Leonard B. Goldstein, Alfred Mauro, Lindsay M. Gilbert - A Guide To Dental Sedation-Quintessence Publishing Co, Inc (2022)

A Guide to Dental
SEDATION
Edited by
Leonard B. Goldstein, dds, phd
Alfred Mauro, md
Lindsay M. Gilbert, msm, msed, edd
A Guide to Dental Sedation
A Guide to Dental Sedation 1

A Guide to Dental
SEDATION Edited by
Leonard B. Goldstein, DDS, PhD

Assistant Vice President for
Clinical Education Development
Professor, Arizona School of Dentistry and Oral Health
AT Still University
Mesa, Arizona
Professor, Missouri School of Dentistry and Oral Health

AT Still University
Kirksville, Missouri
Alfred Mauro, MD
Diplomate in Anesthesiology
Director Emeritus of Anesthesiology
Jersey City Medical Center
Jersey City, New Jersey
Lindsay M. Gilbert, MSM, MSEd, EdD

Adjunct Faculty
Scottsdale Community College
Scottsdale, Arizona

© 2022 Quintessence Publishing Co, Inc
Quintessence Publishing Co, Inc

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All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval sys-
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Publishing Director: Bryn Grisham

Editor: Marieke Z. Swerski
Production and Design: Angelina Schmelter

Dedications
To my wife Shelley, whose love inspires and strengthens me.
Leonard B. Goldstein
To my late son Alfred. May his memory continue to inspire me.

Alfred Mauro
To my husband Bernie, whose support, encouragement, and pride for everything I do is

unbounding. I am glad we are on this journey together and I love you.
To my parents, for always believing I can and forever being in my corner. Words cannot
express how much I love and appreciate you both and all you do.
Lindsay M. Gilbert

Contents
Section I: Introduction to Dental Sedation
1. A Brief History of Dental Sedation from 1960

Fred C. Quarnstrom | Lindsay M. Gilbert
2. Understanding Dental Sedation

Anthony Charles Caputo | Stuart L. Segelnick | Mea A. Weinberg |
Dena M. Sapanaro
3. Patient Assessment and Evaluation

Chase L. Andreason | Anthony Charles Caputo | Lauren Hanzlik
4. Sedation Strategies
Anthony Charles Caputo
5. Patient Monitoring During Sedation

Chase L. Andreason | Leonard B. Goldstein | Lauren Hanzlik | Alfred Mauro
6. Sedation Drugs
Chase L. Andreason | Leonard B. Goldstein | Lauren Hanzlik | Alfred Mauro |
Stuart L. Segelnick | Mea A. Weinberg | Dena M. Sapanaro
Section II: Sedation in Specialty Practice
7. Periodontic Sedation
Stuart L. Segelnick | Mea A. Weinberg | Dena M. Sapanaro
8. Endodontic Sedation
Maria C. Maranga
9. Orthodontic Sedation
Jae Hyun Park | Dawn P. Pruzansky

10. Pediatric Dentistry and Sedation
Leonard B. Goldstein | John T. Hansford | Mana Saraghi
Section III: Other Considerations
11. Special Needs Dental Patients

John T. Hansford | David J. Miller | Mana Saraghi
12. Complications, Emergencies, and Emergency Management

Leonard B. Goldstein | Alfred Mauro
13. Animal-Assisted Therapy in the Dental Setting

Mai-Ly Duong

Preface
Dental sedation has improved substantially during the past decades, especially since
the publication of the foundational textbooks on the topic. Over the years, many stu-
dents and practicing dentists have requested a “desk reference” to describe the use
of sedation in all the clinical specialties in dentistry, and that is what this book aims
to do. We appreciate the opportunity to share this information and believe we have
assembled an outstanding group of content experts and chapter authors who con-
tributed to the topic of dental sedation.
Our intent is for this book to be used as a reference guide for both dental students
and practicing dentists. We believe that it can help to bridge the gap between class-
room instruction and the actual application of various methods of sedation in the
different specialties.
We have had the honor and pleasure to work with many outstanding and renowned
authors in the field of dental sedation and dental clinical specialties, and none of
them has ever refused to exchange opinions, accept advice, or provide suggestions.
To all of them, we give our most grateful thanks for agreeing to be part of this project,
one of the most exciting in our professional careers.
Together we hope that our efforts will be appreciated by the heterogeneous dental
community of dental students, dental practitioners, and all dental specialists.
Acknowledgments
First of all, we want to thank our families for their constant support and encour-
agement during the preparation of this book. We also want to express our gratitude
to all the chapter authors and content experts who have worked tirelessly on this
project. Because this book is based on many years of combined experience, there are
numerous friends, colleagues, and mentors who have contributed to the information
contained in this text in some way, shape, manner, or form.
We want to thank Norman Gevitz, PhD, Senior Vice President of Academic Affairs
at AT Still University, for his constant support during the preparation of this book. We

also thank Craig Phelps, DO, President of AT Still University, for his support for our
project. In addition, we thank and acknowledge the deans and faculty of the two AT
Still University Schools of Dentistry and Oral Health (Mesa, Arizona, and Kirksville,
Missouri) for their assistance. We also thank our friends and colleagues at the Schools
of Dentistry at UCLA, Stony Brook, and the University of Illinois for their support.
The editors also acknowledge all of the researchers who have added to the exten-
sive body of knowledge regarding dental sedation. And last, but not least, we thank
Ms Bryn Grisham, Publishing Director at Quintessence Publishing USA, who has
ushered this project from conception to completion, and everything in between, in-
cluding during the COVID-19 pandemic when everything came to a halt.

Contributors
Chase L. Andreason, DMD

Private Practice Limited to Oral and Maxillofacial Surgery
Evansville, IN
Anthony Charles Caputo, DDS, MA

Dentist Anesthesiologist
Private Practice
Tucson, Arizona
Adjunct Professor and Attending Anesthesiologist

Center for Advanced Oral Health
Arizona School of Dentistry & Oral Health
AT Still University
Mesa, Arizona
AEGD Program Director

Johnston Memorial Hospital
Ballad Health
Abingdon, Virginia
Mai-Ly Duong, DMD, MPH

Associate Professor
AT Still University
Mesa, Arizona

Adjunct Faculty
Scottsdale Community College
Scottsdale, Arizona

Assistant Vice President for Clinical Education Development
Professor, Arizona School of Dentistry and Oral Health
AT Still University
Mesa, Arizona

Professor, Missouri School of Dentistry and Oral Health
AT Still University
Kirksville, Missouri
John T. Hansford, DMD

Pediatric Dentist and Dental Anesthesiologist
Private Practice
Former Chief of Dental Anesthesiology

Interfaith Medical Center
Brooklyn, New York
Lauren Hanzlik, DDS

Private Practice Limited to Oral and Maxillofacial Surgery
Denver, CO
Maria C. Maranga, DDS

Clinical Assistant Professor
Postdoctoral Residency Program
New York University Langone Dental Medicine
Brooklyn, New York
Alfred Mauro, MD
Diplomate in Anesthesiology
Director Emeritus of Anesthesiology
Jersey City Medical Center
Jersey City, New Jersey
David J. Miller, DDS

Chairman and Chief Administrative Officer
Department of Dental Medicine and Oral and Maxillofacial Surgery
One Brooklyn Health
(Brookdale/Interfaith/Kingsbrook Medical Centers)
Brooklyn, New York

Jae Hyun Park, DMD, MSD, MS, PhD
Professor and Chair/Program Director
AT Still University
Mesa, Arizona
Dawn P. Pruzansky, DMD

Private Practice Limited to Orthodontics
Phoenix, AZ
Fred C. Quarnstrom, DDS

Dentist Anesthesiologist
Affiliate Assistant Professor
Department of Dental Public Health Science/Oral Health Sciences
School of Dentistry
University of Washington
Seattle, Washington
Dena Sapanaro, DDS, MS

Adjunct Clinical Assistant Professor
Department of Pediatric Dentistry
New York University College of Dentistry
New York, New York
Mana Saraghi, DMD

Director, Dental Anesthesiology Residency Program
Jacobi Medical Center
Assistant Professor
Albert Einstein College of Medicine
Bronx, New York
Vice President of Oral Exams

American Dental Board of Anesthesiology
Stuart L. Segelnick, DDS, MS

Adjunct Clinical Professor
Department of Periodontology and Implant Dentistry
New York, New York

Mea A. Weinberg, DMD, RPh, MSD
Clinical Professor
Department of Periodontology and Implant Dentistry
New York, New York

SECTION I
INTRODUCTION TO DENTAL SEDATION

CHAPTER 1
A Brief History of Dental

Sedation from 1960
Fred C. Quarnstrom, DDS
S
ince its development and advent in dentistry, anesthesia has had a complicat-
ed history encompassing both the tension between the fields of medicine and
dentistry and the tensions among dental specialties. Public perception regard-
ing the safety of sedation anesthesia in the dental office has also increased the pres-
sure on all dentists to protect their legal ability to provide this important form of pain
management for their patients. This historical reflection highlights key events over
the past five decades that have greatly influenced the course of sedation anesthesia in
dentistry and who performs it. See Box 1-1 for a list of relevant organizations and the
acronyms they will be referred by.
BOX 1-1 Organizations related to the history of dental sedation

AAOMS American Association of Oral and Maxillofacial Surgeons
ADA American Dental Association
ADBA American Dental Board of Anesthesiology
ADSA American Dental Society of Anesthesiology
ARRC Anesthesia Residency Review Committee
ASA American Society of Anesthesiologists
ASDA American Society of Dentist Anesthesiologists
CODA Commission on Dental Accreditation
NCRDSCB National Commission on Recognition of Dental Specialties and Certifying Boards
SCSOMS Southern California Society of Oral and Maxillofacial Surgeons

In 1960, the American Association of Oral and Maxillofacial Surgeons (AAOMS;
then called the American Society of Oral Surgeons) Committee on Graduate Training
published a statement paper called Essentials of an Adequate Training Program in Oral
Surgery.1 At this time, the organization recommended 12 months’ worth of anesthesia
training for oral and maxillofacial specialty students. By the late 1960s, there were
many general dentists doing intravenous (IV) sedation bordering on general anesthe-
sia with just 3 months of IV general anesthesia training. The American Dental Society
of Anesthesiology (ADSA) was largely comprised of these general dentists. Very few
oral surgeons were members of this organization at that time.
The Author’s Experience in Early Years

I finished my 1-year general anesthesia residency in 1967, the same year the ADSA
initiated its fellowship examination process, which at that time was open to any den-
tist with a minimum of 1 year of operating room–based anesthesia residency train-
ing.1 I came home to Seattle with the intention of doing general anesthesia for general
dentistry. I contacted the Chairman of the Oral Surgery Department at the University
of Washington to see if my training would be of value to the school, because very few
dentists had done a full year of anesthesia training. I had used IV diazepam (Valium,
Roche) in my residency to achieve IV sedation for several procedures that were short
but painful. At that time, diazepam was just coming to market. The chairman ques-
tioned me regarding this drug and my use of it, and we discussed it for several hours.
He then told me, “Do not get in trouble. I will have to serve with the prosecution.” I
asked why he would say that: I had a full year of general anesthesia training, whereas
his residents only received 3 months. In fact, during my residency I had even super-
vised oral surgery residents as they rotated through the operating room.
For a new dentist just opening a practice, the climate for a general dentist doing
general anesthesia in Seattle was at best hostile. I began providing IV sedation. Pa-
tients were awake and talking, but because of the amnesia caused by the diazepam,
they did not remember the procedure and were well relaxed, making the procedure
possible or at least easier. I only did this for severely phobic patients who simply
could not tolerate dentistry because of their fear. For those who were mildly phobic, I
use a combination of nitrous oxide oxygen (N2O-O2). They were awake and comfort-
able but had little, if any, amnesia.

I continued using IV sedation for about 20 years. Dentists could not advertise their
services in the 1960s through the 1990s, so my patients came via referrals from oth-
er dentists or my patients. I did at least one case of IV sedation a week and used
(N2O-O2) sedation on well over 70% of my patients. My practice was largely com-
prised of phobic dental patients who no one else wanted to treat. A difficult patient is
better than a vacant chair!
I became rather adept at treating fearful patients. I often felt patients came in two
varieties: those who were fearful and would admit their fear and those who were
fearful and would not admit their fear. At that time, there was no other option for
them but my practice. They could go to an oral surgeon and have extractions per-
formed under general anesthesia, but I knew of no one else in the greater Seattle
area who would do IV sedation for general dentistry. Later, in 1982, the University
of Washington opened a dental fear clinic that could not only treat fearful patients
with sedation but also had psychologists on the faculty to help patients address and
conquer their fears.
In 1980, Cohen et al published a paper showing that male dentists and female
chairside assistants who worked in dental offices and were exposed to nitrous oxide
had higher incidence rates of liver disease, kidney disease, and neurological disease
than those working in offices that did not use nitrous oxide.2 In the case of female
chairside assistants with heavy exposure to nitrous oxide, the study also showed a
2.3-fold increase in miscarriages. It took several years for this research to make its
way into dental schools. In response, companies developed scavenging techniques
to remove the trace nitrous oxide gas from the air we breathe in dental offices. Dental
schools discussed these hazards. The use of nitrous oxide dropped dramatically, par-
ticularly in the offices of female dentists and offices where dental staff were pregnant.
In 1983, anesthesia in dentistry received nationwide media coverage after a
37-year-old dentist in California named Tony Protopappas was arrested for (and lat-
er convicted of) the second-degree murder of three patients. The patients includ-
ed a 13-year-old child and a 23-year-old dialysis patient whose primary physician
has advised Dr Protopappas that she should not be given general anesthesia due to
her medical condition. At the time of the patient deaths, Dr Protopappas was not
licensed to administer anesthesia.3,4 Before the Protopappas case and the resulting
media storm, clinicians in California could choose to undergo voluntary in-office an-
esthesia evaluations conducted by the Southern California Society of Oral and Max-

illofacial Surgeons (SCSOMS). Afterward, this voluntary evaluation model evolved
into a nationwide system of mandatory state board–regulated permits for the use of
general anesthesia by dentists.1,3
In the mid-1980s, malpractice insurance costs for doing IV sedation skyrocketed.
The increase for my practice was about $5,000 more a year. It was no longer practi-
cal to continue doing IV sedation unless I was doing several IV cases a week. I had
taught nitrous oxide sedation courses and a couple of IV sedation courses since 1969.
At the time, I had close to 200 IV anesthesia patients. I did some research for an alter-
native to IV diazepam. A dentist in Canada, whom I taught with, suggested I should
try an oral medication with my fearful patients. Triazolam (Halcion, Pfizer) was a
popular sleep aid that was reported to keep patients relaxed but awake. Patients had
amnesia of the dental procedure while under the effect of triazolam. I started using
oral triazolam on fearful patients on whom I had previously used IV sedation, and it
worked far better than I expected. The most fearful patients were now able to have
dentistry done while awake and talking. They did not remember the treatments yet
they were awake and comfortable.
In 1990, I started presenting courses on oral conscious sedation using triazolam. In
2003, Dr Michael Silverman came to the American Dental Association’s Committee to
present his case for doing courses in oral conscious sedation with his continuing edu-
cation company, Dentists for Oral Conscious Sedation. Suddenly, there were courses
for general dentists who wanted to go further with sedation than was possible with
just (N2O-O2).
Conflicting Voices: The Many Interests of Dental

Anesthesiology
The first national society for anesthesiology in dentistry, the ADSA, was formed in
1953 to protect, develop, and further the field of anesthesiology in dentistry.5 Most
of the founding members were oral surgeons, but the organization soon attracted
dentists outside the specialty with interest in anesthesiology, including general den-
tists. In 1954, then-president William B. Kinney made clear the ADSA’s main goal in
a letter to all members published in the organization’s first news publication. That
goal was to achieve specialty status for dental anesthesiology from the American

Dental Association (ADA).5 As the group grew in both membership and influence,
it began to tackle the issue of postdoctoral education opportunities in anesthesia for
dentists. In the late 1980s, the ADSA began committing a significant portion of its
financial resources toward funding and supporting dental anesthesiology programs
throughout the country.6 During this period, the ADSA also developed a board ex-
amination, the American Dental Board of Anesthesiology, and began the specialty
application process.7
However, the ADSA Board of Directors discontinued the specialty application pur-
suit in October of 1991. This decision was influenced by two events. In June of 1991,
the Anesthesia Residency Review Committee (ARRC) of the Accreditation Council
for Graduate Medical Education threatened medical program directors with the loss
of program accreditation if dentists were rostered as anesthesia residents.8 This de-
cision was based on pressure by the American Society of Anesthesiologists (ASA),
which was concerned by the number of dentist anesthesiologists in medical resi-
dency programs.1 The ARRC later allowed that dentists could participate in medi-
cal anesthesia rotations of up to 12 months but could not be considered residents.8
The AAOMS successfully negotiated continued anesthesiology rotations for oral and
maxillofacial surgeons (OMS) residents, but non-OMS dentist anesthesiologists were
left unmoored.1
The second event that directly caused the ADSA to abandon the specialty applica-
tion was action taken by the AAOMS. Originally founded by oral and maxillofacial
surgeons who supported the specialty formation, the ADSA had over the decades at-
tracted a large proportion of non-OMS dentist anesthesiologists and general dentists
interested in anesthesia. However, in the 1980s, an influx of oral and maxillofacial
surgeons joined the ADSA, as they felt the additional board certification was in their
best interest. By 1991, 70% of the ADSA membership consisted of oral and maxillofa-
cial surgeons.7 The AAOMS did not support the ADSA’s mission to obtain specialty
status for dental anesthesiology. The AAOMS has historically opposed the creation of
an anesthesiology specialty out of concern that this would limit access to anesthesia
for dentists outside the specialty, including oral and maxillofacial surgeons.9 Of para-
mount concern, also, was protecting the operator-anesthesia team model established
by OMS. The AAOMS therefore exerted political pressure over the ADSA through
an organized effort to reduce membership support for specialty formation by asking
AAOMS members to discontinue their ADSA membership. Ultimately, in October
of 1991, the ADSA Board of Directors voted to discontinue sponsorship of special-
ty recognition in order to preserve the organization, and in 1996, the ADSA House
of Delegates voted for the organization to remain neutral on the issue of specialty
formation.7,8
Back when the membership of the ADSA became populated by mostly oral and
maxillofacial surgeons, this population change became mirrored in their education
focus. Several dentist anesthesiologists became dissatisfied by the ADSA’s educa-
tional course offerings, which were largely designed to serve the oral and maxillofa-
cial surgeon’s position as operator-anesthetist rather than dentist anesthesiologists.
In 1980, Drs Larry Trapp and Ron Davies, two dentist anesthesiologist members of
the ADSA, invited all ADSA members with 2 or more years of anesthesiology train-
ing to a meeting, and 17 dentists attended. Upon discussing their shared desire for
more substantive continuing education on dental anesthesiology, they determined
that the only solution was to start a new society designed for the benefit of dentists
who were trained more extensively in anesthesia than the general ADSA member-
ship. Members would be required to have 2 or more years of anesthesia training, this
number being based on the length of training required to be board-eligible in medical
anesthesia. The name chosen for the new society was the American Society of Dentist
Anesthesiologists (ASDA).10
It was originally intended by the founders that the ASDA would be supplemental
to the ADSA and that all would choose to be members of both societies; after all, the
founders themselves were members of the ADSA.10 However, the ADSA leadership
quickly made it known that they disapproved of the new society, perhaps in part
because the 2-year anesthesiology education requirement excluded most oral and
maxillofacial surgeons. However, the two organizations soon established a positive
relationship based on the willingness of the ADSA Board of Directors to pursue spe-
cialty formation. When the ADSA gave up the gauntlet of specialty formation in 1991,
the ASDA gladly took it up.
The ASDA submitted its first specialty application to the ADA in 1994 and, upon
rejection, submitted again in 1997 and 1999. Each time, the AAOMS strongly opposed
the application. After the 1994 application rejection, the ASDA leadership changed
track. To bolster their next application, it was decided that they should demonstrate
the ASDA’s ability to develop an independent board of anesthesia for dentistry. The
ADSA had previously given up their efforts to establish a board upon surrendering
the pursuit of specialty application, so the ASDA claimed the name and established

the American Dental Board of Anesthesiology (ADBA). A revised specialty applica-
tion was submitted in 1997 after establishment of the ADBA. However, it was reject-
ed, as was the 1999 application.7
After the 1999 rejection, the ASDA changed track again. Because CODA (Commis-
sion on Dental Accreditation) accreditation of postdoctoral training programs is so
closely linked with ADA specialty recognition, it was decided that acquiring CODA
accreditation for dental anesthesiology residency programs should be the next course
of action prior to another specialty application. Of equal importance was the fact that
the 1991 loss of space in accredited medical anesthesiology residencies for non-OMS
dentists had left many practitioners without an accredited postdoctoral option. The
ASDA leadership felt that CODA accreditation acquired separately from ADA spe-
cialty recognition would be a stop-gap measure that would provide and protect den-
tal anesthesiology education until a specialty application could be successful. Ad-
ditionally, the independent oversight and standardization of postdoctoral training
programs in dental anesthesiology would strengthen the defense of anesthesiology’s
place in dentistry.
In 2001, the ASDA submitted a request to the CODA asking for accreditation of
postdoctoral training in dental anesthesia. Organizations that opposed CODA ac-
creditation of dental anesthesiology programs included the AAOMS, the American
Association of Orthodontics, and the American Academy of Oral and Maxillofacial
Pathologists, as well as the ADA and its House of Delegates. Over the next 3 years,
the CODA commissioners developed an application process to evaluate the merits
of accrediting postdoctoral training programs in areas of general dentistry not rec-
ognized by the ADA House of Delegates or its Council on Dental Education and
Licensure. In 2004, the ASDA formally submitted their application for accreditation
of postdoctoral training in anesthesiology for dentistry, and in 2005 the CODA ap-
proved accreditation for dental anesthesiology postdoctoral programs.8,11
In 2012, the ASDA again applied for specialty recognition from the ADA. This ap-
plication was once more rejected. In 1994, 1997, 1999, and 2012, the ASDA’s applica-
tion passed the review process up until the final vote by the ADA House of Delegates.7
After the 2012 rejection, the ASDA removed language from its founding documents
that specifically supported the OMS operator-anesthesia model.
At the 2017 Annual Meeting of the ADA, approval was granted to create the
National Commission on Recognition of Dental Specialties and Certifying Boards

(NCRDSCB). This board consisted of 19 members, and its purpose was to reduce bias
or conflict of interest throughout the process of recognizing a dental specialty. The 19
members of the board included 9 general dentists and 9 specialists, one representing
each of the 9 specialty areas recognized by the ADA. These members were appointed
by the ADA Board of Trustees, under the leadership of President Dr Joseph Crowley.
The last member was a public member who was not a dentist or specialist. The cre-
ation of the NCRDSCB paved the way for a fifth attempt to recognize dental anesthe-
siology as a specialty.12
In 2018, the ASDA submitted its fifth application to officially recognize dental an-
esthesiology as a specialty. Numerous updates were carefully made to the applica-
tion, reflecting changes to ASDA membership requirements. A subcommittee of the
NCRDSCB convened and determined that the application, just like the four previous
applications, met all the ADA standards necessary to be recognized as a specialty.
Following subcommittee review, there was a 60-day public comment period before
the NCRDSCB met again to determine the outcome of the application. The commis-
sion approved the application, at last recognizing dental anesthesiology as a special-
ty area after 67 years and five application attempts.12
Currently, ASDA membership requirements include a minimum of 3 years of train-
ing in an ADA/CODA-accredited anesthesiology program, up from the original 2
years of training required at their founding in 1980. As part of that training, 2 years
must focus on administration of clinical anesthesiology, with 6 months of that time
focused on anesthesiology specific to dental patients. A minimum of 1 year of the 2
required years must be spent as part of a hospital rotation in an anesthesiology de-
partment. This is more than twice the required time for any other anesthesia rotation
in a dental specialty program. A minimum of 800 deep sedation/general anesthesia
cases must also be completed by dental anesthesiologists. Of these, there must be a
minimum of 300 endotracheal intubations, with 59 nasal intubations and 25 other ad-
vanced airway approaches. There are also required minimums of 125 children under
8 years of age and 75 special needs patients, since dental anesthesiology specialists
are likely to work with these patient populations.12

The Current State of Anesthesiology in Dentistry
In the past, the minimal training accepted by most states was a 60- to 80-hour didactic
course and 20 clinical cases under supervision of a dental anesthesiologist, with 1 year
or more of anesthesia residency or supervision of a medical anesthesiologist. These
courses are very costly. Those doing IV sedation are still a small minority of dentists.
In the interim, about 30% of dentists became qualified to do oral conscious sedation.
Nowadays, sedation anesthesia is very fragmented in general dentistry. We have
dentists who only do local anesthesia, 30% or so who use (N2O-O2) sedation, another
30% who do oral conscious sedation in addition to nitrous oxide sedation, a few who
do IV conscious sedation, and probably fewer than 300 dentists who are qualified to
do general anesthesia. In order to provide general anesthesia, dentists are required to
have a 1-, 2-, or 3-year general anesthesia residency, and oral and maxillofacial sur-
geons, who represent about 15% of the total dentist population, complete a surgical
residency that includes some training in general anesthesia.
While sedation anesthesia in dentistry is a continuum of nitrous oxide, light oral
conscious sedation, IV conscious sedation, and true general anesthesia, no single or-
ganization represents all aspects of this continuum. To an extent, each organization
tends to lobby against the others as each organization tries to protect its own position
in treating patients. There certainly is an overlap with other groups in many areas of
practice. The operator-anesthesia model remains unique to dentistry, in contrast to
our medical colleagues. No MD surgeon would both administer general anesthesia
and do surgery. Only in dentistry is this commonly done.
References
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dpt-0722-protopappas-20100721-story.html. Accessed 15 May 2019.

4. Cone M. $1.6 million awarded to 13 patients of convicted dentist. LA Times. 8 October 1992.
https://www.latimes.com/archives/la-xpm-1992-10-08-me-1008-story.html. Accessed 15 May
2019.
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CHAPTER 2
Understanding Dental Se-

dation
Dena M. Sapanaro, DDS, MS
I
t is common to discuss the administration of sedation for patients as a science as
well as an art. The science of administering sedation is discussed throughout this
textbook related to the various aspects of patient physiology and pathophysiology,
available and indicated drugs for sedation, drug pharmacology and pharmacody-
namics, and the combination of patient presentation with drug selection for the safe
and successful treatment of the patient. The goal of this chapter is to combine the
science with the art of sedation administration to understand that patient selection,
sedation approaches, and successful treatment are as influenced by science as they
are by the art of sedation administration. One is not more important than the other,
but rather, they are equally dependent on each other for success.
Definition of Terms
Numerous sedation/analgesia terms that are encountered in articles, conversation,
and written guidelines should be defined before going into depth in the chapter.

• Analgesia: The loss of the ability to feel pain while conscious. It is not sedation but
rather the diminution or elimination of pain.1
• Titration: The administration of incremental doses of an intravenous or inhalation
drug until the desired therapeutic effect is reached, which is important for patient
safety.1 Titration allows for maximum patient comfort while using a minimum
amount of sedative. Titration is unpredictable with oral drugs, often resulting in
oversedation.2 Usually, subsequent doses are given before the first dose is fully ab-
sorbed and exhibiting a therapeutic effect.
• Enteral route of administration: Technique of administration whereby the drug is ab-
sorbed from the gastrointestinal tract into the general circulation. Examples include
oral, sublingual, and buccal (ie, drug is applied to buccal mucosa and absorbed).
• Parenteral route of administration: Pharmacologic agents are administered that by-
pass the gastrointestinal tract. Examples include the intravenous (IV), intramuscu-
lar (IM), subcutaneous (SC), and intrathecal routes.
• Inhalation route of administration: Pharmacologic agents are administered via the
lungs (eg, nitrous oxide-oxygen and volatile anesthetics).
• Combination inhalation route of administration–enteral moderate sedation: Obtaining
moderate sedation with inhalation and enteral agents.
• Transmucosal route of administration: A technique of administration in which the drug
is administered across mucosa such as intranasal, sublingual, or rectal.
Behavioral Assessment
When determining the appropriate sedation approach, one should give particular
focus to the behavioral assessment of the patient.1 This is directly influenced by how
we interpret and process pain. The International Association for the Study of Pain
(IASP) defines pain as “an unpleasant sensory and/or emotional experience that is
associated with actual or potential tissue damage.”3 The key words in this definition
are emotional and potential. It is important to appreciate that pain is an emotional ex-
perience that is influenced by the potential for injury. Clinicians must often make a
critical assessment of a patient who presents with fear or phobia to dental treatment.
We are well aware of the patients who have had a traumatic dental experience and
become fearful for future dental treatment, though we must also appreciate the pa-

tients who present with fear or phobia based on their overwhelming concern that
something bad will happen to them during dental treatment. As compassionate and
sympathetic health care providers, we must allow ourselves to identify and under-
stand the patient’s fear or phobia regarding dentistry whether it is based on an actu-
al experience or not. Related to this is the understanding of the dual nature of pain
involving pain perception and pain reaction (Box 2-1).
BOX 2-1 Pain perception and pain reaction

Pain perception The physiologic and anatomic process by which pain is received and trans-
mitted. The actual process by which the body perceives pain.
Pain reaction The manifestation of the perception of pain. Involves psychologic factors
including age, sex, past experiences, and emotional state.
Effectively, how a person perceives pain is influenced by their reaction. Therefore,

it is completely understandable that a person can be phobic of dental treatment with-
out ever having had treatment provided or have a very strong response to planned
treatment based on previous poor experiences. This is why the behavioral assessment
of the patient before any treatment is provided is so important. Identifying that a pa-
tient would benefit from sedation before planned treatment can facilitate a successful
treatment appointment as well as tremendously benefit the patient’s response to den-
tistry overall. Involved with the behavioral assessment is the identification of how
strongly the patient feels about dental treatment and how they feel about proposed
sedation approaches. Central to this process is the patient’s acceptance of sedation
as a treatment approach and understanding what that level of sedation will mean to
them based on what the dentist can provide.
To have this discussion with the patient and have them agree with the planned
sedation approach, you must know the definitions of the available levels of sedation
and anesthesia. The document to utilize as a primary resource is the American Dental
Association (ADA) Guidelines for the Use of Sedation and General Anesthesia by Dentists.
This document was most recently revised and adopted by the ADA House of Dele-
gates in October 2016.1 Within this document, there are definitions provided for each
level of sedation or anesthesia that an appropriately trained dentist can administer to
a patient in the dental office setting. The new guidelines place more emphasis on the
levels of sedation than on the route of drug administration. Three major changes are

present in the new guidelines. First, the preoperative workup now must include cal-
culation of body mass index (BMI). Second, there is now a need to monitor end tidal
carbon dioxide (CO2) using a capnograph and auscultation of breath sounds with
special equipment (precordial stethoscope). Third, there is an increase in required
training hours for the practitioner to perform sedation1 (Fig 2-1).
Fig 2-1 Precordial stethoscope. (Courtesy of Anthony Ragonese

and Slaton Hoffner.)
Continuum of Sedation
There are four different levels of sedation, ranging from minimal sedation to gener-
al anesthesia.1 As the level of sedation increases, so does the risk of complications.
The American Society of Anesthesiologists (ASA) defines four levels of sedation, as
shown in Table 2-1 and discussed below.1,4

Table 2-1 Comparison of depths of sedation4
Sedation occurs on a continuum
Minimal sedation Moderate sedation Deep sedation General anesthesia

(in practice) (in practice) (in hospital) (in hospital)
Responsiveness Normal Respond Requires repeat- Not aroused
purposefully to ed stimulation to
verbal commands become aroused
Airway patency Maintained Adequate May Needs intubation
require assistance
Ventilation Maintained Adequate May be Impaired;
impaired requires
assistance
Cardiovascular Maintained Maintained Maintained May be impaired
function
Minimal sedation
Minimal sedation, previously known as anxiolysis, is a drug-induced state in which
the patient responds normally to verbal commands and tactile stimulation, although
cognitive function and coordination may be impaired. This method allows the patient
to maintain an airway independently and continuously.1 Breathing and cardiovascu-
lar function are unaffected. Either a single dose or divided doses are administered

until the desired level of sedation is achieved, but never exceeding the maximum
recommended dose (MRD).
In some states, training for minimal sedation is now part of moderate sedation
training. Minimal sedation with oral drugs has a slower and delayed onset of action
due to many variables. It is also difficult to titrate to the desired effect with orally
administered drugs.5
Patients acceptable for minimal sedation should be healthy or medically stable
(ASA I or II as described in Table 2-2). ASA III patients may need more careful con-
sideration.6 There is more of a risk with elderly patients due to prolonged action
of the drugs used. Patients should take the drug in the dental office 1 hour before
the procedure.
Table 2-2 ASA physical classification system
ASA PS
Classification Definition Adult examples (including, but not limited to)
ASA I A normal healthy patient Healthy, nonsmoking, no or minimal alcohol use
ASA II A patient with mild Mild diseases only without substantive functional limita-
systemic disease tions. Current smoker, social alcohol drinker, pregnancy,
obesity (30 < BMI < 40), well-controlled DM/HTN, mild
lung disease
ASA III A patient with severe Substantive functional limitations; one or more moderate to
systemic disease severe diseases. Poorly controlled DM or HTN, COPD, mor-
bid obesity (BMI ≥ 40), active hepatitis, alcohol dependence
or abuse, implanted pacemaker, moderate reduction of ejec-
tion fraction, ESRD undergoing regularly scheduled dialysis,
history (> 3 months) of MI, CVA, TIA, or CAD/stents.
ASA IV A patient with severe Recent (< 3 months) MI, CVA, TIA or CAD/stents, ongoing
systemic disease that is cardiac ischemia or severe valve dysfunction, severe reduc-
a constant threat to life tion of ejection fraction, shock, sepsis, DIC, ARD, or ESRD
not undergoing regularly scheduled dialysis
ASA V A moribund patient who Ruptured abdominal/thoracic aneurysm, massive trauma,

is not expected to survive intracranial bleed with mass effect, ischemic bowel in the
without the operation face of significant cardiac pathology or multiple organ/sys-
tem dysfunction
ASA VI A declared brain dead NA
patient whose organs
are being removed for
donor purposes
DM, diabetes mellitus; HTN, hypertension; BMI, body mass index; COPD, chronic obstructive pulmonary disease; ESRD, end-
stage renal disease; MI, myocardial infarction; CVA, cerebrovascular accident; TIA, transient ischemic attack; CAD, coronary
artery disease; DIC, diffuse intravascular coagulation; ARD, ascites reinfusion dialysis; NA, not applicable.

Moderate sedation
Moderate sedation was previously referred to as conscious sedation and is current-
ly often interchangeable in the medical literature with the term procedural sedation
and analgesia (PSA).7–9 There is no clear demarcation between minimal sedation and
moderate sedation. Theoretically, all patients pass through a lighter level of sedation
before entering moderate sedation. As such, the drugs used for minimal sedation
produce moderate sedation to one degree or another if given in greater dosages, or
in combination with other medications that affect the central nervous system (CNS).
Moderate sedation is defined as a drug-induced depression of consciousness that re-
tains the patient’s ability to independently and continuously maintain an airway and
respond purposefully to light physical stimulation or verbal commands and that is
produced by a pharmacologic or nonpharmacologic method or a combination there-
of.1 It is a technique of administering sedatives or agents with or without analgesics
to induce a state whereby the patient can endure unpleasant, uncomfortable, and
painful periodontal procedures while maintaining cardiorespiratory function. Be-
cause effective sedation may alter consciousness, the older term conscious sedation is
no longer preferred.10,11 Moderate sedation includes the administration of either oral,
inhalation, or intravenous agents. Sedation with parenteral drugs may be achieved
using either a single drug or multiple drugs.1
Since moderate sedation is not expected to induce depths of sedation that would
impair the patient’s own ability to maintain patent airways, intubation should not
be required. Moderate sedation can be performed in the periodontal practice or in a
hospital and is usually indicated for longer periodontal procedures. Onset of drug
action is very rapid, and drug dosing can be titrated to the desired therapeutic effect
(level of sedation), which can be tailored to meet the individual’s needs. The intrave-
nous route of drug administration can be considered for inducing moderate or deep
sedation. Often, nitrous oxide is combined with enteral drugs for combined moder-
ate sedation.
Moderate sedation is contraindicated in patients with physical status ASA IV or
greater, lack of support staff or monitoring equipment, lack of experience/credential-
ing on the part of the clinician, previous adverse reaction to the medications, myas-
thenia gravis, and acute angle-closure glaucoma.6,12 Caution should be used for preg-

nant and obese or morbidly obese patients because of the difficulty in maintaining
airway patency.5
Deep sedation/analgesia
This is a drug-induced depression of consciousness during which patients cannot be
easily aroused but respond purposefully following repeated or painful stimulation.
Optimal deep sedation includes quick onset, low cardiopulmonary depression, and
rapid recovery. Deep sedation is routinely done in a hospital setting.1
General anesthesia
This is a drug-induced loss of consciousness during which patients are not easily
aroused and there is a partial or complete loss of protective reflexes, including the
inability to maintain an airway independently or respond to physical stimulation
or verbal commands. General anesthesia is not routinely used for periodontal pro-
cedures because skeletal muscle relaxation and unconsciousness is not the goal.1 A
comparison of the depths of sedation is reviewed in Table 2-1.
Dissociative sedation refers to a form of anesthesia characterized by trance-like cata-
lepsy, catatonia, analgesia, and amnesia while retaining airway reflexes, spontaneous
respiration, and cardiovascular functions.
When considering the different levels of sedation and anesthesia and the meth-
ods by which they are achieved, one must show appreciation for how the patient
will present at these levels. When minimal or moderate sedation is administered to
a patient, they will be conscious and must remain conscious for the entirety of the
scheduled procedure. When deep sedation or general anesthesia is administered to
a patient, they will be partially or fully unconscious. It is well understood that the
administration of sedation or anesthesia is a continuum, and it is possible for the pa-
tient to intentionally or unintentionally achieve a level of sedation or anesthesia by
the administration of drugs used for this purpose. It is for this very reason that drug
selection is a critical component of sedation or anesthesia as it relates to the level of
sedation as influenced by the presentation of the patient. As an example, a patient
who receives deep sedation for a procedure may not be maintained at that level for
the entire procedure. This would allow the dentist to progress to moderate or mini-

mal sedation or, if desired, general anesthesia. For the dentist administering minimal
or moderate sedation, the change in level of sedation or anesthesia is directed by the
level of training and, if determined by the respective state dental board, the permit
maintained by that dentist.
There is wide variation among state dental boards regarding the training required
for dentists to administer sedation or anesthesia. It is the requirement of the den-
tist to know what the rules are for sedation or anesthesia permitting and to ensure
they are administering sedation appropriately as regulated by their respective state
dental board. This is easily achieved by going to the state dental board website and
reviewing the rules regarding sedation and anesthesia permitting. There are states
that require permitting for nitrous oxide–oxygen administration and others that do
not. There are states that accept the ADA Guidelines for the Use of Sedation and Anesthe-
sia by Dentists as it relates to permitting and others that do not. A dentist should not
administer any level of sedation or anesthesia—regardless of their level of training
and education—without first determining what is required by their respective state
dental board for permitting.
Sedation Phases
Clinical guidelines can be presented in different phases, including preparation, drug
administration, recovery, and discharge. Clinical ADA guidelines for minimal and
moderate sedation consist of the following1:
1. Patient history and evaluation

2. Preoperative evaluation and preparation
3. Personnel and equipment requirements
4. Monitoring and documentation
5. Recovery and discharge
6. Emergency management

Preparation phase
During the preparation phase, equipment and supplies used for administration of
pharmacologic agents and monitoring of minimal or moderate sedation or analgesia
must be functional (Figs 2-2 and 2-3). The patient’s medical, physical, and psycholog-
ic information and experience with sedation must be reviewed before a decision is
reached regarding indications and contraindications for sedation. Patient education
must be performed, including a discussion of key points such as goals of sedation,
drugs to be administered, monitoring during and after sedation, and postsedation
instructions. Written informed consent for sedation and the procedure must be ob-
tained. An IV line is inserted, and continuous infusion access is maintained. Monitor-
ing equipment, including electrocardiogram (ECG), blood pressure (BP), and pulse
oximetry, is attached to the patient. Baseline vital signs are obtained and recorded.
Fig 2-2 Armamentarium needed for moderate sedation. (Courtesy of Anthony

Ragonese and Slaton Hoffner.)

