Dental Sedation Techniques

Sedation and General Anesthesia
in Dentistry
Assistant professor : Akram Thabet Nasher
B.D.S, M.Sc. , Ph.D.
Head department of oral and maxillofacial surgery
Faculty of Dentistry- Sana`a university

Anesthesia


The

practice

psychological,
approaches

of

physical,
to

the

and

various

chemical

prevention

and

treatment of preoperative, operative, and
postoperative anxiety and pain.

Dr.Akram Thabet

Levels of Anesthesia


Local anesthesia



Conscious Sedation



Deep Sedation



General Anesthesia

Dr.Akram Thabet

Local Anesthesia
Local, or regional, anesthesia involves the

injection or application of an anesthetic
drug to a specific area of the body. It

eliminates sensation and pain in a local
area of the body without loss of

consciousness.
Dr.Akram Thabet

According to the degree of CNS
depression:
◦ Conscious Sedation
◦ Deep Sedation
◦ General Anesthesia

Dr.Akram Thabet

Sedation


It is a technique where one or more drugs

are used to depress the Central Nervous
System of a patient thus reducing the

awareness of the patient to his surrounding.

Dr.Akram Thabet

Conscious Sedation


It

is

a

controlled,

pharmacologically

Induced, minimally depressed level of

consciousness that retains the patient’s
ability

to

maintain

independently

and

a

patent

continuously

airway

and

respond appropriately to physical and/or
verbal command.


ventilatory and cardiovascular functions are
unaffected
Dr.Akram Thabet

Deep Sedation
It is a controlled, pharmacologically induced state of

depressed level of consciousness , from which the
patient is not easily aroused and which may be
accompanied by a partial loss of protective reflexes,
including the ability to maintain a patent airway
independently and/or respond purposefully to

physical stimulation or verbal commands.
Dr.Akram Thabet

General Anesthesia


The

elimination

of

all

sensations

accompanied by the loss of consciousness.



Sometimes, the two phrases (GA & Deep
Sedation) refer to one physiologic state.

Dr.Akram Thabet

Dr.Akram Thabet

Risks of Anesthesia
high

Deep
Sedation

General
Anesthesia

Conscious
Sedation

Local
Anesthesia
Anxiolysis

low

N20

Dr.Akram Thabet

Fundamental Concepts:
 It is easy to drift from one state to another.
 Any anesthetic/sedative/opioid regardless of route
of administration can be a general anesthetic (can
cause unconsciousness)
 Patient state is considered in terms of the level of
consciousness rather than the technique involved.
 Sedation techniques
techniques.

are

not

pain-control

Dr.Akram Thabet

Indications:
1- Behaviorally challenged patients (stressful and fearful
patients).
2- Young children

3- Mentally retarded Patients
4- Major operations in oral and maxillofacial surgery

5- Stressful Procedure ( multiple 3 rd Molar
extractions, Interosseous implants ,complex periodontal
surgery)
6- Gagging reflexes
7- Local Anesthesia problems
8- Medically compromised patients Sedation and General Anesthesia
Dr.Akram Thabet

Routes of Administration:









Enteral – any technique of administration in which the agent is
absorbed through the gastrointestinal (GI) tract or oral mucosa
[i.e., oral, rectal, sublingual].
Parenteral – a technique of administration in which the drug
bypasses the gastrointestinal (GI) tract [i.e., intramuscular (IM),
intravenous (IV), intranasal (IN), submucosal (SM), subcutaneous
(SC), intraosseous (IO)].
Transdermal – a technique of administration in which the drug is
administered by patch or iontophoresis through skin.
Transmucosal – a technique of administration in which the drug is
administered across mucosa such as intranasal, sublingual, or
rectal.
Inhalation – a technique of administration in which a gaseous or
volatile agent is introduced into the lungs and whose primary
effect is due to absorption through the gas/blood interface.
Dr.Akram Thabet

Cons. Sedation



Minimally Depressed Consciousness

Deep Sedation
Deeply depressed consciousness

 Anxiolysis

 Sleeplike state

 Interactive

 Non-Interactive

 Arousable

 Non- arousable
(except with tense stimulation)

 Airway is maintained

 Inability to maintain airway

 Protective reflexes are intact

 Partial loss of reflexes

 Responses to command
are intact

 Difficult to respond to
command

Dr.Akram Thabet

Sedation techniques


Non - titrable Technique
Oral Sedation
Rectal Sedation
Intramuscular Sedation
Submucosal Sedation
Intranasal Sedation



