Sedation Dentistry
Ensuring the comfort and safety of anxious patients
Ellen Meyer, MBA
Lack of access is a significant deterrent to receiving oral care, but some patients with the ways and means just can’t bring themselves to go to the dentist’s office—even for routine care—due to crippling anxiety related mainly to fear of pain. For these patients and others who can’t be properly treated with traditional pain, anxiety, and movement-control approaches, sedation or general anesthesia (GA) can be a blessing for them and their dentists.
Unfortunately, sedation dentistry has gotten somewhat of a bad reputation in the media, with high-profile reports of pediatric deaths calling its safety into question. According to our experts, when it comes to sedation dentistry, patient selection and clinician training are paramount to delivering a safe, predictable, high standard of care for adults and children.
Who Benefits from Sedation Dentistry?
Dental anesthesiologist Joel Weaver, DDS, PhD, of Columbus, Ohio, says the need for sedation and GA is growing for many reasons, including because procedures are longer and more involved than in the past.
He mentions two studies that establish the need for sedation or GA in dentistry for anxiety in adult patients1 and children.2 The adult study, a national telephone survey of 1,100 Canadians, found that among the 5.5% who reported having a high level of fear or anxiety, nearly half (49.2%) had avoided a dental appointment at some point because of it, and more than half (54.1%) were interested in sedation, depending on cost.1
Sedation can be especially beneficial for specific patient populations, says Morton Rosenberg, DMD, professor of oral and maxillofacial surgery and head of the division of anesthesia and pain control at Tufts University School of Dental Medicine and associate professor of anesthesiology at Tufts University School of Medicine. This includes adult patients who would “benefit from the ability to be sedated for their dental procedures because of physical disabilities such as Parkinson’s, Alzheimer’s, or pre-senile dementia.” It can also be critically important for safe and effective delivery of medically necessary dental procedures for patients who cannot cooperate due to mental health issues or cognitive disabilities.
Pediatric patients can also benefit, but their experience of anxiety may be different from an adult’s. Joel Berg, DDS, dean of the University of Washington School of Dentistry and professor of pediatric dentistry, explains that adults with dental phobia avoid dental treatment even though they know they need it. Young children, however, don’t understand the need for treatment. “It is a natural, self-protective instinct for them to feel afraid if their cognitive skills aren’t developed enough to understand their environment, especially when it is unfamiliar,” he says.
In Berg’s view, dentistry doesn’t use sedation/GA enough for children. In medicine, it is routinely used in procedures such as ear tube insertion that may actually be simpler than some dental procedures. “What concerns me sometimes is that GA or sedation may not be offered to children who should have it and that more aggressive behavior management methods are used, including restraints, so the operator can get the treatment done,” he says. “It’s not good for the psyche of the child, and it can affect the quality of the treatment performed.”
Rosenberg observes that for some children, the source of their fear is multifactorial. “A lot has to do with culture, the experiences of the parents and other family members, and what one sees in the media associating dentistry with pain.” To help put children at ease, he recommends getting children to a dentist early so they can understand and adapt to the environment.
Depending on the child’s age, anxiety level, and documented behavioral assessment, however, sedation or GA may be required for the dentist to achieve safe and effective care, particularly if the necessary treatment is extensive.
Patient Assessment
Raymond Dionne, DDS, PhD, is a research professor in the department of pharmacology and toxicology at Brody School of Medicine and in the department of foundational sciences in the School of Dental Medicine at East Carolina University in Greenville, North Carolina. He supports measures that make it more likely that patients will receive timely and effective treatment for dental problems. However, he also believes that just as every treatment plan should be individualized for the patient, so should the method of sedation. He says doctors should not use the one-size-fits-all approach of GA when the patient can be adequately treated with minimal or moderate forms of sedation that carry a far lower risk of adverse events. Dionne is concerned about the use of GA, which involves maximum levels of central nervous system (CNS) depression, in cases where the biggest benefit is for the doctor to make it easier to get the job done.
He says the method of sedation chosen should depend upon its goal. “In most cases, anxious patients just need something to take the edge off, not something that will render them unconscious; it’s like the difference between a cocktail and a drug overdose.”
