The purpose of oral sedation dentistry is to allow a dentist to treat patients more effectively by using sedative medications administered orally and sublingually to make them as comfortable as possible.
Appropriately trained dentists can use a variety of protocols customized to a patient’s physiological and pharmacological needs. Several of oral agents developed especially for these purposes, subjected to rigorous research and testing, are safe and have been used for decades. Those in the benzodiazepine class, such as triazolam and diazepam, have “amnesic” properties, meaning that patients remember little to nothing of their time in the dental chair by the next day. Other medications sometimes used in sedation protocols include antihistamines like hydroxyzine and insomnia medications like zaleplon, which aid in relaxing and calming a patient.
Sometimes referred to as "comfortable" or "relaxation" dentistry, the terms describe most patients' feelings during their oral sedation appointments. The term “sleep dentistry” is inappropriate. Patients are never meant to sleep through their appointments and should always respond to cues both verbally and physically.
The difference between conscious sedation and anxiolysis is the patient’s level of consciousness. However, state law generally limits the amount of drug that the dentist can use to bring the patient to either anxiolysis or minimal sedation as the FDA manufacturer's maximum recommended dose (MRD) of the medication. These sedation laws can and do vary from state to state.
Incremental protocols allow more flexibility in dosing and often enable a doctor to administer incremental or supplemental doses to maintain a consistent level of sedation for more extended periods. Whether a permit is required for incremental dosing is also determined by individual state law.
Every state has different oral sedation dentistry regulations. Some states require a permit even for nitrous oxide administration and/or anxiolysis, so it is essential to know your state dental board’s rules and regulations.
If you have given your patients Valium® in the past for anxiolytic purposes, you are already aware of some of the potential benefits of sedation. However, there is more to sedation dentistry than just Valium®. Countless years of research have been dedicated to studying and finding new methods and new medications to alleviate pain and anxiety since Valium’s® arrival on the market in the 1960s. Additionally, there are many other components of sedation dentistry that are important to learn, including proper patient selection/assessment, patient monitoring, benzodiazepine reversal agents, patient health history intakes, and drug-drug interaction/contraindication screening. Learning to provide optimum sedation using safe and predictable sedation protocols enables you to provide higher quality care to your patients.
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Historically, Oral Sedation has been one of the safest modalities in dentistry. DOCS Education members alone have completed an estimated 5,000,000 successful oral sedation procedures over the past 21 years. One reason for this outstanding record is that patients’ vital signs are monitored using a pulse oximeter/blood pressure/capnography monitor. This monitor is easy to use yet sophisticated enough to measure blood pressure every five minutes and continuously measure pulse rate, blood oxygen, and end-tidal CO2 before, during, and after a sedation procedure. Many states have enacted regulations requiring its use. Be sure to check your state's regulations.
Usually not, and what’s more, some insurance companies welcome sedation dentists. You need to notify your carrier in writing that you are providing sedation.
Most states require some team certification, even if it is only Basic Life Support. The more appropriate question is how much training does your team need to be effective and efficient?
With sedation, your team has added roles and responsibilities, including being the first point of contact with fearful patients. Your front office staff needs to be able to explain to each patient how the entire process works. They are also responsible for patient admittance and dismissal, including sedation-specific forms and documentation.
It is critical for the clinical team to appropriately monitor patients' vital signs using equipment like a pulse oximeter, a blood pressure monitor, a capnograph, and recognize potential emergencies before they become an actual emergency. Team members must also train to respond appropriately in the unlikely event there is a true emergency in your office.
Maybe. It depends on the state in which you practice. While many states allow anxiolysis without a permit, most have dosage restrictions. Be sure to check your state regulations.
Patients with high dental anxiety and fear often exhibit behaviors that delay treatment or make it difficult to provide. They may wiggle, squirm, and ask questions during treatment that compromise a dry field. They often require a tremendous amount of reassurance. With sedation, these patients will become your easiest patients to treat because they are no longer afraid but are relaxed and comfortable. And since sedation produces an anterograde amnesic effect, the patients seldom remember much about the procedure. Their anxiety often falls to a very low level, and they become much like your most relaxed patient.
Relaxing the patients with a severe gag reflex can make the dental experience comfortable for both patient and practitioner. The patient no longer needs to worry about the pending sensation, and the dentists can provide treatment without the worry of sudden jerking movements.
In today's world, busy executives and everyday people alike cannot afford to take repeated time off to complete the dentistry they want and need. Sedation allows them to have it completed in fewer visits, opening the door to the smile they have always wanted.
Existing patients who have put off needed treatment or who abandoned treatment plans also benefit from sedation. A large percentage of patients who come in for prophylaxis have put off routine treatment for decades often because they are secretly anxious. Although they will sometimes come in for hygiene appointments, they stop when it comes to more extensive treatment because they are afraid. When they discover that they can have their dentistry performed while they are sedated, people become much more likely to complete their treatment plans.
For patients who suffer from acute or chronic jaw soreness or have difficulty remaining open for long periods, the muscle relaxation properties of sedation medications can make longer appointments possible. By using sedation in combination with frequent resting times, extensive treatment can be completed in one visit comfortably, and patients experience little to no jaw soreness post-operatively.
Sedation also helps patients who complain they cannot get numb. These patients experience a comfortable dental visit and can achieve anesthesia with sedation dentistry.
For patients with physical limitations such as back or neck problems, sedation helps them to relax allowing them to comfortably sit in the chair for lengthy procedures. Sedation dentists report that these patients experience little or no post-operative back or neck soreness.
