PRINCIPLES OF SURGICAL DENTAL CARE. GENERAL AND SPECIAL PREPARATION OF THE PATIENT TO OUTPATIENT SURGERY AND POSTOPERATIVE PERIOD. ANESTHESIA, PREMEDICATION, CHOICE OF ANESTHESIA DURING DENTAL SURGERY IN THE HOSPITAL AND CLINIC. APPLICATION AND TISSUE INFILTRATION ANESTHESIA OF MFA. CARDIOPULMONARY RESUSCITATION.
Oral and Maxillofacial Surgery
Instruction is provided in local anaesthesia of the oral and maxillofacial area, normal and surgical tooth extraction, suturing techniques, and the diagnostics and treatment of dental and maxillofacial injuries as well as the principles of surgical pain medication and antibiotic therapy. Studies cover the most common pathologies and problems of the maxillofacial area that require surgical treatment, as well as provide students with the means to diagnose rarer conditions and to refer patients with such conditions to specialist treatment. Instruction will also address restrictions pertaining to patients’ general health and existing medication.
Basic studies
The theoretical instruction included in the basic studies begins in the preclinical phase (H1) with a course in head and neck anatomy. In the clinical phase, theoretical instruction begins with a course in local anaesthesia (H31). After the lectures, students will practice anaesthesia techniques on each others. The introductory course in oral and maxillofacial surgery (H32) includes lectures on the basics of tooth extraction, wound healing and the patient’s qualification for treatment. In addition to the lectures, students will practice tooth removal and suturing.
The lectures of the advanced course in oral and maxillofacial surgery (H41) include surgical tooth extraction, periapical surgery, dental and jaw injuries, odontogenic infections, temporomandibular joint disorders, orthognathic surgery and osteopathies, as well as cysts and both benign and malignant tumours of the maxillofacial area from the points of view of clinical diagnostics and surgical treatment. Students will observe the treatment of oral and maxillofacial surgery patients at the specialist dental care unit of the Greater Helsinki area in Ruskeasuo (Dental Hospital) as well as take turns observing emergency care services (with a focus on maxillofacial surgery) at the Töölö Hospital of the Helsinki University Central Hospital.
Salivary gland diseases and implantology (H42) will be taught as lectures and group sessions in collaboration with other disciplines. During their final year of study (H51 and H52), students will attend a course in oral diseases as well as a refresher course in oral and maxillofacial surgery, and during their fifth year, they will also observe the treatment of hospitalised oral and maxillofacial surgery patients at clinics, operating theatres and wards at the Surgical hospital, Department of oral and maxillofacial surgery, Helsinki University Central Hospital.
Patient work in oral and maxillofacial surgery will be carried out at the academic health centre of the City of
Order of study
H11
* Introductory seminar and presentation of the discipline
H12
* Head and neck anatomy
H31
* Anaesthesia (Local anaesthesia)
H32
* Introductory course in oral and maxillofacial surgery
H41
* Advanced course in oral and maxillofacial surgery
H42
* Salivary gland diseases, Course in implantology
H51
* Course in oral diseases
H52
* Refresher course in oral and maxillofacial surgery
Specialist training: Oral and maxillofacial surgery
Oral and maxillofacial surgery is both a medical and a dental speciality. The discipline of oral and maxillofacial surgery is concerned with the diagnosis and surgical treatment of diseases, infections, injuries and functional deficiencies of the mouth, dentition, jaw, face, head and neck. Other medical and dental specialities also focus on this anatomical area.
Dental specialist training in oral and maxillofacial surgery takes six years to complete and includes nine months of service in a community health centre, as well as studies in medicine. These supplementary studies in medicine span approximately 150 credits and must be completed according to a plan approved by the
Degree requirements for specialist training in dentistry (in Finnish)
Medical specialist training in oral and maxillofacial surgery takes six years to complete and includes nine months of service in a community health centre, as well as studies in dentistry. Supplementary studies in dentistry span approximately 50 credits and must be completed according to a plan approved by the
Degree requirements for specialist training in medicine (in Finnish)
Objectives
The programme provides oral and maxillofacial surgeons with the knowledge and skills necessary to independently perform duties in the field:
1. Surgical and other treatment of maxillofacial trauma, including reconstructive surgery
2. Surgical treatment of malignant oral and maxillofacial tumours, including reconstructive surgery and microsurgical reconstruction
3. Temporomandibular joint disorders and their surgical and other treatment
4. Comprehensive surgical treatment of facial and maxillofacial deformities and anomalies as well as the planning thereof
5. Dentoalveolar surgery
6. Odontogenic infections
7. Preprosthetic surgery and related implantology
8. Surgical treatment and reconstructive surgery of cysts and benign tumours of the jaw
9. Surgically treated diseases of the salivary glands
10. Treatment of chronic pain in the oral and maxillofacial area
11. Diseases of the oral mucosa
12. Scientific research in oral and maxillofacial surgery
13. Key areas of dentistry for oral and maxillofacial surgery, such as orthodontics, dental, maxillofacial and facial prosthetics, oral pathology, surgery (including plastic surgery), otorhinolaryngology and oncology.
Dental surgery is any of a number of medical procedures that involve artificially modifying dentition, in other words surgery of the teeth and jaw bones.
Types
Some of the more common are:
- Endodontic (surgery involving the pulp or root of the tooth)
- Root canal
- Pulpotomy The opening of the pulp chamber of the tooth to allow an infection to drain; Usually a precursor to a root canal
- Pulpectomy – The removal of the pulp from the pulp chamber to temporarily relieve pain; Usually a precursor to a root canal.
- Apicoectomy – A root-end resection. Occasionally a root canal alone will not be enough to relieve pain and the end of the tooth, called the apex, will be removed by entering through the gingiva and surgically extracting the diseased material.
- Prosthodontics (dental prosthetics)
- Crowns (caps) — artificial coverings of the tooth made from a variety of biocompatible materials, including CMC/PMC (ceramic/porcelain metal composite), gold or a tin/aluminum mixture. The underlying tooth must be reshaped to accommodate these fixed restorations
- Veneers — artificial coverings similar to above, except that they only cover the forward (labial or buccal) surface of the tooth. Usually for aesthetic purposes only.
- Bridges — a fixed prothesis in which two or more crowns are connected together, which replace a missing tooth or teeth through a bridge. Typically used after an extraction.
- Implants — a procedure in which a titanium implant is surgically placed in the bone (mandible or maxilla), allowed to heal, and 4-6 months later an artificial tooth is connected to the implant by cement or retained by a screw.
- Dentures (false teeth) — a partial or complete set of dentition which either attach to neighboring teeth by use of metal or plastic grasps or to the gingival or palatial surface by use of adhesive.
- Implant-supported prosthesis — a combination of dentures and implants, bases are placed into the bone, allowed to heal, and metal appliances are fixed to the gingival surface, following which dentures are placed atop and fixed into place.
- Orthodontic treatment
- Implants and implant-supported prosthesis — also an orthodontic treatment as it involves bones
- Apiectomy — also an orthodontic treatment as part of the underlying bone structure must be removed.
- Extraction — a procedure in which a diseased, redundant, or problematic tooth is removed, either by pulling or cutting out. This procedure can be done under local or general anesthesia and is very common — many people have their wisdom teeth removed before they become problematic.
