Retrograde amnesia after intravenous sedation and general anaesthesia in a dental hospital

Midazolam, a benzodiazepine, is commonly used for intravenous sedation for dental procedures and, together with other benzodiazepines, can cause anterograde amnesia. Retrograde amnesia, however, is rare. It is defined as a loss of access to memory of events that occurred, or information that was learned, before the injury or event that caused the amnesia. We know of no reports of this occurring after the intravenous use of midazolam alone and few after general anaesthesia. We present two cases of retrograde amnesia: one after intravenous sedation and one after general anaesthesia.     

Enteral sedation: safety, efficacy, and controversy

This article reviews the safety and efficacy of enteral sedation use by dentists to provide an evidence-based perspective on the current controversy associated with the use and training requirements for enteral sedation in dental outpatients. Despite the many benefits to patients and dental practitioners, the administration of anxiolytic agents by the oral, sublingual, or rectal route (collectively referred to as enteral sedation) is controversial and has engendered efforts to limit its use and increase training requirements to levels similar to those for parenteral sedation. Factors contributing to this controversy include the off-label use of sedative-hypnotics for outpatient sedation, idiosyncratic reactions to triazolam, and incremental dosing. Evidence supports the continued need and demand for anesthesia and sedation services to ensure access to care for highly anxious and phobic patients, the very young, and special-needs patients. The published evidence and vast clinical experience for oral sedation with benzodiazepines also supports the safety of administering benzodiazepines for anxiety relief with little evidence of deleterious effects when administered incrementally to patients undergoing a dental procedure or at doses greater than those used for hypnosis. Enteral sedation with benzodiazepines remains a time-tested, safe, and widely used modality that needs to be maintained as part of general practice to ensure adequate access to dental care for the many patients for whom fear of dentistry remains a significant barrier to oral health care.     

Anxiety control in the dental patient

Oral sedation with benzodiazepines and anxiolysis with nitrous oxide are 2 effective methods to help alleviate anxiety and fear of dental procedures. Many patients would prefer to have their dentistry performed with sedation if it were offered to them. This article presents a detailed discussion on minimal sedation that should give the reader a good understanding of this valuable aspect of clinical care.     

Clinical evaluation of the effects of ketamine sedation on pediatric dental patients.

This study was undertaken to determine the dosages, treatment times and side effects of ketamine HCI with and without two benzodiazepines when used for sedation on a group of precooperative children at the UCLA Children's Dental Center. Ketamine was evaluated when used alone, and in conjunction with two benzodiazepines, diazepam or a new water-soluble midazolam. An anti-muscarinic, atropine or glycopyrrolate, and nitrous oxide-oxygen were included in all sedations. Mean treatment times were increased significantly when ketamine and a benzodiazepine were used in combination. Additionally, mean ketamine dosages were decreased significantly when ketamine was utilized in combination with a benzodiazepine. All children tolerated the sedation well and there were no severe adverse reactions. Side effects included nausea, vomiting, and a rise in post-operative temperatures.     

Handicapped patients. General anesthesia or sedation?

The Authors consider the problems involved in dental treatment of the handicapped patients. Accuracy in diagnosis of the handicap factor, knowledge about its consequences on pathophysiological status and about chronically assumed drugs are the first step: in fact these patients may be affected by a wide variety of physiopathologic and mental diseases. Failure of cooperation requires general anesthesia or sedation techniques. General anesthesia can be dangerous (malignant hyperthermia in myopathies, difficult intubation in facial anomalies, pharmacological interactions); furthermore, its frequent application even in order to perform minimal treatment is often unsuitable. Sedation techniques offer a more convenient possibility, but must be practised by trained operators. Nitrous oxide alone rarely produces in fact a sufficient degree of sedation and is suitable only in patients affected by very slight mental insufficiency. In the other cases, association with various drugs (as benzodiazepines, barbiturates etc) is needed. In such a situation, the active and continuous presence of the anesthesiologist becomes mandatory.     

