General Anesthesia and Sedation in Dentistry

8/14/2019 General Anesthesia and Sedation in Dentistry

1/45

General Anesthesia andGeneral Anesthesia and

Sedation In DentistrySedation In DentistryIyad Abou RabiiIyad Abou RabiiDDS. OMS. MSc. PhDDDS. OMS. MSc. PhD


2/45

General AnesthesiaGeneral Anesthesia

Dr. William Morton, a Massachusetts dentist,Dr. William Morton, a Massachusetts dentist,was looking for a way to painlessly extractwas looking for a way to painlessly extractteeth.teeth.

There was no local or general anesthesiaThere was no local or general anesthesiaavailable to make removing teeth tolerable.available to make removing teeth tolerable.

Although Dr. Morton knew about nitrous oxideAlthough Dr. Morton knew about nitrous oxide

from his association with another dentist, Dr.from his association with another dentist, Dr.Horace Wells, he wanted a more powerfulHorace Wells, he wanted a more powerfulagent. He discussed the problem with Dr.agent. He discussed the problem with Dr.Charles T. Jackson, a physician and scientistCharles T. Jackson, a physician and scientistwho suggested that he try ether.who suggested that he try ether.


3/45


Anxiety and pain can be modified by bothAnxiety and pain can be modified by bothpsychological and pharmacologicalpsychological and pharmacological

techniques.techniques. In some instances, psychological approachesIn some instances, psychological approaches

are sufficient. However, in many instances,are sufficient. However, in many instances,pharmacological approaches are required.pharmacological approaches are required.


4/45


5/45


The use of sedation and general anesthesia inThe use of sedation and general anesthesia indentistry is safe and effective when properlydentistry is safe and effective when properly

administered by trained individuals.administered by trained individuals.

General anesthesia (GA) is when you areGeneral anesthesia (GA) is when you aretotally unconscious. In this state, you can'ttotally unconscious. In this state, you can'tfeel any pain, even without local anesthesia.feel any pain, even without local anesthesia.


6/45


In General anesthesia patient can't reliablyIn General anesthesia patient can't reliablybreathe on his own, so for more complexbreathe on his own, so for more complex

procedures (such as fillings - these areprocedures (such as fillings - these areactually more complex than extractions underactually more complex than extractions underGA!) and procedures of longer duration youGA!) and procedures of longer duration youneed to having a "breathing tube" inserted.need to having a "breathing tube" inserted.


7/45

Minimizing the RiskMinimizing the Risk

Dentists who are qualified to utilize sedation andDentists who are qualified to utilize sedation andgeneral anesthesia have a responsibility to minimize riskgeneral anesthesia have a responsibility to minimize riskto patients undergoing dental treatment by:to patients undergoing dental treatment by:

Using only those drugs and techniques in which theyUsing only those drugs and techniques in which theyhave been appropriately trained;have been appropriately trained;

Limiting use of these modalities to patients who requireLimiting use of these modalities to patients who requirethem;them;

Conducting a preoperative evaluation of each patientConducting a preoperative evaluation of each patient

consisting of at least a thorough review of medical andconsisting of at least a thorough review of medical anddental history, a focused clinical examination anddental history, a focused clinical examination andconsultation, when indicated, with appropriate medicalconsultation, when indicated, with appropriate medicaland dental personnel;and dental personnel;


8/45


Conducting physiologic and visual monitoring of the patient;Conducting physiologic and visual monitoring of the patient;

Having available appropriate emergency drugs, equipment andHaving available appropriate emergency drugs, equipment andfacilities and maintaining competency in their use;facilities and maintaining competency in their use;

Maintaining fully documented records of drugs used, dosage,Maintaining fully documented records of drugs used, dosage,vital signs monitored, adverse reactions, recovery from thevital signs monitored, adverse reactions, recovery from theanesthetic, and, if applicable, emergency procedures employed;anesthetic, and, if applicable, emergency procedures employed;

Utilizing sufficient support personnel who are properly trained forUtilizing sufficient support personnel who are properly trained forthe functions they are assigned to perform;the functions they are assigned to perform;

Treating high-risk patients in a setting equipped to provide forTreating high-risk patients in a setting equipped to provide fortheir caretheir care..


