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6/16/2013

Oral in Dentistry Oral Sedation for General Dentistry: “Post‐Prandial Lecture” Sedation “What Works, What’s Safe, and What’s Allowed in Florida”

Florida Dental Society of Anesthesiology

• State component of American Clive B. Rayner, DMD Dental Society of Anesthesiology • Membership open to all dentists •Board Certified in Oral & Maxillofacial Surgery • Annual CE meeting •Board Certified in Dental Anesthesiology • Annual SimMan ‘hands‐on’ high‐ •Board of Directors, Florida Society of Oral & Maxillofacial Surgery fidelity sedation emergency •Co‐founder & past‐President of Florida Dental Society of Anesthesiology (FDSA) simulation training •Currently Executive Director of FDSA • Newletter •Editor & author of “Vital Signs” newsletter of the FDSA • Advocacy for anesthesia in •Liaison from FSOMS and FDSA to Board of Dentistry dentistry •Consultant & Expert Witness to Board of Dentistry on Anesthesia • Website: •Member, Anesthesia Committee of Board of Dentistry – Scientific Articles •Office anesthesia site evaluator for FSOMS, Board of Dentistry – Sedation & anesthesia meeting information

Conflict of Interest Disclosure

FDNC lecture notes are not complete: – Go to www.fdsahome.org for complete, updated • None: no commercial or industry connections lecture notes, copies of reference articles, and • Founder, Past‐President, and currently Exec Director other course information. (unpaid) of Florida Dental Society of Anesthesiology – Contact information: • [email protected] (Dr. Clive Rayner) • [email protected] (Tricia Cross, FDSA Administrator)

1 6/16/2013

Wireless Audience Response System Question: Have you ever had to terminate a procedure because of patient ?

• Respond to questions with wireless keypad 80% 1. Yes 70% 67% • You will have 10 seconds 2. No 60% • Your last ‘click’ is the one recorded 50% • 40% 33% Computer will tabulate results 30% • Results are anonymous 20% 10% • Please return transmitter when you leave 0% Yes No 10

How would you manage this Question: patient? How would you manage this patient?

1. Tell him “hold still, it 35% 33% 33% 33% doesn’t hurt” 30% 25% 2. Use relaxation 20% techniques 15% 10% 3. Use sedation 5% 0% 0% 4. Take him to the 0% hospital for anesthesia 5. Send him to another dentist 10

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Question: Question: Who’s in the audience? Are you a: Did you have any sedation / anesthesiology training?

1. General dentist 80% 80% 67% 70% 67% 1. Dental school 70% 60% 60% 2. Periodontist 50% 50% 2. GPR 40% 33% 3. Endodontist 40% 33% 30% 30% 3. Specialty residency 20% 4. Prosthodontist 20% 10% 0% 0% 0% 10% 0% 0% 0% 4. Post‐grad course 0% 5. Oral surgeon or 0% Dental 5. None anesthesiologist 10 10

Question: What We’ll Discuss If you practice sedation, what kind of sedation permit do you hold? • Why, who, when, and how to use oral sedation • Non‐ anxiety / stress reduction techniques 80% 67% 1. None 70% • Published guidelines (ADA, AAOMS, APD, etc) 60% 2. Moderate sedation 50% • Rules governing use of oral sedation in Florida 40% 33% 3. Deep sedation / 30% • Different levels of sedation 20% general anesthesia 10% 0% 0% 0% • Basic pharmacology and 0% 4. Pediatric moderate • Oral classes –in general sedation • –in depth, specifically those useful to 5. Don’t know what I dentistry have 10

What We’ll Discuss Why Use Anxiolysis / Sedation?

• Adult oral sedation protocols • Pain vs anxiety vs phobia • Pain is an emotional response to a noxious physical stimulus • Drug titration • PAIN is whatever the patient says hurts, • Patient evaluation and preparation not what the dentist thinks should hurt • Anxiety causes the brain to interpret all noxious stimuli (e.g. pressure) as • Informed consent pain • Recovery, disc harge, record kkieeping • Most dldental phbhobics and ffflearful patients • Monitoring were created by dentists! (So you can thank your colleagues when you get one of these patients) • Complications: emergency preparation and • “We have met the enemy and he is us” –Pogo management, airway management, drug reversal • Sedation failures, and alternatives to oral sedation • And yet, anesthesia was invented by dentistry – It is our heritage, yet we don’t use it, and we are losing it. • Resources for further training and education

3 6/16/2013

Horace Wells –dentist and father of Who should not do oral sedation? modern anesthesia (somewhat tongue in check)

• You don’t want to relearn pharmacology & physiology • You don’t want to take time to review the patient’s medical history & consult with MDs • You prefer to be a technician than doctor of the mouth • You don’t want to spend time training your team • You don’t want to regularly practice emergency drills with your staff • You don’t know difference between syncope and allergic reaction, nor how to treat

Why Use Oral Sedation? Why Use Oral Sedation?

My philosophy:

Let’s not create any more Never hurt a patient, even when they say… dldental phbihobic patients…… “It’s ok doc, keep going,” …and especially if they tell you, “It hurts!!”

Why Use Sedation? Why Use Sedation?

• The greatest fear patients have is of PAIN • The primary goal of sedation is to permit the STRESS‐ • Local are the most effective in for the INTOLERANT patient to receive dental treatment in a safe and prevention of pain efficient manner • However, the act of receiving the local is THE most traumatic part of the dental experience for most. • 75% of medical emergencies in the dental office are related to • Deal with the FEAR first then PAIN will be a minor problem during stress and anxiety (fear and pain), usually from the injection, procedure not from the local itself. • Most “failures” of adequate local anesthesia and “reactions” to local • Therefore, another goal of sedation is to PREVENT medical anesthesia are actually anxiety reactions emergencies

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75% of dental office medical emergencies Question: are stress or pain related! How you ever had a patient that is allergic to ? Stress‐related Non‐stress • Syncope • 1. Yes 80% 70% 67% • Angina pectoris • Postural 2. No 60% • hypotension • 50% • Hypoglycemia • Hyperventilation 40% 33% • Acute pulmonary edema • Local anesthesia 30% • CVA overdose 20% • Acute adrenal insufficiency 10% • MI 0% Yes No 10

Another good use for oral sedation: When to Use Oral Sedation the gagging patient! • Oral sedation can help the majority of patients with mild to moderate levels of fear and anxiety, but may be ineffective in patients with severe anxiety or in more stressful or painful procedures. • Sedation can be useful in preventing medical emergencies in compromised patients. • Gagging is usually • However, some patients will not be successfully related to anxiety / managed with oral sedation, because empiric stress dosing is not an exact science. • That’s why hypnosis & • These patients may require deeper sedation and distraction work intravenous titration.

Stress Reduction Protocol Anxiety • Recognition of anxiety • Discuss / offer sedation Evaluation • Effective pain control Questionnaire • AM appointment • Keep appointments short • New patient: start with non‐invasive, simple treatments • Get the patient out of pain before you work on them • Don’t work on a patient already in pain (they’ll associate it with you) • Good nights before – Give sedative night before if needed • Reduce time in waiting room • Give patient permission to stop procedure at any time, and do it! • Guided relaxation, breathing exercises, guided visualizations

Source: Stanley Malamed, DDS, “Oral Sedation for the General Dentist,” FDSA CE presentation, 2011

5 6/16/2013

Non‐drug Techniques of Anxiolysis Question: • Acknowledge patient’s fears and anxiety and discuss What is your preferred adjunctive stress • Chairside manner: calm & reassuring reduction technique? • Give patients control: give breaks, stop when asked 80% 67% • Clinical hypnosis 1. Hypnosis 70% 60% • Acupuncture 2. Distraction 50% 40% 33% • Distraction: (headphones, video) 30% – Audio, earphones 20% 10% 0% 0% 0% – Video, dark glasses 3. Breathing exercises 0% • Guided imagery / relaxation training 4. Guided imagery, • Breathing exercises guided relaxation 5. None of the above 10 Source: Stanley Malamed, DDS, “Oral Sedation for the General Dentist,” FDSA CE presentation, 2011

The Art and Science of Sedation The Art and Science of Sedation

Science: Art: – Anatomy & physiology – Clinical experience in the administration of CNS – Pharmacology drugs (yes, you have to learn “that pharmacology stuff”) – Clinical experience in the dental treatment of sedated – Patient evaluation patients – – Emergency preparedness Sedation is an art that is learned through experience – Techniques

Guidelines for Practice Regulations for Practice

• American Dental Association Board of Dentistry Rules: http://www.ada.org/sections/about/pdfs/anesthesia_guidelines.pdf Florida Administrative Code, Chapter 64B5‐14 • American Academy of Pediatric Dentisry • American Association of Oral & Maxillofacial Surgeons • https://www.flrules.org/gateway/ChapterHome.asp?Chapter=64B5‐14 • AiAmerican AAdcademy of PidPeriodonto logy • American Dental Society of Anesthesiolgoy • http://www.doh.state.fl.us/Mqa/dentistry/info_julylaws10.pdf • American Society of Dental Anesthesiologists • http://www.asahq.org/For‐Members/Standards‐Guidelines‐and‐ • American Society of Anesthesiology Statements.aspx

6 6/16/2013

Definitions of Sedation Levels But SEDATION & ANESTHESIA are really a CONTINUUM OLD NEW

• Anxiolysis • Minimal Sedation ANXIOLYSIS CONSCIOUS SEDATION DEEP SEDATION GENERAL ANESTHESIA • Conscious Sedation • Moderate Sedation • Deep Sedation • Deep Sedation • General Anesthesia • General Anesthesia

• Minimal Sedation (Anxiolysis): is a drug‐ • Moderate Sedation/Analgesia (“Conscious induced state during which patients respond Sedation”) is a drug‐induced depression of normally to verbal commands. Although consciousness during which patients respond purposefully** to verbal commands, either alone or cognitive function and physical coordination accompanied by light tactile stimulation. No may be impaired, airway reflexes, and interventions are required to maintain a patent ventilatory and cardiovascular functions are airway, and spontaneous ventilation is adequate. unaffected. Cardiovascular function is usually maintained.

