Conscious Sedation for Dentistry - N. M. Girdler - ebook

Conscious Sedation for Dentistry ebook

N. M. Girdler

209,99 zł


A comprehensive textbook on the principles and practice of sedation in dentistry Drawing on the success of Clinical Sedation in Dentistry, this new edition covers all aspects of conscious sedation in dentistry. Written by experienced educators and internationally renowned researchers in the field, Conscious Sedation for Dentistry, Second Edition has been fully updated to include new national guidelines and equipment recommendations, and a companion website featuring self-assessment questions. Clear, concise, and reader-friendly throughout, chapters cover anxiety management, applied anatomy and physiology, patient assessment, pharmacology of sedation agents, oral and intranasal sedation, inhalation sedation, intravenous sedation, complications and emergencies, sedation and special care dentistry, and medico-legal and ethical considerations. Conscious Sedation for Dentistry, Second Edition is ideal for undergraduate dental students and dentists undertaking conscious sedation, as well as dental nurses completing post-registration sedation courses.

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Table of Contents


Title Page

About the Companion Website

1 Spectrum of Anxiety Management


Fear and Anxiety as a Normal Phenomenon

Aetiology of Dental Anxiety

Measuring Dental Anxiety


Behaviour Management

Conscious Sedation

General Anaesthesia


Further Reading

2 Applied Anatomy and Physiology


Cardiovascular System

Vascular Anatomy of Upper Limb Relevant to Sedation

Route of Drug Transfer to the Brain

Respiratory System

Intravenous Drugs and Excretion

Further Reading

3 Patient Assessment


Assessment Process

Preparation of Patients for Sedation


Further Reading

4 Pharmacology of Sedation Agents


Inhalation Sedation Agents

Intravenous Sedation Agents

Basic Pharmacology of Intravenous Sedatives

Further Reading

5 Premedication, Oral and Intranasal Sedation


Oral Sedation

Intranasal Sedation


Further Reading

6 Principles and Practice of Inhalation Sedation


Inhalation Sedation in Dentistry

Further Reading

7 Principles and Practice of Intravenous Sedation


Intravenous Sedation

Further Reading

8 Complications and Emergencies


Emergency Equipment

Airway Management

Drug Administration

Sedation‐Related Emergencies

Medical Emergencies

Local Complications with Intravenous Sedation

Further Reading

9 Sedation and Special Care Dentistry


The Use of Conscious Sedation



Further Reading

10 Medico‐Legal and Ethical Considerations


The Legal System in the United Kingdom

Rights and Responsibilities of a Patient

Duties and Responsibilities of the Dentist

Criminal and Civil Charges


Risk Assessment

Dealing with Sedation‐Related Incidents


Further Reading


End User License Agreement

List of Tables

Chapter 02

Table 2.1 Average heart rates.

Table 2.2 Definition and classification of blood pressure levels (mmHg).

Table 2.3 Lung volumes.

Chapter 03

Table 3.1 ASA classification system.

Table 3.2 Interactions of benzodiazepines with other drug groups.

Table 3.3 Blood pressure values and associated ASA class.

Table 3.4 BMI classification.

Chapter 04

Table 4.1 Health risks of chronic exposure to nitrous oxide.

Table 4.2 Properties of main benzodiazepine drugs used for sedation.

Chapter 08

Table 8.1 Emergency equipment essential for the provision of conscious sedation.

Table 8.2 Emergency drugs, doses and application.

List of Illustrations

Chapter 01

Figure 1.1 A model of dental fear in children proposed by Chapman (1999).

Figure 1.2 Visual analogue scale – A straight line measuring 10 cm, labelled Very Anxious at one end to Not at all Anxious at the other end. The patient is asked to place a X on the line to represent the extent of their anxiety.

Figure 1.3 Smiley faces anxiety scale – The child is asked to circle the face that best represents how they feel.

Figure 1.4 Factors influencing behaviour.

Figure 1.5 Ceiling‐mounted television.

Figure 1.6 By explaining the procedure to the patient and showing them the equipment the patient may feel more confident to proceed with treatment.

Chapter 02

Figure 2.1 Transverse section of an artery and vein.