- Fiberotomy — a procedure to sever the fibers around a tooth, preventing it from relapsing.
Professional dental care
Regular tooth cleaning by a dental professional is recommended to remove tartar (mineralized plaque) that may develop even with careful brushing and flossing, especially in areas of the mouth that are difficult to clean. Professional cleaning includes tooth scaling and tooth polishing, as well as debridement if too much tartar has accumulated. This involves the use of various instruments and/or devices to loosen and remove tartar from the teeth. Most dental hygienists recommend having the teeth professionally cleaned at least every six months.
More frequent cleaning and examination may be necessary during the treatment of many different dental/oral disorders or due to recent surgical procedures such as dental implants. Routine examination of the teeth by a dental professional is recommended at least every year. This may include yearly, select dental X-rays. See also dental plaque identification procedure and removal.
Oral and maxillofacial surgery
Oral and maxillofacial surgery is surgery to treat many diseases, injuries and defects in the head, neck, face, jaws and the hard and soft tissues of the oral (mouth) and maxillofacial (jaws and face) region. It is an internationally recognized surgical specialty. In some countries, including the
Regulations
In several countries oral and maxillofacial surgery is a speciality recognized by a professional association, as is the case with the American Dental Association, Royal College of Surgeons of England, Royal College of Surgeons of Edinburgh, Royal College of Dentists of Canada, Royal Australasian College of Dental Surgeons and the Brazilian Federal Council of Odontology (CFO).
In other countries oral and maxillofacial surgery as a specialty exists but under different forms as the work is sometimes performed by a single or dual qualified specialist depending on each country’s regulations and training opportunities available.
Summary
An oral and maxillofacial surgeon is a regional specialist surgeon treating the entire craniomaxillofacial complex: anatomical area of the mouth, jaws, face, skull, as well as associated structures.
Depending upon the jurisdiction, maxillofacial surgeons may require training in dentistry, surgery, and general medicine; training and qualification in medicine may be undertaken optionally even if not required. An optional medical qualification can qualify the holder for hospital and operating room access not open to others.
Oral and maxillofacial surgery is universally recognized as one of the specialties of dentistry. In the
They also may choose to undergo further training in a 1 or 2 year subspecialty Oral and Maxillofacial Surgery Fellowship Training in the following areas:
- Head and neck cancer – microvascular reconstruction
- Cosmetic facial surgery
- Craniofacial surgery/Pediatric Maxillofacial surgery/Cleft Surgery
- Cranio-maxillofacial trauma
- Head and neck reconstruction (plastic surgery of the head and neck region)
- Maxillofacial regeneration (reformation of the facial region by advanced stem cell technique)
The popularity of oral and maxillofacial surgery as a career for persons whose first degree was medicine, not dentistry, seems to be increasing in few EU countries. However, the public fund spend for 14 years of training is a big concern of the state. Integrated programs are becoming more available to medical graduates allowing them to complete the dental degree requirement in about 3 years in order for them to advance to subsequently complete Oral and Maxillofacial surgical training.
Surgical procedures
Treatments may be performed on the craniomaxillofacial complex: mouth, jaws, neck, face, skull, and include:
- Dentoalveolar surgery (surgery to remove impacted teeth, difficult tooth extractions, extractions on medically compromised patients, bone grafting or preprosthetic surgery to provide better anatomy for the placement of implants, dentures, or other dental prostheses)
- Diagnosis and treatment of benign pathology (cysts, tumors etc.)
- Diagnosis and treatment (ablative and reconstructive surgery, microsurgery) of malignant pathology (oral & head and neck cancer).
- Diagnosis and treatment of cutaneous malignancy (skin cancer), lip reconstruction
- Diagnosis and treatment of congenital craniofacial malformations such as cleft lip and palate and cranial vault malformations such as craniosynostosis, (craniofacial surgery)
- Diagnosis and treatment of chronic facial pain disorders
- Diagnosis and treatment of temporomandibular joint (TMJ) disorders
- Diagnosis and treatment of dysgnathia (incorrect bite), and orthognathic (literally “straight bite”) reconstructive surgery, orthognathic surgery, maxillomandibular advancement, surgical correction of facial asymmetry.
- Diagnosis and treatment of soft and hard tissue trauma of the oral and maxillofacial region (jaw fractures, cheek bone fractures, nasal fractures, LeFort fracture, skull fractures and eye socket fractures).
- Splint and surgical treatment of sleep apnea, maxillomandibular advancement, genioplasty (in conjunction with sleep labs or physicians)
- Surgery to insert osseointegrated (bone fused) dental implants and Maxillofacial implants for attaching craniofacial prostheses and bone anchored hearing aids.
- Cosmetic surgery of the head and neck: (rhytidectomy/facelift, browlift, blepharoplasty/Asian blepharoplasty, otoplasty, rhinoplasty, septoplasty, cheek augmentation, chin augmentation, genioplasty, oculoplastics, neck liposuction, lip enhancement, injectable cosmetic treatments, botox, chemical peel etc.)
In Australia , New Zealand , and North America
Oral and maxillofacial surgery is one of the nine dental specialties recognized by the American Dental Association, Royal College of Dentists of
The typical training program for an oral and maxillofacial surgeon is:
- 2 – 4 years undergraduate study (BS, BA, or equivalent degrees)
- 4 years dental study (DMD, BDent, DDS or BDS)
- 4 – 6 years residency training (6 years includes 2 additional years for acquiring medical degree)
- After completion of surgical training most undertake final specialty examinations: (US “Board Certified (ABOMS)”), (Australia/NZ: “FRACDS(OMS)”), or (
Canada - Many dually qualified oral and maxillofacial surgeons are now also obtaining fellowships with the
American College - Average total length after secondary school: 12 – 14 years
In addition, graduates of oral and maxillofacial surgery training programs can pursue fellowships, typically 1 – 2 years in length, in the following areas:
- Head and neck cancer – microvascular reconstruction
- Cosmetic facial surgery (facelift, rhinoplasty, etc.)
- Craniofacial surgery and pediatric maxillofacial surgery (cleft lip and palate repair, surgery for craniosynostosis, etc.)
- Cranio-maxillofacial trauma (soft tissue and skeletal injuries to the face, head and neck)
Notable oral and maxillofacial surgeons
- Luc Chikhani reconstructed Trevor Rees-Jones‘s face, which was flattened by the impact of the car crash that killed Diana, Princess of Wales.
- Bernard Devauchelle a French oral and maxillofacial surgeon at
Amiens University Hospital - Varaztad Kazanjian Pioneer in plastic and reconstructive surgery, Harvard’s first professor of plastic surgery
Organizations
- American Association of Oral and Maxillofacial Surgeons
- American College of Surgeons
- College of Physicians and Surgeons Pakistan
- Faculty of Dental Surgery of The Royal College of Surgeons of England
Introduction
To achieve an acceptably high standard of clinical practice, it is essential that all surgeons including dentists and oral surgeons – have a background knowledge of surgery in general.
Such a knowledge of ‘surgery in general’ is essential for dental/oral surgeons to ensure that they will be able to: • recognise disease by detecting key abnormalities in the patient assessment • recognise important disorders that might impinge on their practice • assess and balance the needs for treatment against the risks of avoiding therapy in the patient with coincidental illness • identify illness that needs to be treated • refer patients with specific problems to appropriate specialists • avoid operating on patients who have specific or relative contraindications to surgery • understand the need to have the patient in optimal condition before surgery and how to achieve this
treat and manage basic problems that might arise in the course of patient care afford a good level of patient care pre- and postoperatively understand the basic principles of surgical techniques be aware of potential problems, especially life threatening complications, which may arise in the course of surgery and how to manage these understand the role of specialist colleagues in all aspects of patient care.
