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Ce: an Overview Sedation in the Dental Office: An Overview Hussein M. Assaf, DDS, MS; Marna L. Negrelli, RDH Continuing Education Units: 2 hours Online Course: www.dentalcare.com/en-US/dental-education/continuing-education/ce464/ce464.aspx Disclaimer: Participants must always be aware of the hazards of using limited knowledge in integrating new techniques or procedures into their practice. Only sound evidence-based dentistry should be used in patient therapy. Dental anxiety can be a barrier to the patient to seek dental treatment and a challenge to the treating dental team. An overview of the available pharmacological means to manage the anxious patient in the dental office is presented. The advantages and disadvantages as well as indications and contraindication of each sedation modality are discussed. Conflict of Interest Disclosure Statement • The authors report no conflicts of interest associated with this work. ADA CERP The Procter & Gamble Company is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at: http://www.ada.org/cerp 1 ® ® Crest Oral-B at dentalcare.com Continuing Education Course, January 5, 2015 Approved PACE Program Provider The Procter & Gamble Company is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of this program provider are accepted by AGD for Fellowship, Mastership, and Membership Maintenance Credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 8/1/2013 to 7/31/2017. Provider ID# 211886 Overview Dental anxiety can be a barrier to the patient to seek dental treatment and a challenge to the treating dental team. An overview of the available pharmacological means to manage the anxious patient in the dental office is presented. The advantages and disadvantages as well as indications and contraindication of each sedation modality are discussed. Learning Objectives Upon completion of this course, the dental professional should be able to: • Understand the history of modern sedation in the dental office. • List the different levels of the sedation continuum and their features. • Recognize the ADA educational requirements for the various levels of sedation. • List the different sedation techniques available to the trained dentist. • Discuss the advantages and disadvantages of each of the sedation techniques. • Discuss the indications and contraindications of the different sedation methods. • Discuss the pre-sedation assessment of patient physical status. Course Contents • Introduction ranges from 4% to 20%.2-5 While the cause or • History source of dental anxiety may be influenced by • Sedation Continuum cultural differences, the prevalence of anxiety • Levels of Sedation seems to transcend countries and cultures.6,7 Minimal Sedation (Anxiolysis) Moderate Sedation Depending on the severity of dental anxiety and/ Deep Sedation and General Anesthesia or phobia, it may lead to broken appointments, • Clinical Considerations postponing treatment and in some severe cases, Oral Sedation a complete avoidance of professional oral Inhalation Sedation care.8 Ultimately, severely anxious and fearful Intravenous Sedation patients have increased number of decayed and • Patient Evaluation and Assessment decreased number of restored or functional teeth.9 • Conclusion Such patients usually require more extensive and • Course Test Preview complicated treatment, which causes additional • References fear and anxiety to the patient and increased • About the Authors stress to the dental team.10-12 Introduction Regardless of the cause and level of anxiety Although the public’s opinion of dentistry as a which may vary among phobic patients, all profession has always been mostly favorable, a patients expect and deserve treatment in a visit to the dental office has remained a source safe environment without fears and stress. In a of fear and anxiety for a substantial number of successful practice, the management of patient patients.1,4 It has been shown that the percentage anxiety is paramount for both the patient and the of people with dental anxiety in western societies dental team. As in any other dental procedure, 2 ® ® Crest Oral-B at dentalcare.com Continuing Education Course, January 5, 2015 understanding the patient’s needs, expectations, Over the past decades, the efforts and contributions fears and apprehension is the first step in of many great practitioners led to the modern successfully managing the patient. practice of intravenous sedation in ambulatory settings. The technique of administering multiple Malamed coined the term ‘the pain of fear’ to drugs to induce sedation by titration was introduced describe a circular relationship between pain and be Niels Bjorn Jorgensen (1945) who is recognized fear, where dental fear ultimately leads to more as the father of intravenous sedation in dentistry. anxiety.13 This leads to poor oral health, and the This technique deservedly bears his name as the negative effect of dental anxiety on oral health Jorgensen technique.23 leads to reduced quality of life.10,14-19 The aim of this article is to provide an overview of conscious Sedation Continuum sedation in dentistry, and the various techniques Just as the history of sedation is a continuum of available to the dental professional. It is by no events and discoveries, it is important to understand means intended to be an instructional guide on that sedation itself is a continuum. The boundaries the use of sedation in the office. between the different levels of sedation may not always be evident to the untrained or inexperienced History and progression from one level to a higher level The contributions of dentistry to the management may quickly occur as patients do not always of pain and anxiety have been well-documented.20,21 respond predictably to any particular sedative In 1844, Dr. Horace Wells, a dentist from New agent, i.e., they may respond idiosyncratically. England, in public demonstration to the staff Table 1 summarizes the different levels of sedation of the Massachusetts General Hospital, used continuum and their characteristics. nitrous oxide to sedate a patient undergoing tooth extraction. The demonstration was deemed Levels of Sedation a disaster when the patient cried or moaned Definitions of sedation and guidelines are published during the procedure. Two years later, in 1846, by several dental professional organizations, Dr. William T.G. Morton, on the same stage, notably the American Academy of Pediatric successfully demonstrated the use of ether during Dentistry, the American Association of Oral tooth extraction. Maxillofacial Surgeons, and the American Dental Association (ADA). Information on the guidelines Dr. Wells and Dr. Norton are considered the can be found on their respective websites.24-28 fathers of anesthesia (although official recognition is given to Dr. Wells) for the introduction of The ADA’s guidelines also include the educational nitrous oxide and for the successful use of ether, requirements needed to qualify a dentist to provide respectively.22 It is of note, that twenty years after sedation in their office as well as guidelines for Dr. Wells’ ill-fated demonstration, the use of 100% teaching sedation to dentists and dental students.28 nitrous oxide was popularized by Dr. William Although most state dental boards base their T.G Morton in 1863.23 The current practice of requirements on the ADA guidelines, dentists using a mixture of nitrous oxide and oxygen was should contact their respective state board for introduced by Andrews in 1869.23 specific information. Table 1. The Sedation Continuum. 3 ® ® Crest Oral-B at dentalcare.com Continuing Education Course, January 5, 2015 Sedation is defined as the use of a drug or a accompanied by light tactile stimulation (e.g., open, combination of drugs to depress the central nervous close...). No interventions are required to maintain system (CNS), thus reducing the awareness of the a patent airway and spontaneous ventilation is patient to their surroundings. Depending on the adequate. Cardiovascular function is usually degree of CNS suppression, the sedation may be maintained. In this state, the reflex response to conscious, deep, or general. Sedation does not pain is not considered purposeful. control pain and, consequently, does not eliminate the need for the use of local anesthetics. • Educational Requirements for Moderate Enteral (i.e., Oral) Sedation Conscious sedation is a controlled, In addition to the nitrous oxide/oxygen course pharmacologically induced, minimally depressed described under minimal sedation, the dentist level of consciousness that retains the patient’s must complete a minimum of 24 hours of ability to maintain a patent airway independently didactic instructions as well as 10 adult clinically and continuously and respond appropriately to oriented cases that include 3 live clinical physical and/or verbal commands. The drugs cases. The dentist should also demonstrate used should have a wide margin of safety to competency in airways management, i.e., be prevent loss of consciousness. BLS and Advanced Cardiac
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