Titrable Technique
Inhalational Sedation
Intravenous Sedation



Combination Of the two

Dr.Akram Thabet

I- Oral Sedation
By far, it is the most universally accepted and
easiest method of sedation administration.
 The most variable (non-titrable) technique
 Recovery time prolonged
 Difficult to reverse unwanted effect
 Utilizing escort
 No repeated doses
Dr.Akram Thabet

Advantages of Oral Sedation
Universal acceptability
 Ease of administration
 Low cost
 Incidence of adverse reactions less than
some other techniques
 No needles, syringes or special techniques
 Various drugs, dosage forms available
 Allergic reactions less severe than seen in
parenteral administration
 No specialized training


Dr.Akram Thabet

Disadvantages of oral Route


Reliance on patient cooperation



Prolonged onset



Erratic absorption, unpredictable effect



Inability to titrate to effect



Inability to readily lighten or deepen



Prolonged duration of effect



Adverse interactions of sedative drugs
Dr.Akram Thabet

Contraindications to oral Sedation


Severe dental anxiety & fear



High probability of adverse drug interaction



Poor past experience with oral sedation



Allergy to drug being used



Other

drug

contraindications

(pregnancy

, glaucoma, etc.)


Need for rapid onset and/or rapid recovery
Dr.Akram Thabet

Factors Influencing Oral Drug Absorption
 Lipid solubility
 pH of gastric tissues
 Mucosal surface area
 Gastric emptying time
 Dosage form of drug

 Drug inactivation (“first pass effect”)
 Presence of food in stomach
 Bioavailability of drug

 Genetics
Dr.Akram Thabet

II- Inhalational Sedation


Nitrous oxide/oxygen inhalation sedation is
the most commonly used technique in
dentistry for sedation .



Nitrous oxide/oxygen (N²O/O²) sedation is
a combination of these gases that the
patient inhales to help eliminate fear and
to help the patient relax.

Dr.Akram Thabet

Equipments


Continuous flow design

with flow meters


Safe delivery of O2 and

N2O.


Pin-indexed yoke system



Efficient scavenger
Dr.Akram Thabet

Nasal Mask

Dr.Akram Thabet

Advantages of Nitrous Oxide
Rapid onset (almost equal to that of IV. administration )
 Ability to titrate & to reverse
 Depth of sedation readily altered
 Flexible duration of action
 Rapid recovery from sedation
 Safe
 No injection required
 Very few side effects
 No adverse effects on vital organs
 Patient can be discharged alone
 Non addictive.
 Produces stage I anesthesia.
 Dulls the perception of pain.


Dr.Akram Thabet

Disadvantages of Nitrous Oxide


Initial cost of cumbersome equipment is high



Continuing costs of gases high



Equipment takes up operatory space



Requires constant patient cooperation



Chronic exposure of office personnel can cause
Carcinogenicity , Teratogenicity or Toxicity



Not always effective
Dr.Akram Thabet

Relative Contraindications to Inhalation
Sedation:











Severe dental anxiety & fear
Compulsive personalities
Poor past experience with oral sedation
Pregnancy
URI, COPD
Nasal obstruction: Problems inhaling through the
nose
Emphysema: Increased O²
Multiple sclerosis: Breathing difficulties
Emotional stability: Altered perception of reality
Dr.Akram Thabet

Potential Problems
 Diffusion hypoxia

 Vomiting
 Toxicity: inhibit vitamin B12 dependent
enzymes (Pernicious anemia)
Reproductive Abnormalities

Dr.Akram Thabet

Administration of Inhalation sedation
Start with pure oxygen while establishing the
patient’s tidal volume.
 Slowly titrate the nitrous oxide until the desired
results are achieved.
 Patients should refrain from talking or mouth
breathing.
 The N²O/O² analgesia should end with the
administration of 100% O² for 3 to 5 minutes.
 Obtain postoperative vital signs and compare
them to the preoperative recordings.


Dr.Akram Thabet

How to reduce N²O hazards to dental personnel ??

◦ Use a scavenger system.
◦ Use a patient mask that fits well.
◦ Discourage patients from talking.
◦ Vent gas outside the building.
◦ Routinely inspect equipment and hoses
for leaks.
◦ Use an N²O monitoring badge system.

