Conscious Sedation

Robert L. Merin and Perry R. Klokkevold

CHAPTER OUTLINE
Rationale for Sedation during
Periodontal and Implant Surgical
Procedures
ADA Policy Statement and
Guidelines for Conscious
Sedation
Definitions and Levels of Sedation
Mild Sedation (Anxiolysis) (e-only)
Moderate (Conscious) Sedation
(e-only)

CHAPTER 36
Sedation Failures
Emergency Preparedness
Conclusion
For online-only content on mild sedation/anxiolysis and moderate (conscious) sedation, please visit the
companion website at
www.expertconsult.com. Some figures, boxes, and tables may be out of numeric order in this printed chapter.

Periodontal and implant surgery should be performed painlessly and with minimal or no apprehension. The patient should be
assured of this at the outset and throughout the procedure. The mostreliable means of providing painless surgery is with
effective administration of local anesthesia. However, patients who are apprehensive may require treatment under mild or
moderate sedation.The use of sedation can help make patients more comfortable during periodontal and implant surgery,
especially when the procedure is expected to continue for 2 hours or more. Routes of administration for sedation agents
include inhalation, oral, intramuscular, and intravenous (IV). The specific agent(s) and modality of administration are based
on the desired level of sedation, anticipated length of the procedure, overall condition of the patient, and training of the
clinician and staff. This chapter reviews the rationale, definitions, techniques, and guidelines for the use of mild-tomoderate
conscious sedation in the dental office for periodontal and implant surgical procedures.

Rationale for Sedation During Periodontal and Implant Surgical Procedures

Many patients delay or avoid having needed dental treatment because of fear and anxiety. This avoidance behavior often
results in compromised health and quality of life. Anxiety toward dental therapy has not changed significantly over the past
50 years; publications report that about 30% to 50% of patients are at least somewhat fearful of dental procedures. 1-4
New evidence suggests that genetic variations are associated with anxiety related to dental care, which could help to explain
the consistent avoidance patterns despite improved treatment methods. 5 According to a national survey of the Canadian
population, more than 68% of patients would prefer to have sedation or general anesthesia for periodontal surgery 6 (Figure
36-1). Anxiety reduction is an important part of delivering advanced periodontal services. 7 Furthermore, since
dental anxiety results in avoidance behavior and is associated with more dental and periodontal problems, 8,9 it is likely that a
disproportionate number of patients referred to periodontal specialists will have dental anxiety. Interestingly, there appears to
be a close relationship between anxiety and postoperative pain. In fact, preoperative anxiety may be considered a predictor of
postoperative pain.10,11 In addition, high levels of anxiety (stress) can affect wound healing after periodontal treatment
12-14 (see Chapter 11). Sedation techniques have been shown to be effective in reducing physiologic markers of stress. 15 For
these reasons, it is important for clinicians who provide advanced periodontal and implant therapy to be knowledgeable and
skilled in providing sedation in order to reduce anxiety in their patients.

ADA Policy Statement and Guidelines for Conscious Sedation

In 2007, the American Dental Association (ADA) released three documents related to the use of sedation and general
anesthesia in dentistry, including (1) the ADA Policy Statement: The Use of Sedation and General Anesthesia by Dentists,16
(2) the ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists, and (3) ADA Guidelines for Teaching
Pain Control and Sedation to Dentists and Dental Students.18 The ADA Policy Statement and the ADA Guidelines provide
educational and practice standards for anxiety control in dental practice. The ADA Committee on Anesthesiology, consisting
of representatives from dental organizations involved with sedation and anesthesia (Table36-1), produced these documents
after review of the relevant scientific evidence, expert opinion, and comment by all communities of interest. The following
paragraphs describe the important elements of these document as they relate to treating anxious periodontal patients.

ADA Policy Statement: The Use of Sedation and General Anesthesia by Dentists
The dental professions continued ability to control anxiety and pain effectively depends on a strong educational foundation
in the discipline. Training to competency in minimal and moderate.

