behavior management

1. Pharmacological behavior
management
Presented by : Dr Assjad Ansari

2. Conscious sedation
• Minimally depressed level of consciousness
that retains the patients ability to maintain an
air way independently and continuously
respond appropriately to phisical stimulation
and verbal command and that is produced by
pharmacologic or non pharmacologic method
or a combination

3. Deep sedation
• Controlled state of depressed consciousness
accompanied by partial loss of protective
reflexes including inability to respond
purposefully to verbal command and is
produced by pharmacologic or non
pharmacologic method or its combination

4. General anasthesia
• A controlled state of unconsciousness
accompanied by partial or complete loss of
protective reflexes including inability to
maintain an airway independently and
respond purposefully to physical stimulation
or verbal command and is produced by a
pharmacologic or non pharmacologic
combination

5. History
• The discovery of oxygen in 1771 by carkarl
sheele and englishman joseph priertley
• Nitrous oxide and co2 was discovered in year
1772 by joseph prietley and paved away for
humphry davy 1778 -1829 to experiment with
the inhalation effects of nitrous oxide
• In 1799 humphry davy published book titled
reasearch for chemical and philosophical
chiefly concerning nitrous oxide

6. • The first published work : “a letter suspended
animation on surgical anasthesia included by inhalating
gas(co2) was by Henry hickman -1800-1830”
• About 20 years later Gardner Q cotton a travelling
lecturer of chemistry gave a demonstration of the
inhalation effects of No2 at Hartford
• A local dentist Horace wells (1815-1848) was at his
demonstration and noticed
• Several months later Horace wells demonstrated his
inhalation and extraction procedure at harvard medical
school

7. • Cotton reestablished its clinical usefulness in
dentistry in 1863
• The name anasthesia as suggested by Holmes
had been used by Plato in 400b.c to describe the
absence of feelings in a philosophical sense
• In 1st century A.D Dioscorides also used the term
to denote the absence of physical sensation
• William T.G moratn and Horace wells discoveres
of ansthesia

8. • But in 1870 the american medical association followed
suit and resolution and passed the recognizing the
discovery of anesthesia by Horace wells
• Mortan fought Bitterly seeking to obtain recognition as
the founder of anesthesia
• Mortan died of a cerebral hemorrhage in 1868
discouraged and disappointed man
• His Tombsdone reads “inventor and revealer
inhallation ansthesia before whom, in all times, surgery
was agony by whom pain in surgery was averted and
allulled since whom science has control of pain

9. • Horace wells commited sucide while he was in jail by
cutting the fumeral artety in his left thigh with a rasor
• In 1868 Admund andrew M.D of chigago illinorn
combined o2 with No2
• He is also given credit for inventing the first pratical
machine for giving No2 and O2 in fixed proportion
(1887)
• Eimckesson M.D of toledo(1881-1935) ohio classified
signs of anasthesia with No2 and O2 and desined and
manufactured the mckeeson anasthtic machine

10. • Dr.scldin describes the ways in which the drug
was used in 1940
1. Pure No2 with the exclusion of the air or O2
usulally referred to as straight No2
2. Its procedure is also termed as blue gasing
3. No2 with air
4. No2 with O2

11. • By the year 1918 the four major manufactures
of anesthesia devices in U.S were mckesson,
connell, vonforegger and herdrink

12. Inhalation sedation
• NITROUS OXIDE: is a colorless sweet smelling gas with
a density of 1.5
• The gas is marketed in steel cylinder compressed to a
pressur of 50 atmospheres and is in a liquid sate
• Upon its release from a cylinder it revert to a gaseous
state
• No2 is not explosive or flammable but it will support
comblusion of flammable materials as actively as O2
• At lower con. It has wide spread application in
analgesia techniques utilized during child delivery and
dental treatment

13. • Inhalation: ______________ and aerosols are
rapidly absorbed across the pulmonary
epithelium. Conscious sedation by the inhalation
route is accomplished by the administration of
nitrous oxide and oxygen
• The onset of action depends on;
• Concentration of the gas being administered
• The rate of alveolar ventilation
• The solubility of the gas in blood other gases used
are

