#16 – In Office Sedation | Dental Practice Coaching

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#16 – In Office Sedation

In Office Sedation (Auxiolysis)

A small number of potential clients are so frightened of dentistry (noise, shots, pain, gag reflex, difficulty getting numb, etc) that they need more than nitrous oxide. Oral conscious sedation can be administered by any general dentist with no added training.

Levels of Sedation

Conscious Sedation
• Level 1 – Awake and calm
• Level 2 – Drowsy/slurred speech, may need some help walking
• Level 3 – Asleep but easily aroused

Deep Sedation
• Level 4 – Asleep and requires physical stimulus to be aroused
• Level 5 – Asleep and unarousable

IV Sedation
Unlike general anesthesia, where a patient is completely unconscious, asleep and unable to respond, IV sedation is usually used by dentists with specialized training and special certification. With this type of sedation, medications are administered directly into the blood stream. The greatest advantage of IV sedation is that if someone is not sedated enough, the doctor can administer more medication and the effects are more effective than the same drugs taken orally. There is a more profound amnesia associated with this technique. This technique requires special training, passage of a state sponsored examination and a certificate of successful completion.

Oral Conscious Sedation (OCS)

Conscious sedation is defined as a minimally depressed level of consciousness that retains the patient’s ability to independently and continuously maintain an airway and responds appropriately to physical stimulation and verbal command and that is produced by pharmacological or no pharmacological methods or combinations thereof.

The oral medications used for oral conscious sedation in dentistry are from a group of drugs known as Benzodiazepines. The most common drugs are Halcion, Ativan, and Valium.

OCS is most helpful for clients who are:
1. Moderately anxious, fearful, phobic
2. Mentally impaired
3. Children who won’t cooperate
4. Moderately, long procedures
5. Severe gag reflex

Advantages of OCS:
 Easy to administer
 Works well for most people
 Low cost
 Client can breathe on their own
 Some amnesia occurs
 Wide safety margin
 Reduces gagging

Disadvantages of dental oral sedation:
• The level of sedation is not easily increased and is difficult to reverse
• Someone must drive client to and from the dental appointment (no driving for 48 hours)

The most common medication is Halcion (triazolam). Halcion provides a deep level of relaxation and amnesia effect

OCS Procedure:
A. OCS evaluation to see if client is a good candidate
1. Review health history
a. History of bleeding
b. Past sedation history
c. Medical consult required?
d. Blood pressure
e. Weight (BMI)

2. Concerns
a. Over 65
b. Lung disease (chronic)
c. Obesity

3. Client/ Family signs consent form for sedation after discussion on risks. Benefits and alternatives discussed. Client given our brochure.
4. Financial arrangements made
5. Obtain a written consent
6. Give a prescription for Halcion

B. Appointment (Halcion Only)
1. Before appointment
a. Client takes .125 Halcion the night before appointment for relaxation
b. No heavy meal before appointment
c. Client driven to HealthPark (responsible party must stay for appointment)
d. Client is identified by dentist.
e. Client takes .25mg Halcion one hour before appointment at HealthPark.
f. Client will be awake and feeling very drowsy and relaxed.

