Oral Surgery

Enhanced CPD DO C

Charlotte Richards

Carole Boyle

Using Inhalation Sedation

for Oral Surgery
Abstract: With increasing waiting lists across the UK for oral surgery under general anaesthesia (GA), inhalation sedation (IS) may provide
the answer for patients to be treated more quickly. The authors believe it is an underused technique for the management of anxious and
medically compromised patients requiring oral surgery. This article demonstrates, with patient examples, how IS can be used effectively.
CPD/Clinical Relevance: This article is relevant to general dental practitioners, oral surgeons and those working in sedation services.
Dent Update 2024; 51: 57–60

Many dentists associate inhalational are concerns about the effects of nitrous The gases are delivered by dedicated
sedation (IS) as a method of managing oxide (N2O) as a greenhouse gas and machines (Figure 1), which have the
anxiety in children. While it is an excellent its contribution to climate change. The following safety features:
technique for younger people IS has advantages for patients are obvious  Impossible to deliver less than
applications for adults particularly those with its fast action, anxiolytic effects 30% oxygen;
with medical complexities. This article and fast recovery, which make it very  Pin index system which
highlights how the technique can be suitable for mild to moderately anxious prevents gas cylinders being
very effective for adult patients requiring patients having oral surgery procedures. incorrectly interchanged;
oral surgery and can avoid the need for Although good local anaesthesia is  Bodok seal which ensures a gas tight
general anaesthesia for some. required for any successful oral surgery, fit between the manifold and the
With waiting lists at an all-time high N2O has excellent analgesic properties valve block;
and a shortage of anaesthetists, IS may and can be as effective as morphine.1  Oxygen fail safe: if the oxygen supply
provide the answer to long oral surgery N2O meets almost all the fails the N2O supply cuts out;
waiting lists. The technique does require requirements of the ideal gas for sedation  Oxygen flush button allowing delivery
the operator to give psychological (Table 1). N2O acts on GABA receptors of 100% oxygen in the event of
support and works best with an operator- to produce anxiolysis in a similar way to an emergency.
sedationist. The equipment is bulky benzodiazepines.2 It has a weak potency,
and requires either gases to be piped with a mean alveolar concentration of
from centrally stored supplies or mobile 105%, higher than all anaesthetic gases, Clinical technique
E size cylinders. For mobile cylinders making it near impossible to anaesthetize Pre-operative
suitable gas storage is required. There with N2O alone. Before using the machine, standard
checks must be carried out to ensure
the safety features are working. Written
consent for treatment should be gained
Charlotte Richards, BDS, MFDS RCPSG, Dip Con Sed(KCL), FHEA, Clinical Lecturer/
at a prior assessment appointment and
StR Oral Surgery, School of Dentistry, Cardiff University. Carole Boyle, BDS MMedSci
confirmed on the day of treatment. No
FDSRCSEng FDS RCSEd MSNDRCSEd FDTFEd, Consultant and Honorary Senior Lecturer
escort is required for this technique,
in Special Care Dentistry; Clinical Lead, Department of Sedation and Special Care
although some anxious or medically
Dentistry, Guy’s and St Thomas’ NHS Foundation Trust, London.
compromised patients may choose
email: richardsc34@cardiff.ac.uk
to bring one.

