Dental Sedation Techniques Overview

Sedation

• Sedation is a technique used in dental procedures to manage patients
• Local anesthesia is used for most dental procedures
• Sedation is needed for uncooperative children, adults with dental phobia and medically compromised patients (e.g., cardiovascular disease, asthma).
• General anesthesia is for patients meeting ASA I & II criteria
• Pioneers include Langa (nitrous oxide) and Jorgenson (IV agents)
• Sedation techniques range from full consciousness to deep sedation

Intravenous Sedation

• Intravenous sedation uses IV medications for sedation
• Different levels of sedation have different effects on airway and response

Introduction

• Local anesthesia is the standard approach for most dental procedures
• Sedation is necessary for uncooperative patients, dental phobias, or medical conditions (e.g., cardiovascular disease, asthma)
• General anesthesia is an option for patients meeting ASA I & II criteria.
• Pioneers in sedation techniques include Langa (nitrous oxide) and Jorgenson (IV agents)
• Varying techniques range from full consciousness to deep sedation

Levels of Sedation

• Conscious Sedation: Minimally depressed consciousness; patient maintains airway and responds to commands.
• Minimal Sedation: Slightly depressed consciousness; retains airway and normal response to touch and verbal cues.
• Moderate Sedation: Drug-induced depression; purposeful responses to commands; airway maintenance is unnecessary.
• Deep Sedation: Significant depression; may not easily arouse; requires assistance for airway maintenance.
• General Anesthesia: Complete loss of consciousness; not arousable; requires assistance for airway and ventilation.

Methods of IV Drug Administration

• Direct IV Administration: No vein patency maintenance; drug injected directly into the vein (after aspiration). Tourniquet used to manage the procedure.
• Needle Maintained in the Vein: Needle remains in place without continuous infusion with periodic flushing to maintain patency
• Continuous IV Infusion: Indwelling needle/catheter connected to IV solution; continuous flow to prevent occlusion during treatment.

Techniques of Intravenous Sedation

• Advantages: Highly effective, smooth induction, rapid onset, possible titration, safe patent vein, less nausea and vomiting, gag reflex diminished and diminished motor disturbances.
• Disadvantages: Need for venipuncture, possible complications (infiltration, hematoma, thrombophlebitis), more intense monitoring, possible delayed recovery and need for escort

Drugs Commonly Available

• Sedative, Hypnotics, and Antianxiety Drugs: Diazepam, Midazolam.
• Nonbarbiturate Hypnotics: Thiopentone, Methohexitone, Propofol, Ketamine, Etomidate
• Antihistaminics: Promethazine
• Narcotic Agonists: Pethidine, Pentazocine, Fentanyl

Techniques of Intravenous Midazolam Sedation

• Advantages: Short-acting, potent, excellent anxiolytic and anterograde amnesic effects.
• Dosage: 0.03-0.05 mg/kg (useful sedation for ~45 minutes)
• Monitoring & Safety: Essential monitoring, pulse oximetry for oxygen saturation, administering oxygen (1-2 LPM) via nasal cannulae and post-procedure care (discharge criteria met, patient accompanied home; use of Flumazenil for benzodiazepine overdose)
• Caution: Careful titration; maintain verbal contact with patient

Propofol

• Recent Advancements: Latest agent in clinical practice; used for induction and maintenance of anesthesia, and sedation for short dental procedures
• Key Benefits: Titration possible; rapid recovery; amnesia (at higher infusion rates).
• Comparison: Faster onset/offset than midazolam; effective antiemetic properties at low doses.
• Ideal Settings: Day care settings; minimizes hangover effects, allows for quick patient turnover.

Ketamine Hydrochloride

• What is it? Phencyclidine derivative, non-barbiturate hypnotic; produces dissociative anesthesia.
• Effects: Sedation, amnesia, intense analgesia
• High Safety Margin: Good tissue compatibility, minimal vein irritation.
• Ideal for Dentistry: Maintains airway patency, tongue muscle tension, and mechanical airway management (excess salivation, operator pressure).
• Clinical Considerations: Increases heart rate/blood pressure; manage with benzodiazepines (midazolam). Avoid in hypertension and ischemic heart conditions.
• Side Effects: Transient respiratory depression, increased intracranial/intraocular pressure, nausea and vomiting.
• Management Strategies: Use low dosages for sedation/analgesia (0.1-0.5 mg/kg IV); consider continuous infusion (10-20 μg/kg/min); and premedication for emergence reactions (vivid dreams, hallucinations).

Propofol and Ketamine Combination

• Combination Benefits: Titrable sedation, intense analgesia, increased hemodynamic stability.
• Reduced Risks: Less respiratory depression, low incidence of psychomimetic effects.
• Dosage Guidelines: Ketamine (10-30 µg/kg/h), Propofol (0.5-1.5 mg/kg/h)

Fentanyl

• Advantages: Short duration of action (30-45 minutes), hemodynamic stability.
• Considerations (at higher doses): Potential: bradycardia, respiratory depression, nausea and vomiting, and muscle rigidity
• Sedation Protocol: Administer IV at 1-2 µg/kg; can be combined with sedatives/hypnotics (midazolam, Methohexitone, Propofol).

Neurolept Analgesia

• Definition: State of indifference and immobilization; patient pain-free, deeply sedated, partially/wholly amnesic, and capable of simple commands and questions.
• Composition: Innovar (combination of Droperidol and Fentanyl). Droperidol is a tranquilizer, potent antiemetic (6 hours); Fentanyl is a narcotic (limited action, 45 minutes)
• Limitations: Not suitable for outpatient dental practice; discouraged in modern anesthesia practices

Pethidine and Promethazine Combination

• Composition: Pethidine (Narcotic 50mg), Promethazine (Antihistamine 25mg); 5 mg/mL of pethidine & 2.5 mg/mL of promethazine.
• Administration: Dosage 1-2mL IV until sedation achieved.
• Sedation Duration: 60-90 minutes.
• Post-Procedure: Patient remains drowsy for several hours (delayed recovery)
• Relevance: Abandoned technique; replaced by easily titratable, shorter-acting alternatives

Antidotal Drugs

• Importance: Essential for reversing adverse effects of sedative drugs.
• Categories: Opioid antagonists (Naloxone), Benzodiazepine antagonists (Flumazenil), Emergence delirium reversal agents (Physostigmine), Vasodilators (Procaine).
• Emergency Kit Requirement: Each category should be represented

Complications

• Venipuncture complications: Nonrunning IV infusion, venospasm, hematoma, infiltration, local venous complications, air embolism, overhydration.
• Local Complications of Drug Administration: Extravascular drug administration, intraarterial injection, local venous complications
• General Drug-Related Complications: Nausea and vomiting, localized allergy, respiratory depression, emergence delirium, laryngospasm

Specific Drug Complications

Thank You

This quiz covers important aspects of sedation techniques in dentistry. It discusses the use of local anesthesia, intravenous sedation, and general anesthesia for different patient needs. It also highlights pioneers in sedation methods and how to manage uncooperative patients effectively.