The document discusses sedation and general anesthesia techniques used in dentistry. It describes four levels of anesthesia from local anesthesia to general anesthesia. For sedation techniques, it covers oral, inhalational and intravenous sedation. For oral sedation it discusses drugs, factors influencing absorption and advantages and disadvantages. For inhalational sedation it focuses on nitrous oxide use and equipment. Intravenous sedation outlines commonly used drug combinations. Risks, indications and administration techniques are also outlined. The document provides a detailed overview of sedation and anesthesia in dentistry.
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Sedation and general anesthesia in dentistry
1. Sedation and General Anesthesia
in Dentistry
Assistant professor : Akram Thabet Nasher
B.D.S, M.Sc. , Ph.D.
Head department of oral and maxillofacial surgery
Faculty of Dentistry- Sana`a university
3. Levels of Anesthesia
Local anesthesia
Conscious Sedation
Deep Sedation
General Anesthesia
Sedation and General Anesthesia
Dr.Akram Thabet
4. Local Anesthesia
Local, or regional, anesthesia involves the
injection or application of an anesthetic
drug to a specific area of the body. It
eliminates sensation and pain in a local
area of the body without loss of
consciousness.
Sedation and General Anesthesia
Dr.Akram Thabet
5. According to the degree of CNS
depression:
◦ Conscious Sedation
◦ Deep Sedation
◦ General Anesthesia
Sedation and General Anesthesia
Dr.Akram Thabet
6. Sedation
It is a technique where one or more drugs
are used to depress the Central Nervous
System of a patient thus reducing the
awareness of the patient to his surrounding.
Sedation and General Anesthesia
Dr.Akram Thabet
7. Conscious Sedation
It
is
a
controlled,
pharmacologically
Induced, minimally depressed level of
consciousness that retains the patient’s
ability
to
maintain
independently
and
a
patent
continuously
airway
and
respond appropriately to physical and/or
verbal command.
ventilatory and cardiovascular functions are
unaffected
Sedation and General Anesthesia
Dr.Akram Thabet
8. Deep Sedation
It is a controlled, pharmacologically induced state of
depressed level of consciousness , from which the
patient is not easily aroused and which may be
accompanied by a partial loss of protective reflexes,
including the ability to maintain a patent airway
independently and/or respond purposefully to
physical stimulation or verbal commands.
Sedation and General Anesthesia
Dr.Akram Thabet
13. Fundamental Concepts:
It is easy to drift from one state to another.
Any anesthetic/sedative/opioid regardless of route
of administration can be a general anesthetic (can
cause unconsciousness)
Patient state is considered in terms of the level of
consciousness rather than the technique involved.
Sedation techniques
techniques.
are
not
pain-control
Sedation and General Anesthesia
Dr.Akram Thabet
14. Indications:
1- Behaviorally challenged patients (stressful and fearful
patients).
2- Young children
3- Mentally retarded Patients
4- Major operations in oral and maxillofacial surgery
5- Stressful Procedure ( multiple 3 rd Molar
extractions, Interosseous implants ,complex periodontal
surgery)
6- Gagging reflexes
7- Local Anesthesia problems
8- Medically compromised patients Sedation and General Anesthesia
Dr.Akram Thabet
15. Routes of Administration:
Enteral – any technique of administration in which the agent is
absorbed through the gastrointestinal (GI) tract or oral mucosa
[i.e., oral, rectal, sublingual].
Parenteral – a technique of administration in which the drug
bypasses the gastrointestinal (GI) tract [i.e., intramuscular (IM),
intravenous (IV), intranasal (IN), submucosal (SM), subcutaneous
(SC), intraosseous (IO)].
Transdermal – a technique of administration in which the drug is
administered by patch or iontophoresis through skin.
Transmucosal – a technique of administration in which the drug is
administered across mucosa such as intranasal, sublingual, or
rectal.
Inhalation – a technique of administration in which a gaseous or
volatile agent is introduced into the lungs and whose primary
effect is due to absorption through the gas/blood interface.
