In intravenous sedation, a cannula is placed into a vein and a drug is administered directly into the patient’s blood stream with the patient in supine position.
A cannula (thin plastic tube) will be put into a vein in the back of one of your hands.
The primary goal of IV sedation is to reduce your anxiety, make you feel relaxed and less aware of the dental procedure.
The use of intravenous sedation is indicated in the management of patients with high level of dental anxiety or patients that unable to tolerate stress (epileptic, stroke patient).
During the procedure, adequately sedated patient is demonstrated by expressionless face, drowsiness, and slow speech but they will still be able to understand and respond to verbal contact. However, this patient may not be able to recall events that occurred during the procedure after the treatment.
The major side effect with midazolam sedation is respiratory depression. Thus, the use of a pulse oximeter (device attached to your finger to measure oxygen level and heart rate) is mandatory to monitor patient from this potentially dangerous side effect during the procedure.
Patient who is allergy to benzodiazepines is an absolute contraindication but is extremely rare. IV sedation should be aware in pregnant patient, patient with kidney, liver and heart disease, elderly patient, and children.
Before intravenous sedation
Take your routine medicines at usual times and discuss your medical history and the medicines you took with your dentist
Inform your dentist if you think you may be pregnant
Have a light meal 2 hours before your appointment
Do not take alcohol in any form
Bring an adult that can bring you home and take care of you afterwards
After intravenous sedation
You will need to stay in our recovery room for at least one hour before you leave the clinic.
The effects of sedation can last up to 12 hours, thus during this period:
Do not drive any vehicle, or operate any machinery, or travel alone
Do not take alcohol in any form
Do not use internet and social media
Do not return to work
Do not make any important decisions or sign any legal documents
When compared to general anaesthesia, intravenous sedation is simpler, easier to administer, faster onset with fewer complications and contraindications, patient remains conscious and can breathe on their own throughout procedure.
In general anesthesia (GA), drugs are administered by intravenous or inhalation routes which makes the person to be unconscious and do not feel or remember anything during the surgery. This patient is not wakened even by painful stimulation. General anaesthesia currently can only be performed in the operating room under the hospital setup where the sleep doctor (anaesthesiologist) will be the one to make the patient sleep.
GA is recommended for:
Complicated, extensive, and prolonged treatment to be performed
Working in difficult or multiple areas in the mouth
Patient with special needs
Uncooperative patient
Patient with extremely dental anxiety – only if other form of sedation are ineffective
Advantages
The patient is unconscious – allows the dentist to perform surgery without concern of constantly moving, uncooperating or anxiety patient.
Patient do not feel pain
Patient cannot remember events occurred during the surgery
Longer operating time
Disadvantages
The patient is unconscious – can be life threatening
Higher risk of complications – higher risk of airway obstruction because patient unable to cough
Patient cannot control the situation – do not respond to sound and touch
Require assistant to maintain a patent airway – patient cannot breathe on his own
Very expensive – require special equipment
Patient must fast at least 8 hours before surgery
Requires adequately and specially trained doctor (anesthesiologist) to perform
Time consuming procedure – long recovery period
Procedures
Before administering GA, the patient should be assessed thoroughly by the anesthesiologist by taking detailed medical history, drug history, physical test, and extensive laboratory test. The patient should be explained about the procedure and informed consent form should be signed by the patient. Patient must fast at least 8 hours before the procedure.
Then, GA drug administered intravenously or by inhalation to induce general anaesthesia.
After GA is induced, the doctor will secure your airway by placing a tube into your lung via the nose, mouth or a opening in the neck to ensure sufficient oxygen to reach your lung before dental treatment begins.
When dentist has finished the dental treatment, the doctor will stop the administration of GA drugs and begins to bring the patient back to consciousness. The patient should be monitored for 1-2days before discharging.
The uses for general anesthesia in dentistry have decreased over the years as other less invasive sedation techniques have evolved. Nevertheless, there are still many situations that require the use of GA.
