MD.Vladivoj Tuzar

10 years of experience in the controlled sedation

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 10 years experience in controlled sedation in dentistry

Visiting a dental clinic and the dental treatment itself is very stressful not just for a few people. If you hear a conversation between patients and dentists, almost always occurs during the talk to the concerns expressed on varying degrees. Moderate degree of concern is completely natural phenomenon and results from some annoying aspects of even very gentle dental examination and treatment. Considerable or insurmountable fear of visiting dental practice is less frequent, but not exceptional.

Then we talk about the overwhelming phobia of dental treatment, and such a people usually do not visit the dentist on a regular basis, but only for acute pain and in the last stages of destruction of teeth. Here comes the dentist himself. With appropriate approach to such a patient, consisting of a combination of proper psychological functioning with friendly and suitable pharmacological premedication, he can rid of a considerable proportion unnecessary concerns of the patients and gains of them mostly grateful and permanent clients.

If even this approach misses its effect and phobic patient still refuses offered cooperation, here comes into consideration another two possible solutions. The first is to send the patient with unsurpassed phobia to the clinic where in co-operation with anesthesia department will be the teeth redeveloped under general anesthesia. General anesthesia usually provided on dental workplaces of hospital type is the classic “anesthesia” with securing the airway frequently by nasotracheal intubation, preceded neuromuscular blockade (muscle relaxation), with controlled ventilatory and mainly requires two days of hospitalization as a minimum.

In practice, there comes a fact of long order terms, what is for a patient with unsurpassed phobia and acute pain greatly limiting factor. The second option is subject to certain conditions (see below) to perform the dental treatments under so called analgosedation (or sedation only) in collaboration with a physician – anesthesiologist. This sedation is performed in a dentist’s office and does not require on the dentist side no special equipment or training. We talk about a mere sedation, if only a sedative is used for the psychovegetative divert of the patient, analgosedation is a combination of painkillers and appropriate sedatives.

Ten years of experience with the implementation of controlled analgosedation in practice of dentists and dental surgeons confirms that this method is highly secure, easy and very welcome by the patients. The purpose of this information is not to acquainted the dentist in detail with the pharmacology of the used drugs, there is more emphasis on the description of the sedation, correct indication and highlight the advantages of this method so that also the hesitant or skeptical dentists won’t hesitate in to use this method the future to increase the prestige of their dental practice.

The inalienable page of analgosedation is understandably the financial issue. Unsurpassed phobia is not a disease entity and dental treatment under general anesthesia before 1990 has always meant the need for a patient to visit a doctor psychiatrist who has been authorized to recommend general anesthesia, and indicate it together with a dentist. None of the health insurance companies in the country or even in the world covers the analgosedation.

Therefore, is the controlled sedation performed for direct payment by the patient and the amount is a matter of agreement between the patient and the anesthesiologist. However, if the dental status forces the person with unsurpassed phobia of dental treatment to consent to the performance of a controlled sedation, finances don’t play such a significant role.

Perioral premedication

It is possible to effectively calm the anxiety patients before the treatment by a combination of psychological impact and oral premedication. As a premedication is recommended Midazolam (Dormicum Roche®). After perioral application is Midazolam quickly and completely absorbed. The oral bioavailability is 65%. Maxim

„Untreatable“ child in surgery

It’s certainly familiar: a child aged two to six years and the need for early treatment of dental caries, or even extraction of deciduous teeth. After lot of persuading from a mum side the child sits in a chair, my mouth pressed tightly together, looking skeptical, sometimes hostile, often loudly crying and screaming. The dentist explains in a persuasive voice, calming, promises rewards, or rides on a chair up and down, all at substantial support of mom and father’s verbal threats. Precious time passes without the child being examined, let alone treated! After exhaust of promises, persuasion and threats the child is without treatment, usually crying, stressed. Parents promise to persuade the kid at home and that the next time it definitely will be all good! But experienced dentist knows that next time it will be the same scenario, so parents are leaving the office with a recommendation to the nearest clinic with assurances that “there they could work with him somehow!”