2. The pulseoximeter is kept in Dr. Smith’s office behind door. Take monitor to operatory and place behind doc cart; visible for doctor to see screen. (white cord: pulse ox cord plugs in on the R of monitor. Plug monitor into wall outlet. Place oxygen tank out of operatory, but close to room for fast availability. Hook up BP cuff and place on client’s left arm.
3. The dental assistant will seat the client, place the pulseoximeter attachments for monitoring pulse/blood pressure. Put the blood pressure cuff on the client’s left arm and the white pulse monitor clip on the right index finger. Push black button on lower left on/off (push blue button to start monitoring client) and start the N2O. Verify all treatment procedures and make sure equipment to manage airway, CPR are in the treatment room. Take initial readings on client. The pulseox machine gives us several read outs – reading from top down: pulse, oxygen saturation in top box, and systolic and then diastolic blood pressures in the bottom boxes.
i. Record your initial readings (see next page “IV or Oral Sedation Consult Form.”)
ii. The pulseox machine will automatically recheck the client’s vital
iii. signs every 15 minutes. The form is set up in 15 minutes intervals. Put the time above the vertical line (see examples in master manual). In the box “N2O/O2” write number of liters in the box where it’s started. Run an arrow through all the boxes until you begin the 100% O2 flush. Record this in the appropriate box.
4. Client’s baseline status is documented (mental status, respiratory rate, oxygen saturation, BP and pulse). Assistant confirms reversal drug, flumanzenil present (5 ml vial). If overly sleepy, inject .2 mg submucosally.
5. The dentist will evaluate how effective the 1st tablet was the previous evening. If the client slept soundly and is well rested, then 1 tablet should be enough for the procedure. If the client was anxious, then your dentist will give 2 tablets. Client takes .125 mg Halcion, taking into consideration age, weight, and client condition.
6. Client started on nitrous oxide by chairside: 3LN2O, 4LO2
7. Secretary (or assistant) to stay with client until dentist begins treatment
8. Client will be awake and feeling very drowsy and relaxed.
9. Dentist confirms all treatment with chairside
10. Vital signs will be carefully monitored during the entire appointment at 15 minute intervals by both the assistant and dentist.
a. blood pressure-cuff takes a reading automatically every 15 minutes – make record
b. oxygen saturation
c. level of consciousness
d. pain control
e. nitrous oxide level

11. Clinical notes will include entry on sedation. (See oral sedation record)
12. Begin treatment. If client not comfortable stop treatment and refer for IV sedation.
13. Discharge to home criteria:
The patient must have returned to their pre-procedural level of assessment prior to discharge. Patient and significant other are given full discharge instructions. Any patient receiving sedatives and/or narcotics are advised not to drive or operate equipment, or stay alone for 24 hours following discharge. The following data and patient responsiveness should be documented before discharging the patient:
a. Stable BP
b. Stable Pulse
c. Oxygen Saturation WNL (Pulse Ox) – 95% on room air
d. Patient is fully responsive and conscious
e. Time of removal of IV
f. Time of Discharge of patient
g. Post op instructions should be given to individual taking patient home
14. When treatment is completed, client’s escort will drive him/her home once BP and pulse are stable.

Light (conscious) sedation:
The patient will take a pill that minimally depresses the level of consciousness and retains the client ability to independently and continuously maintain a patent airway and respond to physical stimulation and/or verbal command. The drugs, doses and techniques used are not intended to produce a loss of protective reflexes.
Guidelines:
The medications are selected by the dentist within consideration of age, weight and patient condition. Sedation is given in incremental doses and titrated to effect. Reversal drugs must be stocked and in the work area (narcan and flumazenil).

Protocol for Sedation:
The dentist is supported by an assistant who is CPR certified and responsible for monitoring the patient during treatment. The dentist is responsible for assessment of monitoring information collected and supervises the assistant. Dentist marks client’s chart for designated treatment..

Equipment for airway management and CPR, including pharmacologic agents, should be available in the immediate area. The supplemental oxygen and suction will be available in the treatment room.

Pre-Sedation guidelines:
Risks, benefits and alternatives are discussed with the patient/family prior to administration.
The patient will have IV access
The patient’s baseline status is documented (mental, pregnancy status, respiratory rate, oxygen saturation, BP and pulse)
The patient should have nothing by mouth (NPO) except water as needed to take medication 4-6 hours prior to procedure. In some cases clear liquid must be appropriate up until 2 hours prior to procedure.

Intra-Procedure monitoring:
Oxygen saturation is monitored every 15 minutes for 30 minutes following the last dose of sedative medication or until the patient has reached pre-procedural level of assessment.
Treatment procedure:
1. Operating team verifies
a. Client identity
b. Procedures
c. All needed equipment in OR

2. Secretary with CPR training to stay with client until treatment is completed

3. Dentist confirms all is ready

4. Staff performs repeated frequent assessments
a. Blood pressure
b. Oxygen saturations
c. Level of consciousness
d. Pain control

The patient should have only a light meal (juice, toast) and water as needed to take medications 1 hour prior to procedure.

Intra-Procedure monitoring:
Oxygen saturation is monitored every 15 minutes until the patient has reached pre-procedural level of assessment. Whenever warning signs occur, the dentist will immediately stop, and not resume until normal vital signs.

Emergency – Have a sedative reversal agent: Flumazenil (Romazicon) in our emergency drug kit.

