INDEX

• Introduction
• Historical development of conscious
sedation
• Objectives of conscious sedation
• Philosophy of conscious sedation
• Indication of conscious sedation
• Contraindication of conscious sedation
• Pharmacology of sedative agents

• Routes of drug administration

• Initial assessment & treatment
planning
• Equipment for conscious sedation
• Complication
• Sedation in special circumstances
 AMERICAN DENTAL SOCIETY OF
ANAESTHESIOLOGY defined conscious sedation
as “the production of a state of pleasant relaxation
& freedom from fear & anxiety in the conscious
patient through the use of drugs. “

The house of delegates of AMERICAN

DENTAL ASSOCIATION (ADA) defines
conscious sedation as “a minimally depressed level
of consciousness that retains the patient’s ability
to independently & continuously maintain an airway
& responds appropriately to physical stimulation or
verbal command & that is produced by a
pharmacological or non-pharmacological method or
a combination thereof”.
• The drugs & techniques that are acceptable
for producing conscious sedation should have a
reasonably large therapeutic index, making it
unlikely that the patient will loose
consciousness.

• Depressing the level of consciousness to the

patient at which the patient’s only response is
a reflex withdrawal from painful stimulation is
well outside of the range of conscious sedation
& is to be avoided.

• Conscious sedation is not to be used as a way

to reduce pain during dental treatment! Local
anesthesia is still required as the principle
means for elimination the sedation of orofacial
pain during treatment.

• However, conscious sedation may make the

process of local anesthetic administration
much more acceptable to the patient.
HISTORICAL DEVELOPMENT OF
CONCIOUS SEDATION
• Conscious sedation techniques have been used in dentistry
for over 50 years.
• The ability of twenty first century dentists to provide
comfortable treatment for their patients has its origin in
the discovery & development of general anesthetic drugs in
the 19th century.
• In the USA, HORACE WELLS used nitrous oxide for the
first time in 1844 & WILLIAM MORTON, administered
ether for the dental extractions in October 1846.
• In ENGLAND, JAMES ROBINSON, was the first to
administer ether to a patient in LONDON in December
1846.
• By the 1904, procaine was available for use in dental
patients.
• By the 1930s, an intravenous barbiturate, hexobarbitone,
was in use in UK dental practices for sedation.

YEAR DEVELOPMENT

1940s “Relative Analgesia “ ( nitrous oxide / oxygen )

1945 The Jorgensen Technique
1960s IV methohexitone (Brietal)
1966 IV diazepam (Valium)
1970s IV diazepam (Diazemuls)
1983 IV midazolam (Hypnovel)
1988 IV flumazenil (Anexate)
1990s IV propofol (Diprivan)
 OBJECTIVES OF CONCIOUS
SEDATION

1. The patient’s mood must be altered.

The primary objective of the conscious sedative

techniques is to alter the patient’s mood so that a procedure that
was previously pharmacologically unacceptable now becomes
readily accepted.

The goal of conscious sedation is to eliminate fear &

apprehension & thereby aid in control of pain reaction. Control of
pain perception will be gained by judicious addition of regional
anesthesia.

2. The patient must remain cooperative.

Certainly when regional analgesia is being used for

the control of operative pain, the cooperation of the patient is
imperative.

3. The pain threshold should be elevated.

Even though the dentist is relying on regional

analgesia for the control of operative pain, it is advantageous to
choose drugs for conscious sedation that also elevate the pain
threshold at a central nervous system level.

4. All protective reflexes must remain active.

In the conscious state the patient will maintain his

airway clear of secretions & patent all times.
 The possibility of airway obstruction by soft tissue,
as occurs when consciousness is lost, is absent.

5. There should be only minor deviations in the patient’s

vital signs.

The patient’s physiology is not altered to the extent

seen in an unconscious state.

With proper drug doses & rates of administration,

minor changes in vital signs within normal limits may occur
because a previously fearful or apprehensive patient is now
calmed.

6. There may be a degree of amnesia.

Depending upon the drug & dose used, amnesia may

be produced. At no time should the patient be rendered
unconscious for the sake of producing amnesia.
 PHILOSOPHY OF CONCIOUS
SEDATION

• Without doubt most patients who need dental care may

undergo treatment in a comfortable state with the use of
local anesthesia alone.
• But, because of fear, anxiety, & apprehension, many patients
are psychologically unable to withstand dental care even
though operative pain is controlled with local anesthesia.

