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SEDATION DENTISTRY

 

General Anaesthesia (GA) / Unconcious Sedation

Nowadays, general anaesthesia in Adults / Children (being put to sleep) is a treatment available for all.. For most adults / children, general sedation works acceptably well. If sedation fails then GA can be provided. General Anaesthesia is used to perform root canal therapy procedures or even to have a complete cosmetic makover done. Talk to our dentist to find out more.

 

What are General Anaesthesia and Deep Sedation?

General anesthesia (GA) is when you are totally unconscious. In this state, you can't feel any pain. You can't reliably breathe on your own, so for more complex procedures (such as fillings - these are actually more complex than extractions under GA!) and procedures of longer duration you need to having a "breathing tube" inserted.

Deep sedation is a state of depressed consciousness, where you may lose the ability to breathe independently and you can't respond to verbal commands. However, you can still feel noxious stimuli like pain, so local anesthesia is necessary.

 

How is General Anaesthetic Adminstered ?

All Day All Night Dentist arranges to have GA administered by a registered Aust Qualified Anaesthetist, in a theater environment (following the guidelines of the Australian Anaesthetists Society).

The dental surgeon requires special additional training which is provided the faculty of dentistry (Sydney University) to be able to provide this dental treatment under GA.

"In assessing the needs of an individual patient, due regard should be given to all aspects of behavioural management and anxiety control before deciding to treat or refer for treatment under general anaesthesia. General anaesthesia for dental treatment should only be administered in a hospital setting with critical care facilities. All dentists involved in arranging or providing treatment under general anaesthesia should discuss with the patient advice and treatment options to avoid or reduce future episodes of general anaesthesia.

GA is usually started off with an injection in the hand or arm. It can be supplemented by a face mask but if a face mask is used you probably won't remember it.

If post-op pain is expected, the normal practice is to inject a long acting local anaesthetic during the GA, so that when you wake up everything is nice and numb for a good few hours (say 6 hours?) afterwards, which should give you time to take some painkillers and allow them to kick in. It's much better to premptively stop pain than it is to try to deal with it once it has started.

Apart from the risk of death (which, while very small, is still significantly higher than for conscious IV sedation), general anesthesia has a few major disadvantages:

(1) Complications are more likely with GA compared with conscious sedation both during and after the procedure. GA depresses the cardiovascular and respiratory systems. For some groups of medically compromised patients, it is contraindicated for elective procedures.

(2) Laboratory tests, chest x-rays and ECG are often required before having GA, because of the greater risks involved.

(3) Very advanced training and an anesthesia team are required, and special equipment and facilities are needed.

(4) You can't drink or eat for 6 hours before the procedure (otherwise, vomiting is possible and this would be extremely dangerous during GA).

(5) There are additional costs regarding theatre fees and Anaesthetists fee ( however medicare provides up to 70% rebate on the anaesthetists fee)

Are there any circumstances under which general anesthesia should be used?
Exceptional circumstances include treatment for certain groups of special needs patients, procedures which would be very unpleasant if you were conscious (such as very complex extractions of bony impacted wisdom teeth), certain other types of oral surgery, and people with an extreme anxiety of dental procedures for whom conscious IV sedation isn't enough (although IV sedation works fine for about 97% of people with a high anxiety of dental procedures).

If it's extractions that really terrify you, it may be possible to be put to sleep for the extractions and then have fillings etc. done under conscious sedation with local anaesthetic. However, general anaesthesia is not widely on offer, and must be carried out in a hospital, in the UK at least.

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Intravenous Sedation (IV)

Fear of the dental experience has been demonstrated to be one of the most significant barriers to the delivery of quality dental care. When the stress of the dental treatment situation is combined with dental fears, some patients find themselves unable to successfully have dental treatment done. In our practice, the most common type of anesthesia used is local anesthesia. In most cases, this is the only drug agent necessary. Most patients tolerate the local anesthesia well, and they recognize this feeling of having their lip numb for a dental procedure.

As noted above, there are many people who require a different approach for various reasons. For the patient who fears the required treatment, I.V. sedation offers a way to have required dental treatment done in a non-threatening manner. Other patients who benefit are those who need surgical procedures or a very large amount of work to be done at one time.

