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CONSCIOUS SEDATION Neuroleptanalgesia- administration of a neuroleptic such

as droperidol and an analgesic such as fentanyl
• Done to put patients at ease during dental
treatment Neuroleptanesthesia- intravenous administration
• When local anesthesia is not enough to treat of neuroleptic drugs, together with inhalation of a
dental fear and anxiety weak anesthetic with or without neuromuscular relaxants
• Allows patients to enter a state of relaxation Dissociative anesthesia- characterized by catalepsy,
while awake during the procedure catatonia, analgesia, and amnesia
• No pain felt but responsive to questions and
commands General anesthesia- patient receives medications for
• Excellent option for fearful dental patients amnesia, analgesia, muscle paralysis, and sedation

Objectives of Conscious-Sedation
Spectrum of Pain Control
1. The patient’s mood must be altered- to eliminate fear
and apprehension which thereby aid in control of pain
reaction.

2. The patient must remain cooperative- In conjunction

with the alteration of the patient’s mood

3. The pain threshold should be elevated- Choose drugs

for conscious sedation that also elevate the pain
threshold at a central nervous system level

4. All protective reflexes must remain active- The patient

must maintain his airway clear of secretions and patent
at all times

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 patient, and with
Vertical bar- Denotes a very significant barrier, which is proper drug doses and rates of administration, minor
a point at which consciousness is lost changes in vital signs within normal limits may occur
Right half- Techniques heading to general anesthesia 6. There may be a degree of amnesia
Left half- may be termed psychosedation, sedation,
conscious sedation, or as minimum, moderate, or deep Philosophy of Conscious-Sedation
sedation
• Most of the patients are comfortable with the
1. No anesthesia- patients who require absolutely
dental treatment with the use of Local
no sedation or local anesthesia during their
anesthesia.
dental treatment
2. Pharmacosedation- the use of drugs to control • However, some are unable to withstand dental
anxiety care because of fear and apprehension.
3. Iatrosedation- relief of anxiety through the
dentist’s behavior is the building block for all Fear of “the needle”
other forms of psychosedation. A technique of
- This prevents a large segment of the population
communication between the dentist and the
from obtaining routine dental care.
patient that creates a bond of trust and
confidence Patients will have varying degrees of apprehension
or levels of awareness, so the dentist should select an
Conscious-Sedative-Analgesics Techniques Defined appropriate medication for each patient.
Conscious- When a patient is capable of rational
response to command and has all protective reflexes
intact, including the ability to clear his airway and to
maintain it in a patent state
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 most popular agent used to

produce conscious-sedation
 requires regulators, flowmeters,
and other special equipment
capable of accurately metering
gas concentrations
- equipment used for conscious sedation
purposes should not be capable of
producing anesthesia in any degree
- placing a potentially dangerous machine
in the hands of an untrained individual is
inexcusable
2. Oral Administration
- Most convenenient yet the least reliable
- Drug doses are based on educares
guesses based on age or body size
- Onset, effect, duration are least
Patient Preparation predictable

PARENTERAL ADMINISTRATION

• This is done after the dentist selected and  Intravenous, intramuscular and subcutaneous
chosen the drugs and techniques of are most frequently used
administration best suited to his needs.  Require minimum amount of equipment and
skills
1. The conscious-sedation procedure should be  Mastered easily
explained briefly and concisely.
2. Patient should be instructed to wear 1. Intravenous administration
comfortable, loose fitting garments. - Most reliable (in line with inhalation
3. Patient is instructed to eat a light liquid meal no route)
- Rapid effect
less than 2 to 3 hours before the scheduled
- Dose accurately controlled
treatment.
- Dentist administers small incremental
4. Those patient who will be receiving nitrous oxide
doses while observing patient, titrates
and oxygen alone must be told that they will
small drug increments to produce
have to be escorted from the office by a
desired effect.
responsible adult.
- Dose is quantum sufficit
- Drugs have predictable duration
- Circumvents the disadvantage of
ROUTES OF ADMINISTRATION inhalation route – the lack of potent
agents
1. Inhalation - Safe / safer than oral or other parenteral
- Dependable, convenient routes
- Rapid onset - Patient acceptance is good
- Short recovery period - A patient who usually objects to an
- Effects may be rapidly reversed by injection in the oral cavity will willingly
 Lowering concentration of agent consent to an intravenous injection.
 Discontinuation and 2. Venipuncture technique
administration of only oxygen or - Every dentist should acquire a degree of
room air skill in performing this technique
- Disadvantage - Importance:
 Most commonly used agent is a) For obtaining maximum
the weakest agent available effectiveness of drugs
- Nitrous Oxide b) Most advantageous in
emergency situations
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- A 2-step procedure: 10. The vessel is lifted on the bevel

