Dental Tribune Israel Edition

11 DentalTribune Israel Edition Department of Therapeutic Stomatology, Tver Medical Academy, Russia. A.Z.Petrikas DMD Professor D.V.Medvedev DMD. Assistant Professor O.E.Efimova DMD. Assistant Professor L.A.Yakupova, DMD. Assistant Professor E.V.Chestnyh DMD. Assistant Professor E.B.Olkhovskya DMD. Assistant Professor Abstract Separation of the methods of local anesthesia on diffuse and vascular that we proposed [Petrikas et al], is related to the safety of dental spongy anesthesia.. PURPOSE: to evaluate the systemic complications of dental spongy vascular injection based on publications and our records. Spongy anesthesia containing epinephrine, in each subject causes systemicreactionsofthesympathetic or parasympathetic type, usually the first. There are significant changes in heart rate and systolic blood pressure. They do develop in the first minute, falling to fourth. They are not typical to classical anesthesia. Headache and tachycardia are specific symptoms of severe systemic reactions to spongy injection. Chest pain is another terrible symptom. After classic (293) and spongy (431) anesthesia it was analyzed 17/56 systemic complications, properly. Quantitatively, the complication to vascular (spongy) injection was more common. It is essential that the vegetative (sympathetic and parasympathetic) reactions were observed only after a spongy injection. All reactions - complications were mild, transient and reversible. However, the transformation of reactions in severe complications are possible. Key Words: Intraosseous anesthesia, Intraligamrntal anesthesia, Intraseptal anesthesia. Spongy anesthesia, Vascular anesthesia Vascular spongy intraosseous (intraosseous itself - IOA, intraligamentary - ILA, intraseptal- ISA) anesthesia, located in the supplemental section, take the larger place in dental practice[1]. Lalabonova et al.(2005) showed that in Bulgaria for 76% of dentists ILA has become a routine[2]. A survey of 800 from 2500 American endodontists found that about 95% of them use supplemental methods of anesthesia, mostly ILA - 50%, and also intraosseous two-stage injection [3]. The popularity of spongy anesthesia contributed to the simplicity of it implementation, more than 2 times smaller dose and high efficiency in the absence of severe paresthesias of soft tissues [4,5,6].Prevalence contributed to a new injection technique: pressure (multiplication) [1] and computer syringes (C-CLAD Systems) [7], as well as a special needle [8]. Separation methods of local anesthesia on diffuse and vascular that we proposed [1,9], is related to the safety of dental spongy anesthesia. PURPOSE: to evaluate the systemic complications of dental spongy vascular injection based on publications and our records. The main factor that creates the relative harmlessness of the spongy anesthesia is a low dose of anesthetic, amounting 0.3 to 0.6 - 0.9 ml [9]. Given the small volume of injected substances the crucial role in the manifestation of adverse reactions, is vasoconstrictor not the anesthetic. It is needed from 5 to 9 cartridges 1.8 ml to create toxic effects of local anesthesia [10]. The main system complication in traditional injection is also due to a vascular factor. This is usually accidental introduction of the solution into the lumen of the vessel, in the vein [11,12](Fig.1). There is almost a lack of researches, devoted to systemic complications of dental spongy anesthesia. There are researches of reactions of HVS after spongy anesthesia at the best, of ILA and ISA are hardly ever. It analyzed 12 reports of the Committee on Safety of Medicines (UK) about severe adverse reactions of local dental anesthetics with the painful hypertensive headaches, including death. It was estimated Xylestesin (ESPE), contains 2% of lidocaine and norepinephrine in high concentrations of 1:25.000. In 2 cases out of 12, hypertensive crisiswasdevelopedafterconducting intraosseous anesthesia which was very rare at that time in England. Both patients had intense headaches immediately after intraosseous injection for 4-5 minutes. One addition was a dimming of consciousness memory, speech and sensory disorientation for several days. Boakes had not a thought about hypertensive crisis because of a vascular nature of intraosseous anesthesia, in response to our observation (Petrikas AZ/Boakes AJ .1973)[14]. In the Boakes,s work was found a link between the use of tricyclic antidepressants and local anesthesia with norepinephrine in high concentrations. It can be seen in 6 cases. Antidepressants were not appliedforpatientswithintraosseous anesthesia. Although the main clinical syndrome for investigated states was a hypertensive crisis, in two cases, the headache joined the pain in heart and chest tightness. We believe that the headache is an important clinical sign of possible complications of spongy injections. In 80s the vascular nature of spongy anesthesia was often investigated, but was not studied as a risk factor[15,16,17]. In the 21st century the diffuse mechanism of local anesthesia was the only one. Wood et al (2005) showed that the blood level of lidocaine used in conjunction with epinephrine, is the same as in the case of infiltration, and intraosseous injections, ignoring the epinephrine as cause of side effects[18](table 1). He excludes a vascular mechanism, because, in his opinion, the anesthetic would pass by without stopping and