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  1. 1. General Anesthesia andSedation In DentistryIyad Abou RabiiDDS. OMS. MSc. PhD
  2. 2. General Anesthesia Dr. William Morton, a Massachusetts dentist, was looking for a way to painlessly extract teeth. There was no local or general anesthesia available to make removing teeth tolerable. Although Dr. Morton knew about nitrous oxide from his association with another dentist, Dr. Horace Wells, he wanted a more powerful agent. He discussed the problem with Dr. Charles T. Jackson, a physician and scientist who suggested that he try ether.
  3. 3. General Anesthesia Anxiety and pain can be modified by both psychological and pharmacological techniques. In some instances, psychological approaches are sufficient. However, in many instances, pharmacological approaches are required.
  4. 4. Local and General Anesthesia Local anesthetics are used to control regional pain. Sedative drugs and techniques may control fear and anxiety, but do not by themselves fully control pain and, thus, are commonly used in conjunction with local anesthetics. General anesthesia provides complete relief from both anxiety and pain.
  5. 5. General Anesthesia The use of sedation and general anesthesia in dentistry is safe and effective when properly administered by trained individuals. General anesthesia (GA) is when you are totally unconscious. In this state, you cant feel any pain, even without local anesthesia.
  6. 6. General Anesthesia In General anesthesia patient cant reliably breathe on his own, so for more complex procedures (such as fillings - these are actually more complex than extractions under GA!) and procedures of longer duration you need to having a "breathing tube" inserted.
  7. 7. Minimizing the Risk Dentists who are qualified to utilize sedation and general anesthesia have a responsibility to minimize risk to patients undergoing dental treatment by: Using only those drugs and techniques in which they have been appropriately trained; Limiting use of these modalities to patients who require them; Conducting a preoperative evaluation of each patient consisting of at least a thorough review of medical and dental history, a focused clinical examination and consultation, when indicated, with appropriate medical and dental personnel;
  8. 8. Minimizing the Risk Conducting physiologic and visual monitoring of the patient; Having available appropriate emergency drugs, equipment and facilities and maintaining competency in their use; Maintaining fully documented records of drugs used, dosage, vital signs monitored, adverse reactions, recovery from the anesthetic, and, if applicable, emergency procedures employed; Utilizing sufficient support personnel who are properly trained for the functions they are assigned to perform; Treating high-risk patients in a setting equipped to provide for their care.
  9. 9. Minimizing the Risk Throughout the IV Sedation procedure, patient`s pulse and oxygen levels are measured using a "pulse oximeter". This gadget clips onto a finger or an earlobe and measures pulse and oxygen saturation. It gives a useful early warning sign if youre getting dangerously low on oxygen  unresponsiveness  slow breathing. Blood pressure before and after the IV Sedation procedure should be checked
  10. 10. IV Sedation In contrast, what is usually called "IV sedation” in dentistry is conscious sedation. Conscious sedation is a minimally depressed level of consciousness during which the patient is able to breathe independently and/or respond purposely to verbal command.
  11. 11. IV Sedation When a drug, usually of the anti-anxiety variety, is administered into the blood system during dental treatment, this is referred to as Intravenous Conscious Sedation. Conscious sedation is sometimes (incorrectly) referred to as "twilight sleep" or "sleep dentistry".
  12. 12. IV Sedation The drugs which are usually used for IV sedation are not painkillers (although some pain-killing drugs are occasionally added), but anti-anxiety drugs. While they relax you and make patient forget what happens, he will still need to be numbed
  13. 13. IV Sedation: Drugs used Anti-anxiety sedatives ("benzos"): Midazolam and Diazepam  For procedures up to about 1 1/2 hours  IV administered benzos have 3 main effects: they reduce anxiety/relax patient, they make him sleepy, and they produce partial or total. Total amnesia is more common with midazolam compared to diazepam  The Venflon is the reversal agent for benzos (Flumazenil)
  14. 14. IV Sedation: Drugs used Barbiturates(sleep-inducing drugs)  For procedures more than 2 hours  The only barbiturate which is still occasionally used is called Pentobarbital Sodium (tradename: Nembutal).  In the absence of a trained anesthesiologist, barbiturates are pretty dangerous to use, for a number of reasons: its very easy to have the patient slip into general anaesthesia by mistake, where breathing and heart rate are dangerously lowered and coma and death can follow. And theres no reversal agent.
  15. 15. IV Sedation: Drugs used Opioids  can be used as an add-on to either benzos (for procedures up to about 1 1/2 hours) or barbiturates (for procedures longer than 2 hours).  Opioids are always used in the so-called Jorgensen technique (which in its basic form involves pentobarbital, an opioid, and an anticholinergic) sometimes used in the US for procedures taking 2 hours or more.
