Moderate Sedation and Emergency Medicine for Periodontists Joseph A Giovannitti Jr 123 Moderate Sedation and Emergency Medicine for Periodontists www.ajlobby.com Joseph A. Giovannitti Jr Moderate Sedation and Emergency Medicine for Periodontists www.ajlobby.com Joseph A. Giovannitti Jr., DMD Dental Anesthesiology University of Pittsburgh Pittsburgh, PA USA ISBN 978-3-030-35749-8 ISBN 978-3-030-35750-4 (eBook) https://doi.org/10.1007/978-3-030-35750-4 © Springer Nature Switzerland AG 2020 This work is subject to copyright All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed The use of general descriptive names, registered names, trademarks, service marks, etc in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland www.ajlobby.com Preface The inspiration for this text began with an invitation to speak at the 104th Annual Meeting of the American Academy of Periodontology held in Vancouver, British Columbia, Canada, in 2018 The Commission on Dental Accreditation had recently mandated that periodontal training programs train their residents to competency in moderate sedation As I began my outline, I could see that each segment of the talk resembled a distinct chapter, and the idea for a book was formed This book is intended for periodontal residents and practicing periodontists who wish to incorporate the principles of moderate sedation into daily practice A history of the development of sedation in dental practice sets the stage for understanding the need for a comprehensive preanesthetic evaluation to identify potentially reactive patients prior to treatment Useful drugs for moderate sedation and reversal agents in the office setting are reviewed to ensure proper perioperative usage Comprehensive airway management and rescue skills are documented in detail so that the patient may be properly managed in the event that the sedation progresses beyond the intended level A key aim is to equip the reader with sufficient knowledge and preparedness to overcome the patient management challenges associated with common and uncommon deviations from intraoperative norms Finally, for those academicians interested in teaching the principles of sedation to periodontal residents, a curriculum development tool is provided to ensure comprehensive training leading to competency In a special way, this book is an homage to my teacher, mentor, and friend, Dr C. Richard Bennett His seminal text, Conscious-Sedation in Dental Practice, set forth the principles and philosophy of what we now call moderate sedation These principles have stood the test of time, and I have done little to improve upon them I also owe much to my friends and colleagues, Drs James C. Phero, William A. MacDonnell, and Morton B. Rosenberg Their constant support and encouragement has empowered me Finally, I am eternally grateful to my wife Christine, my greatest supporter and lifesaver in every way Pittsburgh, PA Joseph A. Giovannitti Jr., DMD v www.ajlobby.com Contents 1 Principles and the Development of Sedation in Dentistry������������������������ 1 1.1 It All Began with Nitrous Oxide ���������������������������������������������������������� 1 1.2 Intravenous Anesthesia ������������������������������������������������������������������������ 3 References������������������������������������������������������������������������������������������������������ 4 2 Sedation in Dental Practice ������������������������������������������������������������������������ 5 2.1 Nature of Pain �������������������������������������������������������������������������������������� 6 2.2 Fear and Anxiety ���������������������������������������������������������������������������������� 7 2.3 Spectrum of Pain Control���������������������������������������������������������������������� 8 2.4 Cardiovascular Stress Response ���������������������������������������������������������� 9 2.5 Objectives of Moderate Sedation �������������������������������������������������������� 9 2.6 Indications and Contraindications�������������������������������������������������������� 10 2.7 Definitions�������������������������������������������������������������������������������������������� 11 2.7.1 Minimal Sedation���������������������������������������������������������������������� 11 2.7.2 Minimal Sedation via the Enteral Route���������������������������������� 12 2.7.3 Moderate Sedation�������������������������������������������������������������������� 12 2.7.4 Deep Sedation �������������������������������������������������������������������������� 12 2.7.5 General Anesthesia������������������������������������������������������������������� 12 References������������������������������������������������������������������������������������������������������ 13 3 Preanesthetic Evaluation for Periodontal Sedation���������������������������������� 15 3.1 Components of a Preanesthetic Evaluation������������������������������������������ 16 3.2 Review of