SEDATION / PAIN FREE DENTISTRY

Sedation dentistry allows you to be sedated just enough to be pain free and unaware of the treatment, as if you were relaxing. That is why it is normally referred to as conscious sedation dentistry. So if you have sensitive teeth, a fear of dentists, have a bad gag reflex, hate needles, or have limited time to spend on dental care at the dentist, Sedation during dentistry procedures can help you.

Whatever the case may be sedation by your dentists can help you be more anxiety free during your dentistry treatment. Your dentist's ultimate goal is to make your visit to the dentist a relaxing and enjoyable one. Since you are completely comfortable, relaxed, and pain free your sedation dentist can do years of dental treatments in one or two dental visits.
With sedation your dentist can restore sore gums to good dental health, fix a chipped tooth, replace crowns or dentures, whiten yellow or stained teeth, and more. All pain free.

THE WAND

The Wand Plus® Computer Controlled Anesthetic Delivery System

You may have heard about a device known as "The Wand". The wand is essentially a computer controlled injection. This means that the injection is guaranteed to be slow and therefore more comfortable. Obviously it is possible for the dentist to control the speed himself with a standard injection, but the idea of the wand is to take out the "human error" in the speed of the injection and therefore ensure a reproducable painless injection every time................

The Wand is a useful gadget because it doesn't look like a traditional syringe, it works really well! Needle phobics love it... it's a bit slow though, but apart from that, no major disadvantages! If your dentist offers it, cool, if not, many dentists are well able to give painless injections without it - it's not that widely available.

Here at The Smiles Dr we utilise this technology for the benefit our Patients.

We want to make sure that your Dental Experience is the most comfortable and pain free one yet.

 

 

 

 

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Laughing Gas ( Nitrous Oxide)

Inhalation sedation, laughing gas, relative analgesia, RA, happy gas, gas, nitrous, nitrous oxide, N2O-O2... this one has more synonyms than any other sedation technique! And deservedly so. Inhalation sedation with nitrous oxide (N2O) and oxygen (O2) has been described as "representing the most nearly 'ideal' clinical sedative circumstance"...

What is it? And what does it do?
Nitrous oxide (N2O) is simply a gas which you can breathe in. It's colorless, sweet-smelling, and nonirritating. It was discovered in 1772. Gordon loves the stuff! And why wouldn't he... Humphrey Davy (1778-1829), one of the pioneers of N2O experimentation, described the effects of N2O on himself following self-administration for a toothache and gum infection as follows:

"On the day when the inflammation was the most troublesome, I breathed three large doses of nitrous oxide. The pain always diminished after the first four or five inspirations; the thrilling came on as usual, and uneasiness was for a few minutes swallowed up in pleasure."

Sounds like fun!! The extract above pretty much summarizes the effects of nitrous oxide: it kills pain - and it induces a pleasureable feeling. After 5 minutes or so of breathing in the gas, you should feel a euphoric feeling spread throughout your body. It really kind of feels like a 'happy drunk' feeling. Some people find that there are auditory or visual effects as well. You will feel a bit light headed and often people get 'the giggles' (hence the name laughing gas!). As an interesting aside, nitrous oxide was one of the drugs of choice for young people in the late1700s and early 1800s, when "laughing gas demonstrations" were a popular source of entertainment and enjoyment!

Since those days, it's been discovered that nitrous oxide (N2O) on its own can only safely be used for short periods of time (because the lack of oxygen in pure N2O can lead to unconsciousness and even death) - but that it's safe to use for longer periods of time if you mix it with oxygen (O2). Hence, the "laughing gas" used these days is called N2O-O2, and contains at least 30% oxygen (that's all the machines used nowadays will permit!). Usually, the mix is about 70% oxygen to 30% nitrous oxide.

Depending on the concentration and length of administration of laughing gas, four levels of sedation can be experienced (after an initial feeling of light-headedness):

(1) a tingling sensation, especially in the arms and legs, or a feeling of vibration ("parasthesia"), quickly followed by

(2) warm sensations, and

(3) a feeling of well-being, euphoria and/or floating ("drift"). During heavier sedation, hearing may dissolve into a constant, electronic-like throbbing.