9/45


Throughout the IV Sedation procedure, patient`sThroughout the IV Sedation procedure, patient`spulse and oxygen levels are measured using a "pulsepulse and oxygen levels are measured using a "pulseoximeter".oximeter".

This gadget clips onto a finger or an earlobe andThis gadget clips onto a finger or an earlobe andmeasures pulse and oxygen saturation.measures pulse and oxygen saturation.

It gives a useful early warning sign if you're gettingIt gives a useful early warning sign if you're gettingdangerously low on oxygendangerously low on oxygen unresponsivenessunresponsiveness

slow breathing.slow breathing.

Blood pressure before and after the IV SedationBlood pressure before and after the IV Sedationprocedure should be checkedprocedure should be checked


10/45

IV SedationIV Sedation

In contrast, what is usually called "IVIn contrast, what is usually called "IVsedation in dentistry is conscious sedation.sedation in dentistry is conscious sedation.

Conscious sedation is a minimally depressedConscious sedation is a minimally depressedlevel of consciousness during which thelevel of consciousness during which thepatient is able to breathe independentlypatient is able to breathe independentlyand/or respond purposely to verbaland/or respond purposely to verbal

command.command.


11/45


When a drug, usuallyWhen a drug, usuallyof the anti-anxietyof the anti-anxietyvariety, isvariety, isadministered into theadministered into theblood system duringblood system duringdental treatment,dental treatment,this is referred to asthis is referred to asIntravenousIntravenousConscious Sedation.Conscious Sedation.

Conscious sedation isConscious sedation issometimessometimes(incorrectly) referred(incorrectly) referredto as "twilight sleep"to as "twilight sleep"or "sleep dentistry".or "sleep dentistry".


12/45


The drugs which are usually used for IVThe drugs which are usually used for IVsedation are not painkillers (although somesedation are not painkillers (although somepain-killing drugs are occasionally added), butpain-killing drugs are occasionally added), butanti-anxiety drugs.anti-anxiety drugs.

While they relax you and make patient forgetWhile they relax you and make patient forgetwhat happens, he will still need to be numbedwhat happens, he will still need to be numbed


13/45

IV Sedation: Drugs usedIV Sedation: Drugs used

Anti-anxiety sedatives ("benzos"): MidazolamAnti-anxiety sedatives ("benzos"): Midazolamand Diazepamand Diazepam

For procedures up to about 1 1/2 hoursFor procedures up to about 1 1/2 hours IV administered benzos have 3 main effects:IV administered benzos have 3 main effects:

they reduce anxiety/relax patient, they makethey reduce anxiety/relax patient, they makehim sleepy, and they produce partial or total.him sleepy, and they produce partial or total.

Total amnesia is more common with midazolamTotal amnesia is more common with midazolam

compared to diazepamcompared to diazepamThe Venflon is the reversal agent for benzosThe Venflon is the reversal agent for benzos

(Flumazenil)(Flumazenil)


14/45


Barbiturates(sleep-inducing drugs)Barbiturates(sleep-inducing drugs)

For procedures more than 2 hoursFor procedures more than 2 hours

The only barbiturate which is still occasionallyThe only barbiturate which is still occasionallyused is called Pentobarbital Sodium (tradename:used is called Pentobarbital Sodium (tradename:Nembutal).Nembutal).

In the absence of a trained anesthesiologist,In the absence of a trained anesthesiologist,barbiturates are pretty dangerous to use, for abarbiturates are pretty dangerous to use, for a

number of reasons: it's very easy to have thenumber of reasons: it's very easy to have thepatient slip into general anaesthesia by mistake,patient slip into general anaesthesia by mistake,where breathing and heart rate are dangerouslywhere breathing and heart rate are dangerouslylowered and coma and death can follow. Andlowered and coma and death can follow. Andthere's no reversal agent.there's no reversal agent.


15/45


OpioidsOpioids can be used as an add-on to either benzos (forcan be used as an add-on to either benzos (for

procedures up to about 1 1/2 hours) orprocedures up to about 1 1/2 hours) or

barbiturates (for procedures longer than 2 hours).barbiturates (for procedures longer than 2 hours).

