Message Boards
Today's Active Topics Today's Active Cases Browse Forum Categories My Recent Activity My Messages Private Groups My Marked Threads My Subscriptions
Today's Active Images Today's Active Polls Most Active Topics Global Townie Map Advanced Message Board Search Message Board Terms of Use

IV Sedation by Michael E. Mermigas, DDS

Start Discussion

It has been suggested that as much as five to 20 percent of the adult population in the United States avoid dental treatment because of dental anxiety.1 It has also been demonstrated that a major cause of this anxiety involves conditioning from painful or other traumatic experiences.2 These experiences can be traced back to an unpleasant childhood dental procedure, inadequate local anesthesia, resistance to local anesthesia or other similar factors.

Anesthesia and sedation dentistry have their very roots in dentistry. Only during the last half of the 20th century has the practice of sedation (enteral, inhalation and intravenous) and deep sedation/general anesthesia become more widely available in the dental office. Pioneers in anesthesia such as Drs. Leonard Monheim and Richard Bennett took the first steps in educating and training dentists to administer IV sedation. They developed the first undergraduate and postdoctoral training programs at the University of Pittsburgh School of Dental Medicine. Since this program was instituted, several other dental schools have followed and now offer undergraduate training in IV sedation.

IV sedation certification programs for dentists already practicing are now being offered as continuing education courses.

Dr. Bennett was the first to use the term “conscious sedation.” This term implies that the patient remains fully conscious during the intraoperative period, but in a relaxed, anxiety-free state. By definition the protective reflexes remain intact. This implies that the airway is not compromised and that cardiovascular function is maintained by the patient’s own physiologic mechanisms.

The term “conscious sedation” within the last decade has been supplanted by more specific terminology. Minimal, moderate, deep sedation and general anesthesia are the terms that are now in use to describe the various levels of anesthesia. Herein are the definitions of levels of sedation as defined and adopted by the American Society of Anesthesiologists (ASA).3

  • Minimal sedation: Also known as anxiolysis. A druginduced state during which the patient responds normally to verbal commands. Cognitive function and coordination might be impaired. Ventilatory and cardiovascular functions are unaffected.
  • Moderate sedation/analgesia (conscious sedation): A drug-induced depression of consciousness during which the patient responds purposefully to verbal command, either alone or accompanied by light tactile stimulation. No interventions are necessary to maintain a patent airway. Spontaneous ventilation is adequate. Cardiovascular function is usually maintained.
  • Deep sedation/analgesia: A drug-induced depression of consciousness during which the patient cannot be easily aroused, but responds purposefully following repeated or painful stimulation. Independent ventilatory function might be impaired. The patient might require assistance to maintain a patent airway. Spontaneous ventilation might be inadequate. Cardiovascular function is usually maintained.
  • General anesthesia: A drug-induced loss of consciousness during which the patient is not arousable, even to painful stimuli. The ability to maintain independent ventilatory function is often impaired. Assistance is often required in maintaining a patent airway. Positive pressure ventilation might be required due to depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function might be impaired.

Because sedation and general anesthesia are a continuum, it is not always possible to predict how an individual patient will respond. Hence, practitioners intending to produce a given level of sedation should be able to diagnose and manage the physiologic consequences (rescue) for patients whose level of sedation becomes deeper than initially intended.4

The vast majority of moderate to severely anxious dental patients can be easily and safely managed with moderate levels of sedation.

Advantages of Moderate Sedation:
  • Relaxed patient, dentist and staff
  • Increased access to care for those who would normally avoid treatment
  • If benzodiazepines are employed there is an amnesic effect. The patient has little or no recall of unpleasant procedures.
  • Diminishes extreme gag reflex
  • Increases productivity

There are multiple modalities that may be employed to induce a state of moderate sedation. Among them are oral (enteral), inhalation (nitrous oxide/oxygen) and IV sedation. There are many advantages to offering the patient IV sedation.