January 2024 DentalUpdate 57

pg57-60 Richards.indd 57 11/01/2024 12:18

 Oral Surgery
Figure 1. Photo of an IS machine (Matrx MDM
machine, Porter, USA).
Intra-operative
When the patient is comfortable in the
chair, the nasal hood is passed over the
patient’s head, and the mask adjusted to
ensure a tight seal. The patient breaths
100% oxygen for a few minutes to get
them used to the mask and the flow rate
is adjusted. The correct flow rate, usually
6–7 litres/minute, can be determined
by monitoring the movement of the
reservoir bag, to ensure there is no over
or under inflation. Clinical monitoring
is sufficient during the procedure,
although some operators use pulse
oximetry to provide an indication of
anxiety reduction.
Titration of N2O commences with 10%
and most modern machines (e.g. Matrx
MDM, Accutron Digital Ultra, HuFriedy
Group, USA) automatically reduce O2 to
90%. After 1 minute, there is a further
10% change to 20% N2O. Following this,
increase the N2O concentration by 5%
every minute until the titration endpoint
is reached. A maximum of 70% N2O can
be delivered. Even at this concentration
the patient is receiving 30% oxygen,
which is more than in room air.3
Sedation with N2O requires
psychological support and verbal
reassurance throughout for success.
The drug alone cannot be relied upon
58 DentalUpdate
pg57-60 Richards.indd 58
Property Ideal gas Nitrous oxide
Pharmacokinetics (how the body affects the drug)
Induction Odourless, Odourless, nasal hood can
non‑threatening, smooth be threatening to some
patients, smooth
Speed of onset Rapid (low blood Rapid (0.47)
gas solubility)
Metabolism Nil, no active metabolites Minimal, no
active metabolites
Titration Steady Steady
Speed of change Rapid Rapid
of sedation
Recovery Rapid Rapid
Pharmacodynamics (how the drug affects the body)
Effects on Minimal Minimal
cardiorespiratory system
Anxiolysis Excellent Yes – response variable
Analgesia Excellent Excellent
Potency Weak (high minimal Weak (105%)
alveolar concentration)
Systemic toxicity None Yes, in chronic misuse
Other effects
Environmental effects None Yes
Table 1. Ideal properties of inhalational agents compared with nitrous oxide.
to provide the anxiolysis required for prevent the theoretical risk of diffusion
treatment. Although a mouth prop is not hypoxia where N2O quickly fills the lungs
usually advocated for IS because mouth displacing oxygen. The patient can then be
closure is a sign of over sedation, a mouth discharged once they have re-orientated in
prop can make surgical procedures more time and space. They can return to work if
comfortable and can be used with IS. they feel well enough to do so after the oral
The relative concentrations of each surgery procedure.
gas can be easily adjusted throughout
treatment. For example, a patient who Oral surgery cases treated
is needle phobic may require 65% N2O
under inhalation sedation
for local anaesthetic administration, but
require 30% N2O for the extractions. The Case 1
titration method ensures the correct A 21-year-old female was referred
following multiple episodes of pericoronitis
dose for the patient as overdose with N2O
associated with her lower wisdom teeth.
can make patients feel restless, agitated,
She was fit and well and treatment
and panicky, which is not conducive
planned for extraction of LR8, LL8 and UL8.
to successful oral surgery. Should
The patient requested sedation, but as a
oversedation occur ,the N2O level should
student new to Cardiff, was unable to bring
be reduced, and the patient encouraged
an escort. Given the lack of escort, IS was
to keep breathing through the nasal mask.
offered to the patient over two visits for
extraction of three wisdom teeth (Figure 2).
Post-operative At the first visit, the patient required 40%
Once treatment is complete, the patient N2O for surgical removal of the LR8 and
should be given 100% oxygen for simple extraction of the UL8. At the second
2 minutes at the end of treatment to visit, the patient required 50% N2O and
January 2024
11/01/2024 12:18

