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Your dental care under IV SEDATION IN CLINIC
UNCONSCIOUS DENTAL SEDATION
TAKE CARE OF YOUR TEETH DESPITE THE FEAR OF THE DENTIST
Unconscious dental sedation is a protocol that is necessarily performed by an anesthesiologist, who puts the patient in a stage I (neuroleptanalgesia) or stage II (general anesthesia) coma. It is reserved for patients who, depending on the procedure to be performed, their state of health or their phobia of the dentist, have no other alternative than to resort to this solution.
In all cases, the choice of the mode of unconscious sedation will be made in consultation with the dental surgeon and the anesthesiologist.
WHO CAN BE OFFERED UNCONSCIOUS SEDATION?
In practical terms, the indications for unconscious sedation are fairly easy to identify:
- Patients with major dentophobia, for whom lighter sedation techniques, such as relaxation tablets or diazanalgesia, have not been found satisfactory;
- Patients whose health status is considered fragile and for whom vital functions must be monitored;
- Patients who are far from specialized dental clinics and who wish to compact their dental care to optimize their time and travel in optimum conditions of comfort and safety;
- Patients, who are often busy with their professional activities, also wish to have recourse to excellent methods, grouped together in one or more sessions, always with a particular requirement;
- Patients who are accustomed to excellence at all levels, and who want the best services for their health and every aspect of their lives.
Chosen in concert by the dental surgeon and the anesthesiologist-resuscitator, the “comas” are characterized as follows:
- They place the patient in a state of total indifference. The latter remains conscious, but has no memory of the act itself, nor of the duration of the intervention;
- They take place in a clinic and must be practiced by an anaesthetist-intensive care physician who is well versed in dental sedation methods;
- They require a prior consultation with an anesthesiologist,
- They cancel the pain and stress phases, as well as the emotional tension that some physically and psychologically fragile patients are not always able to bear;
- They offer the patient optimal safety during the entire procedure thanks to permanent monitoring of cardiac functions (cardiovascular monitoring) and oxygenation and blood pressure
- They are applicable for any type of procedure, from the simplest (for the phobic patient who is psychologically unable to come to the office) to the most complex (oral, periodontal, implant, pre-implant surgery…). The range of indications is therefore the widest, even if the patient is uncooperative,
- They exclude any random effect of anesthesia, which always remains perfectly controllable by the anesthesiologist, thus guaranteeing quality and safety during the entire operation;
Conducted by an experienced anesthesiologist, there are no contraindications, as this is the protocol of choice for emergency situations or life-saving interventions.
During the pre-anesthetic consultation, you will review your health status with the doctor. If you are undergoing treatment, you will have to inform him/her of this. You will choose your dental sedation method with the anesthesiologist according to the indications of your pathology and your wishes of comfort.
As a precautionary measure, your dentist will ask you to bring a complete blood test and X-ray at your first appointment. This approach sometimes allows us to diagnose certain diseases or deficiencies that the patient did not expect, and which must be treated before any dental care can be considered. The latter will be started only after the management of any pathologies detected.
There are four levels of “coma”. Only the first two are used in therapy. The “comas” of stages 3 and 4 are pathological “comas” close to death.
— The first level of “coma” corresponds to the neuroleptanalgesia protocol.
— The second level of “coma” corresponds to thegeneral anesthesia protocol.
CHOICE OF SEMI INCONSCIOUS DENTAL SEDATION
NEUROLEPTANALGESIA
When diazanalgesia is not indicated, neuroleptanalgesia represents an interesting and even more powerful alternative. Indeed, for medical reasons or because diazanalgesia is not deemed to be the appropriate dental sedation method for the care you will receive, your anesthesiologist, in consultation with your dental surgeon, may propose neuroleptanalgesia. The term neuroleptanalgesia is part of the vocabulary of anaesthetists, a bit like the fridge is part of the vocabulary of the housewife. This means that this term is a bit overused and designates protocols that are not necessarily related to the one that was precisely designated by this term. Today, this terminology encompasses a number of protocols, which often vary according to the anesthetist, each one having "their recipes". The term "neuroleptanalgesia" is derived from a class of drugs, the neuroleptics, which no longer have marketing authorization for dental sedation. This term is now medically inappropriate, since it is no longer neuroleptics, but Benzodiazepines that are injected into the patient.
A number of medications, including benzodiazepines, combined with painkillers, will be injected into your vein.
Neuroleptanalgesia begins with pre-medication with Benzodiazepines and inhalation of a MEOPA gas, containing nitrous oxide.
A short-acting hypnotic is then administered and the “type 1 artificial coma” is maintained throughout the procedure by successive or continuous pump injections of hypnotics, such as Benzodiazepines. Short-acting morphine will also be prescribed, as its mode of action excludes respiratory pauses.
Of course, neuroleptanalgesia does not exclude the systematic use of local or locoregional anesthesia of the operated area(s).
Postoperative:
When the procedure is over, the patient is directed to the recovery room where his or her vital functions are monitored.
