Therapeutics under GA and conscious sedation
1- Introduction
Performing an oral-dental procedure, particularly surgical, on an anxious, phobic or disabled patient remains difficult and sometimes impossible.
Faced with these difficulties, the patient will either abandon treatment, which worsens their dental condition, or be referred for general anesthesia, which remains an expensive and risky solution. However, other alternatives exist today, such as conscious sedation.
2-Definitions
2-1 General anesthesia : Drug-induced loss of consciousness during which patients cannot be aroused, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Cardiovascular function may be impaired.
2-2 Deep sedation : Drug-induced depression of consciousness in which the patient cannot be easily aroused but responds deliberately after repeated or painful stimulation. Patients may require assistance in maintaining ventilation.
2-3 Minimal sedation : A drug-induced state in which patients respond normally to verbal commands.
2-4 Moderate sedation : Drug-induced depression of consciousness in which patients respond deliberately to verbal commands, alone or accompanied by mild tactile stimulation.
3- Purpose of conscious sedation
The goal of conscious sedation is to never reach a state of deep sedation and general anesthesia by using drugs with a sufficient safety margin and/or administration techniques that allow for perfect control of central nervous system depression (administration by titration). The main advantage is to ensure optimal management combining efficacy and safety.
4- Definition of a disability
Disability According to the definition of the World Health Organization (WHO) “A person is disabled whose physical or mental integrity is temporarily or permanently diminished, either congenitally, or as a result of age or an accident, such that their autonomy, their ability to attend school or to hold a job are compromised.”
5- Types of disabilities
Mental disability: Down syndrome, autism, intellectual disability
Mental disability : mental disorders or mental illness, neurosis, psychosis, depression, addiction, etc.
Physical disability : Sensory, motor disability, etc.
Disabling diseases : Myopathies, Alzheimer’s.
6- Care of patients with disabilities
The use of appropriate techniques is recommended in particular
- Behavioral approach: building the child’s confidence
6-2 Sedative premedication
Definition: Sedation is a calming effect using a sedative. It is defined as the use of medicinal or non-medicinal means intended to ensure the physical and psychological comfort of the patient and to facilitate treatment techniques.
6-3 Conscious sedation
6-3-1 Definition
Where, despite the reduced level of vigilance, the patient retains the effectiveness of his protective reflexes, control of the airways and the ability to respond appropriately to stimulation.
This type of sedation is perfectly suited to all dental surgery procedures.
Sedation is not intended for anesthesia. Anesthesia is only achieved with local anesthetics.
- Types of conscious sedation
A-Oral sedation : Easy, affordable with sedatives (Benzodiazepines) such as Diazepam, prescribed the day before or the day of the procedure.
Anxiolytics: type Atarax 25 mg can be used
B-Inhalation Analgesic Sedation (MEOPA)
- Special features
– Colorless, odorless gas composed of a mixture of 50% oxygen and 50% nitrous oxide, acting by inhalation.
– This mixture is anxiolytic and provides surface analgesia.
-On a physiological level, nitrous oxide has a triple action: an anxiolytic effect, an analgesic effect, a euphoric and amnesic effect, particularly in children.
-These combined actions result in an altered state of consciousness. It is the patient’s processing of sensory information that is disrupted. Verbal contact with the patient can be made at any time.
b- Contraindications
-Precarious hemodynamic state.
– Altered consciousness preventing patient cooperation.
-Maxillofacial trauma preventing correct application of the mask.
-Pain that is too intense requiring different treatment
-Medical procedure too long
- Benefits
– Speed of induction and speed of elimination, it is eliminated by the pulmonary route, also quickly and does not present a delayed effect;
-Maintaining vigilance,
-High safety: it does not accumulate in the body and there is no risk of delayed release
-Absence of disturbance of laryngeal reflexes
-Ease of use: the 50% N2O /50% O2 mixture is ready to use in a single bottle.
d- Instructions for use
This gas is breathed through a suitable nasal mask, connected to a secure bottle, placed on the patient’s nose and mouth for a few minutes; Just before the start of dental treatment,
He is asked to breathe calmly.
Inhalation must be continuous and last at least 3 minutes before the start of the painful act.
It can only cause tingling and even make you want to laugh (MEOPA was formerly called “laughing gas”) . Once the session is over, the patient will remain seated; the effects of MEOPA dissipate in just a few minutes.
C- Intravenous conscious sedation This is the third level of sedation through powerful disinhibition of the patient.
It is called “semi-conscious” because the patient, although totally unaware of what is happening in the office during dental treatment, paradoxically maintains a certain vigilance and responds to simple orders such as “open your mouth”.
This sedation is said to be “vigilant.”
This sedation is induced by intravenous sedatives injected just before and throughout the procedure, from the benzodiazepine family, hence its name “diazanalgesia”.
Before the first appointment it is important to obtain:
- Medical history (referent and medical correspondents);
- informed consent by the authorized person.
- A FNS blood test, hemostasis test, VS, Blood sugar, Grouping
- The patient must be fasting on the day of the procedure (unlike MEOPA)
6-4 general anesthesia
6-4-1 Indications of the AG
– Related to the patient’s general condition, behavioral conditions preventing any oral assessment and/or treatment while awake after failure of attempts at chairside care;
-Need for heavy and urgent oral preparation before specific urgent medical and surgical treatments, for example: oncology, limitation of oral opening preventing immediate examination and/or treatment.
-Pronounced gag reflexes
6-4-2 Contraindications of GA
– Major anesthetic risks: benefit-risk assessment necessary.
-Refusal by the patient and/or parents or legal representative.
At no time should general anesthesia be chosen as a first-line treatment to the detriment of lighter sedation protocols.
6-4-3 Characteristics of the AG
General anesthesia is characterized by four criteria:
– narcosis which corresponds to a profound loss of consciousness requiring endotracheal intubation;
– central analgesia which corresponds to a loss of sensitivity;
-muscle relaxation;
– neurovegetative protection of the organism against the aggression of the surgical procedure.
The protocol under AG must be carried out by an anesthesiologist-resuscitator practicing in an operating room and not in a dental office.
6-4-4 Intubation procedures
– Nasotracheal intubation has the advantage of freeing the oral cavity and reducing the risk of accidental extubations.
– Orotracheal intubation can also be used in dentistry and stomatology .
6-4-5 Complications
-Respiratory depression upon waking.
-Cardiac complications: myocardial ischemia was the most common.
-Among the vascular complications, hemorrhage played an important role in their appearance.
7- CONCLUSION
Child dental care presents complex psychological characteristics
The dental surgeon must have a good knowledge of the child’s cognitive and emotional development; understand the reasons that lead them to become resistant to treatment and establish a climate of trust in order to implement the most appropriate approach to their care.
8- Bibliographies
- INDICATIONS AND CONTRAINDICATIONS OF GENERAL ANESTHESIA FOR ROUTINE DENTISTRY AND STOMATOLOGY PROCEDURES, The High Authority of Health, June 2005.
- R. Atash and A. Vanden Abbeele, Use of equimolar oxygen/nitrous oxide mixture (MEOPA) in pediatric dentistry, Dentistry Clinic, Erasme Hospital, 2008.
- Mélanie Garat. General anesthesia in pediatric dentistry: a retrospective study of cases treated at the children’s hospital of the Nancy University Hospital from 1990 to 2007. Implications for the definition of a specific care program. Life Sciences [q-bio]. 2010. ffhal-01739113
- Bettayeb Youcef Boukellal Ahmed Rafik Mahfoud Ibrahim Massaid Chahrazed, Conscious sedation in the dental office: For whom and when?, July 2017.
Therapeutics under GA and conscious sedation
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