Mild Sedation/Anxiolysis
Oral Sedation
Oral sedation can help reduce anesthetic failures and decrease anxiety in a large percentage of dental patients. 22,23 Oral
premedication is cost-effective and Requires minimal monitoring when correct doses are used. 2,3

Most states do not require special permits for dentists who are prescribing sedatives to achieve mild sedation/ anxiolysis.
State laws do vary, and dentists need to check with their own dental board. Mild sedation dosages are generally defined as
less than or equal to the single maximum recommended dose that can be prescribed for home use. Generally, these maximum
doses can be found in references such as the package inserts, pharmaceutical websites, articles in the dental literature, and
yearly updated books such as the Physicians Desk Reference. The use of oral sedation premedication is both an art and a
science. It is wise for dentists to become very familiar with a small number of oral sedative regimens. In this way, one has a
better chance of accurately predicting the correct dose for each patient and understanding the precautions and side effects of
each agent. Although there are a large number of oral sedative agents available by prescription, recent dental articles have
concentrated on the use of zaleplon, triazolam, and lorazepam. 24-29 As an example, diazepam has been recommended for
dental anxiety in several references. 30-32 Its duration of action is 6 to 8 hours. However, ithas a primary half-life of 20 to 80
hours and a 40- to 120-hour half-life for active secondary metabolites. In addition, two headto-head
comparisons of diazepam and triazolam found triazolam to be a more effective anxiolytic agent. 33,34
The remainder of this section discusses guidelines and protocols for the use of these three oral sedative agents. Zaleplon is a
short-acting hypnotic in the pyrazolopyrimidine class. The onset of action of zaleplon is usually within 30 minutes, and it is
rapidly eliminated with a half-life of approximately 1 hour. Zaleplon is a relatively new agent, and there are relatively few
articles on its use in dentistry. Both triazolam and lorazepam are benzodiazepine medications, and the main difference is the
effective time of sedation. The duration of action of triazolam is 2 to 4 hours compared to 4 to 8 hours for lorazepam (Table
36-6). It is important for the dentist to carefully review the patients past medical history to rule out any contraindications to
these medications before the treatment appointment. Suggested patient pretreatment instructions are presented in Box 36-3.
Patients must understand that they will need a responsible adult to escort them home when they take a sedative medication.
Patients who are not reliable at following directions are not good candidates for oral sedative premedication.

411.e1
CHAPTER 36 Conscious Sedation
Guidelines for Mild Sedation with Oral Medications.
This section provides guidelines for the mild sedation/ anxiolytic doses for these medications, but these recommendations
should not be a substitute for good clinical judgment and direct patient assessment. Patient factors, such as diminished liver
enzyme function, extremes of age, and drug tolerance as the result of past drug use may cause alterations in the proposed
protocol. Precautions and drug interactions for zaleplon, triazolam, and lorazepam are presented in
Boxes 36-5, 36-6, and 36-7, respectively. If the calculated amount of medication is ineffective, the dentist can choose to
terminate the dental appointment or continue if the patient is willing. If the patients anxiety is not sufficiently diminished,
the dentist must follow all normal dismissal procedures, including releasing the patient to a responsible adult because the
sedative agent may impair motor activity even when not relieving dental anxiety. A failure to produce anxiolysis may require
changing
future prescriptions, using the services of a dental anesthesiologist in your office, or referring the patient to an office that
provides conscious sedation or general anesthesia. Anxiolytic dosing guidelines for zaleplon, triazolam, and lorazepam
are presented in Table 36-7. A recent review of the dental literature suggests a maximum dose of 0.625 mg of triazolam or
2.5 mg

TABLE 36-6 Comparison of Zaleplon, Triazolam, and

Lorazepam28
However, it is important to recognize that individual tolerance and responses vary and that

BOX 36-5 Zaleplon

Relative and Absolute Contraindications

Pregnancy, liver impairment, severe renal disease, respiratory disease, mental depression, children

Drug Interactions That May Increase Effects

Imipramine, thioridazine, cimetidine, erythromycin, ketoconazole, other CNS depressants

Drug Interactions That May Decrease Effect

Hepatic cytochrome P450 enzyme inducers such as carbamazepine, phenobarbital, phenytoin,

rifampin

Foods That May Increase Effect

Alcohol, valerian, kava, gotu kola

Foods That May Decrease Effect

St. Johns wort, caffeine. A high-fat or heavy meal can reduce the peak blood levels by 35% and the
time to peak plasma levels by 2 hours.*Note this is a relatively new drug and there are many
potential drug interactions that
have not been studied. CNS, Central nervous system. Available dosages 5 and 10 mg capsules 0.125 and

