Do you know and understand the different levels of sedation and the qualifications needed to administer each level?
Which route of sedation will work best for you?
Oral Sedation is not the same as IV sedation. These are the questions you need to know:
- Has oral sedation not met your needs?
- Is oral sedation the safest route of sedation?
Dr. Kandare is certified to administer nitrous oxide, oral sedation, and IV moderate sedation. He also works with a team of highly qualified Registered Nurses and Board Certified Anesthesiologists.
We have a solution for virtually any sedation need. Find out what most of our patients seem to think is the most clinically effective, safe and cost effective method of sedation.
Our goal is to meet whatever sedation need you may have. You owe it to yourself to give us a call for more information.
Sedation Facts You Need To Know to Be a Better Informed Consumer
I will present information in a series of videos and website productions that will edify you on most aspects of dental sedation. The attempt will be to educate you on sedation and hopefully make you a more informed consumer of dental sedation treatment.
I will attempt to explain the levels of sedation, the routes of sedation, and the qualifications to administer different levels of sedation. I will explain the difference between oral conscious sedation and intravenous (IV) conscious sedation. Which type of sedation do most people choose and why? So let's begin. back to top
Levels of Sedation
According to the American Society of Anesthesiologists (ASA), there are four levels of sedation. I will give you their formal definition and then try to exemplify each level for a better understanding.
Minimal Sedation– this type of sedation method is characterized as a minimally depressed level of consciousness produced by a pharmacological method that retains the patient’s ability to independently and continually maintain an airway and respond normally to tactile stimulation and verbal command. Although cognitive function and coordination may be modestly impaired, ventilatory and cardiovascular functions are unaffected. In accordance with this particular definition, the drug(s) and/or techniques used should cover a margin of safety wide enough never to render an unintended loss of consciousness. Furthermore, patients whose only response is reflex withdrawal from repeated stimuli would not be considered to be in a state of minimal sedation.
Another term that is used somewhat synonymously with minimal sedation is anxiolysis, which simply means the diminution or elimination of anxiety.
One of the key concepts with minimal sedation is the ability of the patient to remain in a conscious state. Even though there may be a modest impairment of cognitive ability, they can still respond to you in a normal manner. For example, I can ask them a question or lightly tap them on the shoulder and they can respond. Swallowing reflexes are intact and they have no problem breathing on their own.
I will use examples of alcohol consumption. I know many of you do not drink, but I think everyone has observed people at different levels of intoxication.
Minimal sedation may be equivalent to someone who has had 2-3 drinks. Obviously this is hard to quantify because everyone responds differently. This is an important point to remember because the same principal applies to sedative medications. That being said, we can still draw some general cogent conclusions.
The individual who is minimally sedated may or may not get a DUI but they are still able to function in a somewhat normal fashion. Maybe we can say the patient is awake but drowsy.
Patients at this level of sedation would be given a drug in an amount equal to or less than the minimal recommended dose (MRD) as recommended by the FDA for the drug's recommended purpose. For example, triazolam, which is a common oral sedation drug, would only be given in an amount no greater than 0.5mg to an ambulating (walking) or unmonitored person. Its intended FDA use would be for insomnia. back to top
Moderate Sedation– this type of sedation method is characterized as a drug induced level of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.
The key word here is purposeful. The patient can respond in a purposeful manner to verbal commands or light tactile stimulation. I can still ask the patient a question or tap them on the shoulder and they can respond, but it is purposeful. What does purposeful mean?
Again, I will use an alcohol example. This may be tantamount to someone who has had 4-9 drinks. There is quite a bit of variation because everyone responds differently. Factors such as tolerance, absorption, food intake, and metabolism can all affect the influence of alcohol. People also have different levels of susceptibility to the influence of alcohol. The same concept applies to sedative drugs.
This person may be asleep, but they can be easily aroused. Their cognitive function is noticeably influenced. They can respond, but may have to think about what they are saying.
All swallowing reflexes are intact and they have no trouble breathing on their own.
This person would be obviously intoxicated, but still able to function. They better not drive home. They would endanger themselves and others. They would definitely get a DUI. I think we have all witnessed folks at this level of intoxication.
For those of you who have had the pleasure of receiving a colonoscopy, you probably had moderate sedation. You would probably describe it as a pleasant experience, in which you remembered very little, if anything.
This is still considered to be conscious sedation. back to top
Deep Sedation– this sedation method is characterized as an induced state of depressed consciousness that's accompanied by partial or complete loss of protective reflexes, including the inability to continually maintain an airway independently and/or respond purposefully to physical stimulation or verbal command, and is produced as a pharmacological method, a non-pharmacological method, or a combination thereof.
