Drugs used in sedation in Dentistry

Sedation in dentistry has very important role to play as many patients patients have fear and anxiety for dentistry and donot want to get any treatment done and for these patients sedation dentistry is very effective. Depending upon the level of fear and anxiety, other things like type of dental procedure, the sedation dentist decides which dental sedation drug is to be used and which route for sedation has to be followed. It can be oral sedation, IV sedation or inhalation sedation.  Normally in dentistry concious sedation is used and for which Nitrous Oxide sedation is used. There are many kinds of drugs used for sedation in dentistry.

Oral Sedation Drugs in Dentistry

Barbiturates :Barbiturates were the first truly effective sedation dentistry drugs for the management of anxiety that were widely prescribed. They are generalized CNS depressants.

  1. They produce a reduction in anxiety levels.
  2. Decreased mental acuity and
  3. Drowsiness
  4. At higher dosages, depression of the respiratory center occurs, leading to respiratory depression and possible cardiovascular depression.
  5. Barbiturates are capable of producing any level of CNS depression, ranging from light conscious sedation through hypnosis, general anaesthesia, coma and death.

Oral barbiturates in dentistry -The barbiturates are classified as sedative hypnotics, which at different dosage levels produce different levels of CNS depression manifested as relaxation (sedation) or drowsiness (hypnosis). Barbiturates are normally categorized by their duration of clinical action following an average oral dose (when possible).

  1. Long acting barbiturates – 16-24 hours of clinical CNS depression eg. Phenobarbital.
  2. Intermediate acting barbiturates – 6-8 hours action. Far too long for the usual dental or surgical appointment. They are used as sleeping pills in specific types of insomnia.
  3. Short acting barbiturates – 3-4 hours action. Better suited for dental situations. Eg. Pentobarbital, secobarbital.

Benzodiazepine sedative hypnotic - Many other drugs share with barbiturates the ability to produce a state of hypnosis. They are called non – barbiturate sedative hypnotics. They differ form barbiturates as: 

  1. They are less potent than barbiturates.
  2. They are not cross allergenic with barbiturates.

Drugs included in this category are listed here by their major classification:Benzodiazepines ; they include some drugs categorized as sedative hypnotics and others categorized as anxiolytics. One of the primary benefits gained from Benzodiazepines instead of barbiturates as sedative hypnotics is the decreased occurrence of the hangover effect that so often accompanies barbiturates. Commonly used Benzodiazepines are as follows:

  1. Flurazepam
  2. Temazepam
  3.   Triazolam
  4. Lorazepam
  5.  Midazolam

Non Benzodiazepine sedative hypnotics

  1. Zolpidem
  2. Zalelom 

Chloral derivatives 

  1. Chloral hydrate

Anti Anxiety drugs for Sedation in Dentistry - They are used to manage mild to moderate daytime anxiety and tension. Drugs in this group have similar CNS depressant action. At therapeutic dosages, they produce a mild degree of anxiolysis without impairing the patients mental alertness or psychomotor performance. Groups of drugs that are commonly categorized as anti anxiety drugs are as follows:

  1. Benzodiazepines
  2. Chlordiazepoxide
  3. Diazepam
  4. Oxazepam
  5. Clorazepate
  6.  Alprazolam 

INHALATIONAL SEDATION: Nitrous oxide is used. It has excellent anxiolytic, sedative and analgesic properties with little or no depression of myocardial function or ventilation. Induction and recovery are rapid. It has a very wide margin of safety.

Inhalational Sedation

Anesthetic equipment required:

1)    A supply of gases, O2 and N2O.
2)    A machine to control the flow of gases the con. of administered vapour.
3)    A suitable system to administer the inhaled mixture to the patient.
 
Patient monitoring : The following aspects are to be monitored.
a)   Respiration
b)   Circulation.
c)   Anesthetic / sedation apparatus.
d)   Monitoring by machine.
e)   Circulation monitoring.
f)    Anesthetic equipment monitoring.
 
INTRAMUSCULAR SEDATION :
Drugs :
Antianxiety drugs and sedation hypnotics :
  1. Diazepam.
  2. Larazepane.
  3. Midazolam.

Histamine blockers :

Promethazine
  1. Barbiturates.
Seco / pentobarbital
   Opioid analgesics :
  1. Morphine
  2. Tentanyl
Opioid agonists / antagonists
  1. Pentazocine
Dissociative anesthetic
Ketamine hydeochloride
Anticholinergics
  1. Atropine
  2. Glycopycrolate
  3. Scopolamine.
Determination of dosage
Depends on :
  1. Body weight.
  2. Degree of anxiety.
  3. Level of sedation desired.
  4. Age
  5. Health satics
  6. Prior response to CNS depressant druge.
  7. Education and experience of drug administrator
  8. Surface area (pediatric patient).
 
RECTAL SEDATION
Drugs :
1) Barbiturates :
    a) Phenobarbital.
    b) Thiopental
    c) Pentobarbital.
    d) Methohexital
2) Opioids :
a)    Hydromorphone
b)    Oxymorphone
3) Promethazine.
4) Chloral hydrate.
5) Benzodiazepenes
a)    Diazepan
b)    Midazolan.
c) Ketamine 
 
TRANSDERMAL SEDATION
Drugs :
a) opioids :
·         Fentanyl – used in both chronic (cancer) and acute (post op) pain.
b) Antiemetics :
  1. Swallowed blood + opioid analgesis à vomiting
  2. Scopolamine à one of the 1st drugs employed transdermally in the management of motion sickness.
SUBLINGUAL SEDATION
a) Opioids :
  1. SL opioids produce good post operative pain relief but requires thorough monitoring because of the potential for respiratory depression.
  2. Nausea.
  3. ong term pain relief in cancer patients.
b) Oral Transmucusal fentanyl citrate (fentayl :Lollipop”)

Fentanyl has also been formulated as a lozenge or lollipop.

 
INTRANASAL SEDATION
Drugs :
  1. Midazolam.
  2. Sustentanil.
  3. Opioid analgesic.

INTRAVENOUS SEDATION

Drugs:
Benzodiazepines
Histamine blockers
   Promethazine
   Hydroxizine
Barbiturates
Opioid Analgesics
  1. Morphine
  2. Fentanyl
  3. Sulfentanil
  4. Alfentanil
  5. Meperidine

      Antidotal Drugs

  1. Flumezanil
  2. Naloxone
  3. Nalbuphine
  4. Physostigmine
Opioid Antagonist
  • Naloxone
Anticholinergics
  1. Atropine
  2. Scopolamine
  3. Glycopyrrolate
Others
  1. Ketamine
  2. Propofol 
 

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