The use of sedation in general dentistry has undergone many changes in recent years, particularly within the areas of clinical application and government regulation. Public awareness has also increased. The result of this focused and expanding interest has been to further improve sedation and thus add to the benefits it affords patient and practitioner alike. Sedation is a welcome enhancement to the general dentist’s depth of care, providing among other tools an inducement to those avoiding visits due to fear. For all of its utility and widespread value, however, sedation requires careful training in order to assure safe delivery. The American Dental Association recognizes the need for this education and identifies different levels of sedation as part of its recommendations.1 Many if not most state associations have devised rules governing the practice of sedation in the dental office setting. Regardless of where it is applied, the importance of obtaining proper instruction before performing any kind of sedation cannot be overstated, and a recent study urges specific training in airway management.2 Most dentists administer either minimal or moderate sedation through means of one or a combination of three routes: inhalation, oral or IV. Use of the inhalant nitrous oxide constitutes a relatively simple approach; the method dates back 150 years.3 Properly executed, oral sedation involving triazolam and other benzodiazepines has proven a popular means to minimal and moderate adult sedation.4 Oral sedation is often vital to those who fear needles and/or those who require long appointments. Once largely confined to the Jorgensen Technique in dentistry, IV sedation has become safer and more predictable through modern benzodiazepines and better patient monitoring.5 IV sedation offers rapid onset of action and the ability to accurately titrate to effect. Other advantages include providing a parenteral route for reversal agents and emergency drugs.
Dentistry has evolved, but patients still fear
As we’ve discussed, dentistry’s rapid evolution provides continual improvement in tools and approaches. Yet in many ways the needs of patients remain consistent. They understandably crave comfortable care in settings free from anxiety and pain. But in many respects little progress has been made on this front. In fact, it could be argued that despite dentistry’s technological advancements patients very often feel their care comes in a climate that is full of stress. You’ve no doubt heard the phrase, “I hate dentists.†So common is the sentiment that a patient education book carries the same title.6 The expression is not without merit. Dentistry services can indeed be not only uncomfortable but downright painful. Of course people are afraid. Many of us have seen patients who allowed 20 or more years to pass between visits because of a single bad experience. As a result they may suffer such severe problems that their dentition is severely compromised. Some experience serious clinical phobias such as aversion to dental noise or fear of needles. Many require large-case complex dentistry requiring multiple lengthy appointments. But neither these patients nor Americans in general should accept pain and anxiety as an inevitable aspect of dentistry. And that is precisely why the practice of sedation clearly promotes not only the short-term target of relaxation but the long-term goals of routine care and good oral health. Advances in anesthetics, pain medication, and sedatives do provide the climate that Americans seek. Sedation clearly helps practitioners meet the challenges of patient apprehension, lack of time, and the increasing complexity of procedures. One reason is the drug triazolam, which has a clearance half-life of up to 5.5 hours. This renders it ideal for long appointments. Combinations of both oral and IV medications—effectively employed in some offices—is another example. The appeal of long action can’t be overstated. Our lives have grown increasingly more complex and busy. Expanded office hours and flexibility are the keys to ensuring patients keep appointments. Sedation offers fearful patients the ability to make fewer dental visits.
Sedation dentistry complements invasive procedures
Sedation also complements the trend toward more invasive procedures in the offices of general dentists. For example, procedures such as root canal therapy and implant placement have become vastly simpler. Such short-duration procedures are especially suited to IV sedation with midazolam. Midazolam boasts rapid onset, lasts about an hour, and is readily titratable. Narcotics such as fentanyl can also be added for analgesic effect. Many sedation patients have developed strong bonds and deep trust of their general dentist. It is their preference not to be referred elsewhere, even for specialty procedures. It should be stressed that while sedation has many advantages it takes place within the context of an increasingly medicated society. According to the Centers for Disease Control and Prevention, prescription drug use is rising among Americans of all ages: five out of six people over the age of 65 take at least one medication and almost 50 percent of the elderly use three or more.7 While the presence of other medications in the patient renders sedation more complicated, it rarely makes it impossible. Dental sedation can be safe even in complex medical situations.8
Trained dentists can treat most high-fear patients
With proper patient selection, appropriately trained dentists can treat most high-fear patients in their offices, referring them only when the risks outweigh the benefits. The fact that patients can have an anxiety-free dental appointment in a safe environment represents the great lengths dentistry has come in a relatively short time. Advances in techniques, equipment and training have placed sedation within safe reach of the general dentist. Proper training is paramount, and those who choose to perform sedation must continue to pursue further knowledge not only for patient safety, but also to protect the future of dental sedation. Dentistry is unique for its combination of art, engineering, science, and medicine. Indeed, many doctors chose to practice dentistry precisely because it asked this combination of skills. Dentists are no longer mere technicians, but rather oral physicians. And as physicians we should respect the psychological well-being of our patients, in other words, eliminate fear and anxiety. With this in mind, the benefits of sedation to both patient and dentist are clear. We possess the ability to change lives for the better. Those who already practice sedation dentistry know the smiles, hugs, and tears of joy that come from replacing fear with hope. That is a future we can all embrace. 
Dr. Scott Bridges performs oral and IV sedation at his practice in Paducah, Kentucky. He is Director of Practice Development for the Atlanta Center for Dental Excellence and is a DOCS Education Diplomate. References:
- ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists: As adopted by the October 2007 ADA House of Delegates, 2007.
- Dionne RA, Yagiela JA, Cote, CJ, et al.: Balancing efficacy and safety in the use of oral sedation in dental outpatients J Am Dent Assoc, 4:137, 2006.
- Clark MS, Brunick AL: Handbook of Nitrous Oxide and Oxygen Sedation, St. Louis, 1999, Mosby.
- Gordon SM, Shimizu N, Shlash D, et al.: Evidence of safety for individualized dosing of enteral sedation, General Dentistry, 6:415, 2007.
- Malamed, SF: Sedation: A Guide to Patient Management, ed 4, St. Louis, 2003, Mosby.
- Lee M, Jackson J, and Audette VJ: Nothin’ Personal Doc, But I Hate Dentists!, 1999, IHD Publishing.
- Health, United States, 2009: U.S. Department of Health and Human Services, Centers For Disease Control and Prevention, National Center for Health Statistics, 2009.
- Bridges S: Treating a 60 year old ASA III Hypertensive Patient with Oral Sedation, DOCS Digest, Issue III, 2009.
