There’s no better dental treatment than one carried out by a wonderful dentist with a soft hand. So soft, that you can’t even tell something significant is being done inside your mouth. That’s the sign of a great dentist.

But, regardless of how nice your dentist is or magical his or her hands are, people can be and are still terrified of the dentist or of getting any dental treatment done. Dentists have unfortunately been stereo-typed as those evil pain givers who do excruciating procedures within and around your teeth.

That’s not true, and the fault usually lies with the people who allow their dental health to deteriorate to an extent that such treatment is needed. As a result, they end up with an infection which could need more than just a simple filling, that will hurt and then the dentist becomes the culprit for causing pain. Makes sense, doesn’t it?

So, if you’re one of those people or know someone with an impossible-to-get-over fear of the dentist, there is a solution for you all – Sedation dentistry.

What is Sedation Dentistry?

Sedation Dentistry

The basics of sedation dentistry are simple: you are sedated to a certain degree while your treatment is performed by the dentist. You wake up with the completed dental treatment and never had to face the fear, pain or anxiety you felt while sitting in the dental chair.

To be more specific, it involves the use of pharmacological agents or drugs known as sedatives which act by exerting a depressive effect on the central nervous system, in those areas typically concerned with controlling conscious awareness.

Sedation dentistry is practiced by skilled, Board certified sedation dentists who use these pharmacological agents to induce sedation. It is meant to aid in treating dental anxiety, but is not the only solution.

For those who have severe dental anxiety or dental phobia, various psychological approaches, a very caring dentist and behavioral therapy may be helpful in addition to using sedatives for any dental procedure.

The States of Sedation

A certain level of sedation can also be achieved, such as minimal, moderate and deep sedation. These represent the levels of consciousness of the patient under sedation, which correspond to the degrees central nervous depression achieved by the sedatives.

Patients under minimal sedation are still conscious and responsive to their surroundings, with less anxiety. Moderate sedation relaxes the patient further, but a larger stimulus is needed to trigger a response. It is only under deep sedation that the patient is completely unaware of his/her surroundings and does not respond to any external stimulus.

Types of Dental Sedation

There are different types of dental sedation that may be used, according to what level of sedation is needed or required. A detailed description of each is given later.

Inhalation Sedation:

This form of sedation involves providing Nitrous Oxide gas, also known as ‘’laughing gas’’ or ‘‘happy gas’’. It allows slight analgesic effects and you are not completely unconscious while under its effects. It gives a feeling of light-headedness and reduces anxiety greatly. Most dentists prefer this form of sedation.

Oral Sedation:

As the name suggests, sedatives are given orally in the form of pills, normally a few hours before the dental procedure is scheduled to take place.

Intra-Venous (IV) Sedation

The sedative drugs are given directly by an IV line, into the venous blood stream. This is most effective and quickest form of sedation that can be given to a patient who is to undergo a dental procedure, and is preferred for lengthy, complicated cases such as extractions of all four wisdom teeth, complete mouth reconstruction and other complex dental surgeries. The patient is completely unconscious with no awareness of time and place and feels no pain.

Who is a Candidate for Sedation Dentistry?

Sedation is not for everyone – it meant to ease dental anxiety and to help with those who absolutely cannot be treated by the dentist without it. It is beneficial for both, the patient and the dentist, as it makes things a lot simpler for the dentist to treat an extremely dental phobic patient while the patient himself experiences a pain and anxiety free procedure.

Some factors that make one a candidate for sedation dentistry:

• Dental phobia or dental anxiety sufferers
• For those whom the dental procedure can be made more comfortable by a little laughing gas
• Those who have a great fear of needles and sharp dental instruments
• Patients who are extremely embarrassed about how bad their teeth have become
• Those whom have difficulty in becoming numb before a procedure
• Mentally unstable patients
• Patients with a strong gag reflex
• Those who need extensive oral surgery like full mouth reconstruction, multiple implants or who need to have all their wisdom teeth extracted at once
• Also, patients who wish to have all their dental work done in one, long sitting and simply don’t want to be aware of anything happening

There are some benefits of sedation dentistry too, which make sedation a good optional treatment adjunct for those who simply want a comfortable experience at the dentist:

• Complete relaxation and comfort of the patient
• More control for the dentist to perform the procedure quickly and effectively
• Patient’s gag reflex is controlled
• Time saving for both the dentist and the patient
• Better patient compliance

Sedation- How it Works

I’ll explain here how each form of sedation works, what their advantages and disadvantages are, what drugs are normally used and the contraindications of each type.

Inhalation Sedation

Inhalation Sedation

Inhaling ‘laughing gas’ or Nitrous oxide is considered the most convenient method of sedating a patient. All you literally do is make the patient breathe in some gas and there! You get a less anxious, more relaxed and happy patient. The best part is, their pain begins to diminish within four or five inspirations of the gas, so it acts really fast too.