14. • Intramuscular
• The intramuscular technique has the advantage of
a more predictable uptake of drug a more rapid onset
of action compared with the oral route. Drugs in
aqueous solution are absorbed well. It is used in
patients who are incapable of cooperating.
•
• Disadvantage:
• Prolonged duration of action
• Potential for tissue damage
• Onset of action: Within 15 minutes

15. • Intravenous: It is the most effective means to
achieve conscious sedation deep sedation or
general anaesthesia for any patient. Drug is
administered directly into the blood stream.
•
• Advantages: Rapid onset of action

16. • Presence of a patient intravenous line is
extremely valuable in the management of an
emergency.
•
• Disadvantage: Rapid onset of action may
increase the likelihood of overdose or adverse
effects if titration is carried out too quickly.

17. • Sublingual: The sublingual route is restricted to
those drugs available for absorption under the
tongue.
• Advantage: More rapid absorption and not ____
first pass metabolish from the liver
• There may be a large difference in recommended
doses when comparing oral with sublingual
absorption depending on the extent of the first
pass effects of the drug.
• Action within in minutes

18. •
• Rectal: The rectal route has been used in
pediatric patients but rare in adults. Through
rectal route it is assumed that 50% of the
absorbed drug bypasses the liver.
•
• Disadvantage: Inconsistencies in bioavailability, a
partial first pass effects, potential for irritation to
mucosa and inconvenience.
•

19. • Intranasal: The intranasal route is a topical
application to the nasal mucosa and as such
has rapid absorption and should have a rapid
onset of action.
•
• Disadvantages: Discomfort, variable
absorption making dose determination
difficult and potential for damage to the nasal
mucosa.

20. • Submucosal: The submucosal route of
administration is analogous to the
subcutaneous injection except it comprises
the intraoral injection of sedative drugs. It
shares many of the same characteristics as the
intramuscular route.
•

21. • Oral sedation
• Indications:
• Major indication for oral sedation s management
of patient anxiety during a dental procedure.
• It also used to facilitate venipuncture for
intravenous sedation or general anesthesia.
• Managing preoperative anxiety, either for the
night before the dental procedure when it is
believed that the patient may not be able to
obtain adequate slap.

22. • Contraindication:
• It arises if the medical history and physical
assessment determine that the patient is at
high risk for sedation.
• In mentally challenged or has dementia and in
unwilling to take an oral medication
• Pregnancy is a relative contraindication

23. • There are relatively few drug groups that are
recommended for oral sedation. They are;
• Benzodiazepies
• Antihistamines
• Alcohold
• Other agents

24. • Diazepam: Diazapam was synthesized in 1961 and is a
crystalline solid.
• Because of its sedative effect, diazepam is used to
relieve anxiety associated with all varieties of necrosis
and anxiety states.
• It has also been used in the treatment of alcoholism,
epilepsy, labour, tetanus and cerebral palsy.
• It is frequently used prior to surgery and dental
treatment because of sedation and amnesia produced.
• Also of interest to the dentist its effectiveness in
relieving sparticity and _______ in patients with
cerebral palsy.

25. •
• Action: Diazapam is an antianxiety drug which
produces sedation through its depressant effect
on the brain stem reticular system and on the
limbic system, thalamus and hypothalamus.
•
• Drug is also a muscle relaxant and has
anticonvulsant properties.
•
• Absorption and extretion:

26. • Administered
• Orally
• Intramuscularly
• Intravenously
•
• Absorption from  GIT and injection site
• Peak blood levels are reached in approximately one to two hours
after administration of an oral dose.
• Metabolish of diazepam includes demethylation and oxidation.
Metabolities as well as unaltered diazepam, are excreated in two
phases: a portion of the drug in excreted rapidly (half life two to
three hours) and a portion in excreted slowly (half life two to eight
days).

27. •
• Adverse reaction
• (1) Confusion (2) Nausea (3)
Headache (4) Vertigo
• (5) Increased appetite (6) Decreased salivation (7)
Jaundice (8) Neutropenia
• Of interest to the dentist are the reports of decreased
salivation and increased appetite. It is possible that
patient undergoing long term therapy with diazepam
could experience an alteration in their caries rate
because of there side effects.

