Sedation is most commonly used during extensive procedures, for patients with dental phobia or for patients who find it difficult to sit still. There are different types of sedation, including nitrous oxide (“laughing gas”), IV sedation, oral sedatives and general anesthetic.
Sedation is endorsed by the American Dental Association and is an effective way to make many patients comfortable during their dental visit. Before using a sedative or anesthetic, it is important to tell us about any medications or medical treatments you are receiving. Before administering any sedative or anesthetic, we will talk to you about the process of sedation and pre- and post-sedation instructions.
Nitrous oxide, more commonly known as laughing gas, is often used as a conscious sedative during a dental visit. The gas is administered with a mixture of oxygen and has a calming effect that helps phobic or anxious patients relax during their dental treatment. Because it is a mild sedative, patients are still conscious and can talk to their dentist during their visit. After treatment, the nitrous is turned off and oxygen is administered for five to 10 minutes to help flush any remaining gas. The effects wear off almost immediately. Nitrous oxide rarely has side effects, although some patients may experience minor nausea and constipation.
For those patients who require a higher level of sedation, we offer conscious sedation in our office. With our level of conscious sedation, the patient still breathes on their own but is unaware of any treatment being performed.
Our goal is to allow a necessary procedure to be accomplished, in an office setting, safely and comfortably.
An intravenous (i.v.) catheter is started, and connected to tubing and i.v. fluid. The i.v. is used to administer the sedative drugs, and any additional drugs which may be necessary. It also provides access in the unlikely event that emergency drugs need to be given. Depending on the individual situation, an oral medication may be ordered prior to, or upon arrival of the office.
Oral pre-op medications are occasionally given, and these are usually a sedative type drug. I.V. medication is typically composed of midazolam (Versed), a sedative, ketamine, a dissociative drug, and an amnestic/hypnotic called propofol (Diprivan). These are given according to the patient’s weight, and are administered by an infusion pump, which can be adjusted on a moment-to-moment basis. The effect of these drugs are short-lived, and therefore wear off very quickly. Oxygen is usually used.
An EKG monitors the heart rhythm. A pulse oximeter monitors blood oxygen levels. Respiration is monitored, utilizing capnography and direct observation. An automatic blood pressure monitor is also used. Close observation is employed.
Recovery and Post-op
Patients are usually ready to leave the office within one hour of the conclusion of the procedure. They will be able to sit and stand without any undesirable symptoms, and they will be able to walk by themselves or with minimal help. The patient should take pain medications, as prescribed by their doctor, without worry of interaction with any of the sedative drugs. They may eat or drink as allowed by their doctor. They should not drive, operate machinery, or make important decisions until the next day. They must have an adult available at their home on the evening of surgery.
I.V. Starts in Uncooperative Mentally Handicapped Adults
If you believe the patient cannot cooperate with an i.v. start, we will modify our approach. We will administer an intramuscular injection in the patient’s buttock, leg, or arm. This can be accomplished through the clothing, if necessary. The medicine is not painful, just the needle stick. Within 3-4 minutes they become drowsy, stare vacantly, and often become flaccid. The i.v. will then be started without the patient’s awareness.
All anesthetics carry a risk. These include, but are not limited to cardiac arrest, allergic reactions, aspiration of stomach contents into lungs, nerve damage, and even death. With modern anesthetic agents and monitoring devices, however, the overall risk in the United States is very small. Indeed, statistically, your chances of death are greater during your trips to and from the facility, than during the anesthetic itself. We have resuscitation equipment and medications on hand, as well as years of experience in dealing with emergencies and airway management in the hospital setting.
The alternative site for your procedure would be a hospital or ambulatory surgery center setting. Non-treatment is also an alternative.
To allow your child’s dental procedure to be accomplished, in an office setting, safely and comfortably.
An intravenous (i.v.) catheter is started, and connected to tubing and i.v. fluid. In most cases we will ask one of the parents to sit in the dental chair, with the child on their lap. The parent will help keep the child looking away from the anesthetist (often with the help of another family member), while the i.v. is started. Your child will experience only a slight sting. Typical reactions range from mild suprise to a little crying. Medications can then be swiftly given, to have the child sleeping within seconds.
In children who are unable to tolerate this, we will administer an intramuscular injection of medications (see below) which will allow us to place an i.v. without them being aware of it. We will ask the child to give the parent a ‘big bear hug”, and the parent should hug the child tightly, keeping their arms clear of the upper part of the buttocks. The injection will be administered quickly, through the clothing, and we will try to convince the child that a mosquito has bitten them. The medication does not sting, and the reactions of children can vary greatly. Many children don’t cry, some cry mildly, and some respond vigorously. Within several minutes the child will be unaware of their surroundings, and an i.v. can be safely placed. Occasionally, a parent will prefer to tell the child that they will be getting a shot. We will be happy to do this, but our experience leads us to favor the surprise approach, as the child doesn’t become apprehensive, and doesn’t tighten their muscles prior to the injection.
After the i.v. is placed, it will be used to administer sedative drugs, and any additional drugs which may be necessary. It also provides access in the unlikely event that emergency drugs need to be administered.
Intramuscular Ketalar (ketamine) and Versed (midazolam) may be used if the patient is uncooperative. This combination of drugs works quickly, and the child will become unresponsive within several minutes. They will typically stare blankly, and become flaccid. They may also drool and become teary eyed. These are normal responses to the medication, and are not cause for alarm.
I.V. medication is typically composed of an amnestic/hypnotic called Diprivan (propofol). This is given according to the patient’s weight, and is administered by an infusion pump, which can be adjusted on a moment-to-moment basis. These drugs are very short acting, and therefore wear off very quickly. Supplemental oxygen is usually given, as well.
Dental restoration carries a high incidence of post-operative nausea and vomiting (PONV). For this reason, anti-nausea drugs are given through the i.v. in all cases, as a preventative measure. The overall occurrence of PONV with our protocol is extremely low. When it occurs, it is usually self-limiting, meaning vomiting may occur once or twice, and the nausea subsides. Unchecked vomiting in a child can be a very serious problem. If your child experiences PONV at home which lasts for more than two hours, notify your dentist, who will prescribe an anti-nausea suppository.
An EKG monitors the heart rhythm. A pulse oximeter monitors blood oxygen levels. Respiration is monitored by capnography and direct observation. An automatic blood pressure monitor is also used. Close observation is employed.
Recovery and Post-op
Patients are usually ready to leave the office within one hour of the conclusion of the procedure. They will be able to sit without any undesirable symptoms, their vital signs will be stable, they will be responding in an appropriate fashion, and will display appropriate , but diminished, physical coordination. Children are discharged when still somewhat drowsy, and will usually require carrying. They must have adult supervision for the remainder of the day, and should not be allowed to participate in any activities in which lack of coordination or alertness would endanger them.