Sedation in the Dental Office Pamela J Hughes, DDS Assistant Professor and Graduate Program Director; Division of Oral and Maxillofacial Surgery Objectives 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 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?) Levels of anesthesia Analgesia Local (regional) anesthesia Anxiolysis Moderate Sedation (aka conscious sedation) Deep sedation General anesthesia Analgesia: The diminution or elimination of pain in the conscious patient How is this accomplished? Local anesthesia: The elimination of sensations, especially pain, in one part of the body by the application or regional injection of an anesthetic agent 1
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 In the dental setting, this is usually achieved with nitrous oxide or oral premedication e.g.: Valium 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 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 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 2
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 3
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 Oral sedation Common drugs used Halcion (triazolam) Valium (diazepam) Ativan (lorazepam) Versed (midazolam) chloral hydrate Routes of administration: intramuscular Advantages of IM sedation No IV access required More rapid onset of action than oral administration More reliable absorption than oral administration IM administration Disadvantages of Intramuscular sedation Not titratable; overdose 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 Intravenous administration 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 4
Intravenous sedation Disadvantages Monitoring needed IV access needed Pre-op fasting required Operator/assistant training required Intravenous sedation Common Drugs used for IV sedation (moderate and deep) Versed (midazolam) Fentanyl Ketamine Propofol Methohexital common side effects of sedative agents CNS depression Respiratory depression/arrest Nausea Disphoria/dreaming Cardiovascular effects Drug interactions Amnesia 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 5
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 6
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 System evaluation Cardiovascular system Pulmonary system Renal system Hepatic system Endocrine system Case #1 65 yo woman with Hypertension controlled with atenolol Blood pressure today is 128/84 pulse is 70 Type II diabetes controlled with diet Last Hgb A1c = 6 Case #1 What is the patients ASA classification? Is she a candidate for office moderate sedation? 7
Case #2 57 yo man Hypertension Angina Diabetes (type I) Renal failure Dialysis three time a week Case #2 cont Meds Atenolol Lisinopril Hydrochlorothiazide Nepho caps Insulin Regular and ultralente Nitroglycerin as needed What else might you want to know about this patient? Case #2 cont 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) Do you think this patient s medical conditions are under good control? What is his ASA classification? Is he a candidate for office sedation? 8