Kyle J.

Kramer, DDS, MS
7/12/11

Inhalation Minimal Sedation

14 hours of instruction
Clinical competency

Enteral and/or Combination Inhalation-Enteral

Minimal Sedation

Current BLS
16 hours of instruction
Clinical competency
Experience compromised airway management

Note: Guidelines do not pertain to sedation of pediatric

patients

 Moderate

Enteral Sedation

24 hours of instruction
10 adult patient case experiences*
Enteral
Enteral-Nitrous Oxide

Clinical competency
Management of compromised airway
Note: Guidelines do not pertain to sedation of
pediatric patients

 Moderate

Parenteral (IV) Sedation

60 hours of instruction
20 adult patient case experiences
Clinical competency
Management of compromised airway
Note: Guidelines do not pertain to sedation of
pediatric patients

Successful completion fulfills didactic requirements

14 hours ACLS
10 classes over next 5 weeks
Lectures
Midterm
8/1 to 8/8

Final exam
8/15 to 8/22

Labs
IV placement/IM injections
Preoperative evaluation and ASA Monitors

2 sessions
Airway Lab (2 half-days w/ Dr. Kramer in OMS clinic)

Competency Evaluation
Case review and presentation/oral evaluation

 Define

and describe pain, anxiety and fear

Review historical, philosophical and
psychological aspects of anxiety and pain
control
Define consciousness and levels of
sedation
Minimal sedation
Moderate sedation
Deep sedation
General anesthesia

 40%

of population doesnt receive routine

dental care
Apprehension given for most common reason

Mild

apprehension of dental treatment

Very common: 75% of population

Severe

anxiety leading to avoidance of

treatment
Less common: 6-20% of population

In the US an estimated
6-14% of the
population avoids
dental care due to fear
of dentistry
14-34 million

Anxiety and fear

remain significant
roadblocks to patient
care

Despite advances in pain

control

n = 400

Problems
1.

Poor oral health

2.

Patients are fearful of dental

treatment

3.

Inadequate access to care

1.
2.

Few dental sedationists

compared to number of patients
Remains a problem despite
improvements

Fear continues to be
significant barrier to
patient care
Public Speaking 27%
Dentists 21%
Heights 20%

Our Goals

Improve access to care

Improve patient care and
comfort
Our professional obligation to
do better

Methods of improving access to

care

Non-pharmacologic

Pharmacologic

Verbal guidance and reassurance

Distraction (listen to music, watch a
movie)
Hypnosis

Anxiolysis
Minimal sedation
Moderate sedation
Deep sedation
General anesthesia

 An

unpleasant sensory and emotional

experience associated with actual or
potential tissue damage, or described in
terms of such damage International
Association for the Study of Pain

 Neural

processes of encoding and

processing noxious stimuli
Afferent activity blocked by local anesthetics

Autonomic

process
Consciousness not required
Intraoperative and postoperative
importance
An absolute must for all types of sedation

 Activation

of the sympathetic nervous

system
Release of epinephrine from adrenal glands
Fight or flight response
Emotional responses
Crying, scared, etc.

Physical responses
Tachycardia, hyperventilation

Short-lived
phenomenon,
disappearing when the
external danger or
threat passes

Autonomic response
dependent of the
threat
If the threat (a spider) is
present activation of the
fear response
Once spider is gone, the
fear response resolves

1.

Fear of pain*
Is it going to hurt?

2.
3.
4.
5.

Fear of the unknown

Fear of helplessness and dependency
Fear of bodily change and mutilation
Fear of death

Arise from many

sources
Past traumatic
experiences
Observation of others
Concerns or worries
Exposure to anecdotal
stories

1.

Fear of pain*
Is it going to hurt?

2.
3.
4.
5.

Fear of the unknown

Fear of helplessness and dependency
Fear of bodily change and mutilation
Fear of death

Both groups had

similar fears
Dentists can
eliminate some
triggers
What do patients
care about?

No pain!
Work quality???

A specific unpleasurable state of

tension which indicates the
presence of some danger to the
organism Weiss and English

Autonomic response
independent of the threat
Memory of the spider -> activation
of fear response

Can arise with anticipation of the

triggering event
Usually a learned response

Can lower pain threshold

significantly
Innocuous stimuli -> interpreted as
pain

 Several

types of anxiety

Generalized anxiety disorder

Panic disorder
Obsessive-compulsive disorder (OCD)
Social anxiety disorder
Specific phobias (arachnophobia)
Post-traumatic stress disorder (PTSD)
Situational stress anxiety****
Note: May often have additional diagnosis of
depression

General Anxiety

Situational Anxiety

Mood disorder
Anxious but dont know why

Biochemical changes in the

CNS

Treatment modalities

Non-pharmacotherapeutics
Iatrosedation
Hypnosis

Pharmacotherapeutics

Pharmacotherapeutics

Mood stabilizers

Nitrous oxide
Anxiolytics

Antidepressants
Anxiolytics

May require larger doses

Anxious secondary to an
event (dental visit)
Treatment modalities

May respond to smaller

doses

Similarities

Autonomic response

Differences

Threat present/not present

Learned response?

Physical
Emotional

Learned response?