Systems�������������������������������������������������������������������������������� 18 3.2.1 Cardiovascular System�������������������������������������������������������������� 18 3.2.2 Respiratory System ������������������������������������������������������������������ 22 3.2.3 Diabetes Mellitus���������������������������������������������������������������������� 26 3.2.4 Neurological and Developmental Disorders ���������������������������� 29 References������������������������������������������������������������������������������������������������������ 34 4 Drugs Suitable for Moderate Periodontal Sedation���������������������������������� 35 4.1 Opioids�������������������������������������������������������������������������������������������������� 35 4.1.1 Adverse Effects ������������������������������������������������������������������������ 36 4.1.2 Tolerance and Opioid-Induced Hyperalgesia���������������������������� 37 4.1.3 Useful Opioids for Moderate Sedation ������������������������������������ 38 vii www.ajlobby.com Contents viii 4.2 Benzodiazepines ���������������������������������������������������������������������������������� 39 4.2.1 Precautions for Use ������������������������������������������������������������������ 40 4.2.2 Useful Benzodiazepines for Moderate Sedation���������������������� 40 4.3 Alpha-2 Adrenergic Receptor Agonists������������������������������������������������ 41 4.3.1 Dexmedetomidine �������������������������������������������������������������������� 42 4.4 Moderate Sedation Technique�������������������������������������������������������������� 42 References������������������������������������������������������������������������������������������������������ 44 5 Periodontal Airway Management Strategies�������������������������������������������� 45 5.1 Preoperative Airway Evaluation����������������������������������������������������������� 45 5.2 Airway Management���������������������������������������������������������������������������� 46 5.3 Difficult Mask Ventilation and Airway Considerations in Obesity �������������������������������������������������������������������� 51 5.4 Key Point to Remember������������������������������������������������������������������������ 51 References������������������������������������������������������������������������������������������������������ 52 6 Monitoring During Periodontal Sedation�������������������������������������������������� 53 6.1 Monitoring Consciousness�������������������������������������������������������������������� 54 6.2 Monitoring Respiratory Function �������������������������������������������������������� 55 6.2.1 Monitoring Oxygenation���������������������������������������������������������� 56 6.2.2 Monitoring Ventilation�������������������������������������������������������������� 58 6.3 Monitoring Circulation ������������������������������������������������������������������������ 60 Reference ������������������������������������������������������������������������������������������������������ 62 7 Emergency Medicine for Periodontists������������������������������������������������������ 63 7.1 Airway Complications�������������������������������������������������������������������������� 67 7.1.1 Obstruction�������������������������������������������������������������������������������� 67 7.1.2 Laryngospasm �������������������������������������������������������������������������� 67 7.1.3 Bronchospasm�������������������������������������������������������������������������� 69 7.1.4 Negative-Pressure Pulmonary Edema�������������������������������������� 70 7.1.5 Emesis/Aspiration �������������������������������������������������������������������� 70 7.2 Cardiovascular Complications�������������������������������������������������������������� 72 7.2.1 Hypertension ���������������������������������������������������������������������������� 72 7.2.2 Hypotension������������������������������������������������������������������������������ 73 7.2.3 Dysrhythmias���������������������������������������������������������������������������� 74 7.2.4 Acute Coronary Syndromes������������������������������������������������������ 75 7.2.5 Stroke���������������������������������������������������������������������������������������� 76 7.3 Miscellaneous Complications �������������������������������������������������������������� 77 7.3.1 Delayed Awakening and Readiness for Discharge�������������������� 77 7.3.2 Local Anesthetic Toxicity �������������������������������������������������������� 78 References������������������������������������������������������������������������������������������������������ 81 8 Curricular Development and Training Requirements for Periodontal Sedation������������������������������������������������������������������������������ 83 8.1 Moderate Sedation for Periodontal Residents�������������������������������������� 84 8.1.1 Course