28. •
• Contraindicated in
• Myarthenia gravis
• Sleep apnea
• Acute narrow angle glautoma
• In infants
• Hypersensitivity (known)

29. • Toxicity of diazepam : In relatively low.
• Central nervous system depression is the
major finding in overdose cases and includes:
drowsiness, alaxia, confusion, sleep and coma.
•
• Effects on respiration, pulse and blood pressure
are minimal with overdose (400 mg) recovery
within 8 hour.
• Treatment of overdosage should include support
of respiratory and cardiovascular function.

30. • Dosage and commercial preparation
• Adult dose range from 2 mg/day for mild anxiety to 40 mg/day for
alcoholism or cerebral palsy.
• Recommended initial children’s dosage in 1.0 to 2.5 mg three to
four times daily. Dosage may be increased as needed.
• A typical intravenous or intramuscular dose of diazepam is 2 to 20
mg.
•
• The duration of action of the drug after intravenous injection is
between 30 and 60 minutes.
•
• Valium (diazepam) is supplied by Roche Laboratories in 2, 5, 10
mg tablets and as an injectable containing 5mg/ml.

31. • Clinical investigations
• Oral diazepam: Oral premedication with diazepam has
been recommended as an aid to dental treatment of
children by several clinician.
• Peabody has reported that the recommended dosage
ranging from 2 to 10 mg for children over two years of
age.
• Kurland recommends a standard dose of 15 mg for
children 6 to 12 years old. He reported that completely
untouchable patients have accepted dental treatment
one hour after oral administration.

32. • Moody has reported on 19 patients who were
evaluated as being too difficult to manage at
an initial visit. The children were administered
5mg diazepam tablet the evening before, the
morning of and 15 minute prior to an
operative visit. Moody found that 15 of the 19
children demonstrated improved behaviour
during this visit.

33. • Pautola nad Elomaa have evaluated the
effectiveness of promethazine and diazepam
as oral premedical____ in 92 apprehensive or
different to treat children between 2 and 13
year of age. The dosage range of
promethazine was 0.4 to 3.9 mg/kg of body
weight and that of diazepam was 0.2 to 0.9
mg/kg. Treatment was possible in 74% with
promethazine 70% premedicated with
diazepam.

34. • Creack has reported treating 36 patients, 23 of
whom were children between 3½ and 14 years
of age, with 0.15 mg/kg of diazepam three
times during the 24 hours preceding the
dental visit. Behaviour observed during
operative endodontic and surgical procedures
was evaluated as good in 58% of the patients,
satisfactory in 28% and unimproved in 14%.
•

35. • Intravenous diazepam:
• Diazepam was originally and intravenously in dentistry
to supplement the barbiturate in the Jorgensen
sedation technic.
• Diazepam is contraindicated in infants and that the
safety and efficacy of infectable diazepam in children
under age 12 have not been established.
• Carmichael and Macdonald have reported failure__
with an intravenous diazepam technic. They feel that
they can claim a success rate of only 66% to 70% in
using such a technic in the treatment of 7 to 16 years
old.

36. • Healy and Hamilton have presented, results on
the completed treatment of 19 children, 4 to 16
years of age, over a total of 31 visits. The children
had been judged uncooperative at an initial
examination visit. Children under 10 years of age
were given 1.0 mg of diazepam per year of age
and children over 10 years received a 15 mg dose.
All children cooperated during the I.V. injection.
The investigators report that all of the children
were administered local anesthesia with no
difficulty, whereas this had been impossible
previously.

37. • Healy and coworkers have utilized intravenous
diazepam in the treatment of 44 severely
mentally handicapped patients who had
previously required general anesthesia for
dental treatment. Eleven of there patients
were between age 5 and 14. The results
indicate that 9 of the 11 children were
extensively cooperative during dental
treatment; the other two were able to be
treated but with considerable difficulty.