Requires consciousness

 Goals

of Pharmacologic Management

Induce an altered state of consciousness

Relative analgesia
Co-medication
Twilight sleep
Chemamnesia

Sedation

Reduce/eliminate stress and anxiety

 Analgesia:

The diminution or elimination of pain

Local

anesthesia:

Elimination of sensation, especially pain, in one

part of the body
Predictable and reversible

Via topical application or regional injection of

a drug

 Minimal Sedation (Anxiolysis, Stress reduction):

Minimally depressed level of consciousness
Modest impairment of cognitive function and
coordination
Respond normally to tactile stimulation and verbal
command

Independently and continuously maintain own

airway
Airway reflexes intact

NO cardiovascular or respiratory depression

 Moderate Sedation
Depressed level of consciousness
Respond purposefully to verbal commands, either
alone or with light tactile stimulation

No interventions are needed to maintain a

patent airway
Spontaneous ventilation is adequate
Airway reflex impairment possible

Cardiovascular function is usually maintained

 Deep Sedation
Depressed level of consciousness
Cannot be aroused easily
Do respond purposefully to repeated or painful
stimulation

Ability to maintain patent airway may be

compromised
May require airway support
Airway reflexes impaired
Spontaneous ventilation may be inadequate

Cardiovascular function is usually maintained

 General Anesthesia
Unconscious
Not arousable, not even to painful stimulation

Respiratory function is often impaired

Airway support/patency may be required
Hypopnea/apnea
Positive pressure ventilation

Airway reflexes impaired

Cardiovascular function may be impaired

Best viewed as a continuum

No defined step to reach a set

level

Ability and speed to move along

the continuum varies greatly

Conscious

Dead
Unconscious

How high is this plane?

How far away is it?
Is it high enough to fly over or
under the sun?

Stage I: Induction
Analgesia
Conscious sedation

Stage II: Excitement

Unconscious

Stage III: Surgical

Anesthesia
Planes 1-4

Stage IV: Medullary

Paralysis
Respiratory arrest
Cardiovascular
collapse

Dionne, R Drug Interactions and Adverse Effects In: Anesthesia and Sedation in the Dental
OfficeDionne R and Laskin D (eds). Elsevier 1986 p. 63

Levels of sedation

Minimal sedation

Moderate sedation
Deep sedation
General anesthesia

What is the main goal

of the sedation?
What physiologic signs
are we looking for?
Conscious sedation
Anxiolysis

???

 History

of dental anxiety, fear or phobia

Phobic patient
Patient

management issues

Mentally disability
Alzheimers dementia

Physically disability
Cerebral palsy
Parkinsons disease

Precooperative children

 Invasive

or extensive procedures

Full mouth extraction

Mandibular resection and reconstruction
Physically

compromised patients

Ischemic heart disease

Stress-induced asthma

Need to match the level of sedation with the

patient and the surgical procedure!!!

Class

I
II
III
IV
V
VI
E

Description

Normal, healthy patient

Mild systemic disease
Severe systemic disease that limits activity but is not
incapacitating
Incapacitating systemic disease that is a constant threat
to life
Moribund patient not expected to survive 24 hours with
or without operation
Clinically dead patient kept alive for organ donation
Emergency operation*

Enteral

Drug is absorbed through

the GI tract or oral mucosa
Subject to first pass
metabolism

Parenteral

Drug bypasses the GI tract

NOT subject to first pass
metabolism
Intravenous

Oral

Intramuscular

Rectal

Intranasal

Sublingual*

Submucosal
Subcutaneous
Inhalational

Route DOES NOT determine the depth of sedation

Any route has the potential to induce any degree of sedation or anesthesia*
Route of administration MUST comply with the needs of the surgery and the
patient

1.

2.

Providers MUST:
Be able to identify the
depth of sedation
Be able to rescue patients
who become sedated
deeper than the intended
level
- Reversal of sedation

3.

Be able to manage
sequela that arise due to
the unintended depth of
sedation
- Airway support
- Cardiovascular support

 3 As

Anxiolysis
Amnesia
Analgesia

Cardiovascular and respiratory

Quickly alter depth

Rapid, comfortable induction

Rapid, clean emergence

Postoperative
No PONV
Inexpensive

analgesia

stability

 There

is no magic bullet
Use of balanced anesthetic
Combination of techniques
Benefit/risk of each drug
Example: Benzo + opioid + LA
The

right combination is the one that

works

 No

additional licensing for the following:

Inhalation Minimal Sedation

Nitrous oxide + Oxygen

Enteral and/or Combination Inhalation-Enteral

Minimal Sedation
Moderate Enteral Sedation
However, this

future

is likely to change in the near

Great for anxiolysis

Includes supplemental
oxygen
Easily reversible
If pt is breathing!!!

Can be titrated, even

with oral sedation
Very safe
Caution
Significant additive sedation
and muscle relaxation
AIRWAY, AIRWAY, AIRWAY!!!!!

Light Parenteral Conscious Sedation

Minimally depressed level of

consciousness
Maintain own airway
Respond to stimulation

THIS IS OUR GOAL!!

Awake
Breathing
Calm
Responsive
Relaxed

Deep sedation

Depressed consciousness
Partial loss of protective
reflexes
Inability to continually
maintain airway
Unresponsive to
stimulation

 Applicant

must meet one of the following

criteria:
(1) Graduation from an approved dental
school which included training in conscious
sedation techniques at the predoctoral level
(2) Completion of an intensive postdoctoral
training program in the use of light parenteral
conscious sedation

Satisfactory evidence of completion of

educational and training requirements means the
following:
(1) Certificate of completion of the educational or
training program
(2) Official transcript from a board approved dental
school which clearly designates completion of the
education or training.
(3) Certificate of completion of a continuing
education program

Requirements:
Valid Indiana dental license
Valid LPCS permit
Provide training certificate
Equipment affidavit
ACLS certified

Requirements:
Valid Indiana dental license
Valid GA/DS permit
Provide training program certificate
Dental Anesthesiology
Oral and Maxillofacial Surgery

Equipment affidavit
ACLS certified