Oral sedation with benzodiazepines and anxiolysis with nitrous oxide are 2 effective methods to help alleviate anxiety and fear of dental procedures. Many patients would prefer to have their dentistry performed with sedation if it were offered to them. This article presents a detailed discussion on minimal sedation that should give the reader a good understanding of this valuable aspect of clinical care.
It is estimated that as many as 75% of adults in the United States experience some degree of dental fear ranging from mild to severe and that approximately 5% to 10% are so fearful of dental treatment that they avoid any dental care. Most of these 5% to 10% seek dental care only when they have severe pain or swelling that may result in invasive interventions. This situation often leads to a cruel cycle in which their avoidance causes them to need extensively invasive procedures, which further reinforces their fear of dentistry.
In a European (Netherlands) study to estimate the point prevalence of dental fear and dental phobia relative to 10 other common fears, the prevalence of dental fear ranked fourth, at 24.3%, which was lower than fear of snakes (34.8%), heights (30.8%), and physical injuries (27.2%). Among phobias, dental phobia was the most common (3.7%), followed by height phobia (3.1%) and spider phobia (2.7%). The American Dental Association (ADA) estimated that 35 to 50 million adults have so much anxiety about dental visits that they worry, postpone, or avoid seeing their dentist.
The fear of dentistry is real, profound, and difficult to overcome. Sedation offers a method of alleviating the fear, and for some it is the only way they will have their dental needs treated. From a national telephone survey it was estimated that almost 23 million people would be willing to go to the dentist more frequently if general anesthesia and conscious sedation were more readily available. The more invasive the procedure (such as oral surgery or endodontics), the more fearful people are. The anticipated invasiveness of the procedure dramatically increases the demand for anesthesia or sedation services, with preference rising from 2% for a routine dental cleaning to 47% for a tooth extraction, 55% for an endodontic procedure, and 68% for periodontal surgery. The evidence therefore indicates that there is both a need and a demand for sedation services in general dental practice. This article addresses sedation methods in dentistry using inhalation (nitrous oxide [N 2 O], sometimes referred to as relative analgesia) and oral sedation. Intravenous (IV) sedation, which must meet the standards for general anesthesia, is not covered because most general dentists usually do not have the necessary advanced training in IV sedation.
Sedation is used for the reduction of anxiety, irritability, or agitation by the administration of sedative drugs to facilitate the planned dental procedure. The purpose is to allow the dentist to work more effectively and to help the patient become as relaxed and comfortable as possible. The American Society of Anesthesiologists defines the continuum of sedation as follows :
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Minimal sedation: normal response to verbal stimuli
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Moderate sedation: purposeful response to verbal/tactile stimulation (this is usually referred to as conscious sedation)
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Deep sedation: purposeful response to repeated or painful stimulation
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General anesthesia: unarousable even with painful stimulus.
Sedation as used in this article is minimal sedation, a minimally depressed level of consciousness produced by a pharmacologic method that retains the patient’s ability to independently and continually maintain an airway and respond normally to tactile stimulation and verbal command. Although cognitive function and coordination may be modestly impaired, ventilatory and cardiovascular functions are unaffected.
State laws
Most US states require some combination of formal training and standard-of-care equipment plus a permit issued by the state dental board before dentists can provide sedation to their patients. Some states also have different permits for different levels of sedation. Most of the states have linked their requirements to the recommendations of the ADA’s anesthesia and sedation guidelines, which recommend special training for minimal and moderate sedation ranging from 16 hours (minimal sedation) to 24 hours (moderate oral sedation) to 60 hours (IV moderate sedation) of didactic classroom instruction. The ADA guidelines also require that dentists observe or document a certain number of clinical patient experiences or cases depending on the route of administration used to achieve sedation. Table 1 lists the educational requirements for all 50 states and the District of Columbia.