0.25 mg tablets 0.5, 1, and 2 mg tablets Onset of hypnotic effect 15-30 minutes 30 minutes 30-60
minutes
Peak plasma concentration 1 hour 2 hours 1-6 hours Duration of action 1 hour 2-4 hours 4-8
hours
Mean half-life 1 hour 2.5 hours 12-16 hours

(Data from Donaldson M, Goodchild JH: Gen Dent 55:143-148; quiz 149, 167-148, 2007; Ganzberg SI, Dietrich T,
Valerin M, et al: Anesth Prog 52:128-131)

BOX 36-6 Triazolam Triazolariazolam m

Relative and Absolute Contraindications
Acute narrow angle glaucoma; uncorrected open angle glaucoma;
myasthenia gravis; respiratory diseases, including severe sleep
apnea and severe COPD; pregnancy; lactation; severe liver
impairment; renal impairment; children; mental depression;
hypersensitivity to this drug or other benzodiazepines.

Drug Interactions That May Increase Effect

Other CNS depressants, isoniazid, oral contraceptives, ranitidine,
CYP3A4 inhibitors such as macrolide antibiotics (erythromycin,
clarithromycin), azole antifungals, doxycycline, some calcium
channel blockers.

Drug Interactions That May Decrease Effect

Theophylline, CYP3A4 inducers such as aminoglutethimide,

carbamazepine, nafcillin, nevirapine, phenobarbital, phenytoin,
and rifamycins.

Foods That May Increase Effect

Grapefruit juice, alcohol, kava, gotu kola, star fruit, melatonin,

valerian, chamomile

Foods That May Decrease Effect

St. Johns wort, caffeine.

COPD, Chronic obstructive pulmonary disease; CNS, central nervous system.

BOX 36-7 Lorazepam Precautions and Drug Interactions

Relative and Absolute Contraindications

Acute narrow angle glaucoma; uncorrected open angle glaucoma;

myasthenia gravis; respiratory diseases, including severe sleep
apnea and severe COPD; pregnancy; lactation; severe liver
impairment; renal impairment; children; mental depression,
hypersensitivity to this drug or other benzodiazepines.

Drug Interactions That May Increase Effect

Other CNS depressants, probenecid (used for gout). Drugs that

inhibit the oxidative metabolism of triazolam are less likely to
affect lorazepam, which undergoes direct glucuronide
conjugation.

Drug Interactions That May Decrease Effect

Theophylline. Drugs that induce the oxidative metabolism of

triazolam are less likely to affect lorazepam, which undergoes
direct glucuronide conjugation.

Foods That May Increase Effect

Alcohol, valerian, St. Johns wort, kava, gotu kola.

Foods That May Decrease Effect

Caffeine.

BOX 36-6 Triazolam

Relative and Absolute Contraindications

Acute narrow angle glaucoma; uncorrected open angle glaucoma;

myasthenia gravis; respiratory diseases, including severe sleep
apnea and severe COPD; pregnancy; lactation; severe liver
impairment; renal impairment; children; mental depression;
hypersensitivity to this drug or other benzodiazepines.

Drug Interactions That May Increase Effect

Other CNS depressants, isoniazid, oral contraceptives, ranitidine,

CYP3A4 inhibitors such as macrolide antibiotics (erythromycin,
clarithromycin), azole antifungals, doxycycline, some calcium
channel blockers.

Drug Interactions That May Decrease Effect

Theophylline, CYP3A4 inducers such as aminoglutethimide,

carbamazepine, nafcillin, nevirapine, phenobarbital, phenytoin,
and rifamycins.

Foods That May Increase Effect

Grapefruit juice, alcohol, kava, gotu kola, star fruit, melatonin,

valerian, chamomile

Foods That May Decrease Effect

St. Johns wort, caffeine.

COPD, Chronic obstructive pulmonary disease; CNS, central nervous system.

