Conscious Sedation

 The most reliable means of providing painless surgery is effective

administration of local anesthesia. However, patients who are apprehensive
(anxious or fearful) may require treatment under mild or moderate sedation.
 The use of sedation can help make patients more comfortable during
periodontal and implant surgery, especially when the procedure is expected
to continue for 2 hours or more.
 Routes of administration for sedation agents include inhalation, oral,
intramuscular, and intravenous.
 Many patients delay or avoid having needed dental treatment because
of fear and anxiety. In order to overcome this avoidance of procedure
they opt for sedation or anesthesia.
 High levels of anxiety (i.e., stress) can affect wound healing after periodontal
treatment. For these reasons, it is important for clinicians who provide
advanced periodontal and implant therapy to be knowledgeable and
skilled in providing sedation to reduce anxiety in their patients.

American Dental Association Policy Statement and Guidelines for

Conscious Sedation
 The American Dental Association (ADA) released three documents related to
the use of sedation and general anesthesia in dentistry.
 1) the ADA Policy Statement on the Use of Sedation and General Anesthesia by
Dentists,2) the ADA Guidelines for the Use of Sedation and General Anesthesia
by Dentists,3) the ADA Guidelines for Teaching Pain Control and Sedation to
Dentists and Dental Students.
 The purpose of the guidelines is to assist dentists in the delivery of safe and
effective sedation and anesthesia.
Definitions and Levels of Sedation:

Pediatric Sedation
 Sedation is often administered to children to control behavior, which often
requires deeper levels of sedation. Children can become moderately sedated
despite an intended level of minimal sedation.
 Except in extraordinary situations, the use of preoperative sedatives for
children must be avoided because of the risk of unobserved respiratory
obstruction during transport by untrained individuals.

Adult Sedation
 Minimal sedation can be achieved by the administration of a drug (singly or in
divided doses) by the enteral route to achieve the desired clinical effect.
 Inhalation sedation with nitrous oxide and oxygen (N2O/O2) can be used in
combination with a single enteral drug for minimal sedation.
 When used in combination with one or more sedative agents, N2O/ O2 can
produce sedation that is minimal, moderate, or deep, and in some cases it can
produce general anesthesia.
 The maximum recommended dose (MRD) is the maximum FDA
recommended dose of a drug as printed in FDA-approved labeling for
unmonitored home use.
 A patient whose only response is reflex withdrawal from a painful stimulus is
not considered to be in a state of moderate sedation.
 Titration is the administration of incremental doses of an intravenous or
inhalation drug until a desired effect is reached.
 Knowledge about each drug’s time of onset, peak response, and duration of
action is essential to avoid over sedation.

2
3
Clinical Guidelines for Minimal and Moderate Sedation
 History and evaluation: The patient’s health status is assessed before any
sedation procedure. Evaluation includes determination of the ASA physical
status (ASA) (Table 38.1).
 For healthy or medically stable individuals (i.e., ASA 1 or 2), a review of the
medical history and medication use may be adequate. For patients with
medical considerations (i.e., ASA 3 or 4), a consultation with the primary care
physician or consulting medical specialist is indicated.
 The evaluation must include a focused physical examination, including
baseline vital signs and a focused examination of alertness, respiratory
function, airway, and appearance, as well as a specific evaluation of identified
medical conditions (Box 38.1 and Fig. 38.3).
 Assessment of body mass index (BMI) should be considered for patients
undergoing moderate sedation.
 Preoperative Preparation: The patient, or a parent, guardian, or
caregiver if the patient is a minor, must be informed about the planned
procedure that will occur while under sedation, including benefits, risks,
and instructions for sedation (Fig. 38.4). Informed consent for the
proposed procedure and sedation must be obtained.

4
 Determination of an adequate oxygen supply and the equipment necessary to
deliver oxygen under positive pressure must be completed.
 Baseline vital signs, including weight, height, blood pressure, pulse rate, and
respiration rate, must be obtained. For moderate-sedation patients, blood
oxygen saturation must be obtained by pulse oximetry.
 Body temperature should be measured when clinically indicated. For
moderate sedation, this includes preoperative fasting instructions should be
given.
 Preoperative dietary restrictions are based on the sedation technique
prescribed (Boxes 38.2 and 38.3). For moderate sedation, NPO (nothing by
mouth) status should be confirmed.
 Personnel and Equipment: At least one person trained in basic life support
(BLS) for health care providers must be present in addition to the dentist.
 Monitoring equipment includes a sphygmomanometer, positive-pressure
oxygen delivery system, suction, and, if inhalation sedation is used, a fail-safe
and scavenging system.
 In the case of moderate sedation, a pulse oximeter, equipment for
monitoring end-tidal carbon dioxide (CO2), a precordial or pre-tracheal
stethoscope, equipment for intravenous or intraosseous access, and reversal
agents for drugs used must be available.
 A positive-pressure oxygen delivery system suitable for the patient being
treated must be immediately available.
 When inhalation equipment is used, it must have a fail-safe system that is
appropriately checked and calibrated.
 The equipment must also have a functioning device that prohibits the delivery
of less than 30% oxygen or an appropriately calibrated and functioning in-line
oxygen analyzer with an audible alarm.
 An appropriate scavenging system must be available if gases other than
oxygen or air are used.