Berg says he uses a kind of “decision tree” to determine whether sedation or GA is needed for children who may be difficult to manage. “A child who is cooperative enough to get x-rays done may or may not be cooperative enough to have treatment done in the clinic. Some 4-year-olds can tolerate four or five visits for extensive restorative dentistry without sedation, but we don’t know that until we conduct a proper developmental and behavioral assessment.”
Unless the decision has been made for GA in advance, New York-area dental anesthesiologist Mana Saraghi, DMD, who is qualified to perform all levels of sedation/anesthesia, makes the determination based on a conversation with the patient and the dentist. “We discuss what our goals are. Is it to have the patient completely motionless? For example, some patients who are very young (pre-cooperative) or have severe developmental delay (non-cooperative) may benefit from a more controlled environment, as with general anesthesia. Some need to be completely out, but most patients are willing to try a little sedation, as long as they don’t feel or remember anything.” Once the procedure is underway, she says, she can modify to reach “the ‘sweet spot’ that enables the dentist to get the job done while the patient thinks they are asleep but may in fact be responsive and breathing independently.”
Paul A. Moore, DMD, PhD, MPH, professor of pharmacology, dental anesthesiology, and dental public health at the University of Pittsburgh School of Dental Medicine, stresses the importance of determining whether the patient is even a candidate for sedation. This involves taking a thorough medical history using the American Society of Anesthesiologists (ASA) Patient Physical Status Classifications to rate the patient’s health and anesthesia risk (Table 1).3
Provider Qualifications
Who should provide sedation or anesthesia to dental patients? “Anyone properly trained,” says Kenneth L. Reed, DMD, who is president of the American Dental Society of Anesthesiology (ADSA) and associate program director of the dental anesthesia residency at NYU Langone Medical Center.
Originally a periodontist, Reed received that proper training, including completion of a Commission on Dental Accreditation (CODA)-approved dental anesthesia residency. He now teaches and provides GA and sedation in dental offices and holds academic appointments at the Ostrow School of Dentistry of the University of Southern California, the Oregon Health Science University School of Dentistry, the University of Nevada Las Vegas School of Dental Medicine, and the University of Alberta.
Reed notes that general dentists are qualified to prevent and control their patients’ pain with local anesthetics and prescribed medication before, during, and after dental procedures. “Excellent pain prevention and control in dentistry is achieved primarily and routinely by the administration of local anesthetics. Secondarily, postoperative analgesics are routinely prescribed,” he explains.
Sedation is another matter entirely. States mandate who is qualified to deliver it safely at the various levels. These regulations are frequently based on the American Dental Association (ADA) Guidelines, which Reed says should serve as a guide for all who offer sedation. “When the current ADA Guidelines are followed, minimal sedation, moderate sedation, deep sedation, and even general anesthesia are very, very safe,” he says.
Rosenberg describes a large gamut of practitioners who can provide different types of sedation in keeping with their states’ regulation. “Moderate and deep sedation and general anesthesia can only be provided by graduates of oral and maxillofacial and dental anesthesiology programs, while other general dentists and specialists may have the educational and clinical qualifiers to provide minimal and moderate sedation via the oral, inhalational, and intravenous routes.”
While many patients assume that all dentists can offer nitrous oxide, Rosenberg says this is not the case in many states.
Understanding Current ADA Guidelines
The ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists, which are in the process of being revised, describe the following types of sedation: minimal sedation, moderate sedation, deep sedation, and general anesthesia (Table 2).4 To deliver all but oral anxiolytics for minimal sedation—ie, sedation using drugs such as a benzodiazepine similar to diazepam (Valium)—dentists need to be appropriately trained and licensed according to their individual state regulations. Although they are typically based on ADA Guidelines, Weaver reiterates the guidelines themselves are neither mandated nor enforceable by the ADA. “Some states even regulate minimal sedation by dentists for adults and children,” he explains.
According to these guidelines, for all levels of sedation, the qualified dentist practitioner must have the training, skills, drugs, and equipment to identify any adverse occurrence, such as an airway restriction, until either assistance arrives (emergency medical service) or the patient returns to the intended level of sedation without airway or cardiovascular complications.