• Reflex withdrawal from a painful stimulus is NOT considered a • Deep Sedation/Analgesia is a drug‐induced depression of consciousness during purposeful response. which patients cannot be easily aroused but respond purposefully** following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent • Because sedation is a continuum, it is not always possible to predict airway, and spontaneous ventilation may be inadequate. Cardiovascular function is how an individual patient will respond. Hence, practitioners intending to usually maintained. produce a given level of sedation should be able to rescue patients whose • General Anesthesia is a drug‐induced loss of consciousness during which patients level of sedation becomes deeper than initially intended. Individuals are not arousable, even by painful stimulation. The ability to independently administering Moderate Sedation/Analgesia (“Conscious Sedation”) maintain ventilatory function is often impaired. Patients often require assistance in should be able to rescue patients who enter a state of Deep maintaining a patent airway, and positive pressure ventilation may be required Sedation/Analgesia, while those administering Deep Sedation/Analgesia because of depressed spontaneous ventilation or drug‐induced depression of should be able to rescue patients who enter a state of General Anesthesia. neuromuscular function. Cardiovascular function may be impaired.

7 6/16/2013

REMEMBER!

Without formal anesthesia training:

Conscious & responsive = SAFE

VS. www.flrules.org/gateway/ChapterHome.asp?Chapter=64B5-14 Unconscious or unresponsive = UNSAFE

Regulations Regulations

• 64B5‐14.001 Definitions. 64B5‐14.001 Definitions. • (1) Anesthesia –The loss of feeling or sensation, especially • (3) Deep Sedation –A controlled state of depressed loss of the sensation of pain. consciousness accompanied by partial loss of • (2) General anesthesia –A controlled state of protective reflexes, including either or both the unconsciousness, produced by a pharmacologic agent, inability to continually maintain an airway accompanidied by a partia l or compltlete loss of protttiective idindepen den tly or to respond appropriitlately to phhilysical reflexes, including inability to independently maintain an stimulation or verbal command, produced by airway and respond purposefully to physical stimulation or pharmacologic or non‐pharmacologic method or verbal command. This modality includes administration of combination thereof. Deep sedation includes medications via parenteral routes; that is: intravenous, administration of medications via parenteral routes; intramuscular, subcutaneous, submucosal, or inhalation, as that is intravenous, intra muscular, subcutaneous, well as enteral routes, that is oral, rectal, or transmucosal. submucosal, or inhalation, as well as enteral routes, that is oral, rectal, or transmucosal.

Regulations Regulations

• 64B5‐14.001 Definitions. • 64B5‐14.001 Definitions. • (10) Minimal Sedation (anxiolysis) –The perioperative use of medication • (4) Conscious sedation –A depressed level of consciousness to relieve anxiety before or during a dental procedure which does not produced by the administration of pharmacologic produce a depressed level of consciousness and maintains the patient’s substances, that retains the patient’s ability to ability to maintain an airway independently and to respond appropriately independently and continuously maintain an airway and to physical and verbal stimulation. This minimal sedation shall include the administration of a single enteral sedative or a single respond appropriately to physical stimulation and verbal medica tion addiitministere d in doses appropriitate for the unsupervidised command. This modality includes administration of treatment of anxiety and pain. If clinically indicated, an opiod analgesic medications via all parenteral routes, that is, intravenous, may also be administered during or following a procedure if needed for intramuscular, subcutaneous, submucosal, or inhalation, as the treatment of pain. Except in extremely unusual circumstances, the cumulative dose shall not exceed the maximum recommended dose (as well as enteral routes, that is oral, rectal, or transmucosal. per the manufacturers recommendation). It is understood that even at The drugs, and techniques used should carry a margin of appropriate doses a patient may occasionally drift into a state that is safety wide enough to render unintended loss of deeper than minimal sedation. As long as the intent was minimal sedation consciousness unlikely. and all of the above guidelines were observed, this shall not automatically constitute a violation. A permit shall not be required for the perioperative use of medication for the purpose of providing anxiolysis.

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Regulations Regulations • 64B5‐14.002 Prohibitions • 64B5‐14.001 Definitions. • (7) Titration of Oral Medication. The Board of Dentistry has determined that the perioperative titration of oral medication(s) with the intent to achieve a level of conscious sedation poses a potential overdosing threat due to the unpredictability of enteral (11) Titration of Oral Medication –The absorption and may result in an alteration of the state of consciousness of a patient beyond the intent of the practitioner. adiidministrat ion of small ilincremental doses of Such potentially adverse consequences may require immediate intervention and appropriate training and equipment. Beginning an orally administered medication until an with the effective date of this rule, no dentist licensed in this state shall use any oral medication(s) to induce conscious sedation until intended level of conscious sedation is such dentist has obtained a permit as required by the provisions of observed. this rule chapter. The use of enteral or narcotic analgesic medications for the purpose of providing minimal sedation (anxiolysis) as defined by and in accordance with subsection 64B5‐ 14.001(10), F.A.C., shall not be deemed titration of oral medication and shall not be prohibited by this rule.

Sedation Advertising Rules in Florida Clear & accurate advertising:

• General anesthesia is implied here • Better have a GA permit!

Clear and accurate: Questionable ad: What are you getting? Misleading, and may run afoul of Board of Dentistry

9 6/16/2013

Good: Better: Clear and accurate descriptions of level of sedation implies relaxation and comfort, not sleep

Other Florida sedation rules:

• You must hold a general anesthesia permit to bring a nurse anesthetist to your office. – CRNAs must work under supervision of a DDS with a GA permit or an MD anesthesiologist. • You must hold either a sedation or GA permit to bring in an MD anesthesiologist, and the office can only provide sedation to the level of that dental office permit. • If you do not have a permit, you CAN take your patient to the office of a GA provider (OMS or DA) for sedation or anesthesia while the DA, OMS, or MD provides anesthesia. – You must complete a 4 hour CE course on working on sedated patient with “hands‐on” airway management training.

“Guidelines for the Use of Sedation and General Anesthesia by Dentists” American Dental Association, 2007

Practice Guidelines for Sedation and Minimal sedation –a minimally depressed level of consciousness, produced by a pharmacological method, that retains the patient’s ability to Analgesia by Non-Anesthesiologists independently and continuously maintain an airway and respond normally to tactile stimulation and verbal command. Although cognitive function An Updated Report by the American Society of Anesthesiologists Task Force on and coordination may be modestly impaired, ventilatory and Sedation and Analgesia by Non-Anesthesiologists cardiovascular functions are unaffected. Anesthesiology, V 96: 1004-17, No 4, Apr 2002 Note: In accord with this particular definition, the drug(s) and/or techniques used should carry a margin of safety wide enough never to render unintended loss of consciousness. Further, patients whose only response is reflex withdrawal from painful stimuli would not be considered to be in a state of minimal sedation.

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Sedation as a continuum Continuum of Sedation

• Levels of sedation progress as a continuum and each level can be achieved regardless of the route of drug administration. • Employing oral sedation does not guarantee that a patient will be in a state of anxiolysis nor does it imply that a patient will not drift into deeper levels of sedation. • While it is unlikely that appropriate doses of oral sedatives will produce significant respiratory depression; this is not to be confused with respiratory obstruction. • Respiratory obstruction and depression are NOT synonymous and should not be confused: respiratory obstruction CAN occur with lighter levels of sedation.

Definitions of Sedation Levels Definitions of Sedation Levels

Minimal Sedation Moderate Sedation Deep Sedation General Anesthesia (Anxiolysis) (Conscious Sedation) Purposeful response to Purposeful response Normal response to Unarousable, even with Responsiveness verbal or tactile Responsiveness after repeated or verbal stimulation painful stimulus stimulation painful stimulation No intervention Intervention may be Intervention often Airway Unaffected Airway required required required Spontaneous Spontaneous Unaffected Adequate May be inadequate Frequently inadequate ventilation ventilation

Cardiovascular function Unaffected Usually maintained Cardiovascular function Usually maintained May be impaired

Need for local Need for local Yes Yes Yes ? anesthesia anesthesia

Adapted from Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists Adapted from Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists Anesthesiology 2002;96:1004-17 Anesthesiology 2002;96:1004-17

Drug, amount, and route all combine REMEMBER! to determine depth of sedation • The route of administration alone does NOT determine depth of sedation or anesthesia! • Nor are there any drugs that are regulated or classified by the route of administration.

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Routes of Drug Administration Enteral vs Parenteral:

Enteral vs. Parenteral definition: Enteral: • Drug passes through enterohepatic circulation () before • Parenteral: intravenous, intramuscular, inhalation, entering systemic circulation intranasal, sublingual, transdermal • Liver metablibolizes part of drug • Less drug available to produce clinically desired effect • Enteral: oral, rectal (everything else is parenteral)

Source: Stanley Malamed, DDS, “Oral Sedation for the General Dentist,” FDSA CE presentation, 2011

Enteral vs Parenteral: Why use the oral route? ADVANTAGES: Parenteral: • Almost universal acceptability • Drug enters directly into systemic circulation bypassing the • Ease of administration enterohepatic circulation (liver) • Low cost • More drug availabl e to produce clin ica lly diddesired effect • Decreased incidence of adverse reactions • Decreased severity of adverse reactions • No needles, syringes, or equipment • No specialized training • No specialized permitting or office inspections • No increase in liability insurance needed

Source: Stanley Malamed, DDS, “Oral Sedation for the General Dentist,” FDSA CE presentation, 2011

Is Oral Drug Administration Inherently Safer? DISADVANTAGES of Oral Route • Reliance on patient cooperation • Perhaps; but not always…. • Prolonged onset • Any CNS depressant drug MAY produce any or all • Erratic absorption, unpredictable effect lllevels of seddtiation and anesthes ia, ildiincluding dthdeath. • You can achieve deep sedation with Halcion, or light • Inability to titrate to effect sedation with . • Inability to readily lighten or deepen • Prolonged duration of effect

Source: Stanley Malamed, DDS, “Oral Sedation for the General Dentist,” FDSA CE presentation, 2011

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How do you spell safety with any type Question: of sedation? Which of these drug routes can be safely titrated?