Diagnosis Medication Physician Patient Surgical referral
Surgical operation Preoperative phase Assessment preparation Intraoperative phase Anaesthesia Surgery Postoperative phase Postoperative care follow up
This session will discus the importance of assessment & preparation of patient prior to surgery to identify risk factor for adverse events initiate appropriate prophylactic treatment
Approaches to preoperative evaluation differ significantly, depending on the 1.Nature of the complaint 2. The proposed surgical intervention 3. Patient age & health 4. Assessment of risk factors 5.The results of directed investigation 6. Interventions to optimize the patient’s overall status 7. Readiness for surgery
Determining the Need for Surgery confirmation of relevant physical findings and review of the clinical history and laboratory and investigative tests that support the diagnosis .
Preoperative Decision Making Once the decision has been made to proceed with operative management, a number of considerations must be addressed regarding the 1. Timing and site of surgery 2. The type of anesthesia 3. The preoperative preparatioecessary to understand the patient’s risk and optimize the outcome
Preoperative Evaluation The aim is to identify and quantify any comorbidity that may have an impact on the operative outcome. To uncover problem areas that may require further investigation to perform the preoperative optimization .
The preoperative evaluation is determined in light of the 1.planned procedure (low, medium, or high risk), 2. planned anesthetic technique, 3. the postoperative disposition of the patient (outpatient or inpatient, ward bed, or intensive care). 4. to identify patient risk factors for postoperative morbidity and mortality
consultation with an internist or medical subspecialist may be required to facilitate the workup and direct management. In this process, communication between the surgeon and consultants is essential to define realistic goals for this optimization process and to expedite surgical management
I – Preoperative evaluation To assess the fitness of the individual for anesthesia and surgery. A well‐conducted history and physical examination answer several important questions:
Is this a healthy patient? What is the indication for surgery? Is the surgical procedure low risk, intermediate risk, or high risk? What is the functional status of the patient? What is the effect of the present condition on the patient? What improvement is expected after surgery?
Answers to these questions should then direct preoperative testing and management 1.The tests selected should therefore evaluate existing illness, screen for conditions that could affect outcomes in the preoperative period, and help to determine preoperative risks. Existing illnesses that need evaluation and possible treatment include hypertension, diabetes mellitus, cardiac, vascular, pulmonary, renal, and hepatic diseases. The pregnant patient, the geriatric patient, the patient with oncologic disease, malnutrition, or coagulation disorders also needs directed evaluations
The initial preoperative evaluation of a patient should be supplemented by a complete assessment of the patient’s general health. This involves a thorough history physical examination. Nutritional assessment Investigations Surgical risk assessment
History The history should include information regarding any known medical problems and ongoing treatment, previous surgical procedures, and problems if any during previous anesthesia. These can include difficult intubation, bleeding tendencies, and anesthetic jaundice. • Family history. Drugs allergies
Medications such as digitalis, insulin, and corticosteroids should be maintained and their doses carefully regulated in the preoperative period. • If the patient is on corticosteroids or if it has been discontinued within a month of surgery, he or she may have a hypofunctioning adrenal cortex resulting in impaired physiologic response to surgical stress
Physical examination A comprehensive physical examination to identify co-morbid conditions should be performed Preoperative Considerations by Organ Systems: cardiovascular ,pulmonary ,gastrointestinal, nervous system, renal and endocrine troubles .
Nutritional assessment Poor nutrition causes poor wound healing, leading to Wound dehiscence Infection Weakness Loss of functional independence Assess fluid status along with the nutritional status
Estimate serum albumin level (> 6mg/dl normal) Consider parenteral nutritional supplementation.( very young & very old) TPN is useful in gastric outlet obstruction, malnutrition
4.Investigations 1.Complete blood counts 2.Blood urea and electrolytes 3.An electrocardiogram (ECG) is indicated over 40 years, . 4.Posteroanterior and lateral chest x‐rays 5. Hb%
5.Surgical risk assessment Surgical risk assessment includes the anaesthetic risk also Cardiovascular and pulmonary complications are common causes of peri-operative morbidity and mortality in elders (25 to 30%)
Anaesthesia Preoperative evaluation and optimization of patients are important components of anesthesia practice. At a minimum, the guidelines of the ASA indicate that a preanesthesia visit should include the following : • An interview with the patient or guardian to review medical, anesthesia and medication history • An appropriate physical examination • Review of diagnostic data (laboratory, electrocardiogram, radiographs, consultations)
At a minimum, the preanesthetic examination includes the airway, heart and lungs, vital signs, oxygen saturation, height, and weight. Examination of the airway is always necessary. Auscultation of the heart and inspection of the pulses, peripheral veins and extremities for edema are important diagnostically and in development of care plans.
The pulmonary examination includes auscultation for wheezing and decreased or abnormal sounds. Cyanosis, clubbing and the effort of breathing are noted. Assignment of an ASA physical status score (ASA-PS). A formulation and discussion of anesthesia plans with the patient or a responsible adult
One of the first anesthesia risk categorization systems was the ASA classification. It has five stratifications: ASA I—
II-Preoperative preparation 1-Consent for surgery An informed consent in writing from the patient and/or his relatives is essential before any procedure is undertaken
Patients must receive sufficient accurate information about their illness, the proposed treatment and its prognosis. Describe the procedure itself, including information about its practical implications and its prognosis Outline other surgical or medical alternatives to the proposed treatment, including non‐treatment, along with their general advantages and disadvantages
Counseling The surgeon should gain the confidence of the patient by his kind approach and frank discussion about the problem, and possible benefits and risks especially in cases involving amputation or possible disability or disfigurement Preoperative counseling by the doctors, trained staffs, social workers and patients who had undergone major surgery, will prevent or reduce depressive effect .
2.Prevention of CVS & respiratory complications Efforts to maintain the circulation and ventilation have greater priority in preparing the patient for an operation. Prophylaxis of Postoperative Deep Vein Thrombosis. SC heparin 5000 IU 2 hours preoperatively and 8 hours postoperatively. Respiratory complications can be prevented and also improved through Cessation of smoking Treating bronchospasm Reducing secretions Chest physiotherapy
3. Aspiration prevention Prevention of aspiration is the most important aspect of perioperative care. Starving the patient for 6-8 hours prior to surgery Ryles tube aspiration during surgery Fasting times for children are age dependent
Babies under 1 year No breast milk for 2‐3 h before anaesthesia No formula feed for 6 h before anaesthesia Clear fluids may be given up to 3 h before anaesthesia Children over 1 year No food/milk for 6 h before anaesthesia Clear fluids up to 3 h before anaesthesia
4.Preparation of bowel GIT surgery needs complete evacuation and cleansing of alimentary tract Sterilization of the bowel by oral anti microbial agents Routine nasogastric tube aspiration and strong purgatives, enemas
5.Others Blood grouping and Rh typing: reserve necessary units of blood for possible requirement. Sleep: Good sleep should be ensured on the night before surgery (mild sedation) Skin preparation: haircut, shaving , taking care not to injure the skin. Patient should be given a good bath before surgery . Bladder catheterization: Insertion of urinary catheter to prevent post operative distension of the bladder and to measure the urine output during surgery are important Pre-medication : Routine pre-medication for anaesthesia is best avoided in the ward and is given in the operation theater under the direct supervision of the anaesthetist.