Dr.Akram Thabet

III- Intravenous Sedation


Antianxiety drugs that are administered
intravenously continuously throughout the
procedure at a slower rate, providing a
deeper stage I analgesia.



The most rapid technique; onset
approximately 20 to 25 seconds.



In children under 6 years, the incidence of
untoward effects is increased
Dr.Akram Thabet

is

Drugs for sedations :


Either one drug or combinations of IV drugs



Commonest combinations
Benzodiazepines & opioids
Propofol & opioids

Dr.Akram Thabet

Valium (Diazepam)
Benzodiazepine
 Produces sleepiness and relief of apprehension
 Onset of action 1-5 minutes
 Half-life


◦ 30 hours
◦ Active metabolites


Average sedative dose
◦ 10-12 mg

Dr.Akram Thabet

Versed (Midazolam)


Short acting benzodiazepine
◦ 4 times more potent than Valium

Produces sleepiness and relief of apprehension
 Onset of action 3-5 minutes
 Half-life


◦ 1.2-12.3 hours


◦ 2.5-7.5 mg

Dr.Akram Thabet

Demerol (Meperidine)






Narcotic
Pain attenuation and some sedation
Onset of action
◦ 3-5 minutes
Half-life
◦ 30-45 minutes
Average dose
◦ 20-50 mg

Dr.Akram Thabet

Fentanyl (Sublimaze)


Narcotic/Opiod agonist
◦ 100 times more potent than Morphine

Pain attenuation and some sedation
 Onset of action around 1 minute
 Half-life


◦ 30-60 minutes


Average dose
◦ 0.05 – 0.06 mg

Dr.Akram Thabet

Additional Medications
 Likely

to be seen in scenarios where
deeper levels of sedation are being
performed
◦ Propofol (Diprivan)
◦ Robinul (Glycopyrrolate)

Dr.Akram Thabet

Propofol (Diprivan)
Intravenous anesthetic/sedative hypnotic
 Sedative, anesthetic and some antiemetic
properties
 Onset of action within 30 seconds
 Half-life


◦ 2-4 minutes


◦ Varies

Dr.Akram Thabet

Robinul (Glycopyrrolate)


Anticholinergic
◦ Heart rate increases
◦ Salivary secretions decrease

Dose 0.1-0.2 mg
 Onset of action within 1 minute


Dr.Akram Thabet

Stages of General Anesthesia
Stage I “Conscious Sedation”
◦ Analgesia
 Stage II
◦ Delirium
Stage III (“Deep Sedation/General Anesthesia)
◦ Surgical anesthesia
 Stage IV
◦ Medullary paralysis


Dr.Akram Thabet

Four Stages of Anesthesia:


Stage I: Analgesia is the stage at which a
patient is relaxed and fully conscious. The
patient is able to keep his or her mouth
open without assistance and is capable of
following directions. The patient will have
a sense of euphoria and a reduction in
pain. Vital signs are normal. Depending
on the agent used, the patient can move
into different levels of analgesia.
Dr.Akram Thabet

 Stage

II: Excitement is the stage at
which a patient is less aware of his or
her immediate surroundings and can
start to become unconscious. The
patient can become excited and
unmanageable. Nausea and vomiting
can occur. This is an undesirable stage.

Dr.Akram Thabet

 Stage

III:
This stage of General
anesthesia in which the patient
becomes calm after stage II. This is the
favorable stage for doing surgery. The
patient feels no pain or sensation. The
patient will become unconscious. This
stage of anesthesia can be met only
under
the
guidance
of
an
anesthesiologist
in
a
controlled
environment such as a hospital.
Dr.Akram Thabet

 Stage

IV: Respiratory failure or
cardiac arrest is the stage at which
the lungs and heart slow down or
stop functioning. If this stage is not
reversed quickly, the patient will
die.

Dr.Akram Thabet

Intubation in GA. For maintenance
of respiration :

Dr.Akram Thabet

Types of General Anesthetics


Induction agents( begins the anesthesia)
◦ Induction agents usually administered IV
◦ can be inhalational for those who do not
tolerate IV access



Maintenance
anaestheisa)

agents

(maintain

the

◦ Maintenance agents usually administered
inhalationally or IV with bolus or continuous
infusion technique
Dr.Akram Thabet

Routes for Delivery of General
Anesthetics


Intravenous (IV)



Inhalational

Dr.Akram Thabet

Structural formulas of anesthetic drugs.