a) Skin is punctured of the needle so as to advance
b) Needle directed into the vein the needle (3/4 of length) and
*steps should not be attempted prevent inadvertent puncturing
at the same time of the vessel’s inferior wall.
- SITE/AREA OF VENIPUNCTURE 11. The needle with necessary
o Area where needle will lie flat attachments for administering
and have least chance of being intravenous fluids is taped
dislodged by a slight movement securely to the hand or arm and
of the arm attached tubing taped so there
- PREFERRED VEINS is no pull or drag on the needle.
o On back of the hand: 12. When the procedure is
 Dorsal metacarpal v. completed and the needle is to
 Basilic v. be removed, a sterile piece of
o Lower forearm cotton or gauze is held tightly
over the skin at the site of skin
 Accessory cephalic v.
penetration.
 Median antebrachial v.
13. Needle is withdrawn and one
 Cephalic v.
maintains pressure in the
o Antecubital fossa
venipuncture site by pressing on
 Median antecubital v.
the cotton or gauze for 30-40
*vessel should not be a pulsating
seconds and taping it securely
artery
in place.
- PROCEDURE
1. Entire arm is surveyed.
2. Tourniquet is placed
above/below the elbow CHOICE OF AGENT AND CONSCIOUS-SEDATIVE
depending on site chosen. TECHNIQUE
Should be tight enough to  Before appointment patient should undergo
impede venous return but not routine pretreatment history and physical
interfering with arterial flow. evaluation to determine the patient’s ability to
3. Patient is asked to open and tolerate the stress of dental procedure from both
close his hand 2-3 times and physical and psychological point of view.
then leave his hand clenched  General rule  poorer the patient’s physical
until venipuncture is completed. condition, the greater the indication for
4. If veins are difficult to visualize, conscious-sedation.
the arm may be lowered for a
short period to make the veins Choice of pharmacological agent
stand out more.
 No one agent will work for all patients
5. The area of needle insertion id
 Patients vary in emotional makeup
prepared with an antiseptic
 Drugs vary in potency, effect, onset, duration
solution.
 Object of choosing the conscious-sedative agent
6. The patient’s skin is stretched
- To select a drug or drug combination that
taut in the opposite direction
will alter the patient’s mood to such a degree
from needle insertion.
that the dental procedures can be performed
7. Skin is punctured at about a 45
under local anesthesia while the patient is in
degree angle and approx. ½ to
a conscious state
¾ inch below and to the side of
intended site.
8. After skin has been penetrated,
the angle of the needle should I. Nitrous oxide
be lowered until it is almost - Colorless inorganic gas
parallel with the skin. - Almost completely inert within the body
9. Needle is then inserted slowly - Has pleasant odor & non-irritating
into the vein. - Weakest of all the gas used today
- Nonexplosive & nonflammable
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- Marketed in a blue cylinder as a liquid under - No significant depressing effect on

38atm respiration or circulation
 Concentration of about 10%-15%  Larger doses
- Begin to produce numbness of - Depress respiration
extremities, sedation and tingling - Cause significant fall in blood pressure
 Concentrations of 35%-40%  Smaller therapeutic dose
- Enhanced sedative effects - Does not affect heart muscle or cardiac
- Patient will have a degree of analgesia output
equivalent to that produced by about - Liver and kidneys are not affected
15mg of morphine - Given to patients with impaired
- Patients will feel as if he is floating and cardiovascular, renal or hepatic systems
not contacting dental chair
- Aware of warm sensation over entire
body and may relate to auditory Groups
sensations
1. Ultra-short acting barbiturates
- Most commonly used are:
i. Thiopental sodium (Penthotal)
ii. Thiamylal sodium (Surital)
 Inhaling 50% iii. Methohexital sodium (Brevital)
- Intensify all subjective symptoms but - Administered solely by the intravenous
analgesia route
- If continued to breathe this - Rely on their lipid solubility for their
concentration, patient will become brevity of action
progressively more sleepy and may be - Biotransformation & elimination proceed
rendered unconscious (general at the rate of about 15% per hour
anesthesia) - Very large doses  will tend to saturate
- Peak effect in 3-5minutes. 1st symptoms the nonsensitive fatty depots. These
appear in less than 1minute depots are then free to serve as a
reserve for subsequent release into the
II. Barbiturates circulation with residual effects being
- Derivatives of barbituric acid produced converting them to long-acting
- White powders barbiturates
- melting point b/w 100ºC-200ºC 2. Short acting barbiturates
- primarily CNS depressants - Most commonly used:
- may be administered i. Pentobarbital (Nembutal)
orally, intramuscularly, intravenously ii. Secobarbital (Seconal)
or rectally - Administered solely by the oral route
- ascending reticular system is the - Oral dose  50mg-200mg. requires 30-
first area affected 45minutes for maximum effectiveness.
- when administered alone in the Duration is from 4-6 hours
presence of pain, the decrease the - Intravenous dose  50mg-100mg and
threshold and increase the reaction should be given very slowly. Duration is
to pain 2-4 hours
- when used in combination with 3. Intermediate and long-acting barbiturates
analgesics or narcotics, barbiturates - Although they have a place in dentistry,
potentiate their action their long duration makes them
- extremely low incidence of toxicity unacceptable for use in conscious-
- toxic symptoms  drowsiness, sedative techniques
sleep and depressed respiration
- death occurs as a result of
respiratory depression and hypoxia
- contraindication  history of
porphyria or allergy
 In therapeutic doses
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GENERIC
BRANDNAME
NAME

