Dental anxiety is a leading cause of postponing treatment and/or complete avoidance of professional oral care. Therefore, effective sedation and pain control are integral components of dental care for the fearful and anxious patient. The application of oral sedation aids the trained practitioner to provide care to the anxious dental patient and remains the safest, most established, and most commonly used route of drug administration. Proper training and understanding of pharmacologic properties allows for safe and effective application of analgesics and sedatives for oral sedation.
Key points
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Dental anxiety is a leading cause of postponing dental treatment and can be reduced using oral sedation.
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Effective sedation and pain control are integral components of dental care for the fearful and anxious patient.
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Oral medications used to achieve minimal sedation in adult patients have a wide margin of safety to prevent loss of consciousness.
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Pharmacology of medications commonly used for conscious sedation in dentistry as well as clinical guidelines for administration are highlighted in this article.
Introduction
Dental anxiety is a leading cause of postponing treatment and/or complete avoidance of professional oral care. A study conducted by the American Dental Association (ADA) in the United States has shown that only 52.3% of adults reported dental visits every 6 months and 15.4% once per year. An estimated 18.2% of children aged 5 to 18 years, 26.5% of adults aged 19 to 64 years, and 16.7% of seniors older than 65 years have untreated caries. Dental anxiety has been cited as a main barrier for patients in seeking needed care: 22% of people forgo their dental care because of fear of the dentist. Ultimately, dental anxiety leads to poor oral health, which leads to a reduced quality of life. Therefore, effective sedation and pain control are integral components of dental care for the fearful and anxious patient.
Anxiety and pain control can be defined as the application of various physical, chemical, and psychological modalities to the prevention and treatment of preoperative, operative, and postoperative patient anxiety and pain to allow dental treatment to occur in a safe and effective manner. A survey conducted in the United States found that 18% of adults would visit the dentist more frequently if they were given a drug to make them less nervous. All patients, regardless of the level of anxiety, ought to receive treatment in a safe and fearless environment.
Pain and anxiety has been managed with anesthesia since the 1840s. Dentistry has continued to build upon the foundation of anesthesia in dentistry and has been instrumental in developing safe and effective sedative and anesthetic techniques. The oral route remains the safest, most established, and most commonly used route of drug administration. The oral route offers the following advantages versus other routes of drug administration:
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Lower incidence of adverse reactions
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Decreased severity of adverse reactions
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High degree of patient acceptance and compliance
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Convenience of administration
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Cost-effectiveness
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Additional equipment or personnel not required
Levels of sedation and analgesia
The 4 levels of sedation and analgesia describe a drug-induced state of consciousness that occurs along a dose-related continuum. The continuum of analgesia progresses from a high state of consciousness to unconsciousness ( Fig. 1 ). Table 1 summarizes the 4 levels of sedation.
| Responsiveness | Airway | Spontaneous Ventilation | Cardiovascular Function | |
|---|---|---|---|---|
| Minimal sedation (anxiolysis) | Normal response to verbal stimulation | Unaffected | Unaffected | Unaffected |
| Moderate sedation/analgesia | Purposeful response to verbal stimulation or tactile stimulation | No Intervention | Adequate | Usually maintained |
| Deep sedation | Purposeful response following repeated or painful stimulation | Intervention may be required | May be inadequate | Usually maintained |
| General anesthesia | Unarousable, even with painful stimulus | Intervention often required | Frequently inadequate | May be impaired |
Level 1: Minimal Sedation (Anxiolysis)
Minimal sedation is a drug-induced state during which patients respond normally to verbal commands. Cognitive function and physical coordination may be impaired; however, airway reflexes and ventilatory and cardiovascular functions are unaffected. Patients receive anxiolytic or analgesic drugs for alleviating pain, anxiety, or insomnia.
Level 2: Moderate Sedation/Analgesia
The 2001 Joint Commission replaced the term “conscious sedation” with the new term “moderate sedation and analgesia”; this is a drug-induced depression of consciousness in which patients have purposeful responses to verbal commands with or without light tactile touch. A withdrawal reflex from painful stimuli is not considered a purposeful response. Spontaneous ventilation is adequate with no interventions required to maintain a patent airway, and cardiovascular function is usually maintained.
Level 3: Deep Sedation/Anesthesia
In a state of deep sedation, the patient cannot be easily aroused, but does respond purposefully following repeated or painful stimulation. The patient may lose the ability to independently maintain ventilatory function, so the patient may require assistance in maintaining a patent airway. Spontaneous ventilation also may be inadequate for the patient. Cardiovascular function is usually maintained, and cardiac monitors should be placed. Deep sedation and analgesia may be delivered by an anesthesiologist or privileged practitioner (ie, oral surgeon, intensivist).
Level 4: General Anesthesia
In general anesthesia, the patient is unarousable even by painful stimulation. The patient often loses the ability to independently maintain ventilatory function and often requires assistance in maintaining a patent airway. Positive pressure ventilation is further required because of depressed spontaneous ventilation or drug-induced neuromuscular function depression. Cardiovascular function may also be impaired.
Anesthesia is delivered by an anesthesiologist and is not in the scope of discussion of this article.
Moderate sedation is the focus of this article, as we outline the drug-induced depression of consciousness. An understanding of the full continuum is necessary because patients may pass through minimal to moderate with oral sedatives and can deepen to deep sedation, requiring awareness and response by the practitioner to protect airway and provide ventilation. The classification of the levels of sedation and anesthesia also helps deliver a uniform level of care, with specific requirements and hospital policy for each level.