Dose for debilitated or elderly patients should

be reduced by 50%. Doses for healthy adults
under 40 years can be increased by 25%. With
sublingual administration, systemic availability
is approximately 27% higher compared with the
same dose taken by the conventional oral route.
Maximum single dose listed in the package
insert is 0.5 mg for sleep.

Triazolam tablets: FDA-approved package insert, Pharmacia and Upjohn Company Division of Pfizer, 2008.
Lorazepam tablets: FDA-approved package insert, Ranbaxy Pharmaceuticals, 2009.
Adapted from Goodchild JH, Donaldson M: Gen Dent 54:54-57, quiz 58, 2006.

maximum and average doses are not appropriate for all patients. It is necessary to adjust dosages according to weight, age,
health status, and other prescribed medications, as well as previous patient experiences with sedative agents. The literature
shows that agerelated changes can impair benzodiazepine metabolism, and the maximum anxiolytic dose for elderly patients
should be reduced by 50% for triazolam and 30% to 50% for lorazepam. The opposite is true for younger adult patients
(younger than 40 years of age) who may need a 25% increase in their weight-related anxiolytic dose. Sample prescriptions
for zaleplon, triazolam, and lorazepam are presented in Figures 36-7, 36-8, and 36-9, respectively.
35

When using a very short-acting agent, such as zaleplon, there is a risk that recovery of psychomotor functions may take
longer than 1 hour after the onset of action despite the reported duration Dose for debilitated or elderly patients
should be reduced by 30%-50%. Doses for healthy adults younger than 40 years can be increased
by 25%. Maximum single dose listed in the package insert is 4.0 mg. of action. Also, when using
triazolam with anxiolytic doses (generally
Higher than
The hypnotic dose), there is a risk that full recovery to a normal state of consciousness may take longer than 4 hours.
Ganzberg et al found that 28.5% of the zaleplon-sedated patients and 78.5% of the triazolam-sedated patients felt that the
sedation effects lingered for the rest of the day. 27 Consequently, zaleplon and triazolam patients must be accompanied by a
responsible adult and not resume normal activities for the remainder of the day. The opposite problem can occur when using
short-acting sedative agents. Namely, the sedation effects of the short-acting agent may wear off quickly. For this reason, the
dentist must prevent delays or interruptions so that treatment can be completed in a timely manner. If procedures are
expected to be longer than 2 hours, it may be best to use a longer acting agent such as lorazepam.

Inhalation Sedation
This section is a general description of the N O technique. To be competent in N 22 O sedation, the ADA recommends a
minimum course of 14 hours, including a clinical component. 1 8In 1844, Dr. Horace Wells (Hartford, CT) was the first to
recognize and introduce the use of N O as an analgesic, sedative agent to perform dental surgical procedures. Since that
time, N2O has been used with a long safety record in numerous dental procedures. Advantages of N2O are a rapid onset of
action and rapid recovery.There are few contraindications (e.g., chronic obstructive pulmonary diseases, severe
Emotional disturbances,and early pregnancy). Obstacles to the use of N 2O include the initial cost of equipment, the need for
effective scavenging equipment, periodic maintenance, and the concern that long-term exposure to trace amounts of N 22O
can be hazardous to dental personnel. The N2O/O2 inhalation sedation is divided into three phases. The technique begins
with an induction phase, which leads to a treatment phase and ends with a recovery phase. Each of these phases is described
in the following:

Induction Phase.
1. A flow rate of 100% oxygen is started, and a nasal hood is
placed on the patient and adjusted.
2. The correct flow rate is established while the patient is
breathing 100% oxygen.
3. The scavenging system is adjusted and checked for function.
4. The . A O flow is started usually at 20% and titrated in 10% increments every 60 seconds until patients state that they feel
relaxed and display the signs of relaxation.
2

Treatment Phase.
1. Once the ideal level of sedation is achieved, local anesthetic
may be given and the dental procedure may be started.
2. The The flow of N2O can be reduced when patients are comfortable with The procedure, or increased if more local
anesthetic required (and they have not been given any other sedation medication). 2

Recovery Phase.
2

1. When the patient no longer requires sedation, the N 2O flow is terminated and the patient is given 100% oxygen for 5
minutes or until the patient is recovered from the sedation..
2. Patients may leave the office unescorted if they are completely recovered from the sedative effects of the N 2sO.