| States | Educational Regulations |
|---|---|
| Alabama, Oregon | 16 h of instructive classroom training and obtain a permit |
| Alaska; Connecticut; DC; Hawaii; Illinois; Indiana; Kentucky; Minnesota; Nebraska; Oklahoma; Utah | Board of Dental Examiners does not currently require formal training before providing oral conscious sedation to dental patients; any licensed dentist can administer oral sedation |
| Arkansas; Georgia; Massachusetts. | 24 h of instructive classroom training with 10 clinical patient experiences, and obtain a permit; advanced cardiac life support (ACLS) certification is also required |
| Arizona | 30 h of instructive classroom training with 5 clinical patient experiences and obtain a permit |
| California | General practice, pediatric, or periodontal residency; or 25-hour board-approved course with 1 live adult patient; for a pediatric permit: 1 live pediatric patient experience is required |
| Colorado | 16 h of instructive classroom training in the administration of minimal sedation techniques and must include management of complications and emergencies; no state permit |
| Delaware; Florida; Iowa; Michigan a ; Nevada; South Dakota; Vermont; Wyoming | 60-hour IV sedation course, administer 20 clinical patient cases, and obtain a permit before providing oral or IV conscious sedation |
| Idaho; West Virginia | 18 h of instructive classroom training with 20 clinical patient experiences, and obtain a permit. ACLS certification is also required |
| Kansas; New Mexico; New York; Virginia; Wisconsin |
18 h of instructive classroom training, observe 20 clinical patient experiences, and obtain a permit |
| Louisiana | 16 h of instructive classroom training, a component on handling emergencies, and obtain a permit. ACLS certification is required |
| Maine; New Hampshire; North Carolina b | 24 h of instructive classroom training, document 3 live patient experiences, and obtain a permit. ACLS certification is also required |
| Maryland; Tennessee | 24 h of instructive classroom training with 20 clinical patient experiences, and obtain a permit. ACLS certification is also required |
| Mississippi | 22 h of instructive classroom training with 15 clinical patient experiences, and obtain a permit. ACLS certification is required |
| Missouri | A comprehensive training program in oral conscious sedation; at least 15 additional hours of continuing education pertaining to medical emergencies, anesthesia complications, and patient management; ACLS can be substituted for the 15 additional hours but is not required |
| Montana | 40-hour IV sedation course, administer 20 clinical patient cases, and obtain a permit |
| New Jersey | 40 h of university-based didactic training and obtain a permit |
| South Carolina | 18 h of instructive classroom training with 20 clinical patient experiences; adult patients only; state permit not required |
| Texas | 2-d university-based training course and obtain a permit |
| Washington | 14–21 h of instructive classroom; no state permit needed |
The use of N 2 O is not as regulated nor are there clearly established educational requirements as there are with oral and IV sedation. The ADA guidelines mentioned earlier do not apply if the intent is to provide only anxiolysis (a lightly altered mood in which there is a decrease or elimination of anxiety), in which the N 2 O is carefully titrated to induce anxiolysis rather than sedation. Many states do not clearly address the issue or they adopt the ADA’s policy on anxiolysis. It seems that most states permit the unregulated use of N 2 O by licensed dentists, even although some states may require a permit.
Most states do not have separate requirements for pediatric and adult patients. In addition, the American Academy of Pediatric Dentistry’s guidelines say nothing about the educational requirements necessary before dentists can provide anesthesia to their pediatric patients. The Georgia State Board of Dentistry is changing its sedation rules; in Georgia 120 hours of training would be required before anyone who is not a pediatric dentist could sedate a child.
Oral sedation weekend courses do not give one adequate training to sedate children; you need to be formally trained.
Preoperative evaluation
The preoperative evaluation is an important interaction between the dentist and the patient. This process allows the dentist to carefully evaluate the patient’s overall health status, determine risk factors for sedation, educate the patient, and discuss the procedure in detail. Most general dental procedures are uncomplicated, and extensive patient evaluation is unnecessary. However, of utmost importance is a detailed medical history. The aim of the history is to identify issues that demand attention and caution. Items that must be addressed are:
- 1.
Abnormalities of the major organ systems: cardiovascular, pulmonary, renal, hepatic, and endocrine ( Table 2 )
Table 2Selected medical conditions and implications for ASA 1 and ASA 2 patientsMedical Condition Considerations Diabetes mellitus The patient’s blood glucose level should be controlled, and insulin doses should be adjusted as needed Hypertension Adequate anxiolysis or sedation and good local anesthesia are important in alleviating unwanted stress and anxiety, which could increase the intraprocedure blood pressure Hepatitis Sedatives, lidocaine, and amide-linked local anesthetics should be used with caution Sleep apnea Ancillary oxygen should be used via a nasal prong. Conscious sedation may exacerbate sleep apnea CVA Monitoring the blood pressure is essential, and if it increases significantly the procedure must be terminated Hyperthyroidism May increase cardiac sensitivity to epinephrine Ischemic coronary artery disease or stable angina May need sublingual nitroglycerin, which should be readily available Psychiatric disorders Check medications and avoid drug interactions or oversedation Oral sedation is safe and for ASA 1 or 2 patients there are not many cautions. Cautions include psychosis, impaired lung, kidney or liver function, and advanced age. Age by itself is not a factor, but the presence of comorbid conditions must be determined. Heart disease is generally not a contraindication but patients should not have any functional limitations and must be ASA 1 or 2. - 2.
Drug allergies, latex allergy, current medications, and potential drug interactions
- 3.
History of stroke or transient ischemic attack (TIA) (certain oral sedation methods may trigger a TIA)
- 4.
Neuromuscular disorders (such as muscular dystrophy)
- 5.
History of tobacco, alcohol, or substance use or abuse
- 6.
Pregnancy
- 7.
Previous adverse experience with sedation/analgesia as well as general anesthesia.
Based on the medical history the patient can then be stratified using the classification of the American Society of Anesthesiology (ASA) ( Box 1 ).