(4) At a deeper level of sedation again, sleepiness, difficulty to keep one's eyes open or speak ("dream") can occur. Should nausea set in, it means you're definitely oversedated!

During relative analgesia, you should be maintained within the first three stages. The "dream" stage is indicative of too high an N2O concentration or too lengthy administration, and is associated with ill side effects such as nausea and other potentially unpleasant sensations, including flashbacks of bad experiences. These are definitive signs of oversedation. N2O concentration should always be gradually increased ("titrated") at each visit, because people's tolerance can vary from day to day, depending on both psychological and physiological factors. If you've had bad experiences with laughing gas in the past, it is highly likely that these were due to improper administration and too high a concentration of N2O.

Interestingly, the actual mechanism of action of N2O is still unknown (it appears that there are quite a few different mechanisms at work)! However, it's been observed that N2O depresses almost all forms of sensation - especially hearing, touch and pain, and that it seems to disinhibit some emotional centers in the brain. The ability to concentrate or perform intelligent acts is only minimally affected, as is memory.

How is it administered?

The equipment used for delivering "happy gas" is quite simple. It consists of a supply of compressed gases and an apparatus which delivers the gases to the client. By turning some knobs and flipping on/off switches, the administrator can produce the desired mix of N2O-O2 in the desired quantities. Flowmeters and pressure gauges allow the administrator to keep an eye on the flow of gases.

The desired N2O-O2 mix is fed through a tube to which a nasal hood or cannula is attached. This hood is put over your nose. All you have to do now is breathe normally through your nose - bingo!
The white inner mask (sticking out) comes in vanilla, strawberry, and mint

In modern machines there is a sort of "double mask" where the outside mask is connected to a vacuum machine to suck away the waste gas - you wouldn't want your dentist to get a face full of N2O... The white inside mask, which is placed over your nose, comes in lots of yummy scents - vanilla, strawberry, and mint!

The grey "outer mask" ensures that your dentist doesn't leave work with a headache. The twin tubes running to the mask are for "gas in" and "gas out". The "gas out" line is attached to the vacuum machine, while the "gas in" line is attached to the RA (short for relative analgesia) machine. The inner mask is attached to the "line in", you breathe out through a one-way valve in the inner mask, and the exhaust gas is collected inside the outer grey mask (pictured below)and sucked into the vacuum machine.

What are the advantages?
* Happy gas works very rapidly - it reaches the brain within 20 seconds, and relaxation and pain-killing properties develop after 2 or 3 minutes.

* The depth of sedation can be altered from moment to moment, allowing the person who administers the gas to increase or decrease the depth of sedation. Other sedation techniques don't allow for this. For example, with IV sedation, it's easy to deepen the level of sedation, but difficult to lessen it. Whereas with gas, the effects are almost instant.

* Other sedation techniques have a fixed duration of action (because the effects of pills or intravenous drugs last for a specific time span), whereas gas can be given for the exact time span it's needed for. It can also be switched off when not needed and then switched on again (though to avoid a roller-coaster effect, you shouldn't do this too abruptly).

* There's no "hangover" effect - the gas is eliminated from the body within 3 to 5 minutes after the gas supply is stopped. You can safely drive home and don't need an escort.

* With nitrous oxide, it's easy to give incremental doses until the desired action is obtained (this is called "titration"). So the administrator has virtually absolute control over the action of the drug, preventing the possibility of accidental overdoses. While giving incremental doses is possible with IV sedation, it's not possible with oral sedation (as a result, oral sedation can be a bit of a hit-and-miss affair).

* Unlike IV sedation, no injection is required. In cases of very severe needle phobia, getting laughing gas first can help you feel relaxed enough to allow the needle required for IV sedation to be inserted in your arm or hand. The very deep state of sedation achievable through IV sedation may then allow you to accept local anaesthetic.

* Inhalation sedation is very safe. It has very few side effects and the drugs used have no ill effects on the heart, lungs, liver, kidneys, or brain.

* For certain procedures, especially those involving soft tissues (e. g. deep cleaning), inhalation sedation may be used instead of local anaesthesia. N2O acts as a painkiller; however, its pain-relieving effects vary a lot from person to person and can't be relied upon. So if you're determined to give the needle a miss, you and your dentist will have to try and see what happens...