Preoperative considerations The surgeon should consider the following prior to surgery The diagnosis, nature of the disease, its natural course, the prognosis, presence of comorbid conditions and the general condition of the patient should be taken into account. The benefit of surgery should be weighed against the possible risk and complications Alternative to high-risk surgery and the possibility of a conservative management should also be discussed with the patient and family members
Any requests or preferences made by the patient should also be considered A fully equipped operation theatre, post operative ward with monitoring and resuscitative facilities, and good surgical team are preferable The optimal timing of surgery to be fixed for better outcome
Preoperative Assessment & Preparation Assessment Preparation 1.History 2. Physical examination 3. Nutritional assessment 4. Investigations 5. Surgical risk assessment 1. Consent for surgery 2. Prevention of CVS & respiratory complications 3. Aspiration prevention 4. Preparation of bowel 5. Others
General Anaesthesia
General Anaesthesia (GA) refers to being “put to sleep”. During GA, you are unconscious.
Has general anaesthesia for dental treatment gone out of fashion?
General Anaesthesia is rarely used for dental treatment nowadays. One of the reasons for this is that IV sedation with midazolam works so well for nearly everyone, and is extremely safe. Each general anaesthetic carries a certain amount of risk.
In the
This policy change has resulted in far fewer GAs being given, and an increase in the use of IV conscious sedation.
Any technique resulting in the loss of consciousness is defined as GA and in the
Most dentists never use deep sedation, because if you’re going to go that “risky” you may as well go to GA, where full airway management is provided.
Disadvantages of General Anaesthesia
Apart from the risk of serious complications (which, while very small, is still much higher than for conscious IV sedation), general anesthesia has a few major disadvantages:
- GA depresses the cardiovascular and respiratory systems. For some groups of medically compromised patients, it is contraindicated for elective procedures.
- It’s not recommended for routine dental work like fillings. The potential risk involved is too high to warrant the use of GA. For things like fillings, a breathing tube must be inserted, because otherwise, little bits of tooth, other debris or saliva could enter the airway and produce airway obstruction or cause illnesses like pneumonia.
- Laboratory tests, chest x-rays and ECG are often required before having elective GA, because of the greater risks involved.
- Very advanced training and an anesthesia team are required, and special equipment and facilities are needed. GA introduces a number of technical problems for the operator (i. e. dentist), especially when a “breathing tube” is involved: the tongue is brought forward more into the dentist’s way by the airway tubing, the muscles are paralysed so the operator is working against a dead weight all the time and there are postural problems because the patient can’t be moved about much. The operator can get very tired very quickly when doing a session. It’s physically the most demanding kind of dentistry (usually standing, hot lights, compromised patient position).
- You can’t drink or eat for 6 hours before the procedure (otherwise, vomiting is possible and this would be very dangerous during GA).
- It’s expensive.
- GA does nothing to reduce dental anxiety.
When is general anaesthesia used?
GA can be useful or even indicated for certain situations.
- Conscious IV sedation works for about 97% of extremely anxious people. But there will always be a few people for whom it doesn’t work, either because you find it impossible to cooperate even when sedated and/or because you have a very high tolerance to the drugs used for IV sedation. This appears to be more common if you’ve been taking similar drugs long-term for other mental health conditions. In this case, GA may be the best option.
- For short or longer potentially traumatic procedures, such as the removal of wisdom teeth which are completely covered in bone, or certain other types of oral surgery. While there may be alternatives like multiple shorter appointments, in some cases GA may be preferable. If it’s extractions that really terrify you, it may be possible to be put to sleep for the extractions and then have fillings etc. done under conscious sedation with local anaesthetic.
How is it administered?
GA is usually started off with an injection in the hand or arm. It can be supplemented by a face mask but if a face mask is used you probably won’t remember it.
If post-op pain is expected, the normal practice is to inject a long acting local anaesthetic during the GA, so that when you wake up everything is nice and numb for a good few hours afterwards, which should give you time to take some painkillers and allow them to kick in. It’s much better to prevent pain than it is to try to deal with it once it has started.
Local Anesthesia
Sometimes your dentist needs to numb a part of your mouth. He or she injects medicine into your gum or inner cheek. This medicine is called local anesthesia.
Lidocaine is the most common local anesthetic that dentists use. There are many others. They all have names ending in “-caine.” Many people think of Novocain as the classic numbing drug. But Novocain actually is not used anymore. Other drugs last longer and work better than Novocain. These drugs also are less likely to cause allergic reactions.
The numbing drug is only one part of what’s injected. The liquid in the injection also can include:
- A type of drug called a vasoconstrictor. This drug narrows your blood vessels. This makes the numbness last longer.
- A chemical that keeps the vasoconstrictor from breaking down
- Sodium hydroxide, which helps the numbing drug work
- Sodium chloride, which helps the drugs get into your blood
There are two kinds of numbing injections. A block injectioumbs an entire region of your mouth, such as one side of your lower jaw. An infiltration injectioumbs a smaller area. This is the area near where the injection was given.
If you need local anesthesia in order to have your dental treatment done, your dentist will dry part of your mouth with air or cotton. Many dentists then swab the area with a gel to numb the skin.
Then, your dentist will slowly inject the local anesthetic. Most people don’t feel the needle. Instead, the sting they feel is caused by the anesthetic moving into the tissue.
An injection of local anesthesia can last up to several hours. After you leave the dentist’s office, you may find it difficult to speak clearly or eat. Drinking from a straw can be messy. Be careful not to bite down on the numb area. You could hurt yourself without realizing it.
Side Effects
Local anesthetics are the most common drugs used in the dental office. Side effects are very rare.
One possible side effect is a hematoma. This is a blood-filled swelling. It can form when the injectioeedle hits a blood vessel.
The numbing medicine sometimes causes numbness outside of the targeted area. If this happens, your eyelid or mouth can droop. You will recover when the drug wears off.
If you are unable to blink, you may need to have your eye taped shut until the numbness wears off. The anesthetic usually lasts for only a couple of hours. In some people, the vasoconstrictor drug can cause the heart to beat faster. This lasts only a minute or two. Tell your doctor if this has ever happened to you.
Finally, the needle can injure a nerve. This can lead to numbness and pain for several weeks or months. The nerve usually heals over time.
Concerns
It is rare to have an allergic reaction to a local anesthetic. Be sure to tell your dentist about all of the medicines you take. This should include over-the-counter drugs and also any herbs or vitamins you take. Also, tell your dentist about any reactions you have had with medicines, no matter how minor the reaction was. Some drugs can interact with local anesthetics.
TOPICAL ANESTHETICS IN THE DENTAL OFFICE
Topical anesthetics are applied directly on the skin or inside the mouth. Dentists use them to relieve pain caused by dental injections and procedures. You also can buy topical anesthetics in grocery and drug stores. These products contain drugs such as benzocaine, lidocaine or tetracaine. People use them to ease pain from teething, braces, canker sores or toothache. They also can relieve pain or itching outside the mouth.