1. Oral 35% 33% 33% 33% 30% 2. Intramuscular 25% 20% T I T R A T I O N 3. Inhalation 15% 10% 4. Transdermal 5% 0% 0% 0% 5. Inhalational

10

TITRATION Possible? TITRATION

• Oral NO • You cannot titrate oral drugs effectively or safely by repeated administration. • Rectal NO • With oral sedation, titration is done “by appointment” and “by • Intramuscular NO procedure.” • Adding additional drug when the original dose has produced • Intranasal NO insufficient sedation my lead to extreme over‐sedation • Sublingual NO • Per Dr. Stanley Malamed: “You cannot titrate oral sedative drugs unless you have at least 8 • Transdermal NO hours” • Inhalation YES “It takes at least an hour to see the effect of each dose” • Intravenous YES Source: “Oral Sedation for the General Dentist,” Dr. Stanley Malamed, FDSA Annual CE Meeting, 2011

Source: Stanley Malamed, DDS, “Oral Sedation for the General Dentist,” FDSA CE presentation, 2011

Why? First‐Pass

• Drugs are not absorbed by the stomach, they must get to the • Drugs administered PO must first travel through intestine. the liver before they • With anxiety, there is delayed and unpredictable gastric reach circulation. emptying. • They may be changed to inactive metabolites • Orally administered drugs may not be absorbed at the time bfbefore they acttllually reach anticipated. the systemic circulation • • Therefore, PO doses are “First pass effect” through the liver is unpredictable. generally larger than • Both first and second oral doses may ‘peak’ at the same time those injected. (Also, PO leading to over sedation. doses may be destroyed in the stomach or not be absorbed at all!)

Source: Stanley Malamed, DDS, “Oral Sedation for the General Dentist,” FDSA CE presentation, 2011

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Many Factors Effect Oral Drug Absorption Sublingual vs Oral

Patient Characteristics • Sublingual topical administration is technically – Surface area of GI mucosa parenteral administration, as it bypasses liver. – Stomach pH – Gastric emppytyin g time • Faster onset, increased effect. – Duodenal pH • Eg: giving sublingual increases – Bacterial colonization of GI tract – Baseline clinical condition bioabsorption by 28% over – Presence of food in stomach • Something to think about………. – Anxiety

Courtesy of Morton Rosenberg, DDS, Department of Anesthesia , Tufts‐New England Medical Center

Target Organ of Sedation is the Pharmacokinetics

Central Nervous System

Pharmacokinetics Pharmacokinetics

• Onset most affected by distribution (lipid solubility into brain) • Drug onset: • Duration determined – Absorption more by redistribution – Distribution (absorption by adipose), • Duration and presence of active – Redistribution metabolites – Elimination • “Half‐life” of drug is • Metabolism secondary to above • effects

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Drug Half Lives, T1/2 Drug Half Lives, T1/2 The time it take any drug concentration to fall 50% I.V. Oral Generally a reliable indicator of the rate of removal 100

of a drug from the blood and body Distribution from 75 distribution Depends upon clearance and volume of distribution ( phase) blood to tissue

Duration of action 50 Half Lives, T1/2 Highly lipid soluble drugs are an exception (e.g., Elimination Elimination via liver and kidneys diazepam has a half life of 20 ‐ 50 hours but it is very fat 25 (beta phase) soluble so blood levels fall like a drug with a much shorter half life) 0

0 2 4 8 10 0 2 4 8 10

Courtesy of Dr. Morton Rosenberg, Department of Anesthesia at Courtesy of Dr. Morton Rosenberg, Department of Anesthesia at Tufts-New England Medical Center Tufts-New England Medical Center

African Pediatrics DrugDrug--DrugDrug Americans Geriatrics Interactions Drug Response Variations Age Race Drugs • Age • Drug interactions – Children – Potentiation by CNS CYP3A Grapefruit – Elderly Polymorphisms juice • Genetics – Antagonism by CNS DRUG – CYP liver GGtienetics Diet • Co‐existing diseases • Normal biologic variation • Anxiety Level • Pharmacokinetic factors Liver – Physiological antagonism Mass Gender Disease Body Weight Infection Inflammation Courtesy of Dr. Morton Rosenberg, Department of Anesthesia at Tufts Courtesy of Dr. Morton Rosenberg, Department of Anesthesia at New England Medical Center Tufts-New England Medical Center Renal insufficiency

Factors affecting drug response Dosing of

• Dosage based primarily on: – patient’s level of anxiety – invasiveness / intensity of expected procedure – duration of procedure • Eg: prophy vs. third molar extractions • Secondarily dose based on weight, BMI, age, health, etc.

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Sedative – Drug Classes Benzodiazepines

• Many classes Sedative- +++ +++ ++ – Benzodiazepines anxiolytic – Barbiturates efficacy – Antihistamines Side effects ++ +++ + – – Misc: ege.g., AAnticonvulsantnticonvulsant +++ +++ 0 • All produce similar effects Anterograde +++ 0 0 – Primary effect follows dose response curve – Respiratory depression 0 0 ++ – Dependence – Paradoxical excitation 0 0 ++

• But there are none better than the benzodiazepines Source: Becker; Management of Pain & Anxiety in the Dental Office, 2002

History of Oral Sedatives Oral Sedative Agents • Chloral hydrate (Noctec) 1832 Generalized CNS depressant capable of deep sedation, very low margin of safety, • Ethyl carcinogenic, poor side effects • Chloral hydrate • Barbiturates: Significant cardiovascular and • Barbiturates respiratory side effects, low Benzodiazepines • Imidazopyridines margin of safety, – (Ambien) – (Veronal) 1903 VERSUS – (Sonata) – Amobaribital (Amytal) 1920 – EEilszopiclone (Lunesta) – (Seconal) 1930 • (H1) Blockers • Antihistamines: Primarily anti‐allergy, multiple other • actions, sedation is secondary side (Phenergan) effect • (Vistaril) – Diphenhydramine () 1946 • Diphenhydramine – Promethazine (Phenergan) 1951 (Benadryl) – Hydroxyzine (Atarax) 1956 • Opioids • Benzodiazepines 1960+ Wide margin of safety, minimal respiratory Courtesy of Dr. Morton Rosenberg, Department of Anesthesia, no cardiovascular effects, excellent Tufts-New England Medical Center efficacy, few side effects

History of Benzodiazepines • 1960 Chlordiazepoxide (Librium)

• 1960‐70 Diazepam (Valium) Selection Oxazepam (Serax) (Dalmane)

• 1970‐90 (Klonopin) (Ativan) • Safety and sedative efficacy of the numerous Prazepam (Centrax) Chlorazepate (Tranxene) bdiibenzodiazepines are viitrtua lly iden tica l. • Individual differences in onset and duration are due • 1980‐90 Alprazolam (Xanax) Triazolam (Halcion) to each drug’s unique pharmacokinetic profile. (Restoril) (Versed) • Understanding these differences enables the practitioner to select the right drug at the right dose • 1990‐2005 Zolpidem* (Ambien) Zalephon* (Sonata) for the right patient and right procedure. * (Lunesta)

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Pharmacology of BDZ Benzodiazepine Effect on CNS: • • Depressant effect on limbic system and thalamus: BDZs promotes binding of GABA at neuronal synapse in brain and spine. areas involved in emotion and behavior. • Effect of BDZ is to prolong effect of GABA. • Other sedatives and barbiturates do not exhibit • GABA is an inhibitory neurotransmittor, reducing this selective depression, instead produce nerve transmission in brain. generalized CNS depression. • GABA decreases sensory messages perceived by • and deep sedation only occur at doses brain, causing: beyond anti‐anxiety doses = wide margin of – sedation, anxiolysis, muscle relaxation, and anticonvulsant safety. effects.

GABA Receptor Benzodiazepine Mechanism of Action

• Other sedatives like barbiturates, chloral hydrate, propofol act directly on nerve to decrease nerve transmission; whereas BDZ only potentiates the body’s endogenous neurotransmitter GABA. • This is why BDZs have wider margin of safety than other sedatives. They can only act on existing , not act directly itself. • Other agents can be lethal in high doses, but lethal overdose of BDZ is almost unheard of.

Non‐benzo “benzodiazepines” Benzodiazepine Effects The “Z compounds” zolpidem (Ambien), zaleplon (Sonata), eszopiclone (Lunesta) Primary Therapeutic Anxiolytic / Antipanic Anticonvulsant Ambien, Sonata, Lunesta: The new “Z compounds” are chemically modified Induction of Sleep (hypnosis) bdiibenzodiazepines, and act on the same BDZ receptors, Secondary have similar pharmacokinetics, and effectively act like Effects BNZs, therefore we will treat them as BNZs. Memory Impairment (amnesia) Alleged differences from traditional benzodiazepines are Sedation/ Psychomotor Impairment (ataxia) primarily drug company marketing. Empirically they may be shorter acting…. Tertiary EEG Beta Activity Cortisol, Growth Hormone

Courtesy of Dr. Morton Rosenberg, Department of Anesthesia at Tufts-New England Medical Center

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Acute Adverse Effects Paradoxical Effects of BDZs

Occasional idiosycratic reactions to BNZ: • Respiratory • Crying, hysteria, anxiety, agitation, aggression, etc. – Minimal respiratory depression when administered alone • Caused by “behavioral disinhibition” effect of BNZ. • Note: ventilatory obstruction can still occur • Patients are very fearful, but “keeping it together,” – Higher doses can depress hypoxic drive until BNZ removes conscious ihibiiinhibition (l)(control) – COPD and OSA patients are a concern and patient is then unable to contain anxiety. • Cardiovascular • Use of different BDZ will not help. – Minimal depression of CV system when administered • Use nitrous, , , or propofol, etc, alone instead. • These patients need deep sedation or GA.

Anterograde Amnesia Anterograde Amnesia vs Unconsciousness

• Patients may have little or no memory of the • Patients may be conscious during event, and procedure after benzodiazepine sedation, will experience event, but not remember. especially halcion. • Contrast with barbiturate or general • “Z compounds” have less anterograde anesthetic: patient rendered unconscious will amnesia not experience event, nor remember event. • Patients may believe that they have been “put to sleep.” • Eg, patient sedated with BDZ may cry out • This works to your advantage and during palatal injection, but not remember disadvantage…….. and swear they were asleep.

