Periodontal and implant surgery should be performed painlessly and with minimal or no apprehension. The patient should be assured of this at the outset and throughout the procedure. The most reliable means of providing painless surgery is with effective administration of local anesthesia. However, patients who are apprehensive may require treatment under mild or moderate sedation. The use of sedation can help make patients more comfortable during periodontal and implant surgery, especially when the procedure is expected to continue for 2 hours or more. Routes of administration for sedation agents include inhalation, oral, intramuscular, and intravenous (IV). The specific agent(s) and modality of administration are based on the desired level of sedation, anticipated length of the procedure, overall condition of the patient, and training of the clinician and staff. This chapter reviews the rationale, definitions, techniques, and guidelines for the use of mild-to-moderate conscious sedation in the dental office for periodontal and implant surgical procedures.
Many patients delay or avoid having needed dental treatment because of fear and anxiety. This avoidance behavior often results in compromised health and quality of life. Anxiety toward dental therapy has not changed significantly over the past 50 years; publications report that about 30% to 50% of patients are at least somewhat fearful of dental procedures.1-4 New evidence suggests that genetic variations are associated with anxiety related to dental care, which could help to explain the consistent avoidance patterns despite improved treatment methods.5 According to a national survey of the Canadian population, more than 68% of patients would prefer to have sedation or general anesthesia for periodontal surgery6 (Figure 36-1). Anxiety reduction is an important part of delivering advanced periodontal services.7 Furthermore, since dental anxiety results in avoidance behavior and is associated with more dental and periodontal problems,8,9 it is likely that a disproportionate number of patients referred to periodontal specialists will have dental anxiety. Interestingly, there appears to be a close relationship between anxiety and postoperative pain. In fact, preoperative anxiety may be considered a predictor of postoperative pain.10,11 In addition, high levels of anxiety (stress) can affect wound healing after periodontal treatment12–14 (see Chapter 11). Sedation techniques have been shown to be effective in reducing physiologic markers of stress.15 For these reasons, it is important for clinicians who provide advanced periodontal and implant therapy to be knowledgeable and skilled in providing sedation in order to reduce anxiety in their patients.
In 2007, the American Dental Association (ADA) released three documents related to the use of sedation and general anesthesia in dentistry, including (1) the ADA Policy Statement: The Use of Sedation and General Anesthesia by Dentists,16 (2) the ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists,17 and (3) ADA Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students.18 The ADA Policy Statement and the ADA Guidelines provide educational and practice standards for anxiety control in dental practice. The ADA Committee on Anesthesiology, consisting of representatives from dental organizations involved with sedation and anesthesia (Table 36-1), produced these documents after review of the relevant scientific evidence, expert opinion, and comment by all communities of interest. The following paragraphs describe the important elements of these documents as they relate to treating anxious periodontal patients.
|Dr. Guy Shampaine, Chairperson||Dr. David Moyer|
|American Dental Association
Oral and Maxillofacial Surgeon
|American Association of Oral and Maxillofacial Surgeons|
|Annapolis, MD||Oral and Maxillofacial Surgeon|
|Dr. Michael Edwards||South Portland, ME|
|American Dental Association||Dr. Mort Rosenberg|
|American Dental Society of Anesthesia|
|Dr. Dee Isackson
American Society of Anesthesiologists
|Dental Anesthesiologist, Tufts University School of Dental Medicine|
|M.D. Anesthesiologist||Boston, MA|
|Bothell, WA||Dr. David Rothman|
|Dr. Michael Mashni
American Association of Dental Anesthesiologists
|American Association of Pediatric Dentists
|Dental Anesthesiologist||San Francisco, CA|
|Dr. Robert Merin|
|American Academy of Periodontology|
|Woodland Hills, CA|
The dental profession’s continued ability to control anxiety and pain effectively depends on a strong educational foundation in the discipline. Training to competency in minimal and moderate sedation techniques may be acquired at the predoctoral, postgraduate, graduate, or continuing education level. Dentists who wish to utilize minimal or moderate sedation are expected to successfully complete formal training, which is structured in accordance with the ADA Guidelines for Teaching Pain Control and Sedation for Dentists and Dental Students.18 The knowledge and skills required for administration of deep sedation and general anesthesia are beyond the scope of predoctoral and continuing education. Only dentists who have completed an advanced education program accredited by the Commission on Dental Accreditation (CODA) that provides training in deep sedation and general anesthesia are considered educationally qualified to use these modalities in practice.
Unlike previous ADA documents, the 2007 ADA Guidelines refer to the effects of sedation on the central nervous system and are not dependent on the route of administration. The ADA adopted the American Society of Anesthesiologists (ASA) definitions for levels of sedation (Figure 36-2) and expanded and commented on them specifically as they relate to treating dental patients.19
Children (aged 12 and younger) can become moderately sedated despite an intended level of minimal sedation. The use of preoperative sedatives for children (ages 12 and younger) except in extraordinary situations must be avoided because of the risk of unobserved respiratory obstruction during transport by untrained individuals. The management of children with conscious sedation is beyond the scope of this chapter and is not covered. For children 12 years of age and younger, the reader is referred to the American Academy of Pediatrics/American Academy of Pediatric Dentists Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures.20
Minimal sedation is defined as a minimally depressed level of consciousness produced by a pharmacologic method that retains the patient’s ability to independently and continuously maintain an airway and to respond normally to tactile stimulation and verbal command. Although cognitive function and coordination may be modestly impaired, respiratory and cardiovascular functions are unaffected. When the intent is minimal sedation, the appropriate initial dosing of a single enteral drug is no more than the maximum recommended dose of a drug that can be prescribed for unmonitored home use.
