10: Oral and Parenteral Conscious Sedation for Dentistry: Assessment, Analysis, and Associated Dental Management Guidelines

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Oral and Parenteral Conscious Sedation for Dentistry: Assessment, Analysis, and Associated Dental Management Guidelines

CONSCIOUS SEDATION OVERVIEW

Conscious sedation is what makes dentistry “painless” for the phobic patient or the patient fearful of the dental environment. Elimination of pain and anxiety management are usually the first considerations for patients experiencing fear or phobia toward dentistry. Conscious sedation is an extension of care beyond these measures. Sedation dentistry helps make dental procedures virtually painless. Conscious sedation is not just reserved for the fearful patient. It is also an important option for patients with developmental disabilities and movement disorders so that dentistry can be completed effortlessly. Anesthesiologist-administered general anesthesia for dentistry is not a part of conscious sedation and should be confined to a hospital setting only.

SEDATION CLASSIFICATIONS

Types of sedation include:

1. Anesthesiologist-administered deep sedation
2. Intravenous (IV) sedation or deep conscious sedation
3. Inhalation conscious sedation
4. Oral conscious sedation

Anesthesiologist-Administered Deep Sedation

This type of sedation is to be administered only by an anesthesiologist. The patient has partial or complete loss of protective reflexes, and there is inability to maintain a patent airway independently and at all times. The patient is not easily aroused and the patient is unable to respond to verbal commands or physical stimulation.

Intravenous (IV) Sedation or Deep Conscious Sedation

Most oral surgeons and some trained dentists use this technique. It requires certification by the state board of dentistry. IV sedation is provided using a single drug, usually one of the benzodiazepines. The dose is titrated to match the patient’s needs and underlying vital organ status. More can be injected for immediate effect when the dose wears off. Fixed dose or bolus dose drug use is highly discouraged. Drugs used for this type of sedation are more effective when given intravenously than when the same drugs are taken orally. There is a more profound amnesia associated with this sedation technique.

Inhalation Conscious Sedation

Inhalation sedation is provided by using titrated doses of O2 + N2O. The patient usually falls asleep during the procedure. There is some amount of amnesia and analgesia.

Oxygen/nitrous oxide sedation is the most frequently used sedation in dentistry. This type of sedation requires special delivery and scavenging systems for the gases. The patient should not have had any recent upper respiratory tract infections (URTIs) prior to this type of sedation.

All bodily functions remain normal with this type of sedation and the patient is able to breathe on his own. The patient will often fall asleep and experience some degree of amnesia. Dental inhalation sedation works well for mild-to-moderate anxiety. It has a rapid onset, there is flexibility of duration, and it can be used for any appointment length. The dentist has absolute control because it is easy to titrate the level of sedation, which may be altered moment to moment. The recovery is quick and there are very few side effects. There is an analgesic effect experienced and the patient can resume normal activities immediately.

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The disadvantages of dental inhalation sedation include severe anxiety, which may require a deeper level of sedation, plus it is not indicated for patients with respiratory problems such as severe asthma, significant emphysema, or COPD.

Oral Conscious Sedation

This type of sedation is patient-administered, safe, and easy to monitor. The patient takes oral benzodiazepines prescribed by the dentist. The patient invariably falls asleep, and deep relaxation is experienced with this method of sedation. All bodily functions remain normal and the patient is able to breathe on his/her own, often falling asleep. Some degree of amnesia is common. The disadvantage of oral sedation, however, is that the level of sedation for each patient is not predictable. Someone must drive the patient to and from the dental appointment and there is no analgesic effect.

Inhalation and Oral Conscious Sedation: Additional Facts

Oral conscious sedation and inhalation sedation are the two most common types of sedation techniques used by most dental practitioners doing sedation dentistry, outside of the oral surgery setting. Conscious sedation is not light general anesthesia. In fact, there is a huge difference between conscious sedation and the unconscious state associated with general anesthesia. In conscious sedation the patient maintains all bodily functions independently, including airway, circulation, and responsiveness to verbal commands and/or stimulation. The sedation level is reached when slurring of speech occurs.

The types of phobias experienced by the patient may dictate the type of conscious sedation used. A patient experiencing injection-needle associated phobia may need to be induced with O2 + N2O, prior to IV sedation.

PATIENT SELECTION AND INSTRUCTIONS FOR CONSCIOUS SEDATION

Proper patient selection is very important when deciding on dentistry with sedation. Sedation may not work for all patients. You must do a thorough history and physical examination and assess the patient’s weight, baseline vital signs, mental status, allergy status, airway status, past history of any significant anesthesia outcome, current medical conditions, current medications (many drugs may interfere with the metabolism of sedatives, resulting in prolonged CNS effects), laboratory tests, the patient’s vital organ status, DDIs among the patient’s medications and the sedation medications, and the patient’s ASA status.

