Sedation in Dental Practice -- Presented as a part of weekly presentation in Dhaka Dental College;OMS Department; Dhaka; Bangladesh

1. Sedation in Dental Practice
DR. TSHEWANG GYELTSHEN_49DDCH_2017

2. Overview
 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
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3. Sedation: 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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4. Types 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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5. Conscious 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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6. Sedative 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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7. Indications 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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8. American Society of Anesthesiologists
[ASA-Physical Health Status]
Class I – A normal healthy Patient
Class II – A patient with mild systemic disease
Class III – A patient with severe systemic disease
Class IV – A patient with severe systemic disease
that is a constant threat to life.
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9. ASA-Physical Health Status
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10. Contraindications
 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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11. Characteristics 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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12. Risks 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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13. Conscious 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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14. Pre – 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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15. Physical 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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16. Patient 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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17. Pre-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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18. Sedation 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.TG_DDCH2017_Oral Sedation
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19. Suggested Dosage for Oral Sedation
Minimal Sedation Moderate Sedation
Appointment 2 hours or less
• triazolam 0.125-0.25 mg
Appointment 2 hours or less
• triazolam 0.375-0.50 mg
Appointment longer than 2 hours
• triazolam 0.25 mg
or
• diazepam 10-15 mg
or
• temazepam 15 mg
or
• 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 mgTG_DDCH2017_Oral Sedation
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20. Advantages 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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21. Advantages and Disadvantages of Oral
Sedation
Advantages Disadvantages
Easily 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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22. Patient 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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23. Patient 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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24. Video of Sedation: IV Method
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25. Sedation: Inhalational Method
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26. Reference 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
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