something from happening or arising”.
Oxford English Dictionary. Lexico 2020
GOALS OF PREVENTION
To promote health
To preserve health
To restore health when it is impaired
To minimize suffering and distress
Successful prevention depends upon:
a knowledge of causation
dynamics of transmission
identification of risk factors and risk groups
availability of prophylactic or early detection and treatment measures,
LEVELS OF PREVENTION
1) Primordial Prevention
2) Primary Prevention
3) Secondary Prevention
4) Tertiary Prevention
PRIMORDIAL PREVENTION
It is the prevention of emergence or development of risk factors in countries or population groups in which they have not yet appeared.
Main intervention is through individual and mass education.
Eg: Efforts directed towards discouraging children from adopting harmful lifestyles.
PRIMARY PREVENTION
“Primary prevention can be defined as the action taken prior to the onset of disease, which removes the possibility that the disease will ever occur.”
Intervention is in the pre- pathogenesis phase of a disease or health problem.
The WHO has recommended the following approaches for the primary prevention of chronic diseases where the risk factors are established: –
A) Population (mass) strategy
B) High -risk strategy
SECONDARY PREVENTION
Definition
“ An Action which halts the progress of a disease at its incipient stage and prevents complications.”
Modes of intervention – Early Diagnosis and Specific treatment
The health programmes initiated by governments are usually at the level of secondary prevention.
Advantages:
Important in reducing the high mortality and morbidity of certain diseases like hypertension, cancer cervix and breast cancer.
Disadvantages:
More expensive and less effective than primary prevention.
Patient is already subjected to mental anguish, physical pain;
TERTIARY PREVENTION
It is defined as “all the measures available to reduce or limit impairments and disabilities, and to promote the patients adjustment to irremediable conditions”.
It is the intervention in the late pathogenesis phase.
Treatment, even in late stages of disease, may prevent sequelae and limit disability.
Modes of Intervention - Disability limitation and Rehabilitation.
MODES OF INTERVENTION
“Intervention” can be defined as any attempt to intervene or interrupt the usual sequence in the development of disease in man.
5 modes of intervention
1. Health promotion
2. Specific protection
3. Early Diagnosis and treatment
4. Disability limitation
5.Rehabilitation
CONCLUSION
To initiate preventive measures it is not necessary to know everything about natural history of the disease.
Main objective of preventive medicine - to intercept or oppose the “cause” and thereby the disease process
RECENT ADVANCES IN PREVENTIVE DENTISTRY.pptxDrLasya
Prevention is defined as “Actions directed to preventing illness and promoting health to reduce the need for secondary or tertiary health care.
GOALS OF PREVENTION
1. To promote health
2. To preserve health
3. To restore health when it is impaired
4. To minimize suffering and distress
LEVELS OF PREVENTION
1) Primordial Prevention
2) Primary Prevention
3) Secondary Prevention
4) Tertiary Prevention
5 modes of intervention
Health promotion
Specific protection
Early Diagnosis and treatment
Disability limitation
Rehabilitation
Recent advances in Caries Prevention
2 approaches
1. Measures to prevent demineralization
2. Measures to promote remineralization
a. Newer remineralizing agents
b. Ozone therapy
c. Recent advances in fluoride
1. Measures to prevent Demineralization
a. Newer chemoprophylactic agents – mineral binding micellar drug delivery system
b. Anti microbial peptides (AMPs)
c. Probiotics
d. Replacement therapy - S. mutans strain BCS3-L1 is a genetically modified effector strain – to prevent dental caries
e. Bacteriophage therapy
f. Photodynamic therapy
g. Sugar substitute - stevia
h. Immunizations
2) Measures to prevent Remineralization
a. Newer remineralizing agents
CPP-ACP
TCP (Tricalcium phosphate)
Pronamel
Novamin
Enamelon
DCPD (Dicalcium phosphate dihydrate)
IER (Ion exchange resins)
b) Ozone therapy
c) Recent advances in fluoride
Fluoride glass device
Copolymer membrane device
Fluoride releasing pellets
DCPA Nano composite
Specialized phosphonate
Hydroxyapatite- Eudragit RS 100 Diffusion controlled “F” system
Synergistic effect of fluoride and laser
Newer topical fluoride- amine fluoride and stannous hexafluorozirconate
Recent advances in Periodontal Disease Prevention
1. Microscopic identification
2. Cultures
3. Enzymatic assay – 2 tests- BANA test and perio-check test
4. Immuno assay
5. Polymerase chain reaction
6. Biosensors – Perio 2000 – measures sulfur levels
7. Genetic analyses
8. Regenerative treatment
9. Photodynamic therapy
10. Enamel matrix derivatives
11. Bisphosphonates
12. Local antimicrobial delivery systems
Metronidazole in ointment form (Elyzol)
Chlorhexidine as Periochip
Doxycycline in fibre form (Actisite)
Polymeric delivery system (Atridox)
13. Inhibition of matrix degradation - Periostat
Recent advances in Oral Cancer Prevention
1. Green tea – bunopyrene - decreased
2. Vitamin A, C, E and minerals such as Fe, Zn, Cu, Se, Mn have preventive effects.
3. L1 DNA Vaccine- prevent Papilloma associated oral cancer.
4. Tretinoin biofilm
MECHANISMS OF PAYMENT
1. Private fee - for services
2. Post payment plans
3. Private third party prepayment plans
-Commercial insurance companies
-Non-profit health service corporations
-Prepaid group practice
-Capitation plans
4. Salary
5. Public programs
1. Private fee - for service
• The two party arrangement, traditional form of reimbursement for dental services.
• Integral part of private practice as a delivery method.
Advantages:
1) Culturally acceptable
2) Flexibility
3) Administratively simple
4) Can be used in expensive situations
Disadvantages:
1. Major percent of the population cannot afford dental care.
Post Payment Plans or Budget Plans
• First started in Late 1930's - local dental societies in Pennsylvania & Michigan
• Mechanisms for the individual purchase of service
Advantages:
1. Helpful for middle income people
2. Primarily used to finance prosthetic and other costly treatment
Disadvantages:
1. Lower income people cannot use to the full
2. Problem of defaulted loans
Private Third Party Prepayment Plans
Defined as payment for service by some agency rather than directly by the beneficiary of those services.