Inhalation sedation with nitrous oxide/oxygen (N2O/O2) may be used in combination with a single enteral drug in minimal sedation. It is important to recognize that N2O/O2, when used in combination with one or more sedative agent(s), is capable of producing sedation that is minimal, moderate, or deep and in some cases may produce general anesthesia.
During minimal sedation, supplemental dosing is a single additional dose of the sedative drug being used that may be necessary for prolonged procedures. The supplemental dose should not exceed one-half of the initial total dose and should not be administered until the dentist has determined that the clinical half-life of the initial dose has passed. The total aggregate dose must not exceed 1.5 times the MRD on the day of treatment.
Moderate sedation is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilations are adequate. Cardiovascular function is usually maintained. In accord with this particular definition, the drugs and/or techniques used should carry a margin of safety wide enough to render unintended loss of consciousness unlikely. Repeated dosing of an agent before the effects of previous dosing can be fully appreciated may result in greater alteration of the state of consciousness than is the intent of the dentist. Further, a patient whose only response is reflex withdrawal from a painful stimulus is not considered to be in a state of moderate sedation.
Titration is the administration of incremental doses of a drug until a desired effect is reached. Knowledge of each drug’s time of onset, peak response, and duration of action is essential to avoid oversedation. The concept of titration to effect is critical for patient safety. Thus it is important to know whether the previous dose has taken full effect before administering an additional drug increment when the intent is moderate sedation.
Deep sedation is 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 respiratory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.
General anesthesia is a drug-induced loss of consciousness during which patients are not aroused, even by painful stimulation. The ability to independently maintain respiratory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.
The following clinical guidelines apply to both minimal and moderate sedation.17 These guidelines include (1) patient evaluation, (2) preoperative preparation, (3) personnel and equipment, (4) monitoring and documentation, and (5) recovery and discharge. Differences between guidelines for minimal and moderate sedation are indicated as appropriate.
Patients must be evaluated to assess their current health status before any sedation procedure. This should include a determination of their ASA physical status (ASA PS) (Table 36-2). In healthy or medically stable individuals (ASA PS 1 or 2), a review of their medical history and medication use may be adequate. However, for patients with significant medical considerations (ASA PS 3 or 4), a consultation with their primary care physician or consulting medical specialist is indicated. The evaluation should also include baseline vital signs and a focused physical examination of alertness, respiratory function, airway, and appearance, as well as a specific evaluation of any identified medical conditions (Box 36-1 and Figure 36-3).
|ASA 1||A normal healthy patient|
|ASA 2||A patient with mild systemic disease|
|ASA 3||A patient with severe systemic disease|
|ASA 4||A patient with severe systemic disease that is a constant threat to life|
|ASA 5||A moribund patient who is not expected to survive without the operation|
|ASA 6||A declared brain-dead patient whose organs are being removed for donor purposes|
From American Society of Anesthesiologists: ASA physical status classification system: www.asahq.org, 2009.
The patient (parent, guardian, or caregiver, if patient is a minor) must be informed about the planned procedure under sedation, including benefits, risks, and instructions for sedation (Figure 36-4). An informed consent for the proposed procedure and sedation must be obtained.
Determination of adequate oxygen supply and equipment necessary to deliver oxygen under positive pressure must be completed. A positive-pressure oxygen delivery system suitable for the patient being treated must be immediately available. An appropriate scavenging system must be available if gases other than oxygen or air are used.
When inhalation equipment is used, it must have a fail-safe system that is appropriately checked and calibrated. The equipment must also have either (1) a functioning device that prohibits the delivery of less than 30% oxygen or (2) an appropriately calibrated and functioning in-line oxygen analyzer with audible alarm.
For moderate sedation, the equipment necessary to establish IV access must be available. This includes a catheter or butterfly needle, an IV drip line, a solution bag (saline or dextrose), tourniquet, and appropriate antiseptic/dermal disinfectant (Figure 36-5).
The dentist or an appropriately trained individual, directed by the dentist, must remain in the operatory during active dental treatment with sedation to monitor the patient continuously until the criteria for discharge is met (Box 36-4). The appropriately trained individual must be familiar with monitoring techniques and equipment.
In the case of moderate sedation, a qualified dentist administering moderate sedation must remain in the operatory room to monitor the patient continuously until the patient meets the criteria for recovery. When active treatment concludes and the patient recovers to a minimally sedated level, a qualified auxiliary may be directed by the dentist to remain with the patient and continue to monitor him or her as explained in the guidelines until discharged from the facility. The dentist must not leave the facility until the patient meets the criteria for discharge and is discharged to go home with a responsible adult (see Box 36-4).
Monitoring equipment must include a sphygmomanometer, positive pressure oxygen delivery system, suction, and if inhalation sedation is used, a fail-safe and scavenging system. In the case of moderate sedation, a pulse oximeter, equipment for IV access, and reversal agents for drugs used must also be available (Table 36-3).
|Responsiveness||Responds readily to name spoken in normal tone||5|
|Lethargic response to name spoken in normal tone||4|
|Responds only after name is called loudly and/or repeatedly||3|
|Responds only after mild prodding or shaking||2|
|Does not respond to mild prodding or shaking||1|