• The baseline represents a level of awareness that is

suitable for the performance of dental procedures under
local anesthesia. Most of the patients present in this
condition.
• Whereas others exhibit various degrees of concern,
apprehension & awareness.
• Those persons who are considered mildly apprehensive are
amenable to management with relatively weak agents.
• Moderate and very apprehensive individual require more
potent medications or possibly drug combinations to place
them at a level of awareness suitable for the performance
of dental procedures under local anesthesia.
• All the patients are not amenable to treatment in the
conscious state. Some children, developmentally disabled
persons, & those persons who have severe problems dealing
with fears concerning dentistry are a few examples of
patients who require general anesthesia.
 INDICATION OF CONSCIOUS
SEDATION

• Most patients requiring sedation are those with a simple

genuine fear or phobia of dental treatment.

• Children can present particular problem & often require

very care full handling.

• Patients with mild systemic disorders such as controlled

hypertension, angina, & asthma which may be exacerbated
by the stress of dental treatment represent medical
indication.

• Patient with neuromuscular disorders such as spasticity,

Parkinsonism & involuntary movement conditions often wish
to cooperate but physically can not.

• Dentally related problems such as gagging & trismus,

persistent fainting & moderately difficult or prolonged
surgery.
 CONTRA INDIACATION OF
CONSCIOUS SEDATION

• Patients with significant cardio respiratory disease or

neuromuscular weakness or wasting conditions.

• Patients with severe psychiatric disorders or mental sub

normality.

• Pregnant patients and lactating mothers.

• Uncooperative, unwilling or unaccompanied patients.

• Sedation should not be attempted if the dental practitioner

or his assistants have insufficient training or experience.
 PHARMACOLOGY OF SEDATIVE
AGENTS

To intelligently choose the agent that best fits the

needs of patient & operator, the dentist must realize that no one
agent will work for all patients.

The object of choosing the conscious – sedative agent

is to select a drug or drug combination that will alter the
patient’s mood to such a degree that the dental procedure can be
performed under local anesthesia while the patient is in a
conscious state. The dentist must, in effect, diminish fear and
apprehension so that the patient is no longer psychologically
threatened by dental treatment.

Properties of the ideal sedative drug:

• Comfortable, non-threatening method of administration

• Rapid onset
• Predictable sedative / anxiolytic action
• Controllable duration of action
• Produces analgesia
• No side effects
• Rapid and complete recovery
 INHALATIONAL AGENTS
• Commonly used for dental sedation.
• No currently available agent is ideal.
• The greatest potential danger when using
inhalational sedation is the failure to deliver an
adequate supply of oxygen to the patient, due to
inappropriate or faulty equipment.

Properties of an ideal inhalational sedation agent:

Induction characteristics Smooth

Anxiolysis Yes
Cardio respiratory stability Stable
Ease of titration Easy
Induction & recovery rate Rapid
Metabolism 0%
Ease of breathing Non – pungent
Blood gas solubility Low
Potency (MAC) Weak (high)
Speed of change in sedation level Rapid
Systemic toxicity None
Environmental effects None
Analgesia Yes

The minimum alveolar contraction (MAC) is a value

obtained experimentally which represents the potency of an
inhalational agent.
NITROUS OXIDE
• It is colorless & inorganic agent.
• It has a pleasant odor
• It is non – irritating to the body.
• It is non – explosive & non – inflammable but will support
combustion as well as oxygen.

PHARMACOKINETICS:

It is rapidly absorbed. The rate of absorption depends

on a number of factors, including the solubility of the drug in
blood. Agents with low solubility produce rapid onset of sedation
because the concentration of drug in blood, & therefore in the
brain, rapidly equilibrates with the inspired concentration. When
the agent is discontinued, recovery occurs quickly as the
concentration of the agent falls. Nitrous oxide has a high MAC
compared with most volatile anesthetic agent.

The nitrous oxide molecule is excreted unchanged

almost exclusively by the lungs. It is therefore suitable for
patients with advanced liver or kidney diseases. It has little
effect on the respiratory system as it is non – irritant & does not
increase bronchial secretions or depress respiration centrally.
The cardiovascular effects of nitrous oxide are in significant in
healthy patients.
Planes Definition
Plane I Moderate sedation & analgesia

Usually obtained with concentration of 5 – 25 %N O

Plane II Dissociation sedation & analgesia

Usually obtained with concentration of 20 – 55 % N O

Plane III Total analgesia

Usually obtained with concentration of 50 – 70 % N O

N O – nitrous oxide

Plane I & II are clinically useful for dental sedation.

