Sedation for Dental Procedures By: Dr. Mahmoud Al-mustafa Associate Prof. Dept of Anaesthesia Faculty of Medicine – The University of Jordan 24 December 2013

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 .

Why Sedation?? Dentistry treatment is still one of the most anxiety inducing events in people’s lives. ================================ Adult Dental Health Surveys in the united kingdom ( 1988 and 1998)  Around half of the UK’s adults were anxious about dental treatment.  avoidance of treatment

also…… Dental anxiety is found to affect patients’ quality of life, including sleep disturbance, interference with work and interference with personal relationships !!!

…….. Dental anxiety affects both patient and dentist ! Dentists identify treating nervous patients as a major source of stress !

during dental treatment A survey in 1997 into patient preferences found that: - 65% of those asked would like to be pain-free but conscious, 56% would like to be amnesic Delfino J. Public attitudes toward oral surgery: results of a Gallup poll. J Oral Maxillofac Surg 1997; 55:564–567.

A survey of general dental practitioners in Scotland: - 74% felt there was a need for sedation in their practices * Foley J. The way forward for dental sedation and primary care? Br Dent J 2002; 193:161–164

Stages of Anesthesia 2- Stage of uninhibited response (Excitement): 1- Stage of analgesia: Diminished pain perception, verbal contact maintained, laryngopharyngeal reflexes and voluntary control Present 2- Stage of uninhibited response (Excitement): Consciousness lost, verbal contact and voluntary control lost  uncontrolled, exaggerated, withdrawal type response to any stimulus Protective laryngopharyngeal reflexes maintained ! 3- Stage of Surgical Anaesthesia: 4- Stage of Respiratory Arrest

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 ? Children and young adults Anxious adults

A significant proportion of children remain pre-cooperative despite full utilization of suitable behavior-management techniques Careful assessment of the child’s level of anxiety is essential.

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

(By patient or guardian) Consent Informed, Written Consent regarding the sedation procedure for a course of dental treatment (By patient or guardian)

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

Benzodiazepines Most widely used Wide safety Margin Oral and intravenous formulations available

Benzodiazepines Functions: 1- anxiolytics 2- Sedative (hypnosis)  sleep promotion 3- Amnesia 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) Intravenous or intramuscular: painful on injection

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

Benzodiazepines Midazolam: No oral preparation available (but the I.V preparation is sometimes given to children mixed in paracetamol preparation) Indications: - conscious sedation - induction of anesthesia Dose: - For pre-op sedation 0.07 – 0.08 mg/kg 1 hr before procedure I.M injection - Individualized dose I.V

Benzodiazepines Midazolam (Continued) Best amnesic , good hypnotic Some CV depression Readily produces general anesthesia Duration : < 2 hrs Generally recommended for patients >16 yrs old

Benzodiazepines Temazepam: Oral preparation only available DOSE : - Insomnia : 10 – 30 mg - Premedication: 10 – 20 mg 90 minutes prior to surgery Good Hypnotic Short duration < 4 hrs May cause dysphoric reactions in young adults

Benzodiazepines Antidote: Flumazenil (Anexate) A specific benzodiazepine antagonist I.V injection Essential requirement anywhere Benzodiazepines are used 0.2 mg IV every 15 seconds Rapid reawakening 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 , omnopon® (Morphine, Papaverine , Codeine) ============================= Many side effects  delay in use - Behavioral syndromes: - inhibition of purposeful movement - inhibition of learned behavior - catalepsy: a condition characterized most often by rigidity of the extremities and by 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: around 2 hrs - Fentanyl: - Max. dose 1mcg/kg - Potent Narcotic analgesic - potent respiratory depressant - Duration of action : around 35 min

Nitrous Oxide Inorganic gas N2O A strong Analgesic High safety margin Can be used in concentrations up to 70% Needs special administration machine/anaesthesia machine Safe in to use in the normal time limits of surgery Need a scavenging system Use nasal masks with two-way valve outlets

Sedative Anaesthetics - Propofol: - ultra-short acting - rapid clear-headed recovery - I.V infusion from syringe pump - titrate dose to desired response - can achieve very well controlled sedation. Target-controlled infusions of propofol patient controlled infusions of propofol successfully tried

Propofol…….ctd. - Very easy to render patient unconscious !! - Should only be given by personnel trained in anaesthetic skills: - Tracheal intubation - Artificial ventilation - Cardiovascular resuscitation

Ketamine Etomidate Sodium Thiopental

Dexmedetomidine An alpha2 adrenergic selective agonist It has sedative, analgesic and anxiolytic properties Comparable to propofol with the added advantage of analgesia May cause extra sedation and hemodynamic changes

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 Nil-by-Mouth

Surgery Staffing A trained assistant: - Assistance to Dentist - Monitoring the patient - Cardiopulmonary resuscitation

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

Monitoring Routine use of pulse oximeter Means of blood pressure Monitoring Electrocardiogram ( ECG ) Defibrillator for use in emergency

Emergency drugs that should be available (on Resuscitation trolley) - Adrenaline Atropine Dextrose 50% Flumazenil Lignocaine Naloxone

Recovery and Discharge - Allow patient to recover in a quiet environment - Patient must be under observation until fully recovered Recovery area should be equipped to the same standards as the procedure area Discharge patient after review by qualified practitioner Written instructions regarding after care Avoid alcohol, driving, machinery, signing documents In care of a responsible adult

In Europe England and 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. This stopped in in England in 1998 after introduction of new guidelines followed by growth in the use of conscious sedation Training programs in conscious sedation for dentists - both theoretical and practical - are provided in the public sector and in certain universities . And this includes special emphasis on resuscitation skills as a prerequisite for licensing .

In the States ADA  document on “the use of conscious sedation, deep sedation and general anaesthesia in Dentistry” ADA Educational Guidelines: * Part one: “Teaching The Comprehensive Control of Pain and Anxiety to the Dental Student”  Conscious sedation * Part Two: “Teaching The Comprehensive Control of Pain and Anxiety to the dentist at the advanced educational level”  deep sedation / General anesthesia * Part three: “Teaching The Comprehensive Control of Pain and Anxiety in continuing education program”  conscious sedation ***************************************************************************************** * Completion of ADA accredited post-doctoral training program commensurate with the above document  deep sedation / general anesthesia

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

Thank you