Sedatives and Hypnotics

Sedatives and Hypnotics

Summary

Sedatives and hypnotics are drugs used to induce relaxation in patients who have high levels of anxiety prior to and during dental procedures. These drugs typically may be taken in pill, liquid, injection or inhaled form. They do not relieve pain, but instead help calm patients, making dental work easier for both the patient and the dentist.

Patients who experience anxiety prior to dental work are urged to express these concerns to their dentist. In some cases, the dentist will suggest that the patient take a form of sedative or hypnotic. Minor cases of anxiety usually can be treated with an anti-anxiety medication that is taken in pill form.

Deeper levels of sedation may be required for patients who are especially anxious or for those who will undergo complex procedures. Young children and mentally or physically challenged patients also may need deeper levels of sedation before certain procedures. This type of sedation is often administered either intravenously (I.V.) or is inhaled by the patient through a mask.

Sedatives and hypnotics are usually considered one class of medication. Sedatives can mentally and physically relax the body. Hypnotics may induce sleep. Some medications have both qualities. Sedatives and hypnotics often are given in combination with local anesthesia, which prevents a patient from feeling pain during dental work (e.g., fillings, crowns, root canals, extractions). Many different types of sedatives and hypnotics can be used during dental procedures, including benzodiazepines and barbiturates.

Sedatives and hypnotics used in dental procedures are generally very safe and cause few side effects. However, some patients may experience adverse complications such as headache, drowsiness and impaired performance and judgment. Misuse of some sedatives and hypnotics may cause dependence or be addictive in some patients.

Certain drugs may interact poorly with sedatives and hypnotics and increase the sedative effect of these medications. In particular, patients are urged to avoid use of central nervous system (CNS) depressants such as alcohol or opioid analgesics. Antidepressants, antihistamines and some heartburn medications also interact poorly. Symptoms of overdose can be similar to the medication’s side effects, but are usually more severe.

Patients who take a sedative or hypnotic the night before a procedure should have someone else drive them to their dental appointment. In addition to avoiding driving, patients who use sedatives or hypnotics should not operate heavy machinery and should avoid tasks that require great thought or extreme concentration.

About sedatives and hypnotics

Sedatives and hypnotics are medications that help patients relax. When used in dentistry, these drugs are generally given to patients before or during dental procedures and may be taken in pills, liquids, by injection or inhalation. While these drugs do not control pain, they do provide patients with a sense of calm that makes it much easier to endure certain procedures.

Sedatives and hypnotics are usually considered one class of medication. Sedatives can mentally and physically relax the body. Hypnotics may induce sleep. Some medications in this class have both effects on the body, while others do not.

Some patients feel little or no anxiety prior to dental procedures. However, other patients may experience great nervousness prior to visiting the dentist. Such patients are urged to express these concerns to their dentist. In some cases, the dentist will suggest that the patient take a form of sedative and hypnotic that will help bring on a sense of relaxation.

Certain cases of anxiety can be treated with an anti-anxiety medication (e.g., benzodiazepines) that is taken in pill form. These drugs are often taken anywhere from the night before a procedure to 30 minutes prior to the procedure.

Deeper levels of sedation may be required for patients who are particularly anxious or for those who are to undergo complex procedures. Young children and mentally or physically challenged patients (e.g., patients with mental retardation, cerebral palsy) also may need deeper levels of sedation before certain procedures. These sedatives often are given in combination with local anesthesia, which prevents a patient from feeling pain during dental work such as fillings, crowns, root canals and extractions. There are four major levels of sedation. They are:

  • Anxiolysis. Light sedation that makes patients feel as if they have no worries. Patients can respond to commands given by the dentist with this method and are able to feel touch. This sedative is usually administered orally.

  • Conscious sedation. A medium level of sedation in which patients feel relaxed and in control of their own breathing, but are groggier than in anxiolysis. Patients can still respond to speech and touch. The gag reflex is generally intact. This sedative is usually administered intravenously (through a vein).

  • Deep sedation. A level of sedation that places the patient somewhere between consciousness and unconsciousness. Patients are more deeply sedated than in conscious sedation and may experience a partial loss of the gag reflex and an inability to respond well to commands or stimulation. In some cases, patients may need help breathing. This sedative is always administered intravenously.

  • General anesthesia. Patients are completely unconscious and do not feel any pain. They cannot respond to commands or stimuli and need a tube to help them breathe because the gag reflex is absent. This sedative is always administered intravenously.

Techniques that may be used to sedate patients include:

  • Nitrous oxide. Often called laughing gas, this sedative mixes nitrous oxide with oxygen and is inhaled through a mask. The effects of nitrous oxide wear off soon after removing the oxygen mask, and few people experience side effects. Nitrous oxide is often used to induce sedation at the anxiolysis and conscious sedation levels.

  • Intravenous (I.V.) sedation. This technique involves introducing a sedative through a needle inserted into a vein, usually in the arm. Depending on the type of drugs and dosages of drugs used, I.V. sedation can range from conscious sedation to deep sedation to general anesthesia. Patients may experience a 15- to 20-minute recovery period following the procedure.