38. •
• Triazolam: Provides effective anxiolysis and amnesia it
is one of drug of choice for oral sedation in dentistry.
• Action: Within 1 hour, duration of action is 2 to 3
hours, which in ideally suited for dentistry. This
duration of action increases the likelihood for the
patient being well recovered when discharged.
•
• Adult dose range from oral sedation in dentistry is
0.125 to 0.5 mg and it is available in 0.125 or 0.25 mg
tablets.

39. • Midazolam: Medazolam has wide use as a
parenteral agent but has only recently been made
available in a oral formulation in the us__.
•
• Midazolam in similar to diazepam except it is
prepared in a water soluble _____ and has a
shorts half life because its biotransformation
leads to no significant active metabolities using
the parenteral formulation, it is usually dissolved
in a sweetened vehicle to mark its better taste.

40. • Dose of 0.5 mg/kg have been used, sometimes to
a maximum of 15 mg.
• One major caution with oral midazolam is that it
does have a significant interaction with
erythromycin, leading to increased plasma levels
and therefore may potentiate the magnitude and
duration of the sedative effect. Other
benzodiazepines like flurazepam, oxyzepam,
temazepam are used for treatment of insomnia.

41. • Antihistamines: Antiagonists of the H1
histamine receptors reverse histamine in
actions and possess sedative, antiemetic, anti-
cholinergic and local anaesthetic effects.
•
• Specific H1 antagonists play a role in oral
sedation in dentistry.
• Premethazine
• Hydroxyzine

42. • Promethazine: Is a yellow, odorless, crystalline powder
which is soluble in water, it is introduced in 1946.
Promethazine hydrochloride is a phenothiazine derivative.
•
• Promethazine is used to prevent and to treat nausea and
vomiting associated with motion, pregnancy or surgical
operation.
•
• It is used prior to medical and dental procedure
because it produces sedation and will also reduce swelling,
pain and trismus that may be associated with the
treatment.
•

43. • Action, properties and effects
• Antihistamines antagonise the action of histamine in
allergic and anaphylactic reaction.
• The mechanism by which the antihistamines action the
central nervous system is unknown.
• Antihistamines may alter the responses of smooth muscle,
skin, GIT
• Effects on the central nervous system include sedation or
drowsiness and antiemetic and antimotion sickness
properties.
• Promethazine is also a potent local anesthetic
• Some anticholinergic activity also occurs, producing
dryness of the mouth.

44. • Absorption, fat and excretion
• May be given orally, rectally, intramuscularly and
IV.
• Intra arterial injections are contraindicated since spasm
of digital vessels and subsequent gangrene can occur.
• Subcutaneous injection are not recommended as
chemical irritation and local necrosis have been
reported.
• Metabolism of the drugs is often rapid and occurs
mostly in the liver, with degradation products excreted
in the urine.

45. • Adverse reaction and toxicity
• Dizziness, weakness, drymouth, nausea and
vomiting attempted suicides with promethazine have
resulted in deep sedation, coma, convulsions and
cardiorespiratory symptoms.
• Dosage and commercial preparation:
• Oral adult dose: 25 to 50 mg
• Oral children dose: 12.5 to 25 mg
• Presurgical doses for adult: 50 mg
• For children 1.1 mg/kg of body
• _______________

46. • Clinical investigation: Very few studies have been in which
promethazine is used as the role premedicating agent. In the
previously described study by Pantola and Elomaa, promethazine or
diazepam was administered as an oral premedicant to 92
apprehensive children.
•
• In another study which tests the effects of promethazine,
Jones has evaluated 100 children at an examination appointment
and at three subsequent operative appointments during which they
were premedicated with either premethazine (70 mg), recobarrbital
(80 mg) or a pla____.
•
•

47. • The drugs were administered orally in a double blind
fashion to both cooperative and uncooperative
patients 45 minutes prior to treatment.
• Jones evaluated the children’s behaviour on the bases
of cooperation, crying and apprehension at 15 minute
intervals during each visit.
•
• While promethazine elicited significantly better
behaviour than did the placebo, the behaviour
observed with the use of recobarbital was significantly
better than that obtained with promethazine.

