# Sedation

 Sedation involves the use of sedative drugs to reduce irritability or agitation,

primarily for medical or diagnostic procedures.
 Common sedative drugs include isoflurane, diethyl ether, propofol,
etomidate, ketamine, pentobarbital, lorazepam, and midazolam.

Medical Uses

 Sedation is used in various medical procedures, including minor surgeries

like endoscopy, vasectomy, dentistry, reconstructive surgery, cosmetic
surgeries, wisdom teeth removal, and for high-anxiety patients.
 Dentistry employs methods like inhalation sedation (nitrous oxide), oral
sedation, and intravenous (IV) sedation.
 It is also used in intensive care units to help ventilated patients tolerate an
endotracheal tube and during long-term EEGs to relax patients.

Risks

 Studies suggest that sedation accounts for 40-50% of procedure-related

complications.
 Risks include airway obstruction, apnea, hypotension, unintended levels of
sedation, postoperative somnolence, aspiration, and adverse reactions to
sedation medications.
 Complications could also include perforation, bleeding, and vasovagal reflex
stimulation.
 Pre-sedation evaluation is essential to identify patient risks and potential
airway management difficulties.

Levels of Sedation

 Sedation scales help assess the appropriate degree of sedation to avoid

under-sedation or over-sedation.
 Examples of sedation scales include MSAT, UMSS, the Ramsay Scale, and the
RASS.
 The American Society of Anesthesiologists defines the continuum of
sedation as minimal sedation, moderate sedation, deep sedation, and
general anesthesia.
Intravenous Sedation

 Intravenous sedation with Midazolam is a common technique for conscious

sedation in adults.
 It involves delivering medication via a needle into a vein (IV cannula).
 Indications include reducing dental anxiety, traumatic or prolonged dental
procedures, patients with a gag reflex, and special care for patients with
disabilities.
 Contraindications include uncooperative patients, psychologically immature
individuals, and various medical conditions or allergies that can lead to
complications.

# Inhalation Sedation

 A form of conscious sedation.

 Aims to depress the central nervous system (CNS) to reduce physiological
and psychological stress during surgery.
 Patients should remain conscious and able to respond to verbal commands.
 Emphasizes a wide margin of safety to prevent unintended loss of
consciousness or loss of protective reflexes.

Medical Uses

 Inhalation sedation is used in various medical scenarios, including:

 Dental procedures to address anxiety, phobia, and traumatic cases.
 Patients with medical conditions aggravated by stress, such as heart
disease, hypertension, asthma, and epilepsy.
 Patients with medical or behavioral conditions affecting cooperation.
 Special care requirements.

Side Effects and Contraindications

 Complications from inhalation sedation are rare but can include:

 Over-sedation.
 Respiratory depression or apnea.
 Unconsciousness.
 Airway obstruction.
 Vomiting.
  Idiosyncratic responses.
 Delayed recovery.
 Failure of conscious sedation.
 Contraindications include conditions that compromise sedation medication
inhalation (e.g., nasal blockage, respiratory diseases), recent ear surgery,
certain psychological disorders (e.g., schizophrenia), and early pregnancy.
 Pre-cooperative patients and those with respiratory conditions like COPD
are also potential contraindications.

Patient Assessment and Selection

 Anesthesiologists conduct a thorough assessment to determine the need for

sedation and the most suitable technique.
 Factors considered in assessment include patient history, age, health, drug
history, and social circumstances.
 Only patients in ASA classes I and II are usually suitable for sedation in
primary care dental settings, while ASA class III or IV patients require referral
to secondary care.

Problems and Complications

 Inhalation sedation is generally safe, but issues can arise.

 Dental staff must be trained to manage complications and emergencies.
 Monitoring of vital signs is essential.
 Common complications include vasovagal attacks, airway obstruction, severe
hypotension, and nausea/vomiting.