BDZ Characteristics BDZ Characteristics

• All BDZs are equally effective in producing • Most pharmacology literature categorizes BDZs anxiolysis and sedation. based on half‐life as short, intermediate, or long. • But half‐life is not only or even primary factor in • Great variation among BDZs due to clinical duration. pharmacokinetics: half‐lives, lipid solubility, • After a single dose, lipid solubility is primarily and pattern of elimination. responsible for onset and duration. • Metabolism in liver, elimination by kidneys – Increased lipid solubility = faster onset, faster offset (redistributes to fat stores) • Clearance: some are transformed to active • Half‐life more important in repeated metabolites administration.

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Half‐life vs. Lipid Solubility Choice of BDZ Based On:

Contrast pharmacokinetics of Valium vs Ativan: All equally effective for anxiolysis and sedation, • Diazepam(Valium): active metabolites = long therefore chose by: duration of effect • Rapidity on onset • Lorazepam (Ativan): less lipid soluble, so • Duration of effect slower onset and longer duration, even • Doctor familiarity with agent though short half‐life. • Patient’s prior experience

Special conditions: Dose of BDZ Based On:

• Patient prior experience • Elderly: • Patient age, wt, medical history – reduced hepatic metabolism and renal clearance, decreased – Elderly: less drug needed generally (~ ½) cerebral blood flow, decreased pulmonary fxn, etc – give ½ usual dose, and use shorter acting agents • Invasiveness / stress of procedure • Cardiac dz: – Generally more important than wt – patients will BENEFIT from reduced cardiac stress • Patient’s level of anxiety – but avoid over‐sedation hypoxia • Renal and hepatic disease: • “the art of sedation” – reduced elimination and accumulation more important with • chronic use Start initial appt with lowest dose feasible, & – single dose usually OK increase subsequent appts as needed • Respiratory dz: – Asthma; normal dosing – COPD; consider lower dose

Special Conditions: Special Conditions:

• Epilepsy: – BDZ are protective and beneficial – normal dosing • BDZ use is controversial • Diabetes: • FDA labeling says BDZs are potential risk to fetus – Normal dosing • Ob/Gyn docs usually follow FDA labeling, but these – but beware confusing sedation with hypoglycemia • Obstructive sleep apnea: RED FLAG! recommendations are not supported by current scientific – Pts extremely sensitive to sedatives literature – If over‐sedated, airway can be very difficult to manage • Literature says that a single doses of BDZs are safe, but regular – Consider supplemental oxygen use should be avoided in first trimester • Acute narrow angle glaucoma – BDZs contraindicated, but these patients are not going to dentist! • But since FDA and MDs say not to use BDZ (or ), – Condition is severe, acute, eye pain, N/V, fixed pupil, sudden loss of we’re stuck. vision

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Special Considerations: Special Considerations: Pregnancy Breast Feeding

Consider: • Less drug passes into breast milk than crosses placenta. “Studies suggest that the administration of a , opioid, or sedative drug will not have • Child exposed to approx. 1% of maternal dose. deleterious effects on embryonic or fetal • In the case of midazolam, only 0.0005% of the development. The current consensus is that maternal dose is transferred to the breast milk during a benzodiazepines are not teratogenic and a single 24 hour period. dose appears safe… regular use particularly in the • 2001 AAP policy statement: no reported effects to first trimester should probably be avoided.” nursing infants from diazepam, midazolam, lorazepam. • But mothers may be concerned: tell them to pump and Walton, et al, Cont Education in Anesthesia, Critical Care & Pain, store pre‐op, pump and waste day of procedure. 6(2);83‐85, 2006

Oral Peak Plasma Levels (hr) Drug Half Lives Drug Half-Life (hr) Active Flurazepam 0.5 - 1 Metabolites Midazolam 0.5 Flurazepam 2.3 Yes Triazolam 1.3 Midazolam 1.2 – 12.3 No Alprazolam 1 - 2 Triazolam 1.5 – 5.5 No Oxazepam 1 – 4 Alprazolam 12 – 15 No Diazepam 2 Oxazepam 5.7 – 10.9 No Lorazepam 2 Diazepam 20 – 70 Yes Temazepam 2 -3 Lorazepam 12 No Chlordiazepoxide 4 Temazepam 10 No Chlordiazepoxide 24 – 48 Yes

Courtesy of Dr. Morton Rosenberg, Department of Anesthesia at Tufts-New England Medical Center Courtesy of Dr. Morton Rosenberg, Department of Anesthesia at Tufts-New England Medical Center

Question: Benzodiazepines Which is your preferred oral benzodiazepine? Drug Equivalent Oral MRD (mg) Dose 1. Valium 30% 25% 25% 20% 20% 21% Triazolam 0.25mg 0.5mg 2. Xanax 20% 16% 15% Diazepam 10 mg 20 mg 3. Halcion 10% 5% Alprazolam 0.5mg 2 mg 4. Ambien / Sonata 0% Lorazepam 1 mg 6 mg 5. Other

10 Courtesy of Dr. Morton Rosenberg, Department of Anesthesia at Tufts-New England Medical Center

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The Big Three diazepam (Valium) Triazolam Diazepam Lorazepam Metabolites Insignificant Yes No • “Prototypical” BDZ • Onset 45 ‐ 90 mins T (hr) 1.5 –5.5 20 – 100 10 ‐ 20 ½ • Peak 60 ‐ 120 mins Onset (min) 30‐ 60 60 –90 90 ‐ 120 • Duration of effect 6 –8 hours • Half‐life 80 hours Clinical Effect 1 –3 2 –4 3 ‐ 6 • Adult dose 2 –20 mg (duration hr) • Long half‐life and active metabolites = long duration of Anxiolysis Dose 0.125 ‐ 0.5 mg 5 –10 mg 1 –2 mg effect (mg) • Metabolized by CP450, so subject to age, liver dysfunction, Sedative Dose 0.25 ‐ ? mg 10 –20 mg 2 –6 mg drug interactions. (mg) • Best administered night before surgery for sleep – May have daytime drowsiness, “hang over” Courtesy of Dr. Morton Rosenberg, Department of Anesthesia at Tufts-New England Medical Center

triazolam (Halcion) lorazepam (Ativan)

• Onset 30 –60 mins • Onset 1 –2 hours • Peak 75 –90 mins • • Duration of effect 2 –3 hours Peak 2 –3 hours • Half‐life 1.5 – 5 hours • Duration of effect 3 –6 hours • Adult dose: 0.125 to 0.5 mg PO • Half‐life 10 – 20 hours • No active metabolites, but metabolized by • Adult dose: 0.5 to 4 mg CP450 so subject to age, liver dysfunction, • No active metabolites drug interactions. • • Short acting, quick onset make it ideal choice Not metabolized by CP450, so less affected for most dental procedures. by variables of age, liver disease, drug interactions

zolpidem (Ambien) Drug and Dosage Selection Dependent on: • “Non‐benzodiazepine” hypnotic • • Onset 30 –60 mins Age • Peak plasma 90 mins • Weight • Duration of effect 1 – 2 hours • Medical status • Half‐life: 1.5 –2.4 hours • Adult dose 10 –20 mg • Drug interactions • No active metabolites, • Level of anxiety • “Rapid” absorption/onset and short duration • No muscle relaxant, anti‐convulsant effects at usual • Previous experience doses • Invasiveness / stress of procedure • Less amnestic effect than BDZs

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Drug response curve Adult Sedation Protocols “K.I.S.S.” (keep it simple) Typical bell curve “68 –95 – 99.7 rule” Implications for oral drug dosing…..? • SHORT (1 hour) zolpidem (Ambien) 10 mg • 68 % of patients will respond to usual dose • ~14% will need ½X normal • AVERAGE (1 ‐ 2 hours) triazolam (Halcion) 0250.25 mg dose and 14% will need 2X normal dose • ~2% will need ¼X normal dose • INTERMEDIATE (4 –6 hours) lorazepam (Ativan) 2.0 mg and 2% will need 4X normal dose • Implications for oral dosing: • LONG (for sleep PM before) diazepam (Valium) 10 mg observe patient carefully for oversedation / undersedation

Some Recommendations: Some Recommendations:

Average Duration Appointment Long Duration Appointment • Halcion (triazolam) • Ativan (lorazepam) • Administer 0.25 ‐ 0.5 orally 1 hour, (or • Administer 2 mg orally, two hours prior to the sublingua lly 30 mins) prior to procedure procedure • Titrate nitrous oxide as needed • Titrate nitrous oxide as needed • Use a pulse oximeter • Use a pulse oximeter

Some Recommendations: Some Recommendations:

Short Appointment, Faster onset • Ambien (zolpidem) For sleep at home evening before procedure • Administer 10 mg * orally, thirty minutes prior • Valium (diazepam) to procedure • Take 10 mg orally, 1 hour before bedtime • Titrate with nitrous oxide as needed • May have some drowsiness in AM • Use a pulse oximeter

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Rule Change! To Increase Depth of Oral “Minimal” Sedation • Since 2001, in Florida, it’s OK to combine a single dose of oral sedative with nitrous oxide • Add nitrous oxide to regimen to “titrate” sedation –no permit or advanced training needed. to effect. • Rationale: • If still inadequate, reschedule patient and give evening dose evening before, and / or give higher – Nitrous oxide is easily and quickly titratable and dose pre‐op as allowed by MDR dose. reversible in the event of over‐sedation • Do not administer additional oral drugs day of – Giving nitrous oxide also means giving you are procedure. giving supplemental oxygen

Halcion Package Insert

“Balancing Efficacy and Safety in the Use of Oral Sedation in Dental Outpatients” • ‘The recommended dose for most adults in 0.25 mg before bedtime.’ Continuing concerns over the safety of oral sedation .…. and • ‘A dose of 0.125 mg may be found to be sufficient for new controversies regarding the incremental use (“titration”) some patients (e.g., elderly, small)’ of the benzodiazepine triazolam for the sedation of dental • ‘A dose of 0.5 mg should only be used for exceptional outpatients prompted a 2003 meeting called "Workshop on patients who do not respond to a trial of a lower Enteral Sedation in Dentistry" and cosponsored by the United States Pharmacopeial Convention, the Anesthesia Research dose since the risk of several adverse reactions Foundation of the American Dental Society of Anesthesiology increases with the size of the dose administered.’ and the Dental Anesthesia Research Group of the • ‘A dose of 0.5 mg should not be exceeded. ‘ International Association for Dental Research.

