Different Types of Sedation in Dentistry

There are many techniques used for conscious sedation. It can be pharmacological that is by using drugs to achieve the sedation or it can be by non pharmacological means that is by hypnosis. Basic purpose of sedation is to make the patient free from anxiety and fear of dentistry. So many people they avoid going to the dentist because they are afraid of dentistry. Either they have previous bad experience or they have hear from their friends or peer group. The benefit of sedation is that we can have a calm and anxiety free patient in the dental office that is not afraid of dentistry. We can discuss with the patient about the various techniques of the sedation like oral sedation, inhalation sedation or the IV sedation. The most commonly techniques used are inhalation sedation and the oral sedation.

Different Types of Sedation in Dentistry 

Pharmacosedation - Techniques of sedation requiring the administration of drugs to achieve a desirable clinical effect. 

Latrosedation - Those that do not require administration of drugs.
   
Latrosedation - 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 Psycho sedative techniques in Dentistry

a)    Hypnosis: 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.

b)    Acupuncture.

c)    Acupressure.

d)    Audioanalgesia.

e)    Tens

f)     Electroanesthesia.

g)    Electronic Dental Anesthesia (Eda).

h)   Electrosedation.

Routes of Sedation in Dentistry

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:

1.    Oral

2.   Rectal

3.   Topical

4.   Sublingual

5.   Intranasal

6.   Transdermal

7.   Subcutaneous

8.   Intramuscular

9.   Inhalation

10. Intravenous

11. Intraarterial

12. Intrathecal (within the spinal cord)

13. Intramedullary

14. Intraperitoneal

ORAL SEDATION

  1. The oral route is most common route
  2. In contrast to the inhalation route, the oral route is the most convenient but also the least reliable.

Advantages of oral sedation

  1. Easy to administer
  2. Low cost
  3. Decreased incidence of adverse reactions
  4. No use of needles, syringes, or equipment
  5. No specialized training.

 Disadvantages of oral sedation

  1. It relies on patient compliance
  2. Prolonged latent period
  3. Erratic and incomplete absorption of drugs from the gastrointestinal tract
  4. Inability to titrate
  5. Prolonged duration of action

Inhalational sedation

  1. Dependable and convenient route of drug administration
  2. Short recovery period
  3. Rapid onset
  4. Effects can be effectively revered by lowering the concentration of agent or by discontinuing it entirely and administration of O2 at room air.

Advantages of inhalational sedation

1. Rapid onset

  a). Oral à 30 min onset.

  b). IM à 10-15 min.

  c). Rectal – 30 min

  d). IV – 20 sec.

  e). Inhalation - < 20 sec is pulmonary circulation to brain time.

2. Depth of sedation: may be altered from moment to moment, permitting drug administrator to increase or decrease the depth of sedation.

3. 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.

  1. Oral – fixed duration of action, approx, 2-3 her
  2. IM - 2-4 her
  3. IV – 45 min.
  4. Inhalation - Duration variable at discretion of administrator.

4. No injection is required with inhalation sedation

5. Very few side effects associated with inhalational sedation with nitrous oxide and oxygen.

6. The drugs used in this technique have no adverse effects on liver, kidneys, brain, or heart.

Disadvantages of inhalational sedation

  1. Equipment cost – high.
  2. O2 and N2O cost – high.
  3. N2O is not a potent agent.
  4. Certain degree of co – operation is required from the patient.

 Contraindications :

  1. Patients with compulsive personality
  2. Children with behavioural problems.
  3. Patients on psychotropic drugs
  4. Patients with COPD.
  5. Pregnant women.

 Complications of inhalation sedation :

a) Excessive perspiration.

b) Behavioural problems.

c) Shivering.

 Intravenous sedation

  1. With the exception of inhalational route, I.V. drug administration is most reliable.
  2. Because of its rapid effect, drug doses may be accurately controlled.

 Advantages of intravenous sedation

  1. Rapid onset of action
  2. Highly effective
  3. Recovery shorter than other techniques
  4. Patent vein is safety factor
  5. Nausea and vomiting are uncommon.
  6. Control of salivary secretions is possible
  7. Gag reflex absent

 Disadvantages of intravenous sedation

  1. Venipuncture is necessary
  2. More intensive monitoring required
  3. Recovery not complete – escort needed
  4. Most IV agents can not be reversed.

Contraindications

  1. Patients of < 6 years and > 65 years
  2. Pregnancy
  3. Thyroid dysfunction problems
  4. Adrenal insufficiency
  5. Visible superficial veins cannot be located

 Rectal sedation

  1. For the patients who are unwilling or unable to take drugs orally
  2. Patients with the problem of nausea and vomiting.  

Advantages of rectal sedation

  1. Rapid onset
  2. Avoidance of injection
  3. Ease of administration
  4. Adsorption by feces, lymphatic drainage, metabolism within luminal mucosal cell does not significantly effect the rectallyadministered drugs.

Disadvantages of rectal sedation

  1. Inconvenience to the administrator and the patient
  2. Possible irritation of intestines by some drugs
  3. Inability to reverse the action of the drug easily

     a). Late onset of action.

     b). Deeper levels of anesthesia not obtained.

 Sublingual sedation

  1. The main advantage is that the drug directly enters into the systemic circulation almost entirely bypassing the enterohepatic circulation.
  2. Rapid absorption
  3. Good bioavailability
  4. However not well suited for sustained delivery systems.
  5. Patient co operation is important to the use of SL route of administration which minimizes its use in many pediatric and other uncooperative patients.

TRANSDERMAL SEDATION

The administration of drugs through skin has existed for a long time. Previously the ointments and lotions are used for skin problems. That is also the transdermal route. So transdermal system consists the medications which are used topically and the active ingredient goes into systemic circulation. So basically it is the topically applied sedatives.

Advantages of transdermal sedation

  1. Bypass the hepatic (liver) first pass effect.
  2. Simplified dosage regimens
  3. Enhanced compliance of the patient
  4. Reduced side effects and
  5. Improved disease therapy

Disadvantages of transdermal sedation

  1. Skin inflammation
  2. Allergic reactions
  3. Drug tolerance
  4. Slow onset

INTRANASAL SEDATION:

  1. 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.
  2. Absorption of IN drugs occurs directly into the systemic circulation, avoiding enterohepatic circulation.
  3. 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.

Advantages of intramuscular sedation

  1. Rapid onset à 15 min.
  2. Maximal clinical effect à 30 min.
  3. More reliable absorption. (than oral, rectal).
  4. Patient co-operation not as essential.

Disadvantages of intramuscular sedation

  1. Inability to titrate (15 min onset).
  2. Inability to reverse drug action.
  3. Prolonged duration of drug effect.
  4. Injection needed.
  5. 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.

Complications :

  1. Nerve damage
  2. Hyperesthesia
  3. Air embolism
  4. Periostitis
  5. Hematoma.
  6. Abscess
  7. Scar formation
  8. Necrosis
  9. Sloughing of skin.

 

 

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