Nitrous oxide is a mixture of nitrogen gas with oxygen, just to make it safer to use for longer. It’s a mixture of about 30% Nitrous oxide to 70% of Oxygen. The gas is administered through a nasal hood that you place over the patient’s nose, like those masks you wear for general anesthesia before a surgery. This nasal hood is attached to tubes which are connected to a cylinder of the compressed gas mixture. The knobs and on/off switches give the administrator control over how much gas to use and the flow-meters and pressure gauges are there for monitoring gas levels during administration.

Advantages

Happy gas has quite a few advantages, some of which are:

• It’s extremely safe, with minimal to no side effects on the organs in the body like the heart, lungs, brain, liver and kidneys.
• It works really fast, reaching the brain in about 20 seconds and having pain relieving properties taking effect in just 2 to 3 minutes
• Administration of the gas is under complete control of the administrator, so the depth of sedation can be altered easily, unlike with other forms of sedation.
• It lasts as long as the dentist needs for it to last, until the dental procedure is over, so it doesn’t have a fixed duration of action. It can thus be discontinued when it is no longer needed.
• You can easily prevent an overdose by giving incremental doses of the gas until the desired amount has been administered- this is called the ‘titration’ effect.
• It can even be used in place of local anesthesia for simple procedures such as scaling, as it has analgesic effects on the gums.

Disadvantages

Some possible disadvantages, if they should arise, are:

• It isn’t a good option for claustrophobic patients who can’t have something covering or blocking their nose
• Some people may not be able to undergo enough sedation through just laughing gas
• You may feel nauseous, but that’s only if you’ve over – eaten right before the dental treatment or are over – sedated.

There are just a few if any contraindications for taking Nitrous oxide as a sedative, such as during the first trimester of pregnancy, emphysema and M.S.

If you are unsure about being, you can always have a small test run before your dental procedure is scheduled to see if it suits you.

Oral Sedation

Oral Sedation

Oral sedation or anti-anxiety medications are another simple, straightforward way to sedate patients. The dentist just prescribes an appropriate ‘happy pill’ and the patient takes it a certain period of time before the dental treatment is scheduled, in order to let the drug take its effect. The pills work to relieve anxiety before the dental treatment.

The drugs normally used for this purpose are Benzodiazepines, also known as ‘benzos’. These work by binding to receptors in the brain and decrease the activity of those areas which control fear and anxiety.

Benzodiazepines come in two major types: sedative-hypnotics and anti-anxiety. The former, as the name suggests, induce sedative effects by calming the patient and also cause sleepiness and drowsiness. The latter produce calming effects. All benzodiazepines produce anti-anxiety and sedative effects, where some act in areas of the brain where emotions such as fear are controlled while others act on the areas controlling sleep and alertness. The dosage of benzodiazepines needs to be strictly followed, as controlling anxiety is what we need to do rather than heavily sedating patients and making them fall asleep!

These drugs are Central Nervous System depressants and so affect the heart and respiratory system by decreasing their rate and activity. This can be dangerous if you overdose on the drugs as your heart rate and blood pressure can fall extremely low, along with depressed breathing capabilities. Always strictly follow the dosage prescribed by your dentist and always inform him of any previously taken drugs and alcohol.

Reducing anxiety by decreasing the heart rate is what causes the calming effect of benzodiazepines, which is why they are so effective. They are dangerous only if you deliberately overdose on them, which of course, no one in their right mind would do!

The most widely used Benzodiazepines for oral sedation are:

• Temazepam (Restoril) – Ideally 30 mg works in about half an hour
• Diazepam (Valium) – 5-10 mg works in about an hour, effects lasting more than 20 hours
• Lorazepam (Ativan) – 2-3 mg works in about an hour, effects last up to 12-14 hours
• Midazolam (Versed) – works in about 20 minutes and is mixed into a drink (non-alcoholic!)
• Triazolam (Halcion) – mostly used as an alternative to IV sedation

Advantages

Advantages of oral sedatives are simple:

• They are in a single dosage pill form
• They are safe to use, given that the prescribed dosage is adhered to
• They work relatively fast, giving enough time for effects to kick in before the treatment is scheduled to begin
• Effects last long enough, so the dentist can perform the procedure with ease
• The patient too has a comfortable experience at the dentists, with some degree of slight memory loss of the whole ordeal – making even a long visit seem really short
• They can help to simply induce sleep to relieve anxiety the night before the dental visit, to ease the patient and help him/her rest

Disadvantages

There are some obvious disadvantages of oral sedatives as well:

