Sedation Techniques in Dentistry

Sedation

• Sedation is used for various dental procedures.
• Local anesthesia is the usual approach for most dental procedures.
• Sedation is necessary for children and adults with dental phobias, medically compromised patients (e.g., cardiovascular disease, asthma), and patients with fainting attacks or gagging issues.
• General anesthesia is only appropriate for patients meeting ASA I & II criteria.
• Early pioneers in sedation include Langa (nitrous oxide) and Jorgenson (IV agents).
• Sedation techniques range from full consciousness to deep sedation.

Intravenous Sedation

• Intravenous sedation uses IV medications.
• Sedation levels vary from minimally depressed consciousness to complete loss of consciousness.
• Maintaining an independent airway and patient responsiveness are crucial.
• Monitoring cognitive function, ventilation, hemodynamic stability, and airway support is necessary.
• Intravenous sedation requires careful monitoring of vital signs.
• Possible complications include venipuncture complications (infiltration, hematoma, thrombophlebitis), delayed recovery, and needing an escort.
• IV sedation is not for untrained individuals.

Methods of IV Drug Administration

• Direct IV Administration: No vein patency maintenance; drug injected directly into the vein after aspiration with a tourniquet applied, needle insertion, drug administration and site pressure.
• Needle Maintained in the Vein: Needle remains in place without continuous infusion; periodic flushing to maintain patency; engorge veins, insert needle, attach syringe, and flush periodically.
• Continuous IV Infusion: Indwelling needle/catheter connected to IV solution; continuous flow prevents occlusion during treatment; standard venipuncture with secure catheter/tubing, and flow adjustment for consistency.

Techniques of Sedation: Intravenous Sedation

• Advantages: Highly effective, smooth induction, rapid onset of action, titration is possible, patent vein offers safety, less nausea and vomiting, diminished gag reflex and motor disturbances.
• Disadvantages: Venipuncture necessary, possible venipuncture complications, more intensive monitoring needed, chances of delayed recovery, and needing an escort.
• IV sedation should only be administered by trained personnel.

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 Sedation: Intravenous Sedation - Midazolam

• Advantages: Short-acting and potent, excellent anxiolytic properties, powerful anterograde amnesic effect.
• Dosage: 0.03-0.05 mg/kg (useful sedation for ~45 mins)
• Monitoring & Safety: Essential Monitoring (pulse oximetry for oxygen saturation, administering oxygen (1–2 LPM) via nasal cannulae), Post-Procedure Care (discharge criteria met, patient accompanied home, use of Flumazenil for benzodiazepine overdose) and caution (tittration and verbal patient contact required).

Propofol

• Recent Advancements: Latest agent in clinical practice for anesthesia and sedation; ideal for induction and maintenance of anesthesia, and sedation/short dental procedures.
• Key Benefits: Titration, rapid recovery (5–10 mins post-infusion), amnesia (at infusion rates >30 µg/kg/min).
• Comparison: Faster onset/offset than midazolam, effective antiemetic properties at low doses.
• Ideal for Day Care Settings: Minimizes hangover effects, allowing for quick patient turnover.

Ketamine Hydrochloride

• What is Ketamine?: Phencyclidine derivative and 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 muscles remain tense), airway obstruction typically mechanical (excess salivation, operator pressure).
• Clinical Considerations: Increases heart rate and blood pressure (manage with benzodiazepines); avoid in hypertension/ischemic heart disease patients.
• Side Effects: Transient respiratory depression, increased intracranial/intraocular pressure, nausea & vomiting.
• Management Strategies: Use low doses (0.1-0.5 mg/kg IV), consider continuous infusion (10–20 μg/kg/min) to mitigate side effects, premedication (vivid dreams, hallucinations).

Propofol and Ketamine: Combination

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

Fentanyl: Ideal Narcotic for Dental Practice

• Advantages: Short duration of action (30-45 minutes), hemodynamic stability (does not cause hypotension).
• Considerations: Potential side effects (bradycardia, respiratory depression, nausea & vomiting, muscle rigidity) at higher doses.
• Sedation Protocol: Administer IV at 1-2 µg/kg; can be combined with sedatives/hypnotics (midazolam, Methohexitone, Propofol).

Neurolept Analgesia

• Definition: A state of indifference and immobilization with analgesia, deep sedation, and potential amnesia, while maintaining responsiveness to commands.
• Composition: Produced by the agent Innovar: Droperidol (tranquilizer, powerful antiemetic, up to 6 hours), Fentanyl (narcotic, limited action, max 45 minutes).
• Limitations: Not suitable for outpatient dental practice; use discouraged.

Pethidine and Promethazine Combination

• Composition: Pethidine (narcotic, 50 mg), Promethazine (antihistamine, 25 mg), diluted to 5 mg/mL and 2.5 mg/mL, respectively.
• Administration: 1-2 mL IV until adequate sedation is achieved.
• Sedation Duration: 60-90 minutes, post-procedure drowsiness, delayed recovery.
• Current Relevance: Abandoned due to easier titratable, shorter-acting alternatives.

Antidotal Drugs

• Importance: Essential for reversing adverse effects of sedatives.
• Categories:
• Opioid Antagonists - Naloxone
• Benzodiazepine Antagonists - Flumazenil
• Emergence Delirium Reversal Agents - Physostigmine
• Vasodilators (for extravascular/intra-arterial administration) - Procaine
• Emergency Kit Requirement: Each category represented in the emergency kit for doctors administering sedation.

Complications

• Venipuncture Complications: Non-running IV infusion, venospasm, hematoma, infiltration, local venous complications, air embolism, and overhydration.
• Local Complications of Drug Administration: Extravascular drug administration, intraarterial injection, local venous complications.
• General Drug-Related Complications: Nausea, vomiting, localized allergy, respiratory depression, emergence delirium, laryngospasm.
• Specific Drug Complications in more detail are presented by drug category.

This quiz explores the various techniques and applications of sedation in dental procedures. You will learn about local and intravenous sedation, the importance of monitoring, and the criteria for choosing appropriate anesthetic methods. Additionally, the quiz covers the historical context and pioneers of sedation.