, Artery, lined with nucleated endothelium


Underneath the endothelium is the elastic lamina muscle layer


The muscle layer is surrounded by connective tissue fibres, the adventitia

(a). V

, Vein, has thin endothelial lining


under which is a very thin muscle layer


The adventia


is similar to the artery.

Figure 2.2 Cross‐section of the heart illustrating the flow of blood through the chambers and large vessels.

Figure 2.3 Conduction system of the heart: 1 – Sinoatrial node; 2 – Atrioventricular node; 3 – Bundle of His; 4 – Bundle branches; 5 – Purkinje fibres.

Figure 2.4 Circulation of blood through the vascular system.

Figure 2.5 Veins of the dorsum of the hand.

Figure 2.6 Antecubital fossa illustrating the three important structures to be aware of: brachial artery, median nerve and bicipital aponeurosis.

Figure 2.7 Upper airway.

Figure 2.8 Lower airway.

Figure 2.9 The control of respiration is influenced at several points. At point A, the respiratory centre is affected by all modern sedatives. At points B and C, the phrenic nerve and neuromuscular junction respectively, the influences are less profound.

Figure 2.10 Graphical representation of lung volumes: TV – Tidal volume; ERV – Expiratory reserve volume; IRV – Inspiratory reserve volume; FRC – Functional reserve capacity; VC – Vital capacity; RV – Residual volume; TLC – Total lung capacity.

Figure 2.11 Oxygen/haemoglobin dissociation curve. The curve can be displaced to the left or the right by systemic influences.

Figure 2.12 Principles involved in oxygen availability.

Figure 2.13 The distribution of an intravenously injected drug.

Figure 2.14 Recovery from intravenous sedation occurs initially by redistribution of the drug into adipose tissue followed by elimination of the drug by the liver and kidney.

Chapter 03

Figure 3.1 Mallampati score.

Figure 3.2 Written instruction sheet for patients scheduled for treatment under sedation.

Figure 3.3 Sedation assessment record.

Chapter 04

Figure 4.1 Movement of nitrous oxide gas down the partial pressure gradient during induction and recovery from inhalational sedation.

Figure 4.2 The pressure in the nitrous oxide cylinder remains constant and tends to fall rapidly immediately before the cylinder becomes empty.

Figure 4.3 Biochemical effect of chronic exposure to nitrous oxide.

Figure 4.4 Mechanism of action of gamma‐aminobutyric acid (GABA).

Figure 4.5 Chemical structure of diazepam, showing a benzene ring structure attached to the diazepine part of the molecule.

Figure 4.6 Chemical structure of midazolam, showing a benzene ring structure attached to the diazepine part of the molecule.

Figure 4.7 Chemical structure of flumazenil, the benzodiazepine antagonist. The molecule has no benzene ring attached to the diazepine group.

Figure 4.8 Infusion pump used for the delivery of propofol sedation.

Figure 4.9 Button used by patient to administer propofol.

Chapter 05

Figure 5.1 Nasal syringes for administration of intranasal midazolam.

Chapter 06

Figure 6.1 Guedel’s stages of anaesthesia. Stage 1 is subdivided into three planes of analgesia.

Figure 6.2 Free‐standing inhalation sedation machine.

Figure 6.3 Piped inhalation sedation system.

Figure 6.4 Quantiflex MDM®, flow control head, showing nitrous oxide and oxygen flow meters, mixture control dial, flow control knob and oxygen flush button.

Figure 6.5 The reservoir bag is situated just below the flow control head.

Figure 6.6 Inhalation sedation nose mask, showing the inner and outer units.

Figure 6.7 Pre‐procedural checklist for inhalation sedation.

Figure 6.8 The nose mask is shown to the patient and the procedure explained.

Figure 6.9 The nose mask is comfortably positioned on the patient’s nose. It is important to check for a good seal around the mask to prevent leakage.

Figure 6.10 Spoken and written post‐operative instructions are given to the patient and their escort.

Figure 6.11 Treatment record sheet for inhalation sedation.

Chapter 07

Figure 7.1 Equipment required for the administration of intravenous sedation agents.

Figure 7.2 Pre‐operative checklist for intravenous sedation including information about the emergency equipment, intravenous sedation equipment and patient details.

Figure 7.3 Dorsum of the hand, showing the network of superficial veins.

