Objectives Sedation in the Dental Office

Pamela J Hughes, DDS Assistant Professor and Graduate Program Director; Division of Oral and Maxillofacial Surgery

• Understand why sedation is used in dentistry • Understand what circumstances are appropriate for sedation in dentistry • Understand the differences in the levels of anesthesia • Be able to identify what patients will be candidates for sedation in the dental office • Describe basic sedation techniques

Levels of anesthesia

Why do we use sedation? • Going to the dentist is among the most common adult fears • 6-14% of Americans avoid seeking dental care because of their fear • The practitioner can provide a more comfortable situation • More invasive procedures can be performed in the outpatient clinic setting (healthcare cost savings?)

definitions • Analgesia: The diminution or elimination of pain in the conscious patient – How is this accomplished?

• • • •

Analgesia Local (regional) anesthesia Anxiolysis Moderate Sedation (aka conscious sedation) • Deep sedation • General anesthesia

definitions • Local anesthesia: The elimination of sensations, especially pain, in one part of the body by the application or regional injection of an anesthetic agent

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definitions

definitions

• Anxiolysis: the reduction of anxiety: A druginduced state during which patients respond normally to verbal commands. Cognitive function and coordination may be impaired, but ventilatory and cardiovascular functions are unaffected

• Moderate sedation: A minimally depressed level of consciousness that retains the patient’s ability to independently and continuously maintain an airway and respond appropriately to physical stimulation and verbal command

– In the dental setting, this is usually achieved with nitrous oxide or oral premedication e.g.: “Valium”

definitions • Deep sedation: A drug induced, controlled state of depressed consciousness accompanied by a partial loss of protective reflexes, including the inability to continually maintain an airway independently and/or respond purposefully to verbal command – The patient cannot be easily aroused but will respond purposefully to painful stimulus

definitions • General anesthesia: The elimination of all sensation, accompanied by the loss of consciousness. The patient is not arousable even by painful stimulation. The patient may require ventilation, and cardiovascular function may be affected.

sedation • Common routes of administration – Inhalational – Oral – Intramuscular – Intravenous – Combinations of the above

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Routes of administration • Inhalation anesthesia (Nitrous oxide/oxygen) – Advantages • • • • • •

No absolute contraindications for use No monitoring equipment needed Good patient acceptance Titratable Pre-op fasting not required Quick acting/quick recovery

Inhalation anesthesia • Disadvantages of nitrous oxide – Some patients may not feel adequate effects – Additional equipment needed – Occupational exposure?

Inhalation anesthesia • Can also achieve general anesthesia with inhalation agents – Sevoflurane – Halothane – Desflurane – Isoflurane

• Rarely used in the dental office; more common in OR or surgery center

Inhalation general anesthesia

Routes of sedation: Oral • Advantages of oral sedation – No IV needed – Good patient acceptance – Minimal armamentarium needed

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Routes of administration: oral • Disadvantages of oral sedation – – – – – – – –

Not titratable May not achieve desired effects from single dose Multiple dosing not desirable Need 20-45 minutes for drug to take effect Monitoring required Additional operator training required Not predictable Pre-op fasting required

Routes of administration: intramuscular

Oral sedation • Common drugs used – Halcion (triazolam) – Valium (diazepam) – Ativan (lorazepam) – Versed (midazolam) – chloral hydrate

IM administration • Disadvantages of Intramuscular sedation

• Advantages of IM sedation – No IV access required – More rapid onset of action than oral administration – More reliable absorption than oral administration

Intravenous administration

– Not titratable; o verdose potential – Lag time needed before effects seen (although quicker than oral administration) – “Shot” required – Potential long 2-4 hour duration of action – Monitoring required – Fasting required – Additional operator/assistant training required

Routes of administration: Intravenous • Intravenous administration advantages – Titratable – More predictable effects – Onset in seconds to minutes – Rapid reversal of certain drugs possible – Ready to administer emergency drugs if needed – Replace fluid deficit from fasting

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Intravenous sedation • Disadvantages – Monitoring needed – IV access needed – Pre-op fasting required – Operator/assistant training required

common side effects of sedative agents • • • • • • •

CNS depression Respiratory depression/arrest Nausea Disphoria/dreaming Cardiovascular effects Drug interactions Amnesia

Intravenous sedation • Common Drugs used for IV sedation (moderate and deep) – Versed (midazolam) – Fentanyl – Ketamine – Propofol – Methohexital

Monitoring • Moderate (conscious) sedation – Blood pressure • Before, during, after at the least

– Pulse oximetry – Respiration • Chest rise • Precordial stethoscope • capnography

Monitoring • Deep sedation/general anesthesia – Blood pressure intermittent throughout procedure; e.g.. Every 5 minutes – Continuous pulse oximetry – Respiration – Electrocardiogram (ECG) – Also may need airway support

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Patient evaluation for sedation ASA Classification Airway evaluation Considerations for specific systems

American Society of Anesthesiologists physical status classification

ASA I or II patients are best candidates for sedation in the dental office

Airway evaluation • • • •

Anatomy Range of motion Mallampati classification BMI/neck circumference

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Airway evaluation Most serious office emergencies involve airway/respiratory complications!!!

Preoperative instructions for anesthesia • NPO for at least 6 hours • Escort present and accounted for • Daily medication regimen – Prescription drugs, OTC meds, herbals

• Comfortable clothing and shoes

Case #1 • 65 yo woman with

System evaluation • • • • •

Cardiovascular system Pulmonary system Renal system Hepatic system Endocrine system

Case #1 • What is the patients ASA classification?

– Hypertension controlled with atenolol • Blood pressure today is 128/84 pulse is 70

– Type II diabetes controlled with diet • Last Hgb A1c = 6

• Is she a candidate for office moderate sedation?

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Case #2 cont

Case #2 • • • • •

57 yo man Hypertension Angina Diabetes (type I) Renal failure

• Meds – Atenolol – Lisinopril – Hydrochlorothiazide – Nepho caps – Insulin • Regular and ultralente

– Nitroglycerin as needed

– Dialysis three time a week What else might you want to know about this patient?

Case #2 cont

• Blood pressure is 150/90 • Blood glucose is 260g/dl today in the office • Has daily chest pain brought on by walking • Was hospitalized last month due to hyperkalemia (due to his kidney failure)

Case #2 cont

• Do you think this patient’s medical conditions are under good control? • What is his ASA classification? • Is he a candidate for office sedation?

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