The key words here are partial or complete loss of protective reflexes, particularly the swallowing reflex. They may lose the ability to breath on their own.
This person will not respond to verbal command or light touching. You have to shake the person to awaken them or arouse them with a painful stimulus.
They are asleep but difficult to arouse.
This would be the person who is so intoxicated that they have passed out. You would have to literally shake the person to get a response from them. If they were to regurgitate, they could very well asphyxiate on their own vomit.
This is not conscious sedation! back to top
General Anesthesia– this is an induced state of unconsciousness that's accompanied by partial or complete loss of protective reflexes, including the inability to continually maintain an airway independently or respond purposefully to verbal commands or physical stimulus. It is produced by a pharmacological method, a non pharmacological method, or a combination thereof.
The key word here is unconsciousness. The patient cannot be aroused by shaking or painful stimulation. You can cut a patient with a scalpel and they will not respond. This is surgical anesthesia. There is complete analgesia or pain control.
Protective reflexes such as swallowing are obviously impaired and the patient may not be able to breathe on their own.
This is very obviously not conscious sedation. It is also known as sleep sedation or anesthesia.
Conscious sedation is NOT sleep sedation. This is very important to understand. back to top
Routes of Sedation
I will next try to explain the various routes of sedation.
First, I would like to discuss various means of non-drug relaxation. Some dentists may refer to this as relaxation dentistry, but it is not sedation dentistry by means of a sedative agent.
Some of the techniques are good chairside manners, talking in a low voice, holding an assistant's hand, being kind, using gentle injection techniques, using topical anesthesia, shaking the cheek during an injection, using the wand, using headphones, watching TV, warm compresses, aromatic smells, pedicures, manicures, hypnosis, etc.
I think you get the point. Obviously, all of these things do make a difference.
A gentle caring doctor is of paramount importance. You may have even seen this marketed as "gentle dental." As much as this helps, it is not enough for those of you who need more. You know who I am talking about if you are one of those types.
Inhalation Sedation: Nitrous Oxide is the inhalation gas that's commonly used in dentistry. It is sometimes referred to as laughing gas or sweet air. There are stronger inhalation agents used for general anesthesia, but not in a dental office. Nitrous does afford some analgesia and relaxation. It is a very safe gas. It is not metabolized by the body. In other words, it comes out the same way it went in. It is very safe to use. Nitrous, when used alone, is at the low end of sedation. When used properly, it will only provide a light level of sedation. It works for some people, but not for those with an appreciable degree of apprehension. If used in combination with other sedative agents, it produces a much more significant effect. back to top
Oral or Enteral Sedation: This is what most of you see that's marketed as sedation dentistry or "Oral Conscious Sedation."
There are actually three means of enteral sedation. Enteral sedation passes through the gastrointestinal system. It can be delivered orally, rectally, or sublingually (under the tongue.) It is usually delivered orally or sublingually.
There are pros and cons to its use. The biggest pro is that it is easy to administer. You just swallow the pill.
There is a very important concept to understand at this point. There is a thing in sedation and anesthesia that is called "Titration To Desired Effect." This means that you can deliver a drug in very small amounts until you reach the desired level of sedation. This is very important with respect to safety of the drugs and not overshooting or undershooting the desired level of sedation. If you remember the levels of sedation, the intent of conscious sedation is to never go deeper than moderate sedation. Your intent is to never sedate to the level of deep sedation. Remember the differences between the two?
The problem with oral sedation is that you cannot titrate to effect. The drug has to first go through the GI system where it then goes to the liver, in what we call "the first pass effect."
After swallowing the pill, it has to be passed through the stomach to the small intestine. Obviously, it has to go through an absorption process which takes time. After the small intestine, it is passed to the liver where the drug is then metabolized to a certain extent. It is then passed into the circulatory system, where it will then eventually reach the central nervous system (CNS) and reach the brain. Once it reaches the brain, it will then manifest the sedative effects of the drug.
Obviously, only a portion of the drug will ever reach the brain. There is a time delay from administering the drug before an effect is seen. This time delay is generally about an hour.
An example is the use of triazolam as a sedative agent. It is probably the most common or popular agent used for oral sedation. Other agents, such as lorazepam and valium, are also used but triazolam is probably the most popular. The concept is basically the same for all of the oral agents.
Usually a dose of triazolam is given an hour before the appointment. The patient arrives at the office and they are evaluated for their response to the dose given. At that point, a determination is made as to how much more of the drug should be given. This can be a little hard to determine. If needed, another dose is given. It takes triazolam about 30 minutes before you start to see an effect. It takes 75 minutes to reach it's full effect. What if the dose you gave was not enough? Do you give more and if so, how much? In reality, you need to wait 75 minutes or at least an hour before you will know the true effect of the last dose given. You spend a lot of time waiting. Can you overshoot or undershoot? You have no way of knowing until you see the complete effect of the drug, which, again, will take at least an hour to reach full effect.