48. • Hydroxyzine: It is a piperazine derivative which
may be prepared as either hydroxyzine
hydrochloride or hydroxyzine pamoate.
•
• Because of its antianxiety and antihistamine
properties it is also used in the treatment of
patient with allergies with emotional
components.
•
• It is also used to control nausea and vomiting,
including that associated with pregnancy and
motion sickness.

49. • Action, properties and effects:
• It suppress activity in regions of the
subcortex of the central nervous system and it
has several effects on the CNS.
• It is effective antianxiety, minimal hyp____,
primary and secondary muscle relaxation,
antispasmodic and anti_____.
• Of interest to the dentist is the mild
antisialogogue effect frequently observed with
hydroxyzine.

50. • Absorption, rats and excretion:
• Oral administration noted with 15 to 30
minutes and peak activity within one hour.
Effective duration of action is approximately 3
to 6 hours. Drug is metabolized in liver and
metabolic byproducts are excreted in the
urine.

51. • Adverse reaction and toxicity:
• Contraindicated in unknown
hypersensitivity. Contraindicated for
subcutaneous, intraarterial or intravenous use
became of reported of subsequent
endorteritis, thrombolis and digital gangrene.
•
• Dosae and commercial preparations:
• Adult dosage ranges from 25 to 100 mg
four times daily. Children ranges from 50 to

52. • Commercial preparation:
• Vistaril capsule (25, 50 and 100 mg) oral
suspension (25mg/5 ml)
• IM  25 or 50 mg/cc
• Atarax tab (10, 25, 50 and 100 mg) and
syrup (10 mg/5 cc)
•

53. • Clinical investigation:
• Steward advocates the routine use of
hydroxyzine to reduce children’s anxiety
during dental treatment. He utilize the drug in
98% of his patient and has reported on his one
of it in 2600 patients. He recommends an oral
dose of 10 to 20 mg 45 minutes prior to the
visit. Steward feels that, given either alone or

54. • in conjunction with other psychologic or
sedative techniques, hycroxyzine is a valuable
component in a total program for controlling
apprehension.
• Lang has tested the effects of hydroxyzine v/s
a placebo on 76 children 3 to 9 years of age.
The behaviour palle____ of the children were
evaluated at an initial visit and ranged from
mild apprehension to severe cooperation
difficulty. The medications a placebo or 50 mg

55. • Alcohols: There are only two representative
drugs from the alcohols group.
• (1) Chloral hydrate (2) Ether
• Chloral hydrate: Used in pediatric dentistry. It
is well absorbed, duration of action ranging
from 4 to 8 hours. Its mechanism of action is
by active metabolite, trichloroethanol, which
induces central nervous sysem depression.
•

56. • Adverse effect includes: Gastric upset, nausea,
vomiting and flatulence.
•
• Contraindicated in: Hepatic impairment, several
renal impairment, severe gastritis, gastric ulcers,
cardiac diseases. If patient is one anticoagulants
(if leads to displacement of plasma protein).
•
• Chloral hydrate is usually administered in the
form of an e____, recommended dose of 40 to 50
mg/kg. When administered alone, not to exceed
1500 mg. It is available as either 250 or 500 mg

57. • Ethchlorvynol: Anticonvulsant and muscle
relaxant properties  rapidly absorbed 
duration of action 5 hour.
• Adverse effect: Unpleasant taste, dizziness,
nausea, vomiting, hyp____,
• Contraindicated: Hepatic or renal dysfunction.
• Recommended dosage from 200 to 1000 mg.
• It is available as 200, 500 or 750 mg capsules.

58. • Other agents: Like ketamine, opioids,
barbiturates.
• Ketamine: Mainly given IM (10 and 50 mg/ml)
• It is potent analgesic, potential for oral
use.
• Oral dose  6 mg/kg. It induces deep
sedation.
•
• Opiods: There analgesic are effective in
inducing sedation when given IV.