Dentists use topical anesthetics for several purposes:
- To prevent or reduce the pain caused by a numbing shot
- To prevent people from gagging. The “gag reflex” may occur during an X-ray or when a tray is placed in the mouth to take an impression or give a fluoride treatment.
- To decrease discomfort during scaling and root planing or the removal of stitches
- To relieve pain from dry socket. This problem sometimes occurs after tooth extraction.
Topical anesthetics are applied in several ways:
- Ointments
- Gels
- Sprays
- Adhesive patch
Some topical anesthetics have flavors, such as fruit, mint or bubble gum.
Most topical anesthetics are the same drugs as local anesthetics that you get in a shot. But topical anesthetics usually are stronger. That’s because not all of the drug will work its way through the tissue.
Before giving you a topical anesthetic, your dentist will review your medical and dental history. One reason is to see if you have any history of allergic reaction. People can have a reaction to the anesthetic or to other ingredients, such as flavorings and preservatives.
Before numbing an area, your dentist will dry it with a gauze pad. Then an applicator (usually a cotton swab) is used to hold the anesthetic on the area for two to three minutes. Topical anesthetics also can be applied in the form of a spray or an adhesive patch.
Topical anesthetics numb the nerves 2 to 3 millimeters below the surface. They usually are effective for 15 to 30 minutes. That’s enough time for you to receive a shot or have stitches removed.
Many of the anesthetics used in the dental office also are found in over-the-counter products. These include gels to relieve mouth pain and sprays to relieve sunburn or a sore throat. Over-the-counter products are not as strong as those used in the dentist’s office.
Here are some common topical anesthetics.
Lidocaine
Lidocaine comes in an ointment and a patch. It commonly is used to reduce pain when you get a shot. Viscous lidocaine is a thick liquid form. It can be used to relieve pain from dry socket. Some people have this problem after a tooth extraction.
After lidocaine is applied, the area gets numb in about 3 minutes. The numbness lasts about 15 minutes. Lidocaine is approved for in-office use only in the mouth. Over-the-counter products that contain lidocaine should not be used in the mouth. These products include ointments to treat cold sores.
The patch
The patch is a small adhesive strip that contains lidocaine. It is placed in the mouth for up to 15 minutes. The area usually gets numb in 2 to 5 minutes. The effect lasts for about 30 minutes after the patch is removed.
The patch works at least as well as lidocaine ointment. It’s also somewhat safer because less of the anesthetic enters the bloodstream. The blood level is about half of that produced by applying lidocaine ointment. It’s just over one-tenth of what you get from a typical shot.
Benzocaine
Benzocaine is available in ointments or liquids. They contain from 7.5% to 20% anesthetic. Bezocaine is used to reduce the pain of injections. It works in much the same way as lidocaine. It is also the only topical anesthetic sold over the counter for mouth pain. These products are used to relieve pain and discomfort from toothache, canker sores, braces, teething and dentures.
Tetracaine
Tetracaine is a powerful topical anesthetic. It dissolves in water. For this reason, it spreads through the body faster than other anesthetics do. Tetracaine is used with benzocaine to reduce the gag reflex before taking impressions or X-rays. Numbness occurs very rapidly (within 1 minute). It lasts for about 15 minutes. This two-drug anesthetic is applied in the form of a spray. Tetracaine easily enters the bloodstream. Therefore, it must be used cautiously. Overdoses can lead to severe reactions, including death.
Dyclonine Hydrohloride
This compound is used in many over-the-counter lozenges for relieving sore throat pain. It also is used in the dental office, most commonly in liquid form. Dyclonine hydrochloride takes up to 10 minutes to produce numbness. However, it can be used in people who are allergic to other topical anesthetics.
EMLA
EMLA (eutectic mixture of local anesthetics) is a combination of lidocaine and prilocaine. Generally, it is given in liquid form. Until recently, EMLA was approved only for numbing intact skin. It was not used inside the mouth. This is because EMLA reaches the bloodstream rapidly if applied in the mouth.
In 2004, the U.S. Food and Drug Administration (FDA) approved an EMLA product called Oraqix. Oraqix is a gel that can be inserted into the space between the teeth and gums. The gel numbs the gums within 30 seconds. The effect lasts for about 20 minutes. It is only designed to numb soft tissue. It will not numb teeth. For this reason, Oraqix may be useful during deep cleaning procedures such as scaling and root planing. Scaling and root planing involves cleaning the teeth above and below the gum line and smoothing the surfaces of the teeth.
Pregnancy and Nursing
Topical anesthetics used in the mouth have not been shown to affect developing infants. They also don’t show up at significant levels in breast milk. If you are pregnant or nursing and you are concerned about topical anesthetics, ask your dentist.
Limitations
Topical anesthetics have some limitations:
- They can be toxic if applied across a large area, This is particularly a danger for tetracaine, because it is so easily absorbed. In January 2009, the FDA issued a health advisory to remind consumers and health care providers that improper use of topical anesthetics can cause serious side effects. The FDA advised against using these products over large areas of skin, or covering the area after they are applied. The warning followed several reports of serious problems when topical anesthetics were used for laser hair removal.
- Some people are allergic to the drugs, flavorings or other ingredients.
- Most topical anesthetics have not been tested in very young children (under 1 to 2 years of age) or the elderly.
Risks
The risk of receiving a topical anesthetic is usually quite low. However, risks include:
Allergic reactions
These are rare and usually mild, but severe reactions have been reported. A mild allergic reaction can include swelling and raised welts on the skin that can itch or burn. Some allergic reactions occur up to two days after the anesthetic is given.
Toxicity resulting from too much anesthetic
Symptoms can include:
- Blurry vision
- Unusual nervousness or restlessness
- Dizziness or lightheadedness
- Headache
- Ringing or buzzing in the ears
- Shivering
- Drowsiness
- Difficulty breathing
- Seizures (with a more severe reaction)
- Irregular heartbeat
Excess amounts of benzocaine have caused methemoglobinemia. In this condition, hemoglobin (a substance in red blood cells) is converted to an inactive form. It can’t do its job of carrying oxygen through the body. Mild forms of this condition may not produce any symptoms. More severe cases can cause fatigue, a bluish or grayish cast to the skin and difficulty breathing. This is a relatively uncommon condition. It has occurred primarily in three situations:
- In the operating room where doctors have applied too much benzocaine or tetracaine plus benzocaine to the back of the throat. This is done before placing a tube for breathing or for viewing the stomach or heart. Methemoglobinemia is far more likely to occur in this situation in elderly, weak patients.
- In teething infants, if parents have ignored dosing directions and applied too much benzocaine liquid or gel throughout the entire mouth
- In young children who have accidentally swallowed toxic amounts of benzocaine
For mild cases of methemoglobinemia, the person usually just needs to be observed closely. In more severe cases, methylene blue dye is injected into a vein. This acts as an antidote.
To prevent these problems, follow the instructions on the drug’s package. Keep all medicines out of the reach of young children.
Application of topical anesthetic gel before alveolar nerve block injection.
Premedication for Dental Treatment
What is Premedication?
Premedication is medication which is administered in advance of invasive dental or medical procedures.
Premedication in the dental office is usually a prescribed dose of antibiotics taken by patients with certain medical conditions before an invasive dental procedure.
Why do we prescribe it?
The oral cavity is a portal of entry as well as a site of disease for microbial infections that affect a patients overall general health.