Advantages of IV Sedation:
  • Intravenous access to deliver medications
  • Anesthetic agents, adjunctive agents (antibiotics, antiinflammatory agents) and emergency drugs
  • More predictable depth of sedation as the agents are easily titrated and have a rapid onset
  • Anesthetic agents most often employed are short acting. This makes for a more rapid recovery.
  • Reversal agents administered by the IV route have a more rapid onset and multiple dosing of these agents is less problematic as opposed to other routes such as intra-lingual or submucosal.
  • Volume deficit replacement possible in the fasting patient An emphasis should be made as to the safety of IV sedation. Intravenous access, electronic monitoring of vital signs, EKG, oxygen saturation of hemoglobin and end tidal CO2 all enhance patient safety. The fact that the patient remains conscious and that the protective reflexes remain intact are also factors. Many liability insurance carriers do not surcharge the dentist for offering IV moderate sedation.


It is imperative for any dentist wishing to offer IV sedation to receive proper training and follow-up refresher training. Currently the American Dental Association Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students5 recommend the following:

Moderate Parenteral Sedation Course Duration:
  1. A minimum of 60 hours of instruction, plus management of at least 20 patients by the intravenous route per participant, is required to achieve competency in moderate sedation techniques.
  2. Clinical experience in managing a compromised airway is critical to the prevention of emergencies.
  3. Participants should be provided supervised opportunities for clinical experience to demonstrate competence in management of the airway.
  4. Typically, clinical experience will be provided in managing healthy adult patients.
  5. Additional supervised clinical experience is necessary to prepare participants to manage children (aged 12 and under) and medically compromised adults.
  6. Successful completion of this course does result in clinical competency in moderate parenteral sedation.
  7. The faculty should schedule participants to return for additional clinical experience if competency has not been achieved in the time allotted.

Upon completion of moderate IV sedation training, the participant and staff are also trained in the area of patient evaluation, management of the medically compromised patient and management of dental office emergencies. These greatly enhance the dentist’s ability to safely and effectively tailor treatment to a wide variety of patients with and without the need for sedation.

References
  1. Lindsay S, Jackson, C Fear of routine dental treatment in adults: its nature and management. Psych Health 1993; 8:135-53.
  2. Kent G. Dental phobia. In: Davey, G, editor. Phobias. A handbook of theory and research. London: John Wiley and Sons; 1997.
  3. Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists. Anesthesiology: April 2002 - Volume 96 - Issue 4 - pp 1004-1017.
  4. Excerpted from Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia, 2004, of the American Society of Anesthesiologists (ASA).
  5. As adopted by the October 2007 ADA House of Delegates




Author Bio
Michael E. Mermigas, DDS, is director of the Duquesne University Center for Continuing Dental Education. He is a clinical assistant professor of pharmacology-toxicology at Duquesne’s Mylan School of Pharmacy, and teaches several undergraduate as well as graduate courses. He is the director of continuing dental education at the university. Trained as both a general dentist and a registered pharmacist, Dr. Mermigas is a graduate of the Mylan School of Pharmacy and the West Virginia University School of Dentistry. He completed residency in hospital dentistry at the Department of Veteran’s Affairs Medical Center in Pittsburgh, Pennsylvania, as well as an externship in oral implantology with the Midwest Implant Institute in Columbus, Ohio.

In addition to his teaching responsibilities, Dr. Mermigas maintains a private general and implant dentistry practice where he also provides anesthesia services. He has been providing sedation services to his patients and for other dental practices for more than 20 years. He also served for 15 years as an emergency medical technician. Dr. Mermigas has lectured extensively in the areas of pharmacology, anesthesia and pain control, medically compromised patients and microbiology.
Dentaltown Magazine
September 2025
Dentaltown Magazine September 2025 Read Current Issue Read Archived Issues
Sponsors
Townie Perks
Townie® Poll
Who or what do you turn to for most financial advice regarding your practice?
  
Site Menu
Message Boards Magazine Continuing Education Podcasts Blogs Classifieds Dental News Events Townie® Poll Ebooks Townie Choice Awards
Company Info
Contact Us Advertise With Us Howard Farran DDS, MBA Policies and Agreements
Site Help
Sally Gross, Member Services Specialist
Phone: +1-480-445-9710
Email: sally@farranmedia.com
©2025 Dentaltown, a division of Farran Media • All Rights Reserved
9633 S. 48th Street Suite 200 • Phoenix, AZ 85044 • Phone:+1-480-598-0001 • Fax:+1-480-598-3450