Discharge to home criteria:
The patient must have returned to their pre-procedural level of assessment prior to discharge. Client and significant other are given full discharge instructions. Any client receiving sedatives and/or narcotics are advised not to drive or operate equipment, to stay home alone for 24 hours following discharge. The following date and client responsiveness should be documented before discharging the patient:
a. Stable BP
b. Stable pulse
c. Oxygen saturation WNL (pulse Ox)
d. Patient is fully responsive and conscious
e. Condition of treatment site(s)
f. Time of removal of IV
g. Time of discharge of patient
h. Post op instructions should be given to individual taking patient home
i. CPR certified staff with client until dismissed and dentist is nearby

_______________________________________ _________________
Dentist Date

Oral Sedation Record

Patient Name: __________________________ Date: __________________

Person accompanying patient: __________________ Relationship: ____________

ASA class: I Healthy; II mild systemic disease Dentist: ________________

Preoperative BP __________ Pulse: ___________ Pulse Ox: _____________

Time treatment started: _______________

Medication and doses: _____________________________________________________
Halcion .125 mg: 1 tablet the night before, 1 tablet one hour before procedure. One additional .125mg sublingual dose at 2 hour point if needed.

During procedure (monitor every 30minutes)

Time Systolic/Diastolic BP Pulse SpO2 N2O:O2

Time treatment finished: ______________

Systolic/diastolic BP: __________ Pulse: ___________ PulseOx:_______________

Discharge when: Alert _______________ Ambulatory: ____________

Vital signs normal: Breathing normally, able to swallow normally

Time patient discharged: ______________ Responsible guardian: _________________

Triazolam (Halcion)
Triazolam has rapid onset and is short acting. It is a near ideal antianxiety medication for dental clients. Administer Triazolam the evening before surgery.
Oral Triazolam in doses of 0.25 to 0.5 mg does not produce any adverse changes in respiration, heart rate, or blood pressure despite obvious signs of sedation. Reports indicate that a single dose of Triazolam will not produce respiratory distress in dental clients. The most common side effects include drowsiness, lightheadedness, and decreased coordination. Most adverse effects attributed to Triazolam occur at doses higher (0.5 to 1.5 mg) than those recommended for dental clients, when given to elderly clients, or when administered chronically with inadequate medical supervision. After 2 hours a supplemental dose can be administered under the tongue for rapid uptake.

Characteristics Triazolam
T1/2 (hr) 1-6
Onset (min) 30 -60
Duration (hr) 4-6 hrs
Time to max duration 1 hr
Anxiolysis Dose (mg) 0.25- 0.5
Maximum Sedation Dose (mg) 0.5

Rx: Halcion 0.125 mg
Disp: 3 tablets
Sig: Take 1 tablet ½ hour before bedtime the night before the appointment
Bring the other two tablets to your appointment.

Lorazepam (Ativan)
Lorazepam has rapid onset and is short acting. It is a near ideal antianxiety medication for dental clients. Administration of Lorazepam the evening before your appointment.
Oral Lorazepam in doses of 0.5 and 1 mg does not produce any adverse changes in respiration, heart rate, or blood pressure despite obvious signs of sedation. Reports indicate that a single dose of Lorazepam will not produce respiratory distress in dental clients. The most common side effects include drowsiness, lightheadedness, and dizziness. Most adverse effects attributed to Lorazepam occur at doses higher (5 to 10 mg) than those recommended for dental clients.

Characteristics Lorazepam
Active Metabolites Insignificant
T1/2 (hr) 1-4
Onset (min) 30 -60
Duration (hr) 6-8 hrs
Time to max duration 1 hr
Anxiolysis Dose (mg) 2-3 mg

Rx: Ativan 1mg
Disp: 3 tablets
Sig: Take 1 tablet 1 hour before your appointment. Take 1 tablet ½ hour before bedtime the night before the appointment. Bring the other tablet to your appointment.
Valium (Diazepan) duration 6-8 hours, dose: 2.5 – 10 mg)

Flumanzenil
Flumazenil is a benzodiazepine antagonist that effectively reverses sleepiness and respiratory depression. It is available as a 0.1 mg/ml concentration in 5 ml and 10 ml vials. Although intended for intravenous administration in 0.2 mg increments up to 1 mg, it may be injected submucosally as well. To manage excessive sleepiness and/or respiratory depression, attention should be given first to standard airway support including supplemental oxygenation. This can be followed by submocosal injection of 0.2-0.3 mg flumazenil and can be repeated in 5-10 minutes if necessary. Flumanzenil is contraindicted in clients who are dependent on benzodiazepines, or those having a history of seizure disorders.

