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The Whys and Hows of Adult Sedation Dentistry by Louis Core, DDS, MAGD

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Why should I offer sedation?
It is no secret that many people are afraid to go to the dentist, sometimes to the point of neglecting their oral care. Sedation, either oral or intravenous (IV), allows this segment of the population to be treated without stress, and often becomes the first step to their seeking regular dental care. I have treated numerous patients who initially came to me in such an anxious state that they could not even receive a prophy without IV sedation, yet as time went on and repeated positive dental experiences reduced their anxiety, they were able to handle all but the most invasive procedures without any medication.

What medications are used for sedation?
Benzodiazepines, narcotics, and antihistamines—very often in combination—are the most commonly used medications for both oral and IV sedation. Benzodiazepines such as midazolam (Versed), triazolam (Halcion), and diazepam (Valium) are very safe, have deeply calming effects on most patients, have few bad side effects, and can be potently amnestic. They can interfere with incorporation of memory, often making patients unable to recall much about their visit, even if they seem alert and talkative during the procedure.

Narcotics such as fentanyl are also commonly employed, especially if postoperative pain is anticipated. One of the reasons that benzodiazepines and narcotics are so commonly used is that they are not only very safe when administered properly, but are also reversible. Reversal agents can be administered to quickly antagonize the sedatives' effects, should the need arise.

What equipment will I need?
Exact requirements vary by state, but all states require that blood pressure is measured periodically and oxygen saturation is monitored continuously. Several brands of electronic monitors are available that will automatically measure blood pressure and oxygen saturation, and are small and portable enough to be conveniently used in a dental office.

Portable oxygen tanks are also required, as are emergency medication kits, AEDs, airway management devices, and other supportive equipment. These are good things to have in your office and know how to use, even if you do not choose to provide sedation.

How do I receive sedation training?
Several organizations around the U.S. and Canada provide sedation training. While DOCS Education (Docseducation.com) is one of the highest-profile providers, especially for oral sedation, several other organizations also provide high-quality training.

A list of programs can be found on the American Dental Society for Anesthesiology (ADSA) website, ADSAhome.org/iv.html. Classes vary in number of days and how many live patients are treated as part of the course, so it is important to make sure the course meets the minimum requirements for a sedation permit in your state.

How do I obtain a sedation permit?
Most states have similar standards for IV sedation permits, requiring 60 hours of classroom work and 20 live-patient experiences as part of an approved course. In contrast, standards for oral sedation vary wildly, with some states requiring what amounts to a weekend course with a single live-patient experience, and several others requiring that applicants fulfill the same requirements as for IV conscious sedation. You can check your state's requirements at sedationregulations.com.

Once you have completed the course, you submit an application to your dental board for a sedation permit. Most states have separate permits for oral sedation and IV sedation, although typically, a permit for IV sedation will also allow you to provide oral sedation.

Before the permit is issued, the board will usually conduct a site visit and interview to ensure that that your facility has the proper equipment and that you and your staff are competent to handle medical emergencies. The board also observes sedation on a live patient. Virtually all states also require current advanced cardiovascular life support (ACLS) certification for both IV as well as oral sedation.

What procedures commonly require sedation?
Many surgical procedures are best performed on a sedated patient. I remove a lot of third molars in my office, using IV sedation for the vast majority of cases. Having an IV in place allows me to administer medications in addition to the sedatives, such as steroidal anti-inflammatories and postoperative analgesics.

Full-mouth extractions with immediate denture delivery, implant placements and periodontal surgeries are also common indications for sedation. It is often necessary to cut gum tissue and grind on bone to remove teeth, and it is less stressful for everyone in the operatory if the patient is deeply relaxed and not focused on the sights and sounds of surgery.

When sedated, anxious patients are far less likely to wince and pull away from non-painful stimuli such as pressure, reducing operator stress. Furthermore, the amnestic effect of drugs such as midazolam reduces the trauma patients experience by rendering them unable to remember the procedure.

Surgeries are not the only indications for sedation, however. Whenever I discuss treatment with patients and they express fear, I will offer some form of anxiolytic or sedation. Many will express surprise that this is available and are eager to explore sedation options. A lot of these patients have avoided seeing a dentist for years due to fear, and have several teeth in need of restoration or extraction. With the help of sedation, they can complete their treatment in stress-free visits. Any dentist who regularly sedates patients will tell you that it changes people's lives.

Emergency medicine
If sedation dentistry is safe, then why do all states require you to demonstrate that you can handle a wide range of medical emergencies before issuing a permit? The answer is simple. While the medications themselves are safe, with very few people suffering toxic effects, a patient who is sedated can be vulnerable. Airway management is the biggest concern, with the sedated patient sometimes unable to reposition himself to open the airway should it become obstructed by head or tongue position.

Also, a sedated patient often cannot tell you when he or she is having a medical emergency—such as a heart attack or allergic reaction—so you need to be able to recognize the signs and symptoms and respond appropriately.

Training in handling medical emergencies is something all dentists should acquire even if they do not provide sedation. Many dental meetings, such as the Townie Meeting, held annually in Las Vegas, offer courses on medical emergencies, and excellent training is available in DVD format to help you review emergency procedures and protocols. I have found fellow Townie Dr. Catharine Goodson's DVD series (catharinegoodson.com) to be an excellent resource for both myself and my staff.

Conclusion
While choosing to offer oral or intravenous sedation requires training and specialized equipment, the rewards for both you and your patients can be significant. I cannot imagine practicing without it.



Dr. Louis Core has been offering sedation for more than a decade, and is a conscious-sedation site evaluator for the Arizona Board of Dental Examiners. He is in private practice in Glendale, Arizona, practicing general dentistry.


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