Figure 7.4 Insertion of the cannula. The skin is held taught and the cannula angled at 10–15 degrees to enter the vein.

Figure 7.5 A small flashback of blood confirms that the cannula is in the lumen of the vein.

Figure 7.6 As the needle is withdrawn a further flashback of blood is seen within the cannula tube.

Figure 7.7 The cannula is fixed in place. Special fixing plasters or micropore tape may be used.

Figure 7.8 The position of the cannula is checked by injecting 2 ml of 0.9% saline.

Figure 7.9 Titration of the sedation agent, midazolam at a rate of 1 mg/min.

Figure 7.10 Inability to touch the tip of the nose with the forefinger indicates loss of motor co‐ordination and is known as Eve’s sign.

Figure 7.11 The pulse oximeter measures the patient’s arterial oxygen saturation and heart rate using a finger or ear lobe probe.

Figure 7.12 Nasal oxygen is administered via a nasal cannula.

Figure 7.13 The patient’s blood pressure is most easily monitored before, during and after treatment using an electromechanical blood pressure machine.

Figure 7.14 Following treatment the patient is escorted to the recovery area where monitoring continues until discharge.

Figure 7.15 Written post‐operative instructions are given to the patient and their escort prior to discharge.

Figure 7.16 The cannula is removed just before the patient is discharged.

Figure 7.17 The patient should be monitored throughout their treatment and all information entered on the sedation treatment form.

Chapter 08

Figure 8.1 Guedel oral airways.

Figure 8.2 Nasopharyngeal airway.

Figure 8.3 Ambu‐bag with reservoir bag.

Figure 8.4 Pocket mask used for giving rescue breaths during cardiopulmonary resuscitation.

Figure 8.5 Example of emergency drugs.

Figure 8.6 Automated external defibrillator.

Figure 8.7 Algorithm for adult basic life support.

Figure 8.8 The ‘chain of survival’.

Chapter 09

Figure 9.1 Patients requiring treatment on a day‐stay basis are often managed in a theatre setting with full anaesthetic support.



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Conscious Sedation for Dentistry

Second Edition

N. M. Girdler

Newcastle University

School of Dental Sciences


C. M. Hill

Cardiff University

School of Dentistry


K. E. Wilson

Newcastle University

School of Dental Sciences


This edition first published 2018© 2018 John Wiley & Sons Ltd

Edition History© 2009 N. M. Girdler, C. M. Hill, K. E. Wilson

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Library of Congress Cataloging‐in‐Publication Data

Names: Girdler, N. M., author. | Hill, C. M., author. | Wilson, K. E. author.Title: Conscious sedation for dentistry / N. M. Girdler, C. M. Hill, K. E. Wilson.Other titles: Clinical sedation in dentistryDescription: Second edition. | Hoboken, NJ, USA ; Chichester, West Sussex, UK : John Wiley & Sons Ltd., 2017. |   Preceded by: Clinical sedation in dentistry / N.M. Girdler, C. Michael Hill, Katherine Wilson. Chichester,   West Sussex: Wiley‐Blackwell, 2009. | Includes bibliographical references and index.Identifiers: LCCN 2017014485 | ISBN 9781119274476 (pbk.)Subjects: | MESH: Conscious Sedation | Anesthesia, DentalClassification: LCC RK510 | NLM WO 460 | DDC 617.9/676–dc23LC record available at

Cover design: WileyCover image: (Background) barbaliss/Shutterstock;(Photos) Courtesy of N. M. Girdler, C. M. Hill, and K. E. Wilson

About the Companion Website

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Multiple choice questions and answers

Scan this QR code to visit the companion website

1Spectrum of Anxiety Management


The aim of this chapter is to introduce the reader to the nature and development of dental anxiety and to provide an understanding of how and why patients behave in the way they do. This forms the basis for the practice of conscious sedation in the management of dental anxiety. The latter part of the chapter explains the development of conscious sedation, the accepted definition and the current guidelines relating to the practice of the technique in dental practice.