Figure 2. Orthopantogram of patient requiring removal of LR8, LL8 and UL8.
Figure 3. Intra-oral peri-apical radiograph of the UR4 and left sectional orthopantogram of the UL7 and
UL8, all requiring extraction.
Figure 4. Orthopantogram of patient requiring periodontal treatment, fillings and multiple extractions
prior to cardiac surgery.
the LR8 was extracted simply. Each visit
was carried out by different operator-
sedationists, both with success.
Case 2
A 35-year-old female was referred
from general practice for extraction
January 2024
pg57-60 Richards.indd 59
of the unrestorable UL8, UL7, and UR4
(Figure 3). The patient was dentally
anxious. Medically, she was ASA III
with poorly controlled type 1 diabetes,
asthma and a body mass index of 45.
Given the patient’s medical background,
intravenous sedation was not deemed
Oral Surgery
appropriate, and the patient was offered IS
for treatment. The patient went on to have
all three teeth successfully removed in the
same visit with 45% N2O. The patient was
supported by both the operator and the
dental nurse with psychological support
with a particular focus on breathing
exercises. Although amnesia is not a
listed property of N2O, once treatment
was completed, the patient asked when
the teeth would be removed and was
delighted to learn they had already been
extracted.
Case 3
A 70-year-old male was referred for a
dental assessment to a tertiary centre
before cardiac surgery: resection of
subaortic membrane and possible
aortic valve replacement. His medical
history included severe left ventricular
hypertrophy, moderate mitral valve
regurgitation and episodes of paroxysmal
atrial tachycardia. He was also a smoker.
The cardiologist advised antibiotic cover
to reduce the risk of infective endocarditis.
His general dental practitioner had
referred him to the local district hospital
where they could only offer local
anaesthesia for treatment, which was
declined by the patient. At assessment,
IS was offered and although the patient
was not initially convinced, he went on to
have extraction of six teeth, restorations,
and periodontal treatment over two
visits (Figure 4). Sedation also meant that
treatment was carried out safely and more
quickly than waiting for GA, and prevented
further delay to his cardiac surgery.
Discussion
Many patients are anxious about dental
extractions and are unable to tolerate
treatment under local anaesthetic alone.
There are many cohorts of patients where
operator-sedationist treatment with
intravenous sedation with midazolam is
not suitable. These include patients with
high body mass index in conjunction
with a potentially difficult airway, those
who are difficult to cannulate or cannot
tolerate cannulation, patients with medical
conditions such as sleep apnoea, complex
cardiac conditions and those who are
unable to provide an escort.
As demonstrated by these cases oral
surgeons should consider IS as a routine
part of their armamentarium when
assessing any patient for dental extractions,
DentalUpdate 59
11/01/2024 12:18
 Oral Surgery

and not limit sedation treatment options
to intravenous midazolam. Without
consideration of this modality, patients
who are unsuitable for intravenous
sedation will be referred to an anaesthetic-
led sedation service or for general
anaesthesia. This can result in increased
waiting times for treatment, particularly
pertinent at present where the NHS is
short of 1400 anaesthetists,4 waiting
times for elective surgery are substantial,
particularly following the COVID-19
pandemic, and the cost of an operating
theatre per hour to the NHS is estimated
at approximately £1200.5 In addition, for
medically compromised patients, general
anaesthesia has increased morbidity
and mortality. If patients are deemed
unsuitable for intravenous sedation, some
anxious patients may feel pressured into
local anaesthesia alone, which can make
treatment unpleasant for all involved.
Issues with N2O
Chronic exposure to N2O experienced
by healthcare professionals was a
concern prior to active scavenging, with
links to reduced fertility in males, and
increased miscarriage in females.6 A
1980 study of clinicians exposed to N2O
demonstrated increased risk of liver,
kidney and neurological disease.7 Active
scavenging is compulsory in the UK to
keep background levels below 100 parts
per million.8,9
The biggest obstacle for practitioners
not already offering IS is the cost and
maintenance of equipment, which is more
expensive than intravenous midazolam.
Training in IS requires 10 supervised
cases, appropriate evidenced theoretical
training, immediate life support training
and maintenance of 12 hours of CPD in of 1,400 NHS anaesthetists already means
sedation every 5 years.8 However, once that more than one million surgical
set up, this relatively simple technique procedures are delayed every year. 2021.
will allow the oral surgery treatment of Available at: www.rcoa.ac.uk/news/
patients in primary care. shortage-1400-nhs-anaesthetists-already-
means-more-one-million-surgical-
Conclusion procedures-are-delayed (accessed
December 2023).
This article has demonstrated, with
5. NHS Institute for Innovation and
examples, how IS can be used simply
and effectively to treat anxious and Improvement. The productive operating
medically compromised patients for oral theatre. Improving quality and efficiency
surgery. When assessing any patient for in the operating theatre. Version 1. 2009.
extractions, if the patient is unsuitable Available at: https://alesi-surgical.com/
for local anaesthesia alone, IS should be wp-content/uploads/2019/09/Improving-
seen as a routine treatment option to quality-and-efficiency-in-the-operating-
consider for all patients, particularly in theatre.pdf (accessed December 2023).
those patients unsuitable for intravenous 6. Rowland AS, Baird DD, Shore DL et al.
sedation operator-sedation techniques Nitrous oxide and spontaneous abortion
who would otherwise be referred onto an in female dental assistants. Am J Epidemiol
anaesthetic-led service for treatment.
1995; 141: 531–538. doi: 10.1093/
oxfordjournals.aje.a117468
Compliance with Ethical Standards
7. Cohen EN, Gift HC, Brown BW et al.
Conflict of Interest: The authors declare
that they have no conflict of interest. Occupational disease in dentistry and
Informed Consent: Informed consent was chronic exposure to trace anesthetic
obtained from all individual participants gases. J Am Dent Assoc 1980; 101: 21–31.
included in the article. doi: 10.14219/jada.archive.1980.0345
8. Intercollegiate Advisory Committee
References on Sedation in Dentistry. Standards for
1. Kariman H, Majidi A, Taheri S et al. conscious sedation in the provision of
Analgesic effects of inhalation of nitric dental care. 2020. Available at: https://
oxide (Entonox) and parenteral morphine www.rcseng.ac.uk/dental-faculties/fds/
sulfate in patients with renal colic; a
publications-guidelines/standards-for-
randomized clinical trial. Bull Emerg
conscious-sedation-in-the-provision-of-
Trauma 2015; 3: 46–52.
dental-care-and-accreditation/ (accessed
2. Emmanouil DE, Quock RM. Advances
December 2023).
in understanding the actions of nitrous
oxide. Anesth Prog 2007; 54: 9–18. 9. Scottish Dental Magazine. Nitrous
3. Craig D, Boyle C. Practical Conscious oxide scavenging in the 21st Century.
Sedation. 2nd ed. London: Quintessence 2011. Available at: www.sdmag.
Publishing, 2017. co.uk/2011/02/09/nitrous_oxide/
4. Royal College of Anaesthetists. A shortage (accessed December 2023).

