Sedation Dentistry

The purpose of oral sedation dentistry is to allow a dentist to work more effectively by helping a patient become as comfortable as possible with the use of sedative medications administered orally and sublingually[4,9,21,23,24].

Appropriately trained dentists can use a variety of protocols customized to a patient’s physiological and pharmacological needs[13,26]. A number of oral agents developed especially for these purposes, subjected to rigorous research and testing[5,9], are safe and have been used for decades[9,18,21,24,30,34]. Those in the benzodiazepine class, such as triazolam and diazepam, have “amnesic” properties[6], meaning that patients remember little to nothing of their time in the dental chair by the next day. Other medications sometimes used in sedation protocols include antihistamines, like hydroxyzine, and insomnia medications, like zaleplon, which aid in relaxing and calming a patient.

Sometimes referred to as “comfortable” or “relaxation” dentistry, the terms describe the feelings most patients experience during their oral sedation appointments. The term “sleep dentistry” is inappropriate. Patients are never meant to sleep through their appointments and should always be able to verbally and physically respond to cues from the doctor or team.

There are typically dosing limitations[13] involved with anxiolysis, usually a single dose the day of treatment not to exceed the maximum recommended dose (MRD) of the medication (to achieve the intended level of sedation). However, these sedation laws can vary from state to state. Anxiolysis protocols are designed to treat healthy ASA I & II patients ages 18+ for 1-4 hours of treatment.

Conscious sedation protocols allow more flexibility in dosing and often allow a doctor to administer incremental or supplemental doses to maintain a consistent level of sedation for longer periods of time.

The following states have regulations regarding anxiolysis or minimal sedation: West Virginia, North Dakota, New Hampshire, and Washington.

Every state has different oral sedation dentistry regulations[33]. Some states now require a permit even for nitrous oxide administration and/or anxiolysis, so it’s important to know your state dental board’s rules. One of most helpful benefits of being a DOCS Education member is unlimited access to DOCS’ full-time regulatory attorney and Membership Services Advisors. They can provide you with all of the information on your state’s regulations, how to understand them, and what you need to do in order to meet them.

If you’ve given your patients Valium^® in the past for anxiolytic purposes, then you are already aware of some of the potential benefits of sedation. However, there is more to sedation dentistry than just Valium^® . Countless years of research have been dedicated to studying and finding methods and new medications to alleviate pain[25] and anxiety since Valium’s^® arrival on the market in 1960’s. Additionally, there are many other components of sedation dentistry that are important to learn, including proper patient monitoring[33], benzodiazepine reversal agents, patient health history intakes, and drug-drug interaction/contraindication screening[4,9,13,32]. Learning to provide optimum sedation through DOCS Education's safe and predictable sedation protocols enables you to provide higher quality care to your patients.

Attending a DOCS Education course will help provide you with a broader understanding of adult oral conscious sedation along with proven systems to enhance a patients level of safety and produce consistent results.

Historically, adult OCS has been one of the safest modalities in dentistry. DOCS members alone have completed an estimated 2,000,000 successful sedation procedures over the past seven years. One reason for our outstanding record is that patients’ vital signs are monitored using a pulse oximeter/blood pressure monitor. This monitor is easy to use yet sophisticated enough to measure blood pressure every five minutes and continuously measure pulse rate and blood oxygen before, during and after a sedation procedure. Several states have enacted regulations requiring its use. See your state's regulations.

Usually not and what’s more, some insurance companies are actually welcoming sedation dentists. Call us at DOCS (866) 592-9618 to find out which insurance companies support sedation dentistry.

You need to notify your carrier in writing that you are providing oral conscious sedation. And in Utah, your premium will increase $200/year because of the self-insurance system there.

A few states require some team certification, such as Missouri and West Virginia. The more appropriate question is how much training does your team need to be effective and efficient?

With sedation, you team has added roles and responsibilities, including being the first point of contact with fearful patients. Your front office staff needs to be able to explain how the entire process works to each patient. They are also responsible for patient admittance and dismissal, including sedation-specific forms and documentation. It’s critical for clinical team to understand how to appropriately monitor patients’ vital signs using equipment like a pulse oximeter with a blood pressure monitor, and how to recognize potential emergencies before they become an actual emergency. DOCS recommends that each doctor bring at least one team member. If you are unable to bring a team member, resources like the Team Training DVD and Oral Sedation Dentistry Guidebook can help you prepare your team when you return from the course.