Syllabus������������������������������������������������������������������������ 84 References������������������������������������������������������������������������������������������������������ 86 www.ajlobby.com Principles and the Development of Sedation in Dentistry A new era in tooth pulling! —Horace Wells 1.1 It All Began with Nitrous Oxide In late eighteenth-century England pneumatic medicine was all the rage, treating a variety of diseases with the inhalation of various gases Humphry Davy, a self- taught chemist and employee of the Pneumatic Institute in Oxford, began researching the properties of nitrous oxide which had been discovered by Joseph Priestley in 1792 Thus, in the year 1800, Davy published his findings in Researches, Chemical and Philosophical, Chiefly Concerning Nitrous Oxide, or Dephlogisticated Nitrous Air and Its Respiration In this report he noted the exhilarating effects of the gas and suggested, “As nitrous oxide in its extensive operation appears capable of destroying physical pain, it may probably be used with advantage during surgical operations in which no great effusion of blood takes place” [1] This statement was essentially ignored, and Davy went on to become one of England’s most prominent chemists and discoverers of many other chemical compounds Nitrous oxide was relegated to use as a recreational drug, rising in popularity during the many “frolics” of the 1830s during which revelers engaged in various behaviors while under the influence of the gas Fast-forward 40 years to the United States, where Gardner Quincy Colton, a medical school dropout and self-proclaimed “Professor,” began public demonstrations of nitrous oxide across New England purely for entertainment, and a fee Horace Wells, a prominent Hartford, CT dentist, decided to attend one of these demonstrations on December 10, 1844 A handbill distributed by Colton told the tale: © Springer Nature Switzerland AG 2020 J A Giovannitti Jr., Moderate Sedation and Emergency Medicine for Periodontists, https://doi.org/10.1007/978-3-030-35750-4_1 www.ajlobby.com 1 Principles and the Development of Sedation in Dentistry A Grand Exhibition of the effects produced by inhaling Nitrous Oxide, Exhilarating or Laughing Gas! will be given at Union Hall, this (Tuesday) Evening, Dec 10th, 1844 Forty Gallons of Gas will be prepared and administered to all in the audience who desire to inhale it Twelve Young Men have volunteered to inhale the Gas, to commence the entertainment The entertainment will close with a few of the most surprising Chemical Experiments Entertainment to commence at o’clock Tickets 25 cents—for sale at the principal Bookstores and at the Door Eight Strong Men are engaged to occupy the front seats, to protect those under the influence of the Gas from injuring themselves or others This course is adopted that no apprehension of danger may be entertained Probably no one will attempt to fight The effect of the Gas is to make those who inhale it either Laugh, Sing, Dance, Speak, or Fight, and so forth, according to the leading trait of their character They seem to retain consciousness enough not to say or that which they would have occasion to regret The Gas will be administered only to gentlemen of the first respectability The object is to make the entertainment in every respect a genteel affair [2] Wells and his wife were enjoying the festivities when one of the volunteers, Sam Cooley, took the gas and careened about the stage, suddenly spying someone in the audience that he decided had done him wrong He leaped off the stage and began to chase the unfortunate victim around the hall The audience was delighted and clapped loudly at the spectacle During the chase, Cooley leapt over a bench, knocking it over After the effects of the gas have dissipated, he came to his senses and sheepishly got back into his seat, which happened to be near Dr Wells Wells watched as he rolled up his pants leg, surprised to reveal an abraded and bloody leg Immediately recognizing the potential of nitrous oxide to alleviate pain, Wells met Colton backstage after the show and asked him to come to his office the next day Wells himself had a painful wisdom tooth and wondered if Colton would give him the nitrous oxide while he had his tooth extracted Wells’ colleague, Dr John Riggs, painlessly extracted the offending tooth while Wells was under the influence of nitrous oxide Riggs later wrote: Wells and I had a … conference that night & determination to try the gas on Wells the next morning Wells went to the Hall & asked Colton to let him have a bag of gas as he wanted to take it and have a tooth pulled & he invited the party, Colton, Cooley, and two others to come up and witness the operation I was attending to a patient but was awaiting Wells’ return When I entered Wells’ office, the said parties were there Wells took his seat in the operating chair I examined the tooth so as to be ready to operate without delay Wells took the bag in