Sedation in Dental PracticeDR. TSHEWANG GYELTSHEN_49DDCH_2017

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2Overview

What is Sedation? / Dental Sedation. Types of Sedation: Unconscious Sedation and Conscious Sedation. Unconscious Sedation involves General Anesthesia and is not within the scope of

today’s deliberation. Conscious Sedation – Employed within Dental Practice and hence today’s

deliberation. Pre –Sedation Assessments and Patient Evaluations Techniques Employed for Conscious Sedation Risks / Probable Complications involved during Sedation Video Demonstrations of IV Sedation and Inhalational Sedation

TG_DDCH2017_Oral Sedation

3Sedation: What is Sedation?

Sedation: “Sedation is the reduction of irritability/agitation by administration of drugs, generally to facilitate a patient for diagnostic, interventional, medical or surgical procedures for the purpose of producing a degree of impaired response with or without the loss of consciousness” Starship Children’s Health Guidelines

Conscious Sedation: “Conscious sedation is 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” – Use of Sedation in Dental Practice, Nova Scotia Dental Board.

“The term conscious sedation refers to the administration of medication (an oral, I.V. or inhaled sedative) for the purpose of placing a patient in a relaxed state for their dental procedure. In comparison to general anesthesia however, the patient remains conscious”

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4Types of Sedation

Minimal Sedation (Anxiolysis):- A drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination might

be impaired, ventilatory and cardiovascular functions are unaffected. Moderate Sedation (Conscious Sedation) :-

A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.

Dissociative Sedation:- A trance-like cataleptic state induced by the dissociative drug ketamine characterized by profound analgesia and amnesia, with

retention of protective airway reflexes, spontaneous respirations, and cardiopulmonary stability. Deep Sedation:-

A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. Patient may need assistance in ventilation. Cardio function is maintained.

General Anesthesia:- A drug-induced loss of consciousness during which patients are not arousal, even by painful stimulation. Impaired ventilator function

and cardiovascular function maybe impaired as well

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5Conscious Sedation: How is it achieved?

Conscious Sedation maybe achieved by one of the following methods:

Inhalational Techniques – Nitrous Oxide and Oxygen Inhalation Parenteral IV Administration of the Sedative drugs Oral/trans-mucosal Administration of single sedative drugs Combination of above methods

The above techniques must carry a margin of safety wide enough not to render loss of consciousness.

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6Sedative Agents Used in Conscious Sedation

Inhalational Sedation:- Nitrous Oxide with Oxygen

IV Administered Sedative Drugs: Diazepam, Midazolam and other Benzodiazepine groups.

Orally Administered Sedative Drugs :-, Midazolam, Diazepam, Lorezepam, Triazolam, Zaleplon

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7Indications for Conscious Sedation:

According to the Scottish & British Dental Boards Guidelines, conscious sedations are indicated under following terms:

Anxious/Phobic patients usually, children and people with high fear susceptibility Those patients with movement Disorders with Physical/Mental defects unlikely allowing safe completion of

treatment. For Patients with severe Gag Reflex To Enable prolonged unpleasant procedures to be carried out without distress to the patient; E.g: Surgical

Extraction of 3rd Molars. To avoid general anesthesia to avoid risks related to GA. Sedation is used as intermediary between LA and GA. Medical conditions potentially aggravated by stress; Medical conditions affecting the patient’s ability to cooperate; Special needs.

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8American Society of Anesthesiologists [ASA-Physical Health Status]

Class I – A normal healthy PatientClass II – A patient with mild systemic

diseaseClass III – A patient with severe systemic

diseaseClass IV – A patient with severe systemic

disease that is a constant threat to life.

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9ASA-Physical Health Status

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10Contraindications

Only classes I & II are considered for sedation in dental care settings. Patients in ASA Class III and IV should be referred to hospital care.