1st Party-Dentist; 2nd Party-Patient; 3rd Party-Administrator of Finances
Third Party/ Carrier/ Insurer/ Underwriter/ Administrative Agent.
• Defined as The party to a dental prepayment contract that may collect premiums, assume financial risk, pay claims and provide administrative services
Reimbursement of Dentist in Third Party Plans
The major forms of third-party reimbursement currently in use are:
Usual fee: The fee that an individual dentist most frequently charges for a given dental service.
Customary Fee: The fee level determined by the administrator of a dental benefit plan from actual submitted fees for a specific dental procedure to establish the maximum benefit payable under a given plan for that specific procedure.
Reasonable Fee: the fee charged by the dentist for a specific dental procedure that has been modified by the nature and severity of the condition being treated and by any medical or dental complications may differ from the dentists usual fee or the benefit administrators customary fee.
A table of allowances: A list of covered services with an assigned amount that represents the total obligation of the plan with respect to payment for such service but that does not necessarily represent the dentists full fee for that service”.
Fee schedule: A list of charges established or agreed to by a dentist for specific dental services. A fee schedule is usually taken to represent payment in full, whereas a table of allowances may not.
Capitation: A capitation fee is usually a fixed monthly payment paid by a carrier to a dentist based on the number of patients assigned to the dentist for treatment.
SALARY
Dentists in some group practices, those in the armed forces and those employed by public agencies are salaried.
PUBLIC PROGRAMS
Medicare
Medicaid
NHI
• Non parametric tests are distribution free methods, which do not rely on assumptions that the data are drawn from a given probability distribution. As such it is the opposite of parametric statistics
• In non- parametric tests we do not assume that a particular distribution is applicable or that a certain value is attached to a parameter of the population.
When to use non parametric test???
1) Sample distribution is unknown.
2) When the population distribution is abnormal
Non-parametric tests focus on order or ranking
1) Data is changed from scores to ranks or signs
2) A parametric test focuses on the mean difference, and equivalent non-parametric test focuses on the difference between medians.
1) Chi – square test
• First formulated by Helmert and then it was developed by Karl Pearson
• It is both parametric and non-parametric test but more of non - parametric test.
• The test involves calculation of a quantity called Chi square.
• Follows specific distribution known as Chi square distribution
• It is used to test the significance of difference between 2 proportions and can be used when there are more than 2 groups to be compared.
Applications
1) Test of proportion
2) Test of association
3) Test of goodness of fit
Criteria for applying Chi- square test
• Groups: More than 2 independent
• Data: Qualitative
• Sample size: Small or Large, random sample
• Distribution: Non-Normal (Distribution free)
• Lowest expected frequency in any cell should be greater than 5
• No group should contain less than 10 items
Example: If there are two groups, one of which has received oral hygiene instructions and the other has not received any instructions and if it is desired to test if the occurrence of new cavities is associated with the instructions.
2) Fischer Exact Test
• Used when one or more of the expected counts in a 2×2 table is small.
• Used to calculate the exact probability of finding the observed numbers by using the fischer exact probability test.
3) Mc Nemar Test
• Used to compare before and after findings in the same individual or to compare findings in a matched analysis (for dichotomous variables).
Example: comparing the attitudes of medical students toward confidence in statistics analysis before and after the intensive statistics course.
4) Sign Test
• Sign test is used to find out the statistical significance of differences in matched pair comparisons.
• Its based on + or – signs of observations in a sample and not on their numerical magnitudes.
• For each subject, subtract the 2nd score from the 1st, and write down the sign of the difference.
It can be used
a. in place of a one-sample t-test
b. in place of a paired t-test or
c. for ordered categorial data where a numerical scale is inappropriate but where it is possible to rank the observations.
5) Wilcoxon signed rank test
• Analogous to paired ‘t’ test
6) Mann Whitney Test
• similar to the student’s t test
7) Spearman’s rank correlation - similar to pearson's correlation.
TESTS OF SIGNIFICANCE
Deals with techniques to know how far the difference between the estimates of different samples is due to sampling variation.
Standard error (S.E) of Mean = S.D/√n
Standard error (S.E) of Proportion = √pq/n
Tests of significance:
Can be broadly classified into 2 types
1. Parametric tests (or) standard tests of hypothesis
2. Non – Parametric tests (or) distribution free-test of hypothesis
PARAMETRIC TESTS:
Parametric test is a statistical test that makes assumptions about the parameters of the population distribution(s) from which ones data is drawn.
When to use parametric test???
Subjects should be randomly selected
Data should be normally distributed
Homogeneity of variances
The important parametric tests are:
1) z-test
2) t-test
3) ANOVA
4) Pearson correlation coefficient
Z - Test:
This is a most frequently used test in research studies.
Z - test is based on the normal probability distribution and is used for judging the significance of several statistical measures, particularly the mean.
Z - test is used when sample size greater than 30. Test of significance for large samples
Z = observation – mean
SD
Prerequisites to apply z- test
Sample must be selected randomly
Data must be quantitative
Variable is assumed to follow normal distribution in the population
Sample size must be greater than 30. if SD of population is known, z test can be applied even sample size is less than 30
2) t- Test
• In case of samples less than 30 the Z value will not follow the normal distribution
• Hence Z test will not give the correct level of significance
• In such cases students t test is used
• It was given by “WS Gossett” whose pen name was student. So, it is also called as Student test.
There are two types of student t Test
1. Unpaired t test
2. Paired t test
Criteria for applying t- test
1. Random samples
2. Quantitative data
3. Variable normally distributed
4. Sample size less than 30
Unpaired test:
• Applied to unpaired data of independent observation made on individuals of 2 separate groups or samples drawn from the population.
• To test if the difference between the 2 means is real or it can be due to sampling variability.
Paired t - test:
• It is applied to paired data of observation from one sample only (observation before and after taking a drug)
Examples:
1. Pulse rate before and after exertion
2. Plaque scores before and after using oral hygiene aid
3) ANOVA ( Analysis of Variance):
• Investigations may not always be confined to comparison of 2 samples only
• In such cases where more than 2 samples are used ANOVA can be used.
• Also when measurements are influenced by several factors playing their role e.g. factors affecting retention of a denture, ANOVA can be used.
