General Anesthesia and

Sedation In Dentistry
Iyad Abou Rabii
DDS. OMS. MSc. PhD
 General Anesthesia

 Dr. William Morton, a Massachusetts dentist,

was looking for a way to painlessly extract
teeth.
 There was no local or general anesthesia
available to make removing teeth tolerable.
 Although Dr. Morton knew about nitrous oxide
from his association with another dentist, Dr.
Horace Wells, he wanted a more powerful
agent. He discussed the problem with Dr.
Charles T. Jackson, a physician and scientist
who suggested that he try ether.
 General Anesthesia

 Anxiety and pain can be modified by both

psychological and pharmacological
techniques.
 In some instances, psychological approaches
are sufficient. However, in many instances,
pharmacological approaches are required.
 Local and General
Anesthesia
 Local anesthetics are used to control regional
pain. Sedative drugs and techniques may
control fear and anxiety, but do not by
themselves fully control pain and, thus, are
commonly used in conjunction with local
anesthetics.
 General anesthesia provides complete relief
from both anxiety and pain.
 General Anesthesia

 The use of sedation and general anesthesia in

dentistry is safe and effective when properly
administered by trained individuals.
 General anesthesia (GA) is when you are
totally unconscious. In this state, you can't
feel any pain, even without local anesthesia.
 General Anesthesia

 In General anesthesia patient can't reliably

breathe on his own, so for more complex
procedures (such as fillings - these are
actually more complex than extractions under
GA!) and procedures of longer duration you
need to having a "breathing tube" inserted.
 Minimizing the Risk

 Dentists who are qualified to utilize sedation and

general anesthesia have a responsibility to minimize risk
to patients undergoing dental treatment by:
 Using only those drugs and techniques in which they
have been appropriately trained;
 Limiting use of these modalities to patients who require
them;
 Conducting a preoperative evaluation of each patient
consisting of at least a thorough review of medical and
dental history, a focused clinical examination and
consultation, when indicated, with appropriate medical
and dental personnel;
 Minimizing the Risk

 Conducting physiologic and visual monitoring of the patient;

 Having available appropriate emergency drugs, equipment and
facilities and maintaining competency in their use;
 Maintaining fully documented records of drugs used, dosage,
vital signs monitored, adverse reactions, recovery from the
anesthetic, and, if applicable, emergency procedures employed;
 Utilizing sufficient support personnel who are properly trained for
the functions they are assigned to perform;
 Treating high-risk patients in a setting equipped to provide for
their care.
 Minimizing the Risk

 Throughout the IV Sedation procedure, patient`s

pulse and oxygen levels are measured using a "pulse
oximeter".
 This gadget clips onto a finger or an earlobe and
measures pulse and oxygen saturation.
 It gives a useful early warning sign if you're getting
dangerously low on oxygen
 unresponsiveness
 slow breathing.
 Blood pressure before and after the IV Sedation
procedure should be checked
 IV Sedation

 In contrast, what is usually called "IV

sedation” in dentistry is conscious sedation.
 Conscious sedation is a minimally depressed
level of consciousness during which the
patient is able to breathe independently
and/or respond purposely to verbal
command.
 IV Sedation

 When a drug, usually

of the anti-anxiety
variety, is
administered into the
blood system during
dental treatment,
this is referred to as
Intravenous
Conscious Sedation.
 Conscious sedation is
sometimes
(incorrectly) referred
to as "twilight sleep"
or "sleep dentistry".
 IV Sedation

 The drugs which are usually used for IV

sedation are not painkillers (although some
pain-killing drugs are occasionally added), but
anti-anxiety drugs.
 While they relax you and make patient forget
what happens, he will still need to be numbed
IV Sedation: Drugs used

 Anti-anxiety sedatives ("benzos"): Midazolam

and Diazepam
 For procedures up to about 1 1/2 hours
 IV administered benzos have 3 main effects:
they reduce anxiety/relax patient, they make
him sleepy, and they produce partial or total.
Total amnesia is more common with midazolam
compared to diazepam
 The Venflon is the reversal agent for benzos
(Flumazenil)
IV Sedation: Drugs used

 Barbiturates(sleep-inducing drugs)
 For procedures more than 2 hours
 The only barbiturate which is still occasionally
used is called Pentobarbital Sodium (tradename:
Nembutal).
 In the absence of a trained anesthesiologist,
barbiturates are pretty dangerous to use, for a
number of reasons: it's very easy to have the
patient slip into general anaesthesia by mistake,
where breathing and heart rate are dangerously
lowered and coma and death can follow. And
there's no reversal agent.
IV Sedation: Drugs used

 Opioids
 can be used as an add-on to either benzos (for
procedures up to about 1 1/2 hours) or
barbiturates (for procedures longer than 2 hours).
 Opioids are always used in the so-called
Jorgensen technique (which in its basic form
involves pentobarbital, an opioid, and an
anticholinergic) sometimes used in the US for
procedures taking 2 hours or more.
IV Sedation: Drugs used