without causing an anesthetic effect. Wood M and co-authors Reader A, Nusstein J, Beck M, Padget D, Weaver J. the idea of"adrenalinedepot of anesthesia" did not understand. The only one work devoted to a seemingly random system complications is in interest [19]. Compared to a traditional (infiltration and сconduction) and intraosseous anesthesia (200 injection in 100 patients, lidocaine with epinephrine 1:100000 and mepivacaine one [19]. "No important incidents in this study were observed…", except for the fainting of 7 patients with IOA... and only 3 patients received regular dental anesthesia. For the first time in Western literature was detected an excessive frequency aspirate during the intraosseous anesthesia in 61% (compared to 0%[10] and 90% [9]). Increased heart rate is a new syndromeofspongy injection,which is celebrated by almost all doctors working with them. The main stimulator of these reactions is an epinephrine of anesthetic solution. The reaction occurs under the needle [4,20,21,22]. Increased heart rate is briefly. Heart rate returns to a baseline within 3-4 minutes in most patients. Four minutes is the half-life ofepinephrine.Asignificantincrease in pulse rate is accompanied with a subjective feeling palpitations, fear. Sometimes, it causes the patient’s panic, anxiety, cardiac death fear appears [23]. Increasing heart rate after intraosseous introduction according to different authors, is presented in table 1. This compelling specific symptom of spongy anesthesia distinguishes it from classical [20,33]. Such a condition we refer as the complication and/ or the precursor to more serious complications. The severity of the reaction depends on the speed of injection. To exclude tachycardia Susi et al, 2008, prompted to enter the normal dose, for example, 1,4 ml slowly for 4 min and 45 sec [24]. Blood pressure in contrast to heart rate in spongy anesthesia was not noticeable and was not seriously investigated [25, 26, 27]. Injection creates an alarm condition, thestress,inwhichisbothautonomic (vegetative) nervous systems: sympathetic and parasympathetic are uniformly involved. Increased heart rate in the first minute after injection, caused by a direct hit of epinephrine in a total venous blood flow. Then in the bone tissue venous-capillary depot of anesthetic is formed with the aid of epinephrine (Fig. 2). It is an important part of the desired or, on the contrary, the side effects of the combined anesthetic [1,9]. Primary short reversible reaction can be a part of more serious mechanisms of vegetative crisis, for example, hypertensive stroke or a coronary heart attack. Deferred monitoring cardiovascular performance is not immediately after the injection bypasses the onset of complications [9]. Our researches [20,33,34] proved that the performance of the CVS immediately after injection have a double benefit, both for online evaluation of health status of the patient and to control the injection and its effectiveness. For example, an increased heart rate of 5 beats/min says about the success of spongy injection. An important pattern of observed spongy reactions to vascular introduction of anesthetic containing epinephrine, which we discovered while monitoring heart rate and blood pressure (OmronMX3 plus.E.R.A.tehnology) , is to divide them into two types: sympathetic and parasympathetic. An increase of pulserateandsystolicbloodpressure are observed during the sympathetic type of reactions. This is a tendency to hypertensive risk of anesthesia. A decrease of heart rate and lowering blood pressure is observed during the parasympathetic reactions on the contrary. The potency of vegetative reactions was linked not only with medicine, but also with the emotional state of the volunteer. In this study, the subject knew about the technic of the intraosseous injection, but not its extent. He knew about the unusual experience of anesthesia, the rest was thought out and worried. As a result of lack of information negative emotion appeared. In terms of homeostasis the sympathetic and parasympathetic systems are balanced in each subject. The balance of the sympathetic and parasympathetic systems were violated under the influence of an injection pain, fear, expectations, internal adrenaline and especially external adrenaline (epinephrine), introduced with an injection, . The shift of the response to the stressor could be in the direction of sympathetic as well as parasympathetic systems, but it is more towards the first after vascular anesthesia. This pattern is probably universal, but sharply smeared Systemic reactions of intraosseous (vascular, spongy) anesthesia Fig. 1. Accidental intravenous injection of local anesthetic (LA), which is due to the rapid introduction formed in the vessels the wave (bolus) of concentrated drugs, even undiluted by blood. Meeting with the excited tissues, such as brain cells, it has a blocking effect. Local anesthesia due to the lack of anesthetic in a place of injection does not occur. [12]. Fig.2. Spongy injection passes through the venous vessels anesthetic,s epinephrine to adrenergic receptors in the heart, brain, causes, for example, a tachycardia. The activation of α-adrenoreсeptors in the injection zone creates inside the bones partially isolated depot of local anesthetic containing completely blocked the pulp-periapical complexes. Research tribune

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