* Inhalation sedation has been found to be very effective in eliminating or at least minimizing severe gagging.

Are there any disadvantages?

* Some people are not comfortable with the effects of laughing gas (either because they're afraid they might lose control or because it makes them feel nauseous - this is quite rare, though, and usually due to oversedation).

If you're prone to nausea, it's a good idea to have a meal (not a huge one) about 4 hours before your appointment. If that's not possible (e. g. an early morning appointment), make sure your stomach isn't completely empty - but don't stuff yourself straight beforehand either. According to Gordon, who's a bit of an expert in the field, the normal working concentration of gases is about 70% oxygen to 30% nitrous oxide: "It's rare to go beyond that because that's what brings on the nausea, more than 45% N2O and you're going to have the patient puke on you :-)" Ahh... nothing like a bit of straight talk!

* Some people will not achieve adequate sedation with permissible levels of oxygen.

* On rare occasions, people have a bad experience with N2O. Usually this is due to oversedation. This is easily reversible by reducing the amount of N2O in the mix. For example, a few people have reported auditory and "physical" hallucinations, dizziness, or vertigo:
Don't panic should you experience any symptoms of that nature. While they're usually due to the N2O concentration being too high for you, the machines used nowadays have built-in safety features preventing an accidental overdose. Nonetheless, these sensations can be unpleasant - if you start feeling nauseous or experience any other unpleasant symptoms, communicate these to your dentist asap so that he or she can adjust the percentage of N2O. Laughing, becoming giddy, crying, or uncoordinated movements are other signs that the NO2 concentration is too high, but these will easily be spotted by your dentist. Alternatively, just rip the mask off your nose, and you'll be fine :-) !

Don't confuse "dizziness" with the normal feeling of lightheadedness which many people who've never had N2O before experience after maybe 60 or 90 seconds. The feeling of lightheadedness will pass as the concentration of N2O is increased.

* Some people are unable to breathe through their noses (see above on how nitrous oxide is administered), or they feel too claustrophobic when something is put over their nose. If you have the snuffles and you can't breathe through your nose, it can't be used.

* Depending on where you live, a dentist who offers nitrous oxide may be hard to come by.

Apart from that, most of the disadvantages of inhalation sedation do not affect the client, but the dental team: there's training required, the equipment is quite bulky and takes up a lot of space, and there is a possibility that dental staff who are chronically exposed to nitrous oxide might develop health problems. The cost of the equipment and gases is high, so you'll have to contribute to the cost - but it's quite a bit cheaper than IV sedation.

When should I not use it?
There aren't any major contraindications to RA, except for emphysema and some exotic chest problems. It hasn't been proven to be safe during the first trimester of pregnancy, so you can't use it then. Because you have to breathe it in through your nose, it's not suitable for people who have a cold or some other condition which prevents them from breathing through their nose. M.S. is another contraindication.

You can't be allergic to N2O. It's also safe to use if you suffer from epilepsy, liver disease, heart disease, diabetes, or cerebrovascular disease. It is also used quite successfully in many people with respiratory disease - but it depends on the exact nature of the disease, so check with your dentist!

How do I know if it's for me?
Why not ask if you can have a 5 minute 'sample' so that you know what to expect on the day of your procedure? Some dentists offer that service to patients to help them with the decision of what to do. Your dentist may not like the idea of doing this (costs, time, etc.), but there is no harm in asking!

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Valium

 

In our office, we used diazepam (Valium®) and meperidine (Demerol®) for many years, which are excellent medications for lowering the level of anxiety, for giving a feeling of euphoria that seems to be needed in erasing some of the prior negative conditioning, or, if necessary, bringing about amnesia: forgetting the entire appointment. Recently, oral triazolam (Halcion®) has become very popular with sedation dentists. It also has a high level of safety and wears off more quickly than diazepam, and thus is more convenient for patients.

Sometimes, with very high levels of anxiety, patients, in spite of very adequate levels of sedative, still cannot seem to endure the dental treatment. However, after the appointment, they may not be able to remember the appointment. The treatment then is successful in their mind and this successful experience works for their benefit by reducing their anxiety in subsequent appointments.