The American Society of Anesthesiology Status

The American Society of Anesthesiology (ASA) status establishes the patient’s overall cardiopulmonary status (Table 10.1). The ASA status is determined in all patients undergoing surgery using either local or general anesthesia. The cardiopulmonary status is determined by assessing the patient’s capacity to walk up a flight of stairs or walk two blocks.

Table 10.1 The ASA Classification

ASA Status Task Performance Climbing a Flight of Stairs
ASA I The normal or well-controlled patient reaches the top of the stairs effortlessly.
ASA II The patient is winded upon reaching the top and has to rest to feel comfortable.
ASA III The patient gets winded and stops frequently while climbing, but does reach the top.
ASA IV The patient is very winded and unable to climb.

Note that patients with arthritis may not be able to climb stairs. The ASA status in these patients is established by determining the patient’s capacity to walk a block or two. Additionally, an ASA III or IV patient will experience significant breathing difficulty when made to lie down horizontally in the dental chair. These patients will also state that they need to be propped up on multiple pillows when in bed, so they can breathe comfortably and without difficulty.

Sedation and the Medically Compromised Patient

When deciding on sedation for a medically compromised patient, the dentist must know the total number of medical conditions that are being treated, the level of control of each disease state, and the patient’s cardiopulmonary ASA status. These facts need to be accounted for, prior to assessing the type of conscious sedation that will be safe for the patient (Table 10.2).< ?anchor c10-tbl-0002?>

Table 10.2 Medically Compromised Patient: Disease Associated ASA Status and Conscious Sedation Guidelines

ASA Status Disease Status Comments
ASA I Patient has no known systemic disease. Conscious sedation is OK. No primary care physician (PCP) consult is required.
ASA II Single, mild, or well-controlled systemic disease. Same as ASA I, but get laboratory tests to confirm disease control.
ASA III Multiple or moderately controlled systemic diseases. Get PCP consult. Review patient’s lab tests, medications, and DDIs with the conscious sedation medication(s).
ASA IV Poorly controlled systemic diseases. CS done by anesthesiologist in a hospitalized setting.

Conscious Sedation Contraindications

Conscious sedation is contraindicated in patients with moderate-to-severe liver or kidney disease; patients with moderate-to-severe respiratory disease and COPD; patients with acute narrow-angle glaucoma; patients with unstable arrhythmias; frail, debilitated, and elderly patients; pregnant patients or nursing mothers; and significantly compromised developmentally disabled patients.

Conscious Sedation Patient Instructions

Each patient must be completely evaluated prior to conscious sedation, and conscious sedation is not for all patients. ASA I and ASA II patients are the lowest-risk populations; ASA III patients need for you to have a PCP consult, to determine if conscious sedation is right for the patient. The informed consent must be obtained prior to the procedure and start of conscious sedation. Prior to conscious sedation, inform the patient and the person transporting the patient about post-sedation discharge and give follow-up instructions.

There should be no intake of solid food or full liquids for at least 6–8hours prior to sedation. No clear liquids should be consumed for at least 3–4hours prior to the sedation. However, it is best to have the patient fasting or nil-by-mouth (NPO) for conscious sedation. Patients must be monitored before, during, and after a procedure.

VITAL PARAMETERS AND CONSCIOUS SEDATION

The vital parameters that need to be monitored during conscious sedation are baseline vital signs, oxygen saturation level, heart rate and rhythm, and level of consciousness.

Vital Parameters Timeline Protocol

The timeline protocol for monitoring vital parameters is as follows:

1. Monitor and document the vital parameters every 5 minutes: during administration of the medication(s), during the sedation period, and during the recovery period.
2. Monitor the vital parameters every 15 minutes once the parameters return to baseline in the post-sedation period or if it has been 30 minutes since the last medication was given. The endpoint for monitoring is when the patient regains consciousness and achieves pre-sedation vital parameters status.

Conscious Sedation Recovery Alerts

Take immediate action when there is

1. A ±20% change in the pulse or blood pressure (BP).
2. Change in the cardiac rhythm.
3. Drop in the oxygen saturation by ≥5% below baseline.
4. Dyspnea/apnea/hypoventilation experienced by the patient.
5. Patient experiences sweating.
6. Inability to arouse the patient.
7. A need to maintain the patient’s airway mechanically.

Conscious Sedation and the Aldrete Scoring System

The Aldrete scoring system should be used during conscious sedation to determine the patient’s ability to follow commands, to maintain respiratory and circulation status, to determine consciousness level, and to determine the patient’s ability to maintain color (Table 10.3).

Table 10.3 The Aldrete Scoring System

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Jan 4, 2015 | Posted by in General Dentistry | Comments Off on 10: Oral and Parenteral Conscious Sedation for Dentistry: Assessment, Analysis, and Associated Dental Management Guidelines
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