Opioids are always used in the so-calledOpioids are always used in the so-calledJorgensen technique (which in its basic formJorgensen technique (which in its basic forminvolves pentobarbital, an opioid, and aninvolves pentobarbital, an opioid, and ananticholinergic) sometimes used in the US foranticholinergic) sometimes used in the US for

procedures taking 2 hours or more.procedures taking 2 hours or more.


16/45


OpioidsOpioids can be used as an add-on to either benzos (forcan be used as an add-on to either benzos (for

procedures up to about 1 1/2 hours) orprocedures up to about 1 1/2 hours) or

barbiturates (for procedures longer than 2 hours).barbiturates (for procedures longer than 2 hours).

Opioids are always used in the so-calledOpioids are always used in the so-calledJorgensen technique (which in its basic formJorgensen technique (which in its basic forminvolves pentobarbital, an opioid, and aninvolves pentobarbital, an opioid, and ananticholinergic) sometimes used in the US foranticholinergic) sometimes used in the US for

procedures taking 2 hours or more.procedures taking 2 hours or more.


17/45


OpioidsOpioids

Opioids which may be used for IV sedationOpioids which may be used for IV sedation

include:include:

Meperidine (Demerol)Meperidine (Demerol)

MorphineMorphine

Butorphanol (Stadol)Butorphanol (Stadol)

Nalbuphine (Nubain)Nalbuphine (Nubain)

Fentanyl (Sublimaze)Fentanyl (Sublimaze)

Pentazocine (Talwin)Pentazocine (Talwin)


18/45


PropofolPropofol

Some anaesthetists use Propofol instead ofSome anaesthetists use Propofol instead of

benzos.benzos.

The advantage of this is the very rapidThe advantage of this is the very rapidrecovery time, less than 5 mins.recovery time, less than 5 mins.

The disadvantage is the drug must beThe disadvantage is the drug must becontinuously administered, so the drug iscontinuously administered, so the drug ispumped in using an electric infusion pump,pumped in using an electric infusion pump,the dose rate is set by the anaesthetist.the dose rate is set by the anaesthetist.


19/45

IV Sedation: CautionIV Sedation: Cautionand Contraindicationand Contraindication

IV sedation is EXTREMELY safe when carriedIV sedation is EXTREMELY safe when carriedout under the supervision of a specially-out under the supervision of a specially-trained dentist.trained dentist.

Purely statistically speaking, it's even saferPurely statistically speaking, it's even saferthan local anaesthetic on its own!than local anaesthetic on its own!


20/45


21/45

Oral SedationOral Sedation

Most commonly, oral sedation (usually in theMost commonly, oral sedation (usually in theform of anti-anxiety or "happy pills") isform of anti-anxiety or "happy pills") isprescribed for relieving anxiety in the hoursprescribed for relieving anxiety in the hoursimmediately before a dental appointment.immediately before a dental appointment.

An anti-anxiety or sedative-hypnotic drugAn anti-anxiety or sedative-hypnotic drugtaken the night before the appointment, antaken the night before the appointment, an

hour before going to bed, can help with fallinghour before going to bed, can help with fallingasleep and getting some rest.asleep and getting some rest.


22/45


Anti-Anxiety Pills (Benzodiazepines or "Benzos")Anti-Anxiety Pills (Benzodiazepines or "Benzos")

In dentistry, the most commonly prescribed drugs for (orIn dentistry, the most commonly prescribed drugs for (orrather against =)) anxiety belong to the "benzodiazepine"rather against =)) anxiety belong to the "benzodiazepine"family. You've probably heard of them by their tradenames -family. You've probably heard of them by their tradenames -for example, Valium, Halcion, Xanax, or Ativan.for example, Valium, Halcion, Xanax, or Ativan.

Benzos directly and efficiently decrease anxiety by bindingBenzos directly and efficiently decrease anxiety by bindingwith receptors in the brain which tone down activity in thosewith receptors in the brain which tone down activity in thoseparts of the brain responsible for fear.parts of the brain responsible for fear.

Benzodiazepines come in two flavours:Benzodiazepines come in two flavours: Sedative-Hypnotics: drugs which induce a calming effect,Sedative-Hypnotics: drugs which induce a calming effect,

including drowsiness ("sedation"). In higher doses, they induce aincluding drowsiness ("sedation"). In higher doses, they induce astate resembling physiological sleep ("hypnosis").state resembling physiological sleep ("hypnosis").