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Class 1: normal healthy patient
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Class 2: a patient with a systemic disease that is well controlled and with no functional limitations
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Class 3: a patient with a systemic disease that is not well controlled, or having more than 1 systemic disease, or with some function limitation
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Class 4: a patient with severe systemic disease that is a threat to life and functionally incapacitating
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Class 5: a moribund patient who is not expected to survive 24 hours with or without surgery
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Class 6: a brain-dead patient whose organs are being harvested
Only ASA 1 and ASA 2 patients are acceptable for sedation.
Preoperative evaluation
The preoperative evaluation is an important interaction between the dentist and the patient. This process allows the dentist to carefully evaluate the patient’s overall health status, determine risk factors for sedation, educate the patient, and discuss the procedure in detail. Most general dental procedures are uncomplicated, and extensive patient evaluation is unnecessary. However, of utmost importance is a detailed medical history. The aim of the history is to identify issues that demand attention and caution. Items that must be addressed are:
- 1.
Abnormalities of the major organ systems: cardiovascular, pulmonary, renal, hepatic, and endocrine ( Table 2 )
Table 2Selected medical conditions and implications for ASA 1 and ASA 2 patientsMedical Condition Considerations Diabetes mellitus The patient’s blood glucose level should be controlled, and insulin doses should be adjusted as needed Hypertension Adequate anxiolysis or sedation and good local anesthesia are important in alleviating unwanted stress and anxiety, which could increase the intraprocedure blood pressure Hepatitis Sedatives, lidocaine, and amide-linked local anesthetics should be used with caution Sleep apnea Ancillary oxygen should be used via a nasal prong. Conscious sedation may exacerbate sleep apnea CVA Monitoring the blood pressure is essential, and if it increases significantly the procedure must be terminated Hyperthyroidism May increase cardiac sensitivity to epinephrine Ischemic coronary artery disease or stable angina May need sublingual nitroglycerin, which should be readily available Psychiatric disorders Check medications and avoid drug interactions or oversedation Oral sedation is safe and for ASA 1 or 2 patients there are not many cautions. Cautions include psychosis, impaired lung, kidney or liver function, and advanced age. Age by itself is not a factor, but the presence of comorbid conditions must be determined. Heart disease is generally not a contraindication but patients should not have any functional limitations and must be ASA 1 or 2. - 2.
Drug allergies, latex allergy, current medications, and potential drug interactions
- 3.
History of stroke or transient ischemic attack (TIA) (certain oral sedation methods may trigger a TIA)
- 4.
Neuromuscular disorders (such as muscular dystrophy)
- 5.
History of tobacco, alcohol, or substance use or abuse
- 6.
Pregnancy
- 7.
Previous adverse experience with sedation/analgesia as well as general anesthesia.
Based on the medical history the patient can then be stratified using the classification of the American Society of Anesthesiology (ASA) ( Box 1 ).
- •
Class 1: normal healthy patient
- •
Class 2: a patient with a systemic disease that is well controlled and with no functional limitations
- •
Class 3: a patient with a systemic disease that is not well controlled, or having more than 1 systemic disease, or with some function limitation
- •
Class 4: a patient with severe systemic disease that is a threat to life and functionally incapacitating
- •
Class 5: a moribund patient who is not expected to survive 24 hours with or without surgery
- •
Class 6: a brain-dead patient whose organs are being harvested
Only ASA 1 and ASA 2 patients are acceptable for sedation.
Monitoring
Patients receiving oral sedation must be monitored before, during, and after their procedure. The monitoring must be continuous during the dental procedure and up to the time of discharge. During the procedure, monitoring detects early signs of patient distress such as alterations in oxygenation, pulse, and blood pressure. Hospital-type monitoring equipment is not necessary but continuous monitoring of pulse oximetry, heart rate, and blood pressure is mandatory. A pulse oximeter measures oxygen saturation and enhances the assessment of respiratory status while the individual is sedated. The most common and the most serious adverse outcome of conscious sedation is respiratory compromise and its related consequences. It is therefore imperative that special attention be paid to the airway. Any decrease in the pulse oximetry less than 96% should be addressed immediately. True desaturation is defined as a pulse oximeter reading of Sp o 2 less than 95% while the patient is quiet and still. However, with oral sedation apnea is rarely seen with normal dosing in the absence of airway obstruction. When it does occur, it is easily managed with stimulation, positive pressure ventilation, and supplemental oxygen administration.
Oral sedation is intended to produce only a minimally depressed level of consciousness, and this level of consciousness must be monitored continuously. Responses to verbal commands during the procedure serve as the guide to the patient’s level of consciousness. An appropriate level of consciousness implies that the patient can control their own airway and take deep breaths as necessary. After administration of the sedative medication, response of the patient to verbal commands may be delayed, and responses are frequently slowed or slurred. At times, light tactile stimulation may be required to get the patient’s attention. However, once aroused the patient should respond appropriately to verbal commands. Level of consciousness should be assessed every 15 minutes.
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