Matrx Fraser MDM® is a unique nitrous oxide/oxygen mechanical mixer which allows easy titration of nitrous oxide levels for quick and effective pain relief.
Allows titration with tidal volumes as low as 3.2 lpm
Changes to flow rate do not affect the titration level
Changes to titration levels do not affect the flow rate
Indications
Nitrous oxide sedation – also called Relative Analgesia(RA) – is indicated for pain relief and management ofanxiety during moderately painful procedures and painful surgery such as:
Dental surgery
Emergency medical care
Obstetrics
Suturing of superficial wounds
Reduction of simple fractures
Benefits of Nitrous Oxide Sedation
Reduced pain and anxiety
Nitrous Oxide (N2O) has analgesic, anxiolytic as well as mild amnesic properties which make it an excellent agent to reduce patients’ pain and fear.
Relaxed patients remain fully conscious and responsive
Rapid onset / rapid recovery
Clinical effects may begin in less than 30 seconds with peak effects occurring in less than 5 minutes.
Rapid recovery is achieved after administering 100% oxygen for 5 minutes.
Why choose Fraser MDM® Mixer?
Allows easy titrationMDM®allows easy incremental titration of nitrous oxide levelsIts unique auto-compensation system eliminates the need to constantly readjust the flowrate and mixture percentage during the titration process.
Built-in safety features to ensure patient oxygenation MDM®is designed to supply a minimum of 30% oxygen.
Fail-safe system immediately stops the flow of nitrous oxide if the oxygen supply is discontinued.
Integrated oxygen flush button immediately increases the flow of oxygen to the reservoir bag by 20 lpm.
Automatic air intake valve opens to provide ambient air to the patient if the reservoir bag is depleted
Check valve protects the patient against from re-breathing expired gases.
For many individuals, visiting a dental clinic is the worst fear they are going to face. Partly due to the unknown or unexpected procedure that they are going to face which is usually a painful or uncomfortable. Some people might have previous experiences from childhood dental clinics or traumatic dental treatments have left many patients with underlying dental fears and phobias of the dentist, which in turn leads to missed dental appointments, neglected teeth (dentition) and in worse cases dental toothache / dental pain. Regular dental examinations (check-ups) by your dentist will reduce your need for emergency dental treatment and toothache. If you have any concerns or worries about your teeth and gums, make a dental appointment with our team.
Nervous Patients
We in Prestige Dental Care understand how daunting and nerve wracking a trip to the dentist can be, we aim to take our time with you during your dental appointment and hope to allay those fears. We provide a calming atmosphere starting from your welcoming entry into reception, to the relaxing waiting area, stylish surgeries and friendly staff. Within time you can build up a good relationship with your dentist and feel confident in any dental treatment you may require.
During your initial appointment with your dental practitioner, you should use this time to discuss your fears and anxieties regarding dental care. Perhaps a certain treatment or procedure makes you feel uneasy, often once the dental surgeon has explained what they are going to do, you can feel reassured and know what to expect. It is often advantageous to agree a stop signal with your dentist, such as the lift of your hand, so the dental practitioner knows when you need a rest during the treatment appointment.
For those among us that have a deep set anxiety in relation to dental treatment we offer conscious dental sedation making dental treatment more acceptable.
Conscious Dental Sedation
For some people the word dentist does evoke a deep fear and this unfortunately prevents patients from seeking treatment. For our patients we offer conscious dental sedation which alleviates the anxiety associated with dental treatment making it a more tolerable experience.
Introduction: What is conscious dental sedation?
By definition, conscious sedation is:
“A technique in which the use of a drug or drugs produces a state of depression of the central nervous system enabling treatment to be carried out, but during which verbal contact with the patient is maintained throughout the period of sedation. The drugs and techniques used to provide conscious sedation for dental treatment should carry a margin of safety wide enough to render loss of consciousness unlikely.”