One of the main indications for the use of conscious sedation for dental care is ‘anxiety’. The prevalence of dental anxiety and phobia is high. The 2009 United Kingdom Adult Dental Health Survey indicated that 36% of adults had moderate dental anxiety and a further 12% reported extreme dental anxiety. The significance of dental anxiety as a barrier towards obtaining dental care, particularly as a result of avoidance, is well recognised. It has also been reported that dental anxiety does not just affect the patient but can have a significant effect on the general dental practitioner who treats the anxious patient. Treating the anxious patient can be a major source of stress for dentists within their daily working environment.

It has been postulated that the aetiology of dental anxiety is multifactorial and modifies and evolves with time. This concept is particularly relevant for the twenty‐first century. With the decline in dental caries in childhood, dental trauma will have a reduced role. Other factors such as the attitudes of family, friends and peers, media influence or the extent to which dental anxiety is part of an overall trait, will become more apparent.

There is a need to understand the individual components of dental anxiety as this will help to increase the dental healthcare worker’s awareness in recognising and managing the dentally anxious patient.

Fear and Anxiety as a Normal Phenomenon

Fear is often considered an essential emotion, augmenting the ‘fight or flight’ response in times of danger and manifesting as an unpleasant feeling of anxiety or apprehension relating to the presence or anticipation of danger. Fears are found throughout childhood, adolescence and adulthood.

Intense fears in childhood generally subside with maturity and the development of an ability to reason. If they do persist, however, this can result in the development of a ‘phobia’, a persistent, irrational, intense fear of a specific object, activity or situation. Phobias cause more distress to the patient and are difficult to overcome as they are more resistant to change. Very often some form of psychological/therapeutic intervention is required. Dental phobia invariably leads to dental neglect and total avoidance of dental care and is much more difficult to manage than dental anxiety.

It is therefore important to distinguish between ‘phobia’ and ‘anxiety’.


Anxiety is a more general non‐specific feeling, an unpleasant emotional state, signalling the body to prepare for something unpleasant to happen. Typically, anxiety is accompanied by physiological and psychological responses including the following.

Common Physiological Responses

Increased heart rate

Altered respiration rate




Common Psychological Responses

Feelings of impending danger




Phobia may be considered as a form of fear that

Is irrational and out of proportion to the demands of the situation

Is beyond voluntary control

Cannot be explained or reasoned

Persists over an extended period of time

Is not age specific.

Aetiology of Dental Anxiety

The aetiological factors associated with the development of dental anxiety will be dealt with under the following headings:

General anxiety and psychological development


Traumatic dental experiences

Family and peer‐group influences

Defined dental treatment factors.

General Anxiety and Psychological Development

It has been suggested that dental anxiety is a function of personality development associated with feelings of helplessness and abandonment. It is therefore important to consider the age and degree of psychological development of a child when assessing their ability to cope with stressful situations.

As children mature, so their level of understanding increases and the nature of their fears change. In infancy and very early childhood, fear is usually a reaction to the immediate environment, for example loud noises or looming objects. Relating this to the dental environment, it is understandable therefore that a very young child may find the sounds and smells in a dental surgery overwhelming, as well as the sight of the dentist and dental nurse in clinical uniform.

By the early school years, it is suggested that such fears have broadened to include the dark, being alone, imaginary figures, particular people, objects or events (animals and thunder). This could also equate with the dental situation, where a child is perhaps left in the dental chair with the dentist. He or she is unsure of what is going to happen and is unfamiliar with the dental environment.

At about nine years of age, the fear of bodily injury starts to feature strongly. It is clear therefore that for many children the thought of invasive dental procedures may be anxiety‐provoking. As children mature they are more able to reappraise the potential threat of the situation and may be able to resolve that anxiety.

In adolescence, fear and anxiety are centred on social acceptance and achievement. Some teenagers will be particularly aware of their appearance and possible criticism from peer groups.

In adulthood, although anxieties can develop spontaneously, it is more commonly related to social circumstance or bad experiences.


There are varying reports and opinions regarding the influence of gender on the aetiology of dental anxiety. Female patients tend to have higher scores for dental anxiety and consider themselves more fearful of dental treatment when compared to men. When considering prevalence studies in children, it would appear that generally girls report more fears than boys. There is much debate as to whether this is due to

Men being less willing to admit their anxiety

Women feeling more vulnerable

Women being more open about their anxieties.

