Conscious sedation for wisdom teeth and other tooth extractions. -

Should you be sedated for your procedure? | Oral vs I.V. vs inhalation sedation. | Advantages, disadvantages, precautions. | What drugs are used? - Laughing gas (nitrous oxide), 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, able to respond, communication with the patient can be maintained during their procedure.)

Similar terms.

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:

  • Due to preoperative events (such as the fatigue that develops when enduring prolonged periods of discomfort) the patient's ability to tolerate their procedure is diminished.
  • The patient is exceptionally apprehensive about having their procedure.

    (Beyond just for the appointment, sedation is sometimes used to insure that the patient gets a good night's sleep the night before.)

  • The procedure is expected to be difficult or require an extended period of time (such as when removing multiple teeth, or impacted wisdom teeth). With these types of cases, the patient might become physically or emotionally taxed.

With these situations, the use of sedation helps to make the patient's procedure more tolerable for them. And as a bonus for the clinician, it also helps 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 reported that longer extraction procedures correlated with patients feeling higher levels of pain.
  • Malkawi 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 determined that the strongest predictor of procedure pain was dental anxiety.

Section references - Fagade, Malkawi, Tickle

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 that the use of sedation is chosen 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.

In our discussion here, we describe the use of nitrous oxide, commonly referred to as laughing gas.

How laughing gas is administered.

Nitrous oxide creates its effect as the patient breathes it in via a mask that's placed over their nose.

  • Onset is quick (less than 20 seconds, with clinical signs developing within 2 to 3 minutes). This is more rapid initial onset than with any other sedation technique, including I.V. administration.
  • The depth of the patient's sedation can be easily and rapidly altered (increased or decreased) simply by changing the concentration of the gas being administered. (This is considered a safety characteristic of this technique.)
Levels.

To induce conscious sedation, nitrous oxide is mixed with pure oxygen in a range of 25% to 55%.

  • The goal is to use the lowest concentration that produces the desired effect.

    In most cases the dentist will start off with a concentration of around 20%, and then every minute or two increase the level in roughly 10% increments until the patient starts to feel the gas's effect (a dreamy, floaty state, tingling in their hands and feet).

  • Going above these levels starts to introduce effects that patients find unpleasant (a feeling of remoteness or disassociation, light-headedness, restlessness, nausea).

Laughing gas can be used alone, or in combination with oral or I.V. sedation techniques (see below).

Reversal of effects.

Recovery following the administration of nitrous oxide is the quickest of any sedation technique.

The drug is not metabolized within the body but instead eliminated via the lungs. Recovery is usually complete after 3 to 5 minutes of the patient being administered 100% oxygen.

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 concentration of the gas being breathed in.

  • That means if you require more of an effect during your procedure (like in preparation for your dental shots), 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 the 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 however that nitrous oxide sedation generally should not be administered to patients after a full meal (experiencing nausea is more likely), so watch your timing on that.

Dismissal.

In most cases (per their dentist's instructions), a patient should be able to be discharged unescorted after their appointment. This includes driving home. (A wait period of approximately 20 minutes is usually allowed, so to provide time for the effects of the gas to dissipate and for the dentist to make an evaluation of their patient.)

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. And if they breathe through their mouth, they will dilute the concentration of gas that reaches their lungs, thus reducing the level of sedation that's created.

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.

Section references - Malamed, Wray

2) Oral conscious sedation.

"Oral" sedatives are medications (pill or liquid form) that are taken by-mouth (swallowed). This route of administration is the most commonly used method of inducing conscious sedation.

Oral sedative medications.

Using an example you've probably heard of, Valium (diazepam) is a drug that's frequently used. (It's probably the most used one.)

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 being used.

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 several 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 that time period prior to your appointment, and also 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 is typically minimal. Very little patient cooperation is required.

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 prescribed. (Both the level of absorption of the drug, and how quickly it is metabolized, will vary with each person.)

    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 a person's dental appointment. This makes for a relatively long monitoring period afterward (by a spouse, relative or friend). In comparison, I.V. medications and especially inhaled ones are typically much shorter-acting.

Section references - Malamed, Wray


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: Versed (midazolam), Valium (diazepam), Halcion (triazolam), Ativan (lorazepam), Duragesic (fentanyl) and Diprivan (propofol).

The one(s) chosen will depend on the needs of the patient, the requirements of the procedure, and the dentist's preference. How each drug varies by way of its duration and degree of anesthetic and amnesic effect will also need to play a role in this determination.

Things to know about I.V. sedation.

Advantages.
  • Onset of the medication is quick. (About 20 seconds, with clinical signs developing within 1 to 2 minutes.)
  • As compared to oral sedation, I.V. technique provides a way of creating a more predictable and controlled effect.

    (The rapid onset of I.V. drugs allows the dentist to immediately evaluate their effect and administer more if needed.)

  • 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).
Disadvantages.
  • Pre-appointment as well as pre and post-operative precautions are required. (See below.)
  • Some level of patient cooperation is needed.

    If the fact that the medication is administered via the use of a needle is upsetting to the patient, nitrous oxide or oral sedation might be given first.

  • Intravenous sedatives are more commonly used by oral surgeons as opposed to a general dentists because they have the specialized training and monitoring equipment that's needed when this technique is used.
  • Unless performed under special circumstances, I.V. conscious sedation is not utilized with patients under the age of 16 years. Concerns also exists for persons over the age of 65 years.
  • While less so than when oral sedation is used, I.V. sedatives require a recovery period where the patient is monitored as the effects of the medication wear off. (See below.)
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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've recently experienced 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 for your appointment:

  • 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 at home 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.

Section references - Malamed, Wray

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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Comments

Difficult tooth extraction due to slip jaw

I recently went to the dentist to get a molar removed and I wasn't freezing properly, after over an hour of trying to remove my molar I couldn't take the pain anymore so we stopped. My dentist told me to go to a specialist so I can be sedated and have my tooth removed. Is there another way that I can have the tooth removed without sedation?

Janet

The options for extracting a tooth are:

1) Local anesthetic only (dental shots/injections). (The method that your dentist has tried).
2) Local anesthetic + sedation. The use of sedation typically has to do with patient management (making the procedure more tolerable for the patient), the tooth is numbed up in normal fasion. We have a page that discusses dental consious sedation.
3) General anesthesia. (No local anesthetic is needed.)

So the purpose of the referral would be the question.
Does your dentist think that an oral surgeon (who is used to working with difficult situations) will be able to more effectively numb up your tooth using local anesthetic?
Or do they think that sedation is needed from the standpoint of managing some aspect of your experience so the procedure can be completed.
Or do they think that the use of general anesthesia is indicated (this is the rare case).

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