PAINLESS DENTISTRY

[drsushant]

Written by Jason H. Goodchild, DMD, Anthony S. Feck, DMD, and Michael D. Silverman, DMD
pain control and sedation have become important aspects of dental care. It is now becoming more common for general practitioners to provide in-office sedation for routine dental procedures. A segment of the population that would otherwise not seek care because of fear or anxiety is now receiving treatment. The use of sedation for dental care has become a topic of intense interest, and many states are re-writing their regulations to require a special permit to provide this service. The intent of this article is to introduce definitions and concepts pertaining to oral sedation that may be helpful to the general dental practitioner.

There has been much debate concerning different levels of sedation, and what is appropriate for the dental office. Anxiolysis and conscious sedation are well suited for oral medications, and depending on state regulations, may be safely and effectively administered in the dental office.

The definition of anxiolysis is simply, “a reduction in anxiety.”1 More precisely stated, “…a drug-induced state in which patients respond appropriately to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.”2 In the spectrum of sedation, anxiolysis is the lightest level of sedation (Figure 1). For the purpose of many state regulatory agencies, anxiolysis involves the use of a single anxiolytic drug (per day, not including nitrous oxide), in a single dose, prescribed before a patient’s appointment, and administered prior to the beginning of the dental appointment.

The anxiolysis technique must be distinguished from conscious sedation for the following reasons:

Indications
1. Fearful patients

2. Anxious patients
3. May be a helpful adjunct to the achieving profound local anesthesia
4. Can be useful for longer appointments
5. Can be helpful during invasive procedures (eg, endodontic therapy, third molar extraction)
6. Patients with pronounced gag reflex

CONTRAINDICATIONS
1. Patient who is medically unstable (eg, angina, diabetes)
2. Patient who is medically complex (eg, ASA III to IV).
3. Patient who has had an adverse reaction to medications
4. Pregnant patients
5. Can be helpful during invasive procedures (eg, endodontic therapy, third molar extraction) 5. Elderly patients
(1) Anxiolysis is a technique that all dentists could implement. Many states (and provinces in Canada) have now developed restrictions on the use of conscious sedation by dentists, thereby limiting the ability to perform needed sedation for certain procedures. These restrictions mostly prevent dentists from administering conscious sedation without a special permit, usually one that requires training in intravenous drug administration. However, as defined above, anxiolysis is permitted in all 50 states and in Canada. (Those dentists who are interested in conscious sedation should consider continuing their sedation training and satisfy their state requirements for a conscious sedation permit).
(2) Anxiolysis provides a light level of sedation. A situation may arise in which the dentist and/or patient desires a lighter level of sedation than conscious sedation provides. An example may be the slightly anxious patient who states that they need the “edge taken off” in order to receive treatment. Anxiolysis could be appropriate for this situation. Many patients in general practice presently benefit from a medication given preoperatively, ultimately helping them relax for a perceived invasive procedure.
(3) Anxiolysis is ideal for shorter sedation appointments. Typical anxiolysis protocol consists of an oral medication given pre-operatively. Some newer sedation medications have short durations, and when given orally, can be effective for a short appointment. If, for instance, the expected length of the procedure is 90 minutes or less, anxiolysis may be indicated. It should be noted, however, that anxiolysis may also be appropriate for longer appointments, up to and sometimes exceeding 4 hours