Oral Sedation

Oral Sedation Oldest and most common route Used for stress reduction, pre- & post-op pain

Advantages of Oral Sedation Universal acceptance Ease of administration Low cost Low incidence / severity of adverse reactions No needles, syringes or specialized training

Disadvantages of Oral Sedation Reliance on patient compliance Long latent period (30-60 min) Unreliable drug absorption in GI tract Inability to titrate effect Prolonged duration of action

Use of Oral Sedation Sedation the night before treatment to ensure restful sleep Light levels of sedation for preoperative anxiety reduction

Oral Sedatives Sedative-Hypnotics Ethyl alcohol,Barbiturates,Nonbarbiturates Antianxiety drugs Antihistamines Opioid analgesics

Sedative-Hypnotics Produce either sedation or hypnosis depending on dose and patient response Ethyl alcohol (ETOH) most common

Sedative-Hypnotics Barbiturates Categorized by duration of action Hangover effect common In dentistry, secobarbital or pentobarbital

Nonbarbiturates Chloral Hydrate Common in pediatrics Elixir in fruit juice, 40-60 mg/Kg

Antianxiety Drugs Benzodiazepines most commonly used Wide dosage range of therapeutic activity In dentistry, diazepam or midazolam

Antihistamines Sedation and hypnosis are side effects Hydroxyzine most popular in pediatric dentistry

Narcotics Relief of moderate to severe pain Will alter psychological response to pain Can suppress anxiety and apprehension, but not very effective orally

Rectal Sedation

Rectal Sedation Seldom employed in dental practice Indicated in patients unable or unwilling to take medication orally Most often used in pediatrics, for very uncooperative children

Advantages of Rectal Administration Minimal drug side effects Avoidance of first-pass effect via large intestine No special equipment Ease of administration

Disadvantages of Rectal Administration Long latent period (30 min) Variable drug absorption Inconvenient Possible irritation of intestines Inability to titrate Prolonged duration of action

Rectal Sedatives Barbiturates (phenobarbital, secobarbital) Narcotics (hydromorphone) Promethazine (primarily for N/V) Chloral Hydrate Benzodiazepines (diazepam, midazolam)

Intramuscular (IM) Sedation

IM Sedation Parenteral technique Avoids variable GI absorption Most commonly used in children

Indications for IM Administration Inhalation or IV not available Children with severe management problems Administration of emergency drugs Administration of anticholinergics and antiemetics

Advantages of IM Administration Short onset of action (15 min) Short maximal clinical action (30 min) Patient cooperation is not essential Reliable absorption

Disadvantages of IM Administration Long latent period (15 min) Inability to titrate or reverse the drug action Prolonged duration of action Possibility of injury to tissue at the site of injection

IM Sites Gluteal area Ventrogluteal area (hip) Vastus lateralis ( thigh) Mid-deltoid

Complications of IM Injections Hematoma Abscess Cyst and scar formation Necrosis and sloughing of skin

Complications of IM Injections (cont.) Nerve injury Intravascular injection Air embolism Periostitis

Determinants of IM Dosage Body weight Degree of anxiety Level of sedation desired Age

Determinants of IM Dosage (cont.) Experience of administrator Surface area (pediatric) Prior response to CNS depressant Health status

Calculations for IM Dosage Clark's Rule Peds dose = Wt of Child (lb) X Adult dose 150 Young's Rule Peds dose = Age of Child (yr) X Adult dose Age + 12

IM Sedation Various combinations, largely dependent on administrator experience and preference Demerol: Phenergan: Thorazine (2:1:1) Midazolam Ketamine

IM Sedation The deeper the level of sedation, the more intense the monitoring Pulse oximeter at a minimum Pretracheal stethoscope, BP, ECG