Sedation and General Anesthesia
Dr.Akram Thabet
17. Cons. Sedation
Minimally Depressed Consciousness
Deep Sedation
Deeply depressed consciousness
Anxiolysis
Sleeplike state
Interactive
Non-Interactive
Arousable
Non- arousable
(except with tense stimulation)
Airway is maintained
Inability to maintain airway
Protective reflexes are intact
Partial loss of reflexes
Responses to command
are intact
Difficult to respond to
command
Sedation and General Anesthesia
Dr.Akram Thabet
18. Sedation techniques
Non - titrable Technique
Oral Sedation
Rectal Sedation
Intramuscular Sedation
Submucosal Sedation
Intranasal Sedation
Titrable Technique
Inhalational Sedation
Intravenous Sedation
Combination Of the two
Sedation and General Anesthesia
Dr.Akram Thabet
19. I- Oral Sedation
By far, it is the most universally accepted and
easiest method of sedation administration.
The most variable (non-titrable) technique
Recovery time prolonged
Difficult to reverse unwanted effect
Utilizing escort
No repeated doses
Sedation and General Anesthesia
Dr.Akram Thabet
20. Advantages of Oral Sedation
Universal acceptability
Ease of administration
Low cost
Incidence of adverse reactions less than
some other techniques
No needles, syringes or special techniques
Various drugs, dosage forms available
Allergic reactions less severe than seen in
parenteral administration
No specialized training
Sedation and General Anesthesia
Dr.Akram Thabet
21. Disadvantages of oral Route
Reliance on patient cooperation
Prolonged onset
Erratic absorption, unpredictable effect
Inability to titrate to effect
Inability to readily lighten or deepen
Prolonged duration of effect
Adverse interactions of sedative drugs
Sedation and General Anesthesia
Dr.Akram Thabet
22. Contraindications to oral Sedation
Severe dental anxiety & fear
High probability of adverse drug interaction
Poor past experience with oral sedation
Allergy to drug being used
Other
drug
contraindications
(pregnancy
, glaucoma, etc.)
Need for rapid onset and/or rapid recovery
Sedation and General Anesthesia
Dr.Akram Thabet
23. Factors Influencing Oral Drug Absorption
Lipid solubility
pH of gastric tissues
Mucosal surface area
Gastric emptying time
Dosage form of drug
Drug inactivation (“first pass effect”)
Presence of food in stomach
Bioavailability of drug
Genetics
Sedation and General Anesthesia
Dr.Akram Thabet
24. II- Inhalational Sedation
Nitrous oxide/oxygen inhalation sedation is
the most commonly used technique in
dentistry for sedation .
Nitrous oxide/oxygen (N²O/O²) sedation is
a combination of these gases that the
patient inhales to help eliminate fear and
to help the patient relax.
Sedation and General Anesthesia
Dr.Akram Thabet
25. Equipments
Continuous flow design
with flow meters
Safe delivery of O2 and
N2O.
Pin-indexed yoke system
Efficient scavenger
Sedation and General Anesthesia
Dr.Akram Thabet
29. Advantages of Nitrous Oxide
Rapid onset (almost equal to that of IV. administration )
Ability to titrate & to reverse
Depth of sedation readily altered
Flexible duration of action
Rapid recovery from sedation
Safe
No injection required
Very few side effects
No adverse effects on vital organs
Patient can be discharged alone
Non addictive.
Produces stage I anesthesia.
Dulls the perception of pain.
Sedation and General Anesthesia
Dr.Akram Thabet
30. Disadvantages of Nitrous Oxide
Initial cost of cumbersome equipment is high
Continuing costs of gases high
Equipment takes up operatory space
Requires constant patient cooperation
Chronic exposure of office personnel can cause
Carcinogenicity , Teratogenicity or Toxicity
Not always effective
Sedation and General Anesthesia
Dr.Akram Thabet
31. Relative Contraindications to Inhalation
Sedation:
Severe dental anxiety & fear
Compulsive personalities
Poor past experience with oral sedation
Pregnancy
URI, COPD
Nasal obstruction: Problems inhaling through the
nose
Emphysema: Increased O²
Multiple sclerosis: Breathing difficulties
Emotional stability: Altered perception of reality
Sedation and General Anesthesia
Dr.Akram Thabet
33. Administration of Inhalation sedation
Start with pure oxygen while establishing the
patient’s tidal volume.
Slowly titrate the nitrous oxide until the desired
results are achieved.
Patients should refrain from talking or mouth
breathing.
The N²O/O² analgesia should end with the
administration of 100% O² for 3 to 5 minutes.
Obtain postoperative vital signs and compare
them to the preoperative recordings.
Sedation and General Anesthesia
Dr.Akram Thabet
34. How to reduce N²O hazards to dental personnel ??
◦ Use a scavenger system.
