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Without doubt, great majority of cases like routine restorative techniques or surgery in dental office may be satisfactorily managed through the use of local anaesthesia alone. Yet, the possibility of pain and fear of local aneasthesia or L.A. do exists in patients of all age groups.
How can we manage these overly fearful patients? The answer is to induce a state of consciousness in which a person is more relaxed and carefree than previously.
A variety of techniques are available to the dental and medical professionals to aid in the management of a patient's fears and anxieties regarding dental care and surgery.
Over the years many names are given to this state. Terms like chemamneria, twilight sleep, relative analgesia, co - medication were used which is now called as sedation. This state of altered consciousness allows the dentist to control pain reaction as well as pain perception with patient in a conscious state.
Sedation in dentistry refers to the use of various pharmacological agents to relax the patient and decrease the anxiety before and during a dental appointment.
It is one of the stages of anaesthesia in which the patient is still conscious but is under the influence of a depressant drug. (central nervous system depressant)
The class of drugs used for the same are called sedatives. These pharmacological agents act on central nervous system and depress the areas responsible for conscious awareness.
There are different degrees of central nervous system depression, each corresponding to a level of relaxation which ranges from minimal, moderate to deep sedation.
In general, minimal sedation refers to a patient who has reduced anxiety but is readily responds to verbal or physical stimulation. With moderate sedation the patient is even more relaxed, and will respond to purposeful stimulation. In deep sedation, the patient may not exhibit any signs of consciousness and therefore be unresponsive to stimulation
Few terms we need to know:-
General anaesthesia - it refers to the elimination of all sensation, accompanied by the loss of consciousness.
Conscious sedation - a minimally depressed level of consciousness that retains the patients ability to independently and continuously maintain an airway and respond appropriately to physical stimulation and verbal command and that is produced by a pharmacological or non pharmacological method or combination of both.
Deep sedation - a controlled, pharmacologically induced state of depressed 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 or respond purposefully to physical stimulation or verbal command.
OBJECTIVES OF SEDATION :
The goal of sedation is to have a responsive patient, whose fear or anxiety is diminished.
The patient's mood must be altered: The primary objective of sedative techniques is to alter the patient's mood so that a procedure that was previously psychologically unacceptable now becomes readily acceptor.
This helps patients undergo treatment in a relaxed, comfortable, safe state.
Sedative technique is not used to control or criminate pain.
The goal of conscious sedation is to eliminate fear and apprehension and thereby aid in control of pain reaction. Control of pain perception will be gained by judicious addition of regional analgesia.
The patient must remain co-operative: certainly when regional analgesia is being used for the control of operative pain, the co-operation of the patient is imperative. However, if the fearful patient has been calmed and his mood altered, pt. co-operation will follow.
The pain threshold should be elevated: Though dentists rely on regional analgesia for the control of operative pain, it is advantageous to choose drugs for conscious - sedation that also elevate the pain threshold at CNS system level.
All protective reflexes must remain active: In the conscious state, the pt. will maintain his airway clear of secretions and patent at all times.
The possibility of airway obstruction of soft tissue, as occurs when consciousness is lost, is absent.
In addition, the presume of respiratory system. Reflexes will prevent the patient from becoming hypoxia.
There should be only minor deviations in the patients vital signs :
Patient's physiology is not altered to the extent seen in an unconscious state.
There may be a degree of amnesia : Depending on the drugs and dose used, amnesia may be produced. This may easily be accomplished if desired in the conscious patient.
Types of sedation
Pharmacosedation- Techniques of sedation requiring the administration of drugs to achieve a desirable clinical effect.
Iatrosedation- Those that do not require administration of drugs.
Iatrosedation- Defined as the relief of anxiety through the doctor's behavior. It is the building block for all other forms of psychosedation.
Simply stated, iatrosedation is a technique of communications b/w the doctor and the patient that creates a bond of trust and confidence.
Patients possessing trust and confidence in their doctor are well on their way to being more relaxed and co-operative
Another benefit : Prevention of possible medicolegal complications.
In some situations iatrosedation alone may remove all of the patients fears and anxieties concerning the treatment, permitting us to then proceed in a normal manner, without the need for pharmacosedation. More often, however, iatrosedation produces a decrease in the patients level of anxiety to the point that use of supplemental pharmacosedation will enable the patient to more readily accept and tolerate the planned treatment.
Other Non drug psychosedative techniques
When employed by a trained hypnotherapist, in the proper clinical environment, and on an appropriate patient, hypnosis has proved to be a highly effective means of achieving both relaxed and a pain - tree treatment environment.
ELECTRONIC DENTAL ANESTHESIA (EDA).