Therapeutic Recommendations
Not all clients are responsive to oral sedatives and will remain too anxious to permit administration of local anesthesia or performance of the procedure. Administration of a sedative drug may lower inhibitions in very anxious clients, leading to an increase in a client’s response to noxious stimulation. Case reports of death in the dental office often are based on attempts to manage disruptive behavior with increasing dose or number of drugs, only to produce oversedation, loss of protective airway reflexes, and undetected respiratory depression. If a patient is still anxious and uncooperative after a recommended dose of an oral sedative, and if adequate local anesthesia has been confirmed, the procedure should be terminated and the patient reevaluted for IV sedation. Increasing the sedative dose or repeated readmnistration of local anesthetic, especially in children, could result in CNS depression, leading to respiratory depression or loss of consciousness.

Becker, Daniel E., James C. Phero, Raymond A. Dionne; Management of Pain & Anxiety in the Dental Office; 2002 W.B. Saunders Company; pg 227-229.

Becker, Daniel E., Pharmacological Aspects of Dental Practice; 1998 pg 7.6

IV Sedation

When oral sedation is not enough, we use IV sedation. Only a dentist with extra training is licensed to provide medication directly into the blood stream.

Iv Sedation is usually used by dentists with specialized training and special certification. With this type of sedation, medications are administered directly into the blood stream. The greatest advantage of IV Sedation is that if someone is not sedated enough, the doctor can administer more medication and the effects are instantaneous. The drugs used for IV Sedation are more effective than the same drugs taken orally, there is a more profound amnesia associated with this technique.

During sedation, a patient evaluation must be complete and recorded prior to administration of any drugs (blood pressure, pulse and pulse-ox). The time of the evaluation must be filled in as well as the level of sedation and the drugs administered.

During Deep Sedation, patients are fully asleep and totally unaware of what is going on. This level requires an anesthesiologist. Level 4 deep sedation is the type of sedation we use in this office for our pediatric patients who need treatment by our Pediatric Dentist.

1. Clinical records include entry on anesthesia administration
2. Dentist present, not just immediately available until patient medically discharged
3. Staff CPR qualified present until patient leaves facility
4. IV sedation – mark x-ray or diagram of teeth to designate surgery sites prior to sedation and verified with parents and assistants
5. IV Procedure
a. Operating team verifies client’s identity, intended procedure(s), correct surgical site(s), all needed equipment in the operatory
b. Dentist confirms all is ready
c. Staff performs continuous monitoring and recordings every 5 minutes of blood pressure, oxygen saturation, level of consciousness, pain relief, condition of the procedure site at completion and discharge.

For IV Sedation For Adults
• Who is qualified to perform IV sedation?
• How are the patients screened?
• What instructions are given to the patient?
• What preparation is done the day prior to the procedure?
• What occurs the day of the procedure? – including monitoring, recording, drug documentation, patient discharge, written instructions given.
• What occurs the day after the procedure?

For Oral Sedation for Children
• Who is qualified to perform IV sedation?
• How are the patients screened?
• What instructions are given to the patient?
• What preparation is done the day prior to the procedure?
• What occurs the day of the procedure? – including monitoring, recording, drug documentation, patient discharge, written instructions given
• What occurs the day after the procedure?

For IV Sedation for Adults (Deep)
• Who is qualified to perform IV sedation?
• How are the patients screened?
• What instructions are given to the patient?
• What preparation is done the day prior to the procedure?
• What occurs the day of the procedure? – including monitoring, recording, drug documentation, patient discharge, written instructions given
• What occurs the day after the procedure?

For IV Sedation for Children (Deep)
• Who is qualified to perform IV sedation?
• How are the patients screened?
• What instructions are given to the patient?
• What preparation is done the day prior to the procedure?
• What occurs the day of the procedure? – including monitoring, recording, drug documentation, patient discharge, written instructions given
• What occurs the day after the procedure?