Oral sedation has the ability to take a patient all the way to deep sedation and loss of consciousness. back to top
Intravenous or IV Sedation: IV sedation is accomplished by placing an IV catheter directly into a vein. It allows the sedative drug to go directly to the brain. There is no delayed reaction due to absorption and metabolism as experienced with oral sedation. You will know generally within 2-3 minutes the effect of the drug. It can very easily be "Titrated To Effect."
Midazolam or Versed is probably the most commonly used drug for IV moderate sedation. It is the benzodiazepine drug of choice by most anesthesiologists. It has been used for years and is cleared by the FDA for IV sedation. It will reach its therapeutic effect in 2-3 minutes. You will not experience many of the drug reactions with Versed that you will experience with oral sedatives. IV administration of a drug is much more precise and can render a much more effective means of sedation.
In fact, I will say it is virtually unanimous that it is the preferred delivery style by Oral Surgeons, as well as Dental and Medical Anesthesiologists. IV administration allows for the more safe and effective precision delivery of the sedative drug. IV drugs can be titrated. Oral sedation drugs are not titrated but given in incremental doses. If multiple drugs are given orally, they are "stacked" instead of titrated, with more unpredictable results.
I have performed about 500 oral sedation cases and 500 IV cases. I initially started with oral before I got my license to administer IV sedation. After performing both oral and IV, I almost exclusively administer IV sedation because of its predictability. I think this is in concert with the opinion of anesthesiologists. I will admit this is my personal bias, but I think it is well founded. My experience has shown that IV is the superlative route.
At this time, I generally like to limit oral sedation to mild sedation. This way, I can keep things safer and more controlled. I can keep things in line with the FDA recommended amount for dosing of a particular oral drug. I understand there are many who use oral exclusively but it is not my favorite choice for moderate sedation. back to top
Intramuscular and Subcutaneous Sedation: These are other routes of administration but they are not commonly used in the dental setting for sedation purposes.
Qualifications for Sedation
All states require proper qualification for the administration of the various means and levels of sedation. There are differences amongst states but they all share many of the same regulations.
Mild sedation has the fewest requirements since the doses given are many times prescribed by MDs on an ambulatory basis for at-home use without monitoring. If used within the prescribed guidelines, mild sedation is quite safe.
Since all states are different, I can only speak for the regulations for the Commonwealth of VA.
Oral Conscious Sedation: 18 hours of approved education with 20 virtual patient experiences. This is for the level of moderate sedation.
IV Conscious Sedation: 60 hours of approved education through an accredited agency such as a hospital or university with the treatment of at least 20 live patients under supervised instruction. Again, if kept within the prescribed intended level of sedation, it is very safe and effective. back to top
Deep Sedation and General Anesthesia are generally administered only by licensed Oral and Maxillofacial Surgeons, Certified Registered Nurse Anesthetists, and Anesthesiologists. To see the necessary qualifications for each of these specialties or for further clarifications of the qualifications I have listed for moderate sedation, you can google each individual state board for more in-depth clarification.
So the question remains: what is the favorite route of sedation? I can only speak for my patient population.
- For patients needing only mild sedation, oral sedation seems to work very well.
- For patients needing moderate sedation, the overwhelming majority get IV sedation for its precision, safety, efficacy, and cost.
- For those needing more, deep sedation or general anesthesia is the right choice.
We strive to offer whatever modality best suits the patient. We work with a team of three Registered Nurses, three Board Certified Anesthesiologists, and my staff and I. We feel we can handle most situations for adults. Pediatric sedation is another matter and we refer to the appropriately trained specialists.
Our fee scale depends on the level of sedation. It is less for mild sedation. Our fees are roughly the same for oral or IV moderate sedation. At this time, I am keeping the moderate fees basically the same whether it is oral or IV. Even though there is much more involved on our side for IV, most patients hands down opt for the IV route.
If we utilize the services of an anesthesiologist, the fee obviously increases, but for those who need it, it is worth the additional fee.
The bottom line in my practice is IV moderate sedation. It works for probably 98% of our patients at a very reasonable fee. It generally gets the job done nicely.
I have roughly 300 certified hours in sedation and emergency protocols. I am certified in VA to administer nitrous, oral, and IV moderate sedation. I received my IV training at Albert Einstein Medical School, earning 90 didactic hours and treating 46 live patients. I receive my ACLS certification annually and my entire staff is BLS certified and trained.