For these situations, we use intravenous sedation because it is a very conservative and appropriate method of controlled patient management during dental procedures. Sedation is the calming of a nervous, apprehensive individual through the use of drugs, without inducing the loss of consciousness. This highly effective technique requires the introduction of drugs directly into a vein, and it has the advantage of giving maximum control to the treating doctor as well as giving comfort to the patient.

The patient is not placed under general anesthesia, for the patient’s protective reflexes are still in place, including the ability for the patient to maintain his own airway. Appropriate monitoring equipment is used during the I.V. sedation appointment. A pulse oximeter, an EKG monitor, and supplemental oxygen will be used during the appointment. The use of intravenous sedation has been a very effective tool in our practice for outpatient dental care in many different situations.

It is our hope that this discussion has helped with your understanding of the procedures that have been proposed for you. Please feel free to ask further questions if you have any concern.

Some people have such dread of going to a dentist that they will avoid treatment even when severe problems arise. For these patients, our team of professionals recommends IV Sedation as a safe and painless solution to both their fears and their dental care requirements. IV Sedation allows patients to interact with the dentist in a sleep-like state where they feel no pain and lose subsequent conscious memory of the procedure. IV Sedation uses a variety of FDA-tested drugs that are administered by the dentist to achieve this unique state of consciousness that frees patients from both fear and pain.

During IV Sedation, the dentist uses a combination of anti-anxiety drugs to place the patient in a deeply relaxed state of consciousness that allows the patient extremely limited interaction with the dentist but inhibits sensation. The dentist delivers the IV Sedation dosage through a very small and thin needle wrapped in a soft plastic tube that goes into a vein in either the arm or the back of the hand. After insertion, the dentist removes the needle, leaving only the plastic tube, or “Venflon” in the skin.

The drugs go into the bloodstream through the Venflon, which remains in place throughout the IV Sedation procedure. While administering the dosage, the dentist talks with the patient to determine the appropriate sedation level. Remember, IV Sedation differs from the completely anesthetized condition of surgery patients. Patients often report being in a fog-like state where they feel nothing and forget details of the procedure, although they do remember the needle insertion (normally only a scratch) and the dentist’s initial instructions.

Most drugs used by dentists for IV Sedation fall into the anti-anxiety category- the most common being Benzodiazepine (“benzo”), Midazolam, and Diazepam. The majority of dental professionals prefer Midazolam for IV Sedation because it purges itself from the system more rapidly than other drugs. Some dentists also use Valium, but it remains in the system longer and can produce a burning sensation when first entering the veins.

For sensitive patients, some dentists will mix a local anesthetic with a Diazepam IV emulsion that the drug manufacturer claims makes IV Sedation easier on vein tissue. Diazepam enters the bloodstream at 1mg per minute, while Midazolam enters the bloodstream at 1mg every two minutes due to its additional strength. Each patient is different, so the dentist carefully considers which drug is the best choice in each individual case of IV Sedation. Additionally, the dentist will monitor both patient response to the drug and vital life signs.

Once the patient reaches the correct level of sedation, the drug is turned off, but the Venflon remains in place so that if necessary the dentist can administer additional amounts. In the unlikely event of a rare emergency, the dentist can also use the Venflon to treat the patient with an appropriate counteragent.

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Post-Sedation Orders

1. A responsible adult must accompany the patient home. Sensory imbalance should be expected following the dental office sedation, and the patient must be supported while ambulatory.

2. Following dental office dismissal, mild sleepiness may persist for several hours, and the patient should be encouraged to go to bed and sleep.

3. The patient should be cautioned against sitting up or standing erect suddenly after a rest period at home, as this may lead to transient dizzy spells.

4. The patient is not to engage in any activity that requires sensory or motor coordination for 24 hours following the dental appointment. Driving a car, operating power tools, or making important decisions are not to be done during this period.

5. The patient should not indulge in any alcoholic beverages for 24 hours following the dental appointment.

6. If needle puncture site remains painful, apply moist heat to the site.

7. Nausea may develop if patient is ambulatory too soon or frequently. Make patient lie quietly in bed.

8. Take postoperative medication only as ordered by your dentist.

9. Any unusual event such as pain or swelling at needle puncture site, any rash, prolonged sleeping, fainting episodes, marked vomiting, or bizarre dreaming should be reported.

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