Conscious Sedation Dentistry | About Conscious Sedation Dentistry

What is Conscious Sedation Dentistry

Dental fear and anxiety is a common problem in pediatric patients. There is considerable variation in techniques used to manage them. Various sedation techniques using many different anesthetic agents have gained considerable popularity over the past few years. Children are not little adults; they differ physically, psychologically, and emotionally. The purpose of this review is to survey recent trends and concerning issues in the rapidly changing field of pediatric sedation. We will study the topic from the perspective of an anesthesiologist. It will also provide information to practitioners on the practice of conscious sedation in dentistry and will also outline the route of administration, pharmacokinetics, and pharmacodynamics of various drugs used. 

The term conscious sedation is defined as, “A medically controlled state of depressed consciousness that allows the protective reflexes to be maintained; retains the patient's ability to maintain a patent airway independently and continuously; and permits an appropriate response by the patient to physical stimulation or verbal command.” In 1992, it was stated that patient could readily progress from one level of sedation to another and one should be prepared to increase vigilance and monitoring.[1] The conscious technique must carry a margin of safety wide enough to decrease the chance of unintended loss of consciousness.[2] The safe sedation of children involves careful pre-sedation evaluation, careful evaluation of airway for large tonsils or any anatomic abnormality, appropriate fasting guidelines for elective procedures, a understanding about pharmacodynamics and pharmacokinetics effects of sedating drugs used, appropriate sized airway equipment and venous access and appropriate intraoperative monitoring, properly equipped staff in recovery area and proper discharge criteria. Sedation drugs can be administered through various routes such as oral, nasal, intramuscular, intravenous (IV), subcutaneous, and inhalational routes. 

Sedation for dental procedure carries high risks for both patient and anesthesiologists. The sedation techniques offer alternative for patients where the use of general anesthesia (GA) is unavoidable.[4,5] Oversedation or undersedation is unreasonable or unacceptable in some circumstances.[6] In order to decrease dependency of the patient to sedation other psychological methods can be used, e.g. Cognitive reconstructing, hypnosis, relaxation and distraction techniques, systematic desensitization, and conditioning.[7] Indications for conscious sedation in pediatric age group are:

• Children with low coping capacity
  • Behavior management problem
  • Dental fear and anxiety
  • Mental retardation
  • General disorder, psychiatric conditions.
• Treatment need
  • Emergency treatment
  • Moderate to large and complicated need.

Children <1 year are contraindication for sedation. 

Special consideration should be given because of pediatric patients, the problem of the dental chair and dental setup and because of oral surgery as there are more chances of aspiration in sedated patients.

1. Pre-sedation check-up: Pediatric patients are classified according to American Society of Anesthesiologists class and then considered for sedation.[8] The patient is checked for adenotonsillar hypertrophy and anatomic airway abnormalities. Child with a special need may require individual consideration. Practitioners are encouraged to consult with appropriate specialties for underlying medical and surgical conditions. The pediatric patient should be accompanied by a parent, legal guardian, or other responsible person
2. Back up emergency facilities and emergency services: The institution using sedation should have facilities, equipment and personnel to manage emergency and rescue situation
3. Consent: Preoperative instructions are given to child and parent/guardian in writing. Informed consent is taken. An adult well-known to child should accompany to and fro to hospital. Only in context to school dental clinics and use of nitrous oxide/oxygen sedation schoolchildren with parents’ consent get treatment without the presence of an adult
4. Fasting guidelines: Prior to conscious sedation it is recommended that the patient has fasted accordingly:
   • No clear liquids 2–3 h before sedation
   • No Breast milk or nonclear fluids 4 h before sedation
   • No formula milk 6 h before sedation
   • No solids 8 h before sedation
   • For emergency, where proper fasting not assured, increased risk weighed against benefits of treatment and the lightest effective sedation is used. If possible patient may benefit by delaying the procedure. It is likely that risk of aspiration during procedural sedation differs from that during GA.[9]
5. Monitoring and rescue equipment: Monitoring equipment are electrocardiography (ECG), size appropriate pulse oximeters, end tidal carbon dioxide equipment, size appropriate noninvasive blood pressure cuffs, precordial stethoscope and defibrillator (size appropriate defibrillator paddles), and must have safety checks on a regular basis. An emergency cart or kit should be available with size appropriate drugs and equipment to resuscitate a nonbreathing and unconscious child
6. Preparation and setting up sedation procedures: Part of safety net of sedation is to use systemic approach, and most common used acronym useful for planning and preparation for procedure is SOAP-ME:
   • S: Size appropriate suction catheter and apparatus
   • O: Adequate oxygen supply and functioning flow meters/other devices to allow its delivery
   • A: Size appropriate airway equipment (nasopharyngeal and oropharyngeal airway, laryngoscopes blades, endotracheal tubes, stylets, face mask, bag-valve-mask)
   • P: Pharmacy - all the basic drugs to support life during an emergency
   • M: Monitors; functioning pulse oximeter with size appropriate oximeter probes[10] and other monitors (e.g.: Noninvasive blood pressure, end-tidal carbon dioxide, ECG, and stethoscope)
   • E: Special equipment or drugs for a particular case (e.g.: Defibrillator). 

   
   

Nitrous oxide is a gas and used as the inhalational anesthetic agent. It has anxiolytic and sedative properties with varying degree of analgesia and muscle relaxation. Recent studies suggest both gamma-aminobutyric acid type A (GABA A) and N-methyl-D-aspartate (NMDA) receptors are affected.[11] It has a long history of safe use providing moderate sedation for minimally moderately painful procedures. Care must be taken when used in addition to other sedatives where deep sedation can easily result. Currently, available nitrous oxide/oxygen delivery systems are manufactured with oxygen fail-safe devices that stop the flow of nitrous when the flow of oxygen is stopped, thus preventing this catastrophe. It should be the first choice for pediatric dental patients who are unable to tolerate local anesthesia alone and have sufficient understanding to accept the procedure. It may be offered with mild to moderate anxiety to better accept the treatment which may require a series of visits. It can also facilitate the provision of more complex time-consuming procedures and dental extractions particularly for young and anxious patients undergoing orthodontic extractions.[12] Because of being nonirritant to the respiratory tract, low tissue solubility, and minimum alveolar concentration more than 1 atmosphere, it has a rapid onset, fast recovery and is a poor anesthetic effect. It is very safe because the child remains awake, responsive, and breaths on his/her own. Common cold, tonsillitis, nasal blockage, patients with porphyria, and psychotic patients are few contraindications for N2O use.[13] Dose of N2O is 50% in 50% oxygen, up to 70% can be given. 

All of this info can be found at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5490120/