In pediatric patients it is contraindicated if the child suffers from Congenital Heart Diseases associated with CHF or cyanosis Neurological Impairment with Poor Pharyngeal Coordination Severe Obesity Airway Abnormalities inclusive of URTI Obstructive Sleep Apnea Raised Intracranial Pressure

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11Characteristics of Conscious Sedation

The patient remains awake They remain responsive to stimuli such as verbal commands from their

doctor ("open your mouth," "close down"). The are responsive to sensation of pain except in the area where LA is

used. If the patient does happen to doze off, they are easily awaken. All of the patient's protective reflexes (breathing, coughing) remain

functional. The patient's cognitive function (perception, reasoning, comprehension)

may be modestly impaired. The patient looses all sensation and consciousness. Advantages of opting

for sedation. Procedure acceptability.

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12Risks Involved in Sedation

Unintentional loss of consciousness (i.e. loss of verbal contact with the patient) Depression of protective airway and pain reflexes Depression of respiratory and cardiovascular system Hazards of drug interaction with combination of wide variety of drugs which

may be used. Nausea Hypoxia - not enough oxygen reaching the blood or bodily tissues. Hyperactivity (inability to pay attention).

[Ref 3. Starship Children’s Health and Clinical Guidelines]

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13Conscious sedation for Children with special needs

ADHD- Attention Deficit Hyperactivity Disorder - Anesthetic management is dependent on the level of cooperation of the a patient. Preoperative sedatives maybe used. IV catheter allowed; if not ketamine with or without midazolam is used.

Autism :- Respect to their ritualistic behaviors- benzodiazepines are regarded as drug of choice. IV access may not be possible and thus potent inhalational or intramuscular ketamine maybe considered.

Cerebral Palsy:- Conscious sedation may be contraindicated because of the inability to handle oral secretions involving the risk of gastroesophageal reflux

Down's Syndrome:- It’s a trisomy with craniofacial features like macroglossia, micrognathia and short neck putting patient in increased risk for airway obstruction during sedation. Thus care should ben taken to prevent this.

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14Pre – Sedation Evaluation of Patients

Patient History – A thorough medical, dental and social history must be taken to enable good treatment outcome taking into accounts such as age, state of health, social circumstances and any special needs they may have.

A relevant History include :- Acute illness/injury Prior illness e.g. recent URTI Medications Psychological Assessment Drug allergies Weight Previous sedation experiences and if so drugs used for it

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15Physical Examinations

Following Physical Examination must be performed before Sedation: Airway abnormalities Respiratory rate and oxygen saturation Heart rate Blood pressure Determine ASA Physical Health Status Level of consciousness / Baseline Sedation Score

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16Patient Preparations

Patient must receive careful verbal and written instructions regarding effects of sedation and their responsibilities both before and after treatment.

Fasting before sedation is not normally required except under certain circumstances such as patients with marked gag reflex where there maybe risk for vomiting during treatment.

Patient is advised to eat normally on the day of appointment and not to eat more than normal amounts as this can cause lung aspiration with resultant morbidity. 6-8 hours fasting is even advised. – Peterson

Advised to avoid alcohol drinks and large meals on the day of operation. There must be responsible adult escort accompanying the patient who will be responsible

for post sedation care of the patient. A valid Informed Consent is taken in written form for both the sedation and on the

treatment planed.

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17Pre-Sedation Assessment in Summary:

A Fully recorded patient History inclusive of medical, dental and social History Recorded Blood Pressure Weight if Recorded ASA status of the patient A conscious Sedation and GA History Treatment plan The selected Conscious Sedation technique to be employed Provision of Pre and Post Operative written instructions provided before treatment. Written and well informed consent from the patient side. Any other individual Patient requirements.

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18Sedation Techniques

There are 3 techniques employed in achieving Sedation: 1. Inhalation Technique – Nitrous Oxide is the first choice of inhalational sedation technique.

titration of Nitrous Oxide to Oxygen along with the individual patient’s response Employed and delivered the inhalation through Inhalational Machine

2. Intravenous Technique – only appropriate in fewer cases than N2O. Drug Used. Midazolam Employed if Inhalational technique is unsuccessful. Topical Anesthetic is applied on the local area prior to administration of the drugs

3. Oral and Trans-Mucosal Sedation – Oral /trans-mucosal administration of benzodiazepine usually Midazolam Used when standard titratable inhalational and intravenous administration are deemed inappropriate.