Fig 2-3 Dental operatory equipped with monitor for seda-
tion. (Courtesy of Anthony Ragonese and Slaton Hoffner.)
Because sedation is a continuum whereby the patient progresses from a lighter lev-
el of minimal sedation to moderate sedation and potentionally to general anesthesia
without a distinct separation between stages, it is not always plausible to predict how
a patient will respond.13 Response varies from patient to patient; hence patient safety
requires that personnel be trained and credentialed to rescue patients if they progress
into unexpected deeper levels of sedation.14 Many factors that alter host susceptibility
vary from individual to individual and may account for the majority of overdosing.
Drug administration phase

The route of drug administration, drug selection, and dosing are determined by the
length of the procedure as well as the individual patient assessment. In some special-
ty areas, the oral, intravenous, or inhalation routes of administration are used. Since
there are differences between individuals in how much of the drug is required for the
patient to be sedated, the response to the drug must be monitored. Once the desired
level of sedation is achieved, the drug is stopped. After the first appointment, the
drug regimen may need to be adjusted for future appointments depending on the
patient’s experience. The perioperative-trained practitioner should know the recom-
mended dose, onset of action, duration of action, adverse side effects, drug compati-
bility, antagonists, and contraindications for each medication used during moderate

sedation/analgesia. Based on the patient’s history, physical examination (including
BMI and airway classification), fasting state, baseline vital signs, and anesthesia risk
category (ASA class), the trained practitioner will determine the appropriate seda-
tion/analgesia agent(s).
Monitoring, recovery, and discharge of patients

Monitoring helps to identify the effectiveness of the procedures, predict deterioration,
track the patient’s clinical course, and advise clinical decision-making.15 Constant
monitoring and watching the patient while under sedation allows the perioperative
practitioner to detect notable changes in the patient’s physiologic and psychologic
level and to take appropriate action to minimize or prevent early complications or an
adverse event.16
The patient must be monitored throughout the recovery period until discharged
by the trained practitioner into the care of a responsible adult escort who has also
been given written postoperative care instructions. A qualified dentist who is admin-
istering the moderate sedation must remain in the operatory until the patient meets
the criteria for recovery. The patient must return to a minimal sedation level, then
qualified auxiliary personnel can facilitate the remainder of the recovery.1 All moni-
toring parameters observed and recorded during the drug administration phase are
continued in the recovery phase. Monitoring parameters should include the level of
sedation; this can be assessed by the patient’s response to verbal commands and/or
response to painful stimulus. The patient’s circulation and oxygen level must also be
monitored. This is accomplished by using a continuous pulse oximetry and by con-
tinually monitoring blood pressure and heart rate. A continuous ECG must also be
maintained. All the monitoring parameters must be documented and recorded in a
time-oriented anesthetic record (Fig 2-4). The IV line remains open for at least 1 hour
after the last drug dose is administered and until discharge criteria are met. Patients
should be monitored until they are no longer at risk of cardiorespiratory depression.7

Fig 2-4 Monitor used during sedation.
Many complications (eg, respiratory depression, aspiration) can occur during the
postoperative recovery phase of care.16 There are certain criteria used to determine
when a patient is ready for discharge. The patient should fulfill the following:
• Be awake
• Be breathing without respiratory distress
• No bleeding
• No pain
• Oriented to time and place and appropriately aware of their surroundings
• No nausea or vomiting
• Be ambulatory
• Can understand verbal and written postoperative instructions
In addition, an escort is required for all discharged patients when leaving the office
after sedation. The mode of transportation to the patient’s home and the name of a re-
sponsible person to whom the patient is discharged must be recorded in the medical
record. A discharge assessment using specific discharge criteria to score the physical

condition of the patient on admission, postsurgery, and at discharge is written up,
and if the total score is adequate, then the patient is discharged.6,13,17
Patient Selection
With an understanding of the definitions of sedation and anesthesia as well as the
requirements of each individual state dental board, we can return to the discussion
with the patient regarding the level of sedation that will be the most appropriate and
successful. As will be discussed in the chapter on patient assessment and evaluation,
patient selection is strongly determined based on the medical presentation of the
patient. Also, for the purposes of this textbook, the only sedation approaches being
considered and discussed are minimal and moderate sedation. The most appropriate
patients to select for minimal or moderate sedation are ASA I or II patients. ASA III
patients may be appropriate candidates for minimal or moderate sedation, though
serious consideration should be given to appropriate medical consultations to verify
stability and control of the patient, and it may be appropriate to first consult with
other available dental specialists as it pertains to planned treatment and sedation (eg,
dentist anesthesiologist). In addition, a very clear and direct conversation should be
had with the patient regarding their medical presentation, the planned procedure,
and their understanding of the level of sedation that can be administered safely and
successfully. The key component to be discussed between the patient and the dentist
is if the expectations of the patient are being successfully met by the expectations
of the dentist based on what they can provide for the patient. Successful sedation is
dependent on these two sets of expectations aligning and being accepted by both the
patient and the dentist.
The clearest example of this is the patient that states to the dentist, “I want to be
asleep for this procedure.” This is one of the most common miscommunicated expec-
tations with minimal or moderate sedation. Referring to the definitions of minimal
and moderate sedation, one can explain that these levels of sedation require that the
patient is conscious for the entire procedure, meaning that the patient must be able
to respond to the dentist when prompted verbally or with light tactile stimulation.
It is inappropriate for many people, particularly fearful or phobic patients, this is
not sleep as they would define it. For the dentist to assure a patient that they will be
asleep during minimal or moderate sedation, and it should never be done for any
reason. This is an unrealistic expectation by the patient. The dentist must identify
this, explain what can be achieved with minimal or moderate sedation, and deter-
mine if this is acceptable to the patient. If the patient accepts being comfortable and
conscious, then the discussion can continue. Otherwise, the dentist should direct the
patient to another dentist who can administer other levels of sedation or anesthesia
or consider involving the services of another anesthesia provider such as a dentist
anesthesiologist.
It should also be understood that the patient may have expectations for their level
of sedation or anesthesia that are unrealistic based on their medical presentation. As
an example, a patient who is morbidly obese is not a candidate for deep sedation or
general anesthesia in the dental office setting. This patient presents with tremendous
risk when sedative drugs are administered. If this patient requests deep sedation or
general anesthesia for their planned dental treatment by requesting that they either,
“don’t want to know anything” or “want to be out for the procedure,” it must be
explained that this is not an appropriate request based on their presenting medical
condition as it involves too much risk and significantly impacts their safety during
the procedure. If the patient will not accept this explanation, the dentist should not
proceed with treatment involving sedation. An important foundational principle to
sedation administration is not violating identified limitations established to protect
the safety and well-being of the patient. Understanding that a patient’s medical pre-
sentation does not allow them to receive treatment without compromising their safe-
ty is extremely important when determining an appropriate sedation approach, and
not making a decision only to satisfy the patient and which could potentially create a
situation with unacceptable risk is crucial.
Patients must clearly understand what can be achieved with minimal or moderate
sedation and accept either approach as determined by the dentist in the best interest
of the patient to maintain their safety and well-being. Another related challenge to
this approach is the patient who is medically acceptable (ASA I or II), though their
level of fear or anxiety will not be successfully resolved with minimal or moderate
sedation. This may not be as easy to identify when assessing and evaluating a pa-
tient, but with experience, it does become easier for the dentist to determine. A com-
mon outcome with this type of situation is that the sedation is unsuccessful despite
the dentist administering appropriate sedation within acceptable dosing guidelines.

When this occurs, it must be identified by the dentist as a sedation failure. This is an
extremely important concept to understand and accept. Not every sedation will be
successful, and the dentist must know that this is an acceptable outcome. In fact, the
dentist should always function with the understanding that some sedation proce-
dures will fail.
Generally, this is a situation that decreases over time and with experience, though
the possibility will always exist. What is critical to remember is that identified limita-
tions should never be violated. The dentist must not allow the administration of any
drug beyond the identified dose limitation, even if there is an expectation that the
patient only requires a small additional amount to make the procedure successful.
This presents an unacceptable risk, and the dentist must never allow this to happen
regardless of the situation.
Conclusion
Much has changed in dental sedation, especially with the advanced training of den-
tal anesthesiology residents. The residents are well trained and have been provided
with an excellent environment. The results in terms of the patient’s satisfaction are
notable. Dental sedation complications are minimal, though there have been reports
in the media regarding complications in some pediatric anesthesia cases. Remember,
anesthesia and sedation are not the same. Therefore, it is important and necessary to
review every anesthetic complication.
References
1. American Dental Association. Guidelines for the Use of Sedation and General Anesthesia by
Dentists. http://www.ada.org/~/media/ ADA/Advocacy/Files/anesthesia_use_guidelines. Ac-
cessed 27 April 2021.
2. Yagiela JA. Recent developments in local anesthesia and oral sedation. Compend Contin Educ
Dent 2004;25:697–708.
3. International Association for the Study of Pain. IASP Terminology. https://www.iasp-pain.org/
Education/Content.aspx?ItemNumber=1698. Accessed 7 May 2021.
4. American Society of Anesthesiologists. Continuum of Depth of Sedation: Definition of General
Anesthesia and Levels of Sedation/Analgesia. https://www.asahq.org/standards-and-guide-

lines/continuum-of-depth-of-sedation-definition-of-general-anesthesia-and-levels-of-sedationan-
algesia. Accessed 7 May 2021.
5. Assaf HM, Negrelli ML. Sedation in the dental office: An overview. https://www.dentalcare.com/
en-us/professional-education/ce-courses/ce464. Accessed 27 April 2021.
6. Haas DA. Oral sedation in dental practice. Dispatch 2015;May/June(suppl):1–7. https://www.
globalbeautyllc.com/wp-content/uploads/2016/09/oral-sedation.pdf. Accessed 27 April 2021.
7. Brown TB, Lovato LM, Parker D. Procedural sedation in the acute care setting. Am Fam Physi-
cian 2005;71:85–90.
8. American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthe-
siologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesi-
ology 2002;96:1004–1017.
9. Godwin SA, Caro DA, Wolf SJ, et al. Clinical policy: Procedural sedation and analgesia in the
emergency department. Ann Emerg Med 2005;45:177–196.
10. Green SM, Krauss B. Procedural sedation terminology: Moving beyond “conscious sedation.”
Ann Emerg Med 2002;39:433–435.
11. Sheta SA. Procedural sedation analgesia. Saudi J Anaesth 2010;4:11–16.
12. Juels AN. Procedural sedation. https://emedicine.medscape.com/article/109695-overview.
Accessed 27 April 2021.
13. Becker DE. Pharmacodynamic considerations for moderate and deep sedation. Anesth Prog
2012;59:28–42.
14. Blayney MR. Procedural sedation for adult patients: An overview. Cont Educ Anesth Crit Care
Pain Adv Access 2012;4:176–180.
15. Fencl JL. Guideline implementation: Moderate sedation/analgesia. AORN J 2016;103:500–511.
16. Giovannitti JA Jr, Montandon RJ, Herlich A. The development of dental anesthesiology as a dis-
cipline and its role as a model of interdisciplinary collaboration. J Dent Educ 2016;80:938–947.
17. Moore PA, Boynes SG, Cuddy MA, Giovannitti JA Jr, Zovko J. Educational experiences and pre-
paredness in dental anesthesia: Five-year outcome assessment and conclusions. J Dent Educ
2009;73:1379–1386.

CHAPTER 3
Patient Assessment and

Evaluation
Lauren Hanzlik, DDS
I
n today’s health care culture, many patients have learned to become their own
advocate to help them in achieving their own health care goals. Many times, what
a patient may feel is appropriate is not always what is medically indicated, and it
is up to the provider to provide the appropriate education and make decisions that
are in the patient’s best interest even if it is not what the patient wants to hear. It is
important to keep in mind when discussing sedation with patients that it should not
be taken lightly and there are always risks associated with sedation, just like any sur-
gical or dental procedure. A thorough history and physical examination is important
in the initial assessment of the patient to determine if they are even a candidate for
sedation. The provider must remember that safety comes before everything else and
that the decision to sedate a patient should not be taken lightly.
“Never treat a stranger.” In 1966, Dr John Tarsitano wrote an article published in
the Journal of the American Dental Association (JADA) with this very title.1 Suffice to
say, we have long known and understood that one of our primary responsibilities as
dentists is to complete a thorough and complete assessment and evaluation of each
patient we treat. Though these two words appear synonymous, they really are not.
Assessment refers to the process of collecting and gathering data and information.
Evaluation refers to the process of reviewing the gathered information and making
a decision regarding that information. This is an important distinction as it fulfills

our requirement, as discussed in Tarsitano’s article, to complete a thorough medical
history of our patients. To merely gather information about a patient fails to appro-
priately take that information and incorporate it into our planned treatment for the
patient and aid us in making appropriate decisions regarding treatment and, regard-
ing the administration of sedation, the safety and well-being of the patient.
Medical History
Assessment of the patient prior to any procedure usually follows a standard pro-
tocol. The initial patient assessment and discussion of the procedure will require a
complete history and physical examination. The history should consist of queries
regarding all diseases such as diabetes, allergies, issues with prior anesthesia (includ-
ing family history), and medication history. This step is important even for a patient
that is classified as Class ASA I (see Table 3-2) and is generally healthy.2 Any positive
responses should be discussed and documented. There is always concern regarding
a family history of inhalation anesthetic problems, especially when succinylcholine
(muscle relaxant) is utilized. There is an incidence of malignant hypothermia with
this combination, especially in children.3
The foundation of patient assessment is the medical history form completed by the
patient. For the most part, dentists do an adequate job of having patients complete
this document. Where dentists often fall short is appropriately reviewing the form
with the patient to confirm the information provided as well as collect more infor-
mation. For example, if a patient reports asthma on their form, the dentist should do
the following:
1. Confirm with the patient that they have asthma

2. Ask the patient questions such as what triggers their asthma, what medications
are used to treat their asthma, how often they use medication to treat their asthma,
and if they have ever been hospitalized for their asthma
When considering sedation for a patient, a dentist needs more than the check-box
form handed out by the front desk to conduct the medical history interview. It is not
uncommon for patients to not check the box for “hypertension” or “diabetes” if they

feel like the condition is controlled with their medications. Patients also may not
know why they are taking a certain prescription, which puts the onus on the provid-
er to obtain additional information. Beyond identifying any diagnosis or conditions
that may be afflicting the patient, understanding the disease process or implications
of certain medications is also of pivotal importance. Determining the need for periop-
erative laboratory tests can only be adequately assessed if the provider has done their
due diligence. A straightforward example is a patient who reports a cardiac history
with a mitral valve replacement and is taking warfarin. What kind of valve does the
patient have? What should their therapeutic international normalized ratio (INR) be
in relation to their valve? Is their INR well controlled?
As presented, it is important to identify a positive response in the medical history. It
is also important to make sure that additional information is obtained regarding that
positive response to ensure that the dentist understands the status of that condition
and how the patient is managing that condition. This allows the dentist to determine
if that condition is controlled or uncontrolled, which allows them to make an appro-
priate risk assessment as well as determine if a medical consultation is indicated. The
thorough evaluation of a reported condition allows the dentist to make appropriate
decisions regarding the treatment of a patient, including the administration of seda-
tion. Another important aspect of reviewing the medical history document with the
patient is confirming the negative. This requires the dentist to directly ask the patient
to confirm a negative response. For example the dentist could say the following: “You
have indicated you do not have heart problems, is that correct?” Another approach
would be to ask the patient questions that could impact their cardiovascular status.
Examples include the following:
• “Do you smoke cigarettes or cigars?”

• “What do you do for exercise?” or “Do you exercise regularly?”
• “Have you ever experienced chest pain?”
It is important to confirm that the reported negative is actually negative. Often,

patients will report incorrectly on a question only to correctly respond when asked
during the verbal review of the medical history. This is referred to as the dialog history.
This dialog is essential to ensure a thorough evaluation of the patient. Though it is
appropriate to have a dialog with the patient following the completion of the medical
history document, there is another component to this process that dentists often miss.
This is the physical evaluation of the patient.
Physical Evaluation
The physical evaluation is an integral and necessary part of the thorough evaluation
of the patient, and the failure to complete this evaluation results in an incomplete
and potentially compromised assessment. Without complete information, the patient
is put at risk, and the provision of treatment to any patient on which we lack com-
plete information can result in adversity based on the failure to identify and under-
stand the presenting risk. Though we live in a digital age and the internet provides
a tremendous resource for a variety of information, it is recommended to purchase a
textbook on physical evaluation for guidance and reference. One reliable resource is
Bates’ Guide to Physical Examination and History Taking by Lynn S. Bickley, MD, current-
ly in its 13th edition (Wolters Kluwer, 2021).4 The completion of a thorough patient
assessment and evaluation cannot be overemphasized, and a good resource provides
a strong foundation for this process.
A concept that is critical to understand and incorporate during this assessment is
cultural humility. Cultural humility is defined as a “process that requires humility as
individuals continually engage in self-reflection and self-critique as lifelong learners
and reflective practitioners.”4 An important tenet of cultural humility is to under-
stand and respect others without judgment. As health care providers, we are caring
for our patients in a positive, supportive, and appropriate manner.
When completing the physical evaluation of the patient, we should endeavor to
minimally complete the following:
1. General survey
2. Vital sign assessment
3. Behavioral assessment
When sedation will be considered, a fourth category should be added:

4. Sedation assessment
General survey
The general survey involves the following elements4:
• Apparent state of health

• Level of consciousness
• Signs of distress
• Skin color and lesions
• Dress, grooming, and personal hygiene
• Facial expression
• Odors of body and breath
• Posture, gait, and motor activity
• Height and weight
These assessments are discussed in more detail in Bates’ Physical Examination and
History Taking, though the important concept is the requirement to observe the phys-
ical presentation of the patient in an effort to gather information to aid in the thor-
ough assessment of the patient. For example, does the patient have a certain posture
or gait? This could indicate a recent injury, surgical procedure, or disease such as
Parkinson. Another example is the patient who presents with a body odor and poor
grooming, possibly indicating that they are depressed or anxious. The importance
of this assessment is to allow our observations of the patient to aid us in making ap-
propriate decisions regarding the patient and their potential needs for treatment. See
Table 3-1 for examples of patient observations and related health concerns.

Table 3-1 Examples of patient observations and related health concerns
Patient observation Related health concern

Exophthalmos Hyperthyroidism
Diaphoresis Heart failure, anxiety
Gait alterations Injury, surgery
Obesity Cardiovascular disease, poor exercise tolerance
Respiratory distress (rapid, shallow breathing) COPD, poor exercise tolerance, anxiety
COPD, chronic obsessive pulmonary disorder.
Vital sign assessment

The assessment of height and weight is typically included with vital signs. In addi-
tion to height and weight, other vital signs that should be collected for every patient
are blood pressure, pulse (heart rate), and respiratory rate. The sixth vital sign is tem-
perature, which (prior to COVID-19) was not routinely collected and documented
unless indicated. There are two indications for the collection and documentation of
vital signs:
1. Initial appointment. This covers a thorough assessment, evaluation, and documen-

tation of the vital signs for the patient as a baseline.
2. At every scheduled appointment. This is of particular importance if any medications
or drugs are involved with the appointment: local anesthesia; analgesics; nitrous
oxide-oxygen (N2O-O2) sedation; and sedative drugs administered by oral, sub-
lingual, intranasal, intramuscular or intravenous routes. This is important for the
purpose of comparing the vital signs to the baseline vital signs and making deci-
sions regarding proceeding with treatment, rescheduling the procedure, or need-
ing medical intervention.
Height and weight

The purpose of discussing height and weight as part of the general survey is meant
to direct the practitioner to make observations of the patient’s build, body symmetry,
and proportionality. Related to this is the calculation of body mass index (BMI). Mak-
ing this calculation provides information regarding obesity and potential comorbid-
ities, including diabetes, hypertension, and cardiovascular disease. BMI is not a de-

finitive diagnostic measure, though it provides an opportunity to gather information
and relate it to other assessments. What is important is the collection and documen-
tation of this information for every patient as part of their assessment and evaluation.
This information is critical for any patient being considered for sedation.
The determination of height and weight should not be documented by patient re-
port. It is reasonable to request that the patient report this information on the medical
history document, though this information should be verified by using devices to
assess height and weight. It is not uncommon for dental offices to have a scale for cal-
culating weight, but many offices do not have devices to measure height. This is not
a tremendous expense, and in fact, there are many approaches to determine height.
With the determination of height and weight, BMI can be calculated. This is recom-
mended for any patient receiving sedation.
Blood pressure
There are two available methods for obtaining blood pressure: manual or automated
(Fig 3-1). Though the current state of automated blood pressure monitors is accept-
able for routine use in the office setting, it is recommended to maintain manual blood
pressure devices for the purposes of confirmation and backup.
a b
Fig 3-1 (a) Manual blood pressure reader. (b) Automated blood pressure reader.
Whether using manual or automated blood pressure devices, it is important that the
patient is positioned properly and that the equipment is the correct size and placed
in the correct location. The patient should be in a sitting position and preferably in a
location that is quiet and free of distraction. The patient should be allowed to rest at
least 5 minutes prior to having their blood pressure taken. The patient should have
a place to rest their arm with support and ensure their forearm is above their waist.

There is a marker on the manual blood pressure cuff indicting where the cuff should
be placed over the brachial artery (Fig 3-2).
Fig 3-2 Taking blood pressure. (Reprinted with permission under the
Creative Commons Attribution-Share Alike 4.0 International License.
Source: https://commons.wikimedia.org/wiki/File:100_Blood_Pres-
Prior to placing the blood pressure cuff, the patient’s pulse should be palpated
(Fig 3-3). Next, the correct sized cuff needs to be selected for use. There are range
markers on blood pressure cuffs that allow the correct size to be determined. This is
an important determination. If the blood pressure cuff is too small, the result can be a
blood pressure that is higher than the patient’s actual blood pressure. If the cuff is too
large, the result can be a blood pressure that is lower than the patient’s actual blood
pressure. Once the correct cuff size is determined, the cuff should be placed on the
patient’s arm with the brachial artery marker over the brachial artery (see Fig 3-2).
The next step is to inflate the blood pressure cuff while palpating the radial pulse.
Continue inflating the cuff until the radial artery pulse disappears. Identify the num-
ber on the manometer, and then rapidly deflate the cuff. Use the number identified
when the radial pulse disappeared, and add 30 mmHg to that number. This will be
the number the cuff will be inflated to on the manometer.

Fig 3-3 The pulse is taken at the radial artery. (Reprinted with per-
mission under the Creative Commons Attribution-Share Alike 4.0
International License. Source: https://commons.wikimedia.org/wiki/
File:Pulse.jpg.)
Now, place the bell of your stethoscope over the brachial artery. As much as pos-
sible, avoid placing the bell underneath the cuff to prevent inaccurate measurement.
Inflate the cuff to the determined level and then deflate the cuff slowly at a rate of 2 to
3 mmHg per second. The first sounds you hear should be correlated with the number
on the manometer and identified as the systolic pressure. Continue deflating the cuff
slowly as identified until sounds muffle and then disappear. The disappearance of
sounds should be correlated with the number on the manometer and identified as the
diastolic pressure. Current recommendations are to obtain multiple blood pressure
recordings and record the average of those collected pressures, representing a more
accurate blood pressure for the patient.
According to the Joint National Committee’s current guidelines (JNC 8),5 it is rec-
ommended that patients under 60 years of age have blood pressure recordings (≤
140)/(≤ 90) mmHg and patients over 60 years of age have blood pressure recordings
(≤ 150)/(≤ 90) mmHg. There are modifications based on the presence of cardiovas-
cular disease and other comorbidities that are discussed in detail in the guidelines.5
With blood pressure recordings that are determined to be too high, it is often difficult
to make a decision based solely on the blood pressure and not taking other present-
ing signs or symptoms into account. The American Heart Association identifies two
situations where medical attention should be pursued6:

1. Hypertensive urgency: Blood pressure recording of 180/110 mmHg or greater.
2. Hypertensive emergency: Blood pressure recording exceeding 180 mmHg systolic
or 120 mmHg diastolic
If there is concern regarding the number obtained when taking blood pressure, it is
suggested to use a different device (eg, manual rather than automated blood pressure
reader) to confirm the information. Similarly, when taking multiple blood pressures,
it is important to provide the patient with at least a 2-minute rest between recordings
and up to 5 minutes if there is concern that the blood pressure is too high. Anoth-
er suggestion is to use the patient’s other arm or wrist to obtain additional blood
pressure recordings. The monitors used for blood pressure and other vital signs (eg,
pulse rate) are very accurate and reliable, though the practitioner must ensure that
the monitor is routinely serviced to ensure it functions properly (Fig 3-4).
Fig 3-4 Example of a blood pressure monitor.
Pulse rate
The best location for assessing a patient’s pulse is the radial artery (see Fig 3-3). To
the best of the practitioner’s ability, the quality and the rhythm of the pulse should
also be assessed. For example, if the pulse is determined to be strong and forceful, it

could be described as bounding. This may indicate dysfunction with the heart. When
locating the pulse, only the fingers should be used. The thumb maintains a pulse and,
if used, can confuse the assessment. After identification of the radial pulse, it should
be assessed for a period of 30 seconds, the number of beats counted during that pe-
riod multiplied by 2, and the result recorded as beats per minute (BPM). Generally,
adults should be in the range of 60 to 100 BPM. Tachycardia, an unusually fast heart
rate, is described as a heart rate greater than 120 BPM. It should also be noted that a
patient who is well conditioned physically can present with a pulse rate in the range
of 40 to 60 BPM.
Respiratory rate
As with the pulse rate, the practitioner should also attempt to assess the quality and
rhythm of the patient’s respiratory effort. The work of breathing involves both active
(inhalation) and passive (exhalation) activity.
Breathing is influenced by the movement of the chest wall and diaphragm. With
forced breathing, which can occur with a patient who is under distress, there is the
involvement of accessory muscles (such as the abdominal muscles) to facilitate venti-
lation. Understanding the breathing mechanics during the assessment of a patient is
critical with respect to making determinations about sedation. When assessing respi-
rations, the goal is to not let the patient know what you are doing. A typical approach
is to inform the patient that you are going to assess their pulse for 1 minute, and
after 30 seconds of assessing the pulse, continue maintaining your finger position on
the radial artery and direct your attention to the patient’s respiratory effort for the
remaining 30 seconds. The number of breaths counted during that period are mul-
tiplied by 2 and recorded as breaths per minute (BPM). If the patient knows you are
counting their respirations, there is a tendency to hold their breath, and you do not
obtain an accurate assessment. Generally, adults should be in the range of 12 to 20
breaths per minute.
Behavioral assessment
Understanding the behavior of a patient is critical in the determination of sedation
as a part of the planned procedure. It is not uncommon for a patient to avoid dental
treatment due to anxiety, fear, or phobia. Despite various estimates regarding the
number of patients who avoid seeking dental care due to anxiety, fear, or phobia, it is

accepted that there is a significant amount of the US population with dental anxiety
and fear who would benefit from the administration of sedation for dental treatment.
What is important is to include this assessment as part of the thorough medical eval-
uation of the patient. Too often, the behavioral assessment is not included as part of
the medical history questionnaire, which results in the patient not being assessed and
asked about their underlying anxiety or fear with dentistry. This is a very straight-
forward assessment to make, involving a simple visual analog tool that allows the
patient to indicate how they feel about dental treatment (Fig 3-5).
Fig 3-5 The anxiety scale: 0–3 is mild, 4–8 is moderate, and 9–10 is severe.
With the patient’s reported assessment of how they are feeling, a dialog can take
place identifying specifically which aspects of dentistry impact the patient and how
treatment modifications can be made to accommodate the patient and address their
concerns. Another opportunity is to identify the patient who may desire a level of
comfort during the dental procedure or specific treatment. Examples include the
placement of an implant or a root canal procedure. The behavioral assessment can
help to determine how to proceed with treatment before any appointments are sched-
uled. If it is identified whether the anxiety or fear of a patient is manageable during
the assessment and evaluation process, decisions can be made before treatment be-

gins. This can potentially save time and prevent a poor patient experience. See Fig 3-6
for examples of successful behavioral assessment.
Mild to moderate
Desire for comfort Severe anxiety or fear
anxiety or fear
Good candidate Not a good candidate

for sedation for sedation
Fig 3-6 Successful behavioral assessment.
Behavioral assessments are not absolute. It is important to understand that de-

spite the best assessment, patient response during treatment may not be what was
anticipated. The predictive success of this assessment occurs over time and with ex-
perience, though there will always be the patient who does not respond as expected
based on this assessment. For patients who are not deemed good candidates for se-
dation, considerations for referral or involving the services of an anesthesia provider
should be discussed with the patient.
Sedation assessment
When evaluating a patient for sedation, there are additional physical assessments
that should be completed to facilitate risk identification. They include airway assess-
ment, range of motion (ROM), and thyromental distance.
Airway assessment
Airway assessment is extremely important.7 The oral airway may have abnormal
anatomical features. Anesthesiologists are familiar with craniofacial disorders and
abnormalities. The evaluation of the oral cavity, the temporomandibular joints, and
the range of motion upon mandibular opening is extremely important in the assess-
ment. In children, we must be attentive to abnormalities, especially trisomy 21, or
Down syndrome.
We cannot ignore a history of snoring, sleep apnea, and/or obesity, which may
lead to an obstructed airway. These issues should be discussed during the patient’s

evaluation and history.8 However, during conscious sedation, patients maintain their
own airway. Conditions that may obstruct the airway will require the utilization of
an oral or nasal airway. A patient with difficulty tolerating these airways may require
additional sedation. With the deeper sedation, the monitoring is continued, and the
patient is easily managed by the anesthesiologist or anesthetist.
A simple and easy assessment is the Mallampati (MP) classification. This assess-
ment was originally identified as a predictor of difficult intubation, but it can be
used as an indicator of the difficulty of the patient to maintain their airway when se-
dated. The greater the difficulty involved with maintaining the patient’s airway, the
greater challenge and potential risk to the practitioner and patient during a sedation
procedure. The MP classification provides an assessment of oral soft tissues and the
amount of space they take up when viewing the pharynx. The more diminished the
view of the pharynx, the greater the potential of airway compromise during sedation.
Additionally, an MP Class III or IV airway could indicate the inability or significant
challenge in establishing or maintaining the patient’s airway in the event of a seda-
tion adversity. To complete this assessment, have the patient open their mouth as
wide as possible and protrude their tongue as far as possible while in a sitting posi-
tion (Fig 3-7).
Class I Class II Class III Class IV

Fig 3-7 Mallampati classification:
MP Class I airway Soft palate, uvula, fauces, pillars visible

MP Class II airway Soft palate, uvula, fauces visible
MP Class III airway Soft palate, base of uvula visible
MP Class IV airway Only hard palate visible
Range of motion
This assessment involves the ability of the patient to move their head from side to
side as well as up and down. Limitations in a patient’s ROM could indicate their

inability to be in an appropriate position, which could impact the ability to main-
tain their airway. Additionally, limitations with ROM could indicate the inability or
significant challenge to establish or maintain the patient’s airway in the event of a
sedation adversity.
Thyromental distance
Like the MP classification, this assessment is used as a predictor of difficult intuba-
tion, though it can also serve as a predictor for the difficulty of the patient to main-
tain their airway during sedation. In addition to assessing this distance, observation
of the tissue should also be documented, such as the presence of any scar tissue or
excessive skin and/or fat that results in the lack of a defined space between the chin
and neck. Included with this assessment is the identification of a defined neck length
indicating no neck space, which could impact ROM as well as indicate an excessive
presence of soft tissue. It is recommended that a patient have a thyromental distance
of at least 3 fingerbreadths or 6 cm as an indicator of an appropriate distance to fa-
cilitate successful intubation, which can also be used to indicate adequate airway
patency during sedation. This assessment is performed by determining the horizon-
tal distance between the thyroid prominence and the inner surface of the mandible
when the head and neck are fully extended and the mouth is closed9 (Fig 3-8).

Normal 6.5 cm
Concern < 6 cm
Fig 3-8 The thyromental distance is the distance between the thyroid

prominence and the inner surface of the mandible when the head and neck
are extended, with the mouth closed.
Risk Assessment
Following the completion of the physical examination, the information collected can
be integrated with the review of the medical history through the dialog history with
the patient. It should be noted that the information contained in a medical history
document is not intended for discussion in this chapter, though it is worthwhile for
the purpose of completeness to identify components of a medical history question-
naire that should be present (Box 3-1).

BOX 3-1 Medical history questionnaire
Goals and objectives of the medical history questionnaire

• Received directly from the patient
• To identify and confirm known/diagnosed disorders
• To identify unknown/undiagnosed disorders
Components of the medical history questionnaire
• Identifying information: Date of birth, age, sex, race/ethnicity
• Chief complaint: Reason for visit
• History of present condition: Previous treatment, recent changes
• Medical history: Report of comorbidities, hospitalizations, operations, accidents, injuries,
current medical treatment, and status
• Health status: Current medications (dose, frequency, reason for medication); allergies
(which medication or nonmedication, what happens); exercise (type, frequency); diet; sleep
patterns (use of pillows, snoring, sleep apnea)
• Family history
• Review of systems: Based on reported comorbidities, discussion should be directed to
other potential involvement and complications related to that system. Important systems to
review include neurologic, cardiac, respiratory, and endocrine
Risk assessment involves the identification of potential risk involved with treat-
ment of a patient based on the completion of a thorough medical history evaluation.
There are two goals of risk assessment10:
1. Assess the potential risk in performing the desired procedure on a specific patient
2. Identify modifiable risk factors
The administration of drugs to a patient, regardless of the purpose, always in-

volves risk. How a patient presents medically can directly impact the risk involved,
and that is the purpose of determining a risk assessment for each patient. Despite
being an important component of the overall assessment and evaluation of the pa-
tient, this risk assessment is often not completed for the delivery of routine dental
treatment. However, it should not be avoided when incorporating sedation into the
treatment plan. Identifying the risk of a patient scheduled for a sedation procedure is
critical for the safety and well-being of the patient. It also ensures that there was
identification and discussion with the patient about their risk potential for a proce-
dure involving sedation. The American Society of Anesthesiology (ASA) developed
a physical status classification system that identifies the risk potential of the patient

based on their presenting health and medical condition (Table 3-2). This classification
system was last updated by the ASA in 2020.11
There are six physical status classifications (though, for the purposes of administer-
ing sedation, the focus will remain on the first four classifications). When considering
sedation for a patient following the identification of the risk assessment, appropriate
selection would be the ASA I or II patient. ASA III patients require more involved
ASA PS Adult examples

Classification Definition (including, but not limited to)
lung disease
tem dysfunction
donor purposes
assessment and evaluation. They should have a documented medical consultation

regarding their identified systemic disease and possibly consultation with other den-
tal specialists, including oral and maxillofacial surgeons or dentist anesthesiologists.
Caution should be exercised when considering sedation for the ASA III patient, par-
ticularly if they present with comorbidities that involve the cardiac or respiratory
systems. It would be appropriate to obtain a medical consultation for an ASA I or II

patient if it is determined that the information provided by the patient is incomplete
or unreliable. An ASA IV patient is not a candidate for sedation.
Special Considerations
Female patients of childbearing age

Medications used for sedation carry a fetal toxicity warning. Female patients of child-
bearing age should undergo a pregnancy test or, if they refuse, be asked to sign a
waiver prior to undergoing sedation.
Pregnant patients
Pregnancy can present a problem for the dentist/anesthesiologist and is often im-
mediately assessed when a female patient enters the operating suite. Urine tests are
very accurate in the determination of pregnancy. The question of providing anesthe-
sia or sedation to a pregnant patient is ongoing. It would be prudent not to provide
anesthesia to a pregnant patient. The possibility of teratogenic effect of anesthesia
drugs on the developing embryo is of concern. Certainly, the second trimester may
be the best time to utilize sedation if necessary, because the developing fetus is less
vulnerable. However, it is best practice not to provide anesthesia/sedation to preg-
nant patients.12
Pediatric patients
Pediatric sedation carries an increased risk compared to sedation delivered to an
adult patient. Pediatric patients have significant anatomical and physiologic differ-
ences from the adult population, which can make them a more challenging seda-
tion patient.
Anatomical considerations are important in emergent as well as nonemergent situ-
ations. The provider must be aware of the difference between children and adults to
be successful when providing intervention in the event of an adverse situation. Chil-
dren have proportionally larger tongues than adults, which can easily fall posteriorly

and obstruct their airway while the patient is sedated. The obstruction can easily be
overcome by adequate retraction and/or positioning.
Another significant difference, more important to be aware of in emergent situa-
tions, especially if a definitive airway needs to be placed is the location of the larynx.
In children, the larynx is significantly more cephalad and anteriorly located when
compared to adults. Pediatric patients have a larynx located around the level of cer-
vical vertebrae C3 and C4 in comparison to adults, where it is located at the level of
C6. Additional differences concerning the larynx are its anatomical form and its re-
lationship with the epiglottis. The pediatric larynx is funnel shaped and constricted
at the cricoid cartilage compared to the more cylindrical adult larynx, which has its
narrowest point at the vocal cords. This is of great importance because if a pediatric
patient were to aspirate a foreign object, it is possible for it to lodge below the vocal
cords at the level of the cricoid cartilage. This would create significant airflow ob-
struction of the entire bronchial tree; whereas, in an adult, the object may fall below
the level of the vocal cords, but be more likely to lodge in the right main stem bron-
chi, allowing for continued ventilation of the left lung.
Physiologic considerations are much more significant for the neonatal/infant pa-
tient and will not be discussed in this chapter as they are outside the scope of in-office
sedation. However, a few considerations carry through to older children who are
possible sedation candidates: cardiac output and temperature regulation. In children,
cardiac output is mainly determined by heart rate because their left ventricle does
not have the compliance of an adult or teenage patient, making their stroke volume
relatively fixed. Remembering that cardiac output is equal to the stroke volume mul-
tiplied by the heart rate (CO = SV × HR) helps to demonstrate how quickly cardiac
output in a young patient will diminish with bradycardia that could be brought on
by oversedation. Conversely, in episodes of tachycardia, diastolic filling times will be
greatly diminished. Pediatric patients also tend to have a propensity for heat loss, as
their body surface area relative to weight is often much higher than adults. In-office
pediatric sedations are often for procedures with shorter durations (eg, extraction of
one to two retained primary teeth), and hypothermia is often not problematic. Care
should always be taken to avoid any complication.

