1. CONSCIOUS SEDATION FOR
DENTAL PROCEDURES

2. Level of Sedation Awake Conscious sedation ( sedoanalgesia)
Deep sedation
General anesthesia

3. Conscious Sedation
A minimally depressed level of consciousness which allows the patient to independently and continuously maintain a patent airway and respond appropriately to verbal commands
Anxiolysis
Moderate Sedation

4. Consciousness
Protective reflexes
Patent air way
Verbal contact

5. Deep Sedation
A controlled state of depressed consciousness accompanied by a partial loss of
protective reflexes and
the ability to respond appropriately to verbal commands

6. C.N.S.Depressants Narcotics Tranquilizers Sedatives Hypnotics
Induction agents
Anticonvulsants

7. General Anesthesia
The elimination of all sensation accompanied by the loss of consciousness

8. Stages of General Anesthesia
Stage I
Analgesia
Stage II
Delirium
Stage III
Surgical anesthesia
4 planes of surgical anesthesia

9. Stages of General Anesthesia
Stage IV
Medullar paralysis

10. Provider Responsibilities
Pre-Procedure preparation
Pre-Procedure Patient Assessment
Intraoperative Responsibilities
Post-operative Responsibilities

11. Provider Responsibilities
Pre-Procedure preparation
Equipment
Instruments
Venipuncture
Monitors
Emergency Supplies
“Crash Cart”
Cardiac Monitor
Medications

12. Diphenhydramine Antihistamine that works at H-1 receptors.
Used for mild sedation & its antihistamine properties.
May cause paradoxical excitement.
May produce hypotension, tachycardia, and urinary retention.
Use with caution in infants and young children.

13. Provider Responsibilities
Pre-Procedure Patient Assessment
Vital Signs
Allergies
Contacts/Dentures
NPO status
Air way
Changes in medical history
URI
Hospitalizations
Sick family members

14. Airway Assessment
This picture represents a Mallampati Class One airway. The entire uvula and tonsillar pillars are seen. This individual should be easy to mask ventilate or to intubate with a laryngoscope and endotracheal tube.

15. Airway Assessment
This picture represents a Mallampati Class Three airway. None of the uvula or tonsillar pillars are seen. This individual may hard to mask ventilate, and quite difficult to intubate.

16. Airway Assessment
This image is representative of an extremely short thyromental distance, indicating tremendous difficulty in tracheal intubation, and possible difficulty establishing a satisfactory mask seal.

17. Special Considerations
Pediatric patients
Not “little adults”
Geriatric patients
Unique subclass of patients with physiological changes complicating treatment

18. “Show Stoppers” Food or fluid intake 6 hours prior to surgery
Clear fluid intake within 2 hours of surgery
Can read newspaper print when looking through liquid
Recent alcohol ingestion
Recreational drug use
Pregnancy
Thyroid Dysfunction

19. “Show Stoppers” Recent asthma attack or respiratory failure
Treatment with MAO inhibitors
Tricyclic Antidepressants
Adrenal Dysfunction
Renal Dysfunction

20. Provider Responsibilities
Pre-Procedure Patient Assessment
Informed Consent
Escort Present
Establishes patient’s mental status
Under the influence of alcohol or drugs
Oriented to person, place, time
Documentation

21. A.S.A physical status classification
Class I A normal, healthy patient.
Class II A patient with mild systemic disease.
Class III A patient with severe systemic disease.
Class IV A patient with disease that is a constant threat to his life.
Class V A moribund patient who is not expected to survive without operation.

22. Provider Responsibilities
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

23. Provider Responsibilities
Intr-aoperative Responsibilities
Vital Signs BP
Heart Rate
Respiratory Rate
Oxygen Saturation
Level of Consciousness

24. Provider Responsibilities
Post-operative Responsibilities
Vital Signs at least every 5 minutes BP
Heart Rate
Respiratory Rate
Oxygen Saturation
Level of Consciousness
Sedated patients must be continuously monitored until discharged

26. FACILITIES
The location should be of adequate size equipped to deal with
a cardiopulmonary emergency. This must include:
Tilted operating table, trolley or chair.  
Adequate suction and room lighting.
A supply of oxygen and suitable devices.

27. FACILITIES (2)
Adequate equipments for artificial ventilation and airway management
- Appropriate drugs for cardiopulmonary resuscitation.
- Intravenous equipment.
- Pulse oxymeter.
- Defibrillator.

