清醒镇静在老年患者口腔治疗中应用的研究进展

doi:10.13591/j.cnki.kqyx.2025.04.013

摘要/Abstract

摘要：

近年来,老年患者占口腔科就诊患者比例逐年增加,接受口腔治疗中紧张、疼痛等刺激导致心血管意外发生风险增高。老年患者在清醒镇静下接受口腔治疗需求巨大,因而受到广泛关注。本文详细回顾了口服镇静、吸入镇静、静脉镇静等常用清醒镇静技术研究现状及应用注意事项。多项研究表明不同清醒镇静方法在临床应用有缓解焦虑情绪、降低血流动力学波动等优势,因此有良好的应用前景。然而,该项技术在完善的镇静前评估、恰当的镇静用药、全面的镇静监测及有效的应急方案等基础上,才能更好保证临床安全。

关键词: 清醒镇静, 老年, 笑气, 静脉镇静, 口服镇静

Abstract:

The proportion of elderly patients has been increasing in recent years, as has the risk of cardiovascular accidents caused by tension, pain, and other stimuli in dental treatment. Because there is a high demand for dental treatment for elderly patients under conscious sedation, it has attracted a lot of attention. This paper examines the current state of research on and application precautions for commonly used conscious sedation techniques such as oral sedation, inhalation sedation, and intravenous sedation. A number of studies have shown that different sedation methods have the advantages of reducing hemodynamic fluctuations and relieving anxiety in clinical applications, so they have promising application prospects. However, with perfect pre-sedation assessment, appropriate sedation medication, comprehensive sedation monitoring, and effective emergency plans, this technology can better ensure clinical safety.

Key words: conscious sedation, elderly patients, nitrous oxide, intravenous sedation, oral sedation

中图分类号:

R614.2

刘冰, 张惠. 清醒镇静在老年患者口腔治疗中应用的研究进展[J]. 口腔医学, 2025, 45(4): 306-310.

LIU Bing, ZHANG Hui. Research progress of the application of conscious sedation in dental treatment for elderly patients[J]. Stomatology, 2025, 45(4): 306-310.