Elderly patients
Age in and of itself is not a risk factor for anesthetic complications; however the
provider must keep in mind that even moderate declines in organ function, which
are natural in the aging process, will lead to less overall reserve in a patient, causing
multiple downstream changes. One example of the natural decline in organ function
is the fibrosis of the arterial vasculature and cardiac conduction systems. This change
negatively influences vascular compliance and myocardial compliance, influencing
cardiac output as discussed previously, while fibrosis of the conduction systems leads
to increased likelihood that the patient will develop dysrhythmias (most commonly
atrial flutter and atrial fibrillation). In the elderly patient, every organ system has
undergone a natural aging process, which means the provider should consider that
normal compensatory mechanisms are systemically diminished, and care must be
taken to ensure patient safety.
Obesity
As defined by the BMI, obesity should be of increasing concern to all health care pro-
viders, as the physiologic implications of the condition are widespread. According
to the Centers for Disease Control and Prevention, the prevalence of obesity across
the United States from 2017 to 2018 was 42.4% of adults aged 20 and over and 19.3%
of youth ages 2 to 19.13,14 Assuming the trend continues to rise, as it has since 1999,
more and more patients will fall into the category of obese (as defined as a BMI great-
er than 30).
When patients have such a significant amount of body mass, physiologic and an-
atomical changes occur. This results in an increased level of complexity when pro-
viding their care. From a ventilator standpoint, obese patients are very likely to have
excessive soft tissue in their aerodigestive tract, which will readily cause airway com-
promise in an anesthetized state and will also complicate bag-mask ventilation in an
emergency. The same soft tissue redundancy will be mimicked externally as exces-
sive soft tissue folds around the mouth and neck. Excessive soft tissue around the
atlantoaxial joint can limit cervical spine range of motion, hindering the ability to
position the patient in an optimal fashion and, again, complicating ventilation. Neck
circumference is a good predictor for problematic airways in the obese patient; when
the circumference approaches 40 cm, the probability of airway compromise increases

by 5%. When the circumference increases to around 60 cm, the risk jumps to 35%. The
extensive burden to the chest wall from the extra mass causes a physical, extrapa-
renchymal restrictive-like lung disease with a decreased functional residual capacity
noted on pulmonary function tests.
Diabetes mellitus
Diabetes mellitus, whether it is type 1 or type 2, comes with a whole host of back-
ground issues that need to be looked for, evaluated, and monitored. Obtaining a
perioperative HbA1c helps the provider to understand the patient’s current level of
disease control. Referring to the ASA table, an uncontrolled diabetic would fall into
the ASA III category.
Uncontrolled hyperglycemia wreaks havoc on many different organ systems. A
few of the most important complications of diabetes to be aware of when consider-
ing sedation in controlled and uncontrolled diabetics are the effects on the patient’s
fluid status, autonomic nervous system dysfunction, and gastroparesis (or delayed
stomach emptying). Hyperglycemia causes osmotic diuresis (ie, the extra glucose
molecules draw water into the renal tubules, increasing urination) in a patient who is
already NPO (nil per os or nothing by mouth). This can result in significant volume
depletion, which compounds with inherent autonomic dysfunction seen in these pa-
tients. Postural hypotension is very common in these patients as they have dimin-
ished baroreceptor reflexes. These reflexes are important in moderating vasoconstric-
tion to help control and level blood pressure. Adding these considerations together,
a diabetic patient is likely to have greater volume depletion when compared to a
nondiabetic after a preoperative fast; coupled with the propensity for orthostatic hy-
potension, this puts them at increased risk for a syncopal event. Another common
finding in diabetic patients regarding autonomic dysregulation is that their central
respiratory centers are often impaired when it comes to sensing hypoxia or hypercar-
bia, resulting in issues with adequate respiratory drive.
Diabetic patients must receive a complete evaluation regarding the medication
they are taking, with detail about dosage and frequency. Diabetics who may be NPO
for an extended time may require medication or glucose. In diabetic patients, the
preanesthetic evaluation determines the blood sugar level. Treatment is predicated
on the findings. Hydration and replacement therapy also depend on the findings. In-

travenous fluids are not mandatory but are a consideration depending on the prean-
esthetic evaluation.
Impaired communication
In any situation, clear communication between provider and patient is imperative.
As the inherent risks of a procedure or situation increase, clear communication be-
comes even more important.
Eye, ear, nose, and throat complications

There are two areas that are sometimes overlooked or given minimal attention in the
preoperative evaluation. They may seem minimal or less important, but they unfor-
tunately can cause great upset and pain to the patient. The first area of concern is
the possible eye or ophthalmic complications. Patients with a history of dry eye may
need eye drops prior to the procedure to prevent dryness of the conjunctiva. Also,
corneal abrasion can occur if the patient, anesthesiologist, or provider inadvertent-
ly touches the eye during the procedure. It is also important to access the ear, nose,
and throat situation prior to sedation. Some patients may present with a seasonal
allergy or a chronic cough. While this is not a major problem, it may occur during a
conscious sedation case where the patient undergoing a procedure has a sneezing or
coughing episode. These patients can be treated preoperatively using nasal sprays or
similar medications to reduce the likelihood of these episodes.
Medical Consultation
The decision to obtain a consult for a patient is significant for the purposes of gather-
ing information regarding their current health status, the verification of an identified
disease or condition, and the control of any identified comorbidity. It is important to
remember the purpose of the consult request, which is to gather information from the
medical provider and not to ask for permission to treat the patient in the dental office.
Consults can be obtained from a variety of health care providers, and it is important
that the requested consult is obtained from the medical provider with appropriate ac-
cess to the information being requested. When completing the medical history with
the patient, the dental provider must determine who the patient sees for medical

care. Are there multiple providers involved with their care? Are there specialists in-
volved? What are the present conditions being treated? Gathering as much informa-
tion as possible from the patient regarding their medical care will provide guidance
as to who should be contacted. A consult can provide a very helpful understanding
of the patient’s medical conditions. It also determines how compliant the patient is
with their directed medical care.
The essence of a medical consult is to obtain medical information about the patient
to allow the dentist to determine a course of action in the best interest of the patient.
This does not require that the dentist know anything about the patient when request-
ing a consult, but rather, they will review the information obtained to determine if
additional information is needed to make an appropriate decision regarding treat-
ment. Having appropriate systems in place to gather information is very important
when requesting a consult. It allows the dentist to understand the information gath-
ered and then make informed decisions. This process identifies two pathways for
consultations: known and unknown.
A known consultation is the most straightforward. However, the dentist must rec-
ognize that a consult can provide further insight into a patient’s identified medical
condition(s), allowing for better decisions in the interest of the patient. For example,
the patient reports having high blood pressure and taking medication to control this
condition. The patient’s blood pressure is determined to be 135/90 mmHg. The pa-
tient is obese with a BMI of 31, and they have reported no regular exercise. When
further queried regarding their blood pressure and medication control, the patient
reports regularly taking the blood pressure medication and states they were in hurry
to arrive at the appointment due to a hectic day and there is no issue for concern. It is
possible to believe the patient and to make plans for continued treatment. On the oth-
er hand, it could be prudent to consider a medical consult and verify that the patient
is reporting accurate information regarding their condition. What if the consult was
returned indicating that the patient is not compliant with their medication control, is
not following a regular diet and exercise program, and has not kept their scheduled
medical appointments? Would this cause you to look at the patient’s health status
differently? This is an example of a medical consult confirming and verifying what a
patient is reporting to the dentist.
Another consideration for known consultations would be the patient who has mul-
tiple reported comorbidities. A patient with a reported history of high blood pres-

sure, diabetes, and asthma would be a presentation where a medical consult would
be prudent to ensure that the patient is medically controlled and compliant with their
directed treatment for these conditions. It is also prudent to consider making the re-
ported medical information obtained through a consult request a part of the patient’s
dental records to facilitate baseline documentation and reference for continued care
at subsequent appointments. The major concepts to identify through this process are
reliability, control, and compliance.
Reliability refers to the accuracy of the reported information by the patient. When
interviewing the patient during the medical evaluation, it should be determined if
the patient is reliable or unreliable when responding. A reliable patient is thorough,
forthcoming, and knowledgeable regarding the medical history. Responses that are
thoughtful and accurate result in the patient being believable and trustworthy. An
unreliable patient does not provide clear information and responds in a manner that
appears unbelievable. This is referred to as the unknown consultation pathway. The
patient is determined to be providing information that is not thorough and complete,
or the information provided does not appear consistent with the physical assessment
information gathered. Then the dentist has doubt regarding the actual medical status
of the patient, and a consult request from the patient’s physician would provide in-
formation to establish an accurate medical interpretation of the patient.
The unknown consultation involves requesting information regarding the patient’s
overall health status. As with any consult, you are requesting information from the
medical provider. In a situation where the medical issue is unknown, a reasonable
request is the most recent history and physical (H&P) of the patient. The H&P is a
detailed medical evaluation of the patient involving a thorough review of the pa-
tient, including medical evaluation, physical assessment, and laboratory information
such as bloodwork reports and data. There is value in obtaining the H&P from the
perspectives of compliance and control. Regarding the evasive patient who prompt-
ed the unknown consultation, the obtained H&P can indicate compliance with di-
rected medical care and, if there are any reported comorbidities, how well they are
being controlled. The H&P provides the necessary insight of the patient’s current
health status.
To facilitate the decision for a medical consultation, the provider should query the
patient regarding reported medical conditions. If the responses from the patient do
not indicate that the patient is following through appropriately with medical treat-

ment, it would be appropriate to request a medical consultation. See Box 3-2 for ex-
amples of patient questions for reported history of high blood pressure and diabetes.
BOX 3-2 Questions to ask patients with

reported history of high blood
pressure and diabetes
High blood pressure

• When do you check your blood pressure?
• What is your typical blood pressure?
• How do you control your blood pressure?
Diabetes
• How often do you check your blood sugar?
• What is your typical reading?
• How do you control your diabetes?
• What is your A1C level?
Another consideration for a medical consultation is the progress note. Like the
chart entry made for a dental appointment, the progress note represents the notes
made by the medical provider for the patient during an appointment. Requesting
recent progress notes can indicate if a patient is being treated for any current condi-
tions that may or may not have been reported by the patient when completing the
dental medical history form. Progress notes indicate current treatment, compliance
with treatment, and whether an identified condition is controlled.
It should become clear that the purpose of the medical consult is to gather informa-
tion from the patient’s physician, including specialists, to facilitate sound treatment
decisions that protect the health and well-being of the patient. The response received
from the physician should provide sufficient information to direct the dentist toward
appropriate decisions regarding the delivery of dental treatment, including the ad-
ministration of sedation. It was previously mentioned that the consult should not be
used to ask permission of the physician to treat the patient. There is a distinction to
make here, which is a critical component of the consult request. Just as the physician
is likely unknowing of the involved dental treatment determined for the patient, the
dentist is likely unknowing of the involved medical treatment determined for the
patient. The consult facilitates the determination and confirmation of the patient’s
medical issues and the involved treatment of them.
Understanding that the patient has a relationship with their physician like their
relationship with their dentist, it is reasonable to appreciate that the physician has

a good understanding of how well the patient is complying and controlling their
health. This understanding allows the physician to provide an impression of the pa-
tient based on their presenting medical condition and status. Requesting the consult-
ing physician’s impression of the patient based on their medical history can be very
insightful and helpful to the dentist in determining the best course of action for the
patient. The physician’s impression is their assessment of a patient encompassing
their medical presentation, how well a patient is following through with directed
therapy or treatment, and a perspective of how involved their identified medical con-
ditions are based on directed treatment and patient compliance with treatment. Box
3-3 provides a guide to requesting a medical consult regarding known and unknown
consultations.
BOX 3-3 Examples of process for known and unknown consultations
Known consultation
• Patient reports HTN with medication control
• Blood pressure obtained at appointment was 145/95, taken additional times still elevated
• Send consult request to PCP regarding BP
• Request most recent H&P and progress notes
• Request PCP impression regarding how well BP is controlled and patient compliance
• Confirm medications prescribed for HTN
Unknown consultation
• Patient reports no medical problems or issues on health history
• Patient presents to operatory breathing heavily and appearing in mild to moderate distress
• Patient is obese though indicates regular exercise
• Patient denies any respiratory problems during dialog review
• Send consult request to PCP regarding presenting respiratory condition
• Request most recent H&P and progress notes
• Request PCP impression regarding patient’s pulmonary status and any other identified medi-
cal conditions
HTN, hypertension; PCP, primary care provider; BP, blood pressure.
Patient Selection for Sedation

The foundation for appropriate patient selection when considering sedation options
is the airway and the ability of the patient to appropriately manage their airway
during a sedation procedure. Related to this assessment are important identifications
of the patient regarding sedation:

1. Medical history: Identify any medical conditions that could compromise the pa-
tient’s response to sedation drugs.
2. Physical evaluation: Obtain the patient’s vital signs and interpret them with the
patient’s physical assessment and the reviewed medical history.
a. Perform airway assessment, including Mallampati score, ROM, and temporo-
mandibular disorder (TMD) screening.
b. Provide additional consideration for obesity with possible medical consultation.
c. Evaluate sleep patterns, including using pillows to sleep in upright position,
snoring with sleep, or obstructive sleep apnea including use of CPAP (continu-
ous positive airway pressure) device.
d. Consider the behavior assessment related to anxiety, fear, or phobia and
the appropriateness for sedation or need to consider other sedation or anes-
thesia options.
3. Risk assessment: Identify a risk classification based on the medical history, phys-
ical evaluation, and dialog history.
a. The goal is to select ASA I or II patients for sedation.
b. ASA III patients should have a medical consultation prior to any seda-
tion procedure.
4. Medical consultation: Request a medical consultation to facilitate the appropriate
decision making regarding the patient’s health and well-being related to identified
medical conditions, reliability of the patient in reporting, and if identified medical
issues based on physical evaluation are supported or not supported by the medi-
cal history. Request the impression of the physician regarding the patient’s current
health status with respect to compliance with directed medical care and control of
identified medical conditions.
References
1. Tarsitano JJ. Never treat a stranger. J Am Dent Assoc 1966;73:856–862.
2. Riley R, Holman C, Fletcher D. Inter-rater reliability of the ASA physical status classification in a
sample of anaesthetists in Western Australia. Anaesth Intensive Care 2014;42:614–618.

3. Safety Committee of Japanese Society of Anesthesiologists. JSA guideline for the manage-
ment of malignant hyperthermia crisis 2016. J Anesth 2017;31:307–317.
4. Bickley LS. Bates’ Guide to Physical Examination and History Taking, ed 13. Philadelphia: Wolt-
ers Kluwer, 2021.
5. James PA, Oparil S, Carter BL, et al. 2014 Evidence-based guideline for the management of high
blood pressure in adults: Report from the panel members appointed to the Eighth Joint National
Committee (JNC 8). JAMA 2014;311:507–520 [erratum 2014;311:1809].
6. American Heart Association. Hypertensive crisis: When you should call 911 for high blood pres-
sure. https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pres-
sure-readings/hypertensive-crisis-when-you-should-call-911-for-high-blood-pressure#.WdPIhbp-
Fx9A. Accessed 27 April 2021.
7. Rosenberg MB, Phero JC. Airway assessment for office sedation/anesthesia. Anesth Prog
2015;62:74–81.
8. Okwuone CO, Po W, Swick JT II, Janiki PK. Obstructive sleep apnea—Implications for procedural
sedation. J Radiol Nurs 2006;25:2–6.
9. Kiser M, Wakim JA, Hill L. Accuracy of fingerbreadth measurements for thyromental distance
estimates: A brief report. AANA J 2011;79:15–18.
10. Sweitzer BJ. Preoperative Assessment and Management, ed 2. Philadelpha: Lippincott Williams
& Wilkins, 2008.
11. American Society of Anesthesiologists. ASA Physical Status Classification System. https://
www.asahq.org/resources/clinical-information/asa-physical-status-classification-system. Ac-
12. Cappell MS. Sedation and analgesia for gastrointestinal endoscopy during pregnancy. Gastroin-
test Endosc Clin N Am 2006;16:1–31.
13. Centers for Disease Control and Prevention. Adult Obesity Facts. https://www.cdc.gov/obesity/
data/adult.html. Accessed 11 May 2021.
14. Centers for Disease Control and Prevention. Childhood Obesity Facts. https://www.cdc.gov/
obesity/data/childhood.html. Accessed 11 May 2021.

CHAPTER 4
Sedation Strategies
W
ith agreement and acceptance by the patient and dentist that minimal or
moderate sedation is appropriate for the planned dentistry, the discussion
regarding sedation approach can be determined. The opportunity to ad-
minister minimal or moderate sedation involves several approaches that can be ac-
complished through a single method or a combination approach. Table 4-1 lists the
available approaches for minimal and moderate sedation. Each of these methods will
be discussed further in this chapter.
Table 4-1 Approaches for minimal or moderate sedation
Sedation method Route of administration Ability to titrate

Nitrous oxide-oxygen Inhalation (parenteral) Yes
Oral sedation Mouth/GI system (enteral) Single visit: no
Multiple visits: yes
Sublingual sedation Mouth/transmucosal (parenteral) Yes, though not common
Intranasal sedation Nose (parenteral) Yes, though not common
Intramuscular sedation Muscle (parenteral) Yes, though not common
Intravenous sedation Venous access (parenteral) Yes
GI, gastrointestinal.
Nitrous Oxide-Oxygen Sedation

This method of sedation maintains a long history in dentistry dating back to 1844
when Dr Horace Wells had this drug administered to him for the extraction of a

tooth. As the administration of nitrous oxide–oxygen (N2O-O2) has evolved in den-
tistry, it has become a very safe and effective sedation method administered either
as a singular approach or in combination with other sedation methods. Any office
administering minimal or moderate sedation to patients should strongly consider
making N2O-O2 available as part of the planned sedation approach. It is becoming
commonplace to require the administration of oxygen with any sedation method,
and with N2O-O2 available, this is easily achieved. The opportunity to administer
N2O-O2 as an adjunct to any sedation approach or as the only sedation drug can be
invaluable to the success of the planned sedation.
N2O-O2 is easily administered and can be titrated to effect. This can facilitate the
concomitant administration of another sedative drug or drugs. As a single sedation
approach, it is relatively easy to determine the success of N2O-O2 administration.
The available delivery system for N2O-O2 administration has established safety
limitations for the delivery of this drug. The administration of N2O requires the min-
imal administration of 30% oxygen (O2). Based on this established safety parameter,
the maximal amount of N2O that can be administered is 70%. Generally, most pa-
tients will experience an adequate effect from this drug in the range of 30% to 40%
N2O (Fig 4-1).
There are considerations for the administration of this drug for fearful or phobic
patients, as well as the combination of this drug with other sedation approaches.
When selecting an appropriate sedation approach for a fearful patient, N2O-O2 ad-
ministration alone may not be the best approach. This should be discuessed with the
patient, understanding that the patient must accept this treatment approach for it
to be successful. Acceptance of the planned sedation method(s) is important to the
success of the procedure. When administering N2O-O2 in combination with another
sedation method, consideration should be given to the administration of less N2O-O2
based on other drug(s) already administered to the patient. Anesthesia is a continu-
um, and it is possible for a patient to achieve deeper levels of sedation or anesthesia
when drugs are administered in combination.

% of patients achieving successful sedation effects
% of N2O administered
Fig 4-1 This graph depicts the percentage of patients achieving successful sedation
effects at the corresponding percentage of N2O administered. For example, at 35%
N2O administered, 25% of appropriately selected patients will be successfully sedat-
ed. In addition, 70% of patients will be effectively sedated with N2O ranging from 30%
to 40%.
Though N2O-O2 administration is a very effective sedation method to combine

with other sedation techniques, the dentist must respect that this drug can deepen
the level of sedation or anesthesia based on the individual response of the patient.
The approach of combining sedation methods should always direct the dentist to
proceed with caution and understand that dosing guidelines for any drug(s) to be
administered may need to be reduced to ensure that the patient is not overdosed.
Oral Sedation
This is likely the most common method for administering minimal sedation and a
very common method for administering moderate sedation. Many patients discuss-
ing their fear of dentistry typically identify their fear or strong dislike for needles,

and the idea of being able to swallow a pill or drink a drug solution is more accept-
able than having an IV started. What is most challenging with this sedation method
is that it is accepted that drugs cannot be titrated when administered orally.
In essence, either the administered oral dose of drug(s) produces the desired seda-
tion effect or not. There is no middle road or compromise. This is particularly accept-
ed with oral sedation for children, as it is not recommended to administer additional
oral sedatives to a pediatric patient. This is different for adults, as it is acceptable to
administer additional drugs to an adult patient, though there are specific guidelines
to follow, understanding that titration is not possible during a single appointment.
Particular attention is given to prevent the unintentional overdose of the drug to a
patient with additional dosing.
A typical oral sedation procedure would involve administering a dose of drug(s)
below the MRD (maximum recommended dose) and following prescribed dosing
guidelines, then allowing the necessary time for the drug(s) to achieve the desired
effect. If, at the determined time of effect, it is observed that the patient is not sedated
to the intended level, an additional dose of one drug can be administered. Based on
the assessment of the patient, another consideration is the administration of N2O-O2
to achieve the desired effect. If an additional drug is administered, the necessary time
for that drug to reach its effect must be allowed. Once that time is reached, the patient
is assessed for the desired effect. If the desired effect is still not reached, then N2O-O2
can be administered with the intention to achieve the desired end point of the seda-
tion. If the desired level of sedation is achieved at any point of the described process,
then the dentist should proceed with the planned appointment. If the desired level
of sedation is not achieved after readministration of additional drug and N2O-O2,
the appointment should be considered a failure and should be cancelled. The patient
should be recovered to ensure that sedation does not progress and so they reach a
level that meets established discharge criteria.
Sublingual Sedation
Any drug that bypasses the gastrointestinal (GI) system is a parenteral technique.
Drugs that go through the GI system are orally or enterally administered. When ad-
ministered, these drugs are processed through the liver and undergo the first-pass
effect. The first-pass effect is a phenomenon of drug metabolism whereby the con-

centration of a drug is greatly reduced before it reaches the systemic circulation. It is
the fraction of lost drug during the process of absorption which is generally related
to the liver and gut wall. After a drug is swallowed, it is absorbed by the digestive
system and enters the hepatic portal system. It is carried through the portal vein into
the liver before it reaches the rest of the body. The liver metabolizes many drugs,
sometimes to such an extent that only a small amount of active drug emerges from
the liver to the rest of the circulatory system. This first pass through the liver thus
greatly reduces the bioavailability of the drug. Alternative routes of administration
such as suppository, IV, intramuscular (IM), inhalational, aerosol, transdermal, and
sublingual avoid the first-pass effect because they allow drugs to be absorbed direct-
ly into the systemic circulation.
Sublingual sedation is not a usual sedation approach. It is important to understand
that sublingual administration is not oral administration. A common misconception
with oral drug administration is the process of crushing a pill or tablet and placing it
underneath the patient’s tongue (thus administering the drug sublingually) and be-
lieving the administration is oral. The danger with this approach is that oral dosing
guidelines are based on first-pass metabolism, resulting in oral dosing calculated at
a higher amount versus dosing for other routes of administration. As an example,
oral midazolam is recommended at a dose range of 0.5 to 1 mg/Kg (maximum dose
of 20 mg). Intramuscular midazolam is recommended at a dose of 0.1 mg/Kg, and
intranasal midazolam is recommended at a dose of 0.3 mg/Kg. The oral dosing rec-
ommendation is much higher than dosing via parenteral routes. An oral dose of drug
expected to be processed enterally but administered parenterally (eg, sublingually)
could result in a potential overdose with the patient achieving a deeper level of seda-
tion than intended. This approach violates the consideration for the margin of safety
due to altering the route of administration and increases risk and potential for adver-
sity. It is strongly recommended to never administer oral drugs sublingually unless
the dentist has training in parenteral approaches as well as training to manage a pa-
tient who is sedated beyond moderate sedation. Even if the dentist has appropriate
training, the dose should be adjusted according to acceptable parenteral dosing rec-
ommendations for that drug. If the drug does not have parenteral dosing guidelines,
then the dose administered should not exceed the MRD for that drug.

Intranasal Sedation
Like sublingual administration, this is not a usual sedation approach. The indication
for an intranasal (IN) approach is typically determined by the cooperation of the pa-
tient. A patient who is unwilling to take medication orally would be a candidate for
intranasal administration. The process is to use the IV/IM formulation of the drug
for IN administration. The appropriate dose of drug is drawn into a syringe based on
IN dosing guidelines. There is a device that can be purchased that attaches to the end
of the syringe, allowing the drug to be atomized when expressed from the syringe. It
is recommended to use the drug formulation with a higher concentration to admin-
ister the least possible volume of drug. In situations where there is a larger volume
of drug to administer (>1 mL volume), it is recommended to divide the amount with
the intention to administer half the volume in one nostril and half the volume in the
other nostril. This route of administration is parenteral and would require that the
dentist possess training in parenteral approaches as well as training to manage a pa-
tient who is sedated beyond moderate sedation.
Intramuscular Sedation
Though IM sedation is not a usual approach, there are indications when it can be
helpful with facilitating successful sedation. It is important to understand that this is
a parenteral technique; the primary indication is to facilitate the progression of seda-
tion or anesthesia.
Given that the subject of this textbook is sedation, anesthesia will not be addressed.
In general terms, the concept of employing IM sedation to facilitate the overall seda-
tion approach is considered a combination approach. Due to appropriate rules and
regulations regarding the safety of the patient, when employing parenteral sedation
techniques, an IV line should be established. This was also referenced when discuss-
ing sublingual and IN sedation with regard to the dentist possessing training in par-
enteral sedation and management of the patient who could become sedated beyond
moderate sedation. Establishing and maintaining an IV throughout a parenteral se-
dation approach is strongly recommended as a method of protecting the safety and
well-being of the patient.

One indication for IM sedation would be the patient who presents for IV sedation
but does not present with good venous access. The ability to access a patient’s vein
to establish an IV is influenced by the patient’s level of anxiety, apprehension, or fear.
The peripheral vasculature can constrict, making visualization and access challeng-
ing and difficult. Administering midazolam at a dose of 0.1 mg/Kg up to a maximum
dose of 10 mg can provide a level of sedation that allows the patient to relax, permit-
ting peripheral vasodilation and improved venous access to successfully place an IV
catheter. Though the administration of IM drugs for sedation can be successful and
provide an appropriate level of sedation for treatment, this route of administration
is not typical and generally not encouraged. Understanding that the IM route is par-
enteral, the dentist must consider that the patient could be oversedated more readily
than by using an enteral sedation approach. Being prepared for this possibility, it
would be appropriate to ensure an IV is established and functional. This is the reason
for some state regulations being different for enteral sedation and parenteral seda-
tion. It is considered that the training and education required for the administration
of enteral drugs is not as rigorous or involved as the training and education required
for the administration of parenteral drugs.
Interestingly, this is viewed differently by the ADA Guidelines.1 The ADA Guide-
lines approach training and education according to the level of sedation instead of
the route of administration.1 It is important for the dentist to know whether their
respective state dental board or regulatory entity has separate rules and regulations
for sedation administration or if the ADA Guidelines are accepted and enforced. It is
worthwhile to consider this perspective based on the various approaches discussed
up to this point. If a dentist can administer enteral sedation to the level of moderate
sedation, it does seem reasonable that the route is not as important as the appropriate
management of the patient. This includes the level of sedation intended as well as
unintended (rescue). This would allow the dentist to administer sedation by any of
the routes discussed in this chapter if the intended sedation outcome was minimal or
moderate sedation. It would also require that the dentist be trained in the delivery of
drugs by any of the available routes and have a thorough understanding of dosing
via the route determined.
Another concept to consider is the combination of sedation approaches. The most
typical combination approach is inhalation (N2O-O2) with oral sedation, as previ-
ously described. N2O-O2 can also be administered in combination with any sedation
or anesthesia approach. Additionally, other approaches can be used in combination
to achieve a successful outcome, such as the IM administration of midazolam to fa-
cilitate the successful placement of an IV catheter. The oral presedation approach
discussed previously could also be used for a patient scheduled for IV sedation. The
point is that sedation approaches can be combined to achieve a successful outcome.
It is important to understand that these approaches are different than adminis-
tering N2O-O2 in combination with a sedation approach. N2O-O2 is intended to be
a direct adjunct for the procedure, administered during a part of the procedure or
for the entirety of the procedure. The administered N2O-O2 is intended to increase
the sedation outcome when combined with another sedation approach. Conversely,
administering IM midazolam for the opportunity to improve IV access is an indirect
adjunct that will not be continued once the IV is established. It is important to under-
stand that the administration of drugs orally or IM for the purpose of improving the
presentation for the placement of an IV catheter is intended to be singular event and
not continued at any time during the procedure.
Additionally, there must be consideration for the continued effect of drugs admin-
istered by a selected route (oral or IM) when IV drugs are administered. As an ex-
ample, if midazolam was administered IM and then an IV catheter was successfully
established, consideration must be made regarding the administration of midazolam
IV, with caution given to not overdosing midazolam.
Alternatively, the drugs administered IV might not be midazolam but might in-
stead be an opioid such as fentanyl. Ultimately, combination approaches can facili-
tate a successful sedation outcome and are reasonable considerations given the ap-
propriate education and training of the dentist to perform these procedures.
Intravenous Sedation
Compared to oral sedation, this is likely the most common approach for administer-
ing moderate sedation and is a reasonable approach to administering minimal seda-
tion. Of all the approaches for sedation discussed, this is the most predictable and,
therefore, the most successful and safe. This is due to the administration of drugs
intravenously being well controlled by titration. As discussed in the ADA Guidelines,
titration is achieved by the inhalation or IV routes.1 A drug is administered in small
increments with allowance for the full effect of that dose to occur prior to adminis-
tering another dose until the desired clinical end point is reached. With IV admin-

istration, it is typical to administer a single drug to a determined amount, evaluate
the clinical effect, and administer more of the same drug or another drug following
the same process. The key is ensuring that dosing is incremental and enough time is
allocated to appropriately observe a clinical effect, with the end point of drug admin-
istration being that the clinical result either reaches the intended level of sedation or
it does not.
If the clinical end point is reached, then drug administration is discontinued, and
the procedure begins. If N2O-O2 is also administered, consideration must be given to
the intended level of sedation to ensure that the patient will not reach a deeper level
of sedation with this adjunct. If the clinical end point was reached with the admin-
istration of one drug, the administration of any further drug is avoided. This is the
purpose of incremental dosing and observing the patient while allowing for the dose
of drug administered to reach its full effect.
This approach also maintains the safety and well-being of the patient. If the clinical
end point is not yet reached, the decision to administer additional drug or a differ-
ent drug is based on the dentist adhering to the established dosing guidelines of the
planned drugs to be administered and the clinical end point for the desired level of se-
dation (minimal or moderate). For example, if the procedure started with the admin-
istration of midazolam, and it was given according to prescribed dosing guidelines,
once a determined amount was reached, the dentist would need to assess whether the
patient should exhibit some clinical effect of the drug based on the amount admin-
istered. If it were determined that the clinical effect was not reached, and additional
drug could be administered, additional midazolam could be administered according
to prescribed dosing guidelines, or another drug could be administered.
Continued administration would follow the same dosing progression. Generally,
clinical effects are observed with the administration of the initial drug, and a decision
to administer a second drug would be to enhance the sedation effect and maintain
the desired clinical end point. It is common to administer two sedation drugs (ben-
zodiazepine and opioid) for IV procedures. It is less common to administer three
sedation drugs, and consideration should be given to the possibility of a sedation
failure when two drugs (including N2O-O2) are administered in amounts that reach
their prescribed dosing guidelines.
A sedation failure involves the administration of drug(s) according to their pre-
scribed dosing guidelines and the clinical end point not being reached. The key factor

with this determination is to verify that administration of the additional drug would
violate the dosing guidelines with the potential for the patient to reach a level of se-
dation or anesthesia beyond the intended level and/or the training of the dentist. The
best way to avoid this is to develop a rationale for treatment that involves a sound
sedation plan with identified limitations for the administration of drug(s).
Rationale for sedation maintains its foundation in patient evaluation and assess-
ment. There is no better predictor for sedation success than patient selection. Iden-
tifying patients who are medically and emotionally appropriate for sedation will
greatly influence a positive, safe, and successful sedation outcome. Selecting ASA
I or II patients and carefully identifying appropriate ASA III patients are important
starting points for patient selection.
Once you have established that a patient is medically appropriate for sedation,
determining their emotional status is required. Anxiety and fear assessment must
occur for every patient prior to administering sedation. Ensuring that a patient will
respond appropriately to minimal or moderate sedation will facilitate success of the
procedure and patient safety. A patient who is extremely anxious may not be a good
candidate for minimal or moderate sedation.
Involved with this assessment are the expectations of the patient and the dentist.
Any patient selected to receive minimal or moderate sedation must understand what
these levels of sedation are and the associated clinical effect accomplished with the
planned sedation. This process must occur every time sedation is offered, as it sup-
ports a sound and safe rationale for treatment.
Rationale is also a learned process that progresses and evolves with experience.
This is important because it allows for better patient selection and decreased seda-
tion failure. Never disregard the importance of thorough evaluation and assessment.
With respect to expectation, never inform a patient that their expectations of the se-
dation will always be satisfied, particularly if those expectations are beyond what can
be achieved with minimal or moderate sedation. The goal of sedation is to allow for
patient comfort and acceptance of the scheduled dental treatment while maintaining
patient safety. Poor patient selection and disregard of safe sedation outcomes allow
for adversity and potential bad outcomes.
Established rationale influences appropriate clinical decision making. Poor deci-
sion making during treatment can be avoided if practitioners do not try to accom-
plish more than is possible with sedation. The sedation plan must adhere to proper

protocols, and limits of drug administration must be respected. The goal is to ac-
complish what you can, safely and appropriately. There are many options available
for minimal and moderate sedation, and the completion of training and education
in sedation will address options. How a dentist decides to incorporate sedation into
their practice will be an individual decision. The important determination is that the
approach is safe.
A necessary part of any successful sedation is the administration of profound anes-
thesia. Sedation is never a substitute for inadequately administered local anesthesia.
Additionally, excessive dosing of local anesthesia is not an acceptable approach. It is
recommended that the maximum amount of local anesthetic should be determined
for any dental procedure involving local anesthesia, even when sedation is not being
administered.
Being proficient with local anesthesia administration is essential for any dentist,
and staff should be involved with this calculation as well to ensure that all team
members are aware of maximum dosing amounts. This becomes important with se-
dation procedures because these procedures are often scheduled to be longer with
the plan to complete more dentistry while the patient is sedated. While this may be a
reasonable consideration, it would be more prudent for the dentist to determine the
maximum amount of local anesthesia to be administered for the planned procedure
and then determine an appropriate length to the procedure with the involved seda-
tion approach. Local anesthesia maximums should never be violated, which requires
that the dentist know what those maximums are and ensure involved staff are also
aware of the maximum amounts.
Reference
1. American Dental Association. Guidelines for the use of Sedation and General Anesthesia by

CHAPTER 5
Patient Monitoring During

Sedation
Lauren Hanzlik, DDS
Alfred Mauro, MD
R
eaders of this chapter will have a basic understanding of the anesthesia mon-
itors available for sedation out of the hospital. They will derive a basic un-
derstanding of what is being measured and why. Instruction regarding the
common errors of use will be provided, and the reader will develop an appreciation
for the use of monitors to improve outcomes, recognize latent or emergent unwant-
ed events, and assist in the treatment of such an event if it occurs. It is hoped that
the reader will understand the meaning and value of the results obtained by each of
the devices, but also the shortcomings of any one device by itself. Emphasis will be
placed on the value of observing trends as well as seminal events. To this end, further
emphasis will be placed on how latency (in the physics of the monitor, or the time
taken by the provider to initiate action) impacts intervention.
Once a provider has determined that a patient is acceptable for in-office sedation,
the office must be equipped to monitor the patient while they are sedated as well
as handle any emergent situations that may present themselves during the proce-
dure. Minimum standards according to the American Society of Anesthesiologists
are as follows:

1. Qualified anesthesia personnel shall be present in the room throughout the con-
duct of all general, regional, and monitored anesthesia care.
2. During all use of anesthetics, the patient’s oxygenation, ventilation, circulation,
and temperature shall be continually monitored.
Utilizing these standards, the following monitors are mandatory:
• Pulse oximetry
• Capnography
• Electrocardiogram
• Blood pressure
• Temperature
Monitors are an essential and required standard of care during conscious seda-
tion in dentistry. In-office dental procedures utilizing moderate sedation will require
noninvasive blood pressure (BP) monitoring. Offices should have BP monitors that
automatically provide noninvasive BP monitoring, oxygen (O2) saturation (pulse
oximeter), carbon dioxide (CO2) monitoring with respiration (capnography), and
electrocardiogram readings at set intervals.1 Office-based sedation requires pulse ox-
imetry for baseline oxygen saturation as well as interoperative and postoperative
monitoring. The operator must be cognizant that there are many factors that can lead
to false oxygen saturation readings.2,3 While we understand the importance of oxygen
saturation (between 90%–100%), end-tidal CO2 will react sooner than a pulse oxime-
ter and should be used for this reason.
Carbon dioxide monitoring with respiration (capnography) is a reliable indication
that the dental patient is ventilating spontaneously. Most capnography utilizes in-
frared technology. The ECG (electrocardiogram) is a measurement of the electrical
voltages produced in the heart. The recognition and treatment of irregularities in the
heartbeat (ie, arrhythmias) is discussed in the chapter on emergencies. ECG monitor-
ing is required when the sedation level is deep or when the patient is under general
anesthesia. For moderate sedation, ECG monitoring is required when there is a histo-
ry of cardiovascular disease or when a dysrhythmia is detected or anticipated.4–7

Pulse Oximetry
Pulse oximetry is an indirect means of noninvasively measuring the percent of oxy-
gen saturation of hemoglobin molecules in red blood cells on a continuous basis (Fig
5-1). Office-based anesthesia with any type of sedation requires pulse oximeter mon-
itoring for a baseline reading, as well as interoperative and postoperative monitoring
of arterial oxygen saturation. When office-based IV sedation is monitored by pulse
oximetry, the goal is to maintain the saturated oxygen at greater than 90%. With an
oxygen saturation of over 90%, and a reasonable cardiac output, it can be assumed
that there is adequate oxygen tissue perfusion. However, if the upper airway is
blocked and not corrected, oxygen cannot get into the lungs. The desaturated red
blood cells passing through the oxygen-depleted lungs cannot pick up oxygen to de-
liver to already deoxygenated tissues, causing death. In this case, pulse oximetry is a
way to indirectly determine if a person is being ventilated and obtaining sufficient
oxygen for active tissues. Pulse oximetry does not measure ventilation function di-
rectly (ie, the air movement in and out of the lungs).2
Fig 5-1 Use of a pulse oximeter.

