Torus palatinus - clinical case

 

 

Torus  Palatinus .. Case reported With Dr. Alex, AUST

 

is a bony protrusion on the palate. Palatal tori are usually present on the midline of the hard palate. Most palatal tori are less than 2 cm in diameter, but their size can change throughout life.

 

 

 

Palatal tori are usually a clinical finding with no treatment necessary. It is possible for ulcers to form on the area of the tori due to repeated trauma. Also, the tori may complicate the fabrication of  dentures. If removal of the tori is needed, surgery can be done to reduce the amount of bone present.

 

 

Local Anesthesia

Outline

Properties of LA

Components of LA & Types of LA

Methods of administration

Complication of administration

Contraindication of LA

Side effects & treatment

 

 

 

Properties of LA :

1)Potency & Reliabiability

2) Reversibility of action

3)Safety “should not be toxic”

4)Lack of irritation

5)Rapidity of onset

6)Duration of effect

7)Adequate shelf life

8)Penetration of mucous membrane 

Components of LA

1)Local Anesthetic Agent (Main component)

-Ester : benzocaine, cocaine (topical only)

 

-Amide : Lidocaine, mepivacaine , Bupivacaine

-short acting  :procaine,  chloroProcaine , lidocaine

-long acting  : Bupivacaine, etidocaine

* Bupivacaine “in toxicity , cause cardiovascular collapse and ventricular tachycardia.

2) Vasoconstrictor : ( Adrenaline , felypressin , noradrenaline )
- In some preparations, vasoconstrictors are not  added and the anesthetic drug is used as  plain solution.

* when plain anesthetic solution is used the will be a quick absorption and short duration of action. Chance of overdosage should be kept in mind.

Concentration of adrenaline :
          * 1:50,000
          * 1:80,000
          * 1:100,000

Advantages Of Vasoconstrictors:
1) Reduce the toxic effect by retarding the absorption of the constitution
2) Increase the depth & duration of Anesthesia
3) Produce bloodless field of operation for surgical procedures

3) Reducing agent : sodium metabisulphite

- Vasoconstrictors used in anesthetic solution are unstable. They might get oxidized and discoloration of the solution occurs. To prevent this, small quantity of sodium metabisulphite is added to anesthetic solution. Sodium metabisulphite has great affinity to oxygen compared to the vasoconstrictors and thus prevent its oxidation.

* Sulphites  may result in allergic reactions 
* some Anesthetic preparations Capryl hydro-cuprinotoxin is add as a preservative as this doesn’t cause any allergic reacthions.

4) Preservative : methyl or propyl paraben
- maintain sterility of the solution

- increase it’s shelf life

* Parabens are known to cause allergic reactions

5) antifungal agents :  Thymol
- Prevent any fungal growth

 

6) Vehicle : Ringer’s solution
is used to dissolve all the above constituents and render the anesthetic solution compatible with tissue fluids . 

 

Methods of administration

 

1)Infiltration

2)Topical anesthesia

3)Nerve block

Local Complications

§Post injection Pain

§Paresthesia : most common with lingual nerve block

§Trismus : due to truma to muscles in the infratemporal fossa (medial Pterygoid muscle).

§Truma to nerve sheath : sensation of electric shock through out the distribution of the nerve

§Syncope : most common dental complication, in form of neurologic shock , also known as vasovagal attack or fainting fit. (management?)

§Prolonged anesthesia : Due to hemorrhage in neural sheath

 

§ Hematoma : common with posterior superior alveolar block & infraorbital nerve block – rare with palatal inj. Due to dense hard palatal tissue

§Facial paralysis : due to inj. Of LA  in or near parotid gland capsule (high inferior alveolar NB or more posterior PSA  NB)

§Post injection infection : mostly due to infected Local Anesthetic solution or needle!

§Idiosyncracy : due to underlying genetic cause

§Sterile abscess : in palatal tissue only

§Over dose : mostly with amide LA. , Allergy mostly with ester LA.
* Oxygen is given with overdose to prevent acidosis.

Contraindication of LA

-Cocaine C/I in Kidney disease

-Articaine C/I in patients allergic to Sulphur containing compounds.

-Etidocaine, bupivacaine not given to children due to long duration

-Amide LA : C/I in patient with malignant hyperthermia

-Ester type LA : C/I in patient with cholinesterase deficiency

-Adrenaline : C/I in hyperthyroidism 

-Vasoconstrictors : absolute C/I is thyrotoxicosis & in present of MAO-I drugs

-Fellypresin : C/I in pregnant patients & not recommended for hemostasis

Side effects

 

1) Allergy : To Ester is common due to “PABA” but rest with amide type.

If allergy to both ester & amide then Diphenhydramine can be used as anesthetic “1.5 – 2.0 ml or 15 – 20 mg to give 30 min. of action”

2) Malignant Hyperthermia

3) Toxicity if inject IV & IA local anesthetic

4) Effect on CNS is biphasic “stimulation followed by depression”.
* CNS depression can be the first s/s rather than CNS excitement with lidocaine.

5) Effect on CVS : only depression

Treatment in case of toxicity

airway is maintained and oxygen administered by facemask, using artificial ventilation if apnoea occurs.

 Convulsions should be treated with anticonvulsant drugs such as thiopentone (150-250mg I.V.) or diazepam (10-20 mg I.V.) repeated as necessary.

Profound hypotension and brady -arrhythmias should be treated with intravenous atropine (0.5-1.5mg) and colloid or crystalloid infusions as plasma expanders may be necessary.

Occasionally adrenaline may be required for severe hypotension or bradycardia

In patients with ventricular fibrillation due to bupivacaine toxicity, cardiopulmonary resuscitation should be continued for at least 60mins. Bretyllium may facilitate cardioversion.