Indications:
To compare more than two sample means
Types:
1. one-way ANIVA
2. Two-way ANOVA
3. Multi-way ANOVA
Pearson’s correlation
Steps in conducting a RCT
1. Drawing up a protocol
2. Selecting Reference & Experimental population
3. Randomization
4. Manipulation or Intervention
5. Follow up
6. Assessment of outcome
1. Drawing up a protocol
Aims and objectives of the study
Questions to be answered
Criteria for the selection of study and control groups
Size of the sample & allocation of subjects in both groups
Treatment to be applied - when, where, how
Standardization of working procedures and
Schedules as well as responsibilities of persons involved in the trial up to the stage of evaluation of outcome of the study.
2. Selecting Reference and Experimental Populations
Reference or target population - Population to which the findings of the trial, if found successful, are expected to be applicable (Eg: drugs, vaccines, etc.)
Experimental or Study population
Derived from the Reference population
Has same characteristics as the Reference population
Actual population that participates in the experimental study
Must give informed consent - Should be qualified or eligible for the trial
3. Randomization
Heart of the control trial
Procedure:
Participants are allocated into study and control groups
Eliminates bias and allows comparability
By random allocation every individual gets an equal chance for being allocated in to either groups.
4. Manipulation/ Intervention
Having formed the study and control group, the next step is to intervene or manipulate the study (experimental) group by deliberate application or withdrawal or reduction of a suspected causal factor
Eg: Drug, Vaccine, Dietary component, a habit
5. Follow up
Implies examination of the experimental and control group subjects at defined intervals of time in a standard manner, with equal intensity, under the same given circumstances in the same time frame till final assessment of outcome.
Attrition:
Inevitable losses to follow up (death, migration, loss of interest)
6. Assessment
a. Positive results:
Reduced incidence or severity of disease
Reduced cost to health service
Appropriate outcome in the study
b. Negative results:
Increased severity or frequency of side effects
Complications
Deaths
BIAS:
Any systematic error in the determination of association and outcome.
Bias may arise from errors of assessment of outcome due to human element
Subjective bias
Observer bias
Evaluation bias
1. Subjective Bias:
Participants, subjectively feel better or report improvement if they knew they were receiving a new form of treatment. This is known as “Subject variation”.
2. Observer Bias:
Investigator measuring the outcome of a therapeutic trial may be influenced if he knows beforehand the particular procedure or therapy to which the patient has been subjected.
3. Evaluation Bias:
Investigator may subconsciously give a favorable report of the outcome of the trial.
Blinding:
1. Single Blind Trial: Participant
2. Double Blind: Partcipant + Investigator
3. Triple Blind: Participant + Investigator + Data Analyzer
EPIDEMIOLOGY OF PERIODONTAL DISEASES 1.pptxDrLasya
INTRODUCTION
• Gingival and periodontal diseases in their various forms have affected humans since the dawn of the history.
• Studies in paleopathology have indicated that destructive periodontal disease, as evidenced by bone loss, affected early humans in such diverse cultures as ancient Egypt and pre-columbian America.
• Epidemiologic studies identify risk factors for diseases and provide guidance for primary prevention, recommendations and identify where to intervene in disease process.
PERIODONTAL DISEASES
GINGIVITIS
• Inflammation of the gingival soft tissues with no loss of alveolar bone or apical migration of periodontal ligament along root surface.
• It may be characterized by edema, erythema, bleeding, and occasionally pain.
• Gingivitis is usually reversible with appropriate therapy.
PERIODONTITIS
• An inflammatory disease of the supporting tissues of the teeth caused by specific microorganisms or groups of specific microorganisms, resulting in progressive destruction of the periodontal ligament and alveolar bone with pocket formation, recession, or both.
• The clinical feature that distinguishes periodontitis from gingivitis is the Loss of clinical attachment
CLASSIFICATION OF PERIODONTAL DISEASES
CHRONIC PERIODONTITIS
• The most common form of periodontitis
• Most prevalent in adults but can occur in children
• Amount of destruction consistent with local factors
• Associated with a variable microbial pattern
• Associated with accumulations of plaque and calculus
• Slow to moderate rate of progression with possible periods of rapid progression
• Localized form: < 30% of sites involved
• Generalized form: > 30% of sites involved
• Slight: 1 to 2mm CAL (clinical attachment loss)
• Moderate: 3 to 4 mm CAL
• Severe: 5mm or greater CAL
AGGRESSIVE PERIODONTITIS
• Rapid attachment loss and bone destruction
• Amount of microbial deposits inconsistent with disease severity
• Familial aggregation of diseased individuals
• Generally diseased sites are infected with a specific bacteria (Actinobacillus actinomycetemcomitans)
• Abnormalities in phagocyte function
• Hyper-responsive macrophages, producing elevated PGE2 and IL1B
• Disease progression may be self-limiting
• It is of two types- localized and generalized
LOCALIZED AGGRESSIVE PERIODONTITIS
• Circumpubertal onset of disease
• Localized first molar/ incisor
• Interproximal attachment loss on at least two permanent teeth
• Robust serum antibody response to infecting agents
GENERALIZED AGGRESSIVE PERIODONTITIS
• Usually affecting persons under 30 years of age (however, may be older)
• Generalized interproximal attachment loss affecting at least three teeth other than first molars and incisors
• Pronounced episodic nature of destruction
• Poor antibody response to infecting agents
Periodontitis as a manifestation of Systemic disease
Hematologic disorders
A) Acquired neutropenia
B) Leukemias
Genetic disorders
A) Familial & cyclic neutropenia
B) Down’s syndrome
c) Papillon-Lefevre syndrome
INTRODUCTION
Vitamins may be regarded as organic compounds required in the diet in small amounts to perform specific biologic functions for normal maintenance of optimum growth and health of the organisms
Generally, vitamins are not synthesized by the body, and need to be supplied through the diet
History and Nomenclature
HOPKINS - Coined term ACCESSORY FACTORS to unknown and essential nutrients present in the natural foods
FUNK - 1) Isolated an active principle from rice polishing's and in yeast cured Beri - Beri in pigeons
2) Coined the term VITAMINE from the words vital + amines
3) Later it was called “ VITAMIN ”
Mc COLLUM and DAVIS - Introduced the usage of A, B, and C to vitamins
CLASSIFICATION
There are about 13 vitamins, essential for humans classified as follows
Vitamers:
Chemically similar substances that possess qualitatively similar vitamin activity
VITAMIN A
Fat soluble vitamin
Present only in foods of animal origin
Carotenes - Plants
Dietary Sources:
Animal sources
Liver
Kidney
Egg yolk
Milk
Cheese
Fish liver oils
Plant sources
Carrots
Papaya, Mangoes
Avocado, Melon
Pumpkins
RDA (Recommended Dietary Allowance):
Men - 1000 RE (3500 IU)
Women - 800 RE (2500 IU)
Children - below 6 years - 350 - 400 µg Retinol
- 6-17 years – 600 µg Retinol
Pregnancy – 800 µg Retinol
Lactation – 950 µg Retinol
1 RE – 1 µg of Retinol
1 IU – 0.3 mg of Retinol
Biochemical Functions:
Vision - the role of vit A in the process
of vision was first elucidated
by GEORGE WALD(1968)
The events occur in a cyclic process known as Rhodopsin Cycle (or) Wald’s Cycle
RODS and CONES:
Retina of eye possesses rods and cones
Human eye - 10 million rods
5 million cones
Rods –Periphery – Dim light vision
Cones – Centre – Bright light and color vision
Deficiency of Vitamin A:
1) Night Blindness
2) Conjuctival X
VITAMIN D
ANGUS – Isolated and named it as CALCIFEROL
Resembles sterols in structure
Functions like hormone
Dietary Sources:
Fatty acids
Fish liver oils
Egg yolk
Cheese
Butter
RDA:
400 IU or 10 mg of cholecalciferol
Countries with good sunlight – 200 IU or 5 mg
Deficiency:
1) RICKETS - In young children aged 6 months to 2 years
Due to reduced calcification of young bones
Characterized by Growth failure
Bone deformity
Muscular hypotonia
Tetany and convulsions
Elevated conc. Of alkaline phosphatase in serum
Bony deformities - Bow legs, Deformed pelvis, Pigeon chest, Harrison’s sulcus
walking and teething are delayed.