Equipment and Safety Features

 Equipment for inhalation sedation includes gas cylinders, flowmeters,

reservoir bags, conduction tubing, and breathing apparatus (nasal hoods or
face masks).
 Safety features include an oxygen fail-safe mechanism, scavenging ability,
pin index safety system, diameter index system, pressure relief devices,
oxygen flush, and audible alarms to monitor oxygen supply.

Additional Notes
  Continuous exposure to nitrous oxide can have health hazards for operators,
necessitating active or passive scavenging to remove nitrous oxide from the
environment.
 Inhalation sedation should be used alongside appropriate behavior
management and local anesthesia.
 Machines used for inhalation sedation should adhere to British Standards
and manufacturer guidelines.

# Nitrous Oxide

 Nitrous oxide (N2O), commonly known as laughing gas, is a chemical

compound.
 It's a colorless, non-flammable gas with a slightly sweet scent and taste.
 At elevated temperatures, it acts as a powerful oxidizer similar to molecular
oxygen.

Medical Uses

 Nitrous oxide has significant medical applications in surgery and dentistry

for its anesthetic and pain-reducing effects.
 Its euphoric effects have led to recreational use as a dissociative anesthetic.
 Listed on the World Health Organization's List of Essential Medicines.
 Used as an oxidizer in rocket propellants and motor racing to boost engine
power.

Environmental Impact

 Nitrous oxide is a major scavenger of stratospheric ozone, similar to CFCs,

contributing to ozone depletion.
 Approximately 40% of nitrous oxide emissions are from human activities,
particularly agriculture.
 As the third most important greenhouse gas, it contributes significantly to
global warming.

Medical Administration

 Administered in hospitals using automated relative analgesia machines.

  Used as a carrier gas (mixed with oxygen) in general anesthesia, rather than
as a primary anesthetic.
 Dentists use N2O/O2 mixtures for conscious sedation.

Analgesic Uses

 Inhalation of nitrous oxide is used to relieve pain during childbirth, trauma,

oral surgery, and acute coronary syndrome.
 Considered a safe and effective aid for birthing women.
 Used by ambulance crews for rapid and effective analgesia.

Safety and Occupational Hazards

 Nitrous oxide poses a risk to clinic staff if poorly ventilated due to its
minimal metabolism in humans.
 Occupational safety guidelines recommend exposure control during
administration.
 Prolonged exposure may lead to mental and manual impairment.

Neurotoxicity and Neuroprotection

 Nitrous oxide can cause neurological harm with prolonged habitual

consumption.
 It may produce neurotoxicity in rodents under sustained exposure.
 Some heavy or frequent users report peripheral neuropathy.

DNA Damage

 Occupational exposure to nitrous oxide has been linked to DNA damage in

medical and dental operators.
 The correlation is dose-dependent, but recreational use does not appear to
extend to DNA damage.

Oxygen Deprivation

 Inhaling pure nitrous oxide without oxygen can lead to oxygen deprivation
with adverse effects on blood pressure and health.
 This can occur with continuous large quantity inhalation or breath-holding.

Vitamin B12 Deficiency

  Long-term exposure to nitrous oxide may cause vitamin B12 deficiency.
 Can lead to sensory neuropathy, myelopathy, and encephalopathy, which
may be treated with high-dose vitamin B12.

Prenatal Development

 Chronic exposure of pregnant females to nitrous oxide may have adverse

effects on fetal development based on rat studies.

Chemical/Physical Risks

 Nitrous oxide's pressure is highly sensitive to temperature changes.

 Contamination with fuels can lead to explosive mixtures in rocketry and
plumbing.

Mechanism of Action

 Nitrous oxide affects a broad range of ion channels, including NMDA

receptors and GABA receptors.
 It has anxiolytic and analgesic effects.
 Its mechanism of action in the brain involves interaction with the
endogenous opioid system.

