Conscious sedation options for wisdom teeth and other tooth extractions. -

Should you be sedated for your procedure? | Oral vs I.V. vs inhalation sedation. | Advantages, disadvantages, precautions of each. | What drugs are used? - Nitrous oxide/laughing gas, Valium/diazepam

X-ray of tooth socket after extraction.

What is "conscious" sedation?

The term conscious sedation refers to the administration of medication (an oral, I.V. or inhaled sedative) for the purpose of placing a patient in a relaxed state for their dental procedure. In comparison to general anesthesia however, the patient remains conscious (awake).

Other names and terminology that equate with the use of conscious sedation technique (although possibly just loosely) are "moderate sedation," "twilight anesthesia" and "sedation dentistry."

When should sedation be used for a dental procedure?

A dentist may suggest that conscious sedation should be used in cases where:

  • The patient is exceptionally apprehensive about their procedure.
  • The procedure is expected to be difficult or require an extended period of time (such as when removing impacted wisdom teeth). In these cases the patient might become physically or emotionally taxed.

With either situation, sedating the patient helps to make their procedure more tolerable for them, which generally translates into allowing them to be a more ideal patient.

What's having conscious sedation like? - Characteristics.

When moderate sedation is used the patient remains awake, in the sense that:

  • They remain responsive to stimuli such as verbal commands from their doctor ("open your mouth," "close down"), or the sensation of pain.

    If the patient does happen to doze off, they are easily awaken.

  • All of the patient's protective reflexes (breathing, coughing) remain functional.
  • The patient's cognitive function (perception, reasoning, comprehension) may be modestly impaired.

In comparison, with general anesthesia the patient looses all sensation and consciousness.

Advantages of opting for sedation.

Procedure acceptability.

Two key benefits of utilizing conscious sedation are that:

  • It helps to reduce patient fear or concern about what's planned or is going on.
  • It helps to make difficult or extended procedures more tolerable. (The patient is better able to cooperate with the dentist's requests or the needs of the procedure.)

Especially in the case of a procedure like a difficult extraction, the extra degree of patient cooperation that using sedation can provide can help the process to go more smoothly and therefore quickly. This can be favorable for both what the patient experiences during their procedure and over the course of the healing process that follows.

  • Fagade (2005) reported that longer extraction procedures correlated with patients feeling higher levels of pain.
  • Malkawi (2011) determined that lengthier wisdom tooth surgeries correlated with the patient having more frequent (both immediate and late) post-extraction complications.

Alleviating a patient's anxiety alone will help to improve their experience. A study by Tickle (2012) determined that the strongest predictor of procedure pain was dental anxiety.

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Additional benefits.

Other advantages of using this technique are that:

  • Some of the drugs used also help to raise the patient's pain threshold.
  • Some sedatives create a mild amnesic effect (cause an inability to remember events that occurred during the procedure, or even the procedure itself).

Be sure to choose sedation for the right reasons.

The use of any sedative involves some risks.

The use of any type of medication places the patient at some degree of risk for complications and side effects. And for that reason, when one is administered it should be for good reason.

Generally speaking, the type of anesthesia used for a procedure should be kept to the simplest form possible. So if you're not convinced that you need to be sedated, ask your dentist why they feel you do.

Improved patient cooperation can be a big help for your doctor during procedures such as a difficult extraction. But in some cases it may be used simply for their convenience or to create an additional billable service.

Conscious sedation is primarily used for anxiety control.

Although some types of drugs used can help to elevate the patient's pain threshold somewhat, this technique is primarily used to help control patient anxiety.

That means when it is chosen, your dentist will still need to administer a local anesthetic (give you dental "shots"). So don't choose sedation because you think it will allow you to avoid the use of a needle because it won't. (See below.)


Ways dentists administer conscious sedation.

(We discuss dental fees for sedation services here.)

1) Inhalation technique.

With this method, the sedative medication that the patient is given is a gas that they breathe.