Patients are given premedication with the belief that antibiotics would prevent infective endocarditis (IE), previously referred to as bacterial endocarditis.
Streptococcus viridan is the main infective bacteria that can enter the bloodstream from procedures that cause considerable bleeding in the oral cavity.
When the bacteria enters the bloodstream it can lodge on the heart valves, inflame the myocardium and cause ulcerations on the inner walls of the an artery.
Patients with artificial joints, structural heart defects, prosthesis or pervious severe infections are at a higher risk. The risk of developing endocarditis is closely associated with some dental procedures, making it a concern for heart patients and people with compromised immune systems.
Oral streptococci account for one third of all cases of endocarditis.
Premedication is prescribed to help prevent any bacteria introduced from the dental procedure, from causing an infection in another part of the body, such as the heart lining, or artificial joint.
Who needs premedication?
This subject is of great debate, because there is conflicting evidence whether antibiotic dental premedication is needed at all, and that the over prescription of antibiotics can lead to antibiotic resistant strains of bacteria.
If significant bleeding is not going to occur, it is not necessary to take antibiotics prophylactically before your dental appointment.
You will be able to determine whether or not a patient will need premedication based on their medical history. If you are not sure consult the patients physician prior to treatment.
Prophylaxis Recommendations: Infective Endocarditis (IE)
With input from the
The complete recommendations, including the recommended regimen, can be found in:
The Journal of the American Dental Association (JADA): Prevention of Infective Endocarditis: Guidelines from the American Heart Association
Patient selection for premedication:
The current recommendations recommend use of preventive antibiotics prior to certain dental procedures for patients with:
- artificial heart valves
- a history of infective endocarditis
- a cardiac transplant that develops a heart valve problem
The following congenital (present from birth) heart conditions:*
- unrepaired or incompletely repaired cyanotic congenital heart disease, including those with palliative shunts and conduits
- a completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedure
- any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device
* Patients should check with their cardiologist if there is any question as to whether they fall into one of these categories.
Patients who took prophylactic antibiotics in the past but no longer need them include those with:
- mitral valve prolapse
- rheumatic heart disease
- bicuspid valve disease
- calcified aortic stenosis
- congenital (present from birth) heart conditions such as ventricular septal defect, atrial septal defect and hypertrophic cardiomyopathy
Dental procedures
Premedication is recommended for all dental procedures that involve manipulation of gingival tissue or the periapical region of the teeth, or perforation of the oral mucosa.
Additional considerations about antibiotic prophylaxis:
Sometimes patients forget to premedicate prior to their appointments. The recommendation is that the antibiotic be given before the procedure. This is important because it allows the antibiotic to reach adequate blood levels.
However, the recommendations to prevent infective endocarditis state:
“If the dosage of antibiotic is inadvertently not administered before the procedure, the dosage may be administered up to two hours after the procedure.”
Another concern that dentists have expressed involves patients who require prophylaxis but are already taking antibiotics for another condition.
In these cases, the recommendations for infective endocarditis recommend that the dentist select an antibiotic from a different class than the one the patient is already taking.
For example, if the patient is taking amoxicillin, the dentist should select clindamycin, azithromycin or clarithromycin for prophylaxis.
What is the dose / Regimen given?
For reference, the standard regimen is as follows:
Adult Dosage:
Amoxicillin 500mg
Disp: 4 tablets.
Sig: Take all 4 tabs (2000mg) one hour before procedure
For allergy to penicillin:
Clindamycin 300mg
Disp: 2 tablets
Sig: Take 2 tabs (600mg) one hour before appt
DENTAL ANTIBIOTIC PREMEDICATION:
There are certain medical conditions which require the patient to take a dose of antibiotics prior to their dental appointment. This is done to help prevent any bacteria introduced from the dental procedure, from causing an infection in another part of the body, such as the heart lining, called bacterial endocarditis.
This subject is of great debate, because there is conflicting evidence whether antibiotic dental premedication is needed at all, and the over prescription of antibiotics can lead to antibiotic resistant strains of bacteria.
CONDITIONS WHICH MAY REQUIRE PREMEDICATION:
(This list is not all inclusive, so check with your provider if you have any concerns)
- Artificial Heart Valves
- History of Rheumatic Fever
- History of Infective Endocarditis
- Kidney Dialysis
- Mitral Valve Prolapse with Valvular Regurgitation
- Certain Congenital Heart Conditions
- Cardiac Transplants
DENTAL PROCEDURES WHICH REQUIRE PREMEDICATION: (This list is not all inclusive, so check with your provider if you have any concerns)
If significant bleeding is not going to occur, it is not necessary to take antibiotics prophylactically before your dental appointment.
The ADAs(American Dental Association) says:
The following procedures and events do not need prophylaxis; routine anesthetic injections through non infected tissue, taking dental radiographs, placement and removal of removable prosthetics or orthodontic appliances, adjustment of orthodontic appliances, placement of orthodontic brackets, shedding of primary teeth, and bleeding from trauma to the lips or oral mucosa. (Jada, January 1, 2008, v139). YES, ANTIBIOTICS ARE NEEDED:
All procedures which involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa, such as:
- Extractions
- Periodontal Surgery
- Endodontic Surgery
- Root Canal Therapy
- Periodontal Cleanings
DOSAGE:
AMOXICILLIN, usually administered as 500mg x 4 tablets (2.0 grams), taken 1 hour before dental appointment.
or, if allergic to amoxicillin
CLINDAMYCIN, usually administered as 150mg x 4 tablets (600mg), taken 1 hour before dental appointment.
DENTAL PREMEDICATION FOR ANXIETY:
This is one area of dentistry which is probably UNDERUTILIZED. Many, many patients are not comfortable going to the dentist, which makes them procrastinate and not go, which in turn makes their dental problems worse, which makes their experience more involved, and the whole ordeal SNOWBALLS!
One way to help manage DENTAL ANXIETY, is by PREMEDICATING the patient before their dental appointment. Sometimes a light sedative, such as VALIUM or ATIVAN, can relax a patient a great deal, which relaxes the provider, and can make the experience much more tolerable for both parties.
NITROUS OXIDE AND OR ORAL SEDATION?
Some oral sedatives combined with nitrous oxide are considered a HIGHER LEVEL of sedation, which your dentist may not be licensed to perform. Therefore, it is often recommended to choose either one or the other.
PRO NITROUS: It does not have any lingering effects, therefore after your appointment, your activity will not be limited.
PRO ORAL SEDATION DENTAL PREMEDICATION: Since you take the medication before your appointment, much of the ANXIETY leading to the appointment is reduced. Also, without a NOSEPIECE from the nitrous, the dentist will have much easier access to do the needed work.
THE MAIN DRAWBACK: The main drawback is that after taking a sedative, you will need someone to drive you home, and may be sedated for several hours after the appointment.
DOSAGE: Everybody is different, but most people will probably do fine with one dosage about an hour before the dental appointment. Some may need to take a dose the night before, and another before the appointment.
Cardiopulmonary resuscitation (CPR) is a lifesaving technique useful in many emergencies, including heart attack or near drowning, in which someone’s breathing or heartbeat has stopped. The American Heart Association recommends that everyone — untrained bystanders and medical personnel alike — begin CPR with chest compressions.