Conscious dental sedation is a technique used widely in dentistry to help those patients’ with a fear of the dentist. The sedative drug/gas is introduced through inhalation, orally or via a needle in the back of your hand or in your arm, you will become relax, drowsy and unaware of treatment but will still be able to cooperate with your dentist. The sedative drug will not render you unconscious but it will make you very relaxed and you will still be able to understand and cooperate with your dentist. The sedative drug also has amnesic properties so you may not remember your dental visit.
Throughout your dental procedure, your dentist will monitor your pulse and your oxygen saturation levels in your blood, these measurements helps the dentist keep an eye on you and makes sure you are alright.
Range of Techniques:
Intravenous sedation with midazolam
Inhalation sedation with nitrous oxide and oxygen
Oral sedation with benzodiazepines/midazolam
The majority of anxious or phobic patients can be treated with these techniques or a combination of them. Others may respond better with alternative techniques such as:
Intravenous sedation with more than one drug
Intravenous sedation with propofol
Transmucosal sedation (nasal, sublingual)
Some reasons for prescribing sedation:
To treat anxious or phobic patients who would otherwise be denied access to dentistry.
To enable an unpleasant procedure to be carried out without distress to the patient.
To avoid general anaesthesia
Transforming dental anxiety into soothing, peaceful relaxation with absolute safety.
Breathing nitrous oxide will put a smile on your face from the moment you slip into the dentist’s chair. This safe and highly effective method of patient relaxation has helped millions of people overcome their anxieties about dental treatment.
As you try nitrous oxide, your feelings of anxiety will melt away quickly and be replaced by a warm, gentle feeling. Patient describe the experince as peacefully floating in pleasant dreamlike state. The apprehensive child or adult, nitrous oxide can be the key to an enjoyable, comfortable and anxiety-free dental experience.
Nitrous oxide administrator unit
What is nitrous oxide?
Commonly known as “laughing gas”, nitrous oxide is a non-allergenic, non-irritating gas that affects the central nervous system. It is one of the safest forms of sedation available and is easily and completely reversed by breathing normally for 5 to 10 minutes following treatment.Nitrous oxide is used in combination with pure oxygen to relieve dentistry-related anxiety. When inhaled and absorbed into the body, nitrous oxide has a natural calming effect that lasts only as long as your dental procedure.
The goal of nitrous oxide inhalation..
The goal of use of nitrous oxide in dentistry is to eliminate dental anxiety, making the patient more comfortable while the sedation dentist is able to more effectively complete the planned dental care procedure while the patient is sedated. Consult with your dentist to find out if this pain free procedure right for you.
Is nitrous oxide safe?
COMPLETELY. Nitrous oxide is recognized as the safest sedative used in dentistry today. It is mild, non-toxic and removes itself naturally from your body after use. Its benefits are even recommended for patients with certain medical conditions, including high blood pressure, angina and a history of heart attacks. And, unlike general anaesthesia, patients on nitrous oxide remain fully conscious and responsive at all times.
Is nitrous oxide safe for children?
ABSOLUTELY. While our practice goes to great lengths to make every child feel at ease, some children required a degree of sedation to achieve successful treatment. Nitrous oxide is the safest, most effective form of sedation to relieve your child’s fears and ensure a positive experience.
Patient ready for nitrous oxide adminstration
What are the advantages of nitrous oxide?
It’s fast acting – Within minutes of administration, your stress will be transformed into a sensation of smoothing relaxation and pain-killing properties develop after 2 or 3 minutes..
Your depth of sedation can be adjusted easily – The depth of nitrous oxide sedation can be adjusted to quickly achieve your optimal level of relaxation. Other sedation techniques don’t allow for this. For example, with IV sedation, it’s easy to deepen the level of sedation, but difficult to lessen it.
Recovery time is short – In just 3 to 5 minutes after the flow of nitrous oxide is stopped (100% Oxygen flush), the effects completely disappear from your system. In fact, nitrous oxide is the only form of sedation that has no lasting after-effects that impair your ability to drive. You will simply feel refreshed and ready to go about your daily activities.