tistry
General Den

Call for Papers

C
CPD DO
Enhanced
Restorative Dentistry
Implants Enhanced CPD DO C

Enhanced CPD
DO C

Pynadath George
Martin Kelleher

Tim Newton
aard-Nielsen

A Novel Approach ditions in

Henrik Overg
Wilson
Nairn HF

Placement of Zy for the ental Con

ral and D and Others
Narcissism, Pride, Envy,
Do you have an idea for a Dental Update gomatic ImplaOnts
The Zygomatic Bo
ne Zone IndW in:etasters
Lust and Dentistry
ex e Wine Trade
in th
trade. These

article, or have you written an article

s in the wine ms is Abstract: Platforms such as Instagram have normalized self-adulation and this has affected many patients, and some dentists, in different
and other
winetasters oral and dental proble ways. Some posts demonstrate excessive pride in the appearance of the mouth or face, and seem designed to induce envy in others. The
l hazard of l resultant emotional impacts on envious followers can increase demands to have a similar sort of appearance, which can lead to over-
occupationa prevent occupationa
to be an to treatment, or to potentially dangerous procedures being carried out on their mouth and face regions. This article explores the nature of
Abstract: This article considered wine trade and other
s in
explores the considera ms may be ers of the
g winetasters narcissism and the increasing likelihood of it being ‘normalized’ as one significant factor in the increased demand for, and the delivery
implants is necessary dental proble e to memb ms.
tions and factors Oral and ed. Advic such proble ational hazard amon
, and
tool has been presented if so, the potential considera
that implant dentists Abstract: ms are review gement of occup
of, some questionable dental, oral and/or facial treatments. We outline how the narcissistic traits in some dental healthcare professionals
, the Zygomati tions in planning
for
may use to decide
whether the and dental proble views on the mana tions may be an might lead them to undertake elective, biologically risky, and irreversible procedures, which can invoke ‘the law of unintended
complications and c Bone Zone index, them placemen oral with condi
to allow for further within the zygomatic t of zygomatic together dental
CPD/Clinical Relevanc placement within
to improve the surgical bone.
placement of zygomatic A novel treatment presented, Relevance: Oral and consequences’ for patients and/or themselves. The terms ‘destructodontics’ ‘relapsodontics’ and ‘alignerodontics’ are suggested as being
e: It is important the zygomatic bone linical
planning appropriate descriptions for some dentistry, which is carried out mainly for appearance reasons, but which can produce long-term