Balancing Efficacy and Safety in the Use of Oral Sedation in “Balancing Efficacy and Safety in the Use of Dental Outpatients Oral Sedation in Dental Outpatients” Conclusions. Clinical trials are needed to evaluate oral sedative drugs and combinations, as well as to develop discharge criteria with objective quantifiable measures of home readiness. Courses devoted to airway management should be Raymond A. Dionne, DDS, PhD, John A. Yagiela, DDS, PhD, Charles J. Coté, MD, Mark Donaldson, PharmD, Michael Edwards, DMD, developed for dentists who provide conscious sedation services. State regulation of David J. Greenblatt, MD, Daniel Haas, DDS, PhD, Shobha Malviya, MD, Peter Milgrom, DDS, Paul A. Moore, DMD, PhD, MPH, Guy Shampaine, DDS, Michael Silverman, DMD, Roger L. Williams, MD and Stephen Wilson, DMD, MA, PhD enteral administration of sedatives to achieve conscious sedation is needed to ensure safety. J Am Dent Assoc, 2006, Vol 137, No 4, 502‐513. Practice Implications. Safety in outpatient sedation is of paramount concern, with enteral administration of benzodiazepines appearing safe but poorly documented in Background. Concerns about the safety of pediatric oral the office setting. Conscious sedation by the enteral route, including incremental sedation and the incremental use of triazolam in adults triazolam, necessitates careful patient evaluation, monitoring, documentation, prompted a workshop cosponsored by several professional facilities, equipment and personnel as described in American Dental Association and organizations. American Academy of Pediatric Dentistry guidelines.

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Balancing Efficacy and Safety in the Use of Oral Sedation in Dental Outpatients

• “….these attributes of triazolam suggest that administering additional amounts of the drug at time points less than one hour on the basis of the patient’s sedative response would result in additional dosing while the central effects of the original dose are still increasing.”

• “By the time the increased concentration of drug from the second dose is achieved in the plasma and eventually at the active site, over‐sedation may be produced by the delay in CNS effects.”

J Am Dent Assoc, Vol 137, No 4, 502-513.

Pharmacokinetics and Clinical Effects of Multidose “Pharmacokinetics and Clinical Effects of Multidose Sublingual Triazolam in Healthy Volunteers Sublingual Triazolam in Healthy Volunteers” Journal of Clinical Psychopharmacology 2006 Feb;26(1):4‐8; Journal of Clinical Psychopharmacology 2006 Feb;26(1):4‐8; Jackson DL, Milgrom P, Heacox GA, Kharasch ED. Jackson DL, Milgrom P, Heacox GA, Kharasch ED. Departments of Oral Medicine, Dental Fears Research Clinic, University of Washington School of Dentistry, Departments of Oral Medicine, Dental Fears Research Clinic, University of Washington School of Dentistry, • Ten subjects received SL triazolam (0.25 mg) followed by additional doses after 60 (0.50mg) and 90 (0.25mg) minutes. (D.O.C.S. suggested protocol) • Study designed to determine the pharmacokinetics and • Plasma triazolam concentrations, clinical effects and bispectral index (()BIS) sedative effects of incremental sublingual dosing of triazolam were measured intermittently for three hours. (total 1.0 mg) in healthy adults. • Triazolam concentrations gradually increased with time in all subjects and concentrations and drug effects were greatest … at the end of the three hour evaluation period. • The study was funded by the Dental Organization for • Concentrations were still increasing at the time of the last measurement Conscious Sedation (DOCS). (180 minutes) and thus no max concentration nor minimum BIS could be determined.

Clinical Effects of Multidose Sublingual Pharmacokinetics of Multidose Sublingual Triazolam Triazolam

Jackson DL et al. J Clin PsychoPharm 26:2006 Jackson DL et al. J Clin PsychoPharm 26:2006

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Pharmacokinetics and Clinical Effects of Multidose Pharmacokinetics and Clinical Effects of Multi‐dose Sublingual Triazolam in Healthy Volunteers Sublingual Triazolam in Healthy Volunteers

Journal of Clinical Psychopharmacology 2006 Feb;26(1):4‐8; Journal of Clinical Psychopharmacology 2006 Feb;26(1):4‐8; Jackson DL, Milgrom P, Heacox GA, Kharasch ED. Jackson DL, Milgrom P, Heacox GA, Kharasch ED. Departments of Oral Medicine, Dental Fears Research Clinic, University of Washington School of Dentistry, Departments of Oral Medicine, Dental Fears Research Clinic, University of Washington School of Dentistry,

Conclusion: • Eight subjects had sedation scores consistent with dfiitidefinition of deep sedtidation or general anesthes ia “The current clinical application of incremental dosing with sublingual triazolam in dentistry has moved • Four subjects had BIS scores less than 60. ahead of an adequate research foundation.” • BIS less than 60 is generally regarded as the ‐‐Jackson, et al. threshold for general anesthesia.

QUICK BREAK! Pre‐op, Intra‐op, Post‐op Care

To quote a famous anesthesia educator, Robert Dripps, MD: “The satisfactory outcome of anesthetic care is largely determined by the quality of the pre‐ anesthetic and post‐anesthetic care.”

This also true for dental office sedation.

Pre‐Sedation Evaluation Pre‐Sedation Consultation / Exam

• “Never treat a stranger” • Evaluation of anxiety level • Never do anesthesia on a patient you have not • Review of medical history previously evaluated. • Physical exam • Always have a consuliltation first ! Never sedate • Review medications, drug on first patient visit. • Assign ASA classification • Review prior sedation / anesthetic history • Obtain informed consent • Give pre‐sedation instructions

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Epocrates.com Medical history Free drug reference for computer or mobile device with interactions, warnings, dosages • Diseases to evaluate: CAD, CHF, HTN; asthma, COPD, URI; DM; pregnancy; psychiatric; renal; hepatic; obesity; sleep apnea; etc…. • Medications • Prior anesthetic experience • Allergies • Hospitalizations

Medical Consultations

• Getting pre‐operative “medical clearance” from MD is clinically useless and meaningless, and “Medical Clearance” irrelevant as defense in court of law. • The dentist providing the surgery and anesthesia is entirely responsible for the outcome of the surgery and anesthesia. • The MD does not know what you are doing and There is no such thing! cannot evaluate the risk to the patient. • The surgeon / dentist is “the decider” as to whether it is safe to proceed with the dental or surgical procedure, NOT the consulting MD.

Examples of Useless Medical “Clearance” But the MD said “avoid ”

Consider this: • Written on an Rx pad, “cleared for surgery” • “Failure to produce complete local anesthesia results in significant increased cardiac stress and myocardial • Written on Rx pad, “cleared for surgery under ischemia” which may produce more endogenous local, etc.” epinephrine than was in the local anesthetic. • MDs are used to thinking of epi in mg doses, not the • MD says: “Avoid hypotension, hypertension, microgram doses we use. They have no concept of the epi doses used in dentistry. hypoxia, hypercarbia” • One carpule is ~20mcg of epi, MDs think in terms of • 300mcg for allergy patients and 1000mcg for cardiac arrest MD says “Monitor EKG, SaO2, BP carefully” patients. • MD says “Avoid epi” Source: Anesthesiology, 2006

Source: Andrew Herlich, DMD, MD, Prof. of Anesthesiology, Source: Andrew Herlich, DMD, MD, Prof. of Anesthesiology, Univ of Pitt School of Medicine Univ of Pitt School of Medicine

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So how do you get the info you need? What is helpful: • Ask the right questions; create a form or letter that requires specific questions to be answered. • “this patient has the following medical • Ask for a recent complete H&P, list of all medications, problems X, Y, Z. The patient is compliant allergies, hospitalizations, lab results, progress notes, etc. with their care.” • Then ask the MD: – “condition X has required the following “Considering the patient’s baseline diseases, is the interventions over the years, and is now stable patient in the best possible condition for this ______with appropriate medications and bimonthly elective procedure, in the dental office, using _____ sedation, exams” and _____ monitoring?” – “Y is inactive for 5 years” – “Z is chronic and severe, however the condition is Then decide: Should I do this case? not amenable to further optimization”

Source: Andrew Herlich, DMD, MD, Prof. of Anesthesiology, Source: Andrew Herlich, DMD, MD, Prof. of Anesthesiology, Univ of Pitt School of Medicine Univ of Pitt School of Medicine

What the surgeon and anesthetist need to know from the MD Physical Exam for Sedation • The patient is optimal considering their baseline • Blood Pressure and Heart Rate diseases, or • The patient is not optimal re: baseline diseases, but • Appearance this procedure is important to and elective is not likely • Height, Weight, & BMI (Body Mass Index) to impact their medical condition, or • Mental & psychological status • The patient is not optimal, but the surgery is sufficiently emergent that proceeding is important. • Cardiac & pulmonary eval; The attempts at optimizing medical status may have • Exercise tolerance (“if they can walk up 2 flights of equally adverse outcomes, or stairs to your office, they’re probably ok for • The patient is not optimal re: baseline diseases. anesthesia”) Elective surgery should be postponed until patient is optimized. • Airway evaluation

Source: Andrew Herlich, DMD, MD, Prof. of Anesthesiology, Univ of Pitt School of Medicine

Patient selection: Body Mass Index (BMI) Who NOT to sedate unless you are sure of your airway management skills!