No. Every state considers this anxiolysis. Higher or incremental doses of Halcion require a permit in most states.

• Patients with high dental anxiety and fear often exhibit behaviors that delay treatment or make it difficult to provide. They may wiggle and squirm and ask questions during treatment that compromise a dry field[34]. They often require a tremendous amount of reassurance. With OCS these patients will become your easiest patients to treat because they are no longer afraid, but relaxed and comfortable. And since OCS produces a retrograde amnesiac effect, the patients seldom remember much about the procedure. Their anxiety often falls to a very low level and they become much like your most relaxed patient.
• Patients with a severe gag reflex. Relaxing the gag reflex can make the dental experience comfortable for both patient and practitioner. The patient no longer needs to worry about the pending sensation and the dentists can work without worry of sudden jerking movements.
• Time constraints—those who need to get more dentistry done in fewer visits. In today's world busy executives and everyday people alike cannot afford to take repeated time off to have the dentistry they want completed. Sedation allows them to have it completed in fewer visits, opening the door to the smile they've always wanted.
• Existing patients who have put off needed treatment, or who abandoned treatment plans. Many DOCS members have found a similar pattern. A huge percentage of patients who come in for prophylaxis have often put off routine treatment for decades. The simple reason behind it: they are secretly anxious. Although they will sometimes come in for hygiene appointments, they stop when it comes to more extensive treatment because they are afraid. When they discover that they can have their dentistry performed while they are sedated—without the use of an IV needle—people become much more likely to complete their treatment plans.
• Patients who suffer from acute or chronic jaw soreness. Patients who have difficulty remaining open for long periods of time will find sedation a relief. The muscle relaxation properties of sedation medications can make longer appointments possible. By using OCS in combination with frequent resting times, extensive treatment completed in one visit comfortably and patients experience little to no jaw soreness post-operatively.
• Patients who complain that they can’t get numb. A small percentage of patients do have difficulty getting numb. OCS helps these patients experience a comfortable dental visit.
• Patients with physical limitations such as back or neck problems. OCS helps to relax patients who may have chronic back or neck problems allowing them to comfortably sit in the chair for lengthy procedures. Sedation dentists report that these patients experience little or no post-operative back or neck soreness.
• Patients with extensive treatment needs often delay care overwhelmed by the enormity of the work to be done. Sedation dentistry can make what may seems like a great deal of treatment feel like a few short visits.

Many of our more than 3400 DOCS members found something very interesting - that a huge percentage of patients who come in for prophys put off routine work, often for years and years. The reason is that many patients are secretly anxious. Although they will go for a hygiene appointment, they stop when it comes to more extensive treatment because they are secretly afraid. However, once these existing patients are made aware that their dentist offers sedation, they want to have the treatment performed! OCS is a great way to help your patients get the restorative dentistry that they’ve been postponing.

The DOCS Education protocols require the patient be dismissed to a responsible caregiver who will drive them home. Once home, the patient will stay with their companion until all of the effects of the sedation have worn off.

• Retrograde amnesia. Due to the amnesiac effects of the medications, patients have little or no recollection of the treatment. It is not uncommon for our dentist members to get calls from patients who are amazed that they don’t remember the appointment. The front desk then says, “Have you looked in the mirror yet?” The patient excitedly realizes that they have a new smile and they have no memory of the treatment being performed at all! They are so happy because memories of dentistry are not something they savor. Just read these testimonies.
• Less post-operative soreness[2,6,20]. When patients are afraid, their threshold for pain is much lower. Fear and anxiety trigger the release of certain chemicals in the brain, like adrenaline, which put a patient’s “fight or flight” instincts on high alert. They anticipate that something is going to hurt and so they tense their muscles, even if it is subconsciously, leading to additional soreness post-treatment. With sedation, a patient’s apprehension and hypersensitivity to pain is virtually eliminated, thus reducing the likelihood and severity of post-operative discomfort.
• Dry mouth[25,26]: During a sedation appointment the sedative will decrease salivary flow and allow the dentist to perform treatment in a dryer environment.
• Hiccups: A small percentage of patients (3%) will experience a period of hiccups lasting no longer than ten minutes. They are self-limiting.