There is a possibility of perioral premedication. Before treating a child is given pre-treatment dose on a spoon orally, most often midazolam. If child won’t spit the dose but swallows, you are excited that in about half an hour it will be possible to treat the child in peace. But often unfortunately the promised sedation does not work, the child is happily running around the waiting room, and mom begins to cast suspicious glances.

There are several advice on how to handle an uncooperative patient – from psychological preparation by specialist to serious violence. The dentist can use in practice a popular midazolam. In many situations, it is very useful helper. However, it requires an individual dosage, sometimes going far beyond the recommended limit, which a dentist usually doesn’t want to risk. Dental practice, which cooperate with the anesthesiologist may offer treatments in sedation. But many anesthesiologists have set as a condition for filing sedation an age limit of the child’s age of six years. But what about a preschool children? Undoubtedly they need the treatment. How it can be done without building a lifetime phobia?

As an anesthesiologist, of course, I can offer the only reliable solution – treatment in deep intravenous sedation. I have searched for long a suitable way how to submit a sedation in dental surgery without staying at the hospital that provides to a dentist the necessary calm to work – a calmed child, permanently open mouth, decreased secretion of saliva (a baby crying before the treatment tends to have a significant secretion of saliva and mucus leaking from the nasal cavity into the pharynx).

The classic “controlled conscious sedation” is not suitable for small children. To achieve the required attenuation would be necessary to give very high doses of benzodiazepines. The problem may be as well the subsequent antagonizing effect of the most frequently used midazolam specific flumazenilem antagonist.

After several years of experience using the intravenous anesthetic Propofol for sedation in adult I started using a similar method of sedation in children.

Propofol is a very safe short-acting general anesthetic with fast onset, approximately within 10 to 30 seconds. Duration of anesthesia after a single dose is dependent on the metabolism and elimination and it is about 4 to 6 minutes. During repeated administration or continuous infusion there wasn’t observed any significant accumulation.

After induction of anesthesia it may occur temporarily bradycardia and hypotension caused by inhibition of sympathetic activity, but after a short time the hemodynamics returns to normal. Propofol can be safely administered from one year of age and contraindications are only rare hypersensitivity to Propofol or any other ingredients of the product (soybean oil, egg lecithin, glycerol, oleic acid).

Thanks experts well-managed media campaign, many parents realize that regular visits to the dentist starts at the age two years old child. In the not inconsiderable percentage of children is the sedation in dental practice even required by parents. It turns out that parents are willing to take even a long journey for the dental practice, where treatment is offered to the child in sedation.

If I’m invited to submit a sedation child, everything happens in a standard manner established on a professional level. Initial information on the treatment of sedation receive the parents from a dentist who will issue them an information sheet and questionnaire anesthesiology. It also includes the informed consent of a parent or guardian. There are detailed instructions. If required by the state of health of the child, we arrange with a parents the extent of the preoperative evaluation.  We determine the necessary period of fasting before treatment – 5 hours in the case of solid food, fluids for 3 hours. Parents are usually asked to carry on the treatment the child favorite drink to which is then added the premedication. Furthermore, they must know the exact weight of their child.  We meet the parents and the child in the dentist’s waiting room 30 minutes before the scheduled time of treatment. Based on the weight of the young patient I prepare premedication, which is then given either a syringe directly into the mouth of a child or with a small amount of the drink.

I’m using for the premedication which should calm the uncontrollable child patient, a proven midazolam in dose 1 mg / 5 kg body weight. Midazolam alone may not provide the necessary attenuation child and subsequent venous access in the arm would probably went very dramatically. In hospitals, the effect of midazolam potentiates by opioid (pethidine), but only in children over 20 kg body weight. Previously, Valoron was a popular ingredient for Midazolam but is not available any more. Without response to clinical background I don’t serve opioids not even in premedication. I prefer to use proven ketamine. This dissociative general anesthetic is used for total anesthesia on many workplaces only sporadically. Today the general anesthesia can be led with many other appropriate products. In oral premedication with midazolam to me, however, the use of ketamine appears to be highly competitive. At a dose of 5 mg per kilogram of body weight along with midazolam at the recommended dose in most cases provide the necessary attenuation – the baby sleeps, not against, still breathing, circulation remains completely stable. Nystagmus is present, yet I never noticed increased muscle tone. Parents are advised to keep a child in her arms and not to disturb him.

