Minimal and Moderate Oral Sedation in the Adult Special Needs Patient

Oral minimal/moderate sedation can be an effective tool to aid in the dental management of adult special needs patients. Specific sedative drugs must be chosen by the dentist that can be used safely and effectively on these patients. This article focuses on a select number of these drugs, specific medical and pharmacologic challenges presented by adult special needs patients, and techniques to safely administer oral minimal and moderate sedation.

It is well established in the dental and medical literature that fear and anxiety of dental procedures keep a significant portion of the population from receiving timely and effective dental care. It has also has been shown that adult special needs groups are a large portion of this population. As defined, a special needs individual is one who is unable to receive dental care in a traditional dental setting. However, with the cost of hospital-based care increasing yearly, many of these special needs patients are being seen at an increasing rate in the traditional dental outpatient office setting. With the aging of the United States population, it is estimated that special needs patients will increase significantly and further increase the shift toward a traditional office setting. Many of these adult special needs patients require sedation, either because of behavioral, communicative, or complex medical problems, for a thorough oral examination and subsequent dental care. An increasing segment of this population needs sedation to lower their stress level in a dental setting because of their reduced physiologic reserve capacity and medical status. Undue stress that can be generated during a dental procedure may in fact precipitate a medical emergency in this population.

The use of sedative oral anesthetic agents for dental procedures is well documented, dating back over a century. The use of sedation by appropriately trained dentists continues to enjoy a remarkable record of safety. The use of sedation in dentistry is safe and effective when administered by properly trained individuals. However, because of this continuing shift to a traditional out-patient office setting, the American Dental Association (ADA) convened several workshops between 2003 and 2007 to formalize the guidelines to ensure the delivery of oral conscious sedation safely. In October of 2007, the ADA House of Delegates adopted new guidelines for the use of sedation and general anesthesia by dentists. These guidelines, ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists , represent major changes from the 2000 guidelines. Strongly emphasized throughout these new guidelines is the safe delivery of oral conscious sedation through the following:

  • Defining levels of sedation (regardless of the route of administration)

  • Educational requirements

  • Patient evaluation

  • Preoperative preparation

  • Personnel and equipment requirements

  • Monitoring and documentation

  • Recovery and discharge

  • Emergency management

It should be noted that separate guidelines exist for the pediatric dental patient (under 12 years of age). In addition, the skill and training requirements have been updated to reflect current practice, as well as the ability of the dentist to “rescue” the patient from a level of sedation beyond the dentist’s intent. The goal of the 2007 guidelines, drafted from all communities of interest and regarding sedation and anesthesia, focus now on level of sedation, not route of administration. This will allow guidelines from all communities of medicine and dentistry to translate with common terminology. However, many feel that enteral/oral moderate sedation is the “unique paradigm,” especially directed toward modern dental practice because this level of sedation is more commonly used in dentistry for extended procedures. This aspect of enteral/oral sedation is specifically addressed in the 2007 ADA guidelines. Currently, these guidelines have been adopted, in total or modified in part, by the majority of the state dental regulatory agencies in the United States.

This article addresses pertinent changes in the 2007 Guidelines, oral agents to produce minimal and moderate sedation, and modifications recommended for special needs patients. The reader should thoroughly read the 2007 Guidelines for the Use of Sedation and General Anesthesia by Dentists and the ADA Guidelines for the Teaching Pain Control and Sedation to Dentists and Dental Students. Both can be accessed at www.ADA.org .

Level of sedation

The 2007 ADA Guidelines focus on the level of sedation. The levels are minimal, moderate, and deep sedation general anesthesia. These levels focus on the level of consciousness, status of the airway, and response to stimulation. In addition, cognitive function is addressed, as well as respiratory and cardiovascular function. It must be strongly emphasized that sedation and anesthesia is a continuum, and every level can be reached, regardless of the route of administration. Oral sedation does not assure the patient will remain in a specific level of sedation. The patient may progress into deeper levels of sedation. This is especially true for the special needs patient.

Minimal sedation is a minimally depressed level of consciousness that retains the patient’s ability to independently maintain an airway and respond normally to tactile stimulation and verbal command. Although cognitive function and coordination may be modestly impaired, cardiovascular and ventilatory functions are unaffected.

Moderate sedation involves purposefully responding to verbal commands, either alone or accompanied by light tactile stimulation. Respiratory and cardiovascular function remain unaffected without interventions.

The remaining areas of the guidelines address deep sedation and general anesthesia and are beyond the scope of this article. When reviewing the new guidelines, one must remember this is a “living document,” subject to change as more research, new drugs, and influences from all communities of interest come into the scope of sedation practice.