Pulse oximetry, sometimes referred to as “pulse ox,” measures the patient’s oxy-
genation as well as heart rate. This monitor works through an equation based on the
Beer–Lambert law, which describes the relationship of the concentration of a solute to
the intensity of light able to pass through the solution. In the case of pulse oximetry,
the solute is hemoglobin in its various states. Clinically, it is not realistic to be contin-
uously drawing samples of arterial blood to determine a patient’s oxygenation, so the
pulse oximeter allows us to use the SpO2 (blood oxygenation saturation) to approx-
imate the SaO2 (arterial oxygenation saturation). The difference in the calculations
between SaO2 and SpO2 rests in the fact that SpO2 only considers oxygenated and
deoxygenated hemoglobin while the SaO2 also considers methemoglobin (methHb)
and carboxyhemoglobin (COHb). In the normal physiologic state, methemoglobin
and carboxyhemoglobin account for a relatively insignificant proportion of the total
hemoglobin (1%–2% and < 1.5% respectively), which allows for the SpO2 to make a
reasonable approximation of the SaO2. SpO2 and SaO2 are calculated as follows:
SpO2 = HbO2 / (HbO2 + HHb)

SaO2 = HbO2 / (HbO2 + HHb + metHb + COHb)
A pulse oximeter utilizes two different wavelengths, each of which interacts with
the two most common forms of hemoglobin: deoxyhemoglobin (HHb) at 660 nm (red
spectrum) and oxyhemoglobin (HbO2) at 940 nm (infrared spectrum).
The sensor works by comparing the pulsatile oxygenated arterial blood flow (ie,
HbO2) to the baseline deoxygenated venous state (ie, HHb). By taking hundreds of
readings per second, the sensor can establish a “picture” of a waveform with the
trough representing diastole and the peak representing systole (Fig 5-2). During dias-
tole, the light waves are required to pass through a minimal amount of arterial blood,
the capillary itself, venous blood, and additional tissue such as skin. During systole,
the light still must transmit through all of the previously listed components plus the
full arterial flow volume. The difference in arterial flow between diastole and systole
is known as the pulse volume. By comparing the pulsatile light signal to the baseline
light signal, the sensor calculates the red to infrared ratio, which is then run through
an algorithm to calculate the SpO2. A bonus of the pulse oximeter is that every patient
provides their own baseline flow, so the patient acts as their own control.

Fig 5-2 Pulse oximetry signals. Many tissues absorb red light
(660 nm) and infrared light (940 nm), including skin, connective
tissue, muscle, as well as Hb and HbO2 in venous and arterial
blood. However, to isolate oxygen saturation in arterial blood, the
pulse oximeter detects fluctuating signals of light absorbance,
representing the ebb and flow of blood through the artery during
diastole and systole. These values are then incorporated into the
“ratio of ratios,” along with absorption values from the nonfluctu-
ating signal, to give the SpO2.
Limitations and sensitive sensors

To establish the calibration equations for the algorithm that establishes the SpO2, ar-
terial blood samples were drawn from healthy volunteers. This means that when a
patient is oxygenating in the range of 70% to 100% SpO2, the pulse oximeter can read
within 5% of in vitro measurement. However, as the oxygenation level diminishes,
the ability of the pulse oximeter to provide accurate information drops off rapidly,
and recalling the oxygen-hemoglobin dissociation curve, partial pressure of oxygen
(PO2) drops off sharply as SpO2 encroaches upon 85%.

Inherent signal delay
Because the data must be calculated as previously described, there is a delay between
time of application of sensor and display of information. The time delay is dependent
on the perfusion of the tissue as well as the site of the actual location of the probe. Fin-
ger probes are the most common and carry a signal delay ranging from 19.5 to 35.1
seconds. Ear probes (7.2 to 19.8 s) and toe probes (41.0 to 72.6 s) are also available.
Ambient light
This monitor is very sensitive to its environment. Ambient light or other substances
interfering with light transmission can easily mislead the provider. Direct ambient
light impairs the monitor by elevating the baseline venous reading, resulting in the
overall SpO2 to read out as low. Luckily, this situation is easily rectified—if the light
is accidentally positioned over the probe, either the surgical light can be moved, or a
towel can be placed over the probe to prevent the ambient light from making contact
with the sensor.
Abnormal levels of hemoglobin
As mentioned previously, SpO2 does not consider methemoglobin and carboxyhe-
moglobin despite their natural presence in the bloodstream. The complication arising
from high levels of methemoglobin in the blood is that it absorbs both the 660 nm
and 940 nm wavelengths equally, causing the arterial saturation to appear as 85% on
the monitor regardless of the actual SpO2. Methemoglobin occurs when iron in the
ferrous state is oxidized to the ferric state. Multiple medications exist that result in an
increase in methemoglobin. Some of the more commonly seen are local anesthetics,
nitrates, antimalarial drugs, nitroglycerin, and sodium nitroprusside.
Carboxyhemoglobin also absorbs both the 660 nm and 940 nm wavelengths, but
unlike with methemoglobin, they are absorbed at different rates. When COHb is pres-
ent in high levels in the blood, it will be interpreted as an HbO2 of 90% and a HHb
of only 10%, resulting in an overestimation of the SaO2. The most common cause of
increased COHb is cigarette smoking, which can have a modest impact on COHb but
does not compare to the changes caused when a patient is exposed to large amounts
of combustion products such as a house fire or car exhaust.
Nail polish
Patients who do not follow preoperative instructions to remove nail polish can cause
decreased light transmission through their nailbed if the polish has multiple layers
or has a metallic component to it. As with ambient light, there is a simple remedy to
the situation. If the nail polish cannot be removed, the sensor can be placed sideways
on the fingertip. This bypasses the opaque nail bed and allows for the sensor to accu-
rately pick up the pulsatile blood flow again.
Skin pigmentation
If a patient has very deeply pigmented skin, light transmission may be limited, re-
sulting in inaccurate readings. If there is concern that this may be an issue for a par-
ticular patient, the sensor can be applied preoperatively to determine if additional
means of monitoring will be necessary.
Low BP or decreased blood flow
One of the basics of pulse oximeter use is that to obtain a reading, there must be pul-
satile blood flow present. Many clinical situations can arise where the amplitude of
pulsations is diminished or completely disappears. Some situations are easily reme-
died, while others are more complicated. For example, if the pulse oximeter is placed
on the same extremity as the BP cuff, every time the cuff inflates, it will stop flow to
the fingers temporarily, causing the SpO2 to go down. Once identified, the provider
can easily switch one of the monitors to the other extremity (if available) and continue
the measurement without episodic desaturations. Another easily rectified situation is
if the pulse oximeter is accidentally applied too tightly and acts like a tourniquet to
the finger, preventing pulsatile flow and thereby providing a false low reading.
Complications
Complications associated with the pulse oximeter are mainly related to long-term
wear, such as a patient in an intensive care unit in the hospital. Short-term use during
an outpatient procedure is highly unlikely to cause any complications or harm to
the patient.
Capnography
Capnography is the graphic record of CO2 concentration. The capnograph is the device
that generates the waveform, and the capnogram is the actual waveform.8 Informal-
ly, capnography is the measurement of CO2 in expired gas. Expired CO2 is a reliable
indication that the sedated patient in the dental office is ventilating spontaneously

or, if intubated, that the endotracheal tube is in the trachea and adequate ventilation
is being performed. Utilizing capnography allows the provider to verify that the pa-
tient is adequately ventilating, and the capnogram provides further details about
their ventilation.
Capnography (when used properly during dental sedation) is the only monitoring
that can give an indication of the airway patency and ventilation.3,9 Capnographs
can display the concentration of CO2 of each breath during the expiratory cycle of
breathing and ventilation. Capnographs also display the respiratory rate. Therefore,
capnography measures the movement of air into and out of the lungs (ventilation).
Most capnographs also have alarm capabilities. Alarms will sound in the case of
apnea or blockage of the tube leading to the capnograph.
To evaluate the concentration of CO2 being exhaled by the patient, two different
types of sampling devices are available: sidestream and mainstream sampling. Side-
stream sampling is the most common in both operating room and in-office sedation
and will be discussed here. Sidestream sampling relies on a mean of 200 mL/min
(range of 150–250mL/min) of exhaled air being run through the capnograph. The
gas is then analyzed according to the Beer-Lambert law, just like with pulse oximetry.
The capnograph is designed to analyze the absorption of infrared light by CO2 to de-
termine the pressure of end-tidal CO2 (PetCO2) if the patient is adequately ventilating
by estimating the partial pressure of CO2 (PaCO2). In a normal healthy person, the
difference between PetCO2 and PaO2 is approximately 0.6 mmHg.
Capnograms are very reliable, which helps the provider identify possible com-
plications. The capnogram is divided into three sections: (1) dead space, (2) mixture
of dead space and alveolar gas, and (3) alveolar gas plateau. All capnograms will
exhibit these three features, but their morphologic forms will vary depending on the
clinical condition. Patients sedated in an in-office setting should maintain their own
respiratory drive, and therefore, their capnogram should depict regular, spontaneous
respiration (Fig 5-3).

CO2 (mmHg)
45
0
Time
Fig 5-3 Capnography waveform of normal spontaneous respiration. The

normal range is 35 to 45 mmHg (5% vol).
Considerations
Crying and mouth breathing are events that cause most of the expired CO2 to be vent-
ed out of the mouth. This causes the capnograph to detect and display a signal that
has a lower concentration of expired CO2, since the majority was shunted through the
mouth, leaving less to be detected by the nasal canula.8,10,11
Water condensation can accumulate in the sampling line as the expired air cools on
exposure to room temperature. If the condensation is great enough, the capnograph
is unable to obtain an adequate sample and will provide false readings. For this rea-
son, water traps are built into the design of the capnograph. It will be necessary to
periodically change the water trap and/or flush or replace the sampling line if the
condensation cannot be cleared.
Electrocardiogram
ECGs have been utilized for many years and continue to be used routinely to monitor
the electrical activity of the heart (Fig 5-4). Several papers published in the 1950s and
1960s drew attention to the fact that cardiac arrythmias were not uncommon during
outpatient surgery.12–14

a b
Fig 5-4 (a) QRS complex. (b) Modern ECG monitor in use.
The ECG only portrays the electrical activity of the heart; it provides no indication
of the strength of myocardial contraction and no record of hemodynamic events. It
must also be stressed that the ECG is only an ancillary aid that, while important, is
not a substitute for constant clinical observation of the patient during dental anesthe-
sia or sedation in the effort to avoid hypoxia and hypercarbia.
Additionally, while the ECG should be utilized routinely for outpatient dental
treatment requiring general anesthesia, the use of continuous ECG monitoring in
ASA I or ASA II patients undergoing outpatient dental treatment with moderate se-
dation does not yield clinically relevant information in younger individuals without
known cardiac disease. Monitoring may lead to additional expense, including cardi-
ac evaluation with low clinical yield.15
Blood Pressure
Two basic families of BP monitors exist: invasive means and noninvasive means. In-
vasive means, such as an arterial line, are frequently used in an intensive care unit or
operating room for critically ill patients. Patients requiring invasive BP monitoring
are not candidates for in-office sedation, and this method will not be discussed here.
Noninvasive BP monitoring is commonplace and can be easily interpreted by both
the provider and patient alike. Historically, BP was taken manually using a stetho-
scope placed over a superficial artery located distally to the BP cuff, or sphygmoma-

nometer (Fig 5-5a). The cuff is pumped up until the provider can no longer hear any
heart sounds and then the air valve is slowly opened, allowing the cuff to slowly de-
flate. The systolic BP is audible when the BP is greater than the pressure of the cuff—
classically described as the first heart sound during deflation. As the cuff continues
to deflate at a moderate pass, the heart sounds become muffled until they finally dis-
appear. The point where there is no longer an audible heart sound is the diastolic BP.
This is known as the Korotkoff Method, after the Russian physician Dr Nikolai Korot-
koff. Although taking a manual BP is less commonly used in present-day medicine,
the provider must maintain this skill, as machines can break or can provide falsely
elevated or low BP if they are not utilized as designed.
The second method of noninvasive BP monitoring is by automatic BP cuffs that
rely on oscillometry (Fig 5-5b). Oscillometry uses an algorithm to determine both the
systolic and diastolic pressures based on the mean arterial pressure or MAP. When
the cuff is applied to the patient, arterial pulsations are detected by the cuff in the
form of oscillations. As the cuff inflates above the systolic pressure, the pulsations
become diminished, and the oscillation amplitude decreases. As the cuff releases,
maximal oscillations occur at the MAP, and the amplitude continues to decrease as
the cuff deflates.
One consideration regarding automated BP devices is their accuracy. Personal ex-
perience has identified these devices to be accurate and reliable. From the perspec-
tive of convenience and efficiency, it is recommended to have automated BP read-
ers available for use in the office. Given their low cost, multiple devices could be
purchased for availability for multiple patients. However, it is not recommended to
solely rely on automated devices, specifically wrist cuffs, for obtaining BP recordings.

a b
Fig 5-5 (a) Manual blood pressure reader. (b) Automatic blood pressure reader.
Considerations
Automated BP units provide readings of the systolic, diastolic, and mean arterial BP
at set intervals without operator assistance. The possible complications associated
with an automated noninvasive BP monitor include stasis, pain, nerve compression,
and thrombophlebitis. Care must be taken not to place the BP cuff on the arm of a
patient with an arteriovenous shunt.
The size of the BP cuff selected, whether for automatic or manual evaluation, must
be the appropriate size for the patient. It is recommended that the cuff width be 40%
to 50% of the arm circumference. If the cuff is too big, it can apply greater-than-nec-
essary force on a small patient’s limb, resulting in a falsely low BP. Conversely, if a
cuff is too small, the cuff is unable to generate adequate force to occlude the artery
and will result in falsely elevated BP. Obesity may make placement of the BP cuff on
the upper arm difficult due to the total arm circumference or even a conical shape. If
placement on the upper arm is not possible for any reason, it is acceptable to place the
cuff at another location, such as the calf or forearm, if necessary.
The position of the BP cuff should ideally be level with the heart. If this is not pos-
sible, for every 10 cm the cuff is above or below the level of the heart, 7.4 mmHg can
be added or subtracted, respectively. The algorithms used to determine systolic and
diastolic BPs are proprietary, meaning that each company uses a different equation,
and therefore BP measurements may vary from one device to another.

Temperature
When a patient is under general anesthesia, normal thermoregulatory controls are
impaired, making it important that the provider takes measures to prevent even mild
hypothermia. The only noninvasive temperature probe realistic for in-office sedation
is the skin probe. Unfortunately, it is very prone to artifact, but other options (eg,
bladder probe or esophageal probe) are not remotely reasonable in an office setting.
Monitoring temperature is important, as hypothermia can delay recovery from an-
esthesia. If a patient begins shivering, oxygen utilization will skyrocket, also increas-
ing systemic BP and heart rate. As in-office sedations are often of shorter duration
than an operating room procedure, simple methods such as providing the patient
with a blanket are often adequate to maintain normothermia.
Discharge Criteria
After a patient has undergone any sedation, it is important that they have recovered
adequately so that they can safely be discharged home. Over time, many different
discharge criteria systems have been developed, but they all have the same goal: en-
suring patient safety. One common example is the modified Aldrete discharge crite-
ria. Prior to sedation, patients should score 10/10, and they should not be discharged
if they score < 8/10. Scores are given in the following categories: respiration, oxygen
saturation, consciousness, circulation, and activity (Table 5-1).

Table 5-1 Modified Aldrete discharge criteria16
Criteria Characteristics Points

Activity Able to move four extremities 2
Able to move two extremities 1
Unable to move extremities 0
Respiration Able to breathe deeply and cough freely 2
Dyspnea or limited breathing 1
Apneic 0
Circulation BP +/- 20% of preanesthetic level 2
BP +/- 20% to 49% of preanesthetic level 1
BP +/- 50% of preanesthetic level 0
Consciousness Fully awake 2
Arousable on calling 1
Not responding 0
Oxygen saturation Able to maintain oxygen saturation > 92% on room air 2
Needs oxygen to maintain oxygen saturation > 90% 1
Oxygen saturation < 90% even with supplemental oxygen 0
Conclusion
Monitoring is a means to warn or alert the treating dentist. It enables the clinician to
be alert to the behavioral and physiologic changes that may indicate possible danger
and warns the clinician to act definitively and swiftly to prevent any adverse event.
References
1. American Society of Anesthesiologists. Standards for Basic Anesthetic Monitoring. https://
www.asahq.org/standards-and-guidelines/standards-for-basic-anesthetic-monitoring. Ac-
2. Szocik JF, Barker SJ, Tremper KK. Fundamental principles of monitoring instrumentation. In:
Miller’s Anesthesia, ed 6. New York: Elsevier/Churchill Livingstone, 2005:1213.
3. Barker SJ, Tremper KK. The effect of carbon monoxide inhalation on pulse oximetry and trans-
cutaneous PO2. Anesthesiology 1987;66:677–679.
4. Goldberger AL. Basic ECG waves. In: Clinical Electrocardiography: A Simplified Approach, ed 6.
St Louis: Mosby, 1999:9–29.

5. Hillel Z, Thys DM. Electrocardiography. In: Miller’s Anesthesia, ed 6. New York: Elsevier/Churchill
Livingstone, 2005:1399–1403.
6. Alexander JP. Dysrhythmia and oral surgery. Br J Anaesth 1971;43:773–778.
7. Goldberger AL. Myocardial ischemia and infarction. In: Clinical Electrocardiography: A Simplified
Approach, ed 6. St Louis: Mosby, 1999:87.
8. Gravenstein JS, Paulus DA, Hayes TJ. Gas Monitoring in Clinical Practice, ed 2. Boston: Butter-
worth-Heinemann, 1995.
9. Coté CJ, Rolf N, Liu LM, et al. A single-blind study of combined pulse oximetry and capnography
in children. Anesthesiology 1991;74:980–987.
10. Ayas N, Bergstrom LR, Schwab TR, Narr BJ. Unrecognized severe postoperative hypercapnia: A
case of apneic oxygenation. Mayo Clin Proc 1998;73:51–54.
11. Moon RE, Camporesi EM. Respiratory monitoring. In: Miller’s Anesthesia, ed 6. New York: Elsevi-
er/Churchill Livingstone, 2005:1456.
12. Driscoll EJ, Christenson GR, White CL. Physiologic studies in general anesthesia for ambulatory
dental patients. Oral Surg Oral Med Oral Pathol 1959;12:1496–1514.
13. Christenson GR, Hebert CL, Driscoll EJ. Intravenous barbiturate anesthesia for dental outpa-
tients. Anesth Analg 1961;40:77–86.
14. Kaufman L. Unforeseen complications encountered during dental anaesthesia. Cardiac arrhyth-
mias during dental anaesthesia. Proc R Soc Med 1966;59:731–734.
15. Craft BM, Bollinger T, Malpas P, et al. Tu1379 ECG monitoring during moderate sedation: Less is
more. Gastrointest Endosc 2013;77(suppl 5):AB519–AB520.
16. Aldrete JA. The post-anesthesia recovery score revisited. J Clin Anesth 1995;7:89–91.

CHAPTER 6
Sedation Drugs
Lauren Hanzlik, DDS
Alfred Mauro, MD
T
he choice and selection of drugs used for conscious sedation is varied. Specif-
ic types of sedation drugs include barbiturates, benzodiazepines, antihista-
mines, opioids, and nitrous oxide. Further discussion on these drug types are
included in this chapter. The mechanism of action of the various oral sedative drugs
is listed in Table 6-1.1–3
Table 6-1 General mechanisms for sedation1–3
Drug classification Mechanism of action

Benzodiazepines Anxiolytic/anterograde amnesia/sedation/anticonvulsant: Enhance inhib-
itory neurotransmission through GABA receptor. Enhance the connection
between chloride ion channel and GABA receptor leading to increased
suppression via cellular hyperpolarization.
Barbiturates Sedative/hypnotic: Primary neuronal action at GABAA. Allosterically affect
GABA binding, but GABA is not necessary for action on the channel.
Antihistamines Counteract excitatory effect of histamine and acetylcholine.
Opioids Analgesic: Trigger µ and κ receptors.
Nitrous oxide Enhance inhibitory neurotransmission.
GABA, γ-aminobutyric acid.

A 2012 survey reported the most common drugs used for intravenous (IV) mod-
erate sedation were midazolam (68.9%) and narcotics (64.3%). Diazepam was com-
monly given intravenously, by 37.8% of IV sedation providers. Although 49.8% of the
respondents offered IV sedation, a much higher percentage of respondents (83.4%)
offered oral sedation. The most common medications used for oral sedation are diaz-
epam (52.0%), triazolam (43.0%), and/or lorazepam (24.7%).4
Benzodiazepines
Benzodiazepines are the classification of drugs most utilized for IV conscious seda-
tion, and among them, the most commonly utilized are diazepam (Valium, Roche)
and midazolam (Versed, Roche). There are other drugs available in this group, but
they are not as effective in producing conscious sedation. Lorazepam is rarely used
for producing conscious sedation during IV administration. A diazepam dose aver-
ages 5 to 20 mg total, in incremental doses of 2.5 mg. The time between the incremen-
tal doses is at least 2 or 3 minutes. The onset of action of diazepam is 1 to 2 minutes,
and the duration of effect is 1.5 to 2.0 hours. Elimination is between 15 and 21 hours.5,6
In contrast, midazolam has an average dose of 1 mg, incremental dosage is between
0.5 and 1.0 mg, and the onset is within 3 to 5 minutes, with a duration of 0.5 to 2.0
hours. The elimination, however, is 2 to 4 hours, presenting an extremely low risk of
early discharge.7,8
We should always consider the level of preoperative anxiety. In many cases, the
pending treatment may cause insomnia. This difficulty of sleeping adds to the overall
anxiety of the treatment day. The use of antianxiety or sleeping medications the night
before is wise. Oral Valium (5 to 10 mg, depending on the size of the patient and the
level of anxiety) should produce significant sleep and limit significant apprehension.
Benzodiazepines are anxiolytics that act by binding to receptor sites on the in-
hibitory neurotransmitter GABA (γ-aminobutyric acid), reducing the excitability
of neurons in the CNS (central nervous system) and potentiating GABA-mediated
chloride influx that results in sedation, amnesia, anxiolysis, anticonvulsant effects,
skeletal muscle relaxation, and respiratory depression, but does not provide analge-
sia.9,10 Benzodiazepines act postsynaptically on the receptor to enhance the inhibitory
action of GABA.11 There are two types of GABA receptors, GABAA and GABAB, and
benzodiazepines are primarily active on GABAA.12 There are many subtypes of ben-

zodiazepine receptors that have different actions. For example, α-1 receptors exhibit
sedative effects, while α-2 receptors show anxiolytic effects.13 Benzodiazepines lack
analgesic properties.
Benzodiazepines are classified according to their elimination half-life (t ½), which
is the time taken for drug concentration to decrease by 50%.10 The lipid solubility of
the drug determines its onset and duration of action.14 Alterations in dosing must be
made in patients with renal or liver insufficiency. When not taken with additional
CNS depressants, these drugs have a wide margin of safety, where death by an over-
dose is unlikely.15 Because of this pharmacodynamics feature, benzodiazepines can
be used more safely than drugs with a narrow margin of safety. Benzodiazepines are
used orally and parenterally for minimal sedation and moderate sedation, and they
are effective as single agents.16 When used alone and in a healthy patient, benzodi-
azepines generally exhibit a low risk of acute toxicity with minimal respiratory and
cardiovascular depression; however, combining them with opioids can enhance the
CNS toxic effects.17 A study evaluated oxygen saturation during periodontal surgery
with or without oral conscious sedation in anxious patients and found that there was
better patient acceptance during the surgery without significant respiratory depres-
sion.18 It is important to note that adverse effects on hemodynamic (cardiovascular)
function may occur when sedative and analgesic drugs are administered together.19
Administering two 0.25-mg tablets of oral or sublingual triazolam in divided doses
at different times may be safer than taking a single 0.5-mg dose.20 Because sedation
is a continuum, moderate sedation is reached after minimal sedation is passed. The
same benzodiazepines administered for minimal sedation are used for a deeper state
of moderate sedation at a dosage greater than 1.5 times the MRD.16
Diazepam
Diazepam, a low-potency benzodiazepine, is long acting and has a long half-life be-
cause it is metabolized in the liver into active metabolites, which can lead to me-
tabolite accumulation and oversedation, or a “hangover effect.”10 In elderly patients
and in individuals with hepatic or renal impairment, these adverse side effects may
become chronic.10

Triazolam
Triazolam is a high-potency, short-acting imidazobenzodiazepine indicated for the
treatment of insomnia, and it has an off-label use as a preoperative sedative. Tri-
azolam has a wide margin of safety, a high amnesic effect, and no active metabo-
lites, which make it ideal for oral sedation for the anxious patient.21 There is a faster
recovery time than with diazepam, which prevents a “drug hangover.”22 There is
more total amnesia than with diazepam. Having a short elimination half-life of 2 to
5 hours allows repeated administration of the drug during the day. Peak onset is 1
hour for oral administration but 30 minutes for sublingual.16 The sedative effect is
gone 4 hours after initial drug administration. Excessive sedation is possible when
prescribed to elderly patients.16
Lorazepam
Lorazepam has a slower onset of action and needs to be administered about 2 hours
before the procedure, which does not make it an ideal agent for office sedation.
Midazolam
Midazolam is the most frequently used benzodiazepine as an anxiolytic with some
amnestic properties for procedural moderate sedation. Midazolam is short acting
and is almost twice as potent as diazepam. After oral or parenteral administration,
midazolam has a fast absorption rate and is rapidly excreted, with an elimination
half-life of only about 2 hours, which makes it ideal for procedural sedation and anal-
gesia (PSA).10 It is the only benzodiazepine that is water soluble, which reduces pain
and irritation at the injection site. After administration, midazolam becomes lipophil-
ic, which allows it to be rapidly absorbed and penetrate into the CNS.23 Midazolam
is administered by the oral, intravenous, intramuscular, and rectal routes; however,
it has a rather bad taste when taken orally.23 Intranasal administration has been used,
but there are reports of pain and irritation.24 High doses of midazolam may result in
hypoventilation and hypoxemia.23 Caution should be used when administering mid-
azolam to patients with cirrhosis.25 Midazolam is often coadministered parenterally
with fentanyl, an opioid analgesic, for PSA. Both drugs are easily titratable. When
benzodiazepines are combined with an opioid, the dose should be reduced by one-
third to one-half.26

Using benzodiazepines for sedation
Benzodiazepines have documented pharmacodynamics and pharmacokinetic drug
interactions. They are primarily metabolized by cytochrome P450 (CYP) 3A4 isoen-
zymes in the liver.27 Additive synergistic effect occurs with coadministration of other
CNS depressants (eg, ethanol, opioids, barbiturates, antidepressants, antihistamines,
anesthetics), increasing incidence of respiratory depression and even death.11 Triazol-
am taken with erythromycin or azithromycin can produce a 46% increase in plasma
levels, and grapefruit juice may cause a 26% increase in plasma concentration by
inhibiting CYP3A4, both of which would increase the clinical effects of triazolam.28–30
In summary, for minimal oral sedation, the drug of choice is triazolam (dose: oral
or sublingual 0.25 mg; 0.125 mg for elderly patients) for patients undergoing a proce-
dure that is approximately 2 hours.9,28 The dose should not exceed 0.5 mg. Peak action
occurs after 2 hours.28 For longer procedures, lorazepam (0.5 to 1.0 mg) can be admin-
istered. The patient can also take diazepam 2.5 to 10.0 mg orally the night before the
appointment or triazolam 0.125 to 0.5 mg in the office 1 hour before the appointment.
When more than one enteral drug is used for sedation or when one enteral drug ex-
ceeds the maximum recommended dose, the guidelines for moderate sedation must
be used. Remember that the use of nitrous oxide can produce all levels of sedation.31
For moderate oral sedation, the drug of choice is triazolam (0.375 to 0.5 mg) for
procedures up to 2 hours, triazolam (0.5 mg) or diazepam (20 to 30 mg) for longer
procedures, and lorazepam (2 to 3 mg) for procedures longer than 3 hours.9 The most
frequently used benzodiazepine for moderate intravenous sedation is midazolam
because it has a rapid onset of action of 1 to 2 minutes, short duration (30 to 60 min-
utes), and amnestic properties. There is no analgesic effect. Midazolam has been used
alone or in combination with an opioid, such as fentanyl. In healthy patients, the
recommended sedation dosing of intravenous midazolam is 1 to 5 mg up to 1 hour
prior to surgery.10 As with all intravenous drugs, dosages should be carefully titrated
to achieve the desired anesthetic effect, starting at the lower end of the range of rec-
ommended dosage.

Barbiturates
The barbiturates generally used are the ultra–short-acting and short-acting barbitu-
rates. The common drugs in this class are methohexital (Brevital, Par Pharmaceuti-
cal)32 and sodium thiopental (also called Pentothal [Abbott]). These drugs are often
noted for their rapid induction and rapid emergence. They are generally well toler-
ated by the patient, with minimal complications. Generally, the drugs are adminis-
tered in an IV drip and are utilized for short diagnostic or surgical procedures. The
solution of 1% methohexital (Brevital) is used at a rate of 1 mL per 5 seconds. The
usual dose is between 1 and 1.5 mg/kg. This usually provides sedation within 5 to
7 minutes. Brevital is used in some pediatric cases.33 The mode of administration
can be IV or rectal, in conjunction with inhalation anesthetics for surgical cases. For
this use, nitrous oxide plays a significant role, as it is very effective and produces a
hypnotic state.
Sodium thiopental is a mainstay of IV barbiturates. It has been used for many years
to provide an induction anesthesia for surgical cases, followed by inhalation anes-
thetics. The sodium thiopental can be given in drip form (0.4%) or can be given by IV
push as a bolus of 1%.
Propofol
Propofol (Diprivan, Fresenius Kabi) has almost completely taken over the role that
was once provided by sodium thiopental. The margin of safety is great due to the
rapid emergence from the anesthesia. Propofol is used as an induction agent and is
usually given in a continuous drip, which will produce a sedative state. Propofol an-
esthesia is quickly induced and is faster than sodium thiopental, and the emergence
from anesthesia/sedation is also much faster.
The clinical uses of propofol are numerous.34 Propofol is not an analgesic; how-
ever, it produces a sedative state. Propofol has been used, and continues to be used
successfully, in painful procedures such as endoscopy, colonoscopy, and more. The
patients usually are sufficiently sedated so the procedures can be performed. How-
ever, an area which is often overlooked with the utilization of propofol is the local
irritation in the vein utilized as the IV port for the drug delivery. The dorsal veins on
the dorsum of the hand, though very convenient, are very small, and propofol induc-
tion may cause a burning sensation that alarms some patients. Most anesthesiologists

will utilize larger veins in the antecubital area, or they will inject 1% lidocaine prior
to the injection of propofol. The subdivided dose of propofol is usually 0.5 to 1 mg/
kg. This may be followed by 3.0 to 4.5 mg/kg to produce excellent sedation with
minimal or no respiratory dose dependent effect. The question of rapid induction of
the medication plays a distinct role in lessening the effect of both respiratory35 and
cardiovascular complications.
α2-Adrenoceptor Agonist
Dexmedetomidine is the first drug of this category that is being marketed as a seda-
tive. It is more selective for the α2-adrenoceptors than clonidine. Its primary site of
action is in the locus coeruleus. It is said to mimic natural sleep. Dexmedetomidine
can produce intense sedation without amnesia, hypnosis, or general anesthesia. It
does not have any anticonvulsant properties. It is considered a sedative-hypnotic that
has little respiratory depression. Patients are easily aroused and maintain the ability
to cooperate with the operator. The most common side effects are hypotension and
bradycardia. Cardiovascular effects are more profound in elderly patients, especially
when a bolus is used with a higher infusion rate. These side effects are attributed to
decreased catecholamine release by activation peripherally and in the CNS of the αA
receptor. Dry mouth and nausea can occur.3,36,37
Opioids
Opioids are μ binding receptors and are often used in conjunction with benzodiaze-
pines. The recommendation is to use the opioids to supplement the benzodiazepine
when a maximum dose has been reached and further sedation is required. Within
this classification, we include meperidine (Demerol, Pfizer), morphine, and fentanyl
(Sublimaze, Johnson & Johnson).
Meperidine
The use of meperidine today is minimal. Meperidine has been a long-standing nar-
cotic used for the control of pain, given in the postoperative period in doses of 50, 75,
or 100 mg, depending on the level of pain. IV meperidine has been utilized for seda-

tion in conjunction with benzodiazepines. The maximum dose is between 50 and 100
mg. It is usually recommended that 2.5 mg/kg over a 2- to 3-hour period is safe.
Morphine
Morphine is the “gold standard” for all narcotics. Morphine given for postoperative
pain works extremely well. IV morphine for acute pain episodes is very effective and
well tolerated. A 10-mg IV push will immediately allay any pain experienced by the
patient. Morphine can also be given in a bolus, but in the case of conscious sedation,
it is usually given in 5- to 15-mg doses every 3 to 4 hours incrementally.
Fentanyl
Sublimaze is a short-acting, very powerful narcotic, which is often the choice for use
in conscious sedation. The onset of Sublimaze is very rapid, and it has a short half-life,
which makes it ideal for supplementation with benzodiazepines, especially during
sedation for dentistry. The dosage of Sublimaze varies depending upon the situation,
and dosages can be adjusted easily when given in small increments. The dosage of
100 mcg per hour given in 15-mcg increments is very effective for sedation. Because
of its short half-life, Sublimaze is an excellent choice for early discharge of patients.
A popular combination is midazolam and Sublimaze. Anesthesiology surveys in-
dicate that this combination can be used for conscious sedation and/or deeper seda-
tion when required. Again, it is important to note the effects of the narcotics, especial-
ly on the respiratory and cardiovascular systems. The changes in alveolar ventilation
are notable. Obviously, monitoring PaO2 (partial pressure of oxygen), PaCO2 (partial
pressure of carbon dioxide), and end-tidal capnography is crucial. Rescue medica-
tions should be immediately available.
Naloxone as reversal agent

