Introduction:
In adults and children, the need for dental checkups often arises only when they experience high-intensity pain rather than for the purpose of preserving dental and oral health. This can occur due to various reasons, including dental phobia, anxiety, and fears associated with dental procedures. Conscious sedation techniques are commonly employed in such patients.
When Is There a Need for Conscious Sedation in Dentistry?
Dental fear and anxiety are not only extremely common in most children, but it is also not surprising to know that adults experience the same feelings, contributing to a rising global incidence of dental diseases. Regular dental checkups not only promote oral health and hygiene while reducing the risk of oral lesions or cancers but also establish a bond of trust between the doctor and patient, particularly when children adopt the practice of regular dental checkups early in life.
In the practice of conscious sedation in dentistry, the sharing of the airway between the anesthesiologist and the dentist remains a significant challenge. Conscious sedation in dentistry involves the use of one or more drugs that induce a state of central nervous system (CNS) depression. This enables the treatment to be carried out smoothly while maintaining verbal contact with the patient throughout the procedure or sedation period.
What Are the Indications for Conscious Sedation in Dentistry?
The indications for conscious sedation in dentistry are listed below:
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Dental fears or severe phobia and anxiety regarding dentists or dental procedures.
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Time-consuming dental procedures or surgeries.
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Medical issues or medical history may be further aggravated by stressful conditions, such as angina, asthma, epilepsy, and others.
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Uncooperative children over one year of age and mentally challenged individuals.
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Individuals with increased dental infection for whom local anesthesia would be ineffective.
What Are the Clinical Challenges Faced During Conscious Sedation in Dentistry?
Some of the clinical challenges faced by the dental team during conscious sedation are listed as follows:
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Establishing a shared airway between the dental surgeon and the anesthesiologist.
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Relieving dental phobia and anxiety.
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Successfully establishing an airway in patients with coexisting medical conditions, such as cardiac anomalies, instability, epilepsy, and so on.
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Chances of arrhythmias due to stimulation of the fifth cranial nerve (trigeminal nerve).
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Dealing with enlarged tonsils and adenoids, especially in young children, may lead to respiratory obstruction.
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Avoiding the risk of the patient losing self-consciousness.
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Preventing respiratory and cardiovascular depression in aged individuals.
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Preventing vasovagal syncope in susceptible individuals due to the position of their legs on the dental chair.
What Are the Pre-sedation Checkup and Monitoring Equipment Needs in Conscious Sedation for Dental Surgery?
This is an important follow-up in which the patient's detailed history and examination are performed. According to the American Society of Anesthesiologists (ASA) classification, only patients who satisfy the anesthetic criteria of either ASA Grade I or II are considered for the procedure of conscious sedation in dental surgery. For pediatric patients, it is usually recommended that only ASA Grade I patients should be sedated outside a hospital environment, while others can be sedated in a hospital setting only.
Monitoring equipment, such as electrocardiogram (ECG), pulse oximeter, end-tidal carbon dioxide (ETCO2), non-invasive blood pressure (NIBP), and defibrillator, should be installed in both hospital and non-hospital settings. The crash cart should be made available with all the necessary and mandatory resuscitation equipment. This also includes a list of drugs required to resuscitate a patient if the need arises. Every procedure should be carried out by the dentist and anesthesiologist only after ensuring the availability of appropriately sized airway equipment, including suction catheters, sufficient oxygen supply, functional flow meters, and oxygen delivery tubing for the patient.
What Are the Commonly Used Sedatives for Conscious Sedation in Dental Surgical Procedures?
Commonly used sedatives for conscious sedation in dental surgical procedures include:
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Nitrous Oxide (N2O): A mixture of nitrous oxide (N2O) and oxygen can be used as a sedative that is quite popular in the dental setting. N2O has low tissue solubility and a high minimum alveolar concentration, resulting in a rapid onset of action and quick recovery. Controlled sedation is achieved, allowing patients to return to normal activities promptly. N2O is considered extremely safe as patients remain awake and responsive, retaining their reflexes. However, the use of N2O is contraindicated in patients with a common cold or nasal obstruction, porphyria, and COPD (chronic obstructive pulmonary disease).
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Propofol: Propofol (2,6-diisopropyl phenol) is a drug that is insoluble in water and is available as a white, oil-in-water emulsion. It is facilitated through intravenous (IV) delivery of this fat-soluble agent. It readily oxidizes to a quinine form, which turns the white suspension yellow in color after six hours of exposure to air. It exerts a hypnotic action by effectively activating the central inhibitory neurotransmitter GABA (gamma-aminobutyric acid).
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Sevoflurane: Sevoflurane is an ether-based inhalational anesthetic agent with low pungency and non-irritant odor. Its low blood-gas partition coefficient makes it suitable as a sedative agent.
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Benzodiazepines: Benzodiazepines are commonly used in dental sedation. Diazepam and Midazolam are the common benzodiazepines that have been proven to be safe and effective for intravenous (IV) conscious sedation. These drugs have sedative and selective anxiolytic effects, providing a wide margin of safety. Apart from their use in anxiolysis, benzodiazepines are also known to possess skeletal muscle relaxation and potent anticonvulsant activity. However, these drugs do not have pain-relieving or analgesic properties.
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Opioid Analgesics: These drugs have high analgesic effects. Fentanyl is a short-acting opioid drug that is considered extremely potent (60 to 80 times more potent than morphine) and has a rapid onset of analgesia and sedation, making it useful in dentistry. The duration of action of these drugs is around 30 to 60 minutes for a procedure. Fentanyl can also be easily administered via parenteral, transdermal, nasal, or oral routes. A ‘lollipop’ (medicated and multilayered) delivery system is often considered by physicians or dentists for children, which is more acceptable and convenient in terms of sedation.
Conclusion:
Conscious sedation is the technique followed by dentists when dealing with individuals suffering from dental phobias and anxiety. This technique should not be considered an alternative to effective local anesthesia or behavioral management. The focus of this procedure should be on adequately trained staff in a dental setting equipped with all monitoring tools. It is crucial that the dental team coordinating the drugs and techniques used to provide conscious sedation always ensure a wide margin of safety, rendering loss of consciousness a very unlikely possibility. Conscious sedation should always maintain the patient's ability to independently maintain their airway without losing consciousness.