59. • Meperidine (Demerol) is commonly used.
•
• Barbiturates: Barbiturates are no longer drugs
of choice to induce oral sedation.
• Barbiturates has low therapeutic index
• Barbeturates like, secobarbital and
pentobarbital

60. • The dose for drugs described in the
pharmacology section are estimates assuming
the patient is a healthy 70 kg adult. There are
factors that can modify these
recommendations and lead to adjustment of
the dose above or below those suggested.

61. • These factors are as follows;
• Body weight or body surface area
• Extremies of age
• Medical history
• Concurrent medication
• Presence of chemical dependency
• Level of anxiety
•

62. Use of NO2
• Physiology : No2 doesnt enter into chemical
combination with any body tissue depression
of the CNS
• It doesn’t compete with the O2 and CO2
• Approximately 100ml of blood will dissolve in
its plasma about 45ml of NO2
• Its mode of action is directly proportion to this
type of solubility
• The partial pressure of inhalled NO2 that
arrives in the lung alveoli are a deteminant
tension of this gas in the blood

63. • Therefore the amount of NO2 absorbed from
the lungs relative to the NO2 tension and
partial pressure in the blood
• Pharmacological action: NO2 is an inorganic
gas which is capable of producing anesthetic
properties
• Its anesthetic action is related to its great
solubility in the blood plasma 100ml of blood
will dissolve 45ml of NO2
• Depression of the CNS

64. • Pharmacological effect: NO2 has been
demonstrated to affect all sensations such as
hearing, sight, touch and pain
• Eckenhoff reported that NO2 doesn’t cause
any appreciable changes in cardiac rate or
cardiac output
• Clinically venodialation has been reported
with inhalation of moderate concentration of
NO2
• NO2 in the absence of hypoxia or hypercarbia

65. • Bllod volume and composition are not altered
by the administration of NO2
• It has been reported that those patients with
the sickle cell traits can be develop a sickling
crises as a result of hypoxia rather than as the
effect of NO2
• NO2 decrease the sensitivity of the oral, nasal
larngo tracheal areas
• Larngospasm hazard has also been reported

66. • Stage 1: analgesia is defined as variable
degrees of pain relief with consciousness.
• As analgesia depress, pain sensation can be
lost however the sense of touch is not always
obtunded.
1. The extraction of a tooth
2. Incision with the scalpel
3. Removal of the dental pulp may produce pain

67. • Stage 2: excitement stage: in this stage the
patient is unconscious and the inhibitory
center is released , thereby producing the
manifestations of exaggerated refluxes
• Stage 3: surgical anasthesia: the patient is
unconscious with muscular responses present
• Parbrooks demonstrated that the analgesia
effect of NO2 is greater if the patient receives
a narcotic prior to analgesic administration

68. • The use of atropine should be avoided
because of an anti analgesic action that may
require higher ion concentration of NO2
• Concentration of 20 % NO2 have similar
potency with 15mg of morphine

69. Analgesia or anasthesia
• At concentration of 45-65% there is occasional
nausea and vomiting a 80 % NO2 this problem
increases
• When the concentration reaches or
approaches 80% the patient may slide from
analgesia into anesthesia
• As the duration of the procedure is extended
there may develop a vacillation between the
analgesia and anesthesia stages which may
not be detected by the anesthesia dentist
• In the recovery period following NO2

70. Analgesia and anesthesia
• The term analgesia which is defined as a state
of pain relief without the loss of counciouness
• E.I Mckesson M.D he realized that the classical
stage of ether Guedal didn’t apply to NO2
anesthesia
• Mckenssons classification for stages of NO2

71. Analgesia in dentistry
• Concentration of 6-25% NO2 plus O2 produce
the effect of analgesia and certain restorative
dental procedures may be performed
• Operative dentistry we may suppress the
painful experience with a 50:50 combination
of O2 and NO2
• Pessson in 1951 showed that with 40% NO2
and 60% O2 inhaled for 3 minutes, adequate
analgesia for cavity preparation could be
develop
• Ruben in 1966 showed that in concentration

72. • Lassener reported if a patient is encouraged
during the induction phase to tolerate some
of the painful sensations
• Patient who are apprehensive, extremely
fearful of the dental procedure or suffering
severe pain any find concentration inadequate