Anti-Anxiety Drugs: drugs which act primarily to relieve anxietyAnti-Anxiety Drugs: drugs which act primarily to relieve anxietyand make you feel calm.and make you feel calm.


23/45


Anti-Anxiety Pills (Benzodiazepines orAnti-Anxiety Pills (Benzodiazepines or"Benzos)"Benzos)

While all benzodiazepines act as sedativesWhile all benzodiazepines act as sedativesAND anti-anxiety drugs, some are moreAND anti-anxiety drugs, some are moretargeted at brain areas which control sleeptargeted at brain areas which control sleepand wakefulness, while others are moreand wakefulness, while others are more

specifically targeted at brain areas whichspecifically targeted at brain areas whichcontrol emotions such as fear.control emotions such as fear.


24/45


Anti-Anxiety Pills (Benzodiazepines orAnti-Anxiety Pills (Benzodiazepines or"Benzos)"Benzos)

The classification of whether a benzodiazepineThe classification of whether a benzodiazepineis sedative-hypnotic or anti-anxiety is to someis sedative-hypnotic or anti-anxiety is to someextent an arbitrary one, as the boundaries areextent an arbitrary one, as the boundaries arequite fluid. As a rule of thumb, in higher dosesquite fluid. As a rule of thumb, in higher dosesbenzos act like sedatives and may promotebenzos act like sedatives and may promote

sleep, while in lower doses, they simply reducesleep, while in lower doses, they simply reduceanxiety without sedation.anxiety without sedation.


25/45


To do?To do?

List Benzodiazepines according to theirList Benzodiazepines according to their

sedative or Anti-Anxiety effectssedative or Anti-Anxiety effects


26/45


Non-benzodiazepine hypnotic anti-anxietyNon-benzodiazepine hypnotic anti-anxietydrugs - Ambien and Sonatadrugs - Ambien and Sonata

Ambien (that's the tradename for zolpidemAmbien (that's the tradename for zolpidemtartrate) is a strong sedative with only mildtartrate) is a strong sedative with only mildanxiety-reducing properties.anxiety-reducing properties.

Usual dose: 10 mg one hour before bedtime.Usual dose: 10 mg one hour before bedtime.


27/45


"Sleeping pills" (Barbiturates)"Sleeping pills" (Barbiturates)

Only the short-acting barbiturates,Only the short-acting barbiturates,pentobarbital sodium (tradename: Nembutal)pentobarbital sodium (tradename: Nembutal)and secobarbital sodium (tradename: Seconal)and secobarbital sodium (tradename: Seconal)are occasionally used in dentistry. The averageare occasionally used in dentistry. The averagerecommended dose for adults is 100 mg onerecommended dose for adults is 100 mg onehour before the scheduled appointment forhour before the scheduled appointment for

Nembutal, and 100-200 mg one hour before theNembutal, and 100-200 mg one hour before theappointment for Seconal.appointment for Seconal.


28/45


Antihistamines - Atarax and PhenerganAntihistamines - Atarax and Phenergan

While antihistamines are primarily used toWhile antihistamines are primarily used tomanage allergies, several of them have anmanage allergies, several of them have aninteresting side effect: sedation! Someinteresting side effect: sedation! Someantihistamines, including Atarax andantihistamines, including Atarax andPhenergan, have a strong calming and sleep-Phenergan, have a strong calming and sleep-inducing effect, and are marketed primarily asinducing effect, and are marketed primarily as

sedative-hypnotics. They also help to preventsedative-hypnotics. They also help to preventnausea and being sick.nausea and being sick.


29/45


Antihistamines - Atarax and PhenerganAntihistamines - Atarax and Phenergan

While antihistamines are primarily used toWhile antihistamines are primarily used tomanage allergies, several of them have anmanage allergies, several of them have aninteresting side effect: sedation! Someinteresting side effect: sedation! Someantihistamines, including Atarax andantihistamines, including Atarax andPhenergan, have a strong calming and sleep-Phenergan, have a strong calming and sleep-inducing effect, and are marketed primarily asinducing effect, and are marketed primarily as

sedative-hypnotics. They also help to preventsedative-hypnotics. They also help to preventnausea and being sick.nausea and being sick.