• Patient compliance is required
• The effects are not immediate and last much longer than required
• The level of sedation cannot be altered or adjusted at the administrator’s will
• Effects vary depending on how well the drug is absorbed through the stomach
• The patient always needs a family escort to and from the dental clinic
• They can be highly dangerous, even fatal, if taken more than the required dosage
• Pregnancy
• Known allergies to the drug
• Severe respiratory disease such as COPD and chronic bronchitis
• Narrow-angle glaucoma
• Impaired kidney and/or liver function
• Congestive heart failure (CHF)
• Depression or bipolar disorder
• Therapy with other drugs

Contraindications- when not to use oral sedatives

One piece of advice – don’t take benzos with alcohol! Alcohol itself is a CNS depressant and the mixture of them both wouldn’t be such a great idea as it would double the depressant effects on the nervous system.

Intra-Venous (IV) Sedation

Intra-Venous (IV) Sedation

Intravenous Conscious Sedation is the administration of an anti-anxiety drug directly in the venous blood stream during a dental procedure. Yes, it’s literally like heroin addicts do it- only legally! It is given through IV (intra-venous) catheters which enter a vein either in the arm or on the hand, right before and during the dental treatment.

IV sedation is not meant to put the patient to sleep, as people commonly call it ‘sleep dentistry’. The patient is actually still conscious and can still respond to the dentist – he’ll just be extremely relaxed and least bothered about what’s happening in his surroundings. IV sedation also causes partial or full amnesia while the drug is being given, so the patient will probably not remember a thing when he comes back into full consciousness. What it does not do, however, is numb the patient, so a local anesthesia still needs to be given for the dental procedure.

IV sedatives, as the name suggests, are given through a vein. The IV catheter used is inserted into the surface of the skin and into a vein, either in the arm or on the hand. It’s a very fine needle wrapped within a soft plastic tube, and once it’s inside the vein, the needle is pulled out to leave the plastic tube in place and it stays in there throughout the dental procedure, hence is also known as an indwelling catheter. The drug is set to be given at a constant dosage via the catheter until the procedure is over. Oxygen and pulse rates are also monitored throughout the treatment with a ‘pulse oximeter’ which clips onto a finger, to make sure nothing goes wrong.

So, now that we know exactly what the IV sedation procedure is, we also need to know what drugs are used for sedation by this method. Of course, heroin is not of them!

Here’s a list of drugs used in Intra-Venous Sedation:

• Benzodiazepines (anti-anxiety sedatives)

1. Midazolam (usually preferred for its potency and short duration of action, 1mg every 2 minutes)
2. Diazepam (1mg per minute)

• Opioids (pain-killers) (usually given for post-op pain or as adjuncts to benzodiazepine)

1. Morphine
2. Meperidine
3. Butorphanol
4. Fentanyl
5. Nalbuphine
6. Pentazocine

• Barbiturates (now rarely used- only Pentobartbital Sodium in adjunct with opioids for its analgesic properties)
• Propofol (normally used for inducing General Anesthesia – but used when tolerance to benzodiazepines has developed).

Generally, midazolam is the first drug of choice for IV sedation, given the many options available.

NOTE: Only a qualified, board-certified IV specialist should carry out the IV sedation procedure.

Advantages

Using IV sedation has its advantages, which is why it’s so widely used!

• Fast onset of action of the sedative drug as it enters the blood directly, reaching the brain quickly
• A higher level or moderate sedation can be achieved, more than with inhalation or oral sedation
• Best method of choice if the patient does not wish to remember the procedure or be aware of it at all – as it causes amnesia for the duration of the entire treatment
• Patients are still conscious throughout the treatment and can still cooperate with the dentist
• Helps reduce the gag reflex to a minimum level, if not completely diminished

Disadvantages

Where there are advantages, there’s almost always some disadvantages:

• Some people may not like the amnesia effect of the IV sedatives, wanting to be aware of what’s happening around them
• Recovery time after the treatment is not immediate, and the patient will need an escort back home
• There could be slight complications at the site of the IV injection such as a hematoma (bruise) or slight pain post-operatively
• IV sedation is more expensive to get than oral or inhalation sedation
• Known allergy to the drugs used
• Pregnancy
• Alcohol abuse
• CNS depression
• Glaucoma
• Impaired kidney and/or liver function

Contraindications – when not to have IV sedation

• Known allergy to the drugs used
• Pregnancy
• Alcohol abuse
• CNS depression
• Glaucoma
• Impaired kidney and/or liver function

Now you probably know more than you thought there was to Sedation dentistry. It’s really just a matter of choice, if you want or need it, you can always have it done.

Quite intriguing it is, just the idea of being out of it while your teeth get fixed!

Author: Alina Nasir – Dental Consultant