OSTEOMALACIA
In adults, women, during pregnancy and lactation
Prevention:
Educating parents to expose their children regularly to sunshine.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
2. Contents
*Historical Background
*Definition
*Desirable Properties of Local Anesthesia
*Electrophysiology of Nerve conduction
*Mechanism of Action
*Theories
*Classification of Local Anesthetics
*Composition of Local Anesthetics
*Administration of Local Anesthesia
3. *Techniques of Local Anesthesia
*Local Complications
*Systemic complications
*Special Care Groups
*Newer Local Anesthetic Drugs and Delivery Systems
*Public Health Significance
*Conclusion
*References
4. Historical Background
*COCAINE – First local anesthetic agent - isolated by NIEMAN
1860 – from the leaves of the coca tree
*Its anesthetic action was demonstrated by KARL KOLLER –
1884
*First effective and widely used synthetic local anesthetic –
PROCAINE – developed by EINHORN – 1904 - from benzoic
acid and diethyl amino ethanol
*Agent was introduced into clinical practice by BRAWN 1905
*LIDOCAINE - LOFGREN - 1943
5. Definition
*Local anesthesia is defined as a loss of sensation in a
circumscribed area of the body caused by depression of excitation
in nerve endings or inhibition of the conduction process in
peripheral nerves.
Important feature of LA
*Loss of sensation without inducing a loss of consciousness
6. Desirable properties of Local anesthesia
*It should not be irritating
*It should not cause any permanent alteration of nerve structure
*Its systemic toxicity should be low
*Time of onset of anaesthesia should be short
*It must be effective regardless of whether it is injected into the
tissue or is applied locally to mucous membrane
*The duration of action must be long enough to permit the
completion of procedure.
7. *It should have potency sufficient to give complete anesthesia
without the use of harmful concentrated solutions
*It should be relatively free from producing allergic reactions
*It should be stable in solution and should readily undergo
biotransformation in the body
*It should be sterile or capable of being sterilized by heat without
deterioration
8. Electrophysiology of Nerve Conduction
*In Resting state, nerve possess negative membrane potential of
-70mV
*Na+ /K+ pump acts by transporting the Na+ ions out of the cell and
k+ ions into the cell
*Na+/K+ pump creates a conc. gradient by which it favors the
transport of K+ out of the cell
*Negatively charged ions accumulate within the cell
Depolarization
*When nerve is stimulated, it gets depolarized Impulse
propagation
Na+
K+
9. *Nerve membrane becomes permeable to Na+ ions also
Entry of Na+ into the cell
Threshold potential is achieved (-55mV)
Permeability to Na+ increases rapid influx of Na+
*At the end of depolarization, the potential is around +35mV
*Alterations in nerve membrane potentials Action potential
10. Repolarization
*Nerve membrane permeability to Na+ ions decreases
Along the conc. gradient, K+ moves into the cell and Na+ out of
the cell
Activation of Na+/K+ pump restores the resting membrane
potential of -70mV
*Entire process – 1 millisecond
*Depolarization – 0.3 msec
*Repolarization – 0.7 msec
K+
Na+
11. Mechanism of Action
*LA basically block the influx of Na+ ions
*Weak bases, easily injectable, water soluble
*In aq. solution – salt dissociates into ionized and non ionized forms
*For LA to be effective – it should diffuse into nerve cell membrane
*Non ionized form – lipophilic – responsible for the diffusion into
nerve cell membrane
*Ionized form – responsible for binding to the Na+ channel receptors
– blocks Na+ channel – prevent Depolarization
12. *More than 90% of the nerve membrane is made of lipids
*Proportion of ionized and non ionized forms depends on the ph of
surrounding tissue
*Decrease in ph of surrounding tissue shifts the equilibrium
towards ionized form onset of LA is delayed
*In case of infection or inflammation – acidic environment
increases ionized form – LA is less effective
13. Theories
1) Acetylcholine Theory
*Acetylcholine involved in nerve conduction
*Acts as Neurotransmitter at nerve synapses
2) Calcium Displacement Theory
*Calcium which is present at the sodium channel was responsible
for the transport of Na+ through the channel
*LA said to displace the calcium – prevent sodium influx
3) Surface Charge Repulsion Theory