__________________________
Dr. ____________ Date

Pediatric Ambulatory Anesthesia Cases – Chairside duties

1st Visit – Initial Exam
Usually patients come in as another doctor’s referral, or a parent notices decay and brings them as an emergency, after associated with pain or a first cleaning appointment. During this appointment it is important to discuss home care, diet, fluoride, prevention, and health history with parents. Try to help identify contributing factors to dental decay and discuss with parent in a non-judgmental way. Take x-rays if needed. Take photos of patient (if cooperative get photos of their teeth). Print 2 sets, if dentist recommends IV Sedations he/she will discuss with parents, when dentist is gone answer any other questions parent may have, give them the “Fear of Dentistry” handout, and discuss consult appointment with them. Enter treatment next into computers; walk them to desk to set up consult appointment. Be sure to give patient new patient “goodie bag,” and prescription for antibiotic, or Fluoride supplement if needed.

Consult Appointment
At this appointment, the assistant will meet with the parents and go over treatment, answer all their questions and have them sign necessary forms. The secretary will then discuss scheduling and financial arrangements.

Treatment Days
Arrive a little earlier for setting up on Ambulatory Anesthesia days. Charts would have been reviewed the previous day to make sure all forms and health histories are signed, and schedule will have treatment listed. Set up for all possible treatment in room 15 (have crowns, surgery, bands, etc ready) Turn on N2O/O2 checking fullness of tanks. Help your dentist set up as needed, she will need a trash can, a sharps container, gloves, extra chair, and some videos for the child to choose from. There should be a N2O/O2 unit in recovery room with emergency O2 tank between the two rooms, 14 and 15.

When your dentist is ready to start she will bring parents and child back, listen to the child’s heart and lungs and start the child on N2O/O2 if cooperative she will place IV, if not she will have to give a shot before IV. Someone will need to help hold N2O/O2 nose, and someone will have to help hold child’s arm still when child is sedated parents will be escorted waiting room and child will be put on O2 with plastic nose tubing, monitors are placed and eyes are taped. When she says child is ready placed topical and take x-rays if indicated, then get dentist. He/She will use mouth prop and place throat pack. Put x-rays on view box as soon as ready (before already taken), and begin treatment. One assistant will assist dentist, one will assist assistant, and chart the runner. They will rotate for each case. About half way through procedure the runner will go out and let parents know how child is doing and discuss treatment changes with parents, fill out a change of tx sheet and give to Gretchen after discussing any changes with parents.

After treatment is done be sure to clean off the child’s face, let the secretary know the doctor’s total cost, let parents check out with the secretary and then put them on deck for the dentist he/ she will give parents post-op info. Child will be moved to recovery room with recovery assistant. The parents can come back when your dentist okays and they will leave when she okays. There is a wheel chair if it is needed. As quickly as possible, turn over the room and get ready to repeat the process.

Post Op Visit
Two weeks after the treatment date the patient will be appointed for a post op check. Bring the child back, ask parents how he did after treatment. Take post op photos if patient and family are good candidates for testimonials have them sign a release and write up a brief statement. Sometimes at this appointment we will need to seat space maintainers.

Sedation Instructions – Halcion

Oral sedation, usually described as a sleeping pill, has been used for many years to help people relax for dental treatment. The prescription is very safe and wears off the same day. It can be used for either adults or children.

Do not take this medication if you:
1. Are allergic to benzodiazepines (Valium, Ativan, Versed etc)
2. Are pregnant or breastfeeding
3. Have liver or kidney disease
4. Acute narrow angle glaucoma

Let us know if you are taking nefazodone (Serzone); Cimetidine( Tagamet HB, Novocimetine, or Peptol); levdopa ( Dopar or Larodopa) for Parkinson’s disease; antihistamines ( such as Benedryl and Tavist); Verapamil (Calan); diltiazem ( Cardizem); anti-fungals, erythromycin and the azole antimycotics ( Nizoral, Biaxin, or Sporanox); HIV drugs indinavir and nelfinvoir, and alcohol. Of course, taking recreational / illicit drugs can also cause untoward reactions.