 Opioids
 can be used as an add-on to either benzos (for
procedures up to about 1 1/2 hours) or
barbiturates (for procedures longer than 2 hours).
 Opioids are always used in the so-called
Jorgensen technique (which in its basic form
involves pentobarbital, an opioid, and an
anticholinergic) sometimes used in the US for
procedures taking 2 hours or more.
IV Sedation: Drugs used

 Opioids
 Opioids which may be used for IV sedation
include:

 Meperidine (Demerol)
 Morphine
 Butorphanol (Stadol)
 Nalbuphine (Nubain)
 Fentanyl (Sublimaze)
 Pentazocine (Talwin)
IV Sedation: Drugs used

 Propofol

 Some anaesthetists use Propofol instead of

benzos.
 The advantage of this is the very rapid
recovery time, less than 5 mins.
 The disadvantage is the drug must be
continuously administered, so the drug is
pumped in using an electric infusion pump,
the dose rate is set by the anaesthetist.
 IV Sedation: Caution
and Contraindication
 IV sedation is EXTREMELY safe when carried
out under the supervision of a specially-
trained dentist.
 Purely statistically speaking, it's even safer
than local anaesthetic on its own!
 IV Sedation: Caution
and Contraindication
 However,
 contraindications include pregnancy, known
allergy to benzos, alcohol intoxication, CNS
depression, and some instances of glaucoma.
 Cautions include psychosis, impaired lung or
kidney or liver function, and advanced age.
Heart disease is generally not a
contraindication.
 Oral Sedation

 Most commonly, oral sedation (usually in the

form of anti-anxiety or "happy pills") is
prescribed for relieving anxiety in the hours
immediately before a dental appointment.
 An anti-anxiety or sedative-hypnotic drug
taken the night before the appointment, an
hour before going to bed, can help with falling
asleep and getting some rest.
 Oral Sedation

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

 In dentistry, the most commonly prescribed drugs for (or

rather against =)) anxiety belong to the "benzodiazepine"
family. You've probably heard of them by their tradenames -
for example, Valium, Halcion, Xanax, or Ativan.
 Benzos directly and efficiently decrease anxiety by binding
with receptors in the brain which tone down activity in those
parts of the brain responsible for fear.
 Benzodiazepines come in two flavours:
 Sedative-Hypnotics: drugs which induce a calming effect,
including drowsiness ("sedation"). In higher doses, they induce a
state resembling physiological sleep ("hypnosis").
 Anti-Anxiety Drugs: drugs which act primarily to relieve anxiety
and make you feel calm.
 Oral Sedation

 Anti-Anxiety Pills (Benzodiazepines or

"Benzos”)
 While all benzodiazepines act as sedatives
AND anti-anxiety drugs, some are more
targeted at brain areas which control sleep
and wakefulness, while others are more
specifically targeted at brain areas which
control emotions such as fear.
 Oral Sedation

 Anti-Anxiety Pills (Benzodiazepines or

"Benzos”)
 The classification of whether a benzodiazepine
is sedative-hypnotic or anti-anxiety is to some
extent an arbitrary one, as the boundaries are
quite fluid. As a rule of thumb, in higher doses
benzos act like sedatives and may promote
sleep, while in lower doses, they simply reduce
anxiety without sedation.
 Oral Sedation

 To do?

List Benzodiazepines according to their

sedative or Anti-Anxiety effects
 Oral Sedation

 Non-benzodiazepine hypnotic anti-anxiety

drugs - Ambien and Sonata
 Ambien (that's the tradename for zolpidem
tartrate) is a strong sedative with only mild
anxiety-reducing properties.
 Usual dose: 10 mg one hour before bedtime.
 Oral Sedation

 "Sleeping pills" (Barbiturates)

 Only the short-acting barbiturates,
pentobarbital sodium (tradename: Nembutal)
and secobarbital sodium (tradename: Seconal)
are occasionally used in dentistry. The average
recommended dose for adults is 100 mg one
hour before the scheduled appointment for
Nembutal, and 100-200 mg one hour before the
appointment for Seconal.
 Oral Sedation

 Antihistamines - Atarax and Phenergan

 While antihistamines are primarily used to
manage allergies, several of them have an
interesting side effect: sedation! Some
antihistamines, including Atarax and
Phenergan, have a strong calming and sleep-
inducing effect, and are marketed primarily as
sedative-hypnotics. They also help to prevent
nausea and being sick.
 Oral Sedation

 Antihistamines - Atarax and Phenergan

 While antihistamines are primarily used to
manage allergies, several of them have an
interesting side effect: sedation! Some
antihistamines, including Atarax and
Phenergan, have a strong calming and sleep-
inducing effect, and are marketed primarily as
sedative-hypnotics. They also help to prevent
nausea and being sick.
Nitrous Oxide
 Nitrous Oxide