◦ Use a patient mask that fits well.
◦ Discourage patients from talking.
◦ Vent gas outside the building.
◦ Routinely inspect equipment and hoses
for leaks.
◦ Use an N²O monitoring badge system.
Sedation and General Anesthesia
Dr.Akram Thabet
35. III- Intravenous Sedation
Antianxiety drugs that are administered
intravenously continuously throughout the
procedure at a slower rate, providing a
deeper stage I analgesia.
The most rapid technique; onset
approximately 20 to 25 seconds.
In children under 6 years, the incidence of
untoward effects is increased
Sedation and General Anesthesia
Dr.Akram Thabet
is
36. Drugs for sedations :
Either one drug or combinations of IV drugs
Commonest combinations
Benzodiazepines & opioids
Propofol & opioids
Sedation and General Anesthesia
Dr.Akram Thabet
37. Valium (Diazepam)
Benzodiazepine
Produces sleepiness and relief of apprehension
Onset of action 1-5 minutes
Half-life
◦ 30 hours
◦ Active metabolites
Average sedative dose
◦ 10-12 mg
Sedation and General Anesthesia
Dr.Akram Thabet
38. Versed (Midazolam)
Short acting benzodiazepine
◦ 4 times more potent than Valium
Produces sleepiness and relief of apprehension
Onset of action 3-5 minutes
Half-life
◦ 1.2-12.3 hours
Average sedative dose
◦ 2.5-7.5 mg
Sedation and General Anesthesia
Dr.Akram Thabet
40. Fentanyl (Sublimaze)
Narcotic/Opiod agonist
◦ 100 times more potent than Morphine
Pain attenuation and some sedation
Onset of action around 1 minute
Half-life
◦ 30-60 minutes
Average dose
◦ 0.05 – 0.06 mg
Sedation and General Anesthesia
Dr.Akram Thabet
41. Additional Medications
Likely
to be seen in scenarios where
deeper levels of sedation are being
performed
◦ Propofol (Diprivan)
◦ Robinul (Glycopyrrolate)
Sedation and General Anesthesia
Dr.Akram Thabet
42. Propofol (Diprivan)
Intravenous anesthetic/sedative hypnotic
Sedative, anesthetic and some antiemetic
properties
Onset of action within 30 seconds
Half-life
◦ 2-4 minutes
Average sedative dose
◦ Varies
Sedation and General Anesthesia
Dr.Akram Thabet
45. Stages of General Anesthesia
Stage I “Conscious Sedation”
◦ Analgesia
Stage II
◦ Delirium
Stage III (“Deep Sedation/General Anesthesia)
◦ Surgical anesthesia
Stage IV
◦ Medullary paralysis
Sedation and General Anesthesia
Dr.Akram Thabet
46. Four Stages of Anesthesia:
Stage I: Analgesia is the stage at which a
patient is relaxed and fully conscious. The
patient is able to keep his or her mouth
open without assistance and is capable of
following directions. The patient will have
a sense of euphoria and a reduction in
pain. Vital signs are normal. Depending
on the agent used, the patient can move
into different levels of analgesia.
Sedation and General Anesthesia
Dr.Akram Thabet
47. Stage
II: Excitement is the stage at
which a patient is less aware of his or
her immediate surroundings and can
start to become unconscious. The
patient can become excited and
unmanageable. Nausea and vomiting
can occur. This is an undesirable stage.
Sedation and General Anesthesia
Dr.Akram Thabet
48. Stage
III:
This stage of General
anesthesia in which the patient
becomes calm after stage II. This is the
favorable stage for doing surgery. The
patient feels no pain or sensation. The
patient will become unconscious. This
stage of anesthesia can be met only
under
the
guidance
of
an
anesthesiologist
in
a
controlled
environment such as a hospital.
Sedation and General Anesthesia
Dr.Akram Thabet
49. Stage
IV: Respiratory failure or
cardiac arrest is the stage at which
the lungs and heart slow down or
stop functioning. If this stage is not
reversed quickly, the patient will
die.
