Pre-Testing For the Proper Sedative Agents and Dosages to Prevent Untoward Complications During Sedation

Abstract

About half of the population avoid any dental treatment because of dental phobia and fear. This resulted in a large dental phobia and fear. This resulted in a large dental crippled population. The shaking and trembling due to fear makes the patient unable to sit still for the dental treatment to be rendered. To ease their fear, sedation or general anesthesia are used to perform dentistry. Usually general anesthesia is done at the hospital and sometimes at an outpatient clinic of the hospital, although some, occasionally, done in the office.

With limited monitoring device that was available in the first half of the century, the mortality rate was a major concern, even in the last quarter of the last century with modem monitoring devices for the patient’s vital signs, the mortality rate in the dental chair still took place. Major media networks in the U.S. such as NBC and CBS had broadcasted in their programs to express major concern of death in the dental chair. In the U.S. the death due to sedation or anesthesia is about 1 per 300,000 anesthetic’s, the British surveys also showed that there is not much difference in their ambulatory centers. Lately in the U.S. and the United kingdom there is more legislation and debate to regulate anesthesia and sedation in the office. The driving force for such an endeavor appears to be the office death. Despite the development of pulse oximetry in the early 1980’s which was a major advancement over cyanosis as an early diagnostic acid for hypoxemia, there is still about 2 deaths in the U.S., a number comparable to the British data.

Dating back to 1980’s-95, in the Journal of Pediatarics, it showed that sixty pediatric patients, in death or severe neurological impairment that 32 were dental cases. The other 28 cases were divided among several medical specialties in hospital facilities and the office. The data was collected when pulse oximetry was just beginning to become standard, and capnography was unavailable. With full monitoring devices in place, it would otherwise prevent the office deaths. The oximetry seems to be well established and capnography is becoming more accepted for deep sedation and non-intubated general anesthesia. It gives immediate alert if apena occurs, and is more life saving. Nevertheless, hospital stay is costly and the monitoring equipments arc expensive.

Financial pressures that are placed on the health care industry is considerable. Therefore sedation must be available and affordable. Bi-Digital O-Ring Test (BDORT) for sedation purpose may be both cost effective and complication reducible.

Recently there is much discussion of the controversial practice of “oral sleep dentistry” (cocktail style sedation). The practice involves repeated large doses of oral sedatives over a period of several hours involving several different drugs to induce deep sedation and amnesia. Advertised to the public as “sleep dentistry”, it is being taught at weekend seminars across the U.S. There are concerns about the safety of the technique. Using an oral agent to achieve anxiolysis and relaxation is accepted to be safe, effective, and important to the administration of routine dentistry to anxious patients. However, using oral agents alone to achieve deep sedation is unreliable and a dangerous technique.

Oral agents are not readily titratable nor reversible and, not therefore indicated for deep sedation. They are less safe than IV (intravenous) sedation or combination of oral and nitrous oxide sedation due to titratability, besides, IV benzodiazepines and narcotics are reversible.

The most concerned untoward and adverse reaction in sendation are drug overdose and allergic reaction (including anaphylactic shock). Allergic reaction, though rare, could have deadly consequence if not corrected soon after it occurs. The allergy test for sendatives is tedious and, even after the test, one might still not be sure if the patient is truly allergic. If one wishes to verify cases in doubt, one can use a simple non-invasive method of BDORT as an adjunct diagnostic aid. This test, developed in late 1970, has been used for various diagnostic purposes as well as selecting proper medication and dosage. The two testing methods, direct and indirect testing, are based on criteria determining the compatibility of patient and doctor for the purposes of conducting the O-Ring Test. For compatible patients and doctors, the direct method is applied, while the indirect method is used for incompatible doctors and patients such as very young children, or the debilitated, or the handicapped. If the indirect test is used, then a nurse or assistant can serve as an intermediary during the test. The test result can reveal the sensitivity of the patient to the drug for the patient. Briefly, the direct method involves the patient making a circle (O-ring) with the thumb and another finger of one hand, and holding it tightly together. If the indirect method is being used, the intermediary should form the O-ring. In the other hand would be a viral of the properly selected sedative drug. A compatible clinician would then attempt to separate the patient’s finger and thumb with both fingers of his own hands.

The end of a thin brass rod should gently rest on the skin over the trachea area of the patient if testing for potential allergies or anaphylactic reaction. The other hand of the intermediary person or patient not forming the o-ring would hold the other end of the brass rod. If the patient is allergic to the drug it will be easy for the clinician to separate the patient’s fingers indicating the patient is not allergic to the drug. The strength of the fingers forming the O-ring can be quantified to evaluate the quality of the drug after satisfying certain testing criteria, bassed on which a clinical impression is made.

A clinician can select the proper dosage with O-ring test by pointing brass rod or finger of the tester to the frontal lobes of both right and left hemisphere of the patients brain. The dosage of the sedation can be properly adjusted when the fingers of the O-ring remain closed. Same method is applying to the kidney, liver or heart by pointing to the respective organ individually, for practical purpose, if the drug is compatible with the patient, the recommend manufacturer’s dosage can be given and titrated whenever possible. When and if the second dosage maybe needed later during the dental procedure, the O-ring test with finger or brass rod pointing to myocardium is performed to determine the proper second dosage. For medically compromised patient, O-ring test with the sedative drug pointing to the kidney, liver or brain with finger or brass rod is/are performed to the determine the proper second dose, depending on what medical condition involving that particular organ. Such a practice can even help prevent complications with sleep dentistry that is gaining some popularity. The O-Ring test could be used as a guide to determine the proper dosage, instead of blindly guessing the dosage when patients already being rendered in semi-conscious state. It could potentially reduce complication.