5
 For moderate sedation, the equipment necessary to establish intravascular or
intraosseous access should be available until the patient meets the discharge
criteria.
 This includes a catheter or butterfly needle, an intravenous drip line, a
solution bag (i.e., saline or dextrose), a tourniquet, and appropriate antiseptic
or dermal disinfectant (Fig. 38.5). For moderate sedation, the equipment
necessary for monitoring end-tidal CO2 and auscultation of breath sounds
must be immediately available
 Monitoring (read): For minimal sedation, a dentist or, at the dentist’s
direction, an appropriately trained individual must remain in the operating
room during active dental treatment to monitor the patient continuously until
he or she meets the criteria for discharge to the recovery area.
 In the case of moderate sedation, a dentist administering moderate sedation
must remain in the room to monitor the patient continuously until he or she
meets the criteria for recovery.
 When active treatment concludes and the patient recovers to a minimally
sedated level, a qualified auxiliary may be directed by the dentist to remain
with the patient and continue to monitor him or her as explained in the
guidelines until discharged from the facility.
 The dentist must not leave the facility until the patient meets the criteria
discharge and is discharged to go home with a responsible adult (Box 38.5).
 Vital signs, level of sedation, and oxygen perfusion must be continuously
monitored throughout the conscious sedation procedure.
 Circulation For minimal sedation, blood pressure and heart rate should be
evaluated preoperatively, postoperatively, and intraoperatively as necessary.
 For moderate sedation, the dentist must continually evaluate blood pressure
and heart rate unless invalidated by the nature of the patient, procedure, or
equipment, and this information is noted in the time oriented anesthesia
record.

6
 Continuous electrocardiographic monitoring should be considered for
patients with significant cardiovascular disease. All-in-one monitors with
printers can efficiently perform these functions.
 Consciousness The level of consciousness or sedation (e.g., responsiveness to
verbal command) must be continually assessed. (table 38.3 in end)
 Ventilation and Oxygenation For minimal sedation, the dentist or
appropriately trained individual must observe chest movements and verify
respirations.
 Oxygen saturation by pulse oximetry may be clinically useful and should be
considered.
 For moderate sedation, the dentist must observe chest movements
continuously, and oxygen saturation must be evaluated continuously by pulse
oximetry.
 Ventilation should be monitored by continual observation of qualitative signs,
including auscultation of breath sounds with a precordial or pre tracheal
stethoscope.
 The color of the mucosa, skin, or blood must be evaluated continuously to
assess oxygenation
 The Pao2 level is what determines how much oxygen is entering the body
tissues and is referred to as oxygenation. Normal oxygenation is defined as a
Pao2 of 80 to 100 mm Hg.
 Ventilation or breathing can also be assessed by monitoring end-tidal CO2
(i.e., capnography). A capnography monitor provides a measure of exhaled
CO2 that is more effective than pulse oximetry.
 It provides an immediate alarm for life threatening breathing problems
during moderate sedation.
 Pulse oximeters, which have been the standard of care, take much longer to
register respiratory distress because oxygen levels in the blood can remain
normal for several minutes after a patient stops breathing. Capnography
provides earlier detection.

7
 Documentation ( read) An appropriate, time-oriented anesthetic record (Fig.
38.6) must be maintained with the names of all administered drugs (including
local anesthetics) along with dosages, times administered, and routes of
administration.
 Physiologic parameters, including heart rate, respiratory rate, blood pressure,
and level of consciousness, must be recorded.
 The anesthesia record should also include BMI, Mallampati classification, and
capnography information.
 Recovery and Discharge (read) Oxygen and suction equipment must be
immediately available in the treatment room and the recovery room (if a
separate recovery area is used).
 The qualified dentist must determine and document that the levels of
consciousness, oxygenation, ventilation, and circulation are satisfactory
before discharge (see Box 38.5).
 Postoperative verbal and written instruction must be given to the patient and
a responsible adult (e.g., parent, escort, guardian, or caregiver).
 If a reversal agent is administered before discharge criteria have been met,
the patient must be monitored until recovery is ensured.
 A potential problem when using reversal agents is the possibility that the
duration of action of the reversal agent can be shorter than the sedative
agent used, and the patient can become sedated again.
 It is critical for the clinician to understand and appreciate the duration of
action of all sedative and reversal agents used.

Sedation Failures (read)

 When performing outpatient mild or moderate sedation, the clinician must
realize that sedation will not be 100% effective for all patients.
 (Table 38.5). If a patient is not responding to the sedation procedure, it is
extremely hazardous to go beyond dose limits or to attempt putting the
patient into a deeper level of sedation.

8
 It is best to abort the procedure and reschedule the appointment for another
day, with a different technique or with a dental anesthesiologist.

Emergency Preparedness (read)

 Practitioners intending to produce a given level of sedation should be able to
diagnose and manage the physiologic consequences for patients whose level
of sedation becomes deeper than initially intended (i.e., rescue).
 For all levels of sedation, the practitioner must have the training, skills, drugs,
and equipment to identify and manage such an occurrence until assistance
arrives (i.e., emergency medical service) or the patient returns to the intended
level of sedation without airway or cardiovascular complications.
 The qualified dentist is responsible for sedation management, adequacy of
the facility, competence of the staff, diagnosis and treatment of emergencies
related to the administration of sedation, and providing and maintaining the
equipment and protocols for patient rescue.
 If a patient enters a deeper level of sedation than the dentist is qualified to
provide, the dentist must stop the procedure and focus attention on the
patient until his or her condition returns to the intended level of sedation.
 This can involve monitoring the patient, providing airway management and
support, administering reversal agents, or activating the emergency medical
service.

9
10