Sedation and General Anesthesia
Dr.Akram Thabet
50. Intubation in GA. For maintenance
of respiration :
Sedation and General Anesthesia
Dr.Akram Thabet
58. Types of General Anesthetics
Induction agents( begins the anesthesia)
◦ Induction agents usually administered IV
◦ can be inhalational for those who do not
tolerate IV access
Maintenance
anaestheisa)
agents
(maintain
the
◦ Maintenance agents usually administered
inhalationally or IV with bolus or continuous
infusion technique
Sedation and General Anesthesia
Dr.Akram Thabet
59. Routes for Delivery of General
Anesthetics
Intravenous (IV)
Inhalational
Sedation and General Anesthesia
Dr.Akram Thabet
60. Structural formulas of anesthetic drugs.
Sedation and General Anesthesia
Dr.Akram Thabet
61. General Anesthetics-Intravenous
Agents
Primary role as induction agents
Maintenance with total intravenous anesthesia
◦ Rapid redistribution
◦ Shorter half lives
◦ Environmental risk of inhalational agents
Rapid distribution to vessel rich tissues
High lipid solubility allows for rapid induction
When redistributed out of the brain, the effect decreases
Advantages
◦ Rapid and complete induction
◦ Less CV depression
Sedation and General Anesthesia
Dr.Akram Thabet
62. General Anesthetics-Intravenous
Agents
The most commonly drugs used in GA:
1- Benzodiazepines
2- Opioids
3- Ketamine
4- Methohexital
5- Propofol
Sedation and General Anesthesia
Dr.Akram Thabet
65. Pre‐anesthetic Evaluation
“Never treat a stranger”
Never do anesthesia on a patient you have
not previously evaluated.
Never sedate or aesthesis on first patient visit
Always have a consultation first!
Sedation and General Anesthesia
Dr.Akram Thabet
66. Pre‐anesthetic Examination
Physical examination
Evaluation of anxiety level
Review of medical history
Review medications and drug allergies
Assign ASA classification
Review prior sedation / anesthetic history
Obtain informed consent
Give pre‐sedation/ anesthesia instructions
Sedation and General Anesthesia
Dr.Akram Thabet
67. Medical history
Diseases to evaluate:
HTN;, asthma, COPD, URI, DM
Pregnancy; psychiatric renal; hepatic problems
Obesity; sleep apnea; etc
Medications
Prior anesthetic experience
Allergies
Hospitalizations
Sedation and General Anesthesia
Dr.Akram Thabet
68. Physical Examination
Vital signs
Appearance
Height, Weight, & BMI (Body Mass Index)
Mental & psychological status
Cardiac & pulmonary level ;
Exercise tolerance (“if they can walk up 2
flights of stairs to your office, they’re
probably ok for anesthesia”)
Airway evaluation
Sedation and General Anesthesia
Dr.Akram Thabet
69. Airway Evaluation
BMI (Body Mass Index)
History of obstructive sleep apnea, snoring
Mallampati score
Protrusive (ask: “bite your upper lip with your
lower teeth”)
TMJ range of motion (oral opening)
Neck circumference
Sedation and General Anesthesia
Dr.Akram Thabet
71. ASA Physical Classification
IA
normal healthy patient
II A
patient with mild systemic disease
III A patient with severe systemic
IVA
patient
with
severe
systemic
disease that is a constant threat to life
VA
moribund patient who is not expected
to survive without the operation
Sedation and General Anesthesia
Dr.Akram Thabet
73. Medical Consultations
After
doing
the medical and physical
examination with the full investigations;
the patient should be evaluated by a
medical doctor or anesthetist to do a
medical fitness for him to receive the
anesthesia.
Sedation and General Anesthesia
Dr.Akram Thabet
74. Informed Consent
It’s a process, not a piece of paper.
Verbal and written informed consent must be given at the
pre‐op consultation appointment, not the day of surgery
Cannot be obtained once medications are administered.
New written consent must be obtained for each procedure
or sedation.
Consent to surgery does not imply consent for sedation;
sedation needs to be specified.
Consent must be obtained by the doctor in face‐to‐face
meeting, not a staff member.
Sedation and General Anesthesia
Dr.Akram Thabet
75. Pre‐Sedation/anesthetic Instructions
Give both verbally and in writing
Fasting (“NPO”) instructions (if needed)
“Vested” escort to accompany patient
Patient’s other medications
Sedation and General Anesthesia
Dr.Akram Thabet
76. Pre‐Procedure Fasting (“NPO”)
The patient must be fasted minimum 2-3
hours for clear liquids and 6 hours for
solid food to prevent vomiting causing
Suffocation and aspiration pneumonia.