It’s far better to do something than to do nothing at all if you’re fearful that your knowledge or abilities aren’t 100 percent complete. Remember, the difference between your doing something and doing nothing could be someone’s life.
Here’s advice from the American Heart Association:
- Untrained. If you’re not trained in CPR, then provide hands-only CPR. That means uninterrupted chest compressions of about 100 a minute until paramedics arrive (described in more detail below). You don’t need to try rescue breathing.
- Trained, and ready to go. If you’re well trained and confident in your ability, begin with chest compressions instead of first checking the airway and doing rescue breathing. Start CPR with 30 chest compressions before checking the airway and giving rescue breaths.
- Trained, but rusty. If you’ve previously received CPR training but you’re not confident in your abilities, then just do chest compressions at a rate of about 100 a minute. (Details described below.)
The above advice applies to adults, children and infants needing CPR, but not newborns.
CPR can keep oxygenated blood flowing to the brain and other vital organs until more definitive medical treatment can restore a normal heart rhythm.
When the heart stops, the lack of oxygenated blood can cause brain damage in only a few minutes. A person may die within eight to 10 minutes.
To learn CPR properly, take an accredited first-aid training course, including CPR and how to use an automatic external defibrillator (AED).
Before you begin
Before starting CPR, check:
- Is the person conscious or unconscious?
- If the person appears unconscious, tap or shake his or her shoulder and ask loudly, “Are you OK?”
- If the person doesn’t respond and two people are available, one should call 911 or the local emergency number and one should begin CPR. If you are alone and have immediate access to a telephone, call 911 before beginning CPR — unless you think the person has become unresponsive because of suffocation (such as from drowning). In this special case, begin CPR for one minute and then call 911 or the local emergency number.
- If an AED is immediately available, deliver one shock if instructed by the device, then begin CPR.
Remember to spell C-A-B
The American Heart Association uses the acronym of CAB — circulation, airway, breathing — to help people remember the order to perform the steps of CPR.
Circulation: Restore blood circulation with chest compressions
1. Put the person on his or her back on a firm surface.
2. Kneel next to the person’s neck and shoulders.
3. Place the heel of one hand over the center of the person’s chest, between the nipples. Place your other hand on top of the first hand. Keep your elbows straight and position your shoulders directly above your hands.
4. Use your upper body weight (not just your arms) as you push straight down on (compress) the chest at least 2 inches (approximately 5 centimeters). Push hard at a rate of about 100 compressions a minute.
5. If you haven’t been trained in CPR, continue chest compressions until there are signs of movement or until emergency medical personnel take over. If you have been trained in CPR, go on to checking the airway and rescue breathing.
Airway: Clear the airway
1. If you’re trained in CPR and you’ve performed 30 chest compressions, open the person’s airway using the head-tilt, chin-lift maneuver. Put your palm on the person’s forehead and gently tilt the head back. Then with the other hand, gently lift the chin forward to open the airway.
2. Check for normal breathing, taking no more than five or 10 seconds. Look for chest motion, listen for normal breath sounds, and feel for the person’s breath on your cheek and ear. Gasping is not considered to be normal breathing. If the person isn’t breathing normally and you are trained in CPR, begin mouth-to-mouth breathing. If you believe the person is unconscious from a heart attack and you haven’t been trained in emergency procedures, skip mouth-to-mouth rescue breathing and continue chest compressions.
Breathing: Breathe for the person
Rescue breathing can be mouth-to-mouth breathing or mouth-to-nose breathing if the mouth is seriously injured or can’t be opened.
1. With the airway open (using the head-tilt, chin-lift maneuver), pinch the nostrils shut for mouth-to-mouth breathing and cover the person’s mouth with yours, making a seal.
2. Prepare to give two rescue breaths. Give the first rescue breath — lasting one second — and watch to see if the chest rises. If it does rise, give the second breath. If the chest doesn’t rise, repeat the head-tilt, chin-lift maneuver and then give the second breath. Thirty chest compressions followed by two rescue breaths is considered one cycle.
3. Resume chest compressions to restore circulation.
4. If the person has not begun moving after five cycles (about two minutes) and an automatic external defibrillator (AED) is available, apply it and follow the prompts. Administer one shock, then resume CPR — starting with chest compressions — for two more minutes before administering a second shock. If you’re not trained to use an AED, a 911 or other emergency medical operator may be able to guide you in its use. Use pediatric pads, if available, for children ages 1 through 8. Do not use an AED for babies younger than age 1. If an AED isn’t available, go to step 5 below.
5. Continue CPR until there are signs of movement or emergency medical personnel take over.
To perform CPR on a child
The procedure for giving CPR to a child age 1 through 8 is essentially the same as that for an adult. The differences are as follows:
- If you’re alone, perform five cycles of compressions and breaths on the child — this should take about two minutes — before calling 911 or your local emergency number or using an AED.
- Use only one hand to perform heart compressions.
- Breathe more gently.
- Use the same compression-breath rate as is used for adults: 30 compressions followed by two breaths. This is one cycle. Following the two breaths, immediately begin the next cycle of compressions and breaths.
- After five cycles (about two minutes) of CPR, if there is no response and an AED is available, apply it and follow the prompts. Use pediatric pads if available. If pediatric pads aren’t available, use adult pads.
Continue until the child moves or help arrives.
To perform CPR on a baby
Most cardiac arrests in babies occur from lack of oxygen, such as from drowning or choking. If you know the baby has an airway obstruction, perform first aid for choking. If you don’t know why the baby isn’t breathing, perform CPR.
To begin, examine the situation. Stroke the baby and watch for a response, such as movement, but don’t shake the baby.
If there’s no response, follow the CAB procedures below and time the call for help as follows:
- If you’re the only rescuer and CPR is needed, do CPR for two minutes — about five cycles — before calling 911 or your local emergency number.
- If another person is available, have that person call for help immediately while you attend to the baby.
Circulation: Restore blood circulation
1. Place the baby on his or her back on a firm, flat surface, such as a table. The floor or ground also will do.
2. Imagine a horizontal line drawn between the baby’s nipples. Place two fingers of one hand just below this line, in the center of the chest.
3. Gently compress the chest about 1.5 inches (about 4 cm).
4. Count aloud as you pump in a fairly rapid rhythm. You should pump at a rate of 100 compressions a minute.
Airway: Clear the airway
1. After 30 compressions, gently tip the head back by lifting the chin with one hand and pushing down on the forehead with the other hand.
2. Io more than 10 seconds, put your ear near the baby’s mouth and check for breathing: Look for chest motion, listen for breath sounds, and feel for breath on your cheek and ear.
Breathing: Breathe for the infant
1. Cover the baby’s mouth and nose with your mouth.
2. Prepare to give two rescue breaths. Use the strength of your cheeks to deliver gentle puffs of air (instead of deep breaths from your lungs) to slowly breathe into the baby’s mouth one time, taking one second for the breath. Watch to see if the baby’s chest rises. If it does, give a second rescue breath. If the chest does not rise, repeat the head-tilt, chin-lift maneuver and then give the second breath.
3. If the baby’s chest still doesn’t rise, examine the mouth to make sure no foreign material is inside. If the object is seen, sweep it out with your finger. If the airway seems blocked, perform first aid for a choking baby.
4. Give two breaths after every 30 chest compressions.
5. Perform CPR for about two minutes before calling for help unless someone else can make the call while you attend to the baby.