Certain procedures can be done without local anaesthesia– those that usually involved the gums such as deep cleaning. Nitrous oxide acts as a painkiller on soft tissues such as gums. However, its pain-relieving effects vary a lot from person to person and can’t be relied upon.
Very safe – Inhalation sedation has very few side effects and the drugs used have no ill effects on the heart, lungs, liver, kidneys, or brain.
Reduce gagging – Inhalation sedation can be very effective in eliminating or at least minimizing severe gagging.
Monitoring the oxygen level and the hearth rate throughout the procedure will make gas sedation a safe procedure
Disadvantages of nitrous oxide?
Not comfortable with laughing gas – Some patients might afraid they might ‘lose control’ and some actually feel nauseous when inhaling nitrous oxide which are quite rare and usually due to over-sedation.
Inadequate of sedation – Some people will not achieve adequate sedation with permissible levels of oxygen.
Not comfortable with nasal mask – If you can’t breathe through your nose (either because you’re a pure mouth breather, or because your nose is blocked), or you feel too claustrophobic when something is put over your nose, it can’t be used.
Contraindications of nitrous oxide
Significant respiratory compromise
Upper respiratory tract infection
Conditions related to vitamin B12 deficiency
Nitrous oxide is relatively contraindicated in pregnancy
What does it feel like?
The most common sensations that patients experience are:
tingling of hands and feet
a general feeling of warmth
numbness of your legs, tongue and oral tissues
a ringing sensation or droning sound
feelings of euphoria
feelings of heaviness or lightness
If you feel nauseous while breathing nitrous oxide, please inform the dentist immediately so that the level can be adjusted. Not everyone enjoys the feeling of nitrous oxide. If you feel uncomfortable at any time while breathing nitrous oxide, you can discontinue it at once by breathing deeply through your mouth. Be sure to let the dentist know so that the gas can be turned off.
Before taking nitrous oxide:
1. Do not eat or drink anything for 2 hours prior to your appointment. Otherwise you may feel nauseous or vomit during treatment. 2. Inform us of any changes to your medical history or any medications you are presently taking. 3. Use the restroom before your dental procedure.
Is nitrous oxide right for me?
Please discuss the possibility of nitrous oxide conscious sedation with us. It may be just the solution you or your child have been waiting for. If you have any questions regarding the use of nitrous oxide, feel free to discuss it with our dentist.
Oral sedation dentistry is a medical procedure involving the administration of oral sedative drugs (usually in the form of a tablet), generally to facilitate a dental procedure and reduce patients fear and anxiety related to the experience. It is the most commonly used method in relieving anxiety before a dental appointment. An anti-anxiety or a sleeping pill can be taken the night before the appointment, an hour before going to bed can help with falling asleep and getting some rest; or it can be just taken an hour before dental treatment.
Anti-Anxiety Pills (Benzodiazepines or “Benzos”)
In dentistry, the most commonly prescribed drugs for anxiety belong to the “benzodiazepine” family (eg. diazepam, triazolam, zaleplon, lorazepam, and hydroxyzine). You’ve probably heard of them by their tradenames – for example, Valium, Halcion, Xanax, or Ativan.
Benzos decrease anxiety by binding with receptors in the brain which tone down activity in those parts of the brain responsible for fear.
Travel warning!
You shouldn’t travel on your own after you’ve taken benzodiazepines – make sure you have an escort, even if you’re walking there! It’s easy to become disorientated and miss your stop if going by bus or train, or walk straight in front of a car – or you might even forget that you’re on your way to your dentist’s clinic. So find someone to accompany you. And please don’t pop pills and drive!
Benzodiazepines has two main fuctions:
Sedative-Hypnotics: drugs which induce 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.
Central Nervous System (CNS)
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. 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.