In offices where the dentist is handling sedation, Saraghi says, it’s especially important for the staff to be trained in emergency techniques. “This includes CPR, using the defibrillator, and helping the dentist use the bag valve mask to help the patient breathe. This is covered in basic life support classes, which all members of the team are required to have. The sedation provider should have advanced cardiac life support and/or pediatric advanced life support certification as well.”
Minimal and Moderate Sedation
For minimal and moderate sedation, the ADA Guidelines specify the number of people that must be in the room, the monitors required, and a protocol to follow if anything goes wrong. For conscious sedation (ie, minimal or moderate), there must be a minimum of two people present: the dentist who has the training in minimal and/or moderate sedation and Basic Life Support for Healthcare Providers and one additional person trained in Basic Life Support for Healthcare Providers.
For emergency management, the guidelines require that if a patient enters a deeper level of sedation than the dentist is qualified to provide, the dental procedure must be halted until the patient is returned to the intended level of sedation.
“Interruption of breathing is the most common cause of disasters that occur during moderate sedation as well as deep sedation and general anesthesia,” Weaver notes. “This can be the result of an excessive level of sedation that can result in upper airway obstruction from relaxation of soft tissues within the airway, from drug depression of the respiratory center in the brain, or from spasm of the vocal cords, any of which can cause hypoxia and death if not immediately managed.”
However, Moore says, “If you’re talking about a really healthy, young ASA I patient receiving moderate sedation, the risk of an adverse respiratory event is extremely low.”
Deep Sedation and GA
For deep sedation or GA, there must be a minimum of three people present according to the ADA Guidelines. This includes the person who is qualified to provide deep sedation and GA (it can be a dedicated anesthesiologist who administers the drugs and monitors the patient or the dentist performing the procedure) and two additional individuals who have current certification in Basic Life Support for Healthcare Providers. The guidelines note that when the same individual administering the deep sedation or GA is performing the dental procedure, one of the additional appropriately trained team members must be designated for patient monitoring.
Monitoring Sedated Patients
The level of sedation being used dictates the choice of and requirements for patient monitoring. Weaver notes that practitioners who work without a dedicated anesthesiologist benefit from monitoring devices that can be heard and don’t need to be watched, such as a pulse oximeter, which is required for all sedation procedures.
“Pulse oximetry assesses circulating blood, measuring the amount of oxygen in the red blood cells coursing through the fingertip. Variations in its sound—a beep with each pulse—audibly signal whether the patient is being oxygenated normally or not,” he explains.
As a dedicated anesthesiologist, Saraghi finds that multiple pieces of monitoring equipment are needed to provide a more complete picture of a patient’s status during sedation. These include an audible monitor, precordial stethoscope, which enables her to hear each breath, and a capnograph, which provides a readout of the amount of carbon dioxide that comes out during that breath.
“The pulse oximeter has a delay in reflecting a missed breath and the corresponding drop in oxygen saturation, and this delay may be as long as 1 minute. During that minute, the patient may suffer from going without oxygen,” Saraghi notes. “Meanwhile, the precordial stethoscope may be difficult to hear, especially during the use of a high-speed suction device. The capnograph provides data instantly; however, it too has limitations in that it may not detect the exhaled carbon dioxide in a mouth breather. However, when used together, these monitors complement one another.”
Moore says careful monitoring is critical, especially for those at higher risk. But monitoring standards are different between medicine and dentistry, and that’s problematic. The ADA Guidelines and the many state regulations based on them are less stringent than those for medicine, Moore says, which suggests a double standard of care that continues to dog dentistry. Capnography is one example. Although it is recommended for moderate sedation by both the Academy of Oral and Maxillofacial Surgeons (AAOMS) and the American Society of Anesthesiology (ASA), Moore says, “What I want to know is why MDs and oral surgeons think they should use capnography and dentists don’t. Is the risk different? Sedation risk has to do with drugs and patients, not what type of surgery is being done.”
Drug Safety Considerations
With patient risk uppermost in mind, Dionne believes many doctors in general are too casual about the sedation methods that depress the CNS the most. He asserts that the patient’s interests are better served by focusing not on the doctor’s qualifications and ability to resuscitate a patient, but on avoiding the need by administering safer drugs.