He is also given all the necessary analgesic medications for a pain-free awakening.
When he/she has recovered all his/her senses, if he/she has had an outpatient procedure, he/she will be able to leave the facility, but never alone.
The patient should always be accompanied at the time of discharge and not spend the first night after returning home alone.
Almost all procedures can be performed under neuroleptanalgesia. The indication will depend on the patient’s wish to be put into a level 1 induced coma, but also on the type of intervention performed.
Neuroleptanalgesia puts the patient in a level 1 “coma”. As long as the patient’s condition and/or treatment plan indicate, this sedation can be repeated relatively often.
A discussion should take place between you, your dental surgeon and your anesthesiologist to choose the type of sedation that is best suited to your state of health and the type of care you will undergo.
For safety reasons, and as with diazanalgesia, neuroleptanalgesia will not exceed five hours.
Totally adaptable to the type of care or surgery, neuroleptanalgesia has the major advantage of guaranteeing total control of sedation, unlike milder protocols, where there is unpredictable inter-patient variability prior to the moment of anesthesia.
Moreover, it is completely safe thanks to the continuous presence of the anesthesiologist during the entire procedure.
For fragile patients or those with specific pathologies, neuroleptanalgesia represents a reinforced security, as the surveillance by cardiovascular monitoring, as well as the oxygenation of the blood with a saturometer are continuous. The safety of the procedure for these patients is therefore optimal.
From a psychological point of view, for patients suffering from dentophobia as well as for others, using neuroleptanalgesia allows, during long and invasive treatments, to reduce the duration of the stress phases inherent to the intervention.
Neuroleptanalgesia is proposed whenever a painful operative procedure must be performed and general anesthesia is unnecessary.
The general rule is that during neurolepanalgesia, the patient should not be intubated and ventilated. This is not the case with general anesthesia. The latter is a heavier protocol that lacks the flexibility of neuroleptanalgesia.
A wide variety of treatments, from the simplest to the most complex, can be performed under neuroleptanalgesia.
It is important to understand that the choice of this unconscious sedation is based on the combination of the type of intervention and the patient’s comfort.
Thus, the following treatments or surgical procedures can be considered under neuroleptanalgesia: dental implants, cosmetic dental prostheses, bone filling, dental bone grafting, sinus filling, maxillofacial surgery, bone osteotomy, PRF and PRP with release of bone growth factors, stimulation of stem cells, Bone Morphogenetic Protein, alloplastic bone substitutes, autogenous grafts, allografts, heterografts, collagen membrane placement, oral surgery, periodontal surgery, pre-implant surgery…
the "Artificial Coma Type I".
The "Artificial Coma Type II
GENERAL ANESTHESIA
When the patient has to undergo a series of surgeries in different areas of the mouth (right, left, upper and lower), it is sometimes easier, in order to preserve the patient's often fragile state of health and not to generate increased stress and fatigue, to consider general anesthesia.
Plunged into a "type II artificial coma", totally unconscious and insensitive to pain, the patient can benefit from the grouping of several oral surgery procedures such as periodontology, implantology... in a single operation.
This solution represents a major interest for patients with fragile health, or in search of maximum comfort, or maximum compaction of a series of painful interventions.
These patients who would have no other choice but to be offered to fragment the interventions into several sessions, each more trying than the last, risk giving up before the end of the protocols.
Indeed, this recurrent difficulty generates symptoms of physical and psychological exhaustion that general anaesthesia can avoid.
Considered after eliminating all other lighter types of dental sedation, general anesthesia should be the best option whenever it is offered.
General anesthesia represents the deepest level of sedation in dentistry as in all medical specialties.
Although modern sedation techniques are considered the safest, general anesthesia should be reserved for the most serious cases, i.e., patients in any of the following situations:
- The patient must undergo a series of heavy interventions, most often surgical, and for which general anesthesia is required;
- The patient is frail and needs to be intubated. The dental surgeon and the anesthesiologist-resuscitator then consider it more appropriate to propose an intervention in a hospital or clinic setting, so that his vital functions can be constantly monitored;
- The patient presents a general pathology at risk that contraindicates the realization of a lighter or deeper sedation and that requires that his vital functions be permanently under the control of an anesthetist-resuscitator;
- The patient must undergo one or more grouped and particularly invasive procedures. Suspension of total pain sensitivity is then indicated, but not possible with other lighter sedation techniques. The general anesthesia then takes all its sense here, especially since the patient will have to be hospitalized afterwards;
- The patient suffers from extreme dentophobia that no other lighter type of dental sedation has been able to channel;
- The patient lives far away from specialized dental clinics and wants to combine long invasive treatment sessions in a compact period of time in a hospital;
- The patient has a very busy professional life and wants to rationalize his time as much as possible by considering treating his dental problems in a very compact period.
For safety reasons, general anesthesia for a dental procedure should not exceed five hours.
Because of the specificities of general anesthesia, it is important to inform the anesthesiologist who receives you, during the anesthesia consultation and the pre-anesthesia visit, of any health problem, any treatment in progress and any allergies.