*Charged LA molecules bind to nerve membrane - alter electrical
potential
14. 4) Membrane Expansion Theory
*LA is absorbed into the cell membrane and causes an expansion of
the membrane itself – causes narrowing of Na+ channels –
prevents Na+ influx
5) Specific Receptor Theory
*Specific receptors present at the opening of the Na+ channels
*LA diffuses across the nerve membrane and binds to these
receptors – leads to an alteration in the structure and functioning of
the Na+ channel – prevent Na+ influx
15. Classification of Local Anesthetics
*Classified whether the intermediate chain is an Amide or an Ester
Local Anesthetics
Esters Amides
Cocaine
Tetracaine
Benzocaine
Butacaine
Procaine
Chlorprocaine
Lidocaine
Prilocaine
Mepivacaine
Bupivacaine
Etidocaine
Para-amino
benzoic acid
Benzoic acid
16. 1) Esters
*Metabolized by hydrolysis by Plasma Cholinesterase
*One of the products of hydrolysis of this drug is PABA
*Eg – Cocaine, Procaine, Chlorprocaine, Tetracaine
2) Amides
*Metabolized in the liver by microsomal enzymes
*Lidocaine is metabolized by a specific microsomal enzyme
P – 450 3A4
*Eg – Lidocaine, Prilocaine, Mepivacaine, Bupivacaine, Etidocaine
17. * According to Biological site and Mode of Action
Agents acting at receptor site on external surface
of nerve membrane
Eg: Biotoxins like tetrodoxin, saxitoxin
Agents acting at receptor site on internal surface of
nerve membrane
Eg: Quaternary ammonium analogs of lidocaine
Scorpion venom
Agents acting by a receptor – independent
physico–chemical mechanism
Eg: Benzocaine
Agents acting by combination of receptor and
receptor independent mechanisms
Eg: articaine, lidocaine, mepivacaine, prilocaine
Class A
Class B
Class C
Class D
18. Composition of Local Anesthetic Solution
1) Local Anesthetic
2) Vasoconstrictor
3) Antioxidant
4) Preservative
5) Fungicide
6) Salt
7) Vehicle
*Local anesthetic – Amide or Ester
*Vasoconstrictor – Epinephrine (1:1,00,000)
19. *Local anesthetics are Vasodilators – Vasodilatation of the
peripheral arterioles – LA to be rapidly absorbed into the blood
stream
*Epinephrine is added to the LA – Vasoconstriction – prevents rapid
absorption into the blood stream
*Also reduces systemic toxicity
*Increases the duration of action – as it delays absorption from the
local site
*Also causes hemostasis in the injected area – helps in creating a
blood - free field for operation
20. *Epinephrine has toxic effects
*May produce cardiac arrhythmias in patients with previous heart
disease
*May induce hypertension – Hypertensive and in Hyperthyroid
patients
*May induce arrhythmias when used along with Halothane
*May hamper the healing of a flap
*LA with epinephrine should not be injected in the ala of the nose
or in the helix of the ear
21. *Antioxidant – Sodium Metabisulphite – prolongs shelf life
*Preservative – Methyl Paraben or Capryl hydro cuprinotoxin
*Fungicide – Thymol
*Salt – Bicarbonate – isotonic
*Vehicle – Distilled Water or Ringer’s Lactate solution – dissolves
all the contents of LA to make it injectable
26. Maxillary Nerve
Blocks
Anterior Superior Alveolar Block
Greater Palatine Block
Techniques of LA
Mandibular Nerve
Blocks
Posterior Superior Alveolar Block
Middle Superior Alveolar Block
Naso Palatine Block
Anterior Superior Alveolar Block Inferior Alveolar Block
Lingual Block
Incisive Block
Mental Block
Buccal Block
27. Anterior Superior Alveolar Nerve Block
*Infraorbital nerve block
*Simple technique and Safe
Indications
*Dental procedures involving more than 2 maxillary teeth and their
overlying buccal tissues
*When supraperiosteal injection are ineffective
Contraindications
*Discrete treatment areas
*Hemostasis of localized areas
28. Nerves anesthetized
1) Anterior superior alveolar nerve
2) Middle superior alveolar nerve
3) Infraorbital nerve
A) Inferior palpebral
B) Lateral nasal
C) superior labial
Areas Anesthetized
*Pulps of max. central incisor through the canine on the
injected side
29. *Pulps of max. premolar and mesiobuccal root of the 1st
molar
*Buccal periodontium and bone
*Lower eye, lat. Aspect of nose, upper lip
Target Area – Infraorbital Foramen
Landmarks
*Mucobuccal fold
*Infraorbital Notch
*Infraorbital Foramen
30. Technique
*2 Extra oral
Intra oral
Intraoral Technique
*Infraorbital ridge is palpated and 1cm inferior to it, the
infraorbital foramen is palpated with middle finger.
