A lot of people are afraid of the dentist. Just thinking about sitting in a dental chair why someone does things inside your mouth is already sending chills to the spine.
It is understandable. In fact, experts say it is natural due to our deep biological survival mechanisms. These deep biological survival mechanisms which are triggered when we experience pain. Also, people usually feel more helpless reclining in a dental chair. Some have also experienced trauma which eventually intensified their fears.
To reduce patient’s fear and anxiety and perform dental treatments, dentists often administer sedation to calm or depressed the patient’s consciousness.
The American Dental Association in its Guidelines for the Use of Sedation and General Anesthesia by Dentists described the meting out of sedation and anesthesia as a vital part of the dental practice.
Dental sedation uses medications to “relax” the patient on the dental chair. Additionally, it increases the level of comfort and minimizes the patient’s movements. Moreover, it increases patient’s cooperation amd reduces the gag reflex. Also, it saves time and money and leads to little or no memory of the treatment.
Along with its advantages, dental sedation has possible risks like respiratory depression hyperventilation, nausea, hyperactivity, unintentional loss of consciousness, over-sedation, and drug overdose.
The administration of anxiety and pain control varies and consist of minimal sedation, moderate sedation, deep sedation, and general anesthesia. ADA has issued guidelines related to the administration of dental sedation.
Minimal sedation is a drug-induced condition in which the patient has a mildly reduced level of alertness. In this state, the patient maintains his or her capacity to self-sufficiently and unceasingly sustain an airway and normally react to physical stimulation and verbal command.
However, with minimal sedation, the cognitive function and coordination are modestly reduced, while cardiovascular and ventilatory functions are not influenced.
For this method of sedation, the following guidelines must be noted:
- A patient must be appropriately evaluated. The American Society of Anesthesiologists has come up with a patient physical status classification that categorizes the patient into six — ASA I, ASA II, ASA III, ASA IV, ASA V, and ASA VI. Read more about the categories here. For patients under ASA I and II, the evaluation will involve a review of their medical history and medications, while those under ASA III and IV who has significant medical considerations will need to consult with their physician or a medical specialist first.
- Before undergoing the procedure, the patient, parent, or guardian must be informed of the method and the proposed sedation. Informed consent must also be obtained.
- Adequate oxygen supply and necessary equipment to deliver oxygen under positive pressure must be determined and completed.
- A physical evaluation should be conducted, measuring the baseline vital signs, as well as the body temperature. Preoperative diet restrictions must also be taken into consideration, depending on the sedative technique required.
- Also preoperative instruction — written or verbal — must be given to the patient, parent, or guardian.
- In addition to a dentist, a trained Basic Life Support for Healthcare Providers person must also be present during the procedure.
- Necessary equipment must also be readily available, checked, and calibrated for each administration of sedation.
- The patient’s level of sedation, oxygen saturation, chest excursions, respirations, blood pressure, and heart rate must be continuously and closely monitored by the dentist or an appropriately trained individual at the dentist’s direction during the treatment until criteria for discharge to the recovery area are met.
- The administration of sedation must be recorded with the names of all drugs administered, the time, and route of administration.
- For recovery and discharge, monitoring by a dentist or qualified individual must persist until the level of consciousness, oxygen saturation, ventilation, blood pressure, and heart rate meet satisfactory standards and the patient is ready for discharge. Post-operative verbal and written instruction must also be relayed to the patient or guardian.
- Emergency situations must be handled with urgency and appropriately. The dentist is accountable and responsible for the management of sedation, the sufficiency of the facility and staff, diagnosis and treatment of emergencies accompanying the administration of the sedation. Equipment and protocols for patient rescue must also be provided.
A dentist is qualified to perform minimal sedation upon the successful completion of training in the sedation as prescribed by the Association’s Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students.
A dentist can also administer minimal sedation if he or she completes comprehensive training in moderate sedation that complies with ADA’s Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students or an advanced education program accredited by the Commission on Dental Accreditation that provides complete and proper training essential to the administration and management of minimal sedation equal to ADA’s guidelines.
Aside from appropriate training, a current certification in Basic Life Support for Healthcare Providers is also required.
Moderate sedation is a drug-induced reduction of consciousness. In this condition, the patients respond willfully to verbal commands, has adequate spontaneous ventilation, and retained patent airway without interventions. Cardiovascular function is often kept in moderate sedation.
For this sedation, clinical guidelines are almost similar to minimal sedation aside from additional requirements.
Below are the guidelines for moderate sedation adopted by ADA:
- An evaluation of the patient’s medical history and medication status at an appropriate time must be done. ASA III and IV patients are required to consult with their physician for medical considerations that need to be noted. An assessment of the Body Mass Index is also necessary as those with high BMI may have heightened risk for airway associated morbidity.
- Advise the patient or guardian of the procedure associated with the administration of sedative agents with informed consent for the proposed sedation obtained.
- Ample supply of oxygen and needed equipment to send oxygen under positive pressure must be defined and accomplished.
- A physical examination must be done as well as checking of baseline vital signs like body weight, height, respiration and pulse rates. The body temperature should also be measured.
- Pre-operative verbal or written instruction must be relayed to the patient or guardian. Pre-operative fasting instructions by ASA’s Summary of Fasting and Pharmacologic Recommendations must also be given to the patient or guardian.