++End of third main topic++

Sedation

 Definition: Sedation involves the use of sedative drugs to reduce irritability

or agitation, primarily for medical or diagnostic procedures.
 Common Sedative Drugs: Isoflurane, diethyl ether, propofol, etomidate,
ketamine, pentobarbital, lorazepam, and midazolam.

Medical Uses

 Sedation is used in various medical procedures, including:

 Minor surgeries like endoscopy, vasectomy, dentistry, reconstructive
surgery, cosmetic surgeries, wisdom teeth removal, and for high-
anxiety patients.
 Dentistry employs methods like inhalation sedation (nitrous oxide),
oral sedation, and intravenous (IV) sedation.
 It is also used in intensive care units to help ventilated patients
tolerate an endotracheal tube and during long-term EEGs to relax
patients.
 Risks: Studies suggest that sedation accounts for 40-50% of procedure-
related complications.
 Levels of Sedation: Sedation scales help assess the appropriate degree of
sedation to avoid under-sedation or over-sedation. Examples include MSAT,
UMSS, the Ramsay Scale, and the RASS.

Intravenous Sedation

 Intravenous sedation with Midazolam is a common technique for conscious

sedation in adults.
 Indications: Reducing dental anxiety, traumatic or prolonged dental
procedures, patients with a gag reflex, and special care for patients with
disabilities.
 Contraindications: Uncooperative patients, psychologically immature
individuals, and various medical conditions or allergies that can lead to
complications.
Inhalation Sedation

 Definition: A form of conscious sedation that aims to depress the central

nervous system (CNS) to reduce physiological and psychological stress
during surgery.
 Medical Uses: Inhalation sedation is used in various medical scenarios,
including dental procedures to address anxiety, phobia, and traumatic cases,
patients with medical conditions aggravated by stress, patients with medical
or behavioral conditions affecting cooperation, and special care
requirements.
 Side Effects and Contraindications: Complications from inhalation
sedation are rare but can include over-sedation, respiratory depression,
unconsciousness, airway obstruction, vomiting, idiosyncratic responses,
delayed recovery, failure of conscious sedation, and various
contraindications.

Patient Assessment and Selection

 Anesthesiologists conduct a thorough assessment to determine the need for

sedation and the most suitable technique.
 Factors considered in assessment include patient history, age, health, drug
history, and social circumstances.
 Only patients in ASA classes I and II are usually suitable for sedation in
primary care dental settings, while ASA class III or IV patients require referral
to secondary care.

Problems and Complications

 Inhalation sedation is generally safe, but issues can arise.

 Dental staff must be trained to manage complications and emergencies.
 Monitoring of vital signs is essential.

Equipment and Safety Features

 Equipment for inhalation sedation includes gas cylinders, flowmeters,

reservoir bags, conduction tubing, and breathing apparatus (nasal hoods or
face masks).
  Safety features include an oxygen fail-safe mechanism, scavenging ability,
pin index safety system, diameter index system, pressure relief devices,
oxygen flush, and audible alarms to monitor oxygen supply.
 Additional Notes:
 Continuous exposure to nitrous oxide can have health hazards for
operators, necessitating active or passive scavenging to remove
nitrous oxide from the environment.
 Inhalation sedation should be used alongside appropriate behavior
management and local anesthesia.
 Machines used for inhalation sedation should adhere to British
Standards and manufacturer guidelines.

Nitrous Oxide

 Definition: Nitrous oxide (N2O), commonly known as laughing gas, is a

chemical compound.
 Medical Uses: Nitrous oxide has significant medical applications in surgery
and dentistry for its anesthetic and pain-reducing effects, recreational use as
a dissociative anesthetic, and as an oxidizer in rocket propellants and motor
racing to boost engine power.
 Environmental Impact: Nitrous oxide is a major scavenger of stratospheric
ozone, contributing to ozone depletion and global warming.
 Medical Administration: Administered in hospitals using automated
relative analgesia machines, and dentists use N2O/O2 mixtures for
conscious sedation.