  16. 16. IV Sedation: Drugs used Opioids  can be used as an add-on to either benzos (for procedures up to about 1 1/2 hours) or barbiturates (for procedures longer than 2 hours).  Opioids are always used in the so-called Jorgensen technique (which in its basic form involves pentobarbital, an opioid, and an anticholinergic) sometimes used in the US for procedures taking 2 hours or more.
  17. 17. IV Sedation: Drugs used Opioids  Opioids which may be used for IV sedation include:  Meperidine (Demerol)  Morphine  Butorphanol (Stadol)  Nalbuphine (Nubain)  Fentanyl (Sublimaze)  Pentazocine (Talwin)
  18. 18. IV Sedation: Drugs used Propofol Some anaesthetists use Propofol instead of benzos. The advantage of this is the very rapid recovery time, less than 5 mins. The disadvantage is the drug must be continuously administered, so the drug is pumped in using an electric infusion pump, the dose rate is set by the anaesthetist.
  19. 19. IV Sedation: Caution and Contraindication IV sedation is EXTREMELY safe when carried out under the supervision of a specially-trained dentist. Purely statistically speaking, its even safer than local anaesthetic on its own!
  20. 20. IV Sedation: Caution and Contraindication However,  contraindications include pregnancy, known allergy to benzos, alcohol intoxication, CNS depression, and some instances of glaucoma.  Cautions include psychosis, impaired lung or kidney or liver function, and advanced age. Heart disease is generally not a contraindication.
  21. 21. Oral Sedation Most commonly, oral sedation (usually in the form of anti-anxiety or "happy pills") is prescribed for relieving anxiety in the hours immediately before a dental appointment. An anti-anxiety or sedative-hypnotic drug taken the night before the appointment, an hour before going to bed, can help with falling asleep and getting some rest.
  22. 22. Oral Sedation Anti-Anxiety Pills (Benzodiazepines or "Benzos") In dentistry, the most commonly prescribed drugs for (or rather against =)) anxiety belong to the "benzodiazepine" family. Youve probably heard of them by their tradenames - for example, Valium, Halcion, Xanax, or Ativan. Benzos directly and efficiently decrease anxiety by binding with receptors in the brain which tone down activity in those parts of the brain responsible for fear. Benzodiazepines come in two flavours:  Sedative-Hypnotics: drugs which induce a calming effect, including drowsiness ("sedation"). In higher doses, they induce a state resembling physiological sleep ("hypnosis").  Anti-Anxiety Drugs: drugs which act primarily to relieve anxiety and make you feel calm.
  23. 23. Oral Sedation Anti-Anxiety Pills (Benzodiazepines or "Benzos”) While all benzodiazepines act as sedatives AND anti-anxiety drugs, some are more targeted at brain areas which control sleep and wakefulness, while others are more specifically targeted at brain areas which control emotions such as fear.
  24. 24. Oral Sedation Anti-Anxiety Pills (Benzodiazepines or "Benzos”)  The classification of whether a benzodiazepine is sedative-hypnotic or anti-anxiety is to some extent an arbitrary one, as the boundaries are quite fluid. As a rule of thumb, in higher doses benzos act like sedatives and may promote sleep, while in lower doses, they simply reduce anxiety without sedation.
  25. 25. Oral Sedation To do? List Benzodiazepines according to their sedative or Anti-Anxiety effects
  26. 26. Oral Sedation Non-benzodiazepine hypnotic anti-anxiety drugs - Ambien and Sonata  Ambien (thats the tradename for zolpidem tartrate) is a strong sedative with only mild anxiety-reducing properties.  Usual dose: 10 mg one hour before bedtime.
  27. 27. Oral Sedation "Sleeping pills" (Barbiturates)  Only the short-acting barbiturates, pentobarbital sodium (tradename: Nembutal) and secobarbital sodium (tradename: Seconal) are occasionally used in dentistry. The average recommended dose for adults is 100 mg one hour before the scheduled appointment for Nembutal, and 100-200 mg one hour before the appointment for Seconal.
  28. 28. Oral Sedation Antihistamines - Atarax and Phenergan  While antihistamines are primarily used to manage allergies, several of them have an interesting side effect: sedation! Some antihistamines, including Atarax and Phenergan, have a strong calming and sleep-inducing effect, and are marketed primarily as sedative-hypnotics. They also help to prevent nausea and being sick.
  29. 29. Oral Sedation Antihistamines - Atarax and Phenergan  While antihistamines are primarily used to manage allergies, several of them have an interesting side effect: sedation! Some antihistamines, including Atarax and Phenergan, have a strong calming and sleep-inducing effect, and are marketed primarily as sedative-hypnotics. They also help to prevent nausea and being sick.