 Nitrous oxide gas, often referred to as

laughing gas or sweet air, is an effective
anesthetic drug that has many benefits for
patients seeking dental treatment.
 The benefits of nitrous oxide are many, and
the risks are few. The gas is administered
with a comfortable mask placed over the
nose, and the patient is instructed to breathe
in through the nose and out through their
mouth.
 Nitrous Oxide

 Nitrous oxide gas, often referred to as

laughing gas or sweet air, is an effective
anesthetic drug that has many benefits for
patients seeking dental treatment.
 The benefits of nitrous oxide are many, and
the risks are few. The gas is administered
with a comfortable mask placed over the
nose, and the patient is instructed to breathe
in through the nose and out through their
mouth.
 Nitrous Oxide

 As a precaution, patients should not eat

anything for about two hours prior to use of
the gas. The patient begins to feel a pleasant
level of sedation anywhere from 30 seconds
to three or four minutes. The cheeks and
gums will also begin to feel numb in about a
third of the patients.
 Nitrous Oxide

 After the gas is adjusted to the appropriate

dose and the patient is relaxed and sedated,
the dentist can comfortably give the injection
(if needed) to the patient, and then proceed
with dental treatment.
 Nitrous Oxide

 After the treatment is completed, the patient

is given pure oxygen to breathe for about five
minutes, and all the effects of sedation are
usually reversed. Unlike IV sedation or
general anesthesia, the patient can almost
always leave the office by themselves,
without an escort.
 Nitrous Oxide

 Nitrous oxide has few side effects.

 High doses can cause nausea in some

patients, and about 10 percent of patients do
not benefit from it. Patients that are
claustrophobic or have blocked nasal
passages cannot use nitrous oxide effectively.
 Nitrous Oxide

 Nitrous oxide has few side effects.

 Nitrous oxide is one of the safest anesthetics

available. Interestingly, it is also routinely
used by anesthesiologists for general
anesthesia in combination with other more
potent gases.
 Nitrous Oxide

 Dentists find nitrous oxide especially useful

for fearful patients as well as young children.
 The effect of nitrous oxide is often
remarkable. A patient that was anxious just a
minute or two before treatment will become
relaxed and calm.
 Because nitrous oxide is so effective, dentists
rarely need to prescribe Valium for anxious
patients before treatment.
 Nitrous oxide

 Technique of Nitrous Oxide/Oxygen

Administration
 Nitrous oxide/oxygen must be administered
only by appropriately licensed individuals, or
under the direct supervision thereof, according
to state law.
 The practitioner responsible for the treatment
of the patient and/or the administration of
analgesic/anxiolytic agents must be trained in
the use of such agents and techniques and
appropriate emergency response.
 Nitrous oxide

 Selection of an appropriately-sized nasal hood

should be made.
 A flow rate of 5 to 6 liters/minute generally is
acceptable to most patients.
 The flow rate can be adjusted after observation
of the reservoir bag.
 Nitrous oxide

 The bag should pulsate gently with each breath

and should not be either over- or underinflated.
 Introduction of 100% oxygen for 1 to 2 minutes
followed by titration of nitrous oxide in 10%
intervals is recommended. During nitrous
oxide/oxygen analgesia/anxiolysis, the
concentration of nitrous oxide should not
routinely exceed 50%.
 Nitrous oxide

 Nitrous oxide concentration may be

decreased during easier procedures (e.g.,
restorations) and increased during more
stimulating ones (e.g., extraction, injection of
local anesthetic). During treatment, it is
important to continue the visual monitoring of
the patient's respiratory rate and level of
consciousness. The effects of nitrous oxide
largely are dependent on psychological
reassurance.
 Nitrous oxide

 Therefore, it is important to continue

traditional behavior guidance techniques
during treatment. Once the nitrous oxide flow
is terminated, 100% oxygen should be
delivered for 3 to 5 minutes. The patient must
return to pre-treatment responsiveness
before discharge.
 Nitrous Oxide:
Contraindications
 Contraindications for use of nitrous
oxide/oxygen inhalation may include:
 Some chronic obstructive pulmonary diseases

 Severe emotional disturbances or drug-

related dependencies
 First trimester of pregnancy

 Treatment with bleomycin sulfate

Nitrous Oxide: Potential
harm
 For some patients the feeling of "losing control" with
nitrous oxide may be troubling, and claustrophobic
patients may find the nasal hood confining and
unpleasant.
 Side effects of nitrous oxide include nausea, vomiting,
headache, and disorientation.
 Lack of potency of nitrous oxide/oxygen inhalation

 Interference of the nasal hood with injection to anterior

maxillary region
 Nitrous oxide pollution and potential occupational
exposure health hazards