Analgesic Uses

 Inhalation of nitrous oxide is used to relieve pain during childbirth, trauma,

oral surgery, and acute coronary syndrome.
 Considered a safe and effective aid for birthing women and used by
ambulance crews for rapid and effective analgesia.

Safety and Occupational Hazards

  Nitrous oxide poses a risk to clinic staff if poorly ventilated due to its
minimal metabolism in humans.
 Occupational safety guidelines recommend exposure control during
administration, and prolonged exposure may lead to mental and manual
impairment.

Neurotoxicity and Neuroprotection

 Nitrous oxide can cause neurological harm with prolonged habitual

consumption.
 It may produce neurotoxicity in rodents under sustained exposure, with
some heavy or frequent users reporting peripheral neuropathy.

DNA Damage

 Occupational exposure to nitrous oxide has been linked to DNA damage in

medical and dental operators, which is dose-dependent.

Oxygen Deprivation

 Inhaling pure nitrous oxide without oxygen can lead to oxygen deprivation
with adverse effects on blood pressure and health.

Vitamin B12 Deficiency

 Long-term exposure to nitrous oxide may cause vitamin B12 deficiency,

leading to sensory neuropathy, myelopathy, and encephalopathy.

Prenatal Development

 Chronic exposure of pregnant females to nitrous oxide may have adverse

effects on fetal development based on rat studies.

Chemical/Physical Risks

 Nitrous oxide's pressure is highly sensitive to temperature changes and can

pose risks in rocketry accidents.

Mechanism of Action

 Nitrous oxide affects a broad range of ion channels, including NMDA

receptors and GABA receptors, with anxiolytic and analgesic effects.
Orthodontics

Definition
 Specialty in dentistry addressing mal-positioned teeth, jaw misalignment,
and bite issues
 Dentofacial orthopedics for facial growth modification
 Common occurrence of abnormal teeth and jaw alignment
 Orthodontic treatment needed for 50% of the developed world's population
 Medically necessary orthodontics required for less than 10%
 Lack of conclusive scientific evidence for health benefits
 Factors contributing to malocclusions include childhood diet and smaller
jaws
 Treatment duration ranges from months to years
 Involves dental braces and appliances
 Severe cases may require jaw surgery
 Treatment typically begins in early adulthood for better bone adjustment

Methods

 Orthodontic treatment takes one to two years

 Braces adjusted every 4 to 10 weeks
 Orthodontists specialize in prevention, diagnosis, and treatment
 Various treatment options available
 Treatment often begins in early permanent dentition stage
 Extraction of teeth in about half of cases
 Fixed and removable appliances used

Braces

 Placed on front or lingual side of teeth

 Brackets bonded with adhesive
 Wires for controlled movement in three dimensions
 Elastic bands and springs used for forces
 Ligatures and hooks connect teeth
 Clear aligners considered an alternative
Braces - Treatment Duration

 Duration varies based on severity, room, and oral health

 Typically worn for one to three years
 Retainers needed post-braces

Headgear

 Strapped onto the head to correct malocclusion

 Used in conjunction with braces
 Effective for jaw alignment, particularly in children and teenagers
 Addresses jaw alignment and bite issues like overbite and underbite

Palatal Expansion

 Achieved using a fixed tissue-borne appliance

 Removable appliances less effective
 Proper expansion creates space for teeth and improves airflow

Jaw Surgery

 Required for severe malocclusions

 Bone is broken and stabilized with plates and screws
 Orthodontic treatment follows to position teeth

During Treatment

 Methods to reduce pain include LLLT, vibratory devices, cognitive therapy

 Low-quality evidence and inconclusive results

Post Treatment

 Teeth have a tendency to relapse

 Over 50% of patients experience reversion within 10 years
 Retainers offered to prevent relapse
 Retainers can be removable or fixed

Clear Aligners

 Alternative to braces
 Controversy regarding effectiveness
 Offer flexibility and discretion