  30. 30. Nitrous Oxide
  31. 31. Nitrous Oxide Nitrous oxide gas, often referred to as laughing gas or sweet air, is an effective anesthetic drug that has many benefits for patients seeking dental treatment. The benefits of nitrous oxide are many, and the risks are few. The gas is administered with a comfortable mask placed over the nose, and the patient is instructed to breathe in through the nose and out through their mouth.
  32. 32. Nitrous Oxide Nitrous oxide gas, often referred to as laughing gas or sweet air, is an effective anesthetic drug that has many benefits for patients seeking dental treatment. The benefits of nitrous oxide are many, and the risks are few. The gas is administered with a comfortable mask placed over the nose, and the patient is instructed to breathe in through the nose and out through their mouth.
  33. 33. Nitrous Oxide As a precaution, patients should not eat anything for about two hours prior to use of the gas. The patient begins to feel a pleasant level of sedation anywhere from 30 seconds to three or four minutes. The cheeks and gums will also begin to feel numb in about a third of the patients.
  34. 34. Nitrous Oxide After the gas is adjusted to the appropriate dose and the patient is relaxed and sedated, the dentist can comfortably give the injection (if needed) to the patient, and then proceed with dental treatment.
  35. 35. Nitrous Oxide After the treatment is completed, the patient is given pure oxygen to breathe for about five minutes, and all the effects of sedation are usually reversed. Unlike IV sedation or general anesthesia, the patient can almost always leave the office by themselves, without an escort.
  36. 36. Nitrous Oxide Nitrous oxide has few side effects. High doses can cause nausea in some patients, and about 10 percent of patients do not benefit from it. Patients that are claustrophobic or have blocked nasal passages cannot use nitrous oxide effectively.
  37. 37. Nitrous Oxide Nitrous oxide has few side effects. Nitrous oxide is one of the safest anesthetics available. Interestingly, it is also routinely used by anesthesiologists for general anesthesia in combination with other more potent gases.
  38. 38. Nitrous Oxide Dentists find nitrous oxide especially useful for fearful patients as well as young children. The effect of nitrous oxide is often remarkable. A patient that was anxious just a minute or two before treatment will become relaxed and calm. Because nitrous oxide is so effective, dentists rarely need to prescribe Valium for anxious patients before treatment.
  39. 39. Nitrous oxide Technique of Nitrous Oxide/Oxygen Administration  Nitrous oxide/oxygen must be administered only by appropriately licensed individuals, or under the direct supervision thereof, according to state law.  The practitioner responsible for the treatment of the patient and/or the administration of analgesic/anxiolytic agents must be trained in the use of such agents and techniques and appropriate emergency response.
  40. 40. Nitrous oxide Selection of an appropriately-sized nasal hood should be made. A flow rate of 5 to 6 liters/minute generally is acceptable to most patients. The flow rate can be adjusted after observation of the reservoir bag.
  41. 41. Nitrous oxide The bag should pulsate gently with each breath and should not be either over- or underinflated. Introduction of 100% oxygen for 1 to 2 minutes followed by titration of nitrous oxide in 10% intervals is recommended. During nitrous oxide/oxygen analgesia/anxiolysis, the concentration of nitrous oxide should not routinely exceed 50%.
  42. 42. Nitrous oxide Nitrous oxide concentration may be decreased during easier procedures (e.g., restorations) and increased during more stimulating ones (e.g., extraction, injection of local anesthetic). During treatment, it is important to continue the visual monitoring of the patients respiratory rate and level of consciousness. The effects of nitrous oxide largely are dependent on psychological reassurance.
  43. 43. Nitrous oxide Therefore, it is important to continue traditional behavior guidance techniques during treatment. Once the nitrous oxide flow is terminated, 100% oxygen should be delivered for 3 to 5 minutes. The patient must return to pre-treatment responsiveness before discharge.
  44. 44. Nitrous Oxide: Contraindications Contraindications for use of nitrous oxide/oxygen inhalation may include: Some chronic obstructive pulmonary diseases Severe emotional disturbances or drug-related dependencies First trimester of pregnancy Treatment with bleomycin sulfate
  45. 45. Nitrous Oxide: Potential harm For some patients the feeling of "losing control" with nitrous oxide may be troubling, and claustrophobic patients may find the nasal hood confining and unpleasant. Side effects of nitrous oxide include nausea, vomiting, headache, and disorientation. Lack of potency of nitrous oxide/oxygen inhalation Interference of the nasal hood with injection to anterior maxillary region Nitrous oxide pollution and potential occupational exposure health hazards

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