Benzodiazepines are Central Nervous System (CNS) depressants (for example, there can be a decline in blood pressure and breathing – which is good, because if your heart isn’t racing, you’ll feel calmer). They should not be mixed with other CNS depressants such as alcohol. Don’t self-medicate and stick to the dose your dentist or doctor recommends (which may be a higher dose than specified on the drug package insert. Reason being that the package inserts recommend a dose to induce sedation or sleep in a nonstress situation such as the home environment). It is possible to overdose on these things, and overdoses could lower breathing to dangerously low levels, which could result in coma or even death.
People for whom benzos have worked well describe them as “working wonders”, as having a calming and relaxing effect, or as making you feel “out of it”. Giddiness, confusion and saying silly things are also common. Benzos may make you forget large parts of what happened while you were under their influence, which can be handy if you don’t want to remember very much! However, this effect is not reliable.
Dentists who offer oral sedation will have particular preferences, depending on their experience (and experiences) with various drugs. Commonly prescribed benzos include:
Midazolam (Dormicum):
We use this drug mostly to sedate our customers for dental treatment. Midazolam is a short-acting benzo which can produce high levels of sleepiness and memory loss (amnesia). It is given in tablet form (7.5mg for adult) by dentist usually half an hour before procedure. It kicks in very quickly, after about 10-20 minutes. The effect last 1 to 2 hours.
Diazepam (Valium):
Diazepam is another sedative drug widely used for dental treatment as well as in the hospital setup. It produces a mild level of sleep and amnesia, and takes effect about an hour after taking it. The average dose for an adult is 5 to 10 mg. The disadvantage of diazepam is that it stays in the system for much longer than it is needed (it has a half-life of 20-100 hours).
Temazepam (Restoril):
Temazepam is quite frequently used in the UK. In contrast to Valium, its half-life is about 10 hours, so quite a bit shorter. It kicks in after about half an hour. The recommended dose is 10 – 40 mg (with the most common one being 30 mg). Why this huge range? In some people 40 mg of temazepam produces minimal effects whilst in others as little as 10 mg produces profound sedation. This is a problem with all benzos – there is no known method of identifying who is susceptible and who is resistant to benzodiazepines.
Lorazepam (Ativan):
Lorazepam can produce a higher level of sleepiness and memory loss than diazepam. The usual dose is 2 to 3 mg. It kicks in after about one hour, like diazepam, but its half-life is much shorter (12 to 14 hours).
Midazolam (Versed):
Midazolam is a short-acting benzo which can produce high levels of sleepiness and memory loss. It is given as a syrup or mixed into a drink. The drink would usually be given at the dentist’s. It kicks in very quickly, after about 10-20 minutes.
Triazolam (Halcion):
This is not available in the U.K., but is hugely popular in the U.S. Unlike the other benzos mentioned here, it is not so much used as a premedication, but as an alternative to IV sedation in the dental office. This can work really well for some people and many swear by it! But as with all benzos, other people find it has little effect on them.
Controversies in Dentistry – Titration of Oral Sedatives
Occasionally, Halcion is used in the United States as an alternative to IV sedation. One of the effects of Halcion is that it can induce amnesia (memory loss) for what’s happening from the point the drug kicks in to the point it wears off. (All benzos can have this effect to some extent, but Halcion somewhat more so than others. However, the amnesia effect is unreliable – this also applies to Halcion). If Halcion is given intermittently one hour before an appointment and then during treatment at intermittent intervals, it can work well for some people as a substitute for IV sedation.