Often, patients with memories of traumatic dental care, after a few appointments with sedation, are able to move away from the sedation. With a few successful dental appointments under their belt, the doctor can lower the level of sedation so that they remember the appointments with greater and greater clarity, until they no longer need sedation.

Oral sedation with the proper medications has an excellent safety record. Valium® by itself is extremely safe, even in large doses. Hoffman-LaRoche, the manufacturer of Valium®, has data on file showing patients who have taken up to 2000 milligrams (that would be the equivalent of two full bottles of 10 mg. tablets) in attempts to commit suicide, and no rescue medications or other rescue measures were needed, because vital functions were not adversely affected. Triazolam is of the same drug family, and is also extremely safe. Nevertheless, as a precaution, most dentists using triazolam or diazepam employ monitoring equipment.

 

 

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General Anaesthesia (GA) / Unconcious Sedation

Nowadays, general anaesthesia in Adults / Children (being put to sleep) is a treatment available for all.. For most adults / children, general sedation works acceptably well. If sedation fails then GA can be provided. General Anaesthesia is used to perform root canal therapy procedures or even to have a complete cosmetic makover done.

What are General Anaesthesia and Deep Sedation?
General anesthesia (GA) is when you are totally unconscious. In this state, you can't feel any pain. You can't reliably breathe on your own, so for more complex procedures (such as fillings - these are actually more complex than extractions under GA!) and procedures of longer duration you need to having a "breathing tube" inserted.

Deep sedation is a state of depressed consciousness, where you may lose the ability to breathe independently and you can't respond to verbal commands. However, you can still feel noxious stimuli like pain, so local anesthesia is necessary.

 

How is General Anaesthetic Adminstered ?

The Smiles Dr arranges to have GA administered by a registered Aust Qualified Anaesthetist, in a theater environment (following the guidelines of the Australian Anaesthetists Society).

The dental surgeon requires special additional training which is provided the faculty of dentistry (Sydney University) to be able to provide this dental treatment under GA.

"In assessing the needs of an individual patient, due regard should be given to all aspects of behavioural management and anxiety control before deciding to treat or refer for treatment under general anaesthesia. General anaesthesia for dental treatment should only be administered in a hospital setting with critical care facilities. All dentists involved in arranging or providing treatment under general anaesthesia should discuss with the patient advice and treatment options to avoid or reduce future episodes of general anaesthesia.

GA is usually started off with an injection in the hand or arm. It can be supplemented by a face mask but if a face mask is used you probably won't remember it.

If post-op pain is expected, the normal practice is to inject a long acting local anaesthetic during the GA, so that when you wake up everything is nice and numb for a good few hours (say 6 hours?) afterwards, which should give you time to take some painkillers and allow them to kick in. It's much better to premptively stop pain than it is to try to deal with it once it has started.

Apart from the risk of death (which, while very small, is still significantly higher than for conscious IV sedation), general anesthesia has a few major disadvantages:

(1) Complications are more likely with GA compared with conscious sedation both during and after the procedure. GA depresses the cardiovascular and respiratory systems. For some groups of medically compromised patients, it is contraindicated for elective procedures.

(2) Laboratory tests, chest x-rays and ECG are often required before having GA, because of the greater risks involved.

(3) Very advanced training and an anesthesia team are required, and special equipment and facilities are needed.

(4) You can't drink or eat for 6 hours before the procedure (otherwise, vomiting is possible and this would be extremely dangerous during GA).

(5) There are additional costs regarding theatre fees and Anaesthetists fee ( however medicare provides up to 70% rebate on the anaesthetists fee)

 

Are there any circumstances under which general anesthesia should be used?
Exceptional circumstances include treatment for certain groups of special needs patients, procedures which would be very unpleasant if you were conscious (such as very complex extractions of bony impacted wisdom teeth), certain other types of oral surgery, and people with an extreme anxiety of dental procedures for whom conscious IV sedation isn't enough (although IV sedation works fine for about 97% of people with a high anxiety of dental procedures).

If it's extractions that really terrify you, it may be possible to be put to sleep for the extractions and then have fillings etc. done under conscious sedation with local anaesthetic.