Reversal of midazolam sedation with flumazenil following conservative dentistry

The purpose of this double-blind randomized study was to assess recovery of mental function following reversal of midazolam-induced sedation with the specific antagonist flumazenil (R015-1788) or placebo following conservative dental procedures. Recovery was assessed using choice reaction time and critical flicker fusion threshold, both objective tests of psychomotor function; linear analogue sedation scores and simple memory tests. Assessments were repeated up to 3 h after administration of flumazenil or placebo to discover whether recovery was sustained or whether resedation occurred due to the short duration of action of flumazenil. Flumazenil in doses from 0.5 to 1.0 mg rapidly reversed the sedative and amnesic effects of a mean dose of 8.2 mg of midazolam without apparent evidence of subsequent resedation. Since recovery of mental function in the control group had ordinarily occurred 45 min after administration of placebo, routine reversal of midazolam sedation with flumazenil cannot be justified. Nevertheless, in cases of undue sedation persisting after dental treatment, flumazenil may be used with minimal risk of resedation occurring.     

A randomised crossover trial of post-operative cognitive and psychomotor recovery from benzodiazepine sedation: effects of reversal with flumazenil over a prolonged recovery period

OBJECTIVE: To study the post-operative cognitive and psychomotor recovery from midazolam conscious sedation, after reversal with the benzodiazepine antagonist flumazenil over a prolonged recovery period. DESIGN: A prospective, double-blind, randomised, crossover trial. SETTING: Out-patient Sedation Department, Newcastle Dental Hospital and School METHOD: Eighteen patients, ASA I or II, received midazolam on two separate occasions to undergo equivalent dental treatment. Following treatment patients were reversed with intravenous flumazenil or saline (placebo) at alternate appointments. Assessment of mood and cognitive function was undertaken using a highly sensitive and specific computerised battery of cognitive tests administered by telephone. Cognitive and psychomotor tests were administered prior to sedation and every hour for 6 hours post reversal. RESULTS: Results indicated no significant effect of flumazenil on simple reaction time and choice reaction time but did show a trend of reversing the effects of midazolam on numeric working memory and word recognition. CONCLUSION: The cognitive and psychomotor effects of the sedation were not fully reversed by flumazenil. Cognitive impairments were still present up to 6 hours post-reversal, despite patients appearing clinically more alert. This has important implications for treatment protocols and discharge instructions.     

Inhalational and enteral conscious sedation for the adult dental patient

There are clearly many safe and effective sedatives available to the dental practitioner for reducing patient fear and improving their level of comfort. Careful consideration needs to be given to the objectives of the sedation when deciding which pharmacologic agents to use because they all possess slightly different clinical characteristics and various degrees of risk. Patient selection also is critical when making decisions about sedation because the patient's expectations and general health status factor into keeping the procedure safe. N2O/O2 sedation is an excellent choice for managing the mildly fearful dental patient or when minimal sedation is desirable. Among the sedatives administered enterally, the benzodiazepines are the most commonly used, and for good reason. These drugs are safe, effective, and offer a host of different personalities from which the dentist can choose. If used wisely and thoughtfully, the dentist can tailor the effects and duration of onset and recovery to the needs of the patient and the expected parameters of the appointment. When N2O/O2 sedation is combined with a single enteral sedative, a more profound level of CNS depression is achieved that can be modestly altered by changing the concentration of inhaled nitrous oxide. With these many pharmacologic alternatives, many different dental patient populations can be sedated in a safe, effective manner, thus allowing the delivery of most dental treatments in a setting of reduced psychologic and physiologic stress. These pharmacologic sedatives have truly opened up a wonderful world of possibilities for the comfortable delivery of dental care, and should be integrated into every office's repertoire for delivery of care.     

Making patients safe and comfortable for a lifetime of dentistry: frontiers in office-based sedation.

