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Sedation in Dentistry
Educational Objectives
On completion of this program, the student should be able to:
- Define iatrosedation and give three specific examples
- Name the three levels of sedation and describe their differences
- List the standard-of-care monitoring parameters for minimal and moderate sedation
- Describe the protocol for an oral sedation appointment
- Describe the protocol for an inhalation sedation appointment
- Discuss the management of a CNS-depressant (benzodiazepine or opioid) overdose
Abstract
Odontophobia (fear of dentistry) is a real problem. In a 2015 American Dental Association (ADA) survey of patients who had not visited a dentist within the last 12 months, fear of dentistry (22%) was second only to cost (59%). The goal of sedation is to relax an apprehensive or fearful dental patient. Recognized levels of sedation are minimal, moderate, and deep. Sedation techniques include iatrosedation and pharmacosedation. Pharmacosedation administration routes include oral, intramuscular (IM), intranasal (IN), inhalation, and intravenous (IV). Dental boards regulate sedation use, with permit requirements varying state to state. Monitoring during sedation is critical to patient safety. Pulse oximetry, with appropriate alarms, is standard of care during all levels of sedation, and end-tidal CO2 monitoring is standard of care in moderate and deep sedation. Inhalation sedation (N2O-O2) remains the most commonly used sedation technique followed by oral sedation.
Parenteral techniques of moderate sedation are less frequent. Deep sedation and general anesthesia, which require more intensive training, primarily are used by oral surgeons and dentist anesthesiologists.
Inhalation sedation, considered minimal sedation when no other central nervous system (CNS)-depressant drugs are administered, possesses significant advantages (including rapid onset, complete recovery [in most patients], and the ability to titrate) over enteral and other parenteral sedation routes.The most commonly used drugs in both oral and parenteral minimal and moderate sedation are benzodiazepines (triazolam, midazolam) and opioids (fentanyl, meperidine, hydromorphone).
Complications, including overdose, can arise whenever drugs are administered. Managing sedation overdose invokes the concept of “rescue,” the ability “to rescue a patient who enters a state of sedation beyond which is intended.” Management involves use of the emergency algorithm: P_C_A_B_D (Position, Circulation, Airway, Breathing, Definitive care).
Additional Information
Author Bio
Stanley F. Malamed, DDS
Dr. Malamed was born and raised in the Bronx, New York, graduating from the New York University College of Dentistry in 1969. He then completed a dental internship and residency in anesthesiology at Montefiore Hospital and Medical Center in the Bronx, New York, before serving for 2 years in the U.S. Army Dental Corps at Ft. Knox, Kentucky. In 1973, Dr. Malamed joined the faculty of the Herman Ostrow School of Dentistry of U.S.C., in Los Angeles, where today he is Professor of Anesthesia & Medicine. Dr. Malamed is a Diplomate of the American Dental Board of Anesthesiology, as well as a recipient of the Heidebrink Award [1996] from the American Dental Society of Anesthesiology and the Horace Wells Award from the International Federation of Dental Anesthesia Societies, 1997 (IFDAS). Dr. Malamed has authored more than 140 scientific papers and 17 chapters in various medical and dental journals and textbooks in the areas of physical evaluation, emergency medicine, local anesthesia, sedation, and general anesthesia. In his spare time, Dr. Malamed is an avid runner, exercise enthusiast, and admits an addiction to the New York Times crossword puzzle, which he has done daily since his freshman year in dental school.
Disclosures
Commercial Disclosure
This free Dental Learning presentation is made possible through the continued support of Dental Learning. Stanley F. Malamed, DDS is a consultant and/or speaker for the following companies and/or organizations: Dental Learning, Dental Learning. Stanley F. Malamed, DDS may receive an honorarium as compensation from the CE Supporter of this presentation and/or from Dental Learning for the time involved in preparing and delivering this online presentation.
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