The anesthesiologist will confirm that a general anesthesia can be performed and, if necessary, will adjust your current treatments until the date of the procedure.
The immediate effect of general anesthesia is the temporary and reversible suspension of consciousness and pain sensitivity. It is obtained by injecting powerful drugs (anesthetic drugs) before, during and after the operation. Other medications can also be inhaled.
The patient, thus plunged into a type II “coma”, becomes totally unaware of the passage of time, of the way the operation is going on and is insensitive to pain. The patient’s health is constantly monitored by the anesthesiologist who remains at the side of the dental surgeon during the entire operation.
Indeed, the practice of general anesthesia requires continuous monitoring of respiration (respiratory rate and volume, oximetry), hemodynamics (heart rate and rhythm, blood pressure), thermoregulation and muscle tone.
General anesthesia requires that the patient be intubated orally or nasally. Ventilation during the procedure can be done in two different ways, depending on the wishes of the anesthesiologist or the type of procedure performed:
- Either spontaneously, by reinjecting morphine or by having the patient inhale halogenated gas;
- Or assisted by an artificial respirator, in the case where the patient is curarized, where regular injections of morphine are administered, and where halogenated gases are inhaled.
Whether you are undergoing an outpatient procedure (you leave the evening of the procedure, always accompanied) or whether a few days of hospitalization in a clinic is necessary, the preparation for general anesthesia follows the same protocol.
The pre-anesthetic consultation:
At least one month and up to 24 hours before the operation, except in an emergency, you must consult your anesthesiologist. This pre-anesthetic consultation is a legal obligation. During this consultation, you will have the opportunity to explain your medical history, to say if you have any particular pathologies, if you have any specific allergies…
Even if it is not always necessary, your anesthesiologist may want to perform some additional tests, such as blood tests, electrocardiogram, chest X-ray, to make a precise assessment of your health a few days before the operation.
If you are taking a medical treatment, it may be necessary to stop or modify it. Of course, if you have any questions, you will have the opportunity to ask them during the pre-anesthesia consultation.
Once the anesthesiologist has received the results of any additional tests, he or she will be able to confirm or deny that your health is compatible with the requirements of general anesthesia.
If you need a blood transfusion, you will be informed.
You should know that any anesthesiologist, outside of an emergency context, has the right to refuse to perform anesthesia. Of course, written parental consent is required for anesthesia on a minor.
Day of surgery:
You will not eat or drink for at least six hours before the procedure, to avoid inhalation of gastric contents and to protect your airways.
On the morning of the operation, a light premedication may be prescribed to relax you and optimize the effects of the anesthesia.
When you enter the operating room, you will meet your dentist and an anesthesiologist. This person may not be the same person who saw you during your pre-anesthesia consultation. But in any case, she will have read your file before performing the general anesthesia on you.
All precautions will be taken to ensure that the procedure goes as smoothly as possible. Thus, all the devices in contact with your body will be single-use. Your anesthesiologist will be present throughout the procedure and will constantly monitor your vital functions (blood pressure, breathing, blood oxygenation) to ensure that they remain normal.
At the end of the intervention
You will be taken to the recovery room where you will be continuously monitored.
This post-operative time represents the best possible safety after general anesthesia. A nurse specialized in post-operative care will administer, if necessary, painkillers or any other type of medication necessary for you to return to your room in the best conditions, when you are fully awake.
Your anesthesiologist will write a prescription that the nurse on your service will follow. Thus, all the medications necessary for your recovery will be administered immediately, including analgesics to channel postoperative pain.
If you are hospitalized for several days, you can ask to meet with your anesthesiologist or your dental surgeon who will be available to inform you.
If you have undergone outpatient surgery and have had a general anaesthetic, you will have to leave accompanied and will not be able to spend the first night alone, for safety reasons. Of course, driving and alcohol are to be excluded on the day of your intervention.
Globally, today, performing a surgical act under general anesthesia is an act performed daily by all anesthesiologists who perfectly master the protocols in force. In France, nine million general anesthesias are performed each year. And, as proof of their safety, the mortality rate during anesthesia is now only 0.69 deaths per 100,000 general anesthesias performed.
However, any surgical procedure is subject to undesirable side effects, such as nausea or vomiting. However, current techniques make it possible to drastically limit this type of inconvenience.
If the procedure lasted long enough, you may also experience nerve compression due to prolonged lying down. In any case, these slight discomforts dissipate in a few days, or even weeks.
Finally, you should know that, even if “zero risk” never exists in medicine, modern sedation techniques make general anesthesia extremely reliable. Since the beginning of the 1980s, the number of operations under general anesthesia in France has increased from 3.6 to 8 million. And since then, the number of deaths under general anesthesia has been divided by ten.
To get an idea of the level of reliability, remember that an incident occurs only once in several hundred thousand anaesthesias!
YOU ARE UNIQUE!
CLINICAL CASES SMILE RECONSTRUCTION UNDER UNCONSCIOUS DENTAL SEDATION