Naloxone (Narcan, Emergent BioSolutions) is now the drug of choice to reverse the
effects of narcotics. The average dose is 0.4 mg, and it can be repeated if the manifes-
tation of respiratory depression continues. In cases where postoperative analgesia is
required, oral medication is usually prescribed by the dentist or dental surgeon. A
problem may occur if the patient having had a procedure is unable to swallow. Fortu-
nately, Sublimaze has a transdermal patch available in 25, 50, 75, and 100 mcg. There

is some controversy about the duration of the fentanyl patch. It is said to last for 72
hours, but in most cases postoperatively, it really lasts about 48 hours. Therefore,
this may require repeated use prior to the 72 hours. These patches supply effective
pain management of postoperative pain, with a prolonged period of narcotic control,
which is easily accepted by patients.38,39
Opioid considerations
Opioids interact with binding sites on opioid receptors, which are diffusely centrally
distributed in the pain-suppressing areas of the brain and spinal cord. Opioid re-
ceptors are classified as µ, δ, and ĸ. µ1 receptors mediate analgesia, and µ2 receptors
mediate respiratory depression.40 Besides having an analgesic action, opioids exert
a sedative effect due to stimulation of the µ and ĸ receptors.41 Opioids are classified
based on their potency and duration of action. In many cases, opioid analgesics are
not administered alone but in combination with a sedative to achieve the desired sed-
ative/analgesic effect for moderate sedation. However, the analgesic effect of the opi-
oids may offer no advantage over using a single sedative drug, most likely because
the patient is probably having local anesthesia.41,42 Opioids are often helpful for the
postoperative pain or when the local anesthetic starts to wear off because opioids can
alter the experience of pain. When taken orally, opioids are poorly active, resulting in
differences in their sedative activity in patients.43
Respiratory depression is of concern, especially when benzodiazepines and opi-
oids are used together. It is important to titrate opioids during IV sedation to avoid
this adverse effect.41 Opioids are considered cardioprotective because they decrease
catecholamine release and activate certain receptors.41,44 One commonly used opioid
for dental moderate sedation is fentanyl. Fentanyl is a semisynthetic opioid that is
very potent and lipid soluble, which is ideal to cross the blood-brain barrier very
quickly. It is usually administered slowly through an infusing IV line and is carefully
titrated for the desired anesthetic effect. Oral transmucosal fentanyl is dosed by suck-
ing on a unit dose lozenge on a stick. It is usually used in a hospital setting. Fentanyl
has a more immediate rapid onset, greater potency, and shorter duration of action
than morphine. A short half-life gives it a shorter recovery time. These features make
fentanyl a drug of choice for PSA. Meperidine is no longer recommended because
seizures are commonly associated with the accumulation of its long-lasting metabo-
lite normeperidine.45

All opioids can cause hypotension, especially when used in combination with oth-
er sedative drugs, but fentanyl has fewer hemodynamic effects than other opioids.12,46
Other adverse side effects include hypoventilation, apnea, muscle rigidity, bradycar-
dia, and nausea/vomiting. Morphine has a longer clinical effect, which is desirable
for acute procedural pain and for prolonged painful procedures.
Dissociative Anesthesia
Ketamine
Dissociative anesthesia is used for patients undergoing sedation for operative cases.
Ketamine is an ideal drug for this use.47,48 It is also an analgesic drug, since it affects
the dorsal horn of the spinal cord, therefore blocking transmission in the spinal cord.
Ketamine will block the N-methyl-D-aspartate (NMDA) receptors. The NMDA re-
ceptors are responsible for early dissociative states, which produce a felt-detachment
from the “physical body,” often referred to as an “out-of-body-experience.” Nystag-
mus is also present.
In terms of the effect on the cardiovascular system, it is exactly the opposite of de-
pressive anesthetic drugs. Blood pressure generally rises, and the airway is not com-
promised. This is an ideal drug utilized for burn patients and when dressing changes
are required. Ketamine is often utilized in dental sedation cases, especially for restor-
ative/operative dentistry. Ketamine dosage is usually 0.5 to 1 mg/kg and is recom-
mended in incremental doses of 0.5 mg/kg. These dosages can be changed at the dis-
cretion of the provider, but the utilization should follow the guidelines as indicated.
Ketamine wears off rapidly. The emergence from ketamine can be problematic due
to the patient’s mental state. It is recommended that the patient should be permitted
to wake slowly, not jostled or aroused, in a quiet area of the recovery room. This will
allow for an emergence without complications. However, we must be prepared for
any untoward reaction. If the unexpected does occur, it can be easily remedied with a
well-trained provider and the availability of proper resuscitative equipment.
Again, a complete patient evaluation is key to minimizing intraoperative and/or
postoperative complications. The ASA I patient with conscious sedation/analgesia

must receive the same scrutiny as any patient. Preanesthetic/sedation assessments
must follow a standard protocol including the following:
• Medical and surgical history

• Medication review
• Allergies
• Family history of any anesthesia problems
Nitrous Oxide–Oxygen
Nitrous oxide is readily available in many dental practices and is safely administered
because of its ease of titration and less adverse side effects, including being nonirri-
tating to the tissues.49 It is a colorless and odorless gas that is used as a 30% to 70%
mixture in oxygen, with sedative and analgesic properties. For inhalation sedation,
it is important to make sure that a titrated dose of nitrous oxide is given using units
that are specifically designed to deliver a minimum of 30% oxygen.50 At the end of
the procedure, the patient is administered 100% oxygen until there are no more signs
of sedation.51 It has a quick onset (1 to 2 minutes) and quick elimination (3 to 5 min-
utes) due to rapid diffusion across alveoli in the lungs and not being stored in the
body.45,52 It is necessary to use oxygen with nitrous oxide so that the blood remains
appropriately oxygenated.
There are contraindications to nitrous oxide as well. Because it rapidly diffuses
into gas-filled pockets, it should not be administered to patients with small bowel
obstructions, chronic obstructive pulmonary disease (bronchitis and emphysema but
not asthma), current upper respiratory tract infection, cystic fibrosis, maxillofacial in-
juries, intestinal obstruction, increased intracranial pressure, or middle ear effusions
(recent ear surgery).45 Other contraindications include the inability of the patient to
wear the nasal mask, sinusitis, claustrophobia, vitamin B12 or folate deficiency, preg-
nancy (especially in the first trimester), current or recovering drug use (nitrous oxide
produces euphoria), treatment with bleomycin sulfate (chemotherapy), and severe
emotional conditions.49,53
Nitrous oxide is a titratable gas, which allows the depth of sedation to be con-
trolled. It has a rapid onset due to its low blood-gas partition coefficient or insolu-

bility in blood, and it provides amnesia, sedation, and analgesia.19 It must be used in
combination with a constant oxygen flow of greater than 30%.54 Additionally, it has
a wide margin of safety with a fast recovery and no need for an escort.51 Some dis-
advantages include the cost of the equipment and the fact that patients must be able
to breathe through the nose.55 Ignition of the nasal hood delivering nitrous oxide to
a patient has been reported, which led to severe facial burns. The source of ignition
was heat that originated during the preparation of a titanium post from a high-speed
carbide bur with irrigation. Other sources of ignition could include electrosurgical
units, lasers, and sparks from preparing other dental materials.55
Managing exposure
Dental nitrous oxide–oxygen (N2O-O2) mixing machines can be both stand-alone
units with attached gas cylinders or wall mounted with a central gas supply. They
may have either analog or digital interfaces and are designed with multiple safe-
ty features56:
• Nitrous oxide cylinders/tanks are color coded (blue for nitrous oxide and
green for oxygen)
• Tubing is color coded to match the cylinders/tanks
• Unique fittings that are different for nitrous oxide and for oxygen
• Reservoir bag that allows respiration rate monitoring
• Oxygen flush button that allows 100% oxygen to be delivered quickly and immedi-
ately during any emergency (or simply remove the mask and allow the patient to
breath room air)
While some prior studies have suggested that chronic exposure to certain concen-
trations of nitrous oxide may constitute a health risk for dental staff,57 the dentist and
staff must follow strict guidelines for the use of nitrous oxide, and only use N2O-O2
delivery systems with an effective and efficient scavenger system. These systems uti-
lize suction placed at the mask over the pop-up valve to remove the exhaled air-gas
mixture. It may also be appropriate to open windows to allow for the constant flow
of outside air into the treatment rooms.

Reversal Agents and Rescue
Rescue is another concept to understand and always consider when administering
any sedative drug(s) by any route. The concept of rescue is to be prepared to identify
if a patient exceeds the intended level of sedation and to take the necessary steps to
manage the patient and allow for recovery to a level commensurate with the level
of training maintained by the dentist. This also includes being prepared to call for
help as indicated, though most important would be the effective and appropriate
management of the patient’s airway. This consideration for rescue is also addressed
by carefully following the MRD for any drug administered to establish a margin of
safety that should make a deeper than intended sedation level unlikely.
Flumazenil is the reversal antagonist drug for benzodiazepine overdose. It acts
by selectively attaching to the receptor binding sites, preventing the benzodiazepine
from binding, resulting in the reversal of sedation, along with respiratory depression
and cessation of amnesia.14 It is administered intravenously by titration with 0.2 mg
given over 15 seconds. After 45 seconds, an additional 0.2 mg may be administered
and repeated at 60-second intervals up to 1 mg.58 For patients who are tolerant to ben-
zodiazepines, the drug should be titrated at a slower rate of 0.1 mg/min. This dose
will result in less agitation and confusion. Remember, there is a high risk of with-
drawal seizures for dependent benzodiazepine users, and extreme caution should be
used in this population.58
Naloxone is a competitive antagonist that has no activity but sits on the opioid
receptor, not allowing more of the narcotic to occupy the receptor site. It is used as a
reversal or rescue agent for opioid overdose and can be given by the intramuscular,
endotracheal, subcutaneous, intravenous, or intranasal routes. When administered
intravenously, which has an onset of action of 1 to 2 minutes, it is recommended to
dilute the drug (0.4 mg in 10 mL of saline administered by titration) to prevent stimu-
lation of the sympathetic activity that can occur with abrupt reversal of opioid respi-
ratory depression.59 To reduce the reversal of analgesia and its withdrawal effect, and
to attain the desired effect, the drug should be administered in increments.14 No more
than 0.1 to 0.4 mg should be given over 2 to 3 minutes and up to 0.8 mg can be used.60
Related to the concept of rescue is failure. Some sedation procedures will fail, and
it is important for the dentist to be prepared. The dentist also needs to understand the
importance of not continuing treatment but instead having the patient return for a

consultation to discuss other sedation or anesthesia options. It is critically important
to resist the temptation to administer additional drug with the intention that it will
allow the patient to be successfully sedated. Paying close attention to MRD and dos-
ing guidelines will allow for the safest approach for the patient. The incorporation of
N2O-O2 will also allow for the determination of sedation success or failure, and it can
be managed effectively and efficiently.
Facilitating Successful Oral Sedation

There is an opportunity to determine an appropriate drug dose to administer to a
patient to facilitate a successful sedation appointment as well as to determine if this
sedation approach will be appropriate for the patient. This involves the administra-
tion of a single drug over several days to prepare the patient for the sedation appoint-
ment and determine an effective dose to administer orally on the day of the dental
appointment. It is important to understand that this approach should only be done
with a single drug and never with drugs in combination. Additionally, despite the
administration of sedative drugs as an off-label approach, and given that these drugs
are typically prescribed for sleep or anxiety reduction and not dental sedation, the
maximum recommended dose of the drug administered must never be exceeded.
Maximum recommended dose, as defined by the ADA Guidelines,31 is the maximum
FDA-recommended dose of a drug, as printed in FDA-approved labeling for unmon-
itored home use.
An example of this dosing regimen is with triazolam (Halcion, Pfizer). Based on a
discussion with the patient and their understanding and acceptance of this approach,
the dentist should have the patient start this process 3 to 5 days prior to the scheduled
appointment. One concept to appreciate with this approach is the understanding that
a fearful or phobic patient does not start thinking about their scheduled appointment
the night before the appointment. It is very likely the patient is thinking about it from
the day it was scheduled, and their fear of the appointment only increases with each
day. Allowing the patient to experience a level of sedation several days prior to their
scheduled appointment can increase the success of the appointment. Additionally,
this approach can determine if the prescribed drug will be successful when admin-
istered for the appointment. There are many opportunities available for the patient

and the dentist when incorporating this presedation approach. The following is an
example of presedation with triazolam over a 5-day period.
Five-day triazolam presedation protocol

Prescribe four to six 0.125-mg triazolam tablets and four to six 0.25-mg triazolam
tablets.
1. On night 1, instruct the patient to take one 0.125-mg triazolam tablet 1 hour prior
to their normal bedtime. The patient should also be instructed to assess how they
felt based on the effect of the drug taken, as well as how they felt in the morning.
2. On night 2, based on the effect achieved with the first night’s dose, instruct the
patient to take two 0.125-mg tablets 1 hour prior to their normal bedtime, or stay
at the same dose taken the previous night. The patient should also be instructed
to assess how they felt based on the effect of the drug taken, as well as how they
felt in the morning.
3. On night 3, based on the effect achieved with the second night’s dose, instruct the
patient to take one 0.25-mg tablet and one 0.125-mg tablet (total triazolam dose of
0.375 mg) 1 hour prior to bedtime, or stay at the same dose where an acceptable
effect was identified from a previous evening. At this level, the patient should be
reaching a level of sedation that provides reasonable relaxation and comfort. As
with previous nights, the patient will assess the resulting effect and begin to de-
termine if this is a successful sedation protocol. Understanding that the maximum
dose of triazolam that can be prescribed for unmonitored home administration is
0.5 mg, consideration must be given to the anticipated success of oral sedation for
this patient on the day of the scheduled appointment.
4. On night 4, the patient should be at a dosing level where there is an identified
sedation effect. This identified level should be maintained for this evening and
taken at 1 hour prior to their normal bedtime. This should be the evening prior to
the scheduled appointment.
5. On day 5, the patient should be instructed to take the determined dose of triazol-
am 30 minutes prior to their scheduled appointment. It is recommended that the
patient be present in the office when the sedative drug is taken and in a location
where they can be observed by a member of the staff. The opportunity to use

several days to determine a dose of drug that will sedate the patient successfully
increases the likelihood of a successful sedation procedure, allowing the planned
dentistry to be delivered and minimizing the potential for the appointment to
be a failure.
The goal of this presedation protocol is to determine an appropriate dose of triazol-

am that will be successful for the patient. If this goal is achieved, then the planned
sedation for the scheduled appointment will likely be successful, and the patient will
be well prepared both mentally and physically for dentistry with sedation. If this
goal is not achieved, then the protocol is still helpful before the scheduled appoint-
ment to avoid a likely sedation failure and discuss with the patient other potential
options for sedation or anesthesia.
Any oral sedation approach will require that the patient complete all necessary
documentation, including consents, prior to the administration of a drug. There is
also the requirement to have a responsible adult with the patient, preferably for the
entire appointment, but absolutely for escort home and during their recovery. Pa-
tients scheduled for oral sedation will be required to follow appropriate eating and
drinking instructions. It is also suggested that the patient come to the appointment
in comfortable clothes, understanding that there will be the need to access their arms
for monitoring purposes. All oral sedation approaches will involve the administra-
tion of the drug at a time before the procedure to allow for the onset of the drug to
occur. What is essential for any oral sedation approach is to allow the necessary time
for the drug administered to onset and to observe the effect.
A study by Jackson et al61 looked at the multi-dosing of triazolam to patients
over three identified time intervals. The purpose of the study was to determine if
multi-dosing would maintain the intended level of sedation and not increase the
depth of sedation. The results of the study determined that triazolam concentrations
gradually increased over time in all patients. Of the 10 patients involved in the study,
8 patients met the definition for deep sedation or general anesthesia. It is possible
to render a patient beyond the level of moderate sedation with orally administered
drug(s), and that is why it is important to follow established guidelines for adminis-
tration to protect the safety and well-being of the patient.

Sedation regulations
The administration of any drug to a patient for sedation must be done in accordance
with state dental board rules and regulations. It is imperative that the administering
dentist know and understand the specific state dental board rules and regulations for
sedation. With respect to oral sedation, there can be different requirements based on
the level of sedation being administered. The ADA Guidelines established the same
level of training and education for moderate sedation, regardless of the route of se-
dation (oral or IV). If oral sedation is being administered to the level of moderate se-
dation and the state dental board follows the ADA Guidelines, then the requirements
for that level of sedation apply. Effectively, a dentist requires a permit for the admin-
istration of oral sedation when moderate sedation is the intended outcome for the
patient. There are state dental boards that have separate rules and regulations for oral
sedation. This emphasizes the importance of knowing the state dental board rules as
they apply to the type and level of sedation administered to patients.
As previously discussed, it is accepted that drugs administered orally cannot be
titrated to the desired effect. The ADA Guidelines indicate that if the MRD of a drug
will be exceeded during a single appointment, or if multiple drugs are administered
orally during a single appointment, it should be considered moderate sedation and
the appropriate guidelines apply. The ADA Guidelines31 include the following discus-
sion of orally administered drugs:
Dosing for minimal sedation via the enteral route. Minimal sedation may be
achieved by the administration of a drug, either singly or in divided doses, by the
enteral route to achieve the desired clinical effect, not to exceed the MRD. The ad-
ministration of enteral drugs exceeding the MRD during a single appointment is
considered moderate sedation, and the moderate sedation guidelines apply. N2O-O2
when used in combination with sedative agent(s) may produce minimal, moderate,
or deep sedation or general anesthesia. If more than one enteral drug is administered
to achieve the desired sedation effect, with or without the concomitant use of nitrous
oxide, the guidelines for moderate sedation must apply. Note: In accord with this
definition, the drug(s) and/or techniques used should carry a margin of safety wide
enough never to render unintended loss of consciousness. The use of the MRD to
guide dosing for minimal sedation is intended to create this margin of safety.

Conclusion
There are many drugs available for oral sedation, with benzodiazepines and opioids
as the most commonly administered. Regardless of the drug(s) selected for adminis-
tration, the dentist must possess strong knowledge and understanding of any drug
administered to a patient. MRD, dosing guidelines, and drug interactions are im-
portant concepts to understand. It is also important to understand how the drug(s)
planned for administration will affect the patient with identified comorbidities. Due
to the amount of time required for orally administered drugs to take effect and reach
their onset and peak effects, multiple dosing is generally not conducive to dental
procedures. Typically, the additional dosing of drug is limited to one time. Other-
wise, alternate approaches are pursued, such as the administration of multiple drugs
(usually not more than two different drugs) and/or the administration of N2O-O2 to
the patient.
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SECTION II
SEDATION IN SPECIALTY PRACTICE

CHAPTER 7
Periodontic Sedation
S
edation analgesia is frequently performed in periodontal/implant clinical
practice as well as in the hospital setting. The use of sedation in periodontics
has rapidly transformed in the past decade due to pharmacologic, legal, and
practice management concerns. The demand for sedation services makes it impera-
tive that many clinicians—including periodontists—are trained to provide sedation.
Specific guidelines have been published that the periodontist must follow for safe
and effective sedation and analgesia. Additionally, the periodontist must have re-
ceived formal sedation training.1,2 The opportunities for periodontists performing se-
dation in the office or hospital are widening, with an increasing number of sedation
procedures being performed by non-anesthesiologists.
A 2010 national survey reported that approximately 50% of periodontists offer
intravenous (IV) sedation in their practice, while 34% of periodontists personally
provide IV sedation. More recent graduates are more likely to offer this service.3 To-
day’s graduating periodontists must be trained in all areas of sedation, with clinical
training to the level of competency in minimal enteral and moderate parenteral adult
sedation, as part of all Commission on Dental Accreditation (CODA) approved ad-
vanced education programs in periodontics. Naturally, there are differences in train-
ing and practice in different regions of the country. This survey found that periodon-
tists from the south-central part of the United States used the most IV sedation, while
periodontists in New York and New Jersey used the least.3

While rendering periodontal/implant care, local anesthesia may not be adequate
for anxiety control; hence, procedural sedation may be indicated. Pain and anxiety
are major concerns when treating periodontal patients because each is a natural re-
action to periodontal surgery. Additionally, sedation can provide amnesia, control
secretions, and assist to neutralize hyperactive gag reflex.4 All reactions must be
controlled satisfactorily during the perioperative period to permit safe and effective
completion of the surgical procedure. While the risks associated with the administra-
tion of sedative/analgesic drugs are minimal in the hands of trained periodontists,
adverse reactions can occur and must be recognized and managed properly to avoid
serious events and complications. Potential drug interactions of sedative/analgesic
drugs can lead to morbidity and mortality. All members of the dental team involved
in sedation must be officially trained in sedation techniques, including monitoring
of the patient during treatment and recovery periods. Because the different levels of
sedation are a continuum, the periodontist must be able to monitor patients carefully
to maintain them at the desired level of sedation.
This chapter discusses issues regarding sedation of patients in the periodontal prac-
tice, including factors involved in deciding to sedate, current guidelines for patient
assessment and monitoring during sedation, and factors that determine the choice of
sedative and/or analgesia. Some of the more commonly utilized sedative and anal-
gesic agents are also reviewed.
Minimal sedation is used frequently in the periodontal practice. It is indicated for
mild to moderate anxiety and fear or phobia that will not allow the delivery of dental
care without pharmacologic agents.5 It may be ineffective in patients with a higher
level of anxiety, and it is not effective for pain control. Minimal sedation allows the
patient to feel slightly sedated, relaxed, and more cooperative during periodontal
procedures.6 Advantages of the oral route of drug administration include ease of ad-
ministration and compliance, inexpensive, and lowered incidence and decreased se-
verity of adverse effects.7,8 The oral route of drug administration, depending on the
dose, can induce minimal or moderate sedation. Benzodiazepines are the primary
drugs for the management of fear and mild to moderate anxiety.7

Guidelines from the AAP and the ADA
The 2013 American Academy of Periodontology (AAP) statement on the use of mod-
erate sedation concluded that pain control during periodontal procedures utilizing
local anesthesia or nonpharmacologic agents may not be adequate to make the pa-
tient comfortable.9 Additional pharmacologic agents for anxiety control (eg, moder-
ate sedation) may be appropriate for certain patients and are within the boundaries
of the periodontal practice. The Accreditation Standards for Advanced Dental Educa-
tion Programs in Periodontics require periodontists to have an in-depth knowledge
of all levels of sedation.10
The periodontist must be trained to provide minimal and moderate sedation for
the anxious or fearful patient to effectively deliver periodontal care. The AAP agrees
with the American Dental Association (ADA) regarding guidelines to follow for the
use of sedation in the dental practice.1 In the most current ADA Guidelines for the
Use of Sedation and General Anesthesia by Dentists1 and ADA Guidelines for Teaching
Pain Control and Sedation to Dentists and Dental Students,11 the Council states that there
should be no difference in the training requirements for moderate sedation whether
the enteral or parenteral route of drug administration is used since the same clinical
state is reached no matter the route.1
Goals and Clinical Considerations

The goals of moderate sedation and analgesia are to allow the fearful or anxious pa-
tient to tolerate the discomfort and pain of the periodontal procedure, reduce recall
(ie, induce amnesia), provide patient comfort and cooperation during the procedure,
and facilitate rapid recovery with nominal risk to patient safety.
Practice guidelines are systematically developed recommendations that help the
periodontist as well as the patient in making decisions about sedation. Advantages,
disadvantages, indications, and contraindications of the different routes of drug ad-
ministration should be reviewed for each patient. This will allow the periodontist to
induce a desired level of sedation while minimizing the accompanying risks so that
the patient is maintained at the moderate sedation level without progressing beyond
this level in the sedation continuum.12,13

Periodontal Patient: Evaluation and Presedation
Assessment
First and foremost, the periodontist administering mild to moderate sedation or anal-
gesia must practice within the scope of periodontal practice as defined by their state
and should be compliant with state advisory rules and other regulations that direct
the practice of the trained periodontist. The trained periodontist who is monitoring
the patient receiving moderate sedation or analgesia should have no other responsi-
bilities that would require leaving the patient unattended or that would compromise
continuous monitoring during the procedure.
Preprocedure evaluation and assessment is one of the most important parts of de-
livering safe and effective sedation. Identifying any significant medical history and
specific physical characteristics before sedation or analgesia will reduce the risk of an
adverse outcome. Informed consent must be obtained from the patient for periodon-
tal treatment as well as for the sedation procedure. It is important to make sure that
the name and phone number of the patient’s escort is provided to the periodontal
team before any procedures are started.
Patient selection is most important when doing a presedation assessment because
not every patient is an appropriate candidate for procedural sedation and analge-
sia (PSA). The next recommendation is that the perioperative trained periodontist
should complete a patient assessment before administering mild or moderate se-
dation or analgesia. Inadequate preassessment in patients, especially with comor-
bidities, can result in sedation-related adverse events and poor outcomes. Before a
patient undergoes sedation for a periodontal procedure, it is important to ensure
that the minimum required patient assessment is completed up to 24 hours before
the periodontal procedure and signed/cosigned by the responsible sedation creden-
tialed periodontist (Box 7-1).

BOX 7-1 Minimal assessment required before sedation for periodontal procedures
• Medical history and physical examination, including height, weight, and body mass index (BMI)
• Blood lab tests
• American Society of Anesthesiologists (ASA) physical status score
• Informed consent
• Drug allergies
• Current medication use, including over-the-counter medications and herbal supplements
• Alcohol, tobacco, or substance use
• Airway examination (Mallampati classification) and assessment of neck motility
• Obstructive sleep apnea, snoring
• Previous problems with anesthesia/sedation
• Heart rate, blood pressure, and respiratory rate
• Oxygen saturation
• Level of awareness (consider mental status/orientation)
• Time of last PO intake
• Respiratory and cardiovascular status, which may include findings from heart and lung auscultation
and other physical findings as appropriate
PO, by mouth.
Fasting is recommended before moderate intravenous sedation to prevent aspi-

ration. Patients at risk for impaired gastrointestinal motility (eg, obesity, pregnancy,
history of reflux) should be fasting for at least 8 hours (Table 7-1).
Table 7-1 Presedation fasting recommendations from

the American Society of Anesthesiologists
Ingested material Minimum fasting period

Clear liquids 2 hours
Breast milk 4 hours
Infant formula 6 hours
Nonhuman milk 6 hours
Light meal 6 hours
Fatty meal 8 hours
Important lab tests, including hematocrit, electrocardiogram (ECG), prothrombin

time (PT), and partial thromboplastin time (PTT) should be performed. Currently,
there is no clear benefit from obtaining extensive physical evaluation beyond vital
signs, mental status, and airway and cardiopulmonary assessment before PSA.14 Ob-
taining a consultation with the patient’s physician is recommended for moderate
cases. The medical stability of the patient must be established as well as the patient’s
physical status using the American Society of Anesthesiologists (ASA) physical sta-

tus classification (Table 7-2). Revisions from the 2012 ADA Guidelines include the use
of body mass index (BMI) and the timing of medical history review.1
ASA PS
Classification Definition Adult examples (including, but not limited to)
lung disease

tem dysfunction
donor purposes
Assessment of the patient’s airway is important, as sedatives and analgesics can

impair airway reflexes depending on the degree of sedation and analgesia achieved.
This is especially important in patients with preexisting airway conditions, including
severe obstructive pulmonary disease and obesity. In these cases, adjustments must
be made to the sedative or anesthetic agent. The Mallampati classification was de-
veloped as a technique to categorize a patient’s airway to determine the difficulty of
difficulty for intubation (Fig 7-1).15 As the classification increases, the degree of intu-
bation increases.

Fig 7-1 Mallampati classification:
MP Class I airway Soft palate, uvula, fauces, pillars visible

MP Class II airway Soft palate, uvula, fauces visible
MP Class III airway Soft palate, base of uvula visible
MP Class IV airway Only hard palate visible
There are concerns that obesity may be associated with increased risks of proce-
dural sedation due to airway management and respiratory depression. The pharma-
cokinetics and/or pharmacodynamics may be altered in morbidly obese patients.
Additionally, the morbidly obese patient may be more prone to having obstructive
sleep apnea and deposition of fat in the pharynx, which may put them at risk for
adverse respiratory episodes due to the anesthetic agent.16 Reilly et al stated that in
obese patients, it may be relatively safer to administer inhalation sedation with ni-
trous oxide, during which oxygen levels are maintained at 30% or higher.17 Patients
with obstructive sleep apnea are at risk of mortality and morbidity related to the ad-
ministration of sedatives, anesthetics, and opioids. These pharmacologic agents may
promote pharyngeal collapse and alter normal respiratory responses to obstruction
and apnea.18
To predict a difficult airway for moderate sedation, the following patient evalua-
tion should be done:
• External appearance (facial and neck anatomy): Neck mobility, short neck, limited
neck extension, cervical spine abnormalities
• Excessive overjet of incisors, dental appliances, loose teeth, high arched palate,
uvula not visible, hypertrophy of tonsils
• BMI
• Jaw opening (at least 3 fingers’ opening)
• Thyromental distance (at least 5–6 cm)
• Distance from hyoid to top of thyroid cartilage (2 fingers’ width)
• Mallampati classification (see Fig 7-1)
• Upper airway obstruction
• Previous history of difficult airway
Pharmacologic Agents Used for Sedation

Selection of the appropriate pharmacologic agent for the individual patient is critical
for a successful outcome. Besides choosing the best medication and route of admin-
istration, it is imperative to also have available reversal agents in the event of overse-
dation. Sedative drugs are often combined with local anesthetics to allay anxiety and
fear.19 Additional effects include one or more of the following: hypnotic, anxiolytic,
amnesic, and analgesic. Ideally, a sedative drug would have all these features, but the
majority do not, so other drugs are usually coadministered.20 The increased risks of
sedation must be weighed against benefits; the lightest effective sedation should be
used. Dosages are reduced in elderly patients, when combined with another sedative
or narcotics, and in obese patients.
During and after drug administration, the patient will be closely and continuously
monitored. Every 5 minutes, the patient’s ECG, blood pressure, respiratory depth,
and oxygen saturation are recorded as well as the level of sedation. The patient’s
pain rating is also asked and recorded. The patient must be monitored for any ad-
verse responses.
The periodontal patient requires sedation for an average of 30 to 120 minutes and
ideally would need sedation that has a quick onset of action and a quick recovery
time. Periodontal patients should be initially administered the lowest effective dose.21
Drugs should be slowly titrated, noting time for peak effect to allow for a safe and
effective outcome. A summary of the more commonly administered pharmacologic
agents for PSA in the periodontal practice are listed in Table 7-3.4,5,14,15,22–24

Table 7-3 Common pharmacologic agents administered for minimal and moderate sedation
and analgesia in the periodontal practice4,5,14,15,22–24
Route of Onset Elimination

Drug Classification administration (min) Peak (min) half-life (hr) Initial Dose
Midazolam Benzodiazepine PO 15–30 20–50 1.8–6.4; 1–2 mg (premed)
mean = 3
IV 1–3 3–5 0.2–0.4 mg/

kg (induction)
Diazepam Benzodiazepine PO 20–40 60–120 20–50 + 2–10 mg

active
metabolites
IV 1–5 15–30
Triazolam Benzodiazepine PO 15–30 2.9 ± 1 0.125–0.25mg
Morphine Opioid IV 5–10 10–40 3–4 2–10 mg

Fentanyl Opioid IV 1–3 Up to 12 hrs 2–4 0.5 mcg/kg (load-
ing); 0.01–0.04
mcg/kg/hr (main)
Transdermal 12.5–100 mcg
Propofol Sedative hypnotic IV 15–45 2–24 25–75 mcg/kg/min

sec
Nitrous oxide Gas Inhalation 30 sec 30%–70%
PO, by mouth.
Airway Management
It is important to assess the patient’s airway for respiratory depression during the
procedure.8 When providing mild to moderate sedation during periodontal treat-
ment, the dentist providing the care must ensure that the auxiliary staff are properly
trained in assisting and managing the needs of a patient who is sedated. The assistant
must help maintain a dry airway with high-speed evacuation. If an airway irritant
should pass down the larynx, the patient could experience a laryngospasm, which is
the reflex closure of the glottic muscles. These include the false and true vocal cords.
In the mild or moderate sedated patient, this spasm should be transient, and the pa-
tient will be able to cough to clear the secretions or material irritating the larynx. A
more deeply sedated patient or obtunded patient will not be able to clear the irritant,
and the laryngospasm will be prolonged.25

Conclusion
Appropriate sedation decreases a patient’s movements, anxiety, and pain perception,
and it is useful in performing periodontal and implant procedures on the fearful per-
son who may not otherwise proceed with necessary treatment.26 Because sedation is
a continuum, risk is inherent in procedural sedation, and patient safety is of utmost
importance. All patients have the right and need to be informed of the risks, benefits,
and alternatives of moderate sedation. Resuscitative equipment and reversal drugs
must be readily available. Moderate sedation agents are selected according to the
procedure, familiarity of the provider, and the patient’s history and physical assess-
ment. Monitoring and continual assessment of the patient is an ongoing process,
during the procedure and at recovery, that will ensure patient safety.
References
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2. Blayney MR. Procedural sedation for adult patients: An overview. Contin Educ Anaesth Crit Care
Pain 2012;12:176–180.
3. Tingey BT, Clark SH, Humbert LA, Tingey JD, Kummet CM. Use of intravenous sedation in peri-
odontal practice: A national survey. J Periodontol 2012;83:830–835.
4. Kaye AD, Gayle JA, Kaye AJ, Urman RD, Kaye AM. Pharmacology principles in sedation. In: Ur-
man RD, Kaye AD (eds). Moderate and Deep Sedation in Clinical Practice, ed 2. Cambridge, UK:
Cambridge University Press, 2012:9–35.
7. Sebastiani FR, Dym H, Wolf J. Oral sedation in the dental office. Dent Clin North Am
2016;60:295–307.
8. Donaldson M, Gizzarelli G, Chanpong B. Oral sedation: A primer on anxiolysis for the adult pa-
tient. Anesth Prog 2007;54:118–129.
9. American Academy of Periodontology statement on the use of moderate sedation by periodon-
tists. J Periodontol 2013;84:435.

10. Commission on Dental Accreditation. Accreditation Standards for Advanced Dental Education
Programs in Periodontics. https://www.ada.org/~/media/CODA/Files/perio.pdf?la=en. Ac-
11. American Dental Association. Guidelines for Teaching Pain Control and Sedation to Dentists
and Dental Students. https://www.ada.org/~/media/ADA/Education%20and%20Careers/Files/
ADA_Sedation_Teaching_Guidelines.pdf?la=en. Accessed 19 May 2021.
ology 2002;96:1004–1017.
13. Coulthard P. Conscious sedation guidance. Evid Based Dent 2006;7:90–91.
14. Burbulys DB. Procedural sedation and analgesia. In: Marx JA, Hockberger RS, Walls RM (eds).
Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8 (vol 1). Philadelphia: Elsevier,
2014:50–60.
15. Mallampati SR, Gatt SP, Gugino LD, et al. A clinical sign to predict difficult tracheal intubation: A
prospective study. Can Anaesth Soc J 1985;32:429–434.
16. Ingrande J, Lemmens HJ. Dose adjustment of anaesthetics in the morbidly obese. Br J Anaesth
2010;105(suppl 1):i16–i23.
17. Reilly D, Boyle CA, Craig DC. Obesity and dentistry: A growing problem. Br Dent J 2009;207:171–175.
18. Magliocca KR, Helman JI. Obstructive sleep apnea: Diagnosis, medical management and dental
implications. J Am Dent Assoc 2005;136:1121–1167.
19. Gazal G, Fareed WM, Zafar MS, Al-Samadani KH. Pain and anxiety management for pediatric
dental procedures using various combinations of sedative drugs: A review. Saudi Pharm J
2016;24:379–385.
20. Lingappan AM. Sedation. Medscape. http://emedicine.medscape.com/article/809993-overview.
Accessed 29 April 2021.
21. Adams D, Dervay KR. Pharmacology of procedural sedation. AACN Adv Crit Care 2012;23:349–356.
22. Freeman BS, Berger JS. Anesthesiology Core Review: Part One: BASIC Exam. New York: Mc-
Graw-Hill, 2014.
23. Yaksh TL, Wallace MS. Opioids, Analgesia, and Pain Management. In: Brunton LL, Chabner BA,
Knollmann BC (eds). Goodman & Gilman’s The Pharmacological Basis of Therapeutics, ed 12.
New York: McGraw-Hill, 2012.
24. Napoli AM, Krauss B. Monitoring the emergency patient. In: Marx JA, Hockberger RS, Walls RM
(eds). Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8 (vol 1). Philadelphia:
Elsevier, 2014:61–66.
25. Becker DE, Haas DA. Management of complications during moderate and deep sedation: Respi-
ratory and cardiovascular considerations. Anesth Prog 2007;54:59–69.
26. Johnson S. Sedation and analgesia in the performance of interventional procedures. Semin
Intervent Radiol 2010;27:368–373.