that you like to submit? Then please

Dent Update 2023; for clinicians to in implants, CPD/C
to help reduce
be aware of treatment the future. rs
Wine taste tasters have existed sincein biological and other problems.
50: 927–930 trade. 25
modalities that the wine 50: 923–9
might be of benefit Upda te 2023; comp onents wine others CPD/Clinical Relevance: The normalization of narcissism, as demonstrated by some posts on Instagram and other platforms and in
to some patients.Dent er with
ons. The
major ; Professional
ry BC, togeth s,
9
concentrati general, water (86%) cers, buyer dubious advertising has many worrying implications and possible consequences for patients and the dental profession.
The minimum amount e an are, in cchar ides, the 4th centu including produ mayDent Update 2023; 50: 914–922
of bone required is to provid of wine polysa trade, of whom
a dental implant for Implantology (ITI) this article ; glycerol, elements the wine eliers, all
is a relevant topic, clarified this position, The aim of ntation, ethanol (12%) ounds and trace and somm process
for implant dentists, not just stating that An of the cause, prese of oral and lic comp (0.5% ); and merchants nt wines in the tasting,
but also for general a residual height edentulou s ridge such as this overview gement pheno acid differe ess:
dentists, oral surgeons, inferior to the sinus of bone would ntion and mana nt types of (0.5%). taste many daily busin g the Most people have some narcissistic
require bone grafting by wine (1%); differe le compounds positive about their external validation from others (‘likes’), or smile appearance that is to their exact
periodontists and
prosthodontists,
the
of 4–6 mm justifies to allow implant preve
ms experienced y of volati of going ng, involves swirlin g air
any other health provision of a direct lateral placemen t, or alternatively l proble trade. a variet s have drinki inhalin characteristics, including the present and some exaggerate their appearance, specifications (to match their ‘brand’),
the wine unlike wine cavity, while

send it to Fiona Creagh:

sinus graft, the use ofdenta others in made from component organs,
professional who
provides treatment with simultaneous implant anchored an
in the bone outsidetasters and beverage Many of these s on body
d the oral to assessingauthors. Narcissism is best viewed as a social experiences or accomplishments and which they are convinced is their
implant placemen 2 wine aroun subsequent
planning advice 2013, the ITI considere t. In maxilla, otherwise the an alcoholic produced and negat
ive effect anisms the wine, r) and continuum, with the majority of patients to achieve this. Narcissists can be absolute right.
to patients about
implants. d that a minimum known as ‘extra-max Wine, has been st ular mech to aerate sity and colou
The minimum height of 1 mm of bone implants’. Zygomati illary grape juice, the earlie systems,
cells, molec ing the oral rance (inten cs)
characteristi and dentists being somewhere around
of vertical bone circumferentially c implants are a fermented Some of the appea passive–aggressive and self-critical, but Some dentists, probably those
ensals, includ
4
required for the the planned implant around of extra-maxillary type ands of years. the Caucasus and comm 5 The pH of wine is
largely sity and aroma er of wines the middle of a normal distribution many are hypersensitive to even mild with increased narcissistic tendencies
placement of dental was required before implant that is used for thous from ‘nose’ (inten 10 numb
implants in the support teeth when to of wine is back to . in a While the duals
posterior maxilla considering bone
grafts.3 This would there is an extremelyevidence Georg ia dating microbiome 4, 6 as confirmed
e of the wine. worki ng day by indivi (‘Bell’) curve. However, some people external criticism. They can be arrogant themselves, appear to lust after lots of
originally defined was ’s 1 Wine, apart 3 and the vary
by the Sinus Consensu equate to a ridge
width of 5 mm for
atrophic ridge.
region in
today
5000 BC. between on the erosiv al.7 tasted during wine trade
may with serious narcissistic traits, including and entitled (‘pride’), but not all appear money (‘greed’), or for greater power, and/
Conference in 1996.1 s 6000 and n, publications Rees et roles in the at least on occas ion,
The consensus stated implant that is 3
mm wide.
an
between nal consumptio number of , for example, in different er may, dental
, professionals, can pose so at the first encounter. Narcissists are or for wider recognition of their artistic or
that a residual bone for perso played of wines is huge numb y Wines
Therefore, a posterior Zygomatic implan from its use potential business widely, the For example, Libert other talents.

