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Dental extractions: from anesthesia to send home (Proceedings)

May 01, 2011

There are very few states that allow technicians to legally do dental extractions. The American Veterinary Dental College has a published position statement outlining the dental tasks that can be performed by the veterinary technician.

Assisting for the extraction procedure includes laying out the instruments for the extraction, retraction of tissues, suction, irrigation, cutting suture, and after care. Why should veterinary technicians learn about extractions? Knowing how the extraction procedure is performed, assisting in the extraction procedure which also includes anesthesia and client education gives the best and most expeditious patient care.

Anesthesia and Monitoring Considerations

Once the patient has been cleared for surgery, IV catheterization and fluid therapy need to be prepared. An IV catheter provides a port for analgesics, anesthetics, emergency drugs and fluid therapy during the surgery. IV fluid therapy is essential for circulatory maintenance as dental extractions are often lengthy procedures. Perioperative IV antibiotics can be given at this time so that blood levels rise to the therapeutic levels. Perioperative antibiotics should be dosed according to the manufacturer's recommendations.

A plan for managing the pain of existing dental disease and the pain associated with the extraction procedure should be formulated. An anesthesia protocol that will be the safest for the patient starts with the client interview, physical exam and presurgical bloodwork. It is necessary to have flexibility with your drugs so that you can tailor the protocol to the needs of the patient.

The best results have been found when a multimodal analgesia plan is implemented preemptively, intraoperatively and postoperatively. Preemptive analgesia is the application of analgesia before any painful stimuli is introduced. Multimodal analgesia is done by using two or more analgesic drug classes simultaneously in order to inhibit nociception at different points along the pain pathway. Preemptive analgesia also decreases the intensity and the duration of postoperative pain. Depending on the severity of the extraction, most pain will occur in the first 24-72 hours postoperatively. The most commonly used drugs for multimodal analgesia in managing dental pain are regional anesthestics, opioids, NSAIDS, and α2 - receptor agonists. A good basic analgesic plan would be to include a opioid and α2 in the immediate pre and postoperative periods while the patient is still hospitalized.

Regional nerve blocks are given just prior to starting the surgical procedure and/or postoperatively. Regional nerve blocks are added to decrease peripheral and central sensitization and reduce anesthetic and postoperative analgesic requirements. Common sites for regional nerve blocks for dental extractions are the infraorbital, maxillary, mental, and mandibular inferior alveolar nerve block. Care must be taken with the mandibular nerve block, because inadvertent blocking of the lingual nerve can cause desensitization of the tongue, possibly causing self mutilation upon recovery. Keeping the needle close to the ventral bone of the mandible should avoid the lingual nerve. Care should also be taken with the infraorbital block to avoid inserting the needle too far into the infraorbital foramen and possibly causing ocular damage, especially in cats and brachycephalic dogs. Infiltrative blocks might be another option for regional analgesia. In infiltrative anesthesia, the periodontal ligament and surrounding tissues are directly injected. Infiltrative anesthesia works best where the cortical bone is thin such as around the maxillary teeth and the mandibular incisors. It also works well when only a few teeth need to be desensitized.

Once the patient has been induced, they must be have a cuffed and securely tied in endotracheal tube. The endotracheal tube serves two purposes: 1) it provides a secure airway in case of anesthetic emergency and 2) it prevents aspiration pneumonia caused by aerosolized debris and fluids that occur during the extraction procedure.

Place the patient on a warm, circulating water blanket to prevent hypothermia. Hypothermia is caused by inhalant anesthesia, which reduces the body's ability to respond to hypothermia. It is safer to maintain a core body temperature during anesthesia than to try to regain body heat after surgery. The body's trying to regain core temperature accompanied by severe shivering can increase myocardial activity and systemic hypoxia.

All dental patients should be monitored by a person other than the veterinarian and the assisting technician. Charting the anesthesia trends every 5-10 minutes should be done to avoid problems before they become serious. The monitoring procedure should be done using both hands on auscultation and palpation along with good quality monitoring equipment. Recommended monitoring equipment to have on hand are an ECG, Doppler blood pressure, capnometry, pulse oximetry, and end tidal CO2 level measurement. Apply lubricating ophthalmic ointment to the eyes often to prevent drying and protect from aerosolized fluids