Patients needing extensive treatment often delay care, overwhelmed by the enormity of the work to be done. Sedation dentistry can make what may seem like a great deal of treatment feel like a few short visits.
Many sedation dentists report something very exciting – that a considerable percentage of patients who come in for a prophy put off routine work, often for years and years. The reason is that many patients are secretly anxious. Although they will go for a hygiene appointment, they stop when it comes to more extensive treatment because they are secretly afraid. However, once these existing patients are aware that their dentist offers sedation, they want to have the treatment performed. Oral sedation is a great way to help your patients get the restorative dentistry they have been postponing.
Anterograde amnesia: Due to the amnesic effects of the medications, patients have little or no recollection of the treatment. It is not uncommon for our dentist to get calls from patients amazed that they do not remember the appointment. The front desk then says, “Have you looked in the mirror yet?” The patient excitedly realizes that they have a new smile, and they have no memory of the treatment being performed at all. They are so happy because memories of dentistry are not something they savor.
Less post-operative soreness: When patients are afraid, their threshold for pain is much lower. Fear and anxiety trigger the release of chemicals in the brain like adrenaline, putting a patient's "fight or flight" instincts on high alert. They anticipate that something will hurt, so they tense their muscles, even if it is subconsciously, leading to additional soreness post-treatment. A patient's apprehension and hypersensitivity to pain are virtually eliminated with sedation, thus reducing the likelihood and severity of post-operative discomfort.
Dry mouth: During a sedation appointment, the sedative will decrease salivary flow and allow the dentist to perform treatment in a dryer environment.
Hiccups: A small percentage of patients (3%) will experience a period of hiccups lasting no longer than ten minutes. They are self-limiting.
In a few states, you may prescribe a single dose of Valium® under your dental license and DEA registration. As for a second drug, it depends on the state in which you practice. Most states require minimal training and/or have specific dosage restrictions. Be sure to check your state regulations.
Treating anxious and fearful patients without sedation can be difficult. They often require extra consolation and reassurance and are not always cooperative. It can take an hour to complete what would ordinarily take five minutes. However, with the proper amount of sedation, these patients are safely and quickly transformed into the best and most enjoyable patients to treat. Because they are fully relaxed, you can treat them more efficiently. Their jaws naturally loosen, they become cooperative and quite pleasant to be around. In the end, you get better results and a happier patient.
Sedated patients are the easiest patients to treat. They are conscious and able to do as you ask, yet they are totally relaxed and comfortable, allowing you to do your dentistry. It is truly the best of both worlds – relaxing for the patient and relaxing for you.
Incremental dosing of an oral sedative is quite valuable, effective, and safe when correctly done. It enables you to maintain maximum patient comfort even for lengthy procedures while using a minimum amount of sedative. Sedation dentists provide periodontal care, endodontic therapy, crown preps, and temporaries, all in one visit. What makes this possible is incremental dosing.
Titration is possible only with IV sedation and not with oral sedation.
When you understand drug kinetics and use them to determine the application of an incremental dosing formula, then a predictable result is highly likely. This means that when properly administered, incremental dosing is quite safe.
Sedation medications are chosen based on an individual’s medical history. Training should include learning how to utilize sophisticated yet easy-to-use, dental-specific drug interaction software that automatically cross-checks a patient’s medications (even herbal and nutritional supplements) with sedative medications. In addition to taking a thorough medical history from each patient, drug interaction screening, and patient monitoring (with equipment such as a pulse oximeter with a blood pressure monitor and capnography), help ensure oral sedation dentistry is completed safely and effectively.
As you become more comfortable with sedation dentistry, you will be able to schedule fewer—yet more productive—appointments. This is because sedation patients often require more treatment during a single visit. Dentists who report their days are filled with too many short, low-productivity appointments can create a schedule allowing them to see fewer patients while increasing practice productivity. A convenient way to transition to this workflow can be accomplished by first setting aside one day every week solely for sedation treatments.
The codes for anxiolysis (D9230) and non-IV sedation (D9248) saves the patient and your office time and money. An often-overlooked benefit is that insurance companies will pay for all four quadrants of scaling and root planning (D4341) on a sedated patient in one appointment.
A sedation permit may be necessary for insurance (and Medicaid) reimbursement for sedation.
No, unless you have a general anaesthesia permit. You should not even say “nap,” “doze,” “twilight,” “dream,” “snooze,” or “wake up.”
If you have a sedation permit (oral or IV) appropriate for your state, you can say “sedation dentistry” in your advertising. Some states may require you to say, “minimal sedation.” Otherwise, you should say “anxiety-free dentistry” or “relaxation dentistry.” Be sure to check your state’s law.
DOCS Education courses, specifically designed to meet most state and province regulatory requirements, can be found here.
DOCS Education is an AGD PACE-Approved education provider. Oral Sedation Dentistry covers nine simple techniques that will help you provide relaxation for your patients, treat more extensive cases, and do the dentistry you love to do in a more comfortable environment. You will also participate in hands-on experience and training in critical techniques for ultimate patient safety, something emphasized at all DOCS courses. Whether your goal is simple anxiolysis or oral sedation, these classes have the systems you need to get started.
DOCS Education is a membership group of over 3,000 dentists who routinely practice safe oral and IV sedation. DOCS graduates have safely and successfully completed an estimated 5 million oral and IV sedation procedures in the US and Canada. But more patients need your help.