Ensuring Sedation Safety With Comprehensive Medical Histories

By Genni Burkhart

This topic is included in DOCS Education's top 25 Safety Statements, compiled by our esteemed faculty. The first ten, by Dr. Leslie Fang, can be found here. 

Safely and effectively sedating dental patients requires an informed medical evaluation to determine their unique risk factors.

Examining this topic in-depth, Dr. Steve Yun, MD, anesthesiologist and medical consultant for DOCS Education, presents a course called Pre-Sedation Medical Evaluation on comprehensive pre-sedation evaluations for optimal patient care and safety.

In continuation of our safe sedation series, this article discusses Dr. Yun's course while gaining valuable insight into the benefits of informed physician evaluations for dental patients.

First, Classify Risk

Begin with an overall risk classification of the patient's health status. The American Society of Anesthesiologists (ASA) score is widely used. The classification includes:

• ASA I: Healthy patient with no systemic disease.
• ASA II: Patients with mild systemic disease (e.g., controlled hypertension, asthma).
• ASA III: Patients with severe systemic disease (e.g., severe hypertension, uncontrolled diabetes, Class III obesity).

Sedation Recommendation: ASA I and ASA II patients present lower anesthesia-related risks. While treating ASA III patients is possible, a physician's evaluation may be required to proceed in some states.

Airway Evaluation

The Mallampati Score can help us predict how difficult the airway may be during sedation. Most states will require that you observe and document the Mallampati Score.

Several other factors are significant in evaluating the airway anatomy, such as:

1. Does the patient have a beard?
2. Does the patient have large front teeth?
3. Does the patient have a limited range of neck motion?

Three factors that may obstruct the airway include:

1. Submental space: The space underneath the chin where the tongue typically lays.  
2. Tonsil size: Even if the patient has a Mallampati score of I but has enlarged tonsils, problems may occur.
3. Obesity: Although considered controversial, patient evaluation can help determine the risk factors associated such as pulmonary and respiratory physiology. 

History of Respiratory Issues

For most dental sedation procedures, moderate oral sedation or even IV sedation is reasonable if the patient is otherwise healthy and the symptoms of any upper respiratory infections are mild (no fever, cough, or malaise).

There is, however, always some risk of airway irritation associated with upper respiratory infections. When a patient has a mild upper respiratory infection (URI) and is considering whether to undergo the procedure under sedation, document this as part of informed consent. Furthermore:

1. Discuss the potential risks with the patient and your willingness to proceed.
2. Postpone the procedure if the patient has moderate to severe symptoms, especially if they have other serious conditions like asthma or COPD.
3. Consider postponing the procedure for four to six weeks to allow the upper respiratory infection to resolve completely before undergoing moderate or deep IV sedation, including general anesthesia.

COVID-19

The American Society of Anesthesiology and the Anesthesia Patient Safety Foundation have released guidelines for elective surgery in COVID-19-positive patients. These guidelines recommend that if a patient is symptomatic, the procedure should be delayed for at least two weeks. After that, an informed discussion with the patient about the risks and benefits of proceeding under sedation is recommended.

Neurologic, Psychiatric, and Chronic Pain Conditions

For most patients with well-controlled seizure disorders, ADHD, or minor psychiatric conditions, dental sedation can be safe. However, for patients with major psychiatric conditions such as bipolar disorder, schizophrenia, or severe anxiety, it is advisable to consult an outside anesthesiologist or another doctor before undergoing sedation.

It's important to consider the potential for interactions and recognize the need to increase or decrease tolerance to sedative medications based on each patient’s individual assessment.

Opioid Dependency

Your dental practice may receive patients taking buprenorphine, commonly prescribed as Suboxone.

Suboxone is a sublingual medication used for the treatment of opioid abuse. It contains buprenorphine, which binds to opioid receptors and prevents opioid withdrawal, as well as naloxone, which is less likely to be abused and has less potential for addiction. Long-acting versions of buprenorphine and naloxone are available in injectables (XR-Buprenorphine and XR-Naltrexone).

Caution is advised when sedating patients with a history of opioid abuse. Consulting the patient's physician is recommended to determine the best strategies.

Cardiac Risk Assessment

Cardiac assessment should include questions about a patient's functional activity level to determine their Functional Capacity using Metabolic Equivalents (METs). Patients should have a minimum functional capacity of 4 METs for sedation, equivalent to a modest activity level such as strolling around the neighborhood or climbing stairs. This information helps gauge which patients can tolerate sedation and surgery from a cardiovascular standpoint.

When conducting preoperative dental procedure assessments, it's essential to consider the patient's age and functional capacity. Further evaluation may be unnecessary for adults under 65 with no cardiac risk factors. However, it is recommended that patients over 65 or those with cardiac risk factors undergo a medical assessment. When conducting a cardiac exam, consider the heart's anatomy and listen to it in four locations to correspond with the four chambers.

Hypertension or High Blood Pressure

According to the American Heart Association, a normal blood pressure (BP) should be less than 120 over 80.

Measuring, detecting, evaluating, and managing high blood pressure in sedation patients is imperative. Key factors include:

• Once BP is above 120 or over 80, it is considered elevated.
• High blood pressure or stage one hypertension is >130 systolic or >80 diastolic.
• Stage two hypertension is >140 systolic or > 90 diastolic.
• A hypertensive crisis, a true medical emergency, is >180 systolic or >120 diastolic.
• Some aspects of medical history are essential in evaluating a patient with high blood pressure. Many of the medications that people take, for example, NSAIDs, can increase blood pressure and make hypertension worse.
• Many blood pressure medications have dental side effects. Beta-blockers can cause dry mouth, and ACE inhibitors can cause a dry cough. They also carry the risk of a dangerous condition called angioedema, an anaphylactic reaction in which massive airway swelling can occur.
• It is essential to measure blood pressure before and throughout your dental treatment. The blood pressure should be recorded at the first visit as part of the routine physical evaluation, along with the vital signs and respiratory rate.
• Blood pressure should be monitored or measured at the start of each dental appointment. Using an automated BP recording device also requires a correctly sized cuff. Too small a cuff on a large patient will result in an artificially high reading, and too big of a cuff on a smaller patient will deliver an artificially low reading.

In Conclusion

Preparing patients for dental sedation requires a thorough evaluation that considers pulmonary and cardiac risk factors, medical history, and a pre-appointment medical assessment when necessary.

A comprehensive medical history allows the dentist to assess the patient's health and well-being in advance. It helps identify potential risks, such as respiratory problems, heart conditions, drug interactions, and enables necessary precautions. A thorough evaluation provides valuable insight into the patient's medical past, which assists in making the most informed treatment decisions for patients based on their unique physical, mental, and oral health needs.

For a more in-depth review, the online course Pre-Sedation Medical Evaluation with Steve Yun, MD, qualifies for 1.5 hours of CE credit and is automatically issued with a digital certificate upon completion.

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Author: With over 14 years as a published journalist, editor, and writer, Genni Burkhart's career has spanned politics, healthcare, law, business finance, technology, and news. She resides in Northern Colorado, where she works as the editor-in-chief of the Incisor at DOCS Education.