fiona.creagh@markallengroup.com
height inferior to things, long the wine , significant problems. often manipulative and hold grudges,
sinus floor of 3 mm
or less is best treated
the less than 3 mm maxilla with ts has, among other in religion2 and been Globally, US$30 0bn in 2022) be very large. comp anies in the Narcissists seek attention, praise and/ and many are excessively envious of However, any failure to achieve
residual bone height Brånemark first of over ies largest wine and bars,
with a lateral sinus below the sinus wrote about zygomatic tant role positive and (annual value types, styles is
, variet
one of the retailers, restaurants a narcissistic patient’s expectation of
graft approach, an impor different
or admiration from others. Many seek
central
others (‘envy’). Some ‘lust’ after a facial
a delay in implant with and/or 4 mm or
less implants in 1998
after using them to have both y depending t to tasting in
bucco-palatal width considered with many This marke UK, selling achieving their desired outcome, even if it
placement. In 2008, of bone prevents years.4 This implant for 10 effects, largel es of wine. lly by >5%.8 yearly wine ased
2011 and 2016,
the International placement of conventio the is a longer titanium
rod negat
ive health 3
and vintag holds a twice- ry 2023, they showccers was unrealistic and previously unexpressed,
nal implants and that is apically installed consumed. several to grow annua Janua
Team for could be considere into the zygomatic on the amount comprises expected London. In over 300
produ
it risks complaints, general aggravation and
d ‘extremely’ atrophic. bone, but emanates type of wine very low wines from customers. While Martin Kelleher, MSc, FDSRCS, FDSRCPS, FDSRCS, Specialist in Restorative Dentistry
crest (Figure 1).
from the maxillary Any one , many at circa 800 1000 the sometimes litigation.
Primary stability ed compounds to appro ximately ates tasted alland Prosthodontics, Consultant in Restorative Dentistry, King’s College Dental Hospital, This article outlines some of the
of the hundr
Pynadath George, zygomatic implant
West Londo
n Wine that any deleg some
BDS, MFDS, MSc is often excellent
Educator, and is unlikely possible that winesLondon. J Tim Newton, BA, PhD, Professor of Psychology as Applied to Dentistry, King’s problems involved, and makes some
Fellow CGDent, Rest Dent, MSc can allow for immediat and
SET Wine e London ased, it is nt College London Faculty of Dentistry, Oral and Craniofacial Sciences; Honorary Consultant
General Dental Imp
Surgeon with practice Dent, DClinDent Oral Surg, e placement of and DipW King’s Colleg wines showc to 200 differe suggestions about how to identify patients
prosthodontic and fixed prosthesis 5,6
.
a n, Dentist of Dentistry, tasted up Health Psychologist, Guy’s and St Thomas’ NHS Foundation Trust and Office of the Chief
surgical implantol limited to advanced
/complex aard-Nielse Emeritus Professor stry delegates te 923 (and dentists) with significantly increased
email: georgede
ntsurgeon@hotmail.
ogy. Since the late 1990s Henrik Overg Wilson, General Denti DentalUpdaDental Officer; Honorary Professor of Psychology, University College London.
com have been used zygomatic implants Nairn HF College of narcissistic traits in order to reduce some of
in cases with severe School. Sir Emeritus, email: info@martinkelleher.co.uk
atrophy or tissue bony President ternet.com
the dangers involved.
December 2023 loss. Soft and hard Founding @btin 23 13:59
atrophy from tooth tissue wilson
email: nairn.
06/12/20
loss or previous 914 DentalUpdate December 2023
implant

DentalUpdate 2023
December
pg927-930 George.indd
927 927
pg914-922 Kelleher.indd 914 06/12/2023 13:20

ndd 923
05/12/2023 pg923-9 25 Wilson.i
13:45

60 DentalUpdate January 2024

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