Among the three, Inhalational and Intravenous are effective in majority of the patients in dental settings. [Ref. BDA – Nov 2011]

Low dose benzodiazepine may be prescribed to assist with sleep the night before treatment or to aid an anxious patient.

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19Suggested Dosage for Oral Sedation

Minimal Sedation Moderate SedationAppointment 2 hours or less

• triazolam 0.125-0.25 mgAppointment 2 hours or less

• triazolam 0.375-0.50 mgAppointment longer than 2 hours

• triazolam 0.25 mgor

• diazepam 10-15 mgor

• temazepam 15 mgor

• oxazepam 10-15 mg

Appointment longer than 2 hours• triazolam 0.50 mg

or• diazepam 20-30 mg

or• temazepam 30 mg

or• oxazepam 20-30 mg

Appointment longer than 3 hours• lorazepam 0.5-1.0 mg

or• alprazolam 0.25 mg

Appointment longer than 3 hours• lorazepam 2.0-3.0 mg

or• alprazolam 0.50 mg

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20Advantages and Disadvantages of Parenteral

Sedation Advantages:

Inhalational / IV technique can be titrated as required at the given time.

Disadvantage: 1. Special Instruments required 2. Special Training required 3. Not Cost Effective

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21Advantages and Disadvantages of Oral

Sedation Advantages DisadvantagesEasily Administered Inability to titrate reliably

Less Technique Sensitive Delayed and variable onset of actions

Relatively Safe as it is noninvasive Patient must be accompanied home

Cost effective Excessive effect and duration in elderly

Good Patient acceptance Limited success in Young Children

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22Patient Instructions: Before Sedation You must arrange to have someone escort you

home at the end of your appointment and assist you to your door.

Do not wear facial makeup or nail polish. Wear comfortable, casual and loose-fitting clothing.

Contact us prior to the appointment if there has been a change in your general health (such as a severe cold, fever, etc.).

Nothing to eat or drink for 2 hours before the procedure.

Make a trip to the washroom just prior to being seated.

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23Patient Instructions: After Sedation

You must not drive a car or operate machinery for at least 18 hours. You may be drowsy for the remainder of the day and should be recovering at home in the care of a responsible adult until you are fully alert.

Do not travel by public transit. Do not drink any alcoholic beverages for the

remainder of the day. If there are any problems, call the dentist in

charge

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24Video of Sedation: IV Method

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25Sedation: Inhalational Method

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26Reference Lists:

1. Peterson’s Principles of Oral and Maxillofacial Surgery 2nd Ed 2004 2. An Objective Evaluation of Clinical Signs used to assses Sedation with IV Diazepam- David Donaldson et al 3. Starship Children’s Health and Clinical Guidelines _ http://www.adhb.govt.nz/starshipclinicalguidelines/_

Documents/Sedation%20Paediatric%20.pdf 4. Use of Sedation in Dental Practice, Provincial Dental Board of Nova Scotia; Canada.

http://pdbns.ca/uploads/licensees/Sedation_Guidelines_-_Adopted_January_2010.pdf 5. The Scottish Dental Clinical Effectiveness Programme http://

www.sdcep.org.uk/wp-content/uploads/2013/03/SDCEP+Conscious+Sedation+2nd+Ed.pdf 6.British Dental Association guidelines - http://www.baos.org.uk/resources/BDAGuidanceconscious_sedation_-_

nov_11.pdf 7. Animated Teeth – https://www.animated-teeth.com/wisdom_teeth/t8-oral-surgery-conscious-sedation.htm 8. Veresed [Midazolam]

http://reference.medscape.com/drug/versed-midazolam-342907