28. FACILITIES (3) Emergency drugs should include at least the following:
Adrenaline, atropine
Dextrose 50%
Lignocaine
Naloxone, Flumazenil

29. MONITORING
Pulse oxymeter
B Blood pressure
ECG
Capnometry .

30. The following values are indicative of the “normal” adult patient
The following values are indicative of the “normal” adult patient. Pediatric and Geriatric patients have different values and unique characteristics for which the anesthesiologist/surgeon must be aware

31. Blood Pressure Specifically mean arterial pressure (MAP) MAP
Systolic BP – Diastolic BP/3 + Diastolic BP
Also written as Diastolic BP + 1/3 Pulse Pressure
Normal
Body loses auto regulatory capacity at a MAP less than 50 or greater than 150

32. Heart Rate
Normal range 60-90

33. Respiratory Rate
Normal range per minute

34. Oxygen Saturation Must be greater than 90%
Supplemental oxygen via nasal canula
Initially 2-3 liters/minute

35. OXYGENATION Degrees of hypoxemia occur frequently during intravenous
sedation without oxygen supplementation.
Oxygen administration
Pulse oxymetry

36. Recommended Alarm Limits
Low High
Systolic BP
Diastolic BP
Rate BPM
SP O

37. Level of Consciousness
Must be able to respond to verbal stimuli by the surgeon in the clinic
May be greatly sedated or unable to arouse by verbal stimuli in the operating room

38. Provider Responsibilities
Post-operative Responsibilities
ALDRETE Post-Operative Scoring System
A cumulative score of 8 or above is necessary for discontinuation of monitoring
We generally use a goal of 10 as necessary for dismissal from clinic
Sum of standardized measurements of movement, respiration, circulation, color and level of consciousness

39. Movement
Move all 4 extremities
Move 2 extremities 1
No control

40. Respiration
Breathe deep and cough 2
Dyspnea 1
No respirations

41. Circulation BP +/- 20% pre-sedation level 2

42. Consciousness
Fully alert 2
Arousable 1
No response 0

43. Color
Pink 2
Pale, Dusky, Blotchy 1
Cardboard 0

44. METHODS Sedo –analgesia Ultra light anesthesia R.A Midazolam Fentanyl
Diprivan
Ketamine
R.A
Nitrous oxide

45. 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

46. Midazolam (Dormicom) Short acting benzodiazepine
4 times more potent than Valium
Produces sleepiness and relief of apprehension
Onset of action 3-5 minutes
Half-life
hours
Average sedative dose mg

47. Buccal Midazolam Concentrated formulation – 10mg/ml
Produced by Special Products
Formulated for use in Epileptic Patients

48. Demerol (Pethidine) Narcotic Pain attenuation and some sedation
Onset of action
3-5 minutes
Half-life
30-45 minutes
Average dose
20-50 mg

49. Fentanyl (Sublimaze) Narcotic/Opioid 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

50. The Key to Sedation Local Anesthesia
If a poor local anesthetic block has been given, the patient will continue to feel pain throughout the procedure

51. Additional Medications
Likely to be seen in scenarios where deeper levels of sedation are being performed
Propofol (Diprivan)
Robinul (Glycopyrrolate)

52. 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

53. Robinul (Glycopyrrolate)
Anticholinergic
Heart rate increases
Salivary secretions decrease
Dose mg
Onset of action within 1 minute

54. METHODS Sedo –analgesia Ultra light anesthesia R.A Midazolam Fentanyl
Diprivan
Ketamine
R.A
Nitrous oxide

55. Nitrous oxide Minimum oxygen flow of 2.5 litres/minute.
Maximum flow of 10 litres/minute of nitrous oxide.
Minimum of 30% oxygen.
Ability for 100% oxygen.

56. Nitrous oxide
Ability to cut off nitrous oxide, and opens the system to allow the patient to breathe room air.
Non-return valve to prevent re-breathing.
Reservoir bag.
Ability of scavenging of expired gases .
Low gas flow alarm.
Risks of chronic exposure to nitrous oxide .

57. Nitrous oxide 6 - 25%---------------------Moderate analgesia.
% Dissociative analgesia.
% Near complete amnesia.
% Light anesthesia.

58. Medical Emergency Syncope Hypoglycemia Hypotension Hypertension
Bronchospasm
Laryngospasm
Apnea
Myocardial infarction
Stroke

59. Medical Emergency Know when and how to activate a “Code Blue”
Location of Crash Cart
Medications
Monitors
Location of emergency medications
BLS

60. 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

61. Emergency Drugs These are included for reference only
Dentists should not be administering medications to patients without advanced training in ACLS

62. Emergency Drugs Flumazenil (Romazicon) Naloxone (Narcan)
Esmolol (Brevibloc)
Ephedrine
Epinephrine
Atropine
Dextrose 50%
Lignocaine

63. 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

64. Naloxone (Narcan) Narcotic antagonist Initial dose – 0.4mg
Fentanyl reversal agent
Initial dose – 0.4mg
May repeat every 2-3 minutes at doses of mg
Monitor for re-sedation

65. Esmolol (Brevibloc) Antihypertensive Beta blocker
Initial dose 0.25 –1.0 mg/kg over 30 seconds
Short half-life of approximately 10 minutes

66. Ephedrine Used for hypotension Sympathomimetic Initial dose 5-10mg
Action may not be seen for several minutes

67. Atropine Significant bradycardia or asystole Anticholinergic
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

68. Epinephrine True emergency medication
Administration should be preceded by activation of the emergency response system

69. Questions