DEFINITIONS

The primary goal of this textbook is to aid the dentist in the management of pain and anxiety in the dental patient because it is these two items that, either singly or in combination, produce most of the difficulties associated with patient management.

How may pain and anxiety be managed successfully and safely in the dental office? Pain associated with dental treatment is managed effectively through the administration of local anesthetics at the start of treatment. These chemicals prevent passage of the nerve impulse beyond the site at which they are deposited. Although the tooth or soft tissues have received a noxious stimulus (e.g., drill, curette), the propagated nerve impulse will travel only as far as the site at which the local anesthetic was deposited. The rapid influx of sodium ions into the interior of the nerve (the process responsible for continued propagation of the nerve impulse) is prevented, the impulse is terminated, and the patient experiences no discomfort.

As noted in Chapter 1, however, fear of pain is a major deterrent to the delivery of dental care today. Patients who are not in pain fear the visit to the dental office because they believe that at some time during their dental treatment they will be hurt.¹ Fear of pain produces a heightened anxiety in these patients, a factor that may lead to the avoidance of dental care until they are truly in pain.

How can dentistry alter its image of being painful? It is a fact today that virtually all dental care can be completed without discomfort to the patient. With the availability of a variety of excellent local anesthetics, it is possible to achieve clinically adequate pain control in virtually all situations. The most difficult pain management problems usually occur in endodontically involved teeth and, since the reintroduction of intraosseous anesthesia and the introduction of articaine HCl, only rarely in this situation is effective pain control unattainable.^2–5

The administration of a local anesthetic is also considered to be a traumatic procedure by most patients and indeed by many dentists (see Table 1-1).^6,7 Yet even this aspect of dental care need not be traumatic. Local anesthetic injections may be administered atraumatically anywhere in the oral cavity, including the palate. The technique of the atraumatic injection of local anesthetics is presented in various textbooks of local anesthesia.^8,9

Yet the possibility of pain and the “injection” of local anesthetics are not the only things about dentistry that induce fear in patients. Dentists with extensive clinical experience have probably heard patients express fear of almost every possible procedure that we are called upon to carry out.

How then can we manage these overtly fearful patients? The answer is to distract them, to take their attention away, from what is being done for them (the patient would consider that we are doing things “to them”) in their mouths. This can be accomplished through nondrug techniques, such as headsets with music, video, dark glasses, warm blankets, or through the administration of drugs that induce a state of consciousness (or, more precisely, an altered state of consciousness) in which a person is more relaxed and carefree. Over the years, many names have been given to this drug-induced state. Names such as chemamnesia,¹⁰ sedamnesia,¹¹ twilight sleep,¹² relative analgesia,¹³ and co-medication¹⁴ have been used to describe the state of altered consciousness that is now called sedation.

Many definitions of sedation have been put forth over the years; however, in 1971 following the Third Pain Control Conference sponsored by the American Dental Association (ADA), American Dental Society of Anesthesiology, and American Association of Dental Schools, the “Guidelines for Teaching the Comprehensive Control of Pain and Anxiety in Dentistry,” were published.¹⁵ These guidelines established a standard for the training of dental personnel in this area of patient management. The guidelines have undergone revision on several occasions over the ensuing years,^16,17 most recently in 2007 when the House of Delegates of the ADA passed two documents representing significant revisions of the guidelines, including modification of the terms used to define the various levels of sedation.^18,19

In previous iterations, levels of sedation were defined as follows^16,17:

Anxiolysis: a minimally depressed level of consciousness that retains the patient’s ability to independently and continuously maintain an airway and respond appropriately to physical stimulation or verbal command and that is produced by a pharmacologic or nonpharmacologic method or a combination thereof. Although cognitive function and coordination may be modestly impaired, ventilatory and cardiovascular functions are unaffected.

Conscious sedation: a minimally depressed level of consciousness that retains the patient’s ability to independently and continuously maintain an airway and respond appropriately to physical stimulation and verbal command and that is produced by a pharmacologic or nonpharmacologic method or combination thereof.

Deep sedation: a drug-induced depression of consciousness during which patients cannot be easily aroused, but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function/>