Sedation dentistry has become very popular over the past several years, although the discovery of it occurred in the early 1800s. What is sedation dentistry really? Plainly stated, sedation dentistry uses different types of medications to reduce anxiety and create relaxation in the fearful dental patient. The intent of this article is to be informative to patients, and to allow an understanding of the different levels of sedation for the adult patient and the type of license that a dentist must have to administer them. There are guidelines for the levels of sedation that are set forth by the American Dental Association (ADA). The statutes and rules are mandated by the Department of Health, and vary by state. Since this article will be published in Florida the information will be derived from the Florida Department of Health the division of the Board of Dentistry.
What Is Sedation Dentistry Really?
In order to gain a better understanding of sedation dentistry it is important to first understand some key terminology:
- Sedation is defined as the reduction of anxiety and the act of relaxation by the administration of a sedative drug.
- Anesthesia is considered the loss of feeling and specifically is the loss of the sensation of pain.
- Local anesthesia is the loss of the sensation of pain in a specific area (localized part) of the body; it is achieved through topical application or injection of a local anesthetic (i.e. Novocain).
- Analgesia refers to the sense of pain relief; this can be accomplished with the administration of an analgesic drug (i.e. Narcotic).
Levels of Sedation Dentistry
Once there is an understanding of the basic terms used in sedation dentistry, it is easier to understand the following levels of sedation:
- Minimal Sedation (anxiolysis) (includes Nitrous oxide inhalation analgesia): Refers to a minimal to no depressed level of consciousness, allowing the patient to breathe on their own and respond to physical and verbal stimuli. Medication (sedative or narcotic pill) is given pre- operatively and/or the administration of a mixture of nitrous -oxide and oxygen to achieve the same effect.
- Moderate Sedation (Conscious Sedation): Refers to a drug induced depression of consciousness which allows the patients to respond purposefully to verbal command or accompanied by light physical sensation, and the patient is able to independently maintain their own airway.
- Deep Sedation: Refers to a drug induced controlled depression of consciousness when a patient cannot be easily aroused, but respond purposefully where there is pain or stimuli. The ability to maintain their breathing may be impaired, they may need assistance to maintain their breathing.
- General Anesthesia: Refers to a drug induced controlled state of unconsciousness. Accompanied by a partial or total loss of protective reflexes. This includes an inability to respond to painful stimuli or verbal commands. As well patients are unable to maintain their airway and require assistance and positive pressure ventilation is often required.
Types of Sedation Dentiatry
The most common routes employed in dentistry to administer sedation are the following:
- Oral: The most common route. A pill or liquid is taken by mouth. The advantage is it’s universally accepted by patients. The disadvantages are an inability to easily achieve the desired drug effect (titration) and a prolonged drug effect. Used for minimal and moderate sedation.
- Intramuscular –The least common route in dentistry. The medication is given by injection into a muscle. The advantages are the drug has a rapid onset of action and of clinical effect. The disadvantages are it is impossible to control the desired effect and to reverse if there is a need to. Used in moderate, deep sedation, and general anesthesia.
- Inhalation – This is administered by breathing a medical gas of some kind. There are a variety of gasses that may be given to produce sedation or general anesthesia. In dentistry the only medical gasses utilized are nitrous-oxide and oxygen. This route provides the fastest onset of clinical action, it’s easily reversible, and easily monitored for effectiveness. Used for minimal sedation.
- Intravenous (IV) – This method is the most effective to produce a desired effect in almost all patients. The drugs can be easily titrated and certain drugs may be reversed. IV sedation has a rapid onset but patient cooperation is necessary since an IV needle must be placed. Used for moderate, deep sedation, and general anesthesia.
The Florida Department of Health (DOH) the division of the Board of Dentistry governs the practice of Dentistry in Florida. In order to practice certain types of sedation, the dentist must either be a licensed Oral Maxillofacial surgeon or carry a permit granted by the DOH.
Minimal Sedation does not require a dentist to have any type of sedation permit. However, the dentist is only allowed to administer one sedative pill OR one narcotic pill pre-operatively. Also the dentist may not at anytime induce the patient into a moderate or conscious sedative state. CPR certification is required. To administer nitrous-oxide the treating dentist must have course work in nitrous-oxide training.
Moderate Sedation (conscious sedation) requires the dentist to have a Conscious Sedation permit. As well, the dentist must have an Advanced Cardiac Life Support (ACLS) certificate. A dentist with this permit is prohibited to administer the following drugs; propofol, methohexital, thiopental, etomidate, and ketamine. A dentist whom holds this permit may also administer Minimal Sedation and Pediatric Conscious Sedation (not discussed in this article).
Deep Sedation and General Anesthesia requires the dentist to either be trained as an Oral Maxillofacial Surgeon or have a General Anesthesia permit. As well, the dentist must have an Advanced Cardiac Life Support (ACLS) certificate. A dentist whom is either a surgeon or has a general anesthesia permit may administer any other type of sedation and may use all general anesthetic drugs.
Sedation Dentistry is a safe and effective method to treat the apprehensive patient or patients with special needs. It is important it is performed by a properly trained and licensed dentist on patients whom are not at risk for medical complications.