Oral sedation dentistry

Oral sedation dentistry is a medical procedure involving the administration of sedative drugs via an oral route, generally to facilitate a dental procedure and reduce patients anxiety related to the experience. Oral sedation is one of the available methods of conscious sedation dentistry, along with inhalation sedation (e.g., nitrous oxide) and conscious intravenous sedation. Benzodiazepines are commonly used, specifically triazolam.[1] Triazolam is commonly selected for its rapid onset and limited duration of effect.[1] An initial dose is usually taken approximately one hour before the dental appointment.[1] Treatment may include additional dosing on the night proceeding the procedure, to mitigate anxiety-related insomnia.[1] The procedure is generally recognized as safe, with the effective dosages being below levels sufficient to impair breathing.[2]

Uses

Dental patients with generalized anxiety, belonephobia (fear of needles and sharp instruments), prior dental trauma, or generalized fear of the dentist can take oral medication in order to reduce their anxieties.[3] A variety of single and incremental dose protocols are used to medicate the patient as early as the day before treatment.[4] Medication additionally helps reduce memory or the sights and smells of the dental office to avoid recall of any trauma.[5] The sedative effect allows more dentistry to be completed in fewer appointments as well as allowing complex procedures to be performed in less time.[6]

Drugs

Valium (Diazepam) is the most widely recognized drug in the group. It has been around since the 1960s and is a well known and time-tested sedative with amnesic properties. Valium has a longer half-life than some of the other medications, so it is particularly useful for appointments where extensive dentistry is being performed.
Halcion (Triazolam) is most well known for the treatment of insomnia. It is highly effective when used in oral sedation protocols, and if deemed appropriate by your dentist, can be used in conjunction with an antihistamine.
Sonata (Zaleplon) is similar to Halcion in that it is also commonly used for the treatment of insomnia.
Ativan (Lorazepam) is commonly prescribed for the treatment of anxiety. It possesses many of the desirable effects of other benzodiazepines with amnesic properties. It is an effective sedative with a medium length half-life and is useful for appointments that are longer than two hours.
Vistaril (Hydroxyzine) while classified as an antihistamine has also been shown to have anxiolytic (anti-anxiety) effects. It also works in conjunction with many of the benzodiazepines but has no amnesic properties.
Versed (Midazolam) has the shortest half-life of all of the benzodiazepines, lasting about an hour, and making it ideal for short appointments or simple procedures. It has many of the same anxiolytic and amnesic benefits of other benzodiazepines, but is less commonly used because of its duration.

Risk mitigation

Drug characteristics must be carefully considered when choosing the appropriate medication. Matching factors, such as where the drug is metabolized and any underlying diseases requires a good medical history and thorough knowledge of the drug's characteristics. All risk factors, individual characteristics, and procedural complexities can be taken into account in order to provide the best drug choice.

Education

Courses in Oral Sedation Dentistry are offered across North America at various dental schools and private organizations. The largest for-profit provider of dental sedation continuing education in North America is the Dental Organization for Conscious Sedation. Specialty courses are being taught in pediatric sedation, ACLS, IV Sedation and emergency preparedness. The largest not-for-profit organization that provides educational courses in oral sedation as well as IV sedation and general anesthesia is the American Dental Society of Anesthesiology.[7]

Regulation

Education and training requirements to administer sedation vary by state. The ADA has set forth general sedation guidelines that have been adopted or modified by many states. There are typically dosing limitations involved with anxiolysis, usually a single dose the day of treatment not to exceed the maximum recommended dose (MRD) of the medication in order to achieve the intended level of sedation. However, these sedation laws vary from state to state. Anxiolysis protocols are designed to treat healthy ASA I & II patients ages 18 and up for one to four hours of treatment. Some states now require a permit even for nitrous oxide administration and/or anxiolysis.

Advantages

The main advantages of oral sedation versus other sedation methods are:

Ease of administration (you only have to take a pill)
Effectiveness
No needles involved
High patient acceptance
Amnesic effect
Lower cost vs intravenous sedation

References

Donaldson M, Gizzarelli G, Chanpong B (2007). "Oral sedation: a primer on anxiolysis for the adult patient". Anesthesia Progress. 54 (3): 118–28, quiz 129. doi:10.2344/0003-3006(2007)54[118:OSAPOA]2.0.CO;2. PMC 1993866. PMID 17900211.
Dionne RA, Yagiela JA, Coté CJ, Donaldson M, Edwards M, Greenblatt DJ, Haas D, Malviya S, Milgrom P, Moore PA, Shampaine G, Silverman M, Williams RL, Wilson S (April 2006). "Balancing efficacy and safety in the use of oral sedation in dental outpatients". Journal of the American Dental Association. 137 (4): 502–13. doi:10.14219/jada.archive.2006.0223. PMID 16637480.
"Premedication and Oral Sedation". Dental Fear Central.
"Oral Sedation Info". Dental Sedation.org. Archived from the original on 25 July 2011.
"Ativan (lorazepam)". RxList.com. WebMD.
De Avila J (Jun 19, 2007). "'Did I Really Have a Root Canal?'; More Dentists Offer Drugs To Sedate Nervous Patients; Finding a Designated Driver". The Wall Street Journal.
"American Dental Society of Anesthesiology".

Anesthesia and anesthesiology
Types	General Sedation Twilight anesthesia Local Topical Intercostal nerve block Neuraxial blockade Spinal Epidural Dental Inferior alveolar nerve
Techniques	Airway management Anesthesia provision in the US Arterial catheter Bronchoscopy Capnography Dogliotti's principle Drug-induced amnesia Intraoperative neurophysiological monitoring Nerve block Penthrox inhaler Tracheal intubation
Scientific principles	Blood–gas partition coefficient Concentration effect Fink effect Minimum alveolar concentration Second gas effect
Measurements	ASA physical status classification system Baricity Bispectral index Entropy monitoring Fick principle Goldman index Guedel's classification Mallampati score Neuromuscular monitoring Thyromental distance
Instruments	Anaesthetic machine Anesthesia cart Boyle's machine Gas cylinder Laryngeal mask airway Laryngeal tube Medical monitor Odom's indicator Relative analgesia machine Vaporiser Double-lumen endotracheal tube Endobronchial blocker
Complications	Emergence delirium Allergic reactions Anesthesia awareness Local anesthetic toxicity Malignant hyperthermia Perioperative mortality Postanesthetic shivering Postoperative nausea and vomiting Postoperative residual curarization
Subspecialties	Cardiothoracic Critical emergency medicine Geriatric Intensive care medicine Obstetric Oral sedation dentistry Pain medicine
Professions	Anesthesiologist Anesthesiologist assistant Nurse anesthetist Operating department practitioners Certified Anesthesia Technician Certified Anesthesia Technologist Anaesthetic technician Physicians' assistant (anaesthesia)
History	ACE mixture Helsinki Declaration for Patient Safety in Anaesthesiology History of general anesthesia History of neuraxial anesthesia History of tracheal intubation
Organizations	American Association of Nurse Anesthetists American Society of Anesthesia Technologists & Technicians American Society of Anesthesiologists Anaesthesia Trauma and Critical Care Association of Anaesthetists of Great Britain and Ireland Royal College of Anaesthetists Association of Veterinary Anaesthetists Australian and New Zealand College of Anaesthetists Australian Society of Anaesthetists International Anesthesia Research Society
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