Conscious sedation administered in the office setting is one important method for helping people obtain necessary dental care. Patients who may benefit from sedation include the dentally fearful, young children, the behaviorally or medically challenged, and individuals who are undergoing invasive procedures or have problems with gagging or local anesthesia. In-office sedation is effective in reducing apprehension and can improve patient behavior without adversely affecting the patient's physiological status. Mortality and serious morbidity are exceedingly rare in modern practice. Although behavioral strategies are clearly more cost-effective for the patient receiving routine dental care, in-office sedation is usually the least expensive alternative for patients requiring pharmacologic management. Future advances in conscious sedation may include agents and techniques currently thought to be dangerous for nongeneral anesthesia-trained dentists because of their ability to produce rapid changes in anesthetic depth. However, delivery devices such as infusion pumps for drugs like propofol, when coupled with computers to help regulate the infusion rate and monitor the sedative effect, may provide the necessary control for safe administration of propofol and similar drugs by these individuals. A final approach to drug delivery may involve patient-controlled sedation in which the patient self-infuses small boluses incrementally until the desired effect is achieved.     

Comparison of dexmedetomidine and midazolam for conscious sedation in dental surgery monitored by bispectral index

Although various sedative drugs in different regimens and given by different delivery routes have been used for conscious sedation, the ideal agent and regimen remain to be established. This study was designed to compare the efficacy (sedation, anxiolysis, analgesia, operating conditions, and patients’ satisfaction) and safety of midazolam and dexmedetomidine as sedatives for dental procedures in a randomised, double-blind study in third molar and dental implant surgery. Sixty healthy patients who were American Society of Anesthesiologists (ASA) group I or II were enrolled and we recorded their personal details, the amount of drug used, their degree of satisfaction, duration of operation, and haemodynamic and respiratory variables. The two groups were comparable. The amount of local anaesthetic (p = 0.11) and the duration of operation did not differ significantly (p = 0.32). The patients in the dexmedetomidine group had a slower heart rate, lower systolic and diastolic pressure, and cooperated better. There were no significant differences in their respiratory rates, bispectral index, and total volume of drugs used. We conclude that dexmedetomidine works as well as midazolam for outpatient dental procedures and can be used as an alternative to midazolam.     

The improvement of safe sedation and dental treatment in patients with metabolic syndrome

The paper concerns the anesthetic aspects of safe conscious sedation and dental treatment of patients with metabolic syndrome. BIS monitoring in combination with routine pulse oximetry and blood pressure measurement is getting dental sedation safer. Independently of the bolus or continuous intravenous midazolam infusion the investigators approved high efficacy of bispectral index in benzodiazepine dose titration. Successful dental treatment under conscious sedation and no evident associated with analgesia complications show the importance of BIS-monitoring in the improvement of safe sedation and dental treatment in patients with metabolic syndrome.     

An Analysis of Moderate Sedation Protocols Used in Dental Specialty Programs: A Retrospective Observational Study

Introduction

Pain and anxiety control is critical in dental practice. Moderate sedation is a useful adjunct in managing a variety of conditions that make it difficult or impossible for some people to undergo certain dental procedures. The purpose of this study was to analyze the sedation protocols used in 3 dental specialty programs at the Case Western Reserve University School of Dental Medicine, Cleveland, OH.

Methods

A retrospective analysis was performed using dental school records of patients receiving moderate sedation in the graduate endodontic, periodontic, and oral surgery programs from January 1, 2010, to December 31, 2012. Information was gathered and the data compiled regarding the reasons for sedation, age, sex, pertinent medical conditions, American Society of Anesthesiologists physical status classifications, routes of administration, drugs, dosages, failures, complications, and other information that was recorded.

Results

The reasons for the use of moderate sedation were anxiety (54%), local anesthesia failures (15%), fear of needles (15%), severe gag reflex (8%), and claustrophobia with the rubber dam (8%). The most common medical conditions were hypertension (17%), asthma (15%), and bipolar disorder (8%). Most patients were classified as American Society of Anesthesiologists class II. More women (63.1%) were treated than men (36.9%). The mean age was 45 years. Monitoring and drugs varied among the programs. The most common tooth treated in the endodontic program was the mandibular molar.