73. Indications for the use of NO2 in
dentistry
1. Incision and drainage of an acute abscess
2. Where multiple operative procedures are
required and the patient is extremely
apprehensive
3. Children and adults who are unreceptive to
local anesthesia injection techniques
4. The mentally handicapped and those
patients who have a severe spastic condition

74. Contraindications to NO2 analgesia or
anasthesia
1. Trismus associated with cellulitis of the floor
of the mouth or the neck, which could
possibly embarrass the airway
2. Ingestion of food or liquid recently prior to
the administration of the anesthetic agent
3. Certain medical problems such as severe
cardiac disease, hyperthyroid, uncontrolled
diabetes, sickle cell trait, upper respiratory
infections, severe emphysema and asthmatic
problems

75. Dosage and commercial preparations
• However it is not used unusual for
concentration of 70%-85% of NO2 to be used
during induction with subsequent reduction to
a 50% or 65% concentration
• During the second stage of labor,
administration of 100% NO2 during
contraction and 100% O2
• NO2 may be purchased in either small D or E
size or large G or H size cylinders
• The larger cylinders are considerably more

76. Steps in nitrogen oxide oxygen
technique
• Preparation of equipment
• Preparation of the patient
• Introductory administration
• Administration during treatment
• Preparation of equipment: the NO2
equipment should be prepared for use before
the child is seated in the operatory
• The valves need to be opened and pressure

77. • The centralized system is convenient
• Centralized equipment is more discrete
• This is a significant advantage since many
children may become upset upon seeing a
rather large and formidable looking machine
being wheeled into the operatory with tanks
changing together
• The nasal inhaler and tubing may be the only
equipment seen by the child
• Having an assortment of nosepieces from
different manufacture is helpful in making a

78. • The nosepiece should have been washed with
soap and water after its last use and should be
wiped with scented alcohol to digene the
smell of both alcohol and the nosepiece itself
• Preparation of the patient: the child should be
seated in a reclining position
• More important that the physical preparation
of the equipment is the psychological
preparation of the child and the indroductiory

79. • Put to sleep
• Tell show do
• It is essential that all procedures and
sensation which may be experienced by the
child be described in advance
• The possible sensation of warmth tingling in
the extremities auditory changes and change
in perceived body weight
• The use of good positive descriptions will
make the most of children's susceptibility to

80. • Introductory administration: analgesia machine
delivering a flow of five liters per minute
• Nosepiece should be placed
• Graceful nonthreatening manner
• During the entire period no sudden or rapid
movements
• The child should be allowed to adjust the
nosepeice
• The nasal inhaler should fit snugly

81. • During this period the child reaction should be
carefully monitered
• Increase or decrease the concentration
• Once the desired sensations have been
obtained
• The nasal inhaler is removed before the O2 is
turned off
• the child is allowed ton return to normal
activities

82. Adminstration during treatment
• Administration during treatment: the use NO2
conscious sedation at subsequent follows the
same pattern
• Maintenance levels of NO2
• NO2 can be employed during most dental
procedures like
• It is used to allow fear of injection it doesn’t
interfere with the placement of the rubber
dam
• It is very useful during surgical procedure
• While NO2 provide analgesia it is

83. Drugs used with nitrous oxide oxygen
techniques
1. Narcotic analgesia agents
2. Ultrashort acting barbiturates
3. Other inhalation agents
4. Local anesthetic injections
1. Narcotic analgesic agents: on using these
drugs with NO2 it increase pain threshold
• Where there is a strong possibility of painful
stimuli the narcotic analgesic should be used

84. • This will give profound relief
• With the use of narcotic analgesic agents
there is a possibility of respiratory depression
this effect can be reversed by giving a narcotic
antagonist
• The most commonly used narcotic is
combination with N2O is meperidine
2. Ultrashort acting barbiturates: produces a
state of sedation
• Where as nitrous oxide oxygen produces a