图/表 1

参考文献 42

[1]	栾文民. 中国老年口腔医学的发展历程[J]. 中国实用口腔科杂志, 2021, 14(6): 641-644.
[2]	孙欣怡, 陈晗, 马丁, 等. 老年心血管疾病患者心理状态与拔牙围手术期不良事件的相关性研究[J]. 老年医学与保健, 2022, 28(2): 274-278.
[3]	刘鹏, 许永伟, 吴鹏. 中老年心血管病患者口腔麻醉前后的血压和心率变化[J]. 中国循环杂志, 2020, 35(1): 82-85.
[4]	Fiorillo L. Conscious sedation in dentistry[J]. Medicina (Kaunas), 2019, 55(12): 778.
[5]	邵云, 程庆涛, 何欢, 等. 2种不同舒适化技术在60例高血压患者阻生牙拔除术中的应用评价[J]. 上海口腔医学, 2022, 31(1): 109-112.
[6]	Foley C, Kendall MC, Apruzzese P, et al. American Society of Anesthesiologists Physical Status Classification as a reliable predictor of postoperative medical complications and mortality following ambulatory surgery: An analysis of 2 089 830 ACS-NSQIP outpatient cases[J]. BMC Surg, 2021, 21(1): 253.
[7]	刘友坦, 郭荣鑫, 陈向东, 等. 老年患者手术室外麻醉/镇静专家共识[J]. 临床麻醉学杂志, 2023, 39(6): 659-662.
[8]	潘剑, 薛洋, 赵吉宏, 等. 口服抗栓药物患者门诊拔牙围手术期管理的专家共识[J]. 华西口腔医学杂志, 2022, 8(3): 255-263.
[9]	Huang JX, Liu J, Shi HT, et al. Risk factors for bleeding after dental extractions in patients receiving antithrombotic drugs-A case control study[J]. J Dent Sci, 2022, 17(2): 780-786.
[10]	张舜皓, 王宇轩, 李名立. 牙科焦虑症心理治疗方法的研究进展[J]. 口腔疾病防治, 2022, 30(9): 680-684. doi: 10.12016/j.issn.2096-1456.2022.09.011
[11]	Gurram P, Narayanan V, Chandran S, et al. Effect of heartfulness meditation on anxiety and perceived pain in patients undergoing impacted third molar surgery[J]. J Oral Maxillofac Surg, 2021, 79(10): 2060. e1-2060.e7.
[12]	Conway A, Chang K, Mafeld S, et al. Midazolam for sedation before procedures in adults and children: A systematic review update[J]. Syst Rev, 2021, 10(1): 69. doi: 10.1186/s13643-021-01617-5 pmid: 33673878
[13]	卢博一, 刘冰, 徐浩, 等. 口服药物镇静的实际操作及注意事项[J]. 实用口腔医学杂志, 2015, 1(1): 141-144.
[14]	曾艳, 历泉汝, 王海莲, 等. 2016—2020年中国九城市老年失眠患者镇静催眠类药物使用趋势分析[J]. 药物流行病学杂志, 2022, 31(5): 321-327.
[15]	Li X, Liu YL, Li CJ, et al. Sedative and adverse effect comparison between oral midazolam and nitrous oxide inhalation in tooth extraction: A meta-analysis[J]. BMC Oral Health, 2023, 23(1): 307. doi: 10.1186/s12903-023-02965-5 pmid: 37210490
[16]	武玉红, 庄蕾, 于布为, 等. 患儿术前焦虑的研究进展[J]. 临床麻醉学杂志, 2022, 38(1): 81-85.
[17]	马才顺, 邓悦. 吸入镇静在老年患者种植术中的应用[J]. 中华老年口腔医学杂志, 2020, 18(3): 163-164, 177.
[18]	Khinda V, Rao D, Sodhi SPS. Nitrous oxide inhalation sedation rapid analgesia in dentistry: An overview of technique, objectives, indications, advantages, monitoring, and safety profile[J]. Int J Clin Pediatr Dent, 2023, 16(1): 131-138.
[19]	Nagele P, Palanca BJ, Gott B, et al. A phase 2 trial of inhaled nitrous oxide for treatment-resistant major depression[J]. Sci Transl Med, 2021, 13(597): eabe1376.
[20]	康铖, 朱挺, 韩爽, 等. 笑气联合局麻在阻生牙拔除中的应用效果评价[J]. 中国口腔颌面外科杂志, 2024, 22(2): 165-169.
[21]	Rossit M, Gil-Manich V, Ribera-Uribe JM. Success rate of nitrous oxide-oxygen procedural sedation in dental patients: Systematic review and meta-analysis[J]. J Dent Anesth Pain Med, 2021, 21(6): 527-545. doi: 10.17245/jdapm.2021.21.6.527 pmid: 34909471
[22]	Girdler NM, Hill CM, Wilson KE. 口腔清醒镇静技术[M]. 张惠, 刘冰,译. 西安: 世界图书出版西安有限公司, 2022.
[23]	Chi SI. Complications caused by nitrous oxide in dentalsedation[J]. J Dent Anesth Pain Med, 2018, 18(2): 71.
[24]	Zarour S, Weiss Y, Kiselevich Y, et al. The association between midazolam premedication and postoperative delirium: A retrospective cohort study[J]. J Clin Anesth, 2024, 92: 111113.
[25]	Kleiman RB, Darpo B, Thorn M, et al. Potential strategy for assessing QT/QTc interval for drugs that produce rapid changes in heart rate: Electrocardiographic assessment of the effects of intravenous remimazolam on cardiac repolarization[J]. Br J Clin Pharmacol, 2020, 86(8): 1600-1609.