CHLORPROMA
THORAZINE
ZINE
DIMETHYL
PSYCHOSEDATIVE DRUGS AMINE
PROMAZINE SPARINE
• Classified under CNS depressant drugs THIFLUPROMA
• are specifically given to patients with psychiatric PHENOTHIA VESPRIN
ZINE
ZINES
disorders:
• Ex. Psychosis (schizophrenia), PERPHENAZIN PERPHENAZIN
E E
Neuroses, Psycho-somatic Disorders PIPERAZIN
and Personality Disorders E
PROCHLORPE PROCHLORPE
• the cerebral cortex is not significantly RAZINE RAZINE
depressed, leading to the belief that the reticular MEPROBAMAT
system is depressed to prevent excessive EQUANIL
E
PROPYL ALCOHOL
stimulation of the cerebral cortex. DERIVATIVES
PHENAGLYCO
• excessive doses will not bring about drowsiness,
DOL
lethargy or sleep unlike barbiturates, narcotics
LORAZEPAM ATIVAN
POTENTIATION:
CHLORDIAZPO
- When combined with narcotics or barbiturates, XIDE
LIBRIUM
BENZODIAZEPINE
psychosedatives produce a greater sedative effect.
- Doses of each drug should be reduced when used DIAZEPAM VALIUM
together. OXAZDEPAM SERAX

PHARMACOLOGIC EFFECTS MISCALLANEOUS HYDROXIZINE VISTARIL

1. ANTI-PSYCHOTIC, SEDATION &
DROWSINESS
- Produces slow psychomotor activity,
suppression of hallucinations and
delusions
2. ANTI-EMESIS
- controlling nausea & vomiting induced
by drugs, uremia, and gastroenteritis NARCOTICS
3. DEPRESSION OF MEDULLARY - Excellent ability to elevate the pain threshold by
RESPIRATORY CENTER binding to opiate receptors in the brain and
4. SKELETAL MUSCLE RELAXATION spinal cord whose activation produces analgesia
and euphoria.
ROUTES OF ADMINISTRATION: - Narcotics are also famous for being highly
- Oral - addictive. The body develops a tolerance for
Intramuscular narcotics which means that a higher dose is
- Subcutaneous - Intravenous necessary to produce the same effect. The
**Intravenous is the route of choice because of its euphoria produced and anti-anxiety effects are
efficiency in delivering conscious sedation. usually what makes the patient dependent on
the drug.
EXAMPLES:
CLASSIFICATIONS
The narcotic analgetics may be divided into three
groups:
1. OPIATES or alkaloids of opium, which include
morphine and codeine
2. SYNTHETIC OPIATES, which include
diacetylmorphine (heroin)
3. OPIOIDS or synthetic compounds, which include
meperidine (Demerol) and fentanyl (Sublimaze);
methadone (Dolophene); levorphanol (Levo-Dromoran)
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Pentazocine – sometimes produces

hallucinations
o Increased specificity will decrease the
effectivity of the analgesia.

EFFECTS OF MORPHINE
1. ANALGESIA & SEDATION CONCLUSION:
- can alter the suffering component of pain - Narcotics will remain the premier drug for
resulting in indifference to the experience. conscious sedation since intense analgesia is
- This coupled with the analgesia makes the not as important in conscious sedation as
patient unlikely to react to or perceive pain. euphoria, reduction of anxiety and freedom from
2. EUPHORIA fear are.
3. MEDULLARY RESPIRATORY AND
CARDIOVASCULAR DEPRESSION SEDATION WITH USE OF MULTIPLE AGENTS
- Dose-dependent - Drugs for conscious sedation may be given in
4. CEREBRAL VASODILATION combinations and/or through different routes of
administration to produce a myriad of effects.
OTHER EFFECTS: - These combinations must be made in line with
5. MIOSIS concepts of spectrum of pain control, techniques
- Pin-point constriction of the pupils of conscious sedation, spectrum of medication,
6. VOMITING doses and routes of administration.
- Usually on the first dose only. Succeeding doses
produce anti-emesis.

ROUTES OF ADMINISTRATION:
- Intravenous
- Intramuscular
- Subcutaneous

ADULT DOSE: 8, 10, 16 mg

BIOTRANSFORMATION – liver
EXCRETION – kidneys
- As MONOGLUCONORIDE

AGONIST/ANTAGONIST OPIOIDS
- A new category of pharmaceutical agents whose
goal is to isolate the desirable effects of
narcotics while eliminating the harmful effects.
- they have the ability to stimulate certain opioid
receptors while antagonizing others that produce
harmful effects to the body.

OPIOID RECEPTORS MAY BE SUBDIVIDED INTO:

1. Mu (µ) – analgesia at centers in the brain
o Respiratory depression, euphoria,
physical dependence
2. Kappa (ĸ) – spinal-level analgesia, miosis,
sedation
3. Theta (Ɵ) – dysphoria, hallucinations,
respiratory simulation, increased vasomotor
activity

PRIMARY OBJECTIVE: Selective stimulation of the Mu

receptors while keeping the Kappa and Theta stimulation
to a minimum
**However, this degree of specificity has not yet
been achieved.