Traumatic Dental Experience

Negative dental experiences are often quoted as the major factor in the development of dental anxiety with direct negative experiences including painful events, frightening events and embarrassing experiences leading to the development of dental anxiety. Such experiences can occur during childhood, adolescence and adulthood, however, for dental anxiety to develop, it is the nature of the event that appears to be more important than the age at which it occurs.

Traumatic medical experiences can also have a significant relationship with negative dental behaviour and may be important factors in the development of dental anxiety in children.

Family and Peer‐Group Influences

Influences outside the dentist’s control can often heighten dental anxiety. Indiscriminate comments, conversations and negative suggestions about dentistry can induce fear in children and the expectation of an unpleasant experience during dental treatment. Such comments may be made by family members or the child’s peers and act as an important source of negative information.

Defined Dental Treatment Factors

Specific dental treatment factors have been defined as the immediate antecedents of dental anxiety, the two most anxiety‐arousing being the injection and the drill. Other factors also play a part such as fear of criticism by the dentist, the dentist’s attitude and manner and the dental environment. The dentist’s attitude may lead to the development of a dentally anxious patient. For example, an abuse of trust by one dentist may result in all dentists being mistrusted. A proposed model for dental fear in children can be seen in Figure 1.1 (Chapman and Kirby‐Turner, 1999).

Figure 1.1 A model of dental fear in children proposed by Chapman (1999).

Source: Taken from Chapman and Kirby‐Turner (1999). Reproduced with Permission from Wiley‐Blackwell.

Measuring Dental Anxiety

Within dental education the behavioural sciences have become an increasingly important component. One element of this has been the application of psychological methods to study and quantify behaviour and attitudes relevant to dental care, in particular, dental anxiety and behaviour during dental treatment. This has included a wide range of methodological approaches and techniques, including questionnaires and behaviour measures. Examples of such measures include children’s drawings, observation of behaviour, visual analogue scales, ratings by dentists and self‐report questionnaires. The most common method of measuring dental anxiety is by using questionnaires and rating scales. It is important to ensure the measures used are reliable, valid and applicable to the population to which they are aimed.

Commonly Used Anxiety Scales


Modified Corah Dental Anxiety Scale

Visual analogue scale (

Figure 1.2


Short Dental Anxiety Scale.

Figure 1.2 Visual analogue scale – A straight line measuring 10 cm, labelled Very Anxious at one end to Not at all Anxious at the other end. The patient is asked to place a X on the line to represent the extent of their anxiety.


Children’s Fear Survey Schedule Dental Subscale

Smiley Faces Scale (also known as Wong or Venham faces

Figure 1.3


Figure 1.3 Smiley faces anxiety scale – The child is asked to circle the face that best represents how they feel.


In summary, it is clear that dental anxiety has a multifactorial aetiology comprising age and psychological development, gender of the patient, past traumatic dental and medical experiences, influence of family and peer groups and the immediate antecedents of dental anxiety. All patients will hold their own attitudes and emotions towards the dental situation, as well as their own past dental experiences. The social circumstances and family dynamics will also have an influence on the patient’s behaviour and the level of dental anxiety. It is important therefore for those in the dental profession to be aware of this multifactorial aetiology to be able to provide effective behavioural management in the dental setting.


In order to understand the rationale behind the methods used in treating anxious patients, it is necessary to understand why people behave in the way they do. It is also useful to know how behaviour can be modified in a way that is beneficial for both the patient and the dentist. This can often be achieved without resorting to the use of drugs, allowing long‐term anxiety management.

Nature of Behaviour

Behaviour may be defined as functioning in a specified, predictable or normal way. In psychological terms, behaviour is a response or series of responses of a person to a given stimulus. The borderline between what is normal (or acceptable) and abnormal (or unacceptable) behaviour is blurred by a host of factors including time, culture, conditioning and other considerations.

The intent of adults would most commonly be to want to behave in a rational and sensible manner, whereas the same intent would not always be present in children and adolescents. It therefore follows that the management of what appears to be similar but abnormal behaviour in the different groups needs to be tackled from a different viewpoint. This illustrates the complexity of the problem when it comes to teaching or learning techniques of behavioural management.

In conclusion, behaviour is a complex issue governed by a multitude of factors, some of which are illustrated in Figure 1.4. Equally, the management of behaviour is a difficult and extensive subject. However, the successful treatment of any patient depends on a dentist’s ability to manage the patient’s behaviour satisfactorily and some of the techniques of behavioural management are discussed below.