CHAPTER 8
Endodontic Sedation
Maria C. Maranga, DDS
Pain and Endodontic Treatment

Before pain is experienced by a patient, the central nervous system identifies and
begins a continuous action of processing local tissue damage. Acute pain is the physi-
ologic response that warns us of this danger. Soon, fast-conducting type A-δ and type
C nerve fibers are stimulated, and the patient reports a sensation of pain. In endodon-
tics, we encounter both acute and chronic pain. Performing endodontic treatment to
relieve this pain is successful in most cases. Neither pain medication nor high doses
of antibiotics will truly help in lieu of endodontic care.1
It is necessary to have endodontic treatment when the pulpal tissue of the tooth be-
comes inflamed or infected because of deep decay, insufficient crown margins, mul-
tiple restorative procedures, a crack, or a larger fracture. Trauma to a tooth, either
minor or full luxation, may also cause this same pulpal damage even if the tooth in
question does not display any visible chips or cracks. When pulpal inflammation or
infection is left untreated, the result can be pain or an abscess.
The most difficult and most important aspect of an endodontic emergency is pro-
found pulpal anesthesia. The infamous “hot tooth,” especially in mandibular molars,
is the most difficult to anesthetize. It has been demonstrated in numerous clinical
articles that mandibular blocks will only provide pulpal anesthesia in about one-half
of the cases that present with irreversible pulpitis, regardless of the type, dosage, or
time factor of the anesthetic. Therefore, if a patient presents with acute lingering pain

to a cold stimulus, there is approximately a 50% chance that any mandibular inferior
alveolar block will be unsuccessful.2 Recent studies pertaining to 4% articaine also
support this view.3
When surveyed, pain is the number-one reason that patients fear the words “root
canal.” Therefore, sedation should be considered to complement the endodontic pro-
cess. According to a survey presented in the Journal of Endodontics, fear of pain, the
level of anxiety, and cost were three major factors that influenced the demand for se-
dation. The findings demonstrated that the demand for sedation was high and many
patients would consider it if available.
Sedation should be used to increase patient safety, reduce patient anxiety and pain,
limit the patient’s memory of the procedure, and allow the provider to complete the
treatment. It is advisable to use sedation for endodontic care with patients with any
of the conditions listed in Fig 8-1.
History of high Prior jaw surgery Temporomandibular Tongue thrust

salivary flow joint issues
Developmental Inability to toler-

Bad gag reflex Claustrophobia
disabilities ate rubber dam
Limited High stress and

mouth opening anxiety levels
Fig 8-1 Sedation during endodontic treatment is recommended for patients with any of these conditions.
Proper Case Selection
Sedating patients with Parkinson disease

Parkinson disease can be categorized as both an indication and contraindication for
sedation. According to Little et al,5 Parkinson disease patients should be treated in
the morning session, about 2 to 3 hours after taking their medications. Airway pro-

tection, such as a dental dam, should be used given the impaired swallowing reflex-
es in this patient group. Sufficient suctioning behind the thin dental dam material
should be used so the practitioner can see the pooling of saliva through it. The dental
chair should not be reclined more than 45 degrees, and in advanced stages of the dis-
ease, the chair may need to be kept upright during treatment. Valium (Roche), Ativan
(Bausch Health), and Clozaril (HLS Therapeutics) may be used as sedation medi-
cations, but avoid using Haldol (Janssen) or Risperdal (Janssen). During late stages
of Parkinson, advanced motor, swallowing, drooling, and breathing difficulties are
sometimes contraindicated. If the Parkinson patient has an implanted brain stimula-
tor, the use of the electric surgery unit is another contraindication. No mention of the
implanted brain stimulator and the electric apex locator was found in the literature.
Sedating patients with other disorders

Asthma, pregnancy, obesity, visible short neck, sleep apnea, and chronic obstructive
pulmonary disease (COPD) are contraindications for the use of sedation during end-
odontic care. A patient with a large neck circumference is not an absolute contraindi-
cation; there must be at least 6 cm from the chin to the adam’s apple (ie, thyromental
distance). A deficient mandible is also a contraindication because the tongue can oc-
clude the airway. Obese patients could have fatty tissue distributed in their airway.
This can make airway management more difficult because the airway is more like-
ly to relax and collapse with some degree of sedation. Cornelius and Sakai report-
ed using inadvertent endobronchial intubation on a patient with COPD and a short
neck length.6
If a patient has sleep apnea, there remains a great possibility that the airway will
collapse. If coupled with having a large neck, it is hard to provide a chin lift or jaw
thrust, to perform mask ventilation, or to intubate the patient’s airway. One question-
naire for obstructive sleep apnea is STOP-BANG. This acronym represents the ques-
tions to ask patients when diagnosing sleep apnea (Fig 8-2). A 2014 article by Chung
et al7 stated that the STOP-BANG questionnaire had false positives. They further
concluded that high BMI and neck circumference together with a STOP-BANG score
of 2 were more predictive of sleep apnea.

Snoring
• Can someone hear the patient snoring from another room?
Tired
• Is the patient tired during the day?
Observed apnea
• Has another person observed the patient stop breathing?
Pressure
• Is the patient being treated for hypertension?
BMI
• Is the patient’s BMI over 35?
Age
• Is the patient older than 50 years?
Neck circumference
• Does the patient have a neck circumference greater than 40 cm?
Gender/sex
• What is the sex of the patient?
Fig 8-2 STOP-BANG questionnaire.
Additional considerations
The factors listed in Fig 8-3 should all be considered during case selection (though
this is not an exhaustive list). Practitioners will also need to assess the difficulty of
performing endodontic treatment. This includes considering clinical anatomy of the
tooth, the presence of any dilacerated roots, calcified canals, pulp stones, root curva-
ture, or whether there is an open apex in a pediatric case. It is also important to con-
sider the location of the tooth in the arch. Is it a third molar? Can it be clamped with a
limited jaw opening? Consideration must also be given regarding managing the case.

Patient’s past and present dental and medical history
Medications
Immune stamina
Patient’s physique
Past surgeries
Cardiac health (ie, presence of pacemakers or implantable cardio converter defibrillators)
Precautions with the electro surgery unit, electric apex locator, or ultrasonic endodontic instruments
Fig 8-3 Factors to consider for case selection.
Periodontal assessment is significant when treatment planning any root canal. This
includes the restorative assessment, whether it can be accessed through an existing
crown or bridge, or if the tooth can be isolated properly with a dental dam. Practi-
tioners must identify if there are any radiographic lesions present and their size. It is
also important to determine if an apicoectomy would be necessary in the future or
if it would it be better to perform it immediately following root canal treatment. It is
possible that a CBCT image could be needed, prior to beginning the case, to ascertain
the location of hidden canals. Identify any resorptive defects that will prevent the
practitioner from finishing the case, and determine how long it will take to complete
the case. The treatment plan will depend on whether the tooth is vital or nonvital.
Ultimately, a practitioner must decide if the case can be successfully completed in
one visit or if multiple visits over several months are necessary.
In October 2016, the American Association of Endodontists held a symposium that
dealt with this issue in a respectful debate. Current literature shows that there is no
difference in the healing of root canals when completed in either one or multiple vis-
its. In fact, a 2005 article by Sathorn et al concluded that single-visit root canal ther-
apy appeared to be slightly more effective than multiple visit treatment (ie, 6.3%).8
This reinforced the earlier works of both Weiger et al in 2000,9 and Mulhern et al,
who described no significant difference in the occurrence of pain between the two
groups.10 After case selection is completed, a preoperative physical examination of
the airway is conducted.

Endodontic Armamentarium
The endodontic armamentarium includes the following equipment: dental dam
(thinnest), frame and clamps for tooth isolation, dental floss, bite block, apex loca-
tor, and digital or conventional radiographs. The endodontic instrument tray should
include a #3 pedo-sized mirror, an endo ruler (either separate or attached to finger
holder with sponge), a #23 explorer, an endo explorer, college forceps, a periodon-
tal probe, and iris scissors. Hand files, rotary file system, ultrasonic handpiece, eth-
ylenediaminetetraacetic acid (EDTA) and irrigation solutions such as 5.25% sodium
hypochlorite (NaOCl) and 2% chlorhexidine digluconate (CHX), and safety glasses
should also be used.
The use of the dental dam is still necessary, even in sedation cases. According to
the American Association of Endodontists (AAE) position statement available at aae.
org, “tooth isolation using the dental dam is the standard of care; it is integral and
essential for any nonsurgical endodontic treatment.”11 In an article published in the
ADA News in 2015,12 past AAE President Dr Gerald Glickman stated the following
uses of the dental dam:
• Provides a clean operating field isolated from saliva, hemorrhage, and other
tissue fluids
• Reduction in risk of cross contamination of the root canal system
• Barrier to the potential spread of infectious agents
• Protection of soft tissues
• Improved visibility, providing a dry field, and reducing mirror fog
• Increased efficiency, minimizing patient conversation during treatment and the
need for frequent rinsing
Even so, we still see pictures of the lodging of an endodontic file in the esophago-
gastric junction or full aspiration into the bronchi. Therefore, the use of the dental
dam should not be a barrier to care either in cases utilizing sedation or not utiliz-
ing sedation.

Reliability of Electronic Apex Locators
As far back as 1996 with Shabahang et al,13 the apex locator has been shown to be 96%
accurate and within 0.5 mm of the apex. In 2011, Herrera et al14 showed that the apex
locator was accurate for an apical size of 0.6 mm, independent of the hand file size.
This study also showed that the accuracy of the electronic apex locator is gradually
lost as the foramen widens.
In 2016, Dadalti et al15 studied the effects of endodontic equipment and their re-
lationship in producing electromagnetic interference in cardiac patients. The rotary
motors, laser devices, optical microscope, gutta percha gun, and ultrasonic devic-
es produced no electromagnetic interference with any cardiovascular implantable
electronic devices (CIEDs) such as pacemakers (PMs) or implantable cardioverter
defibrillators (ICDs). However, the apex locator and the gutta percha heat carrier
produced electromagnetic interference that varied based on the type and sensitivity
of the CIED as well as the distance from the CIED to the actual equipment. The rec-
ommendation is for endodontists to turn off electronic devices that are not necessary
while treating patients who have CIEDs.
Prophylactic Antibiotics
Although antibiotic prophylaxis is often used by both general dentists and endo-
dontists prior to endodontic treatment, the literature does not support this practice.
Contardo et al16 concluded that well-instrumented and accurate endodontic treat-
ment was more important to guarantee reduction of postoperative flare-ups. In 2015,
Akbar17 concluded that root canal infections are treated by the mechanical debride-
ment of infected debris from canals and not from the administration of preoperative
antibiotics. In 2001, Pickenpaugh et al18 concluded that a prophylactic dose of amox-
icillin before endodontic treatment of asymptomatic necrotic teeth had no effect on
the endodontic flare-up. These studies reaffirmed previous studies from Walton and
Chiappinelli in 199319 and Fouad et al in 1996.20

Staff Training
Dental assistants should have current CPR (cardiopulmonary resuscitation) training,
but certification in advanced cardiac life support (ACLS) is desired. The utilization of
two assistants is warranted for the procedure: one for normal dental assistant duties
and another for record keeping, reviewing, and documenting the medical records.
They may also take preoperative blood pressure, take baseline temperature, attach
the pulse oximeter, be familiar with the use of capnography, and review the patient’s
medications. They should also be responsible for the care of the medical equipment
before and after the dental procedure.
Local Anesthetics
Local anesthetics should still be used on a patient who will be receiving sedation. As
previously discussed in this chapter, the presence of either extreme inflammation or
periapical infection can limit the ability of the local anesthetic to work to its fullest
potential, including 4% articaine. Goodis et al21 looked at lower pH and inflamed tis-
sues. Ueno et al22 identified inflammatory acidosis as a cause. Malamed23 suggested
buffering local anesthetics to aid in this dilemma. Preoperative oral administration
of a nonsteroidal analgesic, 800 mg ibuprofen, can help the efficacy of the local anes-
thetic in some cases.24
Proper Postoperative Care

Endodontic postoperative care is similar to most sedation postoperative care; the pa-
tient has a stable cardiovascular function and airway, the patient can talk and stand
without assistance, they are well hydrated, and they have an adult escort back to
their home who will stay with them. Patients will be told not to perform any strenu-
ous activities, drive a car, eat a heavy meal, or consume alcohol for at least 48 hours.
Additionally, the patient will be informed that they may experience some degree of
discomfort in the location of both the injection site and the tooth itself. Mild to mod-
erate postoperative discomfort is normal, but patients should be given the doctor’s
contact number in case of an emergency. Regular endodontic instructions such as not

chewing on the side of the root canal will aide in the healing process. Nonsteroidal
anti-inflammatory drugs (NSAIDs) are most useful in post endodontic situations.
Occasionally, a steroid dose pack would be prescribed for predicted additional post-
operative inflammation.
Conclusion
The management of endodontic emergencies remains a great challenge. It should be
accomplished with efficiency and profound pulpal anesthesia. Adding sedation to
the treatment process can enhance the overall patient experience. An AAE discus-
sion forum in February 2018 posted all positive notations from endodontists across
the country. Some believed that the use of a dental anesthesiologist made the seda-
tion deeper; therefore, the practitioner had a better time concentrating on the clinical
procedure itself. It is, however, highly recommended that endodontists contact their
specific state board of dentistry to understand requirements that may be different
from state to state. In addition, malpractice coverage may increase in cost due to this
added in-house patient benefit. While the benefits have been observed, practitioners
must assess the possible risk/benefit ratio in each case.
References
1. Hargreaves KM, Berman LH. Cohen’s Pathways of the Pulp, ed 11. St Louis: Elsevier, 2016.
2. Haas M. Managing endodontic emergencies. Dent Today 2017;36:80–85.
3. Claffey E, Reader A, Nusstein J, Beck M, Weaver J. Anesthetic efficacy of articaine for inferior
alveolar nerve blocks in patients with irreversible pulpitis. J Endod 2004;30:568–571.
4. Huh YK, Montagnese TA, Harding J, Aminoshariae A, Mickel A. Assessment of patients’
awareness and factors influencing patients’ demands for sedation in endodontics. J Endod
2015;41:182–189.
5. Little JW, Falace DA, Miller CS, Rhodus NL. Little and Falace’s Dental Management of the Medi-
cally Compromised Patient, ed 8. St Louis: Elsevier, 2013.
6. Cornelius B, Sakai T. Inadvertent endobronchial intubation in a patient with a short neck
length. Anesth Prog 2015;62:66–70.
7. Chung F, Yang Y, Brown R, Liao P. Alternative scoring models of STOP-bang question-
naire improve specificity to detect undiagnosed obstructive sleep apnea. J Clin Sleep Med
2014;10:951–958.

8. Sathorn C, Parashos P, Messer HH. Effectiveness of single- versus multiple-visit endodontic
treatment of teeth with apical periodontitis: A systematic review and meta-analysis. Int Endod J
2005;38:347–355.
9. Weiger R, Rosendahl R, Löst C. Influence of calcium hydroxide intracanal dressings on the prog-
nosis of teeth with endodontically induced periapical lesions. Int Endod J 2000;33:219–226.
10. Mulhern JM, Patterson SS, Newton CW, Ringel AM. Incidence of postoperative pain after
one-appointment endodontic treatment of asymptomatic pulpal necross in single-rooted
teeth. J Endod 1982;8:370–375.
11. American Association of Endodontists. Dental Dams: AAE Position Statement. https://www.aae.
org/specialty/wp-content/uploads/sites/2/2017/06/dentaldamstatement.pdf. Accessed 14
September 2022.
12. Manchir M. AAE reminder:Dental dams help ensure patient safety. ADA News 2015 May 18.
13. Shabahang S, Goon WW, Gluskin AH. An in vivo evaluation of Root ZX electronic apex locator. J
Endod 1996;22:616–618.
14. Herrera M, Ábalos C, Lucena C, Jiménez-Planas A, Llamas R. Critical diameter of apical foramen
and of file size using the Root ZX apex locator: An in vitro study. J Endod 2011;37:1306–1309.
15. Dadalti MT, da Cunha AJ, de Araújo MC, de Moraes LG, Risso Pde A. Electromagnetic inter-
ference of endodontic equipments with cardiovascular implantable electronic device. J Dent
2016;46:68–72.
16. Contardo L, Meneguzzi E, Cadenaro M, Di Lenarda R. Clinical evaluation of antibiotic prophylaxis
before endodontic treatment of necrotic teeth. Minerva Stomatol 2005;54:153–160.
17. Akbar I. Efficacy of prophylactic use of antibiotics to avoid flare up during root canal treatment
of nonvital teeth: A randomized clinical trial. J Clin Diagn Res 2015;9:ZC08–ZC11.
18. Pickenpaugh L, Reader A, Beck M, Meyers WJ, Peterson LJ. Effect of prophylactic amoxicillin on
endodontic flare-up in asymptomatic, necrotic teeth. J Endod 2001;27:53–56.
19. Walton RE, Chiappinelli J. Prophylactic penicillin: Effect on posttreatment symptoms following
root canal treatment of asymptomatic periapical pathosis. J Endod 1993;19:466–470.
20. Fouad AF, Rivera EM, Walton RE. Penicillin as a supplement in resolving the localized acute api-
cal abscess. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;81:590–595.
21. Goodis HE, Poon A, Hargreaves KM. Tissue pH and temperature regulate pulpal nociceptors. J
Dent Res 2006;85:1046–1049.
22. Ueno T, Tsuchiya H, Mizogami M, Takakura K. Local anesthetic failure associated with inflam-
mation: Verification of the acidosis mechanism and the hypothetic participation of inflammato-
ry peroxynitrite. J Inflamm Res 2008;1:41–48.
23. Malamed SF. Is the mandibular nerve block passé? J Am Dent Assoc 2011;142(suppl 3):3S–7S.
24. Ianiro SR, Jeansonne BG, McNeal SF, Eleazer PD. The effect of preoperative acetaminophen or a
combination of acetaminophen and Ibuprofen on the success of inferior alveolar nerve block for
teeth with irreversible pulpitis. J Endod 2007;33:11–14.

CHAPTER 9
Orthodontic Sedation
Jae Hyun Park, DMD, MSD, MS, PhD
Dawn P. Pruzansky, DMD
S
edation in orthodontics was first suggested in 1967 as an adjunct for the be-
haviorally challenged patient population.1 Although sedation is not routinely
used within the specialty, it is helpful in several clinical situations. Often, the
patients with the greatest need for orthodontics may be the most difficult to man-
age behaviorally due to developmental abnormalities or trauma. In addition, long
procedures such as exposures, extractions, and surgical repositioning are not well
tolerated if sedation is not used. There are three types of sedation methods applicable
to orthodontics depending on the procedure being performed: nitrous oxide, intra-
venous (IV) sedation, and general anesthesia (Table 9-1). Each of these modalities
has morbidities and contraindications that must be considered when the decision to
sedate is being made.
Table 9-1 Comparison of sedation modalities
Nitrous oxide IV sedation General anesthesia

Mode Inhalation IV IV or inhalation
Onset 3–5 min 20–25 sec < 1 min
Orthodontic Moderately apprehensive Special needs, exten- Special needs or extensive

indications patient able to understand sive treatment treatment in which IV seda-
and follow instructions tion is contraindicated; oral
maxillofacial surgery
Contraindications Acute otitis media, nasal ASA class III or IV may Medical condition resulting in
obstruction, pulmonary require consultation; high risk-benefit ratio
disease, maxillofacial defor- airway or pulmo-
mities (that prevent nasal nary disorders
hood placement)
ASA, American Society of Anesthesiologists.

Types of Sedation
Nitrous oxide (N2O) is a colorless, inert gas that is compressed in cylinders as a liq-
uid and vaporizes on release.2 It has a low solubility in blood, with rapid onset and
recovery time. N2O produces central nervous system (CNS) depression with limited
analgesia and no effect on airway reflexes. In addition, patients can still respond to
verbal commands. It is typically administered in concentrations between 20% and
50% with concomitant oxygen. Above 50%, patients may lose consciousness. There
are no recorded cases of serious morbidity, and nausea and vomiting are the most
common adverse effects reported with nitrous oxide sedation.3 In addition, ear pain
has been reported in patients with acute otitis media. Contraindications to nitrous
oxide include behavioral problems, claustrophobia, nasal hood placement restric-
tions, chronic obstructive pulmonary disease, and pregnancy. It should be noted that
N2O, given in conjunction with other medications, may have an additive effect, so all
drug interactions must be known and anticipated.
IV sedation is another technique for conscious sedation. With this method, also
referred to as moderate sedation, patients can still respond to verbal commands. Air-
way function is not impaired, so supplemental ventilation is not needed. In a study
by Karamnov and colleagues,4 adverse side effects were associated with age, body
mass index (BMI), comorbidities, and female sex. Airway disorders may also pre-
clude patients from receiving moderate sedation due to the instability of their airway.
The American Association of Oral and Maxillofacial Surgeons (AAOMS), the Amer-
ican Dental Association (ADA), and the American Academy of Pediatric Dentistry
(AAPD) have all developed sedation protocols outlining the technique and educa-
tional requirements to perform these procedures. With pediatric patients, IV sedation
most often involves a single drug (ie, a benzodiazepine), although a multiple-drug
method can be used in certain situations. Benzodiazepines have amnesic, hypnotic,
sedative, anxiolytic, and anticonvulsant properties.5 The onset of action is 20 to 25
seconds, making it easier to unintentionally render the patient unconscious. Midaz-
olam, a commonly used benzodiazepine, may produce hyperexcitability and further
anxiousness in children.5 In addition, benzodiazepines may cause respiratory depres-
sion, which can be significant in children with enlarged tonsils. When performing IV
sedation, an assistant must be designated to monitor vital signs. An automated mon-
itor should measure blood pressure at regular intervals, oxygen saturation, carbon

dioxide respiration, and electrocardiogram readings.6 Hematoma is a complication,
and venipuncture can be difficult in a small or uncooperative child.
General anesthesia (GA) is described as an irregular, reversible depression of the
higher centers of the CNS that makes the patient unconscious and insensible to pain.7
In addition to loss of consciousness, GA diminishes the ability of the patient to main-
tain their airway and protective reflexes, which makes alternative, less invasive tech-
niques more common. The most frequent use of GA in dentistry is within the scope of
oral and maxillofacial surgery.5 An advantage of GA is that patient cooperation is not
critical to the success of the procedure, since loss of consciousness occurs. An anes-
thesia team is required when performing GA, and a recovery area must be provided.
Contraindications to treatment are inadequate training by providers, inadequate fa-
cility or equipment, and American Society of Anesthesiologists (ASA) IV and certain
ASA III medically compromised patients.
Indications
According to the AAPD6:
Patients who are in ASA classes I and II are frequently considered to be ap-
propriate candidates for minimal, moderate, or deep sedation. Children in
ASA classes III and IV, children with special needs, and those with anatomi-
cal airway abnormalities or moderate to severe tonsillar hypertrophy present
issues that require additional and individual consideration, particularly for
moderate and deep sedation. Practitioners are encouraged to consult with
appropriate subspecialists and/or an anesthesiologist for patients at increased
risk of experiencing adverse sedation events because of their underlying med-
ical/surgical conditions.
Orthodontic treatment warranting sedation may include extractions, exposures of

impacted teeth, surgical procedures, and management of patients with behavioral is-
sues or disabilities. Several studies have compared the effectiveness of nitrous oxide
as an alternative to general anesthesia for orthodontic related extractions.8–11 The re-
sults indicate that nitrous oxide is a viable alternative with decreased morbidity and

facility cost. The studies reported longer procedures when using N2O over GA, but
shorter overall time due to decreased pre- and postoperative preparations.
Surgical procedures, such as orthognathic surgeries, are typically performed under
GA. For extensive procedures requiring a longer operating time, GA is still the seda-
tion method of choice. A study done in 2010 looked at surgically assisted rapid palatal
expansion (SARPE) performed with IV sedation and local anesthetic and found that
the procedure could be performed successfully with less morbidity than GA.12 There
were 283 patients treated successfully with this protocol. The author mentioned that
the protocol is technique sensitive and highly dependent on the skill of the surgeon.
Improvements in sedation techniques have greatly increased the number of chil-
dren with disabilities who can be treated orthodontically.13,14 These patients typically
have a greater need for orthodontics but may have a fear of dental treatment. Neg-
ative reactions to orthodontics and behavioral contraindications can be controlled
with the use of sedation techniques for longer procedures. It should be noted that
these patients must be able to tolerate regular adjustment appointments, since seda-
tion is not employed at every appointment. N2O is a useful adjunct due to its phar-
macokinetic and cardiovascular advantages, but it promotes limited anesthesia and
may cause nausea.5 GA is often used for patients with more behavior management
difficulties, but there are associated costs and complications with this modality.
IV sedation can be an alternative to GA with this patient population. Many stud-
ies have looked at the safety and efficacy of using IV sedation rather than GA.13,15,16
A study in 1992 by Barr and Wynn looked at the effects of IV ketamine and fentanyl
combined with N2O, administered in a private practice pediatric dental office.15 The
most common complication was vomiting. Chaushu et al13 treated ten consecutive
patients with this method using propofol, and successfully performed orthodontic
procedures including bracketing and extractions. Indirect bonding helped to min-
imize the procedure time and risk of inhaling loose brackets. Rubber dam may be
placed for bonding isolation if necessary. An oropharyngeal pack is necessary when
rubber dam cannot be placed when there is a risk for aspiration.
A retrospective study by Dorman and colleagues16 compared IV sedation to GA to
evaluate effectiveness and safety of this method as an adjunct to orthodontic proce-
dures. Cases included exposure of impacted teeth and extraction. In this study, IV
sedation offered effective pain and anxiety control, and procedures were completed
in 25 of the 28 cases. The authors suggest that GA may not be necessary to treat such

cases, and that IV sedation is a viable alternative. They also suggested further research
within the age group of 12- to 15-year old participants to strengthen the results.
A Cochrane review was attempted to compare the morbidity, effectiveness, and
cost analysis of sedation and GA in patients 18 years of age and younger.17 A litera-
ture review found no randomized controlled clinical trials (RCTs), and therefore no
conclusion was made. A similar topic was studied by Rastogi et al18 when comparing
sedation to general anesthesia in patients between the ages of 15 and 50 who required
maxillofacial surgery. In the sedation group, patient satisfaction increased, morbidity
decreased, and discharge time was sooner.
Most orthodontic procedures are performed on an outpatient basis, which reduces
the risk of infection associated with long hospital stays.19 A medical history, physical
examination, and certain lab tests are needed to determine if a patient is a candidate
for an outpatient procedure. Patients with potential airway complications or history
of chronic obstructive pulmonary disease or certain cardiovascular diseases may not
be eligible for outpatient surgery.19 Although a presurgical workup is required for
any patient receiving GA, patients with special needs may not have a presurgical
physical or laboratory test available. According to the ADA anesthesia guidelines,20 in
these cases, the dentist should clearly document the circumstances and reasons why
these tests are missing.
Other Considerations
Orthognathic surgery is considered a medical—not cosmetic—procedure and may be
partially covered by insurance. Pre- and postsurgical orthodontics fall under dental
coverage and are not considered to be a part of the surgical medical expense. Seda-
tion techniques used as an adjunct to orthodontics are not included in the orthodon-
tic fee, and any additional costs incurred should be discussed with the patient before
treatment begins.
Squires and colleagues21 compared the cost of IV sedation versus GA for endoscop-
ic procedures and found that the charges were 2.5 times greater with the GA proce-
dures. A study by Lee et al22 performed a cost analysis of general anesthesia versus
conscious sedation when treating pediatric dental patients. When plotting predicted
regression lines, they found a point at which the cost for conscious sedation would
surpass general anesthesia, when evaluating societal costs and relative values of cer-

tain procedures. Jameson et al23 found that conscious sedation techniques were asso-
ciated with lower costs than hospital-based GA procedures. It should be noted that
all of the studies mention that the type of treatment and overall health of the patient
must be considered when choosing sedation, and that cost may not be a primary se-
lection factor when there are other mitigating circumstances.
Complications
As with any surgery requiring some form of sedation, complications can occur. Pe-
diatric patient sedation requires extensive presurgical planning, surgical monitoring,
and postoperative care above what is normally performed with healthy adults. The
additive effects of multidrug sedations can lead to increased adverse outcomes and
inadvertent overdoses. Increasing liability costs for moderate sedation and general
anesthesia have led to a decrease in these procedures being performed routinely.24
The Pediatric Perioperative Cardiac Arrest Registry (POCA), open from 1994 to 2005,
collected information on cardiac arrests and deaths to investigate the relationship
of anesthesia to these incidents.25 In an article by Domino reviewing this registry,26
36% of the closed claims reported to the POCA before 2000 were from dental/ENT/
maxillofacial procedures, and incorrect dosing was a common cause of these cardio-
vascular events. A separate study by Lee and colleagues27 looked at trends in death
associated with pediatric dental sedation. They reviewed media reports of patients
under 21 years of age who died receiving anesthesia for dental procedures and found
that many of these deaths occurred among 2- to 5-year-old patients in an office set-
ting with a general or pediatric dentist.
Children younger than 6 years of age may be at greater risk of effects on airway, so
the AAPD recommends that other treatment modalities be attempted before the de-
cision is made to sedate.6 Because children may pass into a deeper level of sedation
than initially anticipated, it is required that all practitioners have the skills to man-
age the patient in at least one deeper level (ie, minimal, moderate, deep sedation, or
general anesthesia). It should be noted that children with developmental disabilities
have been shown to have a threefold increased incidence of desaturation compared
with children without developmental disabilities.6 Practitioners must have knowl-
edge of appropriate rescue techniques, monitoring equipment, and pharmacokinet-

ics and titration principles of all sedation agents being utilized. The lowest dose with
the highest therapeutic index should be selected to minimize risk.
Conclusion
With proper planning and communication between disciplines, sedation can be
a useful adjunct to orthodontic treatment. With any type of sedation selected, the
risk-to-benefit ratio must be carefully reviewed and potential complications thor-
oughly discussed. The type of sedation selected should be appropriate to the type
of procedure, patient health, cost, and associated risks. Incorporating sedation al-
lows orthodontists to treat patients who might otherwise receive insufficient or com-
promised care.
References
1. Jackson EF. Orthodontics and the retarded child. Am J Orthod 1967;53:596–605.
2. McDonald RE, Avery DR, Dean JA. Dentistry for the Child and Adolescent, ed 8. St Louis: Mosby, 2004.
3. Levering NJ, Welie JV. Current status of nitrous oxide as a behavior management practice rou-
tine in pediatric dentistry. J Dent Child (Chic) 2011;78:24–30.
4. Karamnov S, Sarkisian N, Grammer R, Gross WL, Urman RD. Analysis of adverse events as-
sociated with adult moderate procedural sedation outside the operating room. J Patient Saf
2017;13:111–121.
5. Malamed SF. Sedation: A Guide to Patient Management, ed 5. St. Louis: Mosby, 2010.
6. Coté CJ, Wilson S; American Academy of Pediatric Dentistry; American Academy of Pediatrics.
Guideliness for monitoring and management of pediatric patients before, during, and after se-
dation for diagnostic and therapeutic procedures. Pediatr Dent 2019;41:E26–E52.
7. Mosby’s Dental Dictionary, ed 2. St Louis: Mosby, 2008.
8. Shaw AJ, Meechan JG, Kilpatrick NM, Welbury RR. The use of inhalation sedation and local
anaesthesia instead of general anaesthesia for extractions and minor oral surgery in children: A
prospective study. Int J Paediatr Dent 1996;6:7–11.
9. Shepherd AR, Hill FJ. Orthodontic extractions: A comparative study of inhalation sedation and
general anaesthesia. Br Dent J 2000;188:329–331.
10. Galeotti A, Garret Bernardin A, D’Antò V, et al. Inhalation conscious sedation with nitrous
oxide and oxygen as alternative to general anesthesia in precooperative, fearful, and dis-
abled pediatric dental patients: A large survey on 688 working sessions. Biomed Res Int
2016;2016:7289310.

11. Lyratzopoulos G, Blain KM. Inhalation sedation with nitrous oxide as an alternative to dental
general anaesthesia for children. J Public Health Med 2003;25:303–312.
12. Hernandez-Alfaro F, Mareque Bueno J, Diaz A, Pagés CM. Minimally invasive surgically assisted
rapid palatal expansion with limited approach under sedation: A report of 283 consecutive cas-
es. J Oral Maxillofac Surg 2010;68:2154–2158.
13. Chaushu S, Gozal D, Becker A. Intravenous sedation: An adjunct to enable orthodontic treat-
ment for children with disabilities. Eur J Orthod 2002;24:81–89.
14. Rada R, Bakhsh HH, Evans C. Orthodontic care for the behavior-challenged special needs pa-
tient. Spec Care Dentist 2015;35:138–142.
15. Barr EB, Wynn RL. IV sedation in pediatric dentistry: An alternative to general anesthesia. Pediatr
Dent 1992;14:251–255.
16. Dorman ML, Wilson K, Stone K, Stassen LF. Is intravenous conscious sedation for surgical
orthodontics in children a viable alternative to general anaesthesia? A case review. Br Dent J
2007;202:E30.
17. Ashley PF, Williams CE, Moles DR, Parry J. Sedation versus general anaesthesia for provi-
sion of dental treatment to patients younger than 18 years. Cochrane Database Syst Rev
2015;2015:CD006334.
18. Rastogi A, Gyanesh P, Nisha S, Agarwal A, Mishra P, Tiwari AK. Comparison of general anaesthe-
sia versus regional anaesthesia with sedation in selected maxillofacial surgery: A randomized
controlled trial. J Craniomaxillofac Surg 2014;42:250–254.
19. Cangemi CF Jr. Administration of general anesthesia for outpatient orthognathic surgical proce-
dures. J Oral Maxillofac Surg 2011;69:798–807.
21. Squires RH Jr, Morriss F, Schluterman S, Drews B, Galyen L, Brown KO. Efficacy, safety, and cost
of intravenous sedation versus general anesthesia in children undergoing endoscopic proce-
dures. Gastrointest Endosc 1995;41:99–104.
22. Lee JY, Vann WF Jr, Roberts MW. A cost analysis of treating pediatric dental patients using gen-
eral anesthesia versus conscious sedation. Anesth Prog 2001;48:82–88 [erratum 2002;49(I):i].
23. Jameson K, Averley PA, Shackley P, Steele J. A comparison of the ‘cost per child treated’ at a
primary care-based sedation referral service, compared to a general anaesthetic in hospital. Br
Dent J 2007;203:E13.
24. Southerland JH, Brown LR. Conscious intravenous sedation in dentistry: A review of current
therapy. Dent Clin North Am 2016;60:309–346.
25. Bhananker SM, Ramamoorthy C, Geiduschek JM, et al. Anesthesia-related cardiac arrest
in children: Update from the Pediatric Perioperative Cardiac Arrest Registry. Anesth Analg
2007;105:344–350.

26. Domino K. Office-based anesthesia: Lessons learned from the closed claims project. Am Soc
Anesthesiol Newsletter 2001;65:9–11.
27. Lee HH, Milgrom P, Starks H, Burke W. Trends in death associated with pediatric dental sedation
and general anesthesia. Paediatr Anaesth 2013;23:741–746.

CHAPTER 10
Pediatric Dentistry and Se-

dation
Mana Saraghi, DMD
O
ffice-based sedation and anesthesia is a critical component of the modern pe-
diatric dental practice. This is especially true for the management of special
populations, including patients with cognitive impairments, developmental
delay, precooperative age, and other conditions that limit the effectiveness of behav-
ior management techniques. Some pediatric dentists provide minimal or moderate
sedation while simultaneously performing dentistry. This practice has been the cor-
nerstone of pediatric dental practice for generations.
The use of a dentist anesthesiologist appears to be an emerging trend in the pedi-
atric dental practice. Dental anesthesiologist provide a broader range of anesthesia
services, ranging from moderate sedation to general anesthesia. The demand for pe-
diatric sedation is increasing due to a growing population. The American Dental As-
sociation (ADA) recommends the use of the American Academy of Pediatrics and the
American Academy of Pediatric Dentists Guidelines for patients under 12 years old.1
In the pediatric population, there is no level 1 evidence supporting sedation over
general anesthesia. However, sedation can avoid the requirement for a general an-
esthetic, which is beneficial. In pediatric sedation, it is recommended that only ASA
class I patients are sedated outside a hospital environment (Table 10-1). Pediatric
dentists who utilize sedation are required to be adequately trained.1

Table 10-1 ASA pediatric physical status classification
ASA
classification Definition Pediatric examples (nonexhaustive list)
ASA I A normal Healthy (no acute or chronic disease), normal BMI per-
healthy patient centile for age
ASA II A patient with mild Asymptomatic congenital cardiac disease, well-controlled dys-
systemic disease rhythmias, asthma without exacerbation, well-controlled epilepsy,
non-insulin-dependent diabetes mellitus, abnormal BMI percentile
for age, mild/moderate OSA, oncologic state in remission, autism
with mild limitations
ASA III A patient with severe Uncorrected stable congenital cardiac abnormality, asthma with
systemic disease exacerbation, poorly controlled epilepsy, insulin-dependent diabe-
tes mellitus, morbid obesity, malnutrition, severe OSA, oncologic
state, renal failure, muscular dystrophy, cystic fibrosis, history of
organ transplantation, brain/spinal cord malformation, symptom-
atic hydrocephalus, premature infant PCA < 60 weeks, autism with
severe limitations, metabolic disease, difficult airway, long term
parenteral nutrition, full-term infants < 6 weeks of age.
ASA IV A patient with severe Symptomatic congenital cardiac abnormality, congestive heart
systemic disease failure, active sequelae of prematurity, acute hypoxic-ischemic
that is a constant encephalopathy, shock, sepsis, disseminated intravascular coag-
threat to life ulation, automatic implantable cardioverter-defibrillator, ventilator
dependence, endocrinopathy, severe trauma, severe respiratory
distress, advanced oncologic state.
ASA V A moribund patient Massive trauma, intracranial hemorrhage with mass effect, patient
who is not expected requiring ECMO, respiratory failure or arrest, malignant hyperten-
to survive without sion, decompensated congestive heart failure, hepatic encepha-
the operation lopathy, ischemic bowel or multiple organ/system dysfunction.
BMI, body mass index; OSA, obstructive sleep apnea; PCA, postconceptual age; ECMO, extracorporeal membrane oxygenation.
Pediatric Patients Versus Adult Patients

The physiologic and legal differences between adults and minors are not very well
aligned. For example, a 17-year-old is legally a pediatric patient, but they are more
like an adult in terms of their anesthetic management and physiologic status. In this
chapter, we will limit our discussion of pediatric sedation to patients between 3 and
12 years of age.
There are similarities between anesthesia for adults and children: a need for prean-
esthetic evaluation, adherence to NPO (nothing by mouth) guidelines, and compe-
tent monitoring, to name a few. Commonalities are discussed elsewhere in this text
and will not be reviewed in this chapter. This chapter focuses on the differences be-
tween adults and children that must be considered when developing an anesthetic
plan because, for pediatric patients, these differences mean that the risk of airway

obstruction is higher, deterioration is more rapid, and resuscitation is mired in extra
challenges.
Anatomical differences
Pediatric anatomy is different from adult anatomy. This may increase obstruction
and produce difficulty in manual ventilation. Pediatric patients have larger occiputs,
relatively larger tongues, and larger tonsils and adenoids. It is therefore necessary
that anesthesiology providers be competent in manual ventilation, chin lift, and jaw
thrust techniques. Additionally, one should be familiar with and prepare oropha-
ryngeal and nasopharyngeal airways, supraglottic airway devices, bag valve masks,
administration of supplemental oxygen, and equipment for intubation in the event
the patient is difficult to ventilate or unable to be ventilated.2
Pediatric anatomical differences may also complicate intubation. The glottic open-
ing is in a more cephalad and anterior position relative to adult anatomy. The epiglot-
tis is longer, floppier, and U-shaped. The epiglottis is directed more posteriorly, and
the vocal cords are not oriented at a right angle to the trachea; the anterior aspect of
the cords is more inferior, and the posterior aspect is more superior. These anatomical
differences increase the difficulty of visualizing the rima glottidis during laryngosco-
py and increase the difficulty of endotracheal intubation. The cricoid is the narrowest
part of the airway, and the airway in general is smaller than in adults. These parts of
the airway do not mature until around age 12 years. Therefore, airway trauma that
results in edema will result in greater obstruction of the airway in a child. For this
reason, the anesthesia provider must be skilled in airway management and should
prepare for difficult intubation by having such instruments as a laryngoscope with
Macintosh and Miller blades, appropriately sized endotracheal tubes, a video-assist-
ed laryngoscope, a bougie catheter, and a supraglottic airway.3–6
Anatomical differences can pose respiratory challenges, too. Pediatric patients’ ribs
are more horizontally oriented, and this limits tidal volume increases. Their lungs are
more compliant, and the functional residual capacity (FRC) is lower. Also, without
positive end expiratory pressure (PEEP), some of the alveoli will undergo atelectasis
during sedation. Additionally, until 8 years of age, the lungs are not fully populated
with alveoli. The reduced FRC and lower number of alveoli clinically correspond to
rapid desaturation during apneic periods.4,7

Differences in pediatric physiology also pose a challenge in pediatric sedation.
Pediatric patients have a higher oxygen demand: 5-year-olds use 4mL/kg/min of
oxygen while adults use 3 mL/kg/min. Furthermore, the heart rate of a 5-year-old
averages 90 beats per minute (bpm) compared to an adult’s 80 bpm. These increased
demands quickly deplete oxygen reserves during periods of apnea.5,6,8,9
Behavioral differences
Younger children present behavioral challenges for the dental team. Many of the be-
havioral issues can be managed with outstanding communication and empathy for
the patient’s situation. The dental team should have a positive approach with the pe-
diatric patient to assist in managing behaviors. Still, many pediatric patients will not
cooperate with the team for routine dental procedures. Therefore, there is the need
for approaches to manage behavior that may include pharmaceutical interventions.
Options for pediatric sedation include the use of nitrous oxide-oxygen (N2O-O2)
analgesia, sedatives, or a combination of sedatives and N2O-O2. The majority of chil-
dren sedated for restorative dental procedures are managed well with nitrous oxide
due to its properties (eg, onset of mild sedation, mild analgesia, ease of administra-
tion and titration, and control of the depth of sedation) and ease of use.
Managing Disruptive Behavior

A child’s age and cognitive development may help the practitioner predict the like-
lihood of disruptive behavior associated with dental treatment. Children who are
3 years old or younger may be expected to have short attention spans, be fearful of
strangers, and/or lack sufficient language or cognitive skills, and they may be diffi-
cult to manage in the dental setting. School-age children, due to emotional growth
and cognitive skills, may show less disruptive behavior.10
Anxiety and fear are often related to disruptive and uncooperative behaviors in
the dental environment. Anxiety and fear cause many varied emotional behaviors.
Parental management style may also be a factor associated with disruptive behavior
in the dental setting. Pediatric dentists are reporting that today’s children are less
cooperative, cry more, and are more disruptive in response to normal guidance tech-
niques than children of a decade or more ago.2 While parents are usually a beneficial

source of knowledge regarding their children and may have invaluable insights re-
garding the child’s typical responses to treatment, parents can become an obstacle to
the smooth delivery of dental care to their children.
In recent years, so-called “helicopter parents” have become common among pro-
fessionals who care for children.11 The term describes parents who become highly
attentive to the child during these procedures, remain physically close to the child
during these professional interactions, and intercede by delaying or stopping a pro-
cedure when the child becomes upset; they may even become overly belligerent to
the dental staff. The child’s behavior will ultimately dictate how the child is managed
in the dental setting and if the choice to use sedation is made. Temperament, age and
cognitive development, fears and anxieties, family relations, and past dental experi-
ences are important in understanding how a child responds to dental treatment and
the dental setting.
Challenges and Complications with Pediatric

Sedation
Pediatric sedation is further complicated by the increased reactivity of the vocal cord.
This results in higher laryngospasm rates in children. Dentistry carries a particularly
high risk for the moderately sedated patient without a secured airway because the
surgical space is in the airway, so stimuli such as saliva, water, blood, tooth debris,
and dust are abundant.12,13
Anesthesia is often compared to flight to illustrate that the most dangerous mo-
ments are at the beginning (induction or takeoff) and end (emergence and landing).
This is only true for intubated cases. When a sedated patient with an open airway is
undergoing a surgery in the airway, the surgical time is the most dangerous time—for
the reasons listed above. Practitioners must also be mindful of pediatric pharmaco-
kinetics. Pediatric patients have a higher surface-area-to-volume ratio, a higher vol-
ume of distribution, and a shorter time to circulate their blood volume than adults.
Therefore, pediatric patients require relatively higher doses and will experience the
effects more quickly.