his lap-held the tube to his mouth & inhaled till insensibility relaxed the muscles of his arms -his hands fell on his breast-his head dropped on the head-rest & I instantly, passed the forceps into the mouth onto the tooth and extracted it Mr Colton, Cooley and the two there stood by the open door ready to run out if Wells jumped up from the chair & made any hostile demonstrations You may ask-Why did he not get up? Simply because he could not Our agreement, the night previous was, to push the administration to a point hitherto unknown We knew not whether death or success confronted us It was terra incognito we were bound to explore-the result is known to the world No one but Wells and myself knew to what point the inhalation was to be carried-the result was painfully problematical to us but the great law of Nature, hitherto unknown, was kind to us & a grand discovery was born into the world [3] When Wells recovered, he said that he hadn’t felt as much as a pinprick and proclaimed “a new era in tooth pulling!” making December 11, 1844, the day that the www.ajlobby.com 1.2 Intravenous Anesthesia discovery of anesthesia was made Nearly 2 years later, on October 16, 1846, Wells’ apprentice, William T.G. Morton, successfully introduced ether into medical practice Thus, two dentists became responsible for discovering and bringing anesthesia into the world Nitrous oxide was well suited for shorter operations, such as the extraction of teeth A common technique was to administer 100% nitrous oxide by facemask until the patient became cyanotic and unconscious The mask would be removed, and the teeth would be extracted as rapidly as possible The stimulation of the surgery caused the patients to inhale room air and reoxygenate themselves until they recovered Occasionally they did not, however, leading to the concomitant administration of oxygen along with the nitrous oxide Thus, the best surgeons were the fastest surgeons 1.2 Intravenous Anesthesia The ultrashort-acting barbiturate, thiopental, was first administered by Dr Ralph Waters in 1934 This led to the use of thiopental, and later methohexital, by dental surgeons Drummond-Jackson, Foreman, and Hubbell, for dental extractions It was used in a similar manner as nitrous oxide; that is, a bolus dose of the drug was given intravenously until the patient became unconscious and the teeth were extracted rapidly as the patient recovered Dr Hubbell pioneered a crude pump device whereby he could readminister the drug incrementally when needed for longer cases or if the patient aroused prematurely Along with local anesthetics, nitrous oxide, ether, and barbiturate anesthesia became the only available options for dental surgical procedures Dentists recognized the need for longer acting sedatives that would enable them to perform dental procedures other than quick extractions This led to two dentists, working independently, to develop intravenous sedative techniques that would permit the performance of longer dental procedures Dr Niels Jorgensen, in Loma Linda, CA, and Dr Leonard Monheim, in Pittsburgh, PA, developed unique sedative techniques using a combination of opioids, psychosedatives, and barbiturates These drugs were titrated incrementally until the patients were relaxed and cooperative, yet conscious With patients in this state, dentists were able to accomplish procedures that took much longer than the extraction of teeth Monheim’s successor, Dr C. Richard Bennett, honed his technique by incorporating the new benzodiazepine, diazepam, into the treatment regimen Bennett’s major contribution came with his seminal text, Conscious-Sedation in Dental Practice [4], in which he outlined the philosophy of what he termed “conscious- sedation.” He stated that maintenance of consciousness was the key to patient safety since patients in the conscious state are constantly capable of independently maintaining and protecting their own airway Because of the inherent safety of conscious- sedation, it has become the backbone of sedation in dentistry in what has now become known as moderate sedation Moderate sedation is the most common anesthetic modality practiced in dentistry by a variety of providers and is the level of sedation indicated for periodontal practice It may be achieved by the administration of nitrous oxide and enteral and/or parenteral agents www.ajlobby.com .. .Moderate Sedation and Emergency Medicine for Periodontists www.ajlobby.com Joseph A. Giovannitti Jr Moderate Sedation and Emergency Medicine for Periodontists www.ajlobby.com... Switzerland AG 2020 J A Giovannitti Jr., Moderate Sedation and Emergency Medicine for Periodontists, https://doi.org/10.1007/978-3-030-35750-4_1 www.ajlobby.com 1 Principles and? ?the Development of? ?Sedation. .. Switzerland AG 2020 J A Giovannitti Jr., Moderate Sedation and Emergency Medicine for Periodontists, https://doi.org/10.1007/978-3-030-35750-4_3 15 16 3 Preanesthetic Evaluation for? ?Periodontal Sedation