Drugs may be administered through 14 routes. The first 13 of these routes are used within the practice of medicine, with the first 10 used in dentistry. The last one is used in veterinary medicine. These routes are as follows:
Intrathecal (within the spinal cord)
The oral route is most common route
In contrast to the inhalation route, the oral route is the most convenient but also the least reliable.
Easy to administer
Decreased incidence of adverse reactions
No use of needles, syringes, or equipment
No specialized training.
It relies on patient compliance
Prolonged latent period
Erratic and incomplete absorption of drugs from the gastrointestinal tract
Inability to titrate
Prolonged duration of action
Dependable and convenient route of drug administration
Short recovery period
Effects can be effectively revered by lowering the concentration of agent or by discontinuing it entirely and administration of O2 at room air.
Oral ïƒ 30 min onset.
IM ïƒ 10-15 min.
Rectal - 30 min
IV - 20 sec.
Inhalation - < 20 sec is pulmonary circulation to brain time.
Depth of sedation: may be altered from moment to moment, permitting drug administrator to increase or decrease the depth of sedation.
Duration of action: in situations in which a sedation technique has a relatively fixed duration of action, the planned procedure may be of any length, foreg., a minute or so for the taking of radiographs or 3 to 4 hours for preparation and impression of multiple tooth preparations for fixed bridgework.
Oral - fixed duration of action, approx, 2-3 her
IM - 2-4 her
IV - 45 min.
Inhalation - Duration variable at discretion of administrator.
No injection is required with inhalation sedation
Very few side effects associated with inhalational sedation with nitrous oxide and oxygen.
The drugs used in this technique have no adverse effects on liver, kidneys, brain, or heart.
Equipment cost - high.
O2 and N2O cost - high.
N2O is not a potent agent.
Certain degree of co - operation is required from the patient.
Patients with compulsive personality
Children with behavioural problems.
Patients on psychotropic drugs
Patients with COPD.
Complications of inhalation sedation :
With the exception of inhalational route, I.V. drug administration is most reliable.
Because of its rapid effect, drug doses may be accurately controlled.
Rapid onset of action
Recovery shorter than other techniques
Patent vein is safety factor
Nausea and vomiting are uncommon.
Control of salivary secretions is possible
Gag reflex absent
Venipuncture is necessary
More intensive monitoring required
Recovery not complete - escort needed
Most IV agents can not be reversed.
Patients of < 6 years and > 65 years
Thyroid dysfunction problems
Visible superficial veins cannot be located
For the patients who are unwilling or unable to take drugs orally
Patients with the problem of nausea and vomiting.
Avoidance of injection
Ease of administration
Adsorption by feces, lymphatic drainage, metabolism within luminal mucosal cell does not significantly effect the rectally administered drugs.
Inconvenience to the administrator and the patient
Possible irritation of intestines by some drugs
Inability to reverse the action of the drug easily
Late onset of action.
Deeper levels of anesthesia not obtained.
The main advantage is that the drug directly enters into the systemic circulation almost entirely bypassing the enterohepatic circulation.
However not well suited for sustained delivery systems.
Patient co operation is important to the use of SL route of administration which minimizes its use in many pediatric and other uncooperative patients.
The administration of drugs through skin has existed for a long time. In the past the most commonly applied systems were to: applied creams and ointments for dermatologic disorders. Transdermal delivery system includes all topically administered drug formulations intended to deliver the active ingredient into systemic circulation.
Bypass the hepatic (liver) first pass effect.
Simplified dosage regimens
Enhanced compliance of the patient
Reduced side effects and
Improved disease therapy
INTRANASAL SEDATION :
This is relatively a recent addition to the drug administration armamentarium, IN drugs have been used primarily in pediatric and uncooperative patients as a way to alleviate the need for injection or oral drug administration in unwilling patients.
Absorption of IN drugs occurs directly into the systemic circulation, avoiding enterohepatic circulation.
Onset : 10 min.
INTRAMUSCULAR SEDATION :
IM route of drug administration is a parenteral technique in which the drug enters the CVS system without 1st passing through the G.I. system.
Rapid onset ïƒ 15 min.
Maximal clinical effect ïƒ 30 min.
More reliable absorption. (than oral, rectal).
Patient co-operation not as essential.
Inability to titrate (15 min onset).
Inability to reverse drug action.
Prolonged duration of drug effect.
Possible injury from injection.
Use of IM route :
1. For sedation in the following types of patients :
a) The adult patient, when inhalation and I.V routes are unavailable.
b) Disruptive pediatric adult patient in whom other routes have proved ineffective.
2.Other uses :
a) Premeditation before IV sedation or G.A. in the pre-cooperative pediatric patient or adult or patient with disabilities.
b) Administration of antiemetics or anticholinergics.
c) Administration of emergency drugs when IV administration is not available.
Sloughing of skin.