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Airway Evaluation Airway Patency

• BMI (Body Mass Index) Mallampati score: • History of Obstructive Sleep Apnea, snoring • Mallampati score • Protrusive (ask: “bite your upper lip with your lower teeth”) • TMJ range of motion (oral opening) • Neck circumference, neck ROM

One reason for doing an airway evaluation before sedation! ASA Physical Classification • IA normal healthy patient • II A patient with mild systemic disease • III A patient with severe systemic disease • IV A patient with severe systemic disease that is a constant threat to life • VA moribund patient who is not expected to survive without the operation

ASA Class 1 ASA 1 examples:

• Normal healthy patient: • No organic, physiologic, or psychiatric • 27 yo healthy male, no meds, with fractured disturbance; excludes the very young and very mandible old. ; healthy with good exercise tolerance. • 72 yo hlthhealthy fflemale, on Zocor, AbiAmbien with • Patients are able to walk up two flights of Ludwig’s Angina stairs or two blocks; little or no risk. • = “green flag”

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ASA 2 ASA 2 examples:

• Patients with mild systemic disease • 37 yo with Type 1 diabetes, well‐controlled • No functional limitations; has a well‐ (HbA1C = 6) controlled disease of one body system. • 25 yo cigarette smoker, no COPD • Acceptable exercise tolerance: able to walk up two flights of stairs, but needs to rest after. • 45 yo with controlled HTN, obesity (BMI 32) • Minimal risk. • 35 yo with severe dental phobia / anxiety • = possible “YELLOW FLAG” • 26 yo pregnant female

ASA 3 ASA 3 examples:

• Patients with severe systemic disease • Some functional limitation; has a controlled • 57 yo with controlled congestive heart failure, disease of more than one system, no stable angina, S/P MI immediate danger of death. • 48 yo with poorly controlled HTN, morbid • Able to walk up one flight of stairs, rests obesity, halfway. • 65 yo smoker with COPD, HTN, angina, chronic • = “RED FLAG” renal failure

ASA 4 ASA 4 examples:

• Patients with severe systemic disease that is a constant threat to life • Has at least one severe disease that is poorly • 65 yo with symptomatic CHF, unstable angina, controlled or at end stage. advanced cirrhosis of liver • Unable to walk up one flight or from parking • 32 yo with end‐stage renal failure (on dialysis, lot; distress even at rest. pending kidney transplant), HTN, CHF • Significant risk; too great for elective treatment. Palliative treatment only. • = “STOP SIGN”

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ASA 5 ASA 5 examples:

• Moribund patient who is not expected to live. • Usually already hospitalized or in hospice care.

• 62 yo in ICU with multip le organ filfailure • 47 wo with sepsis with coagulopathy

Question: ASA classification made easy: You have a 43 yo female patient, PMH: type 2 DM (HgA1c 10.3), Wt 240#, BMI 44, asthma (uses her rescue inhaler sev. times/week), OSA (uses CPAP), can walk up one flight of stairs, but then rests. She wants to oral “sedation” for extraction of several abscessed teeth, I&D of abscess, and cavitron debridement. What ASA class would you rate her?

30% 1. ASA 1 25% 25% 23% 2. ASA 2 22% 20% 17% 15% 3. ASA 3 15% 4. ASA 4 10% 5% 5. “Ask the MD, not 0% ASA 1ASA 2ASA“Ask 3ASA the 4 MD, not me.” me.” 10

Question: Question: You have a 87 yo male patient, PMH: s/p stroke 8 years ago You have a 21 yo male student, plays college soccer, (no residual), walks 2 miles/day, rides a bicycle, controlled smokes “1 PPD,” denies (but your HTN. He needs extractions and crown preps and wants part time scrub tech tells you privately he is reputed to sedation. What ASA class would you rate him? “party with Ecstasy”), who wants GA for removal of wisdom teeth. What ASA class would you rate him? 1. ASA 1 40% 35% 32% 35% 34% 1. ASA 1 30% 2. ASA 2 30% 25% 25% 24% 23% 24% 2. ASA 2 22% 3. ASA 3 25% 20% 20% 17% 3. ASA 3 15% 4. ASA 4 15% 10% 10% 4. ASA 4 5% 5% 0% 0% ASA 1ASA 2ASA 3ASA 4 ASA 1ASA 2ASA 3ASA 4 10 10

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Question: Drawbacks to ASA Classification System In general, what ASA classes would you feel comfortable giving minimal sedation (anxiolysis) to? • Does not consider age or invasiveness of 1. ASA 1 35% surgical procedure 30% 29% 2. ASA 1, 2 25% 25% • However, remains a useflful bbiasis for 25% 21% 3. ASA 1,2,3 20% considering risk for sedation (and surgery) in 15% the dental office 4. ASA 1,2,3,4 10% 5% 0% ASA 1ASA 1, ASA ASA 2 1,2,3 1,2,3,4 10

Question: Informed Consent Do you (the doctor) get written, informed consent for each and every surgical procedure or sedation? • Administration of sedative drugs (or performing surgery) 52% without written consent constitutes “battery.” 1. Yes 51% 51% • It’s a process, not a piece of paper. • Verbal and written informed consent must be given at the 2. No 51% pre‐op consultation appointment, not the day of surgery 50% • Cannot be obtained once medications are administered. 50% 49% • New written consent must be obtained for each procedure or 49% sedation. 49% • Consent to surgery does not imply consent for sedation; 48% sedation needs to be specified. Yes No • Consent must be obtained by the doctor in face‐to‐face 10 meeting, not a staff member.

Pre‐Sedation Instructions Pre‐Procedure Fasting (“NPO”)

• Give both verbally and in writing • Fasting (“NPO”) instructions (if needed) • “Vested” escort to accompany patient • Only necessary if both oral sedative AND • Patient’s other medications ? nitrous oxide together will or may be used • Minimum 2 hours for clear liquids and 6 hours for solid food

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Psychological preparation Recovery • Patients may continue to be at significant risk of Psychological preparation of the patient for the developing complications after procedure is competed. sedation is paramount. • Decreased procedural stimulation, delayed drug Explain the different types of sedation available; absorption, and slow drug elimination, may contribute to do not lead patient to believe they will be asleep. residual sedation and resppyiratory depression during the Tell them they will be “relaxed, drowsy, recovery period. comfortable,” and “aware and in control.” • When sedation is administered to outpatients, one must Give realistic expectations to patient and explain assume there will be no medical supervision once the that every patient reacts differently, and they patient leaves the office. may need more / less medication or different • Patient must be kept in office under observation untl technique at future appointments. completely recovered.

Discharge Criteria Post‐sedation Instructions

• Vital signs normal (within 20% baseline) • Verbal and written instructions must be given to the • Airway patency uncompromised escort upon discharge from the office • Patient awake, or awake on command • Can breathe deeply • Should include: • Protective reflexes intact (can on command) – Potential and anticipated post‐sedation effects • Adequate hydration, able to drink – Limitations of activity (driving, machinery) x 24 hrs • Patient can speak normally – Dietary precautions and suggestions • Patient can sit unaided – No alcohol, or other sedatives x 24 hrs • Patient can walk with minimal assistance – 24 hour contact number for practitioner • Responsible, “vested,” adult escort is available • No pain, no or ,

Discharge Minimal Sedation ‐ Records

• “An appropriate sedation record must be maintained, including the names of all drugs • Record vital signs administered, including local anesthetics, • Docum en t instr ucti on s ggeiven to escort dosagg,es, time of administration, and • Escort signs understanding & acceptance of responsibility monitored physiologic parameters.” • Staff member escorts patient to car • Staff member remains until patient seat‐belted in

ADA “Guidelines on Use of Sedation…. By Dentists,” 2007

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Record Keeping Protocol for Administration Written sedation record should include: of Oral Sedation • Age,height, weight, BMI • Review pre‐op instructions • VS: BP, HR, O2saturation (if used) • Check for escort – Pre‐op, post‐op, and intra‐op • Check for NPO status • ASA class, airway eval note • Doctor administers drug in office (preferred) • Monitors used • Leave patient in an area under direct visual • Medications used and time administered observation throughout induction • Procedure, local anesthetic used • Apply monitors, check vital signs and record • Discharge: time, escort, VS, POI given • Good local anesthesia See www.fdsahome.org for sample moderate • Sedation is NOT a substitute for good PAIN control sedation record • Titrate nitrous oxide to increase sedation if needed

Source: Stanley Malamed, DDS, “Oral Sedation for the General Dentist,” FDSA CE presentation, 2011

Question: What if anxiolysis doesn’t work? What do you do when the anxiolysis / sedation fails? (Unable to continue procedure due to patient anxiety or lack of cooperation) • Add nitrous oxide to “titrate” 25% 23% • If still inadequate: 1. Give more 20% 20% 19% medication and have 16% – reschedule appointment and give PM dose pre‐op, the patient wait an 15% 14% hour 10% – give higher procdure dose as allowed, 10% 2. Reschedule patient – refer for IV sedation or general anesthesia and larger dose next 5% time 0% • Do not administer additional oral drugs on day of 3. Refer to IV sedation appointment provider 4. Tell them to “hang on, we’ll be done in a few minutes.” 10

When to give up on oral sedation! What if oral anxiolysis doesn’t work?

• 0.75 triazolam + nitrous, or

• 30 mg diazepam + nitrous, or There are patients who will require deeper sedation and some will require general • 6 mg lorazepam + nitrous anesthesia.

If treatment cannot be started with patient cooperation using above, need a new technique, not more oral drugs. Explain to patient: “I cannot safely administer any further medication. Do you want to continue? Or we can arrange to refer you to an anesthesia provider, or take you to hospital.”

