Sedation for Dental Procedures Dr Walid Zuabi FCA RCSI Consultant Anesthetist JUH

Sedation Definition: A state of controlled depression of consciousness that allows patients to tolerate unpleasant procedures while maintaining adequate cardio-respiratory function and the ability to respond purposefully to verbal command and/or tactile stimulation.

Stages of Sedation

Stages of Sedation

Aim of Sedation Achieving anxiolysis and patient cooperation Drugs and techniques used should render unintended loss of consciousness unlikely

- Sedation relief of fear and anxiety - Local anesthesia  relief of Pain - Sedation relief of fear and anxiety - General anaesthesia  Relief of both pain and anxiety

Which patient groups ? Dental Anxiety & Phobia. Prolonged traumatic procedures. Medical conditions aggrevated by stress. Patient cooperation. Special needs.

Which patient groups ? Children and young adults Anxious adults

Patient selection Only ASA I and ASA II groups should undergo dental sedation in a general dental practice (clinic).

Risk classification ASA I : A normal Healthy patient 0.06-0.08% ASA II : A patient with mild systemic disease 0.27-0.40% ASA III: A patient with severe systemic disease 1.8 - 4.3% ASA IV: A patient with severe systemic disease that is a constant threat to life 7.8 - 23% ASA V: Moribund patient who is not expected to survive without the operation 9.4-51% ASA VI: A declared brain dead patient whose organs are being removed for donor purposes “E” For Emergency surgery

Consent * Informed, Written Consent regarding the sedation procedure for a course of dental treatment.

DRUGS USED 1- Benzodiazepines 2- Neuroleptanalgesia 3- Nitrous Oxide 4- Sedative Anaesthetics ( I.V. Hypnotic drugs)

SOAPME

Benzodiazepines Most widely used. Wide safety Margin. IV & Oral formulations available.

Benzodiazepines Functions 1- Anxiolytic 2- Sedative (hypnosis)  sleep promotion 3- Amnesia/ RETROGRADE 4- Central muscle relaxant effect 5- Anticonvulsant

Benzodiazepines Diazepam Oral: 2 mg q 8 hrs for anxiety 10-15 mg for premedication 2 hrs pre-op (in Hospital) IV or IM. painful on injection  Diazemulus (lipid emulsion): painless on injection 5 mg/ml

Benzodiazepines Diazepam (Continued) Best anxiolytic Poor amnesic Minimal CV depression Long Duration of action ( > 4 hrs) Active metabolite

Benzodiazepines Midazolam Indications: - Conscious sedation - Co-induction of GA Doses: - For pre-op sedation 0.07 – 0.08 mg/kg 1 hr before procedure I.M injection - Individualized dose I.V

Benzodiazepines Midazolam Best amnesic , good hypnotic Some CV depression Readily produces general anesthesia Duration < 2 Hrs

Benzodiazepines Temazepam Only Oral. Doses : - Insomnia : 10 – 30 mg - Premedication: 10 – 20 mg 2 Hrs Preop Good Hypnotic Short duration May cause dysphoric reactions in young adults

Benzodiazepines Antidote: Flumazenil (Anexate) A specific antagonist I.V Essential requirement if Benzodiazepines are used. 0.2 mg IV every 15 seconds Rapid recovery Duration: 15 min Re-sedation if long acting BZD is used Can precipitate withdrawal reaction in habituated patients.

============================= Neuroleptanalgesia Major tranquilizers: chlorpromazine, droperidol & Opiates: Fentanyl, morphine & Codeine ============================= Many side effects  - Behavioral syndromes: - inhibition of purposeful movement - inhibition of learned behavior - catalepsy: a condition characterized by rigidity of extremities and decreased sensitivity to pain - Alpha adrenergic blockade - Hypothermia - Extra-pyramidal effects - Anti-cholinergic effects

Neuroleptanalgesia cont. Droperidol: - Dose: 5 mg IV - produce marked catalepsis - Inner anxiety - Duration 2 hrs Fentanyl: - Max. dose 1mcg/kg - Potent Narcotic analgesic - potent respiratory depressant - Duration of action 35 min

Nitrous Oxide N2O LAFFING GAS!! LOL!!

Nitrous Oxide N2O Just Say N2O! LAFFING GAS!! LOL!! Just Say N2O!

Nitrous Oxide N2O LAFFING GAS!! LOL!!

Nitrous Oxide N2O LAFFING GAS!! LOL!! Laughing Gas

Nitrous Oxide N2O Inorganic gas/ N2O A strong analgesic High safety margin Can be used in concentrations up to 70% Needs special administration machine Needs a scavenging system Use nasal masks with two-way valve outlets

Sedative Anaesthetics - Propofol: - Ultra-short acting - Rapid clear headed recovery - I.V infusion through a syringe pump - titrate dose to desired response - can achieve very well controlled sedation - Very easy to render patient unconscious!! - Should only be given by trained personnel in skills of: - Tracheal intubation - Artificial ventilation - Cardiovascular resuscitation

Risks of Sedation Depression of Airway Reflexes Inter-individual variability Interactions with other medications Allergic responses Cardiovascular decompensation Disinhibition reaction

Be prepared !! Patient check up: - A concise medical history and relevant examination and investigation - General practitioner Assessment for potential airway problems Informed Consent NPO

Do you need an anaesthetist ?

Do you need an anaesthetist present ?

Do you need an anaesthetist ? Possible airway problems Very young / very old Concurrent medical problem Deep sedation ?

Monitoring Pulse Oximeter BP ECG Defibrillator

Emergency drugs that should be available (in resuscitation trolley) - Adrenaline Atropine Flumazenil Lignocaine Naloxone IVF

Recovery and Discharge Allow patient to recover in a quiet environment - Patient must be supervised until fully recovered PACU should be equipped with same standards of the procedure room Discharge after review by qualified practitioner Written instructions regarding home care Avoid alcohol, driving, machinery, signing documents in case of a adults.

In Europe England, Ireland & Switzerland were the only two countries in Europe where dental procedures under deep sedation or G/A where carried out outside hospitals i.e. in dental clinics. Training programs in conscious sedation for dentists are provided in public sector and in certain universities as a prerequisite for licensing .

Risk Management Using only familiar drugs Only to correctly indicated patients Comprehensive preoperative assessment continuous monitoring Appropriate emergency drugs and equipment Full documentation Well trained support personnel Treating high risk patients in a well equipped setting for their care