“There is a wide margin of safety for nitrous oxide and benzodiazepines, but as reported in a 2001 JADA article5 and elsewhere, there is a greater risk of respiratory depression when opioids, barbiturates, or general anesthetic drugs are administered to produce ‘deep sedation’ but little or no benefit is detected by patients,” Dionne says. “This translates into increased risk without anxiety reduction benefit for the patient.”
The most important determinant of safety, he says, is the drugs (and doses) given, and, secondarily, the skill of the anesthetist. “The ability to perform resuscitation should not be a major consideration—as even in a hospital setting it usually fails. Getting the drugs and doses right minimizes the need for resuscitation.”
Choosing Dental Anesthesiology
Although properly licensed oral surgeons and dentists can legally provide dentistry and anesthesia simultaneously—with the right number of people in the room and equipment—some may choose to leave this job to an expert.
There are distinct advantages to outsourcing this responsibility in the operatory. As Weaver points out, “Anesthesiologists are handling only patient monitoring and anesthesia, so they can quickly and easily identify and respond to problems, especially airway issues.”
Providers like Saraghi have specialized training that allows them to focus strictly on the anesthesia while the dentist performs the required procedure. This offers peace of mind to clinicians and patients. “Dental anesthesiology mimics the medical model,” she says. “Like a medical anesthesiologist, I completed training specifically for anesthesia. The programs, which are accredited by CODA, require the completion of 3 years of residency training and the highest requirements for experience in general anesthesia, pediatric cases, and special needs cases. It is the only dental post-graduate residency program that also mandates that residents have experience administering anesthesia in the office-based setting.”
Emergencies can be managed more easily or prevented more readily with a dental anesthesiologist. “If the patient can’t breathe well on their own or if they are only responding to painful stimulation, that means the provider who is not trained or equipped for these events has gone too far and should halt the procedure,” Saraghi says. She can comfortably handle these situations, however. “I can manage airways and medication in intubated and non-intubated patients because I am trained for it.”
Final Thoughts
It has become increasingly clear that facilitating the delivery of medically necessary oral care is an important aspect of general health care. And part of supporting the delivery of dental treatment is addressing obstacles to receiving treatment that could be moderated by the wider availability of sedation and GA.
As Berg points out, in many cases, dentists can deliver more and better treatment due to movement control/cooperation and reduced anxiety. However, Rosenberg cautions that the need must be met with highly trained providers. “The most important thing we do is to ensure the safety and well-being of our patients. Anything can happen at any level of sedation or anesthesia. Being appropriately trained, having correct monitors, and being able to diagnose and manage emergency situations are essential,” he says.
“This whole issue of the relationship between oral and systemic health makes it more important that we do things that will make it more likely that people, including those who are fearful, will come in and get treatment,” says Dionne. He believes the use of deep sedation or GA for anxiety—when a lesser level of sedation could achieve the same goal—may in fact act as a deterrent due to the limited number of providers who can offer it and the greater risk of serious morbidity or mortality. “There are appropriate uses for all levels of sedation, including general anesthesia. However, the best way to prevent disasters related to sedation is to be more judicious about the drugs and doses on the front end, not trying to train people to be better at ACLS [advanced cardiovascular life support].”
References
1. Chanpong B, Haas DA, Locker D. Need and demand for sedation or general anesthesia in dentistry: a national survey of the Canadian population. Anesth Prog. 2005;52(1):3-11.
2. Hicks CG, Jones JE, Saxen MA, et al. Demand in pediatric dentistry for sedation and general anesthesia by dentist anesthesiologists: a survey of directors of dentist anesthesiologist and pediatric dentistry residencies. Anesth Prog. 2012;59(1):3-11.
3. ASA Physical Status Classification System. American Society of Anesthesiologists website. www.asahq.org/resources/clinical-information/asa-physical-status-classification-system. Accessed February 19, 2016.
4. Guidelines for the Use of Sedation and General Anesthesia by Dentists. American Dental Association website. www.ada.org/~/media/ADA/About%20the%20ADA/Files/anesthesia_use_guidelines.ashx. 2012. Accessed February 19, 2016.
5. Dionne RA, Yagiela JA, Moore PA, et al Comparing efficacy and safety of four intravenous sedation regimens in dental outpatients. J Am Dent Assoc. 2001;132 (6):740-751.
