About Sedation
Our practice can utilize nitrous oxide and oxygen, oral sedation, IV sedation, and general anesthesia to enable patients to obtain dental care. Our doctors and staff are uniquely qualified and highly experienced in the sedation environment. We have over a decade of experience and have served thousands of patients.
Some patients desire sedation to reduce excitement or nervousness prior to and during dental treatment. Although all common dental procedures can be completed with local anesthesia – numbing the teeth and soft tissues in the mouth – sedation can make patients feel better about dental treatment, and help their bodies respond to dentistry as normal as possible by preventing increases in blood pressure and heart rate typically associated with stress and anxiety. Some patients have difficulty feeling numb due to anatomic variations, some patients are unable to cooperate for dental treatment due to developmental delay or physical, cognitive, or emotional disabilities.
The following is a brief discussion regarding levels of sedation and routes of administration. Each and every patient is different, and there is no “recipe” or “cookie cutter” solution to sedation. Patient safety is always first, and risk, benefits, and alternatives always need to be explored prior to embarking on sedation for dental treatment. Our first rule is to “Do no harm”. The decision to treat under sedation is often a complex one, involving not only patients and dentists, but often the primary healthcare team and beyond. Office based sedation for dentistry is always elective, and applicable sedation and anesthesia guidelines are rigorously adhered to.
Levels of Sedation
Anxiolysis
The alleviation of nervousness or anxiety associated with dental treatment.
Moderate Sedation
A level of sedation where the patient is conscious and responsive to verbal commands or light touch, but sedated and comfortable. Airway reflexes are intact – the patient can breathe on their own and protect their own airway. Patients treated under moderate sedation may remember all, some, or none of the procedure.
Deep sedation or general anesthesia
Patients are unconscious, relaxed, and have no feeling or memory of the procedure. Patients in this state often are unable to maintain their own airway and have no protective reflexes – they cannot cough or gag. These patients will not respond to verbal commands or even painful stimulus.
Routes of Administration
Inhalational Administration
Gasses inhaled and absorbed into the bloodstream through the lungs. Gasses administered are oxygen, nitrous oxide, and volatile general anesthetics like Sevoflurane.
Enteral Administration
Also called oral sedation – medications taken orally and absorbed into the bloodstream through the digestive tract. This route is subject to a vast amount of variation between patients and is consequently the least predictable route to administer sedation. Commonly used medications are typically sleeping pills like Valium (diazepam) and Halcion (triazolam) for adults and Versed (midazolam) for children. These medications are often used in conjunction with nitrous oxide and oxygen – which can make them more effective. Oral sedation is intended to provide anxiolysis or minimal sedation -however, the route of administration is unrelated to the resulting level of sedation obtained by individuals.
Intravenous Administration
Commonly referred to IV sedation – Medication is administered intravenously – directly into the bloodstream. This allows for “titration”- medication levels can be controlled precisely by giving separate, small doses. This allows awake, sedated patients to give feedback, enabling us to keep each patient comfortable – and also allows for varying amounts of sedation depending on procedures – for example, a patient may be deepened for tooth extraction and numbing, and allowed to be more awake for less invasive procedures like fillings, radiographs, or impressions. In addition to the level of sedation, the IV can be used to administer pain medications, steroids to minimize swelling, and anti-nausea medications, hydration, and emergency medications like reversal agents, atropine and epinephrine should the need arise. Patients desiring IV sedation must be able to cooperative for the IV start. Intravenously administered sedation is often used in conjunction with nitrous oxide and oxygen, and can be used to administer all levels of sedation throughout the continuum of anxiolysis, moderate sedation, or general anesthesia. This is the safest, most versatile administration route and Dr. Karmy’s preferred method for administering sedation.
General Anesthesia
Patients unable to cooperate or consent due to young age, physical, emotional, or mental disabilities – are only able to be treated under general anesthesia. Patients under general anesthesia are completely unconscious and feel no pain and have no memory of the procedure. Patients under general anesthesia do not have to be cooperative or able to communicate in order to receive general anesthesia. Anesthesia may be induced intravenously, or, if patients are unable to cooperate or tolerate an IV, via intramuscular injection or by the administration of volatile anesthetics via facemask. Patients under general anesthesia have no protective reflexes like coughing and gagging, and may require airway support in the form of endotracheal intubation. General anesthesia outside of the hospital operating room setting is extremely common, and dentist anesthesiologists have an extraordinary safety record. General anesthesia in the office setting is reserved for physically healthy patients, or those with mild, controlled medical conditions. Dr. Karmy reviews the necessary preoperative information and performs a preoperative examination prior to making a go or no go decision for each patient the day of treatment.
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