[26]	Lawler H, Walker P. Evaluation of maximum dose intravenous midazolam used in dental intravenous sedation: A West of Scotland regional audit[J]. Br Dent J, 2022, 233(2): 135-138.
[27]	Li WX, Luo RY, Chen C, et al. Effects of propofol, dexmedetomidine, and midazolam on postoperative cognitive dysfunction in elderly patients: A randomized controlled preliminary trial[J]. Chin Med J, 2019, 132(4): 437-445.
[28]	Shibuya M, Hojo T, Hase Y, et al. Conscious sedation with midazolam intravenously for a patient with Parkinson’s disease and unpredictable chorea-like dyskinesia[J]. Br J Oral Maxillofac Surg, 2018, 56(6): 546-548. doi: S0266-4356(18)30172-4 pmid: 29908706
[29]	Nishizaki H, Morimoto Y, Hayashi M, et al. Analysis of intravenous sedation for dental treatment in elderly patients with severe dementia-a retrospective cohort study of a Japanese population[J]. J Dent Sci, 2021, 16(1): 101-107. doi: 10.1016/j.jds.2020.06.027 pmid: 33384785
[30]	Kim JH, Kim DH, Kim JH. Low-dose midazolam and propofol use for conscious sedation during diagnostic endoscopy[J]. Kaohsiung J Med Sci, 2019, 35(3): 160-167.
[31]	Ding F, Wang XL, Zhang L, et al. Effect of propofol-based total intravenous anaesthesia on postoperative cognitive function and sleep quality in elderly patients[J]. Int J Clin Pract, 2021, 75(7): e14266.
[32]	Shimizu H, Homma Y, Norii T, et al. Incidence of adverse events among elderly vs non-elderly patients during procedural sedation and analgesia with propofol[J]. Am J Emerg Med, 2021, 44: 411-414. doi: 10.1016/j.ajem.2020.04.094 pmid: 32409101
[33]	Liu XT, Li YQ, Kang L, et al. Recent advances in the clinical value and potential of dexmedetomidine[J]. J Inflamm Res, 2021, 14: 7507-7527. doi: 10.2147/JIR.S346089 pmid: 35002284
[34]	Constantin JM, Momon A, Mantz J, et al. Efficacy and safety of sedation with dexmedetomidine in critical care patients: A meta-analysis of randomized controlled trials[J]. Anaesth Crit Care Pain Med, 2016, 35(1):7-15.
[35]	Seto M, Kita R, Kondo S. Sedation with dexmedetomidine in elderly patients during dental surgery: A retrospective case series[J]. J Korean Assoc Oral Maxillofac Surg, 2019, 45(3): 152-157. doi: 10.5125/jkaoms.2019.45.3.152 pmid: 31334103
[36]	王春艳, 于泳浩. 瑞马唑仑临床研究进展[J]. 中华麻醉学杂志, 2019, 39(3): 261-263.
[37]	Rex DK, Bhandari R, Desta T, et al. A phase Ⅲ study evaluating the efficacy and safety of remimazolam (CNS 7056) compared with placebo and midazolam in patients undergoing colonoscopy[J]. Gastrointest Endosc, 2018, 88(3): 427-437.e6.
[38]	Doi M, Morita K, Takeda J, et al. Efficacy and safety of remimazolam versus propofol for general anesthesia: A multicenter, single-blind, randomized, parallel-group, phase Ⅱb/Ⅲ trial[J]. J Anesth, 2020, 34(4): 543-553.
[39]	Pantos MM, Kennedy DR, Nemec EC. Remimazolam: A novel option for procedural sedation in high risk patients[J]. J Pharm Pract, 2023, 36(1): 149-154.
[40]	Stöhr T, Colin PJ, Ossig J, et al. Pharmacokinetic properties of remimazolam in subjects with hepatic or renal impairment[J]. Br J Anaesth, 2021, 127(3): 415-423. doi: 10.1016/j.bja.2021.05.027 pmid: 34246461
[41]	张丽娜, 李乐, 潘旭, 等. 老年牙周病患者利多卡因局麻拔牙术中不同剂量瑞马唑仑镇静效果观察[J]. 山东医药, 2024, 64(15): 75-78.
[42]	中华口腔医学会镇静镇痛专业委员会. 口腔门诊笑气-氧气吸入镇静技术操作指南[J]. 中华口腔医学杂志, 2022, 57(4): 319-325.

镇静方式	适应证	禁忌证	应用优势
口服镇静	简单、短时的口腔治疗;针头恐惧症;无法配合吸入镇静	苯二氮艹卓类药物过敏;肝肾功能受损;严重精神疾病	无特殊设备要求;患者易接受
吸入镇静	轻到中度牙科焦虑症;针头恐惧症;咽反射敏感	气胸;肺囊性纤维化病;慢性阻塞性肺疾病;中耳功能障碍;接受硫酸博来霉素(bleomycin sulfate)治疗;肠梗阻;一周内行气脑造影术等	兼具镇静、镇痛作用;无创;起效恢复迅速;不经肝脏代谢;心血管影响较小
静脉镇静	轻到重度牙科焦虑症;咽反射敏感且笑气效果不佳;全身合并症多	相关药物过敏史;肝肾功能受损;严重精神疾病	可通过药物剂量不同诱导不同深度镇静,静脉通路便于在紧急情况下抢救用药