30/45


31/45


32/45

Nitrous OxideNitrous Oxide

Nitrous oxide gas, often referred to asNitrous oxide gas, often referred to aslaughing gas or sweet air, is an effectivelaughing gas or sweet air, is an effectiveanesthetic drug that has many benefits foranesthetic drug that has many benefits forpatients seeking dental treatment.patients seeking dental treatment.

The benefits of nitrous oxide are many, andThe benefits of nitrous oxide are many, andthe risks are few. The gas is administeredthe risks are few. The gas is administered

with a comfortable mask placed over thewith a comfortable mask placed over thenose, and the patient is instructed to breathenose, and the patient is instructed to breathein through the nose and out through theirin through the nose and out through theirmouth.mouth.


33/45


As a precaution, patients should not eatAs a precaution, patients should not eatanything for about two hours prior to use ofanything for about two hours prior to use ofthe gas. The patient begins to feel a pleasantthe gas. The patient begins to feel a pleasantlevel of sedation anywhere from 30 secondslevel of sedation anywhere from 30 secondsto three or four minutes. The cheeks andto three or four minutes. The cheeks andgums will also begin to feel numb in about agums will also begin to feel numb in about athird of the patients.third of the patients.


34/45


After the gas is adjusted to the appropriateAfter the gas is adjusted to the appropriatedose and the patient is relaxed and sedated,dose and the patient is relaxed and sedated,the dentist can comfortably give the injectionthe dentist can comfortably give the injection(if needed) to the patient, and then proceed(if needed) to the patient, and then proceedwith dental treatment.with dental treatment.


35/45


After the treatment is completed, the patientAfter the treatment is completed, the patientis given pure oxygen to breathe for about fiveis given pure oxygen to breathe for about fiveminutes, and all the effects of sedation areminutes, and all the effects of sedation areusually reversed. Unlike IV sedation orusually reversed. Unlike IV sedation orgeneral anesthesia, the patient can almostgeneral anesthesia, the patient can almostalways leave the office by themselves,always leave the office by themselves,without an escort.without an escort.


36/45


Nitrous oxide has few side effects.Nitrous oxide has few side effects.

High doses can cause nausea in someHigh doses can cause nausea in some

patients, and about 10 percent of patients dopatients, and about 10 percent of patients donot benefit from it. Patients that arenot benefit from it. Patients that areclaustrophobic or have blocked nasalclaustrophobic or have blocked nasalpassages cannot use nitrous oxide effectively.passages cannot use nitrous oxide effectively.


37/45


Nitrous oxide has few side effects.Nitrous oxide has few side effects.

Nitrous oxide is one of the safest anestheticsNitrous oxide is one of the safest anesthetics

available. Interestingly, it is also routinelyavailable. Interestingly, it is also routinelyused by anesthesiologists for generalused by anesthesiologists for generalanesthesia in combination with other moreanesthesia in combination with other morepotent gases.potent gases.


38/45


Dentists find nitrous oxide especially usefulDentists find nitrous oxide especially usefulfor fearful patients as well as young children.for fearful patients as well as young children.

The effect of nitrous oxide is oftenThe effect of nitrous oxide is oftenremarkable. A patient that was anxious just aremarkable. A patient that was anxious just aminute or two before treatment will becomeminute or two before treatment will becomerelaxed and calm.relaxed and calm.

Because nitrous oxide is so effective, dentistsBecause nitrous oxide is so effective, dentistsrarely need to prescribe Valium for anxiousrarely need to prescribe Valium for anxiouspatients before treatment.patients before treatment.


39/45

Nitrous oxideNitrous oxide

Technique of Nitrous Oxide/OxygenTechnique of Nitrous Oxide/OxygenAdministrationAdministration

Nitrous oxide/oxygen must be administeredNitrous oxide/oxygen must be administeredonly by appropriately licensed individuals, oronly by appropriately licensed individuals, orunder the direct supervision thereof, accordingunder the direct supervision thereof, accordingto state law.to state law.