Dentists who use any form of I.V. sedation in their practice must receive special training in these techniques. Oral and maxillofacial surgeons and dental anesthesiologists complete hospital residencies qualifying them to perform conscious sedation, deep sedation and general anesthesia. Patients who use sedatives or hypnotics are urged to follow any instructions they receive from their dentist. For example, patients using nitrous oxide may be asked to eat lightly prior to and after their appointment. Patients using other forms of sedatives may be asked not to eat for at least eight hours prior to an appointment.

Types and differences of sedatives and hypnotics

Many different types of sedatives and hypnotics are used during dental procedures. The most popular choices among dentists include the following:

TypeGeneric Name(s)Brand Name(s)
Benzodiazepinealprazolam
chlordiazepoxide
diazepam
flurazepam
lorazepam
midazolam
oxazepam
temazepam
triazolam
Xanax
Librium
Valium
Dalmane
Ativan
Versed
Serax
Restoril
Halcion
Barbituratethiopental
methohexital
pentobarbital
secobarbital
amobarbital
butabarbital
phenobarbital
primidone
Pentothal
Brevital
Nembutal
Seconal
Amytal
Butisol
Luminal
Mysoline
Hypnoticschloral hydrate
zolpidem
zaleplon
Noctec
Ambien
Sonata

Potential side effects of sedatives and hypnotics

Sedatives and hypnotics used in dental procedures are generally safe when used properly and usually cause few side effects. This is especially true of nitrous oxide. Patients who receive nitrous oxide sometimes experience a headache following their dental procedure. However, this typically can be avoided by administering oxygen to the patient for several minutes following the procedure. This helps to clear the nitrous oxide from the system.

Benzodiazepines are generally considered to be safer than barbiturates. For this reason, benzodiazepines have become the second-choice sedative (following nitrous oxide) for many dentists.

Although side effects are rare, they sometimes do occur. Benzodiazepines may cause temporary inflammation of a vein (thrombophlebitis) when administered intravenously. These drugs also can cause some loss of memory. This typically is limited to events that occur after the drug is administered (retrograde amnesia).

Barbiturates have been associated with certain side effects, including a “hangover” type of effect afterwards, drowsiness and impaired performance and judgment. Barbiturates are not recommended for people with asthma. Misuse of barbiturates may create dependence or be addictive in some patients. Overdose of these medications can lead to respiratory arrest.

Parents or caregivers of children who receive sedation for a dental procedure are advised to keep the child at home for the rest of the day after the procedure.

Other potential side effects associated with use of sedatives and hypnotics include:

  • Changes in appetite
  • Changes in urination
  • Constipation and diarrhea
  • Lethargy
  • Vertigo
  • Vision disturbances
  • Vomiting

Sedatives and hypnotics such as benzodiazepines and barbiturates may cause birth defects and are known to pass into breast milk. As a result, women who are pregnant or nursing generally should not use these drugs. Nitrous oxide has not been studied in pregnant women, but has been associated with birth defects in animal studies.

Sedatives and hypnotics also should be used cautiously in children and elderly adults, who may be more susceptible to side effects associated with these drugs.

Drug or other interactions

Patients should consult their dentist before taking any additional prescriptions, over-the-counter medications, nutritional supplements or herbal medications.

Certain drugs may interact poorly with sedatives and hypnotics and increase the sedative effect of these medications. In particular, patients are urged to avoid using heartburn and ulcer medications, antidepressants, antihistamines and central nervous system (CNS) depressants such as alcohol or opioid analgesics.

Use of certain antacids may prevent sedatives and hypnotics (e.g., benzodiazepines) from working fully. Smoking also may prevent these drugs from working at an optimal level.

Symptoms of overdose

Symptoms of overdose can be similar to the medication’s side effects, but are usually more severe. Patients exhibiting any of these symptoms during or after a dental procedure should contact their physicians immediately:

  • Breathing difficulties
  • Confusion
  • Continued problems with short-term memory
  • Shakiness
  • Severe depression
  • Severe weakness
  • Shortness of breath
  • Slow heartbeat (bradycardia)
  • Slurred speech
  • Staggering

Lifestyle Considerations

Patients who take a sedative or hypnotic the night before a procedure should have someone else drive them to their dental appointment. In addition to avoiding driving, patients who use sedatives or hypnotics should not operate heavy machinery and should avoid tasks that require great thought or extreme concentration.

Questions for your doctor on sedatives and hypnotics

Preparing questions in advance can help patients to have more meaningful discussions regarding their treatment options. The following questions related to sedatives and hypnotics may be helpful:

  1. What type of sedative or hypnotic do you recommend for me?

  2. Can I just take a mild sedative or will I require heavier sedation?

  3. Are there other relaxation techniques I can use instead of taking medication?

  4. What drugs should I avoid before and during use of sedatives and hypnotics?

  5. What other preparatory steps should I take before receiving my medication?

  6. What are the potential side effects associated with this medication?

  7. What should I do if I experience side effects?

  8. Are there activities I should avoid following my use of sedatives and hypnotics?

  9. Are sedatives and hypnotics safe for my children or elderly parents?

  10. I’m pregnant – what are my options in terms of sedatives and hypnotics?

  11. I prefer conscious or deep sedation. What kind of monitoring will be performed?

  12. Are you and your staff trained to deliver conscious and deep sedation?
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