Figure 1.4 Factors influencing behaviour.

Behaviour Management

Simple Methods

There is an element of fear in all unknown situations in the majority of normal individuals. Probably the most important aspect of behavioural management is to ensure that the provoking stimulus is minimised as far as possible. Much of this is common sense and includes paying attention to such factors as room decoration, the way staff are dressed and the playing of gentle music in the background.

Positive Distraction

Positive distraction can be applied with the use of ceiling‐mounted televisions and personal music systems, as in Figure 1.5.

Figure 1.5 Ceiling‐mounted television.

Although the five sensations of sight, sound, hearing, touch and smell can all be offensive to patients at the dentist, it is undoubtedly the fear of pain which is the most commonly quoted factor that inhibits individuals seeking treatment or which underlies the apparently irrational behaviour of many anxious patients.

Tell, Show, Do

Simple behavioural management consists of informing verbally and demonstrating practically before actually performing a procedure. This has commonly been interpreted as a ‘tell, show, do’ sequence and there is good evidence that it is effective for many people (Figure 1.6). It does, however, depend on patients being able to adopt a rational approach to unknown situations. It is unlikely to be very effective in phobic patients or those demonstrating other types of neurotic behaviour.

Figure 1.6 By explaining the procedure to the patient and showing them the equipment the patient may feel more confident to proceed with treatment.

Permissible Deception

Another simple method of behavioural management, and one that is particularly suitable for use in children, is sometimes referred to as ‘permissible deception’. An example of this would be the introduction of an infiltration local anaesthetic into an upper premolar region without a patient being told they were having an ‘injection’. Providing adequate topical anaesthesia has first been given and the needle is not seen by the patient, abnormal behavioural responses are rarely seen in such situations. In such techniques, it is important not to tell lies but to be ‘economical with the truth’ using such terms as squirting some numbing water, washing the gums or making the teeth go to sleep.

Successful application of these simple techniques is highly dependent on the confidence of the person applying them. The success of the administration can then be used as a building block on which further steps can be built.

Relaxation Techniques

Behavioural response is also heightened by stress, and simple relaxation techniques can be applied to enable tense patients to relax. This may be achieved actively, for example by using progressive relaxation strategies, or passively by using soft background music. It has also been shown that patients perceive the degree of stress being experienced by the dentist and react accordingly, developing heightened responses to any stimuli. It is, therefore, essential that dentists review their own reactions in difficult or stressful situations and take every action possible to moderate them accordingly.

Systematic Desensitisation

This is the most common and potentially most effective psychological technique. It involves gradually acclimatising patients to very minor stimuli and teaching them to relax while these are being applied. Once relaxation is achieved the stimulus can be gradually increased usually over a considerable period of time, until even the most feared situation is manageable.

Many dentists intuitively use this approach in treating extremely anxious patients, first of all introducing a mirror and then a probe followed by the use of hand‐scalers, tooth‐brushing with the dental engine, maxillary infiltration, small restoration, inferior dental block, and so on. In many cases, it is possible to teach a new set of learned behaviours, replacing the previously maladapted ones.

Cognitive Behavioural Therapy

Cognitive Behavioural Therapy (CBT) is a talking therapy that addresses a person’s problem(s) by changing the way they think and behave. An important aspect of CBT is that it focuses on the present problems rather than dealing with issues that have occurred in the past, helping the individual to find ways of changing their state of mind on a daily basis. CBT is delivered in a structured and collaborative way where patients are asked to carry out exercises at home as part of the process. CBT helps the patient make sense of their anxiety by breaking the issue down into five main areas that are interconnected and affect each other:




Physical feelings


The behavioural aspect of the therapy includes learning relaxation techniques and carrying out systematic desensitisation of anxiety‐provoking situations. The cognitive element of the therapy is based on the way people think about situations, which has an effect on their emotions and physiological response and can lead to unhelpful behaviours including avoiding dental visits. The aim of CBT is therefore to create a new way of thinking about a situation which in turn leads to a more positive behaviour.

CBT can be delivered by dentists and dental care professionals (DCPs) who have received appropriate training in the technique.