Sedation Agents and Administration Methods
Sedation agents for children can be delivered by several routes of administration,
each with benefits and risks. N2O-O2 (see chapter 6) is an inhalation agent that is the
primary and safest sedation technique for children. The beneficial properties include
ease of use, onset of mild sedation, mild analgesia, ease of administration and titra-
tion, and control of depth of sedation. However, it has limitations in terms of potency
and patient acceptance. Oral sedatives (often added to N2O-O2) are well tolerated
and accepted by both children and their parents.10
Non-IV routes (eg, oral, rectal) are generally well accepted by children and parents,
but they have significant limitations, specifically due to the lack of titration of the
drug. IV sedation has a higher and more consistent rate of success than other routes
of administration. Practitioners who choose to utilize this route of administration
must have a broader scope of special training for managing any adverse events.
The medications used for pediatric anesthesia are, by and large, the same used for
adults, but dosages must be calculated based on patient weight. Table 10-2 shows
a few common medications and their weight-based dose calculations for PO, intra-
muscular (IM), and IV administration routes.14
Table 10-2 Common medications used in pediatric sedation
PO IM IV
Midazolam 0.25–1.0 mg/kg 0.1–0.15 mg/kg 0.05–0.1 mg/kg
Max: 20 mg Max: 0.5 mg/kg Max: 0.6 mg/kg
Diphenhydramine
Up to 20-kg patient 6.25 mg 6.25 mg 0.1–1.0 mg/kg
Max: 37.5 mg/day Max: 37.5 mg/day Max: 37.5 mg/day
From 20 to 50 kg 12.5–25.0 mg 12.5–25.0 mg 12.5–25.0 mg

Max: 50-mg dose Max: 50-mg dose Max: 50-mg dose
Over 50 kg 25–50 mg 25–50 mg 25–50 mg
Max: 50-mg dose Max: 50-mg dose Max: 50-mg dose
Fentanyl 1–2 mcg/kg
Propofol 2.5–4.0 mg/kg
Ketamine 3–6 mg/kg 1–3 mg/kg 1–2 mg/kg
Glycopyrrolate 40–100 mcg/kg 4–10 mcg/kg 4–10 mcg/kg

*Drug calculations retrieved from Epocrates.14

Conclusion
In conclusion, there are many differences between adults and pediatric patients. Ad-
ditionally, the depth of sedation required to atraumatically provide dentistry is often
deep for pediatric patients. Regardless of these differences, sedation is exceedingly
safe if a proficient provider complies with the perioperative guidelines established by
the American Academy of Pediatric Dentistry and the American Dental Association.
References
1. Gonzalez LP, Pignaton W, Kusano PS, Módolo NSP, Braz JRC, Braz LG. Anesthesia-related mor-
tality in pediatric patients: A systematic review. Clinics (Sao Paulo) 2012;67:381–387.
2. Rollert M, Rosenberg M. Anesthetic considerations for pediatric patients. In: Bosack RC, Lieblich
S (eds). Anesthesia Complications in the Dental Office. Hoboken, NJ: Wiley, 2015:93–96.
3. Rosenberg MB, Phero JC. Pediatric considerations. In: Bennett JD, Rosenberg MB (eds). Medi-
cal Emergencies in Dentistry. Philadelphia: Saunders, 2001.
4. Rosenberg MB, Phero JC. Resuscitation of the pediatric patient. Dent Clin North Am
1995;39:663–676.
5. Harless J, Ramaiah R, Bhananker SM. Pediatric airway management. Int J Crit Illn Inj Sci 2014;
4:65–70.
6. Abramson Z, Susarla S, Troulis M, Kaban L. Age-related changes of the upper airway assessed
by 3-dimensional computed tomography. J Craniofac Surg 2009;20(Suppl 1):657–663.
7. Bryan AC, Wohl MEB. Respiratory mechanics in children. In: Macklem PT, Mead J (eds). Hand-
book of Physiology, The Respiratory System, Vol I. Bethesda, MD: American Physiological Soci-
ety, 1986:179–191.
8. Sims C, von Ungern-Sternberg BS. The normal and the challenging pediatric airway. Paediatr
Anaesth 2012;22:521–526.
9. Lopez-Gil M, Brimacombe J, Alvarez M. Safety and efficacy of the laryngeal mask airway. A pro-
spective survey of 1400 children. Anaesthesia 1996;51:969–972.
10. Rosenberg MB, Norris L. Oral Midzolam Syrup as a safe sedative drug for pediatric dentistry.
Dental News 2000;7:69–71.
11. Cassamassimo PS, Wilson S, Gross L. Effects of changing U.S. parenting styles on dental prac-
tice: Perceptions of diplomates of the American Board of Pediatric Dentistry presented to the
College of Diplomates of the American Board of Pediatric Dentistry 16th Annual Session. Atlan-
ta, Ga, Saturday, May 26, 2001. Pediatr Dent 2002;24:8–22.

12. Heinrich S, Birkholz T, Ihmsen H, Irouschek A, Ackermann A, Schmidt J. Incidence and pre-
dictors of difficult laryngoscopy in 11,219 pediatric anesthesia procedures. Paediatr Anaesth
2012;22:729–736.
13. Gavel G, Walker RWM. Laryngospasm in anaesthesia. Contin Educ Anaesth Crit Care Pain
2014;14:47–51.
14. Epocrates. https://online.epocrates.com/. Accessed 15 Sep 2022.

SECTION III
OTHER CONSIDERATIONS

CHAPTER 11
Special Needs Dental Pa-

tients
David J. Miller, DDS
Mana Saraghi, DMD
S
pecial needs patients often require sedation to facilitate dental treatment. Pa-
tients may present with behavioral or developmental issues that barely affect
the anesthetic plan, or they may present with a syndrome associated with a
constellation of comorbidities. In this chapter, we discuss the major organ groups
that may be affected in patients with commonly encountered special needs, and we
discuss anesthetic management for several syndromes and conditions in detail.
Each organ system affected must be well understood, and the anesthetic implica-
tions of each condition must be well researched. The required depth of information is
too immense for this chapter, but a systematic approach to preoperative assessment
is beneficial. See the suggestion in Fig 11-1 as one possible approach.

Clinical overview of condition
• Neurologic manifestations and considerations
• Head, neck, and airway issues
• Cardiovascular manifestations and considerations
• Respiratory manifestations and considerations
• Gastrointestinal manifestations and considerations
• Musculoskeletal abnormalities
• Endocrinologic and immunologic manifestations and
considerations
• Hepatic and nephrologic manifestations and considerations
Plans
•
• Preoperative plan
• Perioperative plan
• Postanesthesia plan
Fig 11-1 Systematic approach to preoperative assessment
A thorough presedation consultation is advised to prepare the patient for the se-
dation appointment. As an example, for patients with cardiac issues, a thorough un-
derstanding of the indications for electrocardiogram (ECG) and echocardiogram and
their interpretation is essential.
Down Syndrome
Down syndrome (DS) is the most common chromosomal abnormality. The Centers
for Disease Control and Prevention (CDC) estimates that DS affects 1 in every 700
live births in the United States, and the World Health Organization (WHO) estimates
that DS affects 1 in every 1,000 live births worldwide.1–3 DS is the most common ge-
netic cause of intellectual disability; it affects between 250,000 and 350,000 people in
the United States.
Clinical overview
DS patients can present with hypotonia, oblique palpebral fissures (the opening be-
tween the eyelids), flat faces, epicanthal folds (the inner fold of the upper eyelid folds
toward the nose), hyperflexible joints, a single crease through the palm of the hand,

and dysplastic middle phalanx of the fifth digit (a missing middle joint in the pinky
finger).4,5
Approximately 50% of patients will present with a cardiac defect. The most com-
mon defects are ventricular septal defect and endocardial cushion defect (the cush-
ions develop into the septum and mitral and tricuspid valves). It is estimated that
10% to 30% of DS patients will have atlantoaxial instability (AAI). Patients will pres-
ent with varying levels of mental impairment.6
Neurologic
• Manifestation: Mental impairment
• Consideration: Prepare for possible intramuscular (IM) sedation to facilitate
phlebotomy.
‒ Ketamine should only be used by providers experienced and comfortable with
breaking laryngospasm, as ketamine increases the spasticity of the vocal cords
and increases salivation, a laryngospasm stimulant.
Head, neck, and airway issues
• Manifestation: Abnormalities of head and neck anatomy
• Consideration: Potentially difficult mask ventilation
‒ Reasons for increased mask ventilation difficulty include increased risk of ob-
structive sleep apnea, abnormal dentition, low Mallampati score, microcephaly
and macroglossia, large tonsils and adenoids.
‒ Anticipate oral pharyngeal airway placement with tongue blade. Prepare equip-
ment for airway management such as a supraglottic device (eg, laryngeal mask
airway (LMA), video-assisted laryngoscope, laryngoscope with Macintosh and
Miller blades, and bougie).
• Manifestation: Laryngeal stenosis
• Consideration: Decrease endotracheal tube (ETT) by 0.5-mm internal diameter
‒ These airway abnormalities do not increase the difficulty of intubation.
Cardiovascular
• Manifestation: 50% of DS patients have septal and/or valve defects
• Considerations: Order cardiology consult, ECG, and echocardiogram when indicated
‒ Consult American Heart Association (AHA) endocarditis prophylaxis guidelines.

Respiratory
• Manifestation: Recurrent bronchitis or pneumonia
• Consideration: Order pulmonology consult when indicated
• Manifestation: Sleep-disordered breathing
• Consideration: Order polysomnogram (PSG; sleep study) when indicated
• Manifestation: Laryngomalacia, tracheobronchomalacia, tracheal bronchus, and
subpleural cysts
• Consideration: Order a pulmonology consult and chest x-ray when indicated
• Manifestation: Pulmonary hypertension
• Consideration: Avoid nitrous oxide, prevent systemic hypotension, prevent acute
right pulmonary arterial pressure
• Manifestations: Subglottic stenosis
• Consideration: Decrease ETT size by 0.5 mm
Gastrointestinal
• Manifestation: Constipation
• Consideration: Prepare for residual gastric content greater than 25 mL despite ad-
herence to NPO (nothing by mouth) guidelines; prepare to manage aspiration
Musculoskeletal
• Manifestation: AAI is observed in 10% to 30% of DS patients and may allow C1 to
C2 subluxation and spinal cord damage.
• Consideration: Limit manipulation of the head into sniffing position. A distance
greater than 4.5 mm between C1 and C2 and laxity in other joints of the body are
associated with AAI. Consider ordering a CT scan. These manifestations increase
the difficulty of intubation.
• Manifestation: Wide hands with short fingers, single creases in the palms, dysplas-
tic middle phalanx of the fifth digit, oblique palpebral fissures, epicanthal folds.
• Consideration: Do not change anesthetic plan.
• Manifestation: Physical development is often slower than in a normal adult.
• Consideration: Judge appropriateness of in-office sedation based on size, not age.

Endocrinologic/immunologic
• Manifestation: Obesity
• Consideration: Obesity is a restrictive lung disease. Prepare for rapid desaturation.
‒ Adipose tissue releases leptin, an airway irritant. Prepare to manage airway com-
plications such as coughing, laryngospasm, and bronchospasm. 90% of obese
patients have gastroparesis to the point where gastric contents remain in the
stomach despite adherence to NPO guidelines. Prepare to manage aspiration.
• Manifestation: Gastroesophageal reflux disease (GERD)
• Consideration: Adhere to NPO guidelines. Prepare to manage regurgitation and
aspiration.
• Manifestation: Hypothyroidism
• Consideration: Patients may present with symptoms of fatigue, irritability, slug-
gishness, and weight gain. The airway may be difficult to manage due to goiter,
anterior mediastinal mass, or recurrent laryngeal nerve involvement. For anesthet-
ic planning, expect the minimum alveolar concentration (MAC) to be lower, emer-
gence to be longer, and the sensitivity to paralytics to be greater. Patients with hy-
pothyroidism are at increased risk for the following:
‒ Aspiration
‒ Congestive heart failure
‒ Low cardiac contractility and rate
‒ Hypoventilation
‒ Hyponatremia
‒ Hypoglycemia
‒ Adrenal insufficiency, also known as lack of cortisol production
‒ Hypothermia
‒ Myxedema coma (life-threatening form of hypothyroidism [mortality > 50%]
precipitated by stress)
• Exaggerated features of hypothyroidism include the following:
‒ Decreased level of consciousness
‒ Risk of aspiration
‒ Increased sensitivity to neuromuscular blockers and sedatives

‒ Decreased cardiac output/heart rate, congestive heart failure, pulmonary edema
‒ Respiratory depression
‒ Hypothermia
‒ Metabolic: SIADH (syndrome of inappropriate antidiuretic hormone secretion),
hypoglycemia, adrenal suppression
‒ High risk for delayed emergence and the need for postoperative ventilation
Hepatic/nephrologic
• Manifestation: Liver disease
• Consideration: Generally severe, often fatal before the age of sedation discussed in
this chapter. If liver condition persists at age 3 years, then obtain consult and pre-
pare accordingly.
Planning
Preoperative plan
Along with the preoperative guidelines in this text, also evaluate the DS patient for
cord compression, abnormalities in range of motion in the neck, and lax joints, as
this is positively associated with increased risk for atlantoaxial dislocation.7–9 Include
cervical spine radiography and evaluation by a radiologist in the preoperative eval-
uation. Include ECG and echocardiogram in the workup.
Perioperative plan
Anticipate poor cooperativity during phlebotomy. If cervical spine radiography sug-
gests and/or clinical demonstration reveals antlantoaxial instability, consider utiliz-
ing a cervical collar. Be mindful of positioning DS patients because their joint laxity
lends itself to dislocation, especially in the hips. Expert skill is required for laryngos-
copy to not hyperextend the cervical spine and to navigate malpositioned teeth and
large tongue. If the patient is difficult to ventilate, consider awake extubation.
Postanesthesia plan
Be aware that sedation carries a great risk of upper airway obstruction in DS patients
if evaluation shows them to be positive for obesity, obstructive sleep apnea, and/or
macroglossia. Patients that cannot comply with PO medications may be provided

nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen by other routes
while sedated (eg, intravenously or rectally).
Autism Spectrum Disorder

Autism spectrum disorder (ASD) affects 1 in 68 American children, and it is the fast-
est-growing serious developmental disability in the United States.10 The WHO esti-
mates that 1 in 160 children are affected worldwide.11 As of 2013, the DSM-5 (Diagnos-
tic and Statistical Manual of Mental Disorders, Fifth Edition) includes autistic disorder,
childhood disintegrative disorder, pervasive developmental disorder not otherwise
specified, and Asperger syndrome as ASD.12
Clinical overview
Patients will present with a constellation of behavioral disorders. Some or all of the
following behaviors may be observed: impaired learning, impaired social skills, un-
derdeveloped communication skills, repetitive behaviors, inability to make eye con-
tact, inability to understand others’ feelings, physical aggressiveness, self-destructive
behavior, and tantrums when provoked.13,14 ASD may have overlap with an addition-
al disorder such as fragile X syndrome, Tourette syndrome, phenylketonuria, tuber-
ous sclerosis, or DiGeorge syndrome.
Neurologic
• Manifestation: Mental impairment
• Consideration: Prepare for possible IM sedation to facilitate phlebotomy
breaking laryngospasm as this drug increases the spasticity of the vocal cords
‒ Communication with staff and the family is paramount: Understanding and
agreement on behavioral management techniques ranging from distraction to
physical restraint should be discussed preoperatively.
• Manifestation: None
• Consideration: Prepare as usual

Cardiovascular
Respiratory
Gastrointestinal
• Manifestation: Malabsorption, maldigestion, irritable bowel syndrome, celiac dis-
ease, food allergies, and malnutrition may be associated with ASD.
• Consideration: Identify if your ASD patient also suffers from these associated co-
morbidities, and include them in preparation if so.
Musculoskeletal
• Manifestation: Poor motor control
• Consideration: Prepare to aid in ambulation and patient transport
• Manifestation: 28% higher risk of autoimmune disorder in ASD patients.
• Consideration: Conduct thorough preoperative evaluation and include manage-
ment for associated comorbidities.
• Manifestation: ASD patients may have increased risk of hypothyroidism.
• Consideration: Steroid administration may be warranted if adrenal derangement
accompanies hypothyroidism.
Hepatic/nephrologic
Planning
Preoperative plan
Along with the preoperative guidelines in this text, also evaluate the ASD patient for
associated disorders such as seizures (30% of individuals with ASD), mitochondrial

disorders (7% of individuals with ASD), homocystinuria (part of the 10%–20% of
inherited metabolic diseases found in ASD patients), and comorbidities related to
associated syndromes.15,16 If intellectual, social, and behavioral disorders are not ac-
companied by other comorbidities, then preoperative sedation may be the only con-
sideration different from a routine sedation/anesthesia plan. Discuss the higher rate
of oral conscious sedation and IV sedation failure with caregivers. Many autistic pa-
tients require general anesthesia to overcome their anxiety and inability to cooperate.
Perioperative plan
Prepare normally.
Postanesthesia plan
Be aware that loud, crowded, new environments can cause distress in any patient,
and these are significant stressors for ASD patients. The more calm, isolated, and fa-
miliar the location, the better ASD patients will tolerate the experience.
Seizure Disorders
Epilepsy has a prevalence of 0.5% to 1.2% of the population and is a common seri-
ous neurologic disorder. Approximately 3.4 million people are affected in the United
States, and 50 million people are affected worldwide.17,18 Those at the extremes of age
and those with structural or developmental brain abnormalities are the most at risk.
A patient with a seizure disorder may suffer from seizures independently, or the
seizure may be accompanied by an array of comorbidities. There are also different
seizure classifications. Some of the signs and symptoms of various seizure types are
listed below.19
Types of seizures
Simple partial seizures
• Alternating contraction and relaxation of muscle groups
• Eye movements and turning of the head to the same side
• Asymmetrical posturing of the limbs
• Speech arrest, vocalization

• Hallucinations
• Aural disturbances
• Olfactory disturbances
• Emotional disturbance
• Dizziness
• Flushing
• Incontinence
• Nausea
• Piloerection (goose bumps)
• Diaphoresis
• Tachycardia
• Time distortion
• No loss of consciousness
Complex partial seizures
• Loss of consciousness
• Falls
• Chewing and drooling
• Facial contortion
• Repetitive hand gestures
• Repeated phrases or swearing
Tonic-clonic seizures
• Loss of consciousness
• Falls
• Yelling
• Extension of arms, legs, and/or face
• Clenching of fingers and jaw
• Hypertension
• Tachycardia
• Diaphoresis

• Apnea
Absence seizures
• Lip licking
• Grimacing
• Blank staring
• Lack of awareness
• Loss of memory
• Confusion
Myoclonic seizure
• Rapid brief muscle contraction
• Falls
Clinical overview
Neurologic
• Manifestation: Improper electrical impulses are the etiology of seizures. Hypoxia,
stress, infection, and hypoglycemia can cause seizures.
• Consideration: Minimize stress with sedation; provide supplemental oxygen to
avoid hypoxia; check blood sugar “fingerstick,” and address any hypoglycemia
with 50% dextrose (D50); treat infection (if dental etiology).
• Manifestation: Falls and flailing may result in head injury.
• Consideration: Prepare to treat lacerations; prepare to position and transport posi-
tion in manner that lowers the risk of falling.
Cardiovascular
Respiratory
• Manifestation: Seizures may depress or obliterate the respiratory drive in the
postictal state.

• Consideration: Be prepared to manage the airway and provide positive pressure
ventilation.
Gastrointestinal
• Manifestation: Borborygmi (ie, rumbling noises due to gas in the intestines)
Musculoskeletal
• Manifestation: Prone to falls.
• Consideration: See above.
• Manifestation: Once anesthetized, none.
• Consideration: Prepare as usual; succinylcholine is appropriate for seizure patients
when the need arises.
Hepatic/nephrologic
• Manifestation: Antiepileptic drugs (AEDs) that induce hepatic enzyme p450 result
in other medications being more rapidly metabolized by this enzyme. AEDs that
induce p450 include the following:
‒ Carbamazepine
‒ Phenytoin
‒ Phenobarbital
‒ Primidone
‒ Oxcarbazepine
‒ Eslicarbazepine
‒ Topiramate
• Consideration: Review pharmacodynamics and pharmacokinetics of intended
medications.
• Manifestation: AEDs that inhibit hepatic enzyme p450 result in other medications
being more abundant in the bloodstream than anticipated due to reduced metabo-
lism. The most common AED that inhibits p450 is valproic acid.

• Consideration: Review pharmacodynamics and pharmacokinetics of intended
medications.
Planning
Preoperative plan
Antibiotics can have adverse reactions with AEDs. Macrolides such as erythromycin
inhibit CYP3A4 and interfere with the breakdown of carbamazepine.20,21 Carbapen-
em antibiotics can lead to significant decreases in valproate concentrations if used
concomitantly. AEDs should be taken regularly and the regimen unchanged for the
dental surgery.
The patient or caretaker should be interviewed regarding the seizure history, the
frequency of seizures, and the date of the most recent seizure. Lab tests to determine
the therapeutic levels of AEDs such as carbamazepine, valproic acid, and phenytoin
should be obtained. However, it is important to note that some patients may require
supratherapeutic levels to control seizures, while others may be seizure free at sub-
therapeutic AED blood levels. Ultimately, the treating neurologist should be consult-
ed to assess whether the drug regimen has been optimized.
Perioperative plan
Be aware that propofol administration may result in muscle twitching and hiccups.
This is not a seizure. In a patient who is already paralyzed, intubated, and under gen-
eral anesthesia, unexpected and unexplained changes in blood pressure and/or heart
rate should raise the anesthesia provider’s suspicion of an intraoperative seizure.
Avoid medications that may lower the seizure threshold, such as nitrous oxide,
ketamine, and methohexital. If a seizure occurs, initial management is supportive.
This includes airway management, supplemental oxygen, and assessment of cardio-
respiratory function. A fingerstick blood glucose test should be obtained, and any
hypoglycemia should be treated promptly. If the seizure persists for longer than 5
minutes, begin pharmacologic management with benzodiazepines followed by phe-
nytoin. Phenytoin should be administered through a large bore IV, and cardiovascu-
lar status should be monitored, as bradycardia and hypotension may develop.

Treatment of status epilepticus
For a seizure that lasts longer than 30 minutes, general anesthesia should be induced.
The patient should be intubated, and anesthesia should be maintained with midazol-
am, propofol, and sevoflurane.
Postanesthesia plan
Be aware that shivering and myoclonus may be observed, which does not indicate
seizure. Be aware that breakthrough seizures may occur in the postanesthesia re-
covery area.
Cerebral Palsy
Cerebral palsy (CP), sometimes called static encephalopathy, is the most common cause
of severe childhood disability.22,23 The United Cerebral Palsy Foundation estimates
that as many as 8,000 infants and up to 1,500 preschool-aged children are newly di-
agnosed each year in the United States. The CDC estimates that 1 in 323 children in
the United States are affected by cerebral palsy. The worldwide incidence is 1.5 to 4
per 1,000 live births.22
Clinical overview
Patients will present with motor deformity. 70% of CP patients have spasticity. Spas-
ticity may manifest as spastic diplegia (affecting the lower extremities, with minimal
effect on the upper extremities), spastic hemiplegia (affecting the same side of the
body as the encephalon damage), or spastic quadriplegia. Epilepsy and mental im-
pairment are common comorbidities in spastic quadriplegia. Joint contracture may
also be present. Patients with CP have often had many procedures and will present
with a record that can be helpful. There is also a higher potential for latex allergy that
should be managed as having a latex sensitivity.
Common medications
The pharmacologic goals are to increase independence through reduction of spastic-
ity and pain, minimize joint contracture, and increase range of motion.
• Botulinum toxin: IM injection inhibits the release of presynaptic acetylcholine (ACh)
• Baclofen: GABAB agonist

• Diazepam: GABAA agonist
• Bigabatrin: Inhibits GABA breakdown
• Tizanidine: α-2 Agonist
• Dantrolene: Muscle relaxant
• Carbamazepine: Antiepileptic
• Valproic acid: Antiepileptic
• Clonazepam: Antiepileptic
• Lamotrigine: Sodium and calcium channel blocker; antiepileptic
• Phenytoin: Sodium channel blocker; antiepileptic
• Vigabatrin: Inhibits GABA breakdown
Neurologic
• Manifestation: Normal mental status to severe mental impairment.
• Consideration: Communication with the patient, caretakers, and physician is cru-
cial. The patient may be lucid and communicate well, lucid and unable to com-
municate, or suffer from varying degrees of mental impairment. Discovering the
neurologic status as early as possible, in the most respectful manner possible, will
help build rapport and allow an appropriate anesthesia plan to be developed (eg,
will IM sedation to facilitate phlebotomy be indicated or not?).
• Manifestation: Decreased minimal alveolar concentration.
• Consideration: Reduce percentage of inhalation anesthetic delivered.
• Manifestation: Lack normal central thermoregulation.
• Consideration: Warm room before patient entry; monitor temperature closely.
• Manifestation: Joint contractures of the head, neck, and airway.
• Consideration: Airway evaluation must include limitations in range of movement
and airway access due to contractures.
• Manifestation: Drooling.
• Consideration: Increased stimulus to trigger laryngospasm and increased difficulty
assessing the airway preoperatively.
• Manifestation: Dental malocclusion.

• Consideration: Prepare for difficult ventilation and/or intubation.
• Manifestation: Repeated tongue thrusting.
• Consideration: If no macroglossia, then use the normal anesthetic plan.
• Manifestation: Temporomandibular joint ankylosis.
• Consideration: Understand difficult airway algorithm as intubation may
prove difficult.
• Manifestation: Difficulty swallowing.
• Consideration: Unable to control spit and/or unable to control water during seda-
tion. Prepare to manage aspiration.
• Consideration: Low airway tone.
• Manifestation: Inability to maintain patent airway once sedated.
• Consideration: Prepare equipment for airway management. Understand difficult
airway algorithm as ventilation and/or intubation may prove difficult.
‒ It may be prudent to have a secured airway with either oral or nasal endotrache-
al intubation due to GERD, increased oral secretions, and increased aspiration
risk. If necessary, be prepared for rapid sequence intubation (RSI).
Cardiovascular
• Manifestation: Patients are often dehydrated; poor fluid intake.
• Considerations: Intravenous fluids preoperatively may offset a drop in blood pres-
sure from induction.
Respiratory
• Manifestation: Ineffective cough and chronic aspiration of pooled pharynge-
al secretions.
• Consideration: Pulmonology consult; prepare to treat aspiration and bronchospasm.
• Manifestation: Restrictive lung disease due to scoliosis or contracture.
• Consideration: Reduced total lung capacity, vital capacity, and resting lung volume.
• Manifestation: Reactive airway disease.
• Consideration: Be prepared to treat bronchospasm.
Gastrointestinal
• Manifestation: GERD

• Consideration: Strict adherence to NPO guidelines. Prepare to treat regurgitation
and aspiration.
• Manifestation: Poor eating, swallowing, and chewing.
• Consideration: Patient may be small for their age. Patient may be malnourished,
resulting in anemia or electrolyte imbalance.
Musculoskeletal
• Manifestation: Patients have extrajunctional receptors.
• Consideration: Patients need less succinylcholine to achieve paralysis. Studies
show no difference in hyperkalemic episodes between patients with and without
CP when given succinylcholine. However, it should not be given unless needed.
• Manifestation: Resistance to nondepolarizing muscle relaxing drugs.
• Consideration: Increase dose. Alternatively, avoid both depolarizing and nondepo-
larizing muscle relaxants and increase depth of anesthesia with sevoflurane and/
or propofol to facilitate intubation.
• Manifestation: Physical development is often slower than in a normal adult.
• Consideration: Judge appropriateness of in-office sedation based on size, not age.
• Manifestation: Difficulty positioning; fixed contractures; sores from pro-
longed postures.
• Consideration: Do not cause muscle or nerve damage by forcing the patient into a
particular posture. Do not aggravate lesions; address them.
• Consideration: CP is associated with a higher incidence of latex allergies.
Hepatic/nephrologic
Urologic
• Manifestation: Incontinent

• Consideration: If the patient has undergone many corrective surgeries, then the
risk of latex allergy is increased. Ensure catheter is functioning or make judicious
use of fluids if not catheterized.
Planning
Preoperative plan
CP patients will have different levels of communication. It is important to question
the patient and guardians to establish an intellectual and communication baseline.
Hydration status, kidney function, and drug history should be investigated as part of
their history and physical. Preoperative medications should be continued through-
out the perioperative period. For example, AEDs should be continued to avoid acute
withdrawal and lowered seizure threshold. Preoperative sedatives should be avoid-
ed due to the increased risk of obstruction and aspiration related to musculoskele-
tal problems.
Perioperative plan
CP patients are prone to hypothermia, hypoxia, and hypovolemia. Keep the patient
warm intraoperatively. Succinylcholine should be used when needed, as studies show
no relevant difference in potassium release between patients with and without CP. If
nondepolarizing neuromuscular blockers are used, expect CP patients to need high-
er doses and recover more quickly due to upregulation of ACh receptors.23–25 There
is no study to indicate that RSI is more advantageous than other induction methods.
Intubation is likely safer than open airway due to musculoskeletal issues, increased
aspiration risk, and increased secretions.
Postanesthesia plan
Hypothermia, anxiety, and pain can trigger muscle spasms. Keep CP patients warm
and comfortable. Analgesics should not decrease respiratory drive. NSAIDs and ac-
etaminophen are preferred.

Multiple Sclerosis
Multiple sclerosis (MS) affects approximately 400,000 people in the United States and
2.5 million people worldwide. It is estimated that 90 per 100,000 individuals in the
United States are affected by MS.26
Clinical overview
MS is an autoimmune disease of inflammation, demyelination, and axonal damage
to the central nervous system. MS symptoms can begin anywhere between ages 10
and 80 years, but onset is usually between 20 and 40 years of age. Patients present
with some or all of the following conditions to varying degrees: paresthesia, muscle
cramping and spasticity, bladder and bowel dysfunction, sexual dysfunction, ataxia,
tremor, visual disturbances and diplopia, trigeminal neuralgia, facial myokymia, heat
intolerance, fatigue and dizziness, memory loss, depression, dysphasia, and seizures.
Neurologic
• Manifestation: Cognitive dysfunction, possibly including loss of comprehension,
abstract reasoning, and use of speech.
• Consideration: Possible need for PO sedation, IM sedation, or inhalation induction
to facilitate phlebotomy.
breaking laryngospasm, as this drug increases the sensitivity of the vocal cords
• Manifestation: Optic neuritis.
• Consideration: Preoperatively evaluate and document vision loss and pain upon
moving the affected eye or eyes.
• Manifestation: Heat sensitivity leading to decline in neurologic function.
• Consideration: Closely monitor temperature and prevent hyperthermia.
• Manifestation: Emotional sensitivity.
• Consideration: Emotional stress may exacerbate MS symptoms. Every effort should
be taken to lower emotional stress.

• Manifestation: Eyes may be affected
• Consideration: Visual impairment
Cardiovascular
• Manifestation: Spasticity consumes energy
• Considerations: Anticipate rapidly depleted reserves
Respiratory
• Manifestation: Quickly fatigued respiratory muscles.
• Consideration: Consider mechanical ventilation.
• Manifestation: Reduced muscle strength leading to inability to cough and
protect airway.
• Consideration: Increased aspiration risk.
• Manifestation: Total lung volume and vital capacity may be normal; however, max-
imal inspiratory and expiratory efforts may be 50% lower than predicted norms.
• Consideration: Intubation may allow for more reliable oxygenation than open air-
way monitored anesthesia care.
Gastrointestinal
• Manifestation: Constipation
• Consideration: Gastroparesis, possible RSI
• Manifestation: Bladder and fecal incontinence
• Consideration: Utilize a urinary catheter and advise the patient to bring a change
of clothes to the appointment
Musculoskeletal
• Manifestation: Limb weakness.
• Consideration: Demyelination and inability to move may lead to hyperkalemia if
succinylcholine is used. There is also a fall risk.
• Manifestation: Spasticity and 5% chance of seizures.
• Consideration: Assess nature of spasticity; investigate seizure management
if indicated.

• Manifestation: Rare, but reported.
• Consideration: Investigate the comorbidity.
• Manifestation: MS is an autoimmune disease.
• Consideration: Patients are often on steroid therapy. Therapy should be continued
through the perioperative period, and stress dosing should be considered.
Hepatic/nephrologic
• Manifestation: It is rare, but liver function may be affected by medications or sec-
ondary viruses.
• Consideration: Investigate the comorbidity.
Planning
Preoperative plan
Along with the preoperative guidelines in this text, also obtain a thorough baseline
neurologic history. Evaluate the MS patient’s corticosteroid therapy regimen, and
plan to maintain that therapy with possible stress dosing.27
Perioperative plan
Reducing heat and emotional stress is crucial.28,29 Depending on the severity of the
disease, MAC may be lower, and emergence may be delayed. Succinylcholine is not
contraindicated but should be used judiciously as the risk for hyperkalemia is in-
creased. MS patients have unpredictable responses to nondepolarizing neuromuscu-
lar blockers and are more susceptible to respiratory distress from residual blockade.
Postanesthesia plan
MS patients require extended monitoring and postoperative care. They must be close-
ly monitored, as weakness and fatigue predispose the patient to respiratory failure in
the postanesthesia period. Supplemental oxygen, bag valve mask, and equipment for
intubation should be at the ready for use by an experienced provider.