Sedation and General Anesthesia
Dr.Akram Thabet
77. Psychological preparation
Psychological preparation of the patient for the sedation or
GA is paramount.
Explain the different types of sedation available and GA
techniques
Tell them they will be “relaxed, drowsy, comfortable,” and
“aware and in control.”
Give realistic expectations to patient and explain that every
patient reacts differently, and they may need more / less
medication or different technique at future appointments.
Sedation and General Anesthesia
Dr.Akram Thabet
78. Intraoperative Responsibilities
◦ Informed consent signed prior to sedation
◦ Name, dose, route and time of all medications
documented
◦ Procedure begin and end times
◦ Prior adverse reactions
◦ Pre-medication time and effect
◦ Vital Signs
BP
Heart Rate
Respiratory Rate
Oxygen Saturation
Level of Consciousness
Sedation and General Anesthesia
Dr.Akram Thabet
79. Monitoring
Level Of Consciousness
Clinical Observation
Pulse Oximetry
Pericardial/pretracheal Stethoscope
BP
ECG
Monitoring oxygenation
Sedation and General Anesthesia
Dr.Akram Thabet
81. Recovery
Patients may continue to be at significant risk of
developing complications after procedure is
completed.
Decreased procedural stimulation, delayed drug
absorption, and slow drug elimination, may
contribute
to
residual
anesthesia
or
sedation and respiratory depression during the
recovery period.
Patient must be kept in office under observation
until completely recovered.
Sedation and General Anesthesia
Dr.Akram Thabet
82. Post-operative Responsibilities
◦ Vital Signs at least every 5 minutes
BP
Heart Rate
Respiratory Rate
Oxygen Saturation
Level of Consciousness
Sedated/ Anesthetized patients must be
continuously monitored until discharged
Sedation and General Anesthesia
Dr.Akram Thabet
83. Recommended Alarm Limits
Low
High
Systolic BP
85
150
Diastolic BP
50
100
Oxygen Saturation
92
100
Respiratory Rate
10
16
Heart Rate
60
90
Sedation and General Anesthesia
Dr.Akram Thabet
84. Medical Emergency
Syncope
Laryngospasm
Hypoglycemia
Apnea
Hypotension
Myocardial infarction
Hypertension
Stroke
Bronchospasm
Sedation and General Anesthesia
Dr.Akram Thabet
85. Medical Emergency
Know how to prevent, recognize, and treat
syncope (fainting)
◦ Supplemental O2
◦ Elevation of lower extremities
◦ Trendelenburg
Be prepared to assist in airway management
Sedation and General Anesthesia
Dr.Akram Thabet
87. Flumazenil (Romazicon)
Benzodiazepine antagonist
◦ Versed reversal agent
Initial dose – 0.2mg
◦ May repeat at 1 minute intervals to dose of
1mg
Onset of action within 1-2 minutes
Must monitor for re-sedation
◦ May be repeated at 20 minute intervals as
needed
Sedation and General Anesthesia
Dr.Akram Thabet
88. Naloxone (Narcan)
Narcotic antagonist
◦ Fentanyl reversal agent
Initial dose – 0.4mg
◦ May repeat every 2-3 minutes at doses of
0.4-2mg
Monitor for re-sedation
Sedation and General Anesthesia
Dr.Akram Thabet
91. Atropine
Significant bradycardia
◦ Slow heart beat or NO heartbeat
Anticholinergic
Initial dose 0.25 – 1.0 mg
◦ May repeat every 3-5 minutes
◦ Maximum total dose .03 mg/kg
Sedation and General Anesthesia
Dr.Akram Thabet
93. Discharge Criteria
Vital signs normal (within 20% baseline)
Airway patency uncompromised
Patient awake, or awake on command
Can breathe deeply
Protective reflexes intact (can cough on command)
Adequate hydration, able to drink
Patient can speak normally
Patient can sit unaided
Patient can walk with minimal assistance
Responsible, “vested,” adult escort is available
No pain, no nausea or vomiting,
Sedation and General Anesthesia
Dr.Akram Thabet
94. Post‐sedation Instructions
Verbal and written instructions must be given to
the escort upon discharge from the office
Should include:
– Potential and anticipated post‐sedation effects
–Limitation of activity (driving, machinery) x 24 hrs
– Dietary precautions and suggestions
– No other sedatives x 24 hrs
– 24 hour contact number for practitioner
Sedation and General Anesthesia
Dr.Akram Thabet