Conclusions

There are differences in the moderate sedation protocols used in the endodontic, periodontic, and oral surgery programs regarding monitoring, drugs used, and record keeping.     

Considerations for the use of oral sedation in the institutionalized geriatric patient during dental interventions: a review of the literature

Some institutionalized elderly persons need a sedative prior to a dental examination or treatment because they have a disturbance due to physical illnesses, degenerative changes in the brain, and/or psychiatric disorders, associated with advanced aging. Oral administration is one of the safest methods of delivery of a sedative drug. It is almost universally acceptable, easy to administer, costs little, has a low incidence and severity of adverse reactions, and requires no additional formal specialized training for the dentist. However, theoretical and practical knowledge of sedation is essential. This paper reviews the literature on oral sedation for the geriatric patient. Benzodiazepines are most often used for oral sedation of geriatric patients. The properties of these drugs were reviewed, and recommendations were made with respect to the drugs of choice and their dosage. Generally, fast-acting benzodiazepines of short duration, with rapid rate of elimination and no active metabolites, are recommended. The drug of choice, and the dosage, may vary according to the medical history and physical condition of the patient.     

Development of new agents and techniques for intravenous analgesia

The search for new anesthetic and analgesic drugs will be aided by analysis of the structures of chemical compounds which variously stimulate the five proposed opioid receptors or the benzodiazepine receptors. The mechanism of interaction between the benzodiazepines, opioids, and the neuroleptics will be further elucidated. These studies will result in discovery of drugs with fewer side-effects and more specific clinical effects.     

Oral rehabilitation under dental general anesthesia, conscious sedation, and conventional techniques in patients affected by cerebral palsy

The purpose of this report is to find the use of different alternatives for dental treatment, from general anesthesia to conventional techniques, in patients affected by cerebral palsy (CP) in a dental school setting. The sample was divided into two groups: (1) children, and (2) adolescents and young adults; 38 patients (20 female and 18 male) with diagnostic of CP were included. Risks and benefits of conscious sedation and general anesthesia were written into a consent form and these were discussed with parents or guardians of each affected patient. The mean age was 7.14+/-2.2 years for children's group and 18.5+/-3.06 years for adolescent and young adult group. Most children (77.3%) were classified as ASA II with a level of behavior I-II according to Frankl's scale and these patients were treated under general anesthesia (GA). For patients that were classified as of positive behavior with little necessity of dental procedures, independent of the medically compromised level, dental treatment was done with conventional techniques or with conscious sedation. Dental frequency procedures were as follows: composites, dental prophylaxis, and dental extractions in children; in adolescents and adults, important to point out is that in anterior teeth and molars endodontic treatment, and surgical procedures increased in frequency. The mixture sevoflurane-propofol worked well during pre-, peri-, and post-operative procedures. During the discharge process, most patients needed a recovery of 20-40 minutes after which they were awake and oriented, breathing comfortably with stable vital signs. It was concluded that GA with sevoflurane-propofol and conscious sedation are an excellent tool to provide dental treatment in CP patients in a dental school setting without most of the major postoperative complications, such as nausea and vomiting.     

Stato attuale della sedazione cosciente in odontoiatria

ObjectivesAim of this paper is to survey the history of sedation in dentistry in Europe, that is so different to USA because the possibility of American DDS to perform other kind of sedation till general anaesthesia.Materials and methodsA wide historical and bibliographic note is explained. In Europe, dentists are entitled just to conscious sedation, administration. It allows the practitioner to safely perform dental procedures without discomfort for the patient, to relieve and eliminate anxiety and to increase patient acceptance and compliance. Among titrable techniques, inhalation nitrous oxide: oxygen technique and intravenously administered benzodiazepines with prevalent central depression action are the favourite. Among non-titrable techniques we mention the enteral administration.Results and conclusionsTo learn how to use these techniques post-graduation courses, organized by University or by specialized continuing education and training society are required, as stated by the actual laws.     