Dr.Akram Thabet

General Anesthetics-Intravenous
Agents








Primary role as induction agents
Maintenance with total intravenous anesthesia
◦ Rapid redistribution
◦ Shorter half lives
◦ Environmental risk of inhalational agents
Rapid distribution to vessel rich tissues
High lipid solubility allows for rapid induction
When redistributed out of the brain, the effect decreases
Advantages
◦ Rapid and complete induction
◦ Less CV depression
Dr.Akram Thabet

General Anesthetics-Intravenous
Agents
The most commonly drugs used in GA:
1- Benzodiazepines
2- Opioids
3- Ketamine
4- Methohexital
5- Propofol


Dr.Akram Thabet

General Anesthetics-Inhalational
Agents
1- Nitrous Oxide
2- Sevoflurane
3- Desflurane
4- Isoflurane (Forane)
5- Halothane

Dr.Akram Thabet

Pre‐anesthetic Evaluation


“Never treat a stranger”



Never do anesthesia on a patient you have
not previously evaluated.



Never sedate or aesthesis on first patient visit



Always have a consultation first!

Dr.Akram Thabet

Pre‐anesthetic Examination










Physical examination
Evaluation of anxiety level
Review of medical history
Review medications and drug allergies
Assign ASA classification
Review prior sedation / anesthetic history
Obtain informed consent
Give pre‐sedation/ anesthesia instructions
Dr.Akram Thabet

Medical history

Diseases to evaluate:
HTN;, asthma, COPD, URI, DM
 Pregnancy; psychiatric renal; hepatic problems
 Obesity; sleep apnea; etc
 Medications
 Prior anesthetic experience
 Allergies
 Hospitalizations


Dr.Akram Thabet

Physical Examination
Vital signs
 Appearance
 Height, Weight, & BMI (Body Mass Index)
 Mental & psychological status
 Cardiac & pulmonary level ;
 Exercise tolerance (“if they can walk up 2
flights of stairs to your office, they’re
probably ok for anesthesia”)
 Airway evaluation


Dr.Akram Thabet

Airway Evaluation







BMI (Body Mass Index)
History of obstructive sleep apnea, snoring
Mallampati score
Protrusive (ask: “bite your upper lip with your
lower teeth”)
TMJ range of motion (oral opening)
Neck circumference

Dr.Akram Thabet

Airway patency

Dr.Akram Thabet

ASA Physical Classification


IA

normal healthy patient



II A

patient with mild systemic disease



III A patient with severe systemic



IVA

patient

with

severe

systemic

disease that is a constant threat to life


VA

moribund patient who is not expected

to survive without the operation
Dr.Akram Thabet

Pre-Procedure Patient Assessment
◦
◦
◦
◦
◦
◦
◦
◦
◦
◦
◦

Investigations :
ECG, echo
Chest – x-ray
CBC
BT,CT ,PT T, PT ,INR
Na , k
R.B.S or F.B.S
LFT
KFT
HBs-Ag
HIV

Dr.Akram Thabet

Medical Consultations
 After

doing

the medical and physical

examination with the full investigations;
the patient should be evaluated by a

medical doctor or anesthetist to do a
medical fitness for him to receive the

anesthesia.
Dr.Akram Thabet

Informed Consent







It’s a process, not a piece of paper.
Verbal and written informed consent must be given at the
pre‐op consultation appointment, not the day of surgery
Cannot be obtained once medications are administered.
New written consent must be obtained for each procedure
or sedation.
Consent to surgery does not imply consent for sedation;
sedation needs to be specified.
Consent must be obtained by the doctor in face‐to‐face
meeting, not a staff member.

Dr.Akram Thabet

Pre‐Sedation/anesthetic Instructions


Give both verbally and in writing



Fasting (“NPO”) instructions (if needed)



“Vested” escort to accompany patient
Patient’s other medications



Dr.Akram Thabet

Pre‐Procedure Fasting (“NPO”)


The patient must be fasted minimum 2-3

hours for clear liquids and 6 hours for
solid food to prevent vomiting causing
Suffocation and aspiration pneumonia.

Dr.Akram Thabet

Psychological preparation


Psychological preparation of the patient for the sedation or
GA is paramount.



Explain the different types of sedation available and GA
techniques



Tell them they will be “relaxed, drowsy, comfortable,” and
“aware and in control.”