Patient evaluation

A thorough patient evaluation by the dentist before minimal/moderate sedation or general anesthesia is the cornerstone for a safe and effective sedation or general anesthesia experience. The patient evaluation consists of a current medical history, which includes a written review of systems, medication review, and a basic physical inspection. It is emphasized by many authors that the pharmacologic history should include prescription medications, over-the-counter medications, and dietary supplements (herbals, alternative medicines, and so forth). Past experiences with sedation and general anesthesia should also be discussed. The special needs patient often provides a unique challenge in the evaluation process. If this patient is unable to provide his or her own medical history, then a guardian or responsible patient escort is required. Often with the elderly and medically complex, a consult with the physician is needed for more specific information. A basic physical inspection should be completed emphasizing the cardiovascular and respiratory systems. Vital signs should be recorded along with the patient’s weight and body structure.

Every patient to undergo minimal or moderate sedation should then be assigned a physical assessment status or risk assessment. The most commonly used classification is the American Society Anesthesiology (ASA) system, first published in 1963. It is recommended those patients with an ASA status of ASA I and ASA II should undergo routine minimal or moderate sedation. Those ASA III and IV patients being considered for minimal or moderate sedation will require consultation from their primary care physician or consulting specialist. Generally speaking, ASA III and IV patients will require a modification in the sedation procedure. Many of the special needs patients fall into ASA III and IV status. It strongly suggested that if the sedating dentist feels uncertain or is uncomfortable with the ASA classification, then appropriate referral to someone with more advance training should occur.

Patient evaluation

A thorough patient evaluation by the dentist before minimal/moderate sedation or general anesthesia is the cornerstone for a safe and effective sedation or general anesthesia experience. The patient evaluation consists of a current medical history, which includes a written review of systems, medication review, and a basic physical inspection. It is emphasized by many authors that the pharmacologic history should include prescription medications, over-the-counter medications, and dietary supplements (herbals, alternative medicines, and so forth). Past experiences with sedation and general anesthesia should also be discussed. The special needs patient often provides a unique challenge in the evaluation process. If this patient is unable to provide his or her own medical history, then a guardian or responsible patient escort is required. Often with the elderly and medically complex, a consult with the physician is needed for more specific information. A basic physical inspection should be completed emphasizing the cardiovascular and respiratory systems. Vital signs should be recorded along with the patient’s weight and body structure.

Every patient to undergo minimal or moderate sedation should then be assigned a physical assessment status or risk assessment. The most commonly used classification is the American Society Anesthesiology (ASA) system, first published in 1963. It is recommended those patients with an ASA status of ASA I and ASA II should undergo routine minimal or moderate sedation. Those ASA III and IV patients being considered for minimal or moderate sedation will require consultation from their primary care physician or consulting specialist. Generally speaking, ASA III and IV patients will require a modification in the sedation procedure. Many of the special needs patients fall into ASA III and IV status. It strongly suggested that if the sedating dentist feels uncertain or is uncomfortable with the ASA classification, then appropriate referral to someone with more advance training should occur.

Patient monitoring

As required by the 2007 ADA Sedation Guidelines, all minimal and moderate patients must have monitoring of oxygenation, color of mucosa, ventilation, and circulation during the sedative procedure. This to be accomplished by the dentist or an appropriately trained individual. In those special needs patients who are not communicative, it is especially important to maintain a vigilant posture when they are sedated. The standard of care for oxygenation is a by continuous pulse oximetery. It is equally valuable in monitoring the nonsedated special needs patient whose reserve capacity may be compromised. Vital signs are to be taken at specific intervals. All recordings must be documented and become part of the patient’s record.

Recovery and discharge

Special needs patients can often present a challenge in determining when they have sufficiently recovered from the sedation and are ready to be discharged with a responsible adult. Mentally challenged patients may not be aware of the classic questions of name, day of the week, birthday, or other such information. They may also, upon recovering, be uncomfortable with their surroundings and strongly wish to leave. It is imperative that the dentist be satisfied with their level of recovery before discharging them. Elderly patients are often unable to ambulate effectively following a sedation and should be escorted out of the office. It is recommended that a member of the dental staff assure the seat is slightly reclined, seat belt applied, and the importance of airway position reviewed for the trip home and after arrival. For the dentist, this aspect reduces the exposure to liability for the postsedation period. The guardians, escorts, or care givers that often accompany special needs patients should be given specific written instructions regarding postoperative care.

