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

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 .

3. 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

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

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

6. 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.

7. 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

8. 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

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

10. - 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

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

12. 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.

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

14. 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

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

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

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

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

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

21. 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

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

23. 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

24. 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

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

26. 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

27. 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

29. 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

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

31. Ketamine
Etomidate
Sodium Thiopental

32. 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

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

34. 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

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

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

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

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

40. 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

41. 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 .

42. 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

43. 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

44. Thank you