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

2. 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.

5. Stages of Sedation

6. Stages of Sedation

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

8. - 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

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

10. Which patient groups ?
Children and young adults
Anxious adults

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

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

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

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

16. SOAPME

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

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

19. 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

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

21. 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

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

23. 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

24. 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.

25. =============================
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

26. 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

27. Nitrous Oxide N2O
LAFFING GAS!! LOL!!

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

29. Nitrous Oxide N2O
LAFFING GAS!! LOL!!

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

31. 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

32. 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

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

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

37. Do you need an anaesthetist ?

38. Do you need an anaesthetist present ?

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

41. Monitoring
Pulse Oximeter BP
ECG
Defibrillator

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

43. 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.

44. 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 .

45. 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