*The needle is inserted at the apex of the canine fossa or along
the long axis of the first premolar
31. Extra oral Technique
*Infraorbital rim is palpated and infraorbital depression is felt 1cm
inferior to it
*A needle is inserted cutaneously near the foramen
Symptoms
*Numbness – Infraorbital region
Lateral aspect of the nose
Upper lip
33. Middle Superior Alveolar Nerve Block
*Minimizes the number of injections and vol. of solution
Indications
*Dental procedures involving only max. premolars
*Where ASA nerve block fails to provide pulpal anesthesia distal to
max. canine
Contraindications
*Infection or Inflammation
*When MSA is absent
34. Nerves Anesthetized
*Middle superior alveolar nerve and terminal branches
Areas Anesthetized
*Pulps of max. premolars, mesiobuccal root of max.1st molar
*Buccal periodontal tissues and bone
Target area
*Maxillary bone above the apex of max. 2nd premolar
Landmarks
*Mucobuccal fold above max 2nd premolar
36. Posterior Superior Alveolar Nerve Block
*Tuberosity Block , Zygomatic Block
*Commonly used dental nerve block
*Atraumatic
*High success rate
*Minimizes the no. of injections
*Minimizes total vol. of solution
Indications
*Treatment involving 2 or more max. molars
*When supraperiosteal injection is contraindicated
37. Contraindications
*When risk of haemorrhage is too great
Nerves Anesthetized
*Posterior superior alveolar nerve and its branches
Areas Anesthetized
*Pulps of max. 3rd , 2nd , and 1st molars
*Buccal periodontium and bone
Target area
*PSA nerve – posterior, superior, and medial to the posterior
border of the maxilla
39. Greater Palatine Nerve Block
*Anterior palatine nerve block
*Minimizes needle penetrations and vol. of solution
Indications
*When palatal soft tissue anesthesia is necessary
*For pain control during periodontal or oral surgical procedures
involving hard and soft tissues
Contraindications
*Infection or inflammation at injection site
*Procedure involving 1 or 2 teeth
40. Nerves Anesthetized - Greater palatine
Areas Anesthetized
*Posterior portion of hard palate and its overlying tissues
Target Area
*Greater palatine nerve as it passes anteriorly between soft tissues
and bone of the hard palate
Technique
Complications
*Ischemia of palate
*Anesthesia of soft palate – leads to gagging
41. Nasopalatine Nerve Block
*Incisive nerve block, sphenopalatine nerve block
*Minimizes needle penetrations and vol. of solution
*Minimizes patient discomfort from multiple needle penetrations
Indications
*When palatal soft tissue anesthesia is necessary
*For pain control during periodontal or oral surgical procedures
involving hard and soft tissues
Contraindications
*Infection or inflammation at injection site
*Procedure involving 1 or 2 teeth
42. Nerves Anesthetized - Nasopalatine nerve bilaterally
Areas Anesthetized
*Anterior portion of hard palate bilaterally
Target Area
*Incisive foramen (beneath incisive papilla)
Landmarks
*Central incisors
*Incisive papilla
44. Inferior Alveolar Nerve Block
*Mandibular nerve block
*Wide area of anesthesia
Indications
*Procedures on mand. teeth in one quadrant
*When buccal and lingual soft tissue anesthesia is necessary
Contraindications
*Infection or acute inflammation
*Very young child
*Mentally or physically handicapped
45. Nerves anesthetized
*Inferior alveolar nerve
*Lingual nerve
*Incisive
*Mental
Areas Anesthetized
*Mand. teeth to the midline
*Body of the mandible, inferior portion of the ramus
*Buccal mucoperiosteum, mucous membrane anterior to the mental
foramen
46. *Ant 2/3rd of the tongue and floor of the oral cavity
*Lingual soft tissues and periosteum
Target area
*Inferior alveolar nerve ( near Mandibular foramen)
Landmarks
*Coronoid Notch
*Pterygopalatine raphe
*Occlusal plane of the mand. posterior teeth
47. Technique
*Anterior border of the ramus is palpated as sharp edge lateral to the
molars.
*Deepest part on anterior border – Coronoid notch
*Pterygomandibular raphe - ‘S’ shape curve - runs from max.
tuberosity to retromolar fossa
*The thumb is still placed on the coronoid notch
*The needle is placed from the opposite side premolar – it bisects
the nail of the thumb
*The needle is inserted around 3/4th till bony resistance is
encountered
48. *Aspirate and 1.5 ml of solution is deposited
Symptoms
*Tingling and numbness – lower lip, tongue
*On instrumentation – labial gingiva anterior to 1st premolar
Complications
*Transient facial nerve paralysis
*Trismus – spasm of Medial Pterygoid
*Hematoma
49. Lingual Nerve Block
Technique
*Similar to an IANB
*After the inferior alveolar nerve block is given , the needle is
withdrawn less than 1cm.
*The remaining solution, around 1cc, is deposited
Symptoms
*Tingling and numbness – ant. 2/3rd of the tongue
*On instrumentation – lingual gingiva
50. Buccal Nerve Block
*Long buccal nerve block, Buccinator nerve block
Indications
*Buccal soft tissue anesthesia (Mandibular molar region)
Contraindications
*Infection or inflammation
Nerves anesthetized - Buccal nerve
Areas anesthetized
*Soft tissues and periosteum – buccal to mand. molar teeth
51. Target Area
*Buccal Nerve – anterior border of the ramus
Landmarks
*Mandibular molars
*Mucobuccal fold
Technique
Complications
*Swelling - superficial mucosal injection
52. Mental Nerve Block
*Atraumatic
Indications
*Buccal soft tissue anesthesia (ant. to mental foramen)
*Soft tissue biopsies
*Suturing of soft tissues
Nerves anesthetized - Mental nerve
Areas Anesthetized
*Buccal mucosa ant. to mental foramen to the midline
*Skin of the lower lip
53. Target area – mental foramen usually between the apices of 1st
and 2nd premolars
Landmarks
*Mandibular premolars
*Mucobuccal fold
Technique
Symptoms
*Numbness – lower lip and labial mucosa
54. Incisive Nerve Block
Indications
*Dental procedures requiring pulpal anesthesia on mand. teeth
*anterior to the mental foramen
*When IANB is not indicated
Contraindications
*Infection or inflammation
Nerves Anesthetized – Mental and Incisive
55. Areas Anesthetized
*Buccal mucous membrane ant. to mental foramen
*Lower lip and skin of chin
Target Area – Mental foramen
Landmarks
*Mandibular premolars
*Mucobuccal fold
Technique
56. Mandibular Nerve Block : The Gow Gates
Technique
*Intraoral technique uses extra-oral landmarks
Indications
*Multiple procedures on mandibular teeth
*When buccal soft tissue anesthesia, from 3rd molar to the midline is
necessary
*Lingual soft tissue anesthesia
*When conventional inferior alveolar nerve block is unsuccessful
57. Contraindications
*In young children, physically or mentally handicapped, adults
*Patients who are unable to open their mouth wide(Trismus)
Nerves Anesthetized
*Inferior alveolar, Mental, Incisive, Lingual, Mylohyoid,
Auriculotemporal, and Buccal nerves
Areas Anesthetized
*Mandibular teeth to the midline
*Buccal mucous membrane
*Ant. 2/3rd of the tongue, floor of the oral cavity
58. *Lingual soft tissues and periosteum
*Body of the mandible, inferior portion of the ramus