Nitrous oxide / Laughing gas

How it's administered.

Nitrous oxide creates its effect as the patient breathes it in via a mask that's placed over their nose. To produce conscious sedation, its mixed with pure oxygen at a concentration of 25 to 40%.

The gas's onset is rapid (usually just a matter of 2 to 5 minutes). And once the patient stops breathing it in, its effects disappear fairly rapidly too.

It can be used alone or in combination with oral or I.V. sedation technique (see below).

Advantages

A very unique feature of inhalation technique, and one that makes it very convenient to work with, is that the patient's level of sedation can be adjusted, almost immediately, just by changing the amount of gas being breathed in.

  • That means if you require more of an effect during your procedure, just indicate to your dentist and it can be achieved in just a few moments with their twist of a dial.
  • Likewise, if you find you would be more comfortable with less of an effect, your level of sedation can be reduced in just a matter of moments by reducing the concentration of nitrous oxide in the mixture you are breathing.

Inhalation technique is the only method where the level of the patient's sedation can be immediately increased or decreased.

Another advantage of inhalation sedation is that minimal prior planning is required. Choosing to use laughing gas during your procedure can usually be opted for as late as at the time of your appointment.

Precautions.

Your dentist will have a set of precautions and instructions they will discuss with you. We will note that nitrous oxide sedation should not be administered to patients after a full meal, so watch your timing on that. In most cases, a patient should be capable of driving home after their procedure.

A difficulty unique to dental procedures.

Dentistry presents a special challenge in the use of laughing gas.

  • During their dental procedure, a person will have their mouth open.
  • If they breathe through their mouth, they will dilute the overall concentration of gas that reaches their lungs, thus reducing the level of sedation that's produced.

So when inhalation technique is utilized, the patient must be sure to breathe only through their nose (the source of the gas) for their entire procedure.

2) Oral conscious sedation.

"Oral" sedatives are medications (pill or liquid form) that are taken by-mouth (swallowed).

As an example, Valium (diazepam) is one drug that's frequently used to create sedation for oral surgery procedures.

Others include: Ativan (lorazepam), Xanax (alprazolam), Vistaril (hydroxyzine), Halcion (triazolam), Versed (midazolam), Serax (oxazepam), Ambien (zolpidem) and Sonata (zaleplon).

All of these are prescription medications.

Administering the drug.

Your dentist will discuss a specific set of instructions and precautions with you. Some are generic, others may vary depending on the specific medication chosen.

A common regimen for oral sedatives used to create conscious sedation is:

  • An initial dose in the evening before going to bed. This helps to insure that you have a good night's sleep prior to having your procedure. (This step isn't always included.)
  • A second dose 1 hour before your scheduled dental appointment. (Onset typically takes 30 to 60 minutes.)
You'll require assistance.

Because oral sedatives are likely to affect both your behavior and ability to function for some hours, once they've been taken you must have someone tend to and assist you.

Oral sedatives.

Oral sedatives can help to put a patient at ease.

This includes prior to and while delivering you to your appointment. As well as escorting you home and monitoring your activities afterward until the effects of your medication have finally worn off.

Advantages or oral sedation.

As compared to inhalation or I.V. technique, when oral sedatives are used no special equipment is needed. The cost of the medication itself to the patient or dentist is minimal.

Disadvantages.

The use of oral sedatives does have some disadvantages as opposed to other techniques.

  • The fact that you must take your dose well before your appointment means that someone must escort you both coming and going. (Instead of just when leaving as with I.V. technique. Or possibly not at all, as with inhalation sedation.)
  • While your dentist will make calculations base on your weight, it's hard for them to predict exactly what level of sedation will be created by the dose you have taken.

    If it's too little, it can't be immediately adjusted by taking more. (Using a combination of oral and inhalation technique can help to address this issue.)

  • The effect created by oral sedatives typically lasts much longer than your dental appointment itself, thus requiring a long monitoring period afterward. In comparison, I.V. medications and especially inhaled ones are typically much shorter-acting.