6. Continue CPR until you see signs of life or until medical personnel arrive.
CPR in basic life support. Figure A: The victim should be flat on his back and his mouth should be checked for debris. Figure B: If the victim is unconscious, open airway, lift neck, and tilt head back. Figure C: If victim is not breathing, begin artificial breathing with four quick full breaths. Figure D: Check for carotid pulse. Figure E: If pulse is absent, begin artificial circulation by depressing sternum. Figure F: Mouth-to-mouth resuscitation of an infant.
How to Perform CPR
Learning how to perform cardio-pulmonary resuscitation (CPR) saves lives. While no statistics are available on the exact number of lives sudden cardiac arrest claims per year, approximately 335,000 people die annually of coronary heart disease without being hospitalized – or about 918 Americans each day, according to the American Heart Association (AHA).
Conventional CPR consists of chest compressions and rescue breathing. The American Heart Association continues to support this approach to CPR, but recent research demonstrates that rescue breathing may be unnecessary and potentially detrimental in cases of cardiac arrest. In the interest of presenting complete information, however, ACEP is including instructions on how to provide rescue breaths in this guide for laypersons who choose to employ them.
The tips provided below are based on procedures recommended by the AHA and are not a substitute for formal training in CPR. The AHA and the American Red Cross offer CPR courses; to register, contact the AHA at 1-800-AHA-USA1 or your local American Red Cross chapter. Everyone in your family should take one of these courses, and you should have your CPR skills tested at least every two years.
Automated External Defibrillators (AEDs) are increasingly available at many locations, such as shopping malls and airports. They are small, lightweight devices used to assess a person’s heart rhythm. An AED can detect the need for and administer an electric shock to restore a normal heart rhythm in people with sudden cardiac arrest. ACEP supports widespread distribution of AEDs, as long as it is coordinated with existing
CPR is typically administered in cases of cardiac arrest. Signs of cardiac arrest include an absence of heartbeats, blood flow and pulse. When blood stops flowing to the brain, the person becomes unconscious and stops regular breathing.
The ABCs of CPR are Airway, Breathing, and Circulation. This acronym is used to help you remember the steps to take when performing CPR.
Airway
- If a person has collapsed, determine if the person is unconscious. Gently prod the victim and shout, “Are you okay?” If there is no response, shout for help. Call 911 or your local emergency number.
- If the person is not lying flat on his or her back, roll him or her over, moving the entire body at one time.
- Open the person’s airway. Lift up the chin gently with one hand while pushing down on the forehead with the other to tilt the head back. (Do not try to open the airway using a jaw thrust for injured victims. Be sure to employ this head tilt-chin lift for all victims, even if the person is injured.)
- If the person may have suffered a neck injury, in a diving or automobile accident, for example, open the airway using the chin-lift without tilting the head back. If the airway remains blocked, tilt the head slowly and gently until the airway is open.
- Once the airway is open, check to see if the person is breathing.
- Take five to 10 seconds (no more than 10 seconds) to verify normal breathing in an unconscious adult, or for the existence or absence of breathing in an infant or child who is not responding.
- If opening the airway does not cause the person to begin to breathe, it is advised that you begin providing rescue breathing (or, minimally, begin providing chest compressions).
Breathing (Rescue Breathing)
Pinch the person’s nose shut using your thumb and forefinger. Keep the heel of your hand on the person’s forehead to maintain the head tilt. Your other hand should remain under the person’s chin, lifting up.
- Inhale normally (not deeply) before giving a rescue breath to a victim.
- Immediately give two full breaths while maintaining an air-tight seal with your mouth on the person’s mouth. Each breath should be one second in duration and should make the victim’s chest rise. (If the chest does not rise after the first breath is delivered, perform the head tilt-chin lift a second time before administering the second breath.) Avoid giving too many breaths or breaths that are too large or forceful.
Circulation (Chest Compressions)
After giving two full breaths, immediately begin chest compressions (and cycles of compressions and rescue breaths). Do not take the time to locate the person’s pulse to check for signs of blood circulation.
- Kneel at the person’s side, near his or her chest.
- With the middle and forefingers of the hand nearest the legs, locate the notch where the bottom rims of the rib cage meet in the middle of the chest.
- Place the heel of the hand on the breastbone (sternum) next to the notch, which is located in the center of the chest, between the nipples. Place your other hand on top of the one that is in position. Be sure to keep your fingers up off the chest wall. You may find it easier to do this if you interlock your fingers.
- Bring your shoulders directly over the person’s sternum. Press downward, keeping your arms straight. Push hard and fast. For an adult, depress the sternum about a third to a half the depth of the chest. Then, relax pressure on the sternum completely. Do not remove your hands from the person’s sternum, but do allow the chest to return to its normal position between compressions. Relaxation and compression should be of equal duration. Avoid interruptions in chest compressions (to prevent stoppage of blood flow).
- Use 30 chest compressions to every two breaths (or about five cycles of 30:2 compressions and ventilations every two minutes) for all victims (excluding newborns). You must compress at the rate of about 100 times per minute.
- Continue CPR until advanced life support is available.
Using an AED in conjunction with CPR:
- If using an AED in the case of a heart attack or cardiac arrest, single shocks should be followed by immediate CPR for two minutes. Heart rhythm checks should be performed every two minutes (or after giving about five cycles of CPR); the AED will provide audible prompts at the appropriate intervals. See AED section for details.
- If using an AED on a one- to eight-year-old child, use a child-dose-reduction system if available. (However, do not use child pads or a child dose on adults in cardiac arrest because the smaller dose may not defibrillate adults properly.)
CPR for Infants (Up to One Year Old)
Airway
With infants, be careful not to tilt the head back too far. An infant’s neck is so pliable that forceful backward tilting might block breathing passages instead of opening them.
Breathing
Do not pinch the nose of an infant who is not breathing. Cover both the mouth and the nose with your mouth and breathe slowly (one to one and a half seconds per breath), using enough volume and pressure to make the chest rise.
With a small child, pinch the nose closed, cover the mouth with your mouth and breathe at the same rate as for an infant. Rescue breathing should be done in conjunction with chest compressions. (See next section.)
Chest Compressions on Infants
- If alone with an unresponsive infant, give five cycles of CPR (compressions and ventilations) for about two minutes before calling 911 or your local emergency number.
- Use only the tips of the middle and ring fingers of one hand to compress the chest at the sternum (breastbone), just below the nipple line, as described in the table below. The other hand may be slipped under the back to provide a firm support. (However, if you can encircle your hands around the chest of the infant, using the thumbs to compress the chest, this is better than using the two-finger method.)
- Depress the sternum between a third to a half the depth of the chest at a rate of at least 100 times a minute.
- Two breaths should be given during a pause after every 30 chest compressions (a 30:2 compression-to-ventilation ratio or two breaths about every two minutes) on all infants (excluding newborns).
- Continue CPR until emergency medical help arrives.
Small Children (ages one to eight)
- Give five cycles of CPR (compressions and ventilations) for about two minutes before calling 911.
- Use the heel of one or two hands, as needed, and compress on the breastbone at about the nipple line.
- Depress the sternum about a third to a half the depth of the chest, depending on the size of the child. The rate should be 100 times per minute.
- Give two breaths for every 30 chest compressions (30:2 ratio) or two breaths about every two minutes.
- Continue CPR until emergency medical help arrives.