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IV Moderate Sedation Advantages: General Anesthesia • Quick onset • High degree of control of depth of sedation, highly titratable • More predictable response • Extremely phobic patients will not respond to • Greater success controlling anxiety & fear • Greater amnestic effect moderate or even deep sedation, and require • Multiple drugs and regimens available • IV access available for rescue general anesthesia • Rapid recovery / emergence • “Open airway” vs. “controlled airway”

Disadvantages: technique • Costs: equipment, training, permitting, CE, staff training, supplies, drugs • Risks associated with deeper sedation: over‐sedation, airway compromise • Office vs. surgery center vs. hospital • More vigilance required, more staff, greater staff training • IV access required; may be problem for occasional provider • Greater time required with patient; doctor cannot leave patient

General Anesthesia Office Preparation Protocol Advantages: • Rapid onset • Highly effective –only technique which is 100% effective on Day of sedation treatment, check for R.O.A.D.S.: all patients • Reversal agent Disadvantages: • Oxygen • Increase risk • May need O.R. facility if medically complex patient or • Ambu‐bag/ Airways difficulty airway • • Intensive training requirement Drugs – Min. OMS residency, or • Suction – Two year GA residency • Increased cost, staffing, staff training, equipment, facility, • Complex permitting / licensing requirements

Monitoring Depth of Sedation Hazards with Minimal Sedation

Continually assess: • Minimal risk if maintained at “mild • Response to verbal command sedation” (“anxiolysis”) level • Response to treatment • Moderate sedation introduces potential • Orientation X3 (person, place, time) airway embarrassment • • Eyelids (droopy) and slow or slurred 99.9% of risks of moderate sedation are speech (but this now moderate sedation) related to airway, ventilation, oxygenation

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Sedation too deep !? Complications

• If inadvertently enter moderate sedation, be • Office based oral sedation is safe if: prepared to: – Correct patient, drug, and dose selected – Patient kept conscious – discontinue dental procedure – Airway is maintained – manage airway , ventilate, & oxygenate as needed • “airw ay, airw ay, airw ay;” Or, “It’s the airw ay, stupid ” – monitor oxygen saturation • Almost all morbidity and mortality from sedation is – return patient to lighter level of sedation related to failure to manage the airway. • Monitoring is essential to recognizing problem quickly • Prevention is key

Airway Complications Airway Management 101

Potential airway complications:

Upper Airway Obstruction • Anatomic obstruction –oversedation, improper positioning • Foreign body obstruction – crown, tooth, file, etc • Laryngospasm – secretions, water spray, blood on vocal cords • Laryngeal edema – allergic reaction

Lower Airway Obstruction • Bronchospasm – asthma, allergic reaction • Aspiration

Airway Anatomy

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Open Airway / Obstructed Airway

Question: Question: You are doing a quadrant of restorative dentistry on an ASA 2 patient, Have you ever ventilated a patient, or BMI 42, who received 0.5 mg Halcion orally 90 minutes ago. You notice that the patient does not answer when asked to open his mouth wider. administered CPR? What do you do?

52% 1. Attempt to arouse the 30% 25% 1. No 51% 23% 22% 51% patient by poking or 25% shaking him. 20% 16% 15% 2. Yes 51% 2. Let him sleep and finish 15% 50% 10% your treatment. 5% 50% 3. Start ventilating with 0% 49% 49% Bag‐Valve‐Mask. 49% 4. Call 911 48% 5. Reversed the sedation No Yes with flumazenil. 10 10

Question: Always perform a primary assessment You notice that the patient, who has been snoring throughout your procedure, now has a pulse oximeter • reading of 92%. What do you do? Airway! Look / suction 1. Nothing; anything 35% 29% 30% 25% 25% • Breathing over 90 is an “A” 25% 21% 20% Look / listen / feel right? 15% 10% • Circulation 5% 2. Check the finger 0% Pulse? Use pulse oximeter sensor. BP 3. Start oxygen 4. Open the airway 10

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First things first…

• Head tilt, chin lift • Jaw thrust • Tongue grasp • Turn on or turn up O2

Open the Airway: Open the Airway: Head Tilt ‐ Chin lift ‐ Jaw Thrust Head Tilt ‐ Chin lift ‐ Jaw Thrust

Question: APNEA! You have opened the patient’s airway, but his chest is not rising, and he does not seem to be breathing. What do you do first? • Ventilate with Bag‐Valve‐Mask • If difficulty ventilating with BVM 1. Call 911 30% 26% 27% 25% 2. Perform “mouth to 25% 22% – Insert oral or nasal airway mouth” rescue breathing 20% 3. Have assistant get Bag‐ 15% • Call 911 Valve‐Mask and start 10% ventilating patient with 5% – (based on your degree of comfort managing oxygen 0% situation) 4. Reverse the sedation with a SL of flumazenil injection.

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Bag‐Valve‐Mask Ventilation: Bag‐valve‐mask ventilation One Hand –One Rescuer • Most effective means of positive pressure ventilation • Squeeze 1/3 bag volume (= 600ml) • 10 breaths / minute = one every 6 seconds • Keep pressure below 20cm (use BVM with manometer gauge) to avoid inflating stomach • Oxygen regulator at max (preferably use a regulator with 15 L/M capability) for optimal oxygenation

Bag‐Valve‐Mask Ventilation: Remember: Two Handed –Two Rescuer

• The “C & E” hand position

• “The seal is the deal!”

Question: Predicting the “Difficult Airway” You are ventilating with the BVM, but the patient’s for Ventilation O2 saturation now drops to 88%. What do you do next? • Large tonsils • Large tongue 30% 28% • Edentulous 1. Call 911 25% 23% 24% 2. Nothing, it will come 25% • Retrognathia 20% • Short “thyromental distance” back up in a couple 15% of minutes • Short / fat neck 10% • Limited neck mobility 5% 3. Make sure the • Obesity oxygen is turned on. 0% • Facial hair / beard 4. Insert an airway • Mallampatti score 3, 4 adjunct and continue • Limited oral opening ventilating. 10

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Oral airway

Oral airway insertion

Nasal airway Nasal airway insertion

Dental masks vs anesthesia masks Nitrous hood vs. nitrous mask

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Advantage of nitrous “mask”: Question: Capable of positive pressure ventilation, with Do you and your staff practice simulated interchangeable universal anesthesia fitting! medical emergencies?

45% 41% 1. Never have 40% 35% 29% 29% 2. Occasionally 30% 25% 3. Frequently 20% 15% 10% 5% 0%

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Aviation Disaster Research & “Crisis Resource Anesthesia Safety Management” Training

Research on commercial aviation disasters revealed • Developed from aviation emergency simulation that failures in leadership, training. communication, decision • Adapted to medical & anesthesia emergencies. making, and group • Designed to train team members how to achieve awareness of the situation effectiveness in time urgent environment under stress accounted for the majority • Simulation training provides the means for teams of disasters. to learn, retain, and use seldom needed, complex, high stakes skills

Experts train for the unexpected New ADSA & FDSA Courses: emergency with simulation training “High‐Fidelity Simulation Management of • Doctors and staff must regularly practice Complications During Sedation” emergency management • Simulated management of sedation emergencies • In a recent study, only is now a BBdoard of DDientistry requirement for 15% of staff could moderate sedation and general anesthesia ventilate adequately permits in Florida • And 50% could not • FDSA will sponsor “high‐fidelity” hands‐on operate the tank emergency simulation training yearly regulator to turn O2 on! • Also available from ADSA, ADA, AAOMS

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“High Fidelity” Emergency New ADA Hands‐On Course: Management Simulation Training “Management of Complications During Sedation”

(a.k.a. “the ADA Airway Course”)

• Given yearly at annual ADA meeting • Emergency siltiimulation ttiiraining, with emphhiasis on airway management • Designed for GPs who provide minimal and moderate sedation • Part I: 4 hours online didactic material • Part II: 5 hour hands‐on emergency management simulation

New ARF Sedation Emergency Initiative Ten Minutes Saves a Life! tm “Ten Minutes Saves A Life” ADSA Anesthesia Research Foundation • Adult sedation emergency management program of the American Dental Society of Anesthesiology • Goal: optimize patient •Practitioner chooses the drugs to place in the management for ten minutes until resolution or EMS arrives Emergency Drug Case and orders from distributor of • “Ten Minutes Saves a Life” their choice program includes: •Case available at manufacturer’s cost – Emergency training programs – Emergency drug kits available at •Vendor supplies practitioner the drugs of choice and “cost” tracks expiration dates for practitioner – Emergency algorithms included in kits

Ten Minutes Saves a Life! Medical ADSA Anesthesia Research Foundation Office Medical Emergency Emergency Case: Checklists Drugs, Syringes, and Checklists

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Ventilation vs Respiration Ventilatory Obstruction from Over‐sedation

• Most common airway complication is obstruction; usually Ventilation = breathing: moving air in & out of from over‐sedation lungs • Respiratory depression is not the same as ventilatory Respiration = transport and exchange of oxygen obstruction – Respiratory depression = decreased rate & volume of ventilation btbetween air and cells – Ventilatory obstruction = decreased or no ventilation from obstruction • After dealing with obstruction and ventilating patient, next Respiratory depression = reduced pulmonary goal is returning patient to lighter level of sedation drive from CNS over sedation • Reversal of benzodiazepine induced respiratory depression: – Oxygenate and / or ventilate Ventilatory obstruction = pulmonary drive still – IV or IM or SL Flumazenil in 0.2 mg increments ~q5 mins present, but airway is obstructed

Flumazenil Flumazenil Indications

• Respiratory depression secondary to benzodiazepine administration • First benzodiazepine antagonist approved for clinical • Paradoxical reactions‐ aggressive behavior, use in 1991 agitation, disorientation, , and • It is a competitive antagonist with a high affinity for the GABA(A) benzodiazepine receptor crying • Does not displace the agonist, but rather occupies • Over‐sedation the receptor when the agonist dissociates from the – caution advised, probable re‐sedation later receptor (dynamic situation)

Courtesy of Morton Rosenberg, DDS, Department of Anesthesia , Tufts‐New England Medical Center

Flumazenil Contraindications Flumazenil Dosage

• Availability 0.1 mg/ml IV solution • Initial dose is 0.2mg (2cc) IV over 15 seconds • Hypersensitivity to flumazenil or to benzodiazepine – Additional 0.2 mg prn • Chronic benzodiazepine therapy – Repeat every five minutes until recovery or total of 1 mg • PiPrior disor der • Doses of approximately .01 to 0.2 mg produce partial • Known or suspected poisoning antagonism • Severe liver disease • Higher doses of 0.4 to 1.0 mg usually produce complete • Known panic disorders antagonism with usual sedating doses of benzodiazepines • Head trauma • Onset of reversal is within 1 to 2 minutes given IV • 80% response within 3 minutes; peak effect at 6 to 10 minutes

Courtesy of Morton Rosenberg, DDS, Department of Anesthesia , Courtesy of Morton Rosenberg, DDS, Department of Anesthesia , Tufts‐New England Medical Center Tufts‐New England Medical Center

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Re‐Sedation • Never reverse sedated patient with flumazenil just to wake them up to go home • T1/2 of flumazenil (~30 mins) is much shorter than triazolam T1/2 (2‐3 hours) Single 0.25mg oral • Therefore, flumazenil will wear off before triazolam is worn off and dose of triazolam patient will re‐sedate • Be prepared to monitor patient for at least one hour after reversal of sedation • Re‐sedation is most likely in long cases where cumulative doses have been given • Again, flumazenil is NOT to be used post‐op as routine part of sedation regimen (same with Narcan) • Reversal agents like flumazenil and narcan are not innocuous drugs; they have their own side effects.