You may prescribe Valium^® by virtue of your dental license and DEA permit. As for the triazolam, the answer is a qualified no. This would qualify as anxiolysis. No state requires a permit to provide anxiolysis, however, West Virginia requires a 6-hour training certificate.

Treating anxious and fearful patients without sedation can be difficult. They often require extra consolation and reassurance, and are not always cooperative. It can take an hour to complete what would ordinarily take five minutes. However, with the proper amount of sedation, these patients are safely and quickly transformed into the best and most enjoyable patients to treat. Because they are fully relaxed, you are able to work more efficiently. Their jaws naturally loosen, they become cooperative, and quite pleasant to be around. In the end, you get better results and a happier patient.

Sedated patients are the easiest patients to treat. They are a lot like “Dexter” the dummy we all worked on in dental school, except unlike Dexter, they are conscious and able to do as you ask, yet they are totally relaxed and comfortable, allowing you to do your dentistry. It is truly the best of both worlds - relaxing for the patient and relaxing for you.

“Titration” of an oral sedative is quite valuable when properly done. It enables you to maintain maximum patient comfort even for lengthy procedures while using a minimum amount of sedative. We have many members who are providing periodontal care, endodontic therapy, crown preps and temporaries, all in one visit. What makes this possible is “titration”.

When you understand drug kinetics and use them to determine the application of a “titration” formula, then a predictable result is highly likely.

This means that when properly administered, “titration” is quite safe and is amongst the DOCS protocols that we teach at our sedation courses. In addition to “titration,” single-dose protocols are also presented.

Special programs at NYU are customized for NY & NJ.

Sedation medications are chosen based on an individual’s medical history. At DOCS’ courses you learn how to utilize sophisticated, yet easy-to-use dental-specific drug interaction software that automatically cross-checks a patients’ medications (even herbal and nutritional supplements) with sedative medications. In addition to taking a thorough medical history from each patient, drug interaction screening and patient monitoring (with equipment such as a pulse oximeter with a blood pressure monitor), helps ensure oral sedation dentistry is completed safely and effectively.

As you become more comfortable with sedation dentistry, you will be able to schedule fewer—yet more productive—appointments[13]. This is because sedation patients often require more treatment during a single visit. Many DOCS members whose days were filled with too many short, low-value appointments are able to create schedules that allow them too see a smaller number of patients while still increasing practice profitability. This is usually accomplished by setting aside one day every week solely for sedation treatments. Dr. Anthony S. Feck, Dean of DOCS faculty, has written several articles on the subject matter illustrating his personal keys to success.

Although insurance companies do not pay for sedation there is a code for non-IV sedation (09248) that can be used to save the patient and your office time and money. Insurance companies often pay for all four quadrants of scaling and root planning (4341) in one appointment if performed while the patient is sedated.

No, unless you have a general anesthesia permit. You shouldn’t even say “nap,” “doze,” “twilight,” “dream,” “snooze,” or “wake up.”

If you have a conscious sedation permit (oral or I.V.), you can say “sedation dentistry.” If not, you should say “anxiety-free dentistry” or “relaxation dentistry.” If you are in a state that does not require a permit for oral conscious sedation, you can say “sedation dentistry.”

The Dental Organization for Conscious Sedation (DOCS) regularly offers a 3-day, hands-on Oral Sedation Dentistry course that has been specifically designed to meet many state regulations. (See upcoming dates.) Check out your Sedation Regulations.

All DOCS programs are AGD PACE-Approved courses. Oral Sedation Dentistry covers 14 simple techniques that will help you provide total relaxation to your patients, perform larger cases, and do the dentistry you love to do in a more comfortable environment. You will also participate in hands-on experience and training in critical techniques for ultimate patient safety, something emphasized at all DOCS courses. Whether your goal is oral conscious sedation or Anxiolysis, this class has all you need to get started.

DOCS Education is a membership group of over 3,400 dentists who routinely practice safe adult oral sedation. DOCS graduates have safely and successfully completed an estimated 1 million oral sedation procedures in the US and Canada. But there are more patients who need help.