Sedation for outpatient dental procedures.

Pain and anxiety in the dental setting prevent many patients from seeking needed treatment. As a result, various techniques of anesthesia or sedation have been developed over the last 150 years to overcome this problem. Both the historic evolution of sedation and the use of several currently popular techniques are described in this article. Also discussed is the balance between individual patient responses to drugs, dosages, and rate of administration. Currently used definitions of pharmacologic depression of consciousness are detailed, as are contemporaneous training requirements. Finally, unexpected, rare, and catastrophic events that can occur with sedation are briefly discussed.

Pharmacosedation.

Anesthesia and pain control are a critical part of dental practice. This article reviews inhalation, intravenous and oral sedative agents and techniques.

Major morbidity or mortality from office anesthetic procedures: a closed-claim analysis of 13 cases.

A closed-claim analysis of anesthetic-related deaths and permanent injuries in the dental office setting was conducted in cooperation with a leading insurer of oral and maxillofacial surgeons and dental anesthesiologists. A total of 13 cases occurring between 1974 and 1989 was included. In each case, all available records, reports, depositions, and proceedings were reviewed. The following were determined for each case: preoperative physical status of the patient, anesthetic technique used (classified as either general anesthesia or conscious sedation), probable cause of the morbid event, avoidability of the occurrence, and contributing factors important to the outcome. The majority of patients were classified as American Society of Anesthesiologists (ASA) status II or III. Most patients had preexisting conditions, such as gross obesity, cardiac disease, epilepsy, and chronic obstructive pulmonary disease, that can significantly affect anesthesia care. Hypoxia arising from airway obstruction and/or respiratory depression was the most common cause of untoward events, and most of the adverse events were determined to be avoidable. The disproportionate number of patients in this sample who were at the extremes of age and with ASA classifications below I suggests that anesthesia risk may be significantly increased in patients who fall outside the healthy, young adult category typically treated in the oral surgical/dental outpatient setting.

Cocaine and sudden cardiac death.

Cocaine may induce totally unexpected cardiotoxicity in young individuals at some time distant from the cocaine ingestion. Commonly, such individuals are asymptomatic for coronary artery disease; some have no demonstrable coronary artery disease even after the cardiac event. Those who use cocaine must be considered at risk of cardiotoxicity at any time after recent cocaine ingestion. Guidelines are suggested for clinical management in oral and maxillofacial surgery.

The combined effect of nitrous oxide and oxygen and electrical stimulation during restorative dental treatment.

A total of 124 adult patients were treated with nitrous oxide (N2O) and oxygen (O2), an electrical analgesic, or a combination of N2O/O2 and an electrical analgesic during restorative dental procedures. The use of electrical analgesic or N2O/O2 without local anesthetics resulted in a high failure rate and poor patient acceptance. However, combining N2O/O2 sedation with electrically induced analgesia resulted in a statistically significant improvement over either technique used alone, and provided an overall 81% success rate when used during restorative dentistry.

Nitrous oxide in dental practice.

Nitrous oxide has been widely employed by dentists as an anesthetic agent throughout its history of clinical use. While hypoxic general anesthetic techniques using nitrous oxide are rarely if ever employed today in the United States, and appear to be on the decline abroad, nitrous oxide is extensively and successfully used in dentistry as a conscious sedative to reduce anxiety and provide some supplemental analgesia. Less frequently it is used as a co-agent with intravenous anesthetics or sedatives during oral surgery or restorative dentistry. Considering the number of patients given this agent on a yearly basis, its relative lack of reported side effects when used appropriately is remarkable.

Death after chloral hydrate sedation: report of case.

A young healthy female died after taking chloral hydrate syrup before surgery to extract third molars. Various aspects of the use of chloral hydrate are discussed, including the metabolism, active moiety, reported side effects, and effects on the heart. Recommendations are made concerning patient supervision, dosage limitations, and degree of sedation.

Achieving oral health in patients with renal failure and renal transplants.

The protocols for oral evaluation and treatment of patients with renal failure and renal transplants are presented. Guidelines for dental treatment planning are outlined, and extraction versus conservation of teeth is discussed. Information on special considerations involving dialysis, antibiotic prophylaxis, drug therapy, and immunosuppression is provided. The goal of treatment is to restore maximum function while minimizing the risk of oral infection after transplantation.

Pharmacological methods and research issues in the management of the adult patient.

Much information about anesthetic/sedative safety is not currently available. Although some information about mortality and its presumed cause has been published, it is based upon retrospective surveys. Even less information is available about morbidity of popular drug combinations used in an outpatient dental setting. Although a number of papers have reported complications from popular intravenous sedative/anesthetic drugs, no large-scale, reliable, prospective data is available to determine the safety of certain drugs, combinations of drugs, or specific types of sedative/anesthetic techniques.

Physostigmine: an antidote for excessive central nervous system depression or paradoxical rage reactions resulting from intravenous diazepam.

A review of the pharmacology and use of the drug physostigmine is presented. Of particular interest is the drug's capability to reverse excessive somnolence or paradoxical responses caused by intravenous diazepam (Valium®) and other clinically available benzodiazepines. Its use for the treatment of anticholinergic syndrome is discussed and incidence and characterization of side effects documented. Recommendations are made for appropriate emergency use.