SYNCOPE AND TRISMUS

                                                      SYNCOPE      

 Syncope or fainting is perhaps the most frequent complication associated with local anesthesia in the dental office. It is a form of neurogenic shock. 

When the patient is sitting on dental chair, the brain is placed in superior position and is most susceptible to reduced cerebral blood flow result in cerebral ischemia   and  increase in peripheral vascular bed (pooling of blood in the lower extremities), with a corresponding drop in blood pressure.
loss of consciousness is an extreme manifestation of cerebral ischemia.

TREATMENT;

1)  the time of treat this complication is in its early phases before patient has lost consciousness.

2) Operator should discontinue any procedure in progress

3)  lower the chair back while the patient’s legs are slightly elevated , thus placing the patient in a semireclining position.

4) This position aids venous return from the lower portions of the body while preventing venous congestion in upper body.

5) If the patient is conscious , he should be instructed to take a few deep breaths.

6) Ammonia or ammonia spirit inhalation (in limit) is indicated to treat or prevent syncope (fainting).

 Adverse effect ;  ammonia comes in contact with eye or skin causes burning sensation/ irritation of eye and skin, inhalation in high concentration of ammonia can cause lung damage.

7) Electrolyte solution, fruit juice or salt tablet are given to raise B.P. which is  very usefull in treat sycope.

                                                                             

                                             MUSCLE TRISMUS

 Muscle trismus is a fairly common complication of regional analgesia or anesthesia, particularly after blocks of the inferior alveolar nerve.

The most common cause of trismus is trauma to muscle during  the insertion of needle.

Irritating solution, hemorrhage , or low grade in fection within the muscle may also cause varying degrees of trismus.

Treatment should depend on the cause of the trismus;

TRISMUS due to trauma ;- slightly excercises and drug therapy  necessary to relieve pain.

·        Muscle relaxants (MR) such as diazepam (valium) 2.5-5.0 mg three time per day or  meprobamate ;- 1200-1600 mg / day with application of warm water

            Example; FLEXON MR , ACECLOFENAC + MR given TDS.

·        Physiotherapy; consisting of opening and closing the mouth as wll as from side to side for 5 to 10 minutes every 3 or 4 hours will also assist recovery.

EMERGENCY DRUG IN DENTISTRY

                 EMERGENCY DRUGS IN DENTISTRY                                                                       

DRUG	ROUTE  ADMINISTRATION	INDICATION
ADRENALINE     1mg/ml	500mg microgram I.M. may be repeated at  5min interval according to B.P.,                pulse, respiratory  function.	Anaphylaxis
ASPIRIN (300mg)	300mg orally or chewed	Suspected heart attack
GLYCERYL TRINITRATE (400mg)	1 – 2 actuations sublingually no more than three doses are recommended at any one time	Angina or suspected heart attack
Glucose	10-20g of short acting carbohydrate oral e.g. glass of lucozade or fruit juice, 3 or more glucose tablets, or 5 sweets	Hypoglycaemia (co-operative, conscious & able to swallow safely
Glucagon 1mg	1 mg I.M.	Hypoglycaemia (impaired consciousness, uncooperative or unable to swallow)
Salbutamol Inhaler (100 micrograms/dose)	1 - 2 actuations inhaled                   Repeated if required	Asthma attack
Midazolam 10mg	10 mg buccal	Prolonged seizures (convulsive movements lasting 5 minutes or longer) Seizures recurring in quick succession

ANTIBIOTICS USED IN DENTISTRY

                                                                                                                  

                                                  ANTIBIOTICS USED IN DENTISTRY                       

I)                    BETA- LACTAM ANTIBIOTIOCS;

PENICIILINS ;

1)      AMOXICILLIN;  Is one of the most frequently used antibiotics for treatment of dental infections

Dose; 250-500mg TDS given for 5 days.

2)      Clavulanic acid ; addition of CV re-established the activity of amoxicillin against bacterias.

CEPHALOSPORINS;

     FIRST GENERATION;  it is highly active against  gram positive  but less active against gram negative bacteria.

1)      Cephalexin ;  commonly use as alternative of amoxicillin.

Dose ; 0.25-1g 6-8 hourly  and in childrens ; 25-100mg/kg/day

2)      Cefadroxil ;  it has good tissue penetration including that in alveolar bone ( tooth socket); exerts more susutained action at the site of infection.

Dose; 500mg  BD

      SECOND GENERATION;  more active against gram negative organisms and some anaerobes.

1)      Cefuroxime axetil;  frequently used in dental infections

Dose ; 250-500mg BD and in children gives half dose

2)      Cefaclors ; active against anaerobes found in oral cavity.

Dose ; 250mg bd

     THIRD GENERATION; active against both gram positive and gram negative bacteria

1)      Cefixime ; 

Dose ; 200mg bd

2)      Cefpodoxime proxetil;  mainly used soft tissue infections.

Dose; 200mg bd

 

II)                   NITROIMIDAZOLES;  broad spectrum antiprotozoal drugs.             .

1)      Metronidazoles; is an effective drug against anaerobic bacterial infections.

 Drug of chice for acute necrotizing gingivitis in which it is often combined with either penicillin v , amoxicillin, erythromycin or tetracycline.

Used in periodontitis, pericoronitis, acute apical infections and some endodontics infection etc for  5-7 days.

Because of it is not active against aerobic and facultative bacteria, metronidazole is mostly combined with  a penicillins, cephalosporins or macrolide antibiotics.

Dose; 200-400mg TDS.

2)      Tinidazole ; is equally efficacious congener of metronidazole

Dose; 500mg bd for 5 days.

III)                TETRACYCLINE  ;

       GROUP  I-  tetracycline, oxytetracycline                              

GROUP-II- demeclocycline

GROUP-III- doxycycline, minocycline

TETRACYCLINE used in oro-dental infections, it have an adjuvant role in the management of chronic periodontitis.

In refractory periodontal diseases 2-week tetracycline (1gm/day) or doxycycline(100mg-200mg/day)  therapy control gingival inflammation and helps to normalize the periodontal microflora.

It is highly active against Actinobacillus sp. that is help responsible for destruction of gums and bone loss in juvenile periodontitis.

ADVERSE EFFECT OF TETRACYCLINE;

Tetracycyline have chelating properties, calcium –tetra cycline chelates gets deposited in developing teeth and bones.

Given from midpregnanacy to 5 months of extrauterine life, the deciduous teeth are affected ; brown discolouration , ill formed teeth, more susceptible to caries.

Given during  late pregnancy  or childhood , it can causes temperory suppression of bone growth.

IV)               MACROLIDES ANTIBIOTICS;                                                

1)      ERYTHROMYCIN;

It is used against aerobic and anaerobic  gram positive bacteria.

Used in periodontal/ pariapical abscess, necrotizing ulcerative gingivitis , post-extraction infections , gingival cellulitis etc.

IT IS ALSO USED IN PATIENTS THOSE ARE ALLERGY TO BETA LACTAM ANTIBIOTICS LIKE PENICILLS OR CEPHALOSPORINS

Dose;250-500mg 6 hourly TDS and in children 30-60mg/kg/day.

2)      AZITHROMYCIN; used in orodental infection in place of erythromycin.

Dose; 500mg once daily .

ANTIFUNGAL

1)      FLUCONAZOLE ;  given orally 150mg/day for 2 weeks is highly effective in Candida infections of mouth.

2)      KETOCONAZOLE  also used for dental infection.