The practitioner responsible for the treatmentThe practitioner responsible for the treatment

of the patient and/or the administration ofof the patient and/or the administration ofanalgesic/anxiolytic agents must be trained inanalgesic/anxiolytic agents must be trained inthe use of such agents and techniques andthe use of such agents and techniques andappropriate emergency response.appropriate emergency response.


40/45


Selection of an appropriately-sized nasal hoodSelection of an appropriately-sized nasal hoodshould be made.should be made.

A flow rate of 5 to 6 liters/minute generally isA flow rate of 5 to 6 liters/minute generally is

acceptable to most patients.acceptable to most patients.The flow rate can be adjusted after observationThe flow rate can be adjusted after observation

of the reservoir bag.of the reservoir bag.


41/45


The bag should pulsate gently with each breathThe bag should pulsate gently with each breathand should not be either over- or underinflated.and should not be either over- or underinflated.

Introduction of 100% oxygen for 1 to 2 minutesIntroduction of 100% oxygen for 1 to 2 minutes

followed by titration of nitrous oxide in 10%followed by titration of nitrous oxide in 10%intervals is recommended. During nitrousintervals is recommended. During nitrousoxide/oxygen analgesia/anxiolysis, theoxide/oxygen analgesia/anxiolysis, theconcentration of nitrous oxide should notconcentration of nitrous oxide should notroutinely exceed 50%.routinely exceed 50%.


42/45


Nitrous oxide concentration may beNitrous oxide concentration may bedecreased during easier procedures (e.g.,decreased during easier procedures (e.g.,restorations) and increased during morerestorations) and increased during morestimulating ones (e.g., extraction, injection ofstimulating ones (e.g., extraction, injection oflocal anesthetic). During treatment, it islocal anesthetic). During treatment, it isimportant to continue the visual monitoring ofimportant to continue the visual monitoring ofthe patient's respiratory rate and level ofthe patient's respiratory rate and level of

consciousness. The effects of nitrous oxideconsciousness. The effects of nitrous oxidelargely are dependent on psychologicallargely are dependent on psychologicalreassurance.reassurance.


43/45


Therefore, it is important to continueTherefore, it is important to continuetraditional behavior guidance techniquestraditional behavior guidance techniquesduring treatment. Once the nitrous oxide flowduring treatment. Once the nitrous oxide flow

is terminated, 100% oxygen should beis terminated, 100% oxygen should bedelivered for 3 to 5 minutes. The patient mustdelivered for 3 to 5 minutes. The patient mustreturn to pre-treatment responsivenessreturn to pre-treatment responsivenessbefore discharge.before discharge.

Nitrous O ideNitrous Oxide:


44/45

Nitrous Oxide:Nitrous Oxide:ContraindicationsContraindications

Contraindications for use of nitrousContraindications for use of nitrousoxide/oxygen inhalation may include:oxide/oxygen inhalation may include:

Some chronic obstructive pulmonary diseasesSome chronic obstructive pulmonary diseases

Severe emotional disturbances or drug-Severe emotional disturbances or drug-related dependenciesrelated dependencies

First trimester of pregnancyFirst trimester of pregnancy

Treatment with bleomycin sulfateTreatment with bleomycin sulfate

Nitrous Oxide PotentialNitrous Oxide: Potential


45/45

Nitrous Oxide: PotentialNitrous Oxide: Potentialharmharm

For some patients the feeling of "losing control" withFor some patients the feeling of "losing control" withnitrous oxide may be troubling, and claustrophobicnitrous oxide may be troubling, and claustrophobicpatients may find the nasal hood confining andpatients may find the nasal hood confining andunpleasant.unpleasant.

Side effects of nitrous oxide include nausea, vomiting,Side effects of nitrous oxide include nausea, vomiting,headache, and disorientation.headache, and disorientation.

Lack of potency of nitrous oxide/oxygen inhalationLack of potency of nitrous oxide/oxygen inhalation

Interference of the nasal hood with injection to anteriorInterference of the nasal hood with injection to anteriormaxillary regionmaxillary region

Nitrous oxide pollution and potential occupationalNitrous oxide pollution and potential occupationalexposure health hazardsexposure health hazards

Date post:	30-May-2018
Category:	Documents
Upload:	iyad-abou-rabii
View:	223 times
Download:	0 times

General Anesthesia and Sedation in Dentistry

Documents