Sedation with nitrous oxide in daily practice

Conscious sedation is recommended, together with behaviour management techniques, to facilitate treatment of dental fear or dental phobia patients. In this article the authors focus on inhalation sedation by means of nitrous oxide. The procedures and indications are explained and illustrated with clinical cases. On the strength of the literature and their own experience the authors reach the conclusion that Inhalation sedation is a kind of pharmacological behaviour management and an important additional tool to increase patient cooperation. Inhalation sedation can only be performed by trained practitioners under internationally accepted safety conditions. Inhalation sedation has a future in Belgium providing the appropriate law is adapted. This technique deserves a place in the dental curriculum.     

Comparing efficacy and safety of four intravenous sedation regimens in dental outpatients.

BACKGROUND: Management of patients' fear and anxiety during dental treatment is a primary concern of dental practitioners. Pharmacological strategies used in outpatient dental settings must be both safe and effective. Regimens of intravenously administered sedative drugs were evaluated in a collaborative, multicenter study of outpatients undergoing removal of impacted third molars. METHODS: A total of 997 patients randomly received one of five treatments: placebo; midazolam administered to a clinical endpoint of conscious sedation (mean dose, 8.6 milligrams); midazolam plus additional midazolam as needed during the procedure (mean total dose, 12.2 mg); fentanyl (1.4 micrograms/kilogram) plus midazolam to achieve the same endpoint of conscious sedation (mean dose, 5.7 mg); or fentanyl (1.4 (micrograms/kg), midazolam (mean dose, 5.8 mg) and methohexital as needed during the procedure (mean dose, 61.0 mg). RESULTS: Each drug regimen reduced anxiety during surgery in comparison with placebo, with the combination of midazolam, fentanyl and methohexital resulting in significantly less anxiety in comparison with the other treatment groups. Pain reports by patients during surgery also were reduced significantly by the combination of fentanyl, midazolam and methohexital. Patients' global evaluations of the efficacy of sedation ranked midazolam with supplemental midazolam and the combination of fentanyl, midazolam and methohexital as significantly more efficacious than the other two drug regiments. The authors noted transient respiratory depression in patients in the two opioid-treated groups, but no other physiological changes were detected. CONCLUSIONS: These data provide evidence that the drugs and doses evaluated resulted in therapeutic benefit to dental outpatients, with minimal incidence of potentially serious adverse effects. CLINICAL IMPLICATIONS: The results of this large-scale study provide assurance to both the public and the dental profession of the safety of parenteral sedation with these drugs and combinations of these drugs when titrated slowly in the recommended doses by appropriately trained dentists.     

Anxiety: its management during the treatment of the adolescent dental patient

Surveys indicate that the adolescent, in particular, suffers from acute anxiety in relation to dentistry. This anxiety is promoted by the general opinion they form of dentists and dentistry through portrayal by their peers and the media. In addition, their own attitude to dentistry, both positive and negative, is influenced to a large extent by the dentist himself. This patient-dentist relationship is, therefore, especially important when treating the adolescent and this should be emphasized in the dental undergraduate curriculum. Psychological methods can be effective in overcoming anxiety but they may be time-consuming. The technique of rapid induction analgesia, using hypnosis by indirect suggestion, may be the most practical modality in this field. Pharmacological techniques remain the principal method of stress reduction. The oral sedative-hypnotic of choice has progressed from the barbiturates to the benzodiazepines mainly due to the selective action of the latter on the limbic system coupled with their high therapeutic index. The newer benzodiazepines combine a more rapid onset with accelerated recovery. Nitrous oxide remains a safe and predictable agent for sedation but its ability to reinforce post-hypnotic suggestion has not been fully realized in the past. Intravenous sedation has evolved from a general anaesthetic technique to a predictable conscious sedation technique with the benzodiazepines again dominating the field. The advent of newer benzodiazepines with much shorter half-lives will improve their properties further. With the combination of the psychological and pharmacological techniques available, anxiety for the adolescent in dentistry may be overcome.