*Skin over the zygoma, posterior portion of the cheek, and temporal
region
Target Area
*Lateral side of the condylar neck, just below the insertion of the
lateral pterygoid muscle
Technique
*An imaginary line is drawn from the corner of the mouth to
intertragic notch
59. *Open the mouth wide
*Intraorally, the needle is penetrated just below the mesiopalatal
cusp of the maxillary 2nd molar along the imaginary line
*Depth of insertion of the needle will be at least 3/4th ( contact the
bone)
*Aspiration and deposition of 2cc solution
Symptoms
*Tingling and numbness along the distribution of the mandibular
nerve
60. Akinosi Vazirani’s Closed Mouth Technique
Indications
*Limited mouth opening
*Multiple procedures on mandibular teeth
*Inability to visualize landmarks for IANB
Contraindications
*In young children, physically or mentally handicapped, adults
*Poor access to the lingual aspect of the ramus
Nerves Anesthetized
*Inferior alveolar, Incisive, Mental, Lingual, Mylohyoid
61. Areas Anesthetized
*Mandibular teeth to the midline
*Buccal mucous membrane anterior to the mental foramen
*Ant. 2/3rd of the tongue, floor of the oral cavity
*Lingual soft tissues and periosteum
*Body of the mandible, inferior portion of the ramus
Target Area - Soft tissue on the medial border of the ramus
Landmarks
*Mucogingival junction of max.3rd molar
*Maxillary tuberosity and coronoid notch
62. Technique
*Patient is asked to close the mouth till the teeth occlude
*Cheek retracted and needle is inserted parallel to the occlusal plane at
the level of mucogingival junction of max. arch
*Needle is inserted medial to the ramus. About 3/4th of the needle is
inserted
*Aspiration and deposition of 2cc solution
Symptoms
*Tingling and numbness – lower lip, anterior 2/3rd of the tongue
*On instrumentation – labial gingiva
Complications – Transient Facial nerve paralysis
63. Local Complications
1) Needle Breakage
Cause
*Use of very narrow gauge needle
*Sudden movement of the patient when needle is within the tissues
Management
*If needle is visible – grasped with hemostat and removed
immediately
*Panoramic and 3D CT Scanning – identify the location of retained
needle fragment
64. *Surgeon removes the needle fragment while patient is under GA
Prevention
*Do not use short needles , 25 gauge needles for IANB
*Do not bend needle when inserting them into soft tissues
65. 2) Prolonged Anesthesia /Paresthesia
Cause
*May be due to
a) Direct injury to the nerve during injection
b) Pressure on nerve from an expanding hematoma
Management
*Usually resolves within app. 8 weeks to 2 months without
treatment
*The patient should be reassured and the problem explained to
them clearly
66. *Patient should be periodically recalled and the improvement in
the nerve regeneration should be noted
*Examination every 2 months
Prevention
*Strict adherence to injection protocol and proper care
67. 3) Transient Facial nerve paralysis
Cause
*Introduction of LA into the capsule of parotid gland which is
located at posterior border of the mand. ramus, clothed by Medial
pterygoid and masseter
Prevention
*Strict adherence to injection protocol and proper care
Management
*Reassurance of the patient
*Any eye patch should be applied to affected eye until muscle
tone returns
68. 4) Trismus
Cause
*Trauma to the muscles due to repeated needle punctures
*Injury to IA vessels during injection
Hematoma
Compresses on the muscle
Spasm and trismus
69. *Use of contaminated needles or infection in local region
Management
*Trismus - Analgesics + Muscle Relaxants
*Infection – Antibiotics
*To relieve muscle spasm
in absence of infection
*Physiotherapy – Gentle mouth opening and lateral excursions
*If physiotherapy is unsuccessful – forceful mouth opening -
Mouth gag
Hot fomentation
+
Muscle Relaxants
70. Prevention
*Use of sharp, sterile, disposable needle
*Use aseptic technique
*Practise Atraumatic insertion and injection technique
*Avoid repeat injections and multiple insertions into same area
71. 5) Soft Tissue Injury
*Inadvertent biting or chewing of lips or tongue
Management
*Analgesics and Antibiotics
*Petroleum jelly or other lubricant to cover lip lesions to minimize
irritation
Prevention
*LA of appropriate duration should be selected
*A cotton roll is placed between lips and teeth
*Parents should be informed to take care that the child is prevented
from lip biting or chewing
72. 6) Hematoma
*Effusion of blood into extravascular spaces
Cause
*Inadvertent nicking of a blood vessel during LA administration
Management
*Immediate treatment – pressure application in the region post. to
max. tuberosity for PSA block
*Ice packs – extra-orally
*Hematoma resolves by itself within 7 – 14 days
73. 7) Pain or Burning sensation on injection
Cause
*Use of blunt needle
*Use of broader gauge needles
*Rapid injection
*Acidic LA – burning sensation
Prevention
*Use of sharp, narrow gauge disposable needles
*Isotonic LA (addition of Bicarbonate)
76. Minimal to Moderate Overdose
Signs
*Talkativeness
*Elevated B.P, Heart rate,
Respiratory rate
*Loss of response to painful
stimuli
*Vomiting
*Sweating
*Apprehension
*Slurred speech
Symptoms
*Lightheadedness
*Dizziness
*Restlessness
*Nervousness
*Numbness
*Tinnitus
*Inability to Focus
*Metallic taste
*Drowsiness and Disorientation
*Loss of consciousness
77. Moderate to High Overdose levels
Signs
*Tonic – Clonic Seizures
*Generalized CNS Depression
*Depressed B.P, Heart Rate, Respiratory Rate
Normal Maximum dose of Lidocaine
*4.5 mg/kg body weight without vasoconstrictor
*7 mg/kg body weight with vasoconstrictor
78. Management
*P – A – B – C – D
For CNS manifestations
*Seizures – Benzodiazepines / Barbiturates
Propofol/Thiopental
For CVS Manifestations
*Cardiac life support may be required which may be prolonged as
the drug takes long time to be eliminated
*IV fluids and Vasopressors like Ephedrine to counter Hypotension
79. 2) Hypersensitivity/ Allergic reaction to LA
*Rare
*Esters of anaesthetics is metabolized by Plasma Pseudo
cholinesterase
*PABA is known to be antigenic and capable of inducing a humoral
immune response
*Amide anesthetics contain methyl paraben as preservative
chemically similar to PABA and capable of initiating similar
response systemically
*Reactions of LA may be type 1 or type 4
81. Management
*Stop the procedure immediately
*Mild Allergy – Antihistamines / Corticosteroids
*Severs reactions – 0.3 – 0.5 ml of 1: 1000 Epinephrine SC – every
20 – 30 minutes. Not more than 3 doses
*If Anaphylaxis still continue – 5 ml of 1: 10,000 Epinephrine IV
82. Special Care Groups
1) Uncooperative Patients
*Choose a shorter needle and/or a larger gauge needle which is less
likely to bent or broken
*Better to use general anesthesia
2) 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 hrs., to be dealt with during the working
weekdays
83. *Local anesthetic containing a vasoconstrictor should be
administered by infiltration or by intra ligamentary injection
* Regional nerve blocks should be avoided when possible.