After accession to the effect of premedication parent with a child comes into the clinic. According to custom dental surgery I either let the child sit on a parent, or put the child to a chair ready in the supine position. Parent according to the dentist remains throughout the treatment in the office, or is asked to wait after “putting to sleep” the child in the waiting room.

Then comes the stage of venous access on the arm of a child. I always ask parents for their presence. They help comfort the child who naturally responds to painful puncture. I assure parents of anterograde amnesia induced with midazolam premedication. Child usually only indicates a resistance but is very flimsy.

After securing intravenous sedation input I initiate the administration of atropine 0.1 mg / 10 kg body weight. The reason is the reduced secretion of saliva in the mouth and mucus in the airways. I connect the baby to the pulse oximeter and slowly adding Propofol in subanestetical dose of 1-2 mg / kg body weight. I always deliver oxygen through oxygen “nose glasses” at a dose of 1-2 l / min. After inducing deep sleep I ensure a continuous open mouth of a child by plastic block.

Although after this dose the defensive cough reflex is distinguishable very well, we try to carefully by suction cooling water and insertion of a tamponade between the tongue and hard palate to minimize the risk of water infiltration into the hypopharynx, followed by a cough. During the extraction, it is desirable to perform local anesthesia accustomed manner. By careful refilled manner I administer a Propofol throughout treatment. The maximum treatment time is 2 hours. But most treatments takes a much shorter time. If a child is sitting on a chair on his own, I’m helping to ensure the position of the head, possibly I improve the airway patency by tilt of his head back slightly, especially if the dentist is working in the lower jaw.

If a child is sitting on a parent, then informed secures the position of the child’s head.

After the end of the treatment I let the effect of Propofol freely subside. This anesthetic has no specific antagonist. Waking up is mainly due to the previously filed premedication gradual and lasts 20-30 minutes. By then the parent already sits with a child in the waiting room, and there I continue to monitor the saturation and pulse with a device. I leave intravenous cannula until the first signs of awakening the child. On time I remove it and by careful compression I try to ensure that the injection site was the least noticeable. After waking the child quickly I remove the compression from the injection site. The child often don’t recognize where the intravenous cannula was introduced.

Obviously I have to be prepared to respond to possible sudden emergence of complications and therefore I am always with everything necessary to solve urgent conditions of a adult and pediatric patient.

After coming into a full consciousness I telling the child’s parents, how they shall treat the patient in the next few hours, when they can serve a first food and drink. I underline the priority of preventing self-injury of the child – not to let run wild, better take to car and out of the car. Parents will receive a record of anesthesia with a listing of a total dose of anesthetic administered, including premedication. I emphasize the possibility of telephone consultations whenever necessary, my phone number is mentioned on the anesthesia record. When the baby is awake, fully ventilation and circulation stabilized, corresponding to simple tasks I dare the parents to leave with a child the dental practice. Always insist on a car ride. I’ll alert parents that a full offset of action will take several hours, and during this time the child needs special attention. It is unacceptable to place immediately a child to kindergarten or school and left unattended.

The payment for administration of anesthesia make the parents before going home. The treatment is not covered by public health insurance. Several parents tried to negotiate in their health insurance reimbursement for the administration of sedation during dental treatment, but their request was always denied by a health insurance.

It turns out that this way of mastering an „untreatable “child patients is associated with an acceptable level of risk, reliable and financially accessible. So far I have not seen any incidence of serious complications for which treatment could not be completed. Despite the occasional failure of cannulation of the vein system on the arm of a child it does not leave the premedication induced amnesia in the child any negative attitude to treatment. The mood state immediately after waking the child are different – from annoyance after merriment. It relates to the perception of changes in the oral cavity and, of course, they are modified by the fading anesthetics. Except in one case, the sedation of a child was always valued by parents very highly and often required repeatedly on subsequent visits to the dentist with the need for dental treatment of the child.

Specialization

MD. Vladivoj Tuzar – anesthesiologist

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