Rationale for Sedation During 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 treatment^12–14 (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.

ADA Policy Statement and Guidelines for Conscious Sedation

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.

ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists

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

Clinical Guidelines for Minimal and Moderate Sedation

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.

Patient Evaluation.

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).

Box 36-1   Preoperative Physical Evaluation

1. Blood pressure and pulse

2. Oxygen saturation and respiration; able to breathe deeply and cough

3. Mallampati airway classification and neck flexibility

4. Appearance and skin color

5. Alertness

6. Exercise tolerance and ambulation

TABLE 36-2

ASA Physical Status Classification System

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.

Preoperative Preparation.

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.

Preoperative dietary restrictions must be considered based on the sedative technique prescribed (Boxes 36-2 and 36-3; see also Figure 36-4).

Box 36-2

Mild Sedation

Suggested Protocol for the Use of Adult Oral Sedative Premedication for Anxious or Fearful Dental Patients

1. The dentist needs to determine the extent of dental treatment, evaluate the patient’s medical history, research potential drug interactions, consult with the patient’s physician if appropriate, and obtain informed consent.

2. The patient must have a responsible adult companion for travel to and from the dental office. The patient must be escorted by this companion to and from the parking lot to prevent the patient from stumbling.

3. Patients take the prescribed medication according to directions and are instructed to have a light meal such as toast and beverage without caffeine.

4. Patients who have received oral sedatives are monitored visually and never left alone.

5. After the treatment is complete, postoperative directions are given to both the patient and responsible adult, and the patient is released into the care of his or her companion for travel home. The companion is informed that the patient may have psychomotor and cognitive impairment for the rest of the day.

From Merin RL: J Calif Dent Assoc 34:959-968, 2006.

Box 36-3

Mild Sedation

Example of Suggested Patient Pretreatment Instructions

1. The sedative __________________ (name of medication) is being prescribed to help reduce your anxiety before and during a dental procedure.

2. The medication may make you sleepy and impair your thinking and coordination. You must have a responsible adult companion for travel to and from the dental office.

3. You must be escorted by this companion to and from the parking lot to prevent you from stumbling.

4. You should take the prescribed medication according to directions. You can have a light meal (no fat) such as toast without butter or margarine and beverage without caffeine. No grapefruit juice.

5. After the treatment is complete, a responsible adult must escort you out of the office and take you home. The sedative effects may linger for the rest of the day so you should not plan to do anything and it is advisable to have a responsible adult stay until you are able to take care of yourself.

From Merin RL: J Calif Dent Assoc 34:959-968, 2006.

Personnel and Equipment.

At least one additional person trained in basic life support (BSL) for healthcare providers must be present in addition to the dentist.

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).

Monitoring.

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.

Box 36-4   Discharge Criteria

Alertness: Able to Answer Three Simple Questions Such as the Following:

Who is driving you home?

Where are you?

What day is it?

Breathing

Normal oxygen saturation on room air

Able to breathe deeply and cough

Circulation

Systolic blood pressure within 20% of baseline

Ambulation

Able to walk with minimal assistance

Color

Normal skin color and appearance

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).

TABLE 36-3

Equipment Required for Mild or Moderate Sedation

Mild or Moderate Sedation	Moderate Sedation
• Sphygmomanometer.

• Pulse oximeter.

• Positive pressure oxygen delivery system.

• Equipment necessary to establish intravenous access.

• Suction equipment.

• Reversal agents for drugs used.

• When inhalation equipment is used, it must have a fail-safe system and scavenging system.