Oral sedative agents

Many oral sedative agents have been used in dentistry. The list includes ethyl alcohol, barbiturates, chloral hydrate, ethchlorvynol, opioids, antihistamines, benzodiazepines, and the Z-drugs. These drugs have been used as a single agent or combined with other sedatives or nitrous oxide. When choosing a sedative agent, especially for the use in special needs patients, factors that should influence the selection include (1) predictable absorption into systemic circulation, (2) predictable depth of sedation, (3) predictable length of action, (4) low adverse side effects, and (5) reversing of the sedative agent if needed. These five factors significantly contribute to the overall safety of the sedative agent. Because of potentially dangerous side effects, unpredictable results, and lack of a reversing agent, the authors do not recommend ethyl alcohol, barbiturates, chloral hydrate, ethchlorvynol, and opioids for the oral sedation of special needs patients. Thus, the discussion will be limited to the benzodiazepines, antihistamines and Z-drugs. It is recommended that all oral sedatives be administered to the patient in the dental office for safer sedations.

Benzodiazepines

The benzodiazepines, first synthesized in 1933 and approved for use in the United States in 1960, have been used extensively as oral sedatives in dentistry. Benzodiazepines act at specific inhibitory receptor sites in the central nervous system and slow down the reuptake of gamma aminobutyric acid (GABA), which in turn reduces anxiety and aggressive behavior, causes muscle relaxation, and exhibits anticonvulsant effects. They have a wide variety of half-lives and some have active metabolites. All benzodiazepines can be reversed by romazicon (Flumazenil). The four benzodiazepine oral agents for minimal and moderate sedation recommended by the authors are alprazolam, lorazepam, triazolam, and midazolam. Each one of these can be used for specific patients depending on the ASA status, depth of sedation desired, and anticipated length of appointment.

Alprazolam (Xanax) is marketed as an antianxiety medication. It has a half-life of 12 to 15 hours and has no active metabolites. It reaches peak plasma levels in 1 to 2 hours. It is used primarily as a minimal sedative agent. The recommended adult dose is 0.25 mg to 1.0 mg.

Lorazepam (Ativan) is used a sedative. It has a long half-life of 14 to 19 hours. It has no active metabolites and reaches its peak plasma level in 1 to 2 hours. Lorazepam has been reported to have significant amnesic properties. The recommended adult dose is 1 mg to 2 mg.

Triazolam (Halcion) is used extensively as a sedative agent. It has half-life of 2 to 4 hours and has no active metabolites. It reaches peak plasma levels in a relative short time of 1 to 2 hours. Triazolam also provides effective amnesia. The recommended adult dose is 0.125 to 0.5 mg.

Midazolam (Versed) is used extensively in intravenous sedation but can also be used as an oral sedative agent. It comes in a liquid form rather than in a tablet. Its half-life is 1 to 2 hours and reaches peak plasma levels in under 1 hour. The recommended dose is 0.5 mg/kg up to a maximum dose of 20 mg.

Antihistamines

Antihistamines (histamine blockers or H1 antagonists) possess sedative properties in addition to their primary purposes of allergies and motion sickness. They are not reversible, unlike the benzodiazepines and Z-drugs, and do not lower seizure threshold but do have a wide margin of safety. The antihistamines are primarily used as combination sedative agents in the pediatric patient but have been reported useful in the adult patient who is a heavy smoker or the asthmatic to cut down on oral secretions.

Hydroxyzine (Atarax, Vistral) has a half-life of 4 to 6 hours and is rapidly absorbed from the gastrointestinal tract and reaches peak plasma level in 30 to 60 minutes. The recommended dose is 50 mg to 100 mg.

Z-Drugs

A new classification of drugs has recently been reported effective in oral minimal and moderate sedation. These are the “Z-drugs” (nonbnenzodiaepine hypnotics or imidazopyridines), so named because of their initial letter. They include zolpidem (Ambien), zaleplon (Sonata), and Eszopiclone (Lunesta). Like the benzodiazepines, they interact with the GABA receptors but appear to selectively affect different subtypes of these receptors. The primary use of the Z-drugs is for the short-term treatment of insomnia. They have a sedative profile similar to the benzodiazepines but have less amnesic, cognitive, or muscle relaxing properties. Both zolpidem and zaleplon have short half-lives, while eszoplicone has a longer half-life. Because of the shorter half-lives, both zolpidem and zaleplon have been used as oral sedative agents in dentistry.

Zolpidem (Ambien) has a half-life of 2.5 hours and reaches peak plasma level in 1.6 hours. It is rapidly absorbed in from the gastrointestinal tract in under 30 minutes and has no active metabolites. The recommended adult dose is 5 mg to 10 mg.

Zaleplon (Sonata) has the shortest half-life of the Z-drugs of 1 hour and reaches peak plasma level in 1 hour. It is rapidly absorbed in under1 hour and has no active metabolites. The recommended adult dose is 5–20 mg.

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Oct 29, 2016 | Posted by in General Dentistry | Comments Off on Minimal and Moderate Oral Sedation in the Adult Special Needs Patient
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