Plane III is generally considered to be too close to anesthesia to
be safe in the dental outpatient setting.

The low solubility of nitrous oxide in blood & tissues

results in rapid out flow of nitrous oxide across the alveolar
membrane when the incoming gas flow is stopped. This reduces
the percentage of alveolar oxygen available for. This
phenomenon – “diffusion hypoxia” – may be counteracted by
giving 100 % oxygen for 2 minutes at the end of the procedure.
 PROPERTIES:

Induction characteristics Smooth

Anxiolysis Yes
Cardio respiratory stability Stable
Ease of titration Easy
Induction & recovery rate Rapid
Metabolism < 1%
Ease of breathing Non – pungent
Blood gas solubility Low ( 0.47)
Potency (MAC) Weak (105 %)
Speed of change in sedation level Rapid
Systemic toxicity Yes (prolong use)
Environmental effects Yes
Analgesia Yes

SUPPLIED AS:

Nitrou
s oxide
is supplied in a blue cylinder containing both a gas & liquid phase
at a pressure of 5400 kPa (800 psi). Oxygen comes as
compressed gas in a black cylinder with a white shoulder at a
pressure of 15,000 kPa (2000 psi).

ADVANTAGES:

• Ability to titrate
• Ability to reverse
• Controlled duration
• Rapid onset
• Rapid recovery
• Patient may be discharged alone.

DISADVANTAGES:

• Patient acceptance is not universe

• Cost of equipment
• Not always effective
• It produces reversible inhibition of the enzyme methionine
synthetase which is involved in the synthesis of vitamin B
• On prolong use can cause bane marrow depression
• Increase in the rate of miscarriage among women dentists &
dental nurses who are exposed to nitrous oxide for prolong
period of time.
SEVOFLURANE:
• It is a fluorinated derivative of methyl isopropyl ether
which was first synthesized in the early 1970s.
• It pleasant to inhale, non – irritant & non – pungent.
• It is partly metabolized and so some care is required in
people with severe liver or kidney disease.

PROPERTIES:

Induction characteristics Smooth

Anxiolysis Yes
Cardio respiratory stability Stable
Ease of titration Easy
Induction & recovery rate Rapid
Metabolism 5%
Ease of breathing Non – pungent
Blood gas solubility Low ( 0.6)
Potency (MAC) High (2 %)
Speed of change in sedation level Fairly rapid
Systemic toxicity Not known
Environmental effects Minimal
Analgesia No
A specially calibrated vaporizer is required in order to titrate low
concentrations of sevoflurane.

INTRAVENOUS AGENTS
Properties of an ideal intravenous agent:

Injection characteristics Painless

Anxiolysis Yes
Cardio respiratory stability Stable
Ease of titration Easy
Induction & recovery rate Rapid
Metabolism 0%
Analgesia Yes
Potency Weak
Reversibility Yes
Speed of change in sedation level Rapid
Systemic toxicity None
Storage / shelf life Stable / long

BENZODIAZEPINES
The benzodiazepine group of drugs has a number of desirable
pharmacodynamic properties which make these agents useful for
conscious sedation.

This includes:

• Anxiolysis
• Sedation
• Muscle relaxation
• Anterograde amnesia
• Anticonvulsant action

CHEMISTRY:

All benzodiazepines have a common core structure

with individual differences which determine their solubility and
precise actions.

MECHANISM OF ACTION:
 It acts throughout the CNS. Specific benzodiazepine
receptors are located on nerve cells within the brain. All
benzodiazepine molecules have a common core shape, which
enables them to attach to these receptors. The effect o
attaching benzodiazepines to cell membrane receptors to alter an
existing physiological filter.

The normal passage of information from the peripheral

senses to the brain is filtered by the GABA (gamma amino butyric
acid) system. GABA is an inhibitory neurotransmitter which is
released from sensory nerve endings as a result of nerve stimuli
passing from neuron to neuron. When released, GABA attaches to
receptor on the cell membrane of the postsynaptic neuron. This
stabilizes the neuron by increasing the threshold for firing. In
this way, the number of sensory messages perceived by the brain
is reduced. Benzodiazepine receptors are located on the cell
membrane close to GABA receptors. The effect of having
benzodiazepine in place on a receptor is to prolong the effect of
GABA. This further reduces the number of stimuli reaching the
higher centers & produces pharmacological sedation, anxiolysis,
amnesia, muscle relaxation and anticonvulsant effects.
Benzodiazepines must cross the blood brain barrier to reach
their target receptors.