However, in 2002 the American Dental Association came out in a position paper against titration of oral sedation medication (titration means adding more of the drug, i. e. giving extra pills until the desired effect is achieved). This statement followed the rise of an organization called the “Dental Organization for Conscious Sedation” (or DOCS for short) which was founded in 2000 by a DDS called Michael Silverman and provides training in oral sedation. In 2004, DOCS had more than 1,900 member dentists in the US. DOCS is where the misleading term “sleep dentistry” (applied to oral sedation) was first invented. The training courses also advocate titration of oral medication. Many dentists feel that this practice is unsafe and/or that the training is not thorough enough. Even with thorough training, many dentists believe that titration of oral medication is too unpredictable. Oral medication can take up to two hours to absorb – so a patient could swallow a pill and the dentist, not seeing the effects of the drug an hour or two later, delivers a second pill. Meanwhile, the first pill is being absorbed and the patient has ingested twice the amount he or she needs. To be fair, it should be mentioned that there have been no adult deaths reported using the DOCS regime so far.
Because of the medical and legal situation, many dentists do not feel comfortable with this method.
Can I take benzos as a premedication before IV sedation?
Yes you can. You must however let your dentist know that you have taken them and what dose (unless your dentist has prescribed them and knows anyway). Be sure to inform your dentist beforehand, rather than on the day, because you may forget to mention it otherwise.
When not to take benzodiazepines (contraindications):
This varies from drug to drug. For example, some benzos are safe to take if you have liver problems, while others are not, and some are safe to take if you have heart problems, while others are not. You should be sure to inform your doctor or dentist if any of the following apply: known allergy to the drug, narrow-angle glaucoma, pregnancy, severe respiratory disease (COPD), congestive heart failure (CHF), impaired kidney or liver function, depression/bipolar disorder/psychoses, chronic bronchitis and some other conditions. Also if you’re taking other medications be sure to mention this.
Oral sedation – A hit-and-miss affair?
One problem associated with oral sedation is that it can be a bit of a hit-and-miss affair. Basically, you don’t know how well the drug will be absorbed from the stomach. Because the response to a drug is unpredictable anyway, you have to tailor the dose so that the 25% of people most susceptible to the drug won’t get an overdose. But that means that the 25% who are least susceptible won’t get enough… Body weight, height, or gender are not good indicators of how high the “ideal dose” should be, because the drug exercises its effects on the nerve cells in the brain. So, if you’re quite large, don’t take a little extra “just in case”. A standard dose might have virtually no effect on a petite female, but a large guy might be totally zonked after taking the same dose… you get the picture!
Other factors which may affect how well a benzo will work include whether you want it to work and your (and your doctor’s/dentist’s!) belief that it will work (the so-called “placebo effect”, which, BTW, has been shown to work even if you’re aware of it). If you don’t want the drug to work, for example because you’re scared of losing control, your brain may try and fight the effects of the drug. As a result, you may not experience much of an effect at all, or else experience the effect as unpleasant. In which case, oral sedation may not be for you.
What people said about benzos:
“My doctor prescribed me valium. I take one 30 minutes before my appt. It makes you a little sleepy and your anxiety disappears. It puts you in a “whatever” mood and helps you stop thinking about the pain or worries. ”
“I remember being taken to the chair and them giving me a vial of liquid Halcion…This stuff tastes like Peppermint Cherry…leaves a strong taste in your mouth, but no side effects… Everything around me went fuzzy and blurry, like I was in a dream or something. They moved me to the other room, where everything happened so fast!!! I don’t actually remember much, but I did feel bits and pieces… it wasn’t like a “Get me out of this chair now, feeling” but something that I could deal with… I remember them preparing the molds for my bridge and crown, but I didn’t quite care, and I didn’t even GAG! Which normally I would have!
I did have some amnesia, and I did feel somewhat calm and distant from the procedures, which made me feel good. The appointment was 2 hours, but it felt like I was in and out of there in like 15 minutes. I don’t remember walking to the car or the ride home.”
Zolpidem (Ambien)
Ambien is a sedative/hyppnotic drug designed to relax you and help you fall asleep. So it can be useful for the night before an appointment. It is chemically similar to benzodiazepines. It is not a barbiturate (the traditional “sleeping pill”, which thankfully has fallen out of favour).
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If you have any question, don’t hesitate to contact us, we are more than glad to provide you with the information you need!
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