3) I.V. Sedatives.

Intravenous ("I.V.") sedatives are administered by way of injecting them into a blood vein.

What medications are used?

Your dentist has a number of drugs that they can choose from when performing I.V. conscious sedation (some may be used in combination). They include: Valium (diazepam), Halcion (triazolam), Ativan (lorazepam), Versed (midazolam), Duragesic (fentanyl) and Diprivan (propofol).

The one(s) chosen will depend on both the needs of the patient and the procedure as well as the dentist's preference. Each drug varies by way of its duration and degree of amnesic and anesthetic effect it creates (see below).

Things to know about I.V. sedation.

  • Some sedatives create an "amnesic" effect, meaning the patient has little or no memory of the dental procedure that has taken place (from the time the medication kicks in until it has worn off). Onset can be as quick as 30 seconds or less.
  • If the fact that the medication is administered via the use of a needle is upsetting to you, ask if nitrous oxide or oral sedation can be given first.
  • Intravenous sedatives are more likely to be administered by an oral surgeon as opposed to a general dentist because they have the specialized training and monitoring equipment that's needed when this technique is used.
  • As compared to oral sedation, I.V. technique provides a way of creating a more predictable and controlled effect.
Precautions - Before your procedure.

Your dentist will provide you with a set of precautions and instructions that must be adhered to. The following points are usually included:

  • No eating or drinking (that means anything, even water) for some hours (usually 6 to 8) prior to the administration of your medication.
  • You need to report any systemic factors you have noticed including: fever, head or chest cold, upset stomach or bowels, sore throat.

Complications with any of the factors above may mean that your procedure will need to be rescheduled.

Your instructions will also include a list of best practices:

  • Wear sensible footwear (no heels, flip-flops or sandals) so your risk of stumbling while under the influence is minimized.
  • If you need to you may wear contact lenses, jewelry, dentures, oral piercings or lipstick to your appointment but they must be removed before your procedure.
  • Wear loose, comfortable clothing. Select a shirt or blouse that has short sleeves or else sleeves that are easily rolled up above the elbows.
  • Don't wear nail polish to your appointment. (It can interfere with some types of vital sign monitors.)
Precautions - Following your procedure.
  • You'll need to make arrangements for someone who after the completion of your appointment can escort you out of your dentist's office, drive and escort you home, as well as monitor your activities until your medication's effects have worn off.
  • Don't place yourself in a situation where you will need to operate a car or machinery, or tend to important matters, for the first 24 hours after your procedure.
Conscious vs. Deep sedation.

As a side note, we'll mention that I.V. technique can also be used to create "deep" sedation. This differs from the conscious form by way of the fact that the patient's responsiveness and protective reflexes are both impaired (you can't respond in a purposeful way to questions or stimuli).

If this method is suggested to you by your dentist ask them why they feel it's needed. With conscious sedation, your ability to communicate and respond (even if only as a reflex) helps to add a layer of safety to your procedure.


A dentist giving a dental injection.

Local anesthetic is administered via an injection.

Even when conscious sedation is used your tooth will still need numbing up.

Some of the medications used to create conscious sedation also create an anesthesia effect (raises the person's pain threshold). Unfortunately, the extent of this effect is just minimal.

(Remember, a part of the definition of conscious sedation specifically involves the fact that you remain responsive to events, like feeling pain.)

You will get a "shot."

That means even when conscious sedation is used your dentist will still need to numb up your tooth and the gum tissue that surrounds it using a local anesthetic (they'll need to give you a dental "shot"). Otherwise you wouldn't be able to tolerate having your dental work done (except for possibly some very minor procedures such as a dental cleaning).

If getting a shot is the scary part for you, you can make your experience more tolerable by requesting that it's not given until you're already fully under the effects of your sedation medication. (Related content: Why do/don't some shots hurt?)

 

 
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