- A person trained in Basic Life Support for Healthcare Providers must be around during the administration of sedation in addition to the dentist.
- Similar to minimal sedation, appropriate and necessary equipment must be readily available and accessible. Equipment must be checked for each sedation administration.
- Monitoring of the patient’s consciousness, oxygenation, ventilation, blood pressure, and heart rate must be constant and done by an individual familiar with monitoring techniques. It must be done until the patient is ready to be discharged to the recovery area.
- Monitoring continues until the patient is ready to go. A qualified dentist will determine and record the patient’s consciousness level, oxygenation, ventilation, blood pressure, and heart rate. More extended period of monitoring must be done before discharge if the pharmacological reversal agent was administered as re-sedation may happen when the reversal agent’s effects have waned.
- Post-operative verbal and written instructions must be communicated to the patient or guardian before discharge.
- Emergency situations must be handled professionally and with urgency. Qualified dentists are responsible for emergencies associated with the administration of moderate sedation. Equipment, drugs, and protocols for patient rescue must be adequately provided.
Dentists who wish to administer moderate sedation must complete comprehensive training program which is satisfactory to the requirements in the moderate sedation section of ADA’s Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students or an advanced education program which provides complete and proper training essential to the administration and management of moderate sedation and accredited by the Commission on Dental Accreditation.
Also, a current certification in Basic Life Support for Healthcare Providers and either a current certification in Advanced Cardiac Life Support or completion of an appropriate dental sedation/anesthesia emergency management course on the same recertification cycle that is required for ACLS.
Deep Sedation and General Anesthesia
Deep sedation, like minimal and moderate sedation, is drug-induced reduced alertness. But, in deep sedation, the patient cannot be easily stirred but can respond willfully with repeated or painful stimulation. Independent maintenance of the ventilatory function may also be impaired, and assistance in maintaining a patent airway may be needed. Spontaneous ventilation may also be insufficient, but the cardiovascular function is usually retained.
In general anesthesia, the patient is not arousable even by painful stimulation. Like deep sedation, the ventilatory function is often impaired. Maintaining a patent airway may require assistance and positive pressure ventilation may also be needed due to reduced spontaneous ventilation or drug-induced depression of the neuromuscular function. Different from minimal, moderate, and deep sedation, general anesthesia can impair the cardiovascular function.
Clinical guidelines for deep sedation and general anesthesia are almost similar to minimal, moderate, and deep sedation with the addition of other reminders.
For deep sedation and general anesthesia, the following guidelines must be noted and followed:
- Patient history and evaluation include a review of the medical history and medication use. Patients under ASA III and IV must consult with their physician. The patient’s BMI must also be part of the pre-procedural work-up as patients with elevated BMI have a higher risk of airway associated morbidity.
- Like other sedation, the patient or the guardian must be notified of the procedure associated with the delivery of any sedative or anesthetic agents. Informed consent for the recommended deep sedation or general anesthesia must also be obtained.
- An adequate supply of oxygen, as well as the equipment to be used for the delivery of oxygen under positive pressure, must be completed.
- A physical examination and measuring of the baseline vital signs must be conducted.
- Pre-operative written and verbal instructions must be relayed including the pre-operative fasting instructions.
- Unlike other sedation, in deep sedation and general anesthesia, an intravenous line must be established and secured throughout the procedure.
- Also, in these sedation methods, a minimum of three individuals must be present: a dentist qualified to perform deep sedation and general anesthesia and two individuals who have a current certification of successful completion of Basic Life Support Course for the Healthcare Provider.
- Necessary equipment must be available including resuscitation medications and defibrillator. Equipment and drugs needed to provide advanced airway management and advanced cardiac life support must also be readily accessible.
- When monitoring, a qualified dentist must be present at all times — until the patient meets the criteria for recovery and the criteria for discharge. He or she must monitor the oxygenation saturation continuously by pulse oximetry, ventilation, circulation, and temperature.
- A proper time-oriented anesthetic record must also be maintained. The record must include all drug dosages and their administration times, and the monitoring done.
- For recovery and discharge, constant monitoring must still be observed until the patient meets the standards or proper levels satisfactory for discharge. Post-operative verbal and written instructions must be relayed to the patient and guardian.
- Emergency situations must always be addressed with urgency, and proper actions must be given when such emergencies occur. The qualified dentist must provide the equipment, drugs, and protocols for the diagnosis and treatment of emergencies.
As deep sedation and general anesthesia are usually administered to patients, who are mentally or physically challenged. Because of this, a comprehensive physical examination and laboratory tests may be difficult to perform and complete. The qualified dentist administering the deep sedation or general anesthesia on patients with special needs must document the reasons why the recommended preoperative management is not done.
A dentist is qualified to administer deep sedation or general anesthesia only if he or she meets the requirements stipulated by ADA such as completion of an advanced education program accredited by the Commission on Dental Accreditation, a current certification in Basic Life Support for Healthcare Providers, either a recent certification in Advanced Cardiac Life Support or completion of an appropriate dental sedation/anesthesia emergency management course.
However, despite the presence of such guidelines as adopted by ADA, severe adverse events have happened about the administration of sedation and anesthesia including deaths — often due to drug overdoses, premature discharge, poor management in the early stages of a developing urgency, delayed calls to 911, among others.