Greenblatt DJ: Triazolam Kinetic Data in Plasma and Effect Site

Courtesy of Morton Rosenberg, DDS, Department of Anesthesia , Tufts‐New England Medical Center

Question: Flumazenil Re‐sedation Can you inject parenteral drugs sublingually? • Re‐sedation after reversal with flumazenil is due to its short half‐life (~1 hour) 1. Yes 40% 37% • When high benzodiazepine plasma levels are 35% 30% 32% anticipated for a pgprolonged time, a single dose 30% 2. No 25% of flumazenil only generates a “window” of 20% 3. Sometimes 15% consciousness 10% • Prolonged monitoring after reversal with 5% flumazenil is indicated since re‐sedation is 0% common

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Comparison of Routes of Flumazenil Administration to Reverse Midazolam-induced Respiratory What about giving flumazenil by Depression in a Canine Model Heniff MS, Moore GP, Trout A, Cordell WH, Nelson DR sublingual injection? Academy of Emergency Medicine, 1997 Dec; 4 (12): 1115-8

Will it work??? “Although reversal of respiratory depression was successful with all injection methods, the mean reversal time was significantly shorter with intravenous administration (120 +/‐ 25), versus sublingual administration (262 +/‐ 95), versus intramuscular administration (310 +/‐ 134) seconds.”

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Sublingual Injection of Romazicon Sublingual flumazenil? (flumazenil)

2 minutes IV vs 4 minutes SL vs 5 minutes IM! • SL injection of flumazenil is far less effective in an emergency than IV administration. • Sublingual injection is an , just a very vascular muscle. • SL = IM – (the tongue / floor of mouth is just another muscle) • Reversal of benzodiazepine with flumazenil SL injection is • Takes 4 –5 minutes, and if you don’t or can’t ventilate unreliable and too slow in airway emergency or respiratory the patient, it will be too late by the time flumazenil depression. takes effect to reverse the respiratory depression • Practitioner must be prepared to support the airway, oxygenate, • IV takes 1 –2 minutes to effect and ventilate the patient for at least 5 minutes if SL route used.

Minimal Sedation Monitoring Monitoring personnel Requirement Description “A dentist, or at the dentists direction, an At least one additional person trained in basic life support (healthcare Personnel appropriately trained individual must remain provider level) must be present in addition to the dentist in the operatory …. to monitor the patient Color of mucosa, skin or blood must be evaluated continually. Oxygen continuously until the patient meets the Oxygenation saturation by pulse oximetry may be clinically useful and should be criteria for discharge to the recovery area. considered The … individual must be familiar with Must observe chest excursions continually. Must verify respirations Ventilation monitoring techniques and equipment.” continually.

Blood pressure and heart rate should be evaluated preoperatively, Circulation postoperatively and intraoperatively as necessary (unless patient is unable to tolerate such) Source: 2007 ADA “Guidelines for the Use of Sedation …..”

ADA “Guidelines for Use of Sedation… by Dentists,” 2007

Definitions Question: Does your office use certified dental anesthesia assistants to monitor patients during sedation? • “Continually” –means repeated regularly 1. Yes 60% 55% and frequently 2. No 50% 45% • “Contilinuously” – means proldlonged and 40% without any interruption 30% 20% 10%

Source: ADA “Guidelines for Use of Sedation… by Dentists,” 2007. 0% Yes No 10

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AAOMS Dental Assistant Anesthesia Certification Program Pulse Oximetry (“DAANCE”) • AAOMS program, open to any and all dental assistants • 6 month self‐study, doctor • Means of continuously monitoring arterial mentored program hemoglobin oxygen saturation (and pulse rate) – Basic sciences – PtiPatien t evaltiluation and preparation – Anesthetic drugs and techniques • Hemoglbilobin oxygen saturation can be – Patient monitorinng extrapolated from oxyhemoglobin dissociation • DAANCE test upon completion • Anesthesia assistants review curve to estimate blood oxygenation. courses available at AAOMS and ADSA • Indispensable safeguard against unexpected • Many states making mandatory for dental assistants to assistant hypoxemia. in office sedation

Oxygen Transport Monitoring Oxygenation

•Only 1-2% Dissolved in Plasma (PaO2) •Color of patient’s blood •98-99% Bound to Hemoglobin •Color of of patient’s skin and mucosa •Pulse oximetry

SaO2 (arterial blood plasma oxygen)

SpO2 (arterial Hb oxygen saturation)

Effect of Age, Obesity, Health on Pulse Oximeters Oxygen Desaturation

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Question: Oxyhemoglobin Dissociation Curve What oxygen saturation would you consider dangerous or an emergency? 1. 95% 30% 28% 24% 25% 2. 90% 25% 23% 20% 3. 80% 15% 4. 71% 10% 5% 0% 95% 90% 80% 71% 10

Pulse Oximetry Oximetry pearls:

• It is NOT an early warning system!! Nail polish: no problem • It takes several minutes from onset of respiratory depression to decline in SpO2. • Low O2 saturation is a delayed / late sign of respiratory / ventilatory problem. • It does NOT monitor ventilation • However, hypoventilation and / or airway obstruction are the principle causes of hypoxemiaduring sedation. Cold hands: will cause problem

Suggested Reading “Oral Sedation: A Primer on Anxiolysis for the Adult Patient” Texts: Mark Donaldson, BScPhm, RPh, PharmD,* Gino Gizzarelli, BScPhm, DDS, MSc,† and • Management of Pain & Anxiety in the Dental Office; Brian Chanpong, DDS, MSc‡ by Dionne, Phero, Becker; Saunders • Sedation: A Guide to Patient Management; by The use of sedatives has established efficacy and safety for managing anxiety regarding dental treatment. This article will provide essential information regarding Malamed; Mosby the pharmacology and therapeutic principles that govern the appropriate use of Articles: orally administered sedatives to provide mild sedation (anxiolysis). Dosages and protocols are intended for this purpose, not for providing moderate or deeper • Oral Sedation: A Primer on Anxiolysis; by Donaldson, sedation levels. Anesthesia Progress • Respiratory Monitoring; Becker, Anesthesia Progress Anesthesia Progress 54:118–129, 2007 • Recognition & Management of Complications of Sedation; by Becker, Anesthesia Progress • Preoperative Medical Evaluation: Part 1, General Principles, Becker, Anesthesia Progress

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Course materials available on FDSA website for course participants: For Further Training: • ADSA two day in depth seminars on oral sedation available www.fdsahome.org www.adsahome.org • Sedation courses online: • Complete handout of this lecture http://www.dentalanesthesiaonline.com/default.aspx • “Anesthesia Progress“ review articles on sedation, moniiitoring, emergency management, pre‐op evaliluation • Malamed oral sedation course online: • Board of Dentistry rule 64B5‐14 (sedation & anesthesia) http://www.dentalanesthesiaonline.com/products/oral‐sedation‐in‐ • Sample dental anxiety questionnaire dentistry‐220/ • “Ten Minutes Saves a Life” emergency algorithms • ADA “Recognition and Management of Complications During • “Ten Minutes Saves a Life” emergency kit recommended Minimal & Moderate Sedation course contents http://www.adaceonline.org/index.aspx?sec=olce&sub=cmain&ce_id=1263

IV sedation training IV sedation training programs • USC School of Dentisty, Los Angeles, CA ‐ Malamed Where to get IV sedation training: • Univ. Oregon School of Dentistry, Portland, OR –Reed • Miami Valley Hospital, Dayton, OH –Becker • Dental schools: few now provide • Medical College of Georgia, Augusta, GA ‐ Getter undergraduate training • Duquesne University, Pittsburgh, PA – Bennett • Residency: GPR, pedo, perio, OMS • Montefiore Hosptial, Bronx NY – O’Reilly • Post‐graduate CE programs: • Univ. of Alabama, Birmingham, AL –Louis • – ADA guideline: 2 week, 60 hour didactic, 20 live Lutheran Medical Center, Brooklyn, NY patient • Univ. of Alberta, Alberta, Canada –Crowell – Likely will change to mini‐residency requirement • Etc….

Quiz: Quiz: Which is the principal feature that distinguishes What is the most effective route of administration of Romazixon to reverse a benzodiazepine in the event of a the so‐called “non‐benzodiazepines” (eg. Ambien) respiratory emergency? from benzodiazepines?

60% 54% 35% 33% 33% 33% 1. Intravenous 50% 46% 1. Molecular structure 30% 40% 25% 2. IM deltoid injection 30% 2. Metabolism and 20% 15% 3. Sublingual injection 20% half life 10% 10% 0% 5% 0% 0% 3. Mechanism of 0% action 4. Sedative efficacy

10 10

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Quiz: Quiz: Since the benzodiazepines have low toxicity and cause Flumazenil can be used to reverse the action of all little “respiratory depression,” you can’t kill a patient by of the following sedatives EXCEPT: giving too much. True or False

80% 80% 1. Triazolam 67% 70% 70% 67% 60% 2. Diazepam 50% 60% 3. Zolpidem 40% 33% 1. True 50% 30% 40% 20% 33% 2. False 30% 4. Hydroxyzine 10% 0% 0% 0% 20% 10% 0% True False 10 10

In conclusion….. If you’re going to do it, DO IT RIGHT Words to practice sedation by:

• If all you have is a hammer, everything looks like a nail! “I do not ask my conscious sedation regimen to do more than it is • Nothing works every time. It’s important to have several techniques in your armamentarium. capable of. That is when people get in trouble”. • If oral sedation with nitrous oxide supplementation is inadequate for treatment, consider referral to pyschotherapist for counseling, hypnosis, or guided imagery relaxation training. Or refer to another provider trained in moderate IV sedation or general anesthesia.

Florida Dental Society of Anesthesiology

• State component of American Dental Society of Anesthesiology • Membership open to all dentists • Annual CE meeting • Annual SimMan ‘hands‐on’ high‐ fidelity sedation emergency simulation training • Newletter • Advocacy for anesthesia in dentistry • Website: – Scientific Articles – Sedation & anesthesia meeting information

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