85. 3. Other inhalation agents: halothane with
nitrous oxide oxygen anesthesia
• Broad spectrum of clinical usefulness
• But the incidence of cardiac arrythmias as
reported by Forbes, is enhanced with
halothane therefore this technique is some
what limited in ambulatory dentistry

86. Local anesthesia
• LA and nitrous oxide oxygen will give a state of
well being to the patient when the local in
fully effective
• The patient may not perceive painful stimuli
• The patient must be cooperative and must
realize

87. Nitrous oxide and its actions,
properties and effect on various
system
• The mechanism by which nitrous oxide exerts
its effect is current unknown
• In concentration of 10%-25% N2O most
frequently produces sensation of tingling and
numbness
• As the concentration of nitrous oxide reaches
25%-50% maximum analgesic properties are
realized and there are aberration of vision,
hearing and proprioception, mild drowsiness,
euphoria, amnesia and increased sleepiness

88. • Its effects of various systems:
1. CNS
2. Respiratory system
3. CVS
4. Fetal system
5. Other system

89. 1. CNS: the CNS specifically the cerebrum is the
system primarily affected by nitrous oxide
2. Respiratory system: the respiratory system is
slightly stimulated by 50%
• While no definite depression of respiration
occurs
• The dentist should be aware that the
respiratory depression associated with
administration of meperidine or thiopental is
deepened by concomitant use of nitrous

90. • CVS: the effects of nitrous oxide alone on the
CVS are generally considered to be significant
• Eisele and smith have evaluated the effect of
nitrous oxide oxygen on ten young adults.
They reported the heart rate decreased by as
much as 10% and cardiac output by much as
19% when subjects inhaled 40% nitrous oxide
as opposed to 40% nitrogen
• Evertl and Allen also conducted the same
study and obtained cardiac output and stroke

91. • Fetal system: Bussard has reviewed both the
literature on the teratogenic effects of nitrous
oxide on pregnanent animals the
epidemiologic evidence indicating that nitrous
oxide and epidemiological evidence indicating
that nitrous oxide may be a cause of
miscarriage in humans
• Cohen and co-workers reported that in a
survey of operating room frequently exposed
gases 29.7% of pregnancies endended in

92. • Other systems: The peripheral nervous system
and receptor sites don’t seem to be depressed
by nitrous oxide
• Depression of some spinal refluxes has been
demonstrated
• Neuromuscular system is not depressed by
nitrous oxide
• The major effect of nitrous oxide on the
gastrointestinal system is nausea and vomiting
• Hematopoietic is affects by prolongs exposure

93. Hypoxia associated with nitrous oxide
• Hypoxia may develop from the following
problems:
1. The anesthetic machine flow meters may be
subject to error, especially at low flow rates
2. Mccarthy, studying both flow meters and
pressure machines suggested that error in high
pressure delivery system is subjected to greater
error in oxygen delivery
3. Hyperventilation may be present during and
after nitrous oxide anesthesia

94. Complications associated with nitrous
oxide anesthesia
1. Hypoxia
2. Airway obstruct
3. Hypotension
4. Reflux stimuli
• Airway obstruction: misplaced oropharngeal
pack, cancer, enlarged tonsils, blood, dental
debris and foreign materials
• Hypotension: Bourse stated main danger in,

95. • Reflex stimuli: the reflex stimuli are initiated
from the throat pack, the dental prop and the
extraction of a tooth
• Frumin and rackow

96. Toxicity associated with nitrous oxide
• Bjorniboe
• In 1956 Lassen reported the recognition and
the role of nitrous oxide in producing
granulocytopenia and bone marrow
depression
• Lassen showed that hematologic complication
appeared 3 or 4 days after nitrous oxide
inhalation
• The administration of 50% nitrous oxide
oxygen resulted in the white cell count

97. Routes of administration for conscious
sedation
1. Oral
2. Inhalation
3. Intramuscular
4. Intravenous
5. Sublingual
6. Rectal
7. Intranasal or submucosa;

98. • ORAL: after swallowing a drug, absorption
occur primarily in the stomach and small
intestine and not from other parts of GIT.
• Drugs taken orally are exposed to the
potential of inactivation in either the stomach
or the liver