Sedation is an ever evolving practice. We are always striving to improve our practice in the art and science of sedation. back to top
Proper monitoring is essential to ensure your safety during your sedation experience. I will outline some of the necessary forms of sedation monitoring.
It really starts with an adequate and complete medical history. Conditions such as past heart attacks, strokes, high blood pressure, chronic obstructive pulmonary disease, asthma, diabetes, obstructive sleep apnea, etc. are absolutely essential to know.
The American Association of Anesthesiologists has different classifications or grades of health.
- ASA I is essentially a healthy person
- ASA II is someone with a mild systemic condition. An example would be someone with well controlled hypertension.
- ASA III is someone with moderate to severe systemic problems that does not pose a constant threat to their life. They are well functioning if their problems are under control. An example might be an individual with HBP, diabetes, and asthma, but who has things well under control.
- There are more advanced classifications, but they are not allowed to be treated in an ambulatory facility.
Anyone who is classified as an ASA III must have a clearance with their physician before treatment.
We also routinely take baseline vitals. We take blood pressures, pulse, SpO2 or tissue oxygenation readings, BMI or weight classifications, and airway evaluations, to name the basics. If someone has uncontrolled high blood pressure, they need to get it under control first. A high BMI or weight may be a contraindication to treatment. COPD may also be a contraindication to treatment.
In other words, probably the most important aspect of sedation is obtaining an accurate and comprehensive medical history, including baseline vitals with an appropriate consultation with the physician when indicated.
Before starting the sedation procedure, all vitals are again taken with an assessment of the individual. If performed properly with good monitoring, sedation can be a very successful and safe procedure. back to top
We have various means for monitoring patients:
- Blood pressure readings and pulse are recorded automatically every 5 minutes.
Tissue oxygenation is recorded continuously. This is a reading of how well your tissues are perfused with oxygen.
- Perhaps one of the most important aspects of monitoring is a patient's breathing or ventilation. There obviously has to be a patent airway for oxygen to get to the lungs so that it can then perfuse to the tissues. Our pulse oximeter, which measures the SpO2 or oxygenation of tissues is important, but it does not tell us everything. It is old news. If a person is receiving additional oxygen, which they generally are, there may be a five minute or more delay from the time a person stops breathing before it is seen on the pulse oximeter.
It obviously becomes of paramount importance to know if a patient is breathing. If a person is in a state of mild to moderate sedation, they are cognitively aware and awake. Remember the levels of sedation. They are conscious and have their reflexes intact. We know they are breathing. If a person may doze off from just being relaxed, not from too much sedation, if they slip into a state of deep sedation or general anesthesia, or if for any reason they stop breathing, we want to know immediately. Typically, this would result from an obstructed airway from relaxed pharyngeal muscles. It can be treated as long as it is promptly recognized.
Obviously, if a person is conscious and mentating, that is recognizable. Visible signs of the chest rising and falling are obvious. The deeper a patient is sedated, the more crucial monitoring becomes. Remember the pulse oximeter is old news.
- Perhaps one of my favorite monitoring techniques is the use of capnography. Capnography actually shows you on a screen the patient's actual breathing and measures the amount and level of carbon dioxide exhaled. This is the true measure of ventilation or breathing. It actually shows you in wave form the quality of breathing as well as the actual amount of CO2 expired. It also measures the rate of respiration. With just a glance, it tells you what is happening. It is mandated for the use of deep sedation and general anesthesia, but it is not required for moderate sedation. However, I routinely use it in my practice for moderate or conscious sedation. It really gives me an extra degree of monitoring that I have come to appreciate. I would not work without it. back to top
- We also have what we call a precordial stethoscope. It is attached to the patient's throat with connecting ear attachments, which I wear. With this, I can hear every breath sound the patient makes. I can know the minute they stop breathing. We can also connect the stethoscope to a bluetooth device with a loud speaker. When connected, this amplifies each breathing sound so that everyone in the room can hear it. Some may consider this going overboard, but we have come to really appreciate these monitoring devices. We consider it well worth the investment.
- We also have a 3 lead ECG machine which has the capaChesapeake to measure the pulse rate.
- We also measure blood sugar levels before, during, and after treatment on our diabetic patients.
I could talk at length about monitoring, but suffice to say, proper monitoring is a requisite for sedation and for your safety.
By following proper protocols, taking good medical histories and baselines, having the proper qualifications, and relying on careful monitoring, sedation can be a great experience for all apprehensive patients. In fact, if it were not for sedation, there would be many dental cripples. There is now a way for virtually any frightened person to have their dental treatment in a relaxed and comfortable way.
All you have to do is give us a call.