You will be given a prescription (Halcion). Get it filled a day or two before your appointment. The night before your appointment, take 1 tablet ½ hour before bedtime to help you get a good night’s sleep.
When you wake the morning of your appointment, take whatever regular medications you would normally take, have a light meal (juice, toast, but NO GRAPEFRUIT), wear comfortable clothes. Plan to arrive one hour before your appointment. Bring the other 2 tablets with you. No alcohol! Someone must drive you and stay with you during your appointment.
You should arrive 1 hour before your appointment. Use the restroom before you are seated. You’ll be brought back to an operatory where your dentist will discuss whether you should take 1 or 2 tablets to help you relax during your appointment. During this waiting time you will also be given nitrous oxide for further relaxation. We’ll start a movie and take your pulse, and a blood pressure reading. Someone will be with you at all times. Side effects may include light- headedness, headache, dizziness, visual disturbances, amnesia and nausea.
During your appointment you will be awake, but you’ll feel drowsy and relaxed. When the treatment is completed, we’ll let you rest in the chair until you feel okay. Your driver can then take you home. On your way home, your seat in the car should be in the reclined position. When home, lie down with your head slightly elevated. Someone should stay with you for the next several hours due to possible disorientation and injury from falling. You should be back to normal in 6-8 hours.
Don’t drive, operate equipment, or stay by yourself for the next 6 hours after you are home. Avoid stairs and alcohol. Side effects may include light- headedness, headache, dizziness, visual disturbances, amnesia and nausea. In some people, Halcion may not work as desired.
Please call us (937-667-2417) anytime if you have any questions.

I understand these considerations and am willing to abide by the conditions stated above. I have had an opportunity to ask questions and have them answered to my satisfaction.

Signed (patient):____________________________________ Date: ___________
Signed (guardian, if under 18):_________________________ Date: ___________

Sedation Instructions – Ativan

Oral sedation, usually described as a sleeping pill, has been used for many years to help people relax for dental treatment. The prescription is very safe and wears off the same day. It can be used for either adults or children.
Do not take this medication if you:
1. Are hypersensitive to benzodiazepines (Valium, Halcion, Versed etc)
2. Are pregnant or breastfeeding
3. Have liver or kidney disease
Let us know if you are taking nefazodone (Serzone); Cimetidine( Tagamet HB, Novocimetine, or Peptol); levdopa ( Dopar or Larodopa) for Parkinson’s disease; antihistamines ( such as Benedryl and Tavist); Verapamil (Calan); diltiazem ( Cardizem); erythromycin and the azole antimycotics ( Nizoral, Biaxin, or Sporanox); HIV drugs indinavir and nelfinvoir, and alcohol. Of course, taking recreational / illicit drugs can also cause untoward reactions.
You will be given a prescription (Ativan). Get it filled a day or two before your appointment. The night before your appointment, take 1 tablet ½ hour before bedtime to help you get a good night’s sleep.
When you wake the morning of your appointment, take whatever regular medications you would normally take, have a light meal (juice, toast, but NO GRAPEFRUIT), wear comfortable clothes. One hour before your appointment take one tablet and bring your final tablet with you. No alcohol! Someone must drive you and stay with you during your appointment.
You should arrive 1/2 hour before your appointment. Use the restroom before you are seated. You’ll be brought back to an operatory where you’ll be given 1 more tablet. During this waiting time you will also be given nitrous oxide for further relaxation. We’ll start a movie and take your pulse, and a blood pressure reading. Someone will be with you at all times. Side effects may include light- headedness, headache, dizziness, visual disturbances, amnesia and nausea. One half hour later we will evaluate your level of relaxation.
During your appointment you will be awake, but you’ll feel drowsy and relaxed. When the treatment is completed, we’ll let you rest in the chair until you feel okay. Your driver can then take you home. On your way home, your seat in the car should be in the reclined position. When home, lie down with your head slightly elevated. Someone should stay with you for the next several hours due to possible disorientation and injury from falling. You should be back to normal in 6-8 hours.
Don’t drive, operate equipment, or stay by yourself for the next 6 hours after you are home. Avoid stairs and alcohol. Side effects may include light- headedness, headache, dizziness, visual disturbances, amnesia and nausea. In some people, Ativan may not work as desired.
Please call us (937-667-2417) at anytime if you have any questions.
I understand these considerations and am willing to abide by the conditions stated above. I have had an opportunity to ask questions and have them answered to my satisfaction.

Signed (patient):____________________________________ Date: ___________

Signed (guardian, if under 18):_________________________ Date: ___________