3) Pregnancy
*Lidocaine + Vasoconstrictor – most common LA 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 conc. is too low to harm fetus
84. 4) Geriatric Patients
*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
85. 5) Liver Disorders
Potential complications:
1. Impaired drug detoxication eg., Sedative, analgesics, general
anesthesia.
2. Bleeding disorders (decrease clotting factors, excess fibrinolysis,
impaired vitamin K absorption).
3. Transmission of viral hepatitis.
*Management – Amides (lidocaine, mepicaine) should be avoided.
Esters should be used
86. Newer Local Anesthetic Drugs and
Delivery Systems
Articaine
*New drug that have proved to be equal or more effective than
lignocaine
*Articaine was introduced clinically in 1976 and is used widely today
*Amide LA
Properties
*Articaine has faster onset of action, longer duration of action, high
success rate, greater potency
*Systemic intoxication of Articaine is lower
87. *Very safe drug
*Enhanced diffusion into the tissues than other Local anesthetics
*Buccal infiltration of the mandibular molar with 1.8ml 0f 4%
Articaine with 1:1,00,000 epinephrine is significantly better than
similar infiltration of 2% Lidocaine with 1:1,00,000 epinephrine in
achieving pulpal anesthesia in mandibular posterior teeth
*4% articaine with 1:1,00,000 epinephrine possesses superior
anesthetic efficiency relative to lidocaine for inferior alveolar
nerve block during 3rd molar extraction
88. Centbucridine
*Quinolone derivative with local anesthetic action
*It has intrinsic vasoconstricting and anti-histaminic properties
*0.5% centbucridine – used effectively for infiltration, nerve
blocks, and spinal anesthesia with anesthetic potency 4-5 times
greater than that of 2% lignocaine
89. Phentolamine Mesylate
*Drug used for reversal of effects of local anesthetic solutions
*Non–selective -adrenergic blocking agent and reverses the effects
of epinephrine and nor – epinephrine on tissues containing the 1
and 2 adrenergic receptors
*Clinical effects – Vasodilation and Tachycardia
*Adverse effects – diarrhea, facial swelling, hypertension, jaw pain,
oral pain, tenderness and vomiting
90. EMLA
*Eutectic mixture of lignocaine and prilocaine in 1:1 by weight
*Designed as topical anesthetic able to provide surface anesthesia
for intact skin
*Clarke et al in 1986 suggested the use of EMLA cream for
anesthetizing the skin prior to needle insertion as this reduces the
incidence of injection pain
91. Dentipatch
*A patch that contains 10-20% lidocaine is placed on the dried
mucosa for 15 minutes
*Used for achieving topical anesthesia for both maxilla and
mandible
JET INJECTION
*Effective for palatal injection
*In this technique, a small amount of local anesthetic is propelled
as a jet into the sub – mucosa without the use of a hypodermic
syringe/ needle from a reservoir
92. *This takes place when the knob is pressed to release air pressure which
produces a fine jet of solution which penetrates the mucosa through a
small puncture wound to produce surface anesthesia
COMPUTER CONTROLLED LOCAL ANESTHESIA
DELIVERY SYSTEM (C-CLAD)
*Milestone scientific – introduced the first C-CLAD System in 1997
and was termed the “WAND” and subsequent versions renamed as
“WAND PLUS” and “COMPUDENT”
*In 2001, DENTSPLY International introduced the Comfort Control
Syringe, Anaeject and Orastar from Japan
93. Public Health Significance
*Incidence of complications of local anesthesia – 4.5%
*The incidence of systemic toxicity to local anesthesia has
significantly reduced in the past 30 years, from 0.2% - 0.01%
*Peripheral nerve blocks are associated with highest incidence of
systemic toxicity – 7.5 per 10,000
*Incidence of IgE mediated (type 1 hypersensitivity) allergic
reaction was 1%
94. Conclusion
*Local Anesthesia remains the backbone of pain control in dentistry
*Adapting local anesthetic techniques can overcome difficulties in
access and limit soft tissue anesthesia.
*Local anesthetic doses must be controlled
*Research has been continued in both medicine and dentistry to
seek new and better means of managing pain associated with
many surgical treatments.
95. References
*Stanley F. Malamed. Handbook of Local anesthesia. 6th Edition.
Elseiver
*Chitra Chakravarthy. Textbook of Oral and Maxillofacial Surgery:
2nd Edition. Hyderabad: Paras
*Richard Bennett C. Monheim’s Local Anaesthesia and Pain Control
in Dental practice: 7th edition, New Delhi: CBS publishers
*Zhang A et al. Anesthetic efficiency of articaine versus lidocaine in
the extraction of lower third molars: a meta-analysis and systematic
review. Journal of Oral and Maxillofacial Surgery. 2019 Jan 1;
77(1): 18-28.
96. *Anil Kumar Karanam et al. Effects of lignocaine with adrenaline
on blood pressure and pulse rate in normotensive and hypertensive
patients undergoing extraction: A clinical study. International
Editorial/Reviewer Board Prof. Raveendranath. Rajendran-Saudi
Arabia. 2017; 3(4): 202-204
*Payal Saxena et al. Advances in dental Local Anesthesia
techniques and devices: An update. National Journal of
Maxillofacial Surgery. 2013 Jan - Jun; 4(1): 19-24
*Sharma S.S et al. Newer Local Anesthetic Drugs and Delivery
Systems in Dentistry. An update. IOSR Journal of Dental and
Medical Sciences. 2012 sep – oct; 1(4): 10-16
97. *Bhole MV et al. IgE-mediated allergy to local anaesthetics:
separating fact from perception: a UK perspective. British journal
of anaesthesia. 2012 Jun 1; 108(6): 903-11.
*Robertson D et al. The anesthetic efficacy of articaine in
buccal infiltration of mandibular posterior teeth. J Am Dent
Assoc. 2007, Nov 138(11): 1418-1420
*Daublander M et al. The incidence of complications associated with
local anesthesia in dentistry. The Journal of Sedation and
Anesthesiology in Dentistry. 1997, 44(4): 132-141
*Faccenda KA et al. Complications of regional anaesthesia incidence
and prevention. Drug safety. 2001 May 1;24(6):413-42.