Methods of anxiety and pain control
Oral medications are suitable for minimal and moderate (conscious) sedation in the dental office. When nitrous oxide/oxygen (N 2 O-O 2 ) is used in combination with sedative agents, levels of anesthesia deeper than minimal sedation can be reached.
Oral medications used to achieve minimal sedation in adult patients have a wide margin of safety to prevent loss of consciousness. The ADA is very specific about the dose of drug used to produce minimal sedation. When the intent is minimal sedation for adults, the appropriate initial dosing of a single enteral drug is no more than the maximum recommended dose (MRD) of a drug that can be prescribed for unmonitored home use. MRD is defined as the maximum US Food and Drug Administration (FDA)-recommended dose of a drug as printed in FDA-approved labeling for unmonitored home use. Incremental and supplemental dosing also apply to minimal sedation. Incremental dosing is the administration of multiple doses of a drug until a desired effect is reached, but not to exceed the MRD. Supplemental dosing is a single additional dose of the initial dose of the initial drug that may be necessary for prolonged procedures, not to exceed one-half of the initial dose, and should not be administered until the dentist has determined the clinical half-life of the initial dosing has passed. The total aggregate dose must not exceed 1.5 times the MRD on the day of treatment. If the administration of enteral drugs exceeds the MRD during a single appointment or if more than one enteral drug is administered to achieve the desired sedation effect, it is considered to be moderate sedation and the moderate sedation guidelines apply.
It is important to emphasize that sedation and general anesthesia are a continuum, therefore, an individual’s response may not always be predictable (see Fig. 1 ). Hence, practitioners intending to produce a given level of sedation must be able to rescue patients whose level of sedation becomes deeper than initially intended. Rescue of a patient is an intervention by a practitioner proficient in airway management and advanced life support, correcting adverse physiologic consequences of the deeper-than-intended level of sedation, and returning the patient to the originally intended level of sedation.
Educational requirements
The ADA first developed clinical guidelines, including educational requirements, for the use of sedation in dentistry in 1996 and has been most recently updated in 2016. In the ADA’s Policy Statement on the Use of Sedation and General Anesthesia by Dentists, it is stated that:
The 2016 ADA Clinical Guidelines for the Use of Sedation and General Anesthesia by Dentists state that to administer minimal sedation
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The dentist must demonstrate competency by having successfully completed :
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Training in minimal sedation consistent with that prescribed in the ADA Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students ;
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Or
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Comprehensive training in moderate sedation that satisfies the requirements described in the Moderate Sedation section of the ADA Guidelines for Teaching Pain control and Sedation to Dentists and Dental Students at the time training was commenced;
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Or
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An advanced education program accredited by the CODA that affords comprehensive and appropriate training necessary to administer and manage minimal sedation commensurate with these guidelines;
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And
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A current certificate in Basic Life Support (BLS) for Healthcare Providers.
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Administration of minimal sedation by another qualified dentist or independently practicing qualified anesthesia health care provider requires the operating dentist and his or her clinical staff to maintain current certification in BLS for Healthcare Providers.
The 2016 ADA Clinical Guidelines for the Use of Sedation and General Anesthesia by Dentists state that to administer moderate sedation
- 1.
The dentist must demonstrate competency by having successfully completed :
- a.
A comprehensive training program in moderate sedation that satisfies the requirements described in the Moderate Sedation section of the ADA Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students at the time training was commenced;
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Or
- b.
An advanced education program accredited by the CODA that affords comprehensive and appropriate training necessary to administer and manage moderate sedation commensurate with these guidelines;
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And
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A current certificate in BLS for Healthcare Providers and either current certification in Advanced Cardiac Life Support (ACLS) or equivalent or completion of an appropriate dental sedation/anesthesia emergency management course on the same recertification cycle that is required for ACLS
- a.
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Administration of moderate sedation by another qualified dentist or independently practicing qualified anesthesia health care provider requires the operating dentist and his or her clinical staff to maintain current certification in BLS for Healthcare Providers.
Individual state dental boards have the responsibility to ensure that only qualified dentists use sedation and general anesthesia.
Preprocedural practices
Before any level of sedation/analgesia administration, the practitioner must evaluate the following parameters.
Patient History and Evaluation
Thorough patient evaluation is critical in determining which patients to consider for any sedative procedure. Several factors need to be taken into consideration including the patient’s chief complaint; comprehensive medical, social, and surgical history; complete list of medications, drug, and food allergies; review of systems; comprehensive examination of the maxillofacial region; a detailed physical examination; and appropriate laboratory results.
A focused medical history includes major organ systems, airway; allergies; medications; use of alcohol, tobacco, and recreational drugs; anesthesia and sedation history; and a risk assessment. After proper assessment, the dentist can consider the need for any further testing that may be required before proceeding with sedation.
Assign an American Society of Anesthesiologists Physical Status Score
When examination is complete, the dentist should have the knowledge to assign patients an American Society of Anesthesiologists (ASA) classification and determine the appropriate anesthesia modality ( Table 2 ). Patients with significant medical considerations (ASA III, IV) may require consultation with their primary care physician or consulting medical specialist before being sedated. In addition, patients with an elevated body mass index are at increased risk for airway-associated morbidity. Ultimately, the clinician must understand their limits based on training, experience, confidence, and ability when making the decision to treat.
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