Give realistic expectations to patient and explain that every

patient reacts differently, and they may need more / less
medication or different technique at future appointments.
Dr.Akram Thabet

Intraoperative Responsibilities
◦ Informed consent signed prior to sedation
◦ Name, dose, route and time of all medications
documented
◦ Procedure begin and end times
◦ Prior adverse reactions
◦ Pre-medication time and effect
◦ Vital Signs
 BP
 Heart Rate
 Respiratory Rate
 Oxygen Saturation
 Level of Consciousness
Dr.Akram Thabet

Monitoring
Level Of Consciousness
 Clinical Observation
 Pulse Oximetry
 Pericardial/pretracheal Stethoscope
 BP
 ECG
 Monitoring oxygenation


Dr.Akram Thabet

Recovery


Patients may continue to be at significant risk of
developing complications after procedure is
completed.



Decreased procedural stimulation, delayed drug
absorption, and slow drug elimination, may
contribute
to
residual
anesthesia
or
sedation and respiratory depression during the
recovery period.



Patient must be kept in office under observation
until completely recovered.
Dr.Akram Thabet

Post-operative Responsibilities
◦ Vital Signs at least every 5 minutes








BP
Heart Rate
Respiratory Rate
Oxygen Saturation
Level of Consciousness

Sedated/ Anesthetized patients must be
continuously monitored until discharged

Dr.Akram Thabet

Recommended Alarm Limits
Low

High

Systolic BP

85

150

Diastolic BP

50

100

Oxygen Saturation

92

100

Respiratory Rate

10

16

Heart Rate

60

90

Dr.Akram Thabet

Medical Emergency
 Syncope

 Laryngospasm

 Hypoglycemia

 Apnea

 Hypotension

 Myocardial infarction

 Hypertension

 Stroke

 Bronchospasm

Dr.Akram Thabet

Medical Emergency


Know how to prevent, recognize, and treat

syncope (fainting)
◦ Supplemental O2
◦ Elevation of lower extremities
◦ Trendelenburg


Be prepared to assist in airway management
Dr.Akram Thabet

Emergency Drugs
Flumazenil (Romazicon)
 Naloxone (Narcan)
 Esmolol (Brevibloc)
 Ephedrine
 Epinephrine
 Atropine


Dr.Akram Thabet

Flumazenil (Romazicon)


Benzodiazepine antagonist
◦ Versed reversal agent



Initial dose – 0.2mg
◦ May repeat at 1 minute intervals to dose of
1mg

Onset of action within 1-2 minutes
 Must monitor for re-sedation


◦ May be repeated at 20 minute intervals as
needed
Dr.Akram Thabet

Naloxone (Narcan)


Narcotic antagonist
◦ Fentanyl reversal agent



Initial dose – 0.4mg
◦ May repeat every 2-3 minutes at doses of
0.4-2mg



Monitor for re-sedation
Dr.Akram Thabet

Esmolol (Brevibloc)


Antihypertensive



Beta blocker



Initial dose 0.25 –1.0 mg/kg over 30
seconds
◦ Short half-life of approximately 10 minutes

Dr.Akram Thabet

Ephedrine


Used for hypotension



Sympathomimetic



Initial dose 5-10mg



Action may not be seen for several
minutes

Dr.Akram Thabet

Atropine


Significant bradycardia
◦ Slow heart beat or NO heartbeat



Anticholinergic



Initial dose 0.25 – 1.0 mg
◦ May repeat every 3-5 minutes

◦ Maximum total dose .03 mg/kg
Dr.Akram Thabet

Epinephrine


True emergency medication



Administration should be preceded by
activation of the emergency response

system

Dr.Akram Thabet

Discharge Criteria
Vital signs normal (within 20% baseline)
 Airway patency uncompromised
 Patient awake, or awake on command
 Can breathe deeply
 Protective reflexes intact (can cough on command)
 Adequate hydration, able to drink
 Patient can speak normally
 Patient can sit unaided
 Patient can walk with minimal assistance
 Responsible, “vested,” adult escort is available
 No pain, no nausea or vomiting,


Dr.Akram Thabet

Post‐sedation Instructions
Verbal and written instructions must be given to
the escort upon discharge from the office
 Should include:
– Potential and anticipated post‐sedation effects
–Limitation of activity (driving, machinery) x 24 hrs
– Dietary precautions and suggestions
– No other sedatives x 24 hrs
– 24 hour contact number for practitioner


Dr.Akram Thabet

Thank You

Dr.Akram Thabet

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