References
1. Mai CT, Isenburg J, Canfield MA, et al. National population-based estimates for major birth de-
fects, 2010–2014. Birth Defects Res 2019;111:1420–1435.
2. Centers for Disease Control and Prevention. Facts about Down Syndrome. https://www.cdc.
gov/ncbddd/birthdefects/downsyndrome.html. Accessed 5 July 2022.
3. World Health Organization. Genes and Human Diseases. https://www.who.int/genomics/public/
geneticdiseases/en/. Accessed 5 May 2021.
4. Bhattarai B, Kulkarni AH, Rao ST, Mairpadi A. Anesthetic consideration in Downs syndrome: A
review. Nepal Med Coll J 2008;10:199–203.
5. Unkel JH, Edwards JS, Piscitelli WP, Tye GW. Dental surgery and anesthetic precautions of
a patient with Down syndrome and juvenile rheumatoid arthritis: A case report. Pediatr Dent
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drome. AANA J 2005;73:103–107.
7. Ihringer K, Russ N, Walther A, Schiff JH. Anesthesiological considerations for patients with triso-
my 21 (Down syndrome) [in German]. Anaesthesist 2013;62:407–419.
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org/resources/endocrine-conditions-syndrome/. Accessed 5 May 2021.
9. Kazemi P, Zolpys L. Hypothyroidism. http://www.anesthesiaconsiderations.com/hypothyroid-
ism. Accessed 5 May 2021.
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https://www.cdc.gov/ncbddd/autism/data.html. Accessed 5 May 2021.
11. American Psychiatric Association. DSM-5: Diagnostic and Statistical Manual of Mental Disor-
ders, ed 5. Washington, DC: American Psychiatric Association, 2013.
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fact-sheets/detail/autism-spectrum-disorders. Accessed 5 May 2021.
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anesthesia: Is their perioperative experience different? Paediatr Anaesth 2015;25:1103–1110.
15. Taghizadeh N, Davidson A, Williams K, Story D. Autism spectrum disorder (ASD) and its periop-
erative management. Paediatr Anaesth 2015;25:1076–1084.
16. Schiff M, Benoist JF, Aïssaoui S, et al. Should metabolic diseases be systematically screened in
nonsyndromic autism spectrum disorders? PLoS One 2011;6:e21932 [erratum 2011;6(8)].
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epilepsy/data/index.html. Accessed 5 May 2021.

18. World Health Organization. Epilepsy. https://www.who.int/en/news-room/fact-sheets/detail/ep-
ilepsy. Accessed 5 May 2021.
19. Perks A, Cheema S, Mohanraj R. Anaesthesia and epilepsy. Br J Anaesth 2012;108:562-571.
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aesthesiol 2010;23:391–399.
21. Kofke WA, Tempelhoff R, Dasheiff RM. Anesthetic implications of epilepsy, status epilepticus,
and epilepsy surgery. J Neurosurg Anesthesiol 1997;9:349–372.
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www.cdc.gov/ncbddd/cp/data.html. Accessed 25 July 2022.
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2013;2:138–140.

CHAPTER 12
Complications, Emergen-
cies, and Emergency Man-
agement
Alfred Mauro, MD
D
entists in all specialties regularly perform invasive procedures. Most proce-
dures are accomplished with the use of local anesthesia alone, or with the ad-
dition of minimal sedation. However, some patients and some procedures can-
not be managed successfully without the addition of pain and anxiety control from
additional agents. There have been some severe events in the United States during
the early years of sedation. State dental boards have investigated issues related to
dental anesthesia and evaluated protocols for emergencies related to the administra-
tion of sedation/anesthesia. Some summary points from the Review of Emergency
Protocols1 were the following:
• Incidents occurred during procedures presided over by medical anesthesiologists,

dental anesthesiologists, and nurse anesthetists.
• They occurred in office settings, hospitals, and outpatient ambulatory sur-
gical centers.
• The type of incident varied, but included drug overdoses, premature discharge,
poor drug selection, and delayed calls to 911.
• No type of provider or sedation type (oral, IV, etc) had better outcomes.

• Management of early stages of urgency was poor.
Each day, hundreds of patients undergo dental procedures under sedation of some
type. Patient safety must be the overarching objective.
Preparing for Emergencies

Avoiding sedation emergencies is covered in many chapters of this text. This includes
the focus of “standard of care” and guidelines for emergency care by reputable sourc-
es (eg, American Society of Dentist Anesthesiologists [ASDA], American Society of
Anesthesiologists [ASA], and American Dental Association [ADA]).2,3 You will find
information regarding:
• Patient interview and history

• Physical examination
• Obtaining signed, written informed consent
• Perianesthesia instructions
• Pre-deciding where the “go/no go” line is
• Maintaining a suitable emergency record
Types of emergency events

Both common events and more serious events can take place in the dental office when
a patient is under sedation. Providers should be familiar with prevention, early rec-
ognition, and out-of-hospital treatment for the emergency events listed in Box 12-1.

BOX 12-1 Emergency events that can be encountered with patients under sedation
Common events
• Emesis
• Pre- and intrasedation events
• IV mishaps
• Hyperactivity, including seizures
• Central nervous system (CNS) events (seizure and disruptive behavior, etc.)
• Panic attacks
• Hyper/hypoglycemia
More serious events
• Hyper/hypotensive events
• Power failure
• Drug reactions
• Hypoventilation
• Airway obstruction (nearly all tragic events involving sedation by dentists/oral surgeons begin
with airway issues)
• Pulselessness
Staff training
Dental treatment under conscious sedation must be provided by highly trained per-
sonnel. The treatment protocols must include the following:
• Proper use of all devices, instruments, and apparatus

• Proper use of all drugs, and actions expected of anyone providing the sedation for
dental procedures
• Acceptable records
• How to keep the record during an acute event
By reading the chapters from the various specialties, the learner will be able to de-
velop a system designed to prepare for, avoid, quickly recognize, and decisively treat
emergency events associated with sedation for dental treatment. The dentist must
be acutely aware of prevention, vigilance, early recognition, and decisive treatment
based upon rehearsed algorithms. The hope is that the reader can prevent even the
least morbid of the emergent events listed above. Of course, there is no training that
prevents all bad things from happening. During an unwanted event, early recogni-

tion leads to simple interdictions which, in turn, prevent very dangerous events that
would occur later. Early recognition is only possible with proper monitoring.
It must be emphasized that the standard of care dictates that sedation providers
be able to rescue a patient promptly and competently from at least the next deepest
level of sedation. The levels of sedation are fluid, often in the same session, even if
properly administered. It is recognized that dentists have varying levels of training
and experience regarding emerging events with high risk, significant morbidity, or
worse. The intent throughout this text is to provide enough background to support
a course of action. However, it is not possible to duplicate the value of in-person
hands-on training and experience. The actions will be limited to proper preparation
and monitoring, drugs and devices, and actions accepted as the standard of care for
out-of-hospital conditions (such as the dental office).
Guided risk assessment

A preoporative guided risk assessment (GRA) to identify patients at risk for seda-
tion-related complications should be utilized. Of the 12 factors in the GRA, 5 are re-
lated to airway issues4 (Fig 12-1). The use of the GRA was found to improve outcomes
in sedation.
Snoring, stridor, Craniofacial History of air-

Pneumonia
or sleep apnea malformation way difficulty
Reactive Vomiting or bow- Gastro- Hypovolemia, car-

airway disease el obstruction esophageal reflux diac disease
History of se- Inadequate

Sepsis Altered mental state
dation failure NPO time
Fig 12-1 Guided risk assessment factors. NPO, nothing by mouth.

Although the prevention of life-threatening emergencies is always a primary goal,
potentially catastrophic situations can develop despite our best efforts. However,
with proper patient evaluation before treatment, appropriate treatment modifica-
tion if necessary, proper selection of techniques and drug administration, and ade-
quate monitoring during the procedure, it is unlikely that serious emergency situa-
tions will arise.
Fortunately, life-threatening situations do not occur with any degree of frequency.
Because of this, skills in emergency management and constant refresher training are
invaluable in maintaining the level of knowledge needed. Although most emergency
situations arising from dental conscious sedation are transient in nature, and easily
managed by the dental office emergency team (eg, bronchospasm, syncope, angina),
occasions may arise in which outside medical assistance is recommended. For this
reason, telephone numbers of emergency services personnel should be readily avail-
able and conspicuously posted.
Emergency kits
Figure 12-2 outlines the primary or basic emergency kits and the secondary emergen-
cy kits.1 Secondary drugs should be in emergency kits of dentists who have advanced
training in emergency medicine or anesthesia. Specific training is required for the
safe and effective usage of secondary equipment, so it should not be included in a kit
unless specific training and experience has been obtained.

Primary Secondary
emergency kit emergency kit
Supplies
Drugs Supplies Drugs
• Oxygen • Artificial airways

Injectable Noninjectable delivery Injectable Noninjectable • Airway adjuncts
drugs drugs system drugs drugs
• Scalpel and/
• Syringes or cricothyroi-
• Epinephrine for • Oxygen for drug • Anticonvulsant • Respiratory dotomy needle
management (respiratory administration (midazolam stimulant
of acute aller- distress) or diazepam) (aromatic
• Suction ammonia)
gic reactions • Vasodilator • Analgesic
• Tourniquets • Antihypertensive
• Antihistamine (nitroglycerine (morphine
translingual (if IV drug ad- or meperidine) (Procardia,
spray) ministration is Pfizer)
contemplated) • Vasopressor
• Bronchodila- (methoxamine)
tors (for acute • Anti-
asthmatic hypoglycemic
attack) (50% dextrose);
• Aspirin corticosteroid
(chewable) (Solu-Cortef,
Pfizer)
• Antihyper-
tensive
(propranolol)
• Anticholinergic
(atropine or
scopolamine)
Fig 12-2 Primary and secondary emergency kits.1

Because the level of training and experience is so varied, emergency kits must not
be “one size fits all.” Each kit must be tailored to the level of training and background
of the dentist responsible for its use.5,6
Management of Emergencies
While the purpose of this text is to enlighten readers regarding the use of dental
conscious sedation in the different dental specialties, it is important that we at least
mention the different types of emergencies that potentially may arise during seda-
tion and some management methods. However, this is not meant to replace the texts
and courses specifically devoted to the treatment of these emergencies.

Syncope
Syncope is a transient loss of consciousness, and it is not uncommon during dental
procedures, with or without sedation. A sudden decrease in heart rate causes a de-
crease in blood pressure (BP). This results in a decrease in the delivery of blood and
oxygen to the CNS. In the dental office, this may be precipitated by situations such as
unexpected pain or the sight of blood. Syncope is less likely to occur in the sedated
patient. It is more likely that the nonmedicated patient may collapse in the reception
room or the treatment room based on fear of the procedure or instrumentation.
Syncope is usually easily managed with the following steps:
1. Terminating the procedure

2. Placing the patient in a supine position with the feet elevated
3. Basic life support as indicated
4. Oxygen administration if required
5. Administration of aromatic ammonia if needed
Consciousness should return within seconds. If the patient does not respond within
15 to 20 seconds, it may not be syncope, and emergency assistance should be sought.
Discharge the patient from the office only after a period of observation.7
Hypotension
It is not unusual to see a slight drop in BP during moderate sedation. Treating hypo-
tension is based on the role ability of circulation to adequately perfuse the tissues.
During sedation, hypotension may be diagnosed with the following methods:
• Monitoring BP throughout the procedure

• Communication with the patient
• Observation of the surgical field (if there is less blood than normally would be ex-
pected, the patient’s BP should be tested)
Hypotension may be caused by the following factors:

• Use of excessive premedication
• Overdose of sedatives
• Hemorrhage
• Postural changes resulting in orthostatic hypotension
• Hypoxia due to poor airway management during deep sedation
• Cardiovascular abnormalities (eg, myocardial ischemia or infarction, heart failure)
• Adrenocortical insufficiency
• Metabolic derangements caused by hyper- or hypoglycemia and/or ketoacidosis
related to patient’s history of diabetes
Figure 12-3 outlines the steps that should be taken in the management of
hypotension.8
Reposition the patient to

a supine position, with legs
Basic life support
elevated to help increase Definitive care
(ie, airway, breathing,
blood flow to the brain as needed
circulation)
and aid in venous return
from the legs
Fig 12-3 Management of hypotension.8
Hypertension
Increased BP may be seen during dental procedures, especially if the level of anxiety
or pain is not well controlled. Transient increases may be prevented by the adminis-
tration of local anesthetics. Minor increases in BP are usually well tolerated and are
of little danger to the patient. However, hypertensive emergencies must be treated
aggressively.

Hypertension during dental treatment, with or without sedation, may be caused
by the following factors:
• Pain
• Hypercarbia or hypoxia
• Overhydration
• Hyperthermia6
Management of hypertensive episodes during dental procedures is usually direct-

ed toward providing adequate pain management. Reversal of hypertension caused
by hypercarbia or hypoxia can be provided by proper airway management and ven-
tilation. Overhydration or fluid overload is best controlled by properly managing the
amount of fluids utilized during sedation. Patient temperature should be recorded
pretreatment and posttreatment. Preoperative temperature increase may be a sign of
infection, especially if the patient appears flushed.
Hypertensive crisis exists when the systolic BP is 250 mmHg or greater and/or
the diastolic BP is 130 mmHg or greater. This will most likely occur in patients with
chronic, stable hypertension. Antihypertensive therapy should not be utilized with-
out the presence of severe hypertension (BP > 200/130 mmHg). The “crisis” must be
distinguished from a modest or transient increase in BP. Eliminating pain through
readministration of local anesthetics or by deepening the sedation may return the
elevated BP to baseline values. If the return to baseline does not occur, hypertensive
crisis should be considered, and management should be initiated. First, however, we
must be able to distinguish between cardiac and noncardiac causes.9
Treatment for hypertension includes the following steps:
1. Termination of the dental treatment and repositioning the patient to an up-

right position
2. Basic life support (ie, airway, breathing, circulation)
3. Monitor BP
4. Administer fluids
5. Oxygen administration

6. Emergency medical personnel should be summoned
Cardiac dysrhythmia
A deviation from the normal cardiac sinus rhythm is a dysrhythmia. Most dysrhyth-
mias that occur during sedation rarely require drug intervention. While rare, the
presence of a cardiac dysrhythmia may be a warning that a condition (physiologic or
pharmacologic) exists that may require immediate attention.
Cardiac dysrhythmias may be precipitated by the following:
• Elevated levels of CO2

• Anoxia
• Intubation
• Longer duration procedures; anesthetic agents
• Vagal responses
Continuous ECG (electrocardiogram) monitoring is only required during deep se-

dation or general anesthesia. While the use of ECG is not necessary during light or
moderate sedation, if it is available, it should be utilized in patients with a history of
any cardiovascular issues. The use of a pulse oximeter can be utilized to detect cardi-
ac dysrhythmias.10–13
Angina pectoris
Stable angina pectoris is usually substernal thoracic pain, precipitated by exercise,
emotion, or a heavy meal, and able to be relieved by rest and vasodilator medication.
It is usually the result of an inadequacy of the coronary circulation.14
Angina pain is usually described as a tightness, a constriction, or a weight on the
chest. An episode usually lasts for a few minutes with drug therapy, but it may last
for an hour. Treatment is usually to sit the patient upright and give nitroglycerine.
Chest pain of longer duration may lead to a presumptive diagnosis of myocardial
infarction (MI) rather than angina.

Myocardial infarction
MI or heart attack is produced by prolonged ischemia of the myocardium, produced
by a partial or total occlusion of the coronary artery blood flow, leading to necrosis
of the heart muscle. Severe chest pain and cardiac dysrhythmias commonly occur
during an MI. If cardiac function stops (ie, cardiac arrest), immediate institution of
life support must be instituted.
MI will often mimic angina pectoris initially. However, over one-half of patients
are at rest when MI occurs, but angina pectoris is usually initiated by an increase in
myocardial activity.15,16
Management of MI includes the following:
• Discontinue dental treatment

• Assess airway, breathing, and circulation
• Administer oxygen
• Activate EMS (emergency medical services), stat
• Administer aspirin
• Manage pain
• Prepare to manage complications (eg, sudden cardiac arrest)
• Transfer to hospital emergency room
Seizures
Seizures are not uncommon during dental treatment. Patients with a history of epilep-
sy are the most likely to have a seizure in the dental office because stress can provoke
a seizure, even in well-controlled patients. An inadvertent intravascular injection of a
local anesthetic may produce an immediate seizure, while a large total dose of a local
anesthetic may bring on a seizure more gradually. A seizure may become associated
with hypoxia or anoxia and hypercarbia if it goes untreated for any extended time.17
Seizures can usually be managed without any resulting injury. Primary goals of
treatment involve the prevention of injury and providing adequate airway and ven-
tilation. Adequate ventilation eliminates or prevents the retention of carbon dioxide
and elevates the seizure threshold of local anesthetics, decreasing the duration of the

seizure. Most seizures are self-limiting (2–5 minutes) and rarely require the utiliza-
tion of anticonvulsants.18
Management of seizures includes the following:
• Terminate the procedure.

• Place the patient in a supine position.
• Provide basic life support as needed.
• Prevent injury by protecting the patient during the seizure. Gently hold the pa-
tient’s arms and legs, without completely restricting movement.
• Do not place any object in the patient’s mouth.
• Ensure airway patency and administer oxygen to minimize hypoxia and hypercarbia.
• Activate EMS if necessary.
Hospitalization may be required for patients having seizures secondary to severe

anoxia or who have utilized anticonvulsant drugs to terminate the seizure.
Laryngospasm
Laryngospasm is very unlikely to occur during light or moderate conscious sedation.
It is a protective mechanism or reflex to maintain the integrity of the airway by pre-
venting any foreign bodies from entering the larynx, trachea, or lungs.6
Management of laryngospasm usually includes the following steps:
• Position the patient supine

• Administer 100% oxygen
• Reposition the tongue anteriorly
• Evaluate the airway, and suction if necessary
• Administer a muscle relaxant (only if prior training has been accomplished)
• Activate EMS as necessary

Hypoglycemia
Low blood sugar is a common occurrence in type 1 (insulin-dependent) diabetes mel-
litus, and less likely in type 2 (non-insulin-dependent) diabetes. While unlikely in a
dental procedure where minimal or moderate conscious sedation is utilized, mild
hypoglycemia may occur. Patients tolerate hyperglycemia better than hypoglycemia.
Although unlikely, when blood sugar levels fall too low, consciousness may be lost,
and seizures may occur. Mild hypoglycemia is generally easily managed, with a rap-
id return to normal nervous system function. However, with the loss of conscious-
ness and/or seizures, EMS must be called, and hospitalization is advised.19
The management of hypoglycemia during dental sedation requires the fol-
lowing steps:
• Termination of procedure
• Place patient in a comfortable position
• Basic life support as necessary
• Administer sugar orally (eg, 8 to 12 ounces of orange juice)
• Activate EMS if necessary
Respiratory depression
Respiratory depression would most likely only be observed during deep sedation or
general anesthesia, due to the administration of CNS depressant medications such as
barbiturates or opioids. It is much less likely to occur during minimal or moderate se-
dation. It may be observed as either decreased rate of respiration or decreased venti-
lation effort. During deep sedation, both pulse oximetry and capnography should be
utilized (see chapter 5). Airway obstruction or decreased ventilation can be detected
almost instantaneously, permitting rapid corrective treatment. Respiratory depres-
sion rarely requires outside medical assistance.20
Management of respiratory depression requires the following steps:
• Termination of the procedure

• Move patient position to supine

• Basic life support as necessary
• Administer 100% oxygen, and continue to monitor BP, heart rate, and cardiac rhythm
• Consider antidotal drug administration
• Contact EMS if necessary
Resuscitation and Airway

Dental anesthesiologists and nurse anesthetists have extensive training in treating
complications that may arise during sedation or anesthesia. Cardiovascular collapse
with depression, airway management, respiratory depression, and respiratory arrest
are an integral part of the training. The emergency kit which contains resuscitative
drugs should be available in every operating room. Part of the required resuscita-
tive equipment is the Ambu bag and mask (Fig 12-4). The Ambu bag and mask was
developed in 1956 by Holden Hesse, an engineer, and Henning Ruben, a dental an-
esthesiologist. Prior to the Ambu bag and mask, patients suffering from apnea were
ventilated manually using anesthesia machines and an oxygen supply. Endotracheal
intubation and the use of ventilators provided a great service to patients in situations
requiring resuscitation. The endotracheal laryngoscope has now been updated to im-
prove intubations. The laryngeal mask airway (LMA) was a development in 1988
that improved resuscitation in adults and children. The automatic external defibrilla-
tor (AED) is a portable device that should be present in every environment where se-
dation/anesthesia will be utilized. Everyone involved in the procedure should have
training on the use of the AED and be aware of its location.20–22

Fig 12-4 Bag-valve-mask device.
Conclusion
To reiterate, emergency situations can and may occur during treatment under dental
conscious sedation. The best treatment for any emergency is prevention. This is best
accomplished by proper preoperative patient evaluation and the strict adherence to
all recommended techniques, proper monitoring, and proper posttreatment manage-
ment. While the purpose of this text is to enlighten readers regarding the use of den-
tal conscious sedation in the different dental specialties, it was important to mention
many of the different types of emergencies that potentially may arise during seda-
tion, and some management methods. However, this is not meant to replace the texts
and courses specifically devoted to the treatment of these emergencies.
References
1. Malamed SF. Medical Emergencies in the Dental Office, ed 6. St Louis: Mosby, 2007.

Dentists. https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/publica-
tions/cdt/anesthesia_guidelines.pdf. Accessed 9 August 2022.
ology 2002;96:1004–1017.
4. Hoffman GM, Nowakowski R, Troshynski TJ, Berens RJ, Weisman SJ. Risk reduction in pediatric
procedural sedation by application of an American Academy of Pediatrics/American Society of
Anesthesiologists process model. Pediatrics 2002;109:236–243.
5. American Dental Association. Guidelines for Teaching Pain Control and Sedation in Dentists
and Dental Students. https://www.ada.org/~/media/ADA/Education%20and%20Careers/Files/
ADA_Sedation_Teaching_Guidelines.pdf?la=en. Accessed 6 May 2021.
6. American Association of Oral and Maxillofacial Surgeons. Office Anesthesia Evaluation Manual,
ed 7. Rosemont, IL: American Association of Oral and Maxillofacial Surgeons, 2006.
7. Malamed SF. Managing medical emergencies. J Am Dent Assoc 1993;124:40–53.
8. International Liaison Committee on Resuscitation. 2005 International Consensus on Cardio-
pulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recom-
mendations. Part 2: Adult basic life support. Resuscitation 2005;67:187–201.
9. Patel HP, Mitsnefes M. Advances in the pathogenesis and management of hypertensive cri-
sis. Curr Opin Pediatr 2005;17:210–214.
10. Atlee JL. Perioperative Cardiac Dysrhythmias: Mechanisms, Recognition, Management, ed 2.
Chicago: Year Book Medical, 1989.
11. Wingard DW. What is a normal heart rate prior to surgery? Anesthesiology 1990;72:1102.
12. Driscoll EJ, Smilack ZH, Lightbody PM, Fiorucci RD. Sedation with intravenous diazepam. J Oral
Surg 1972;30:332–343.
13. DeRango FJ. Management of Common Medical Problems. In: Lichtigen M, Moya F (eds). Intro-
duction to the Practice of Anesthesia, ed 2. Hagerstown, MD: Harper & Row, 1978.
14. Mosby’s Medical Dictionary, ed 7. St Louis: Mosby, 2005.
15. Ferraris VA, Ferraris SP, Gilliam HS, Berry WR. Predictors of postoperative ventricular dysrhyth-
mias: A multivariate study. J Cardiovasc Surg (Torino) 1991;32:12–20.
16. Liau CS, Hahn LC, Tjung JJ, et al. The clinical characteristics of acute myocardial infarction in
aged patients. J Formos Med Assoc 1991;90:122–126.
17. Earnest MP. Seizures. Neurol Clin 1993;11:563–575.
18. Covino BG. Toxicity of local anesthetic agents. Acta Anaesthesiol Belg 1988;39(3 suppl 2):159–164.
19. Diabetes Control and Complications Trial Research Group, Nathan DM, Genuth S, et al. The ef-
fect of intensive treatment of diabetes on the development and progression of long-term com-
plications in insulin-dependent diabetes mellitus. N Engl J Med 1993;329:977–986.
20. Baskett P, Zorab J. The resuscitation greats. Henning Ruben MD, FFARCS(I), FFARCS. The Ru-
ben valve and the AMBU bag. Resuscitation 2003;56:123–127.

21. Fahey DG. The self-inflating resuscitator: Evolution of an idea. Anaesth Intensive Care
2010;38(suppl 1):10–15.
22. Qamarul Hoda M, Samad K, Ullah H. ProSeal versus Classic laryngeal mask airway (LMA) for
positive pressure ventilation in adults undergoing elective surgery. Cochrane Database Syst Rev
2017;7:CD009026.

CHAPTER 13
Animal-Assisted Therapy
in the Dental Setting
Mai-Ly Duong, DMD, MPH
T
his chapter proposes a strategy for managing dental anxiety that is different
than the use of anesthesiology: animal-assisted therapy (AAT). This therapy
can be used in conjunction with sedation or in place of sedation to reduce and
manage anxiety during the provision of dental treatment. AAT is grounded in the
scientific evidence that the human-animal bond is one of mutual benefits and is in-
fluenced by behaviors that directly lead to positive health and well-being for both.1
Because of this, AAT involves goal-centered interventions in which the animal plays
an integral part of the treatment and health care process.
History of AAT
Although AAT is modern-day terminology and a growing field of study in psychol-
ogy research, the use of animals for health benefits can date back to the beginning of
mankind and the relationship between cavemen and wolves.2 However, it was not
until 1792 that the first case of animal therapy was documented in England, when
William Tuke found that farm animals such as rabbits and chickens lessened the need
for drugs and restraints among patients.3 By the 19th century, animals were used as
companions in European mental health institutions to increase comfort in an already
seemingly prison-like environment.4,5 In 1919, the use of companion animals was first
documented in the United States. Most notably, canines were used in the psychiatric

wings of hospitals.5 In the 1940s, animals were used to help US veterans recuperate
and to reduce any posttraumatic stress disorder (PTSD) symptoms. By the end of the
20th century, the use of animals in the health care setting had become very popular,
and the following terms were coined:
• Animal-assisted therapy
• Animal-assisted interventions
• Pet therapy
For the purposes of this chapter, the term AAT will encompass all past and current
terms related to leveraging the human-animal bond for therapeutic and health benefits.
Goals of AAT
Approximately 20% of Americans report a moderate to high level of anxiety toward
obtaining dental treatment. The most common reasons for avoiding dental treatment
include fear of dental experience and previous negative dental experience.6,7 This anx-
iety and fear is what causes an estimated 40 million Americans to avoid the dentist.8
Avoiding or delaying needed dental treatment can lead to extremely detrimental oral
health consequences and inevitably reduces oral health–related quality of life.6 This
reduction in quality of life and its related stresses can further negatively influence
one’s mental and physical health as well.
With stress and anxiety come the activation of an individual’s autonomic nervous
system. This system prepares the body for the sympathetic fight-or-flight response.9
Self-induced regulation is necessary, as it serves as a coping mechanism for the body
in certain situations.10 However, continued sympathetic activation can contribute to
coronary heart disease, reproductive dysfunction, and immunosuppressive disor-
ders.10 Chronic stress and autonomic activation can lead to decreased salivary flow
rate, xerostomia, and increased levels of plaque formation, all of which contribute to
risk for oral disease11 (Fig 13-1).

Fear of dental care Oral disease
Autonom- Decreased
ic activation salivary flow
Avoidance Increased
Stress Dry mouth
of dental care plaque
Fig 13-1 Many factors in conjunction can lead to oral disease.11
To help a patient overcome stress and dental anxiety, it is important for dental
health practitioners to address both the patient’s emotional and physiologic needs.
There is a growing need to understand how to best address this issue. Several studies
have analyzed stress and dental anxiety reduction methodologies. Examples include
the use of audio and visual techniques and cognitive behavioral therapy.10,12–14 One
method that has yet to be extensively researched is the use of AAT.
AAT programs are designed to improve an individual’s physical, social, and emo-
tional health and/or cognitive functioning.15 In recent years, there has been a grow-
ing interest in AAT due to its various health and therapeutic benefits. The use of AAT
has shown cardiovascular, psychologic, and cognitive benefits. Specifically, the use
of AAT helps to decrease anxiety, stress, and depression levels; decrease heart rate
and blood pressure; improve self-esteem and mood; and lower immunoglobulin A
(IgA) levels.16 These changes have been seen with both long- and short-term expo-
sure to AAT. Consequently, nursing homes, hospitals, retirement communities, and
many other institutions are implementing AAT.17 While the benefits of AAT are well
documented in medical care facilities, studies of AAT are virtually nonexistent in
dental settings.

AAT in Dentistry
In 2000, the American Academy of Pediatric Dentistry recommended the use of dis-
traction techniques to alleviate patient fear and anxiety related to dental treatment.18
Along with the other benefits of AAT, Katcher and Friedmann reported that AAT
can work as such a distraction. Petting an animal creates “a passive meditative fo-
cus on a nonthreatening stimulus [that] can relax a person by lowering the body’s
state of arousal”19 (Fig 13-2). In addition to tactile stimulation, AAT can provide deep
pressure therapy (DPT) to anxious patients. DPT involves a dog using its weight
and sometimes warmth to mitigate a psychiatric symptom, often either as a calming
strategy or to minimize disengagement from the world. Like a weighted blanket for
people with autism, DPT can relax and reengage a person enduring an otherwise
disabling symptom.20
a b
Fig 13-2 (a and b) Petting a cat or dog can relax a patient and
distract them from procedures that may otherwise cause anxiety.
One previous study attempted to show the benefits of AAT in a dental setting;
however, the methods resulted in conflicting and inconclusive evidence of benefit.21
Many anecdotal experiences and case studies have shared the benefits of canine-as-
sisted therapy in the dental setting. More properly designed studies need to be imple-
mented to explore the effectiveness of AAT in a dental setting. Because AAT has been
demonstrated to be successful in patient populations with mental illness, trauma,

disabilities, and children and older people, it can be argued that these patients are the
best candidates to experience the benefits of AAT while undergoing dental treatment.
Benefits of AAT
Cardiovascular benefits
The American Heart Association and the American Stroke Association report an es-
timated 83.6 million Americans who have been diagnosed with some type of cardio-
vascular disease (CVD). Further, CVD has been shown to increase premature deaths
and nursing home admissions. Friedman and Thomas found that of the individuals
who have experienced a myocardial infarction, those who owned pets had a 1-year
survival rate that was statistically significantly higher than those who did not own
pets.22 The American Heart Association has assessed the existing evidence and con-
cluded that pet ownership has a positive influence on the presence and reduction of
CVD and is currently examining the causal relationship that may be present23 (Fig
13-3). Other reputable institutions, such as the Mayo Clinic, have incorporated AAT
and are also currently examining the effects of AAT on CVD.
Fig 13-3 Having a pet has been shown to reduce heart dis-
ease.23

Psychologic benefits
The positive benefits of AAT were first documented in the psychology field. It is
also important to note that more than half of psychiatrists and psychologists indicate
that they have prescribed companion animals (or pets) for their patients.24 AAT has
been shown to improve social and communication skills, as well as reducing anxi-
ety, improving mood, and facilitating empathic skills25 (Fig 13-4). Some evidence has
demonstrated that the simple act of petting an animal reduces feelings of loneliness,
depression, and insecurity.26 This provides strong support for the use of AAT in the
dental arena, where so many individuals face anxiety.
Fig 13-4 Psychologic benefits of pets include reduced anxiety,

better mood, greater empathy, and reduced loneliness, depres-
sion, and insecurity.
Cognitive benefits
AAT can serve as a catalyst in communication, especially during psychotherapy ses-
sions, because the presence of an animal makes the experience less threatening and
more inviting. Holding or petting an animal can serve as physical comfort and pro-
vide a sense of security and safety.4 For this reason, the use of AAT in dental treat-
ment is further supported. Additionally, when an individual is comforted and secure,
physiologic signs such as blood pressure and respiratory rate are also decreased or
normalized.22

Types of AAT
Animals involved with AAT include, but are not limited to, dogs, cats, horses, dol-
phins, birds, rabbits, and fish. The most common animals used for AAT are dogs.
Often, dogs, cats, or other small animals are used in health care facilities in which
the patient is receiving treatment. For example, a canine and its handler will visit a
patient who is chronically ill in the hospital or long-term care facility.
Canine-assisted therapy is the most common type of AAT provided in the health
care setting and can be found in short-term and long-term as well as group and indi-
vidual settings. Feline-assisted therapy is more commonly found in long-term facili-
ties where the cats are treated like pets due to their independent nature. They provide
a sense of continuity and a homey feeling to the residents of long-term facilities.
Other types of therapy such as equine-assisted therapy and dolphin-assisted ther-
apy require the human or patient to travel to the animals’ establishments. Having
patients participate in grooming, feeding, and riding horses has shown significant
improvements in health and healing. Further, having patients interact, feed, and
swim with dolphins has also shown increased response to physical therapy and psy-
chologic treatment.
Challenges of Utilizing AAT
Sanitation
Infection control is a primary concern in all health care facilities. Therefore, when
incorporating AAT as a strategy to improve patient well-being, it is important to
ensure that the animal and handler follow all the guidelines set forth by the Centers
for Disease Control and Prevention (CDC) to properly and safely reduce the risk for
infection during AAT activities. These guidelines include, but are not limited to, the
following27:
• Establish and enforce proper handwashing protocols.

• Identify and treat any illness or wound that the AAT animal experiences in a
timely manner.
• Ensure that the AAT animal receives routine and regular veterinary visits, includ-
ing remaining up to date with all recommended vaccinations.
• Regularly bathe and groom the AAT animal within 24 hours of interacting
with patients.
• Provide adequate time for the AAT animal to exercise and relieve themselves prior
to interacting with patients.
• Provide a healthy diet for the AAT animal.
• Maintain an up-to-date record that shows the completion of an animal-assisted cer-
tification program.
Animal welfare
Just as humans are prone to burnout, animals can also experience burnout or fa-
tigue if overworked. Therefore, standards and in-depth guidelines have been cre-
ated by Pet Partners (formerly known as the Delta Society) to protect animals in-
volved with AAT.28 These should be thoroughly reviewed and implemented into any
AAT program.
To reiterate the CDC guidelines, it is vital that the animal be well cared for from a
general health standpoint. More so, the animals must also have time to enjoy being
a pet. They must be trained to understand when it is time to work with patients and
when it is time for them to play. When they are ill, proper action should be taken to
ensure their physical and mental health is restored (Fig 13-5).

Fig 13-5 Pets and service animals should be regularly examined
to ensure they are healthy.
Selection Process
Animals involved with AAT must be properly trained to prevent any bad outcomes
due to miscommunication. They should have mastered basic obedience skills and
behave in a predictable manner. They must also enjoy being around people and
enjoy being touched or held. Because dogs have been domesticated and can learn
how to appropriately respond to voice commands, they are the most common type
of AAT animal.
In addition, the patient receiving the AAT should be considered. Their preferences
may indicate which type of animal will yield successful outcomes. If a patient has
allergies to certain types of animals, those animals should be identified and avoided.
Any animal with which the patient reports a negative history should also be avoided.
Conclusion
Since AAT has been extremely successful in the medical arena, it is not surprising
that it is slowly being incorporated into the field of dentistry. As more and more in-
stitutions incorporate the use of AAT to reduce anxiety, it can be argued that the use
of AAT can be used in the following ways:

• To desensitize patients to a new dental office
• To alleviate anxiety during consultations in the dental office
• To reduce anxiety for invasive dental treatment
• To help reduce anxiety during the induction of deep or general sedation
• To help transition a patient from a deeper to a more conscious sedative state of mind
There is a rich body of evidence that shows the powerful effect that the human-an-
imal bond can have in health and well-being. Therefore, AAT programs have the
potential to be a significant part of patient-centered treatment. It is important that
health care providers recognize, explore, and develop this strategy because it can
have life-changing effects on their patients.
References
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A Guide to Dental

A Guide to Dental Sedation 1

Leonard B. Goldstein, DDS, PhD

Professor, Missouri School of Dentistry and Oral Health

Lindsay M. Gilbert, MSM, MSEd, EdD

A Guide to Dental Sedation 2

Quintessence Publishing Co, Inc

Publishing Director: Bryn Grisham

A Guide to Dental Sedation 3

To my late son Alfred. May his memory continue to inspire me.

To my husband Bernie, whose support, encouragement, and pride for everything I do is

A Guide to Dental Sedation 4

Section I: Introduction to Dental Sedation

1. A Brief History of Dental Sedation from 1960

2. Understanding Dental Sedation

3. Patient Assessment and Evaluation

5. Patient Monitoring During Sedation

Section II: Sedation in Specialty Practice

A Guide to Dental Sedation 5

Section III: Other Considerations

11. Special Needs Dental Patients

12. Complications, Emergencies, and Emergency Management

13. Animal-Assisted Therapy in the Dental Setting

A Guide to Dental Sedation 6

A Guide to Dental Sedation 7

A Guide to Dental Sedation 8

Chase L. Andreason, DMD

Anthony Charles Caputo, DDS, MA

Adjunct Professor and Attending Anesthesiologist

AEGD Program Director

Mai-Ly Duong, DMD, MPH

Lindsay M. Gilbert, MSM, MSEd, EdD

Leonard B. Goldstein, DDS, PhD

A Guide to Dental Sedation 9

John T. Hansford, DMD

Former Chief of Dental Anesthesiology

Lauren Hanzlik, DDS

Maria C. Maranga, DDS

David J. Miller, DDS

A Guide to Dental Sedation 10

Dawn P. Pruzansky, DMD

Fred C. Quarnstrom, DDS

Dena Sapanaro, DDS, MS

Mana Saraghi, DMD

Vice President of Oral Exams

Stuart L. Segelnick, DDS, MS

A Guide to Dental Sedation 11

A Guide to Dental Sedation 12

A Guide to Dental Sedation 1

A Brief History of Dental

BOX 1-1 Organizations related to the history of dental sedation

A Guide to Dental Sedation 2

The Author’s Experience in Early Years

A Guide to Dental Sedation 3

A Guide to Dental Sedation 4

Conﬂicting Voices: The Many Interests of Dental

A Guide to Dental Sedation 5

A Guide to Dental Sedation 7

A Guide to Dental Sedation 8

A Guide to Dental Sedation 9

A Guide to Dental Sedation 10

A Guide to Dental Sedation 11

Understanding Dental Se-