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"SLEEP DENTISTRY"

In this age of anxiety, pain control and sedation have become important aspects of dental care. It is now becoming more common for general dentists 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 (somewhere between 14 and 34 million Americans voluntarily avoid seeking dental care because of their "fear of the dentist"). 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 enteral (medication by mouth) sedation and, depending on the state regulations, may be safely and effectively administered in the dental office.

The definition of anxiolysis is simply "a reduction in anxiety" and involves a patient who can respond to verbal commands and maintains normal respiratory and cardiovascular function. Conscious sedation is a slightly deeper level of sedation defined as "a minimally depressed level of consciousness that retains the patient's ability to independently and continuously maintain an airway and respond appropriately to physical stimulation or verbal commands and that is produced by a pharmacological or non-pharmacological method or a combination thereof". As you can see, there is no clear demarcation between anxiolysis and conscious sedation. Theoretically, all patients pass through a lighter level of sedation (anxiolysis) before entering conscious sedation. The drugs given for anxiolysis produce conscious sedation if given in larger doses or in combination with other drugs and, while there are differences between the two in the eyes of the dental team and state regulators, there appears to be little diffence to the patient. In other words, the patient will perceive a positive dental experience with vague memories of the visit (anterograde amnesia) and may feel that they slept through most of the procedure even though they certainly did not.

With that in mind, it must be said that any of the drugs used for sedation are not without risk albeit small. It is vital that any patient undergoing sedation be carefully monitored before, during and after the dental procedure. Equipment that is capable of taking continuous blood pressures, pulse readings and blood oxygen saturation levels are mandatory and the respiratory rate should be noted periodically. And, of course, a basic emergency kit has to be on hand just in case and among the medications in this kit should be an agent to reverse the effects of any of the sedative agents used in the office.

A year ago, the Oklahoma Dental Board enacted a statute requiring that any dentist who administers oral sedation to a child under thirteen years of age must first be issued a certificate to do so. This requires taking an approved two-day course on enteral sedation and emergency management as well as having an in-office inspection to verify that the proper equipment and procedures are in place. As of now, there isn't a general dentist in the Enid area that has this certificate so, if your child is to be pre-medicated it would be wise to ask some questions. As far as I know, only one of these courses has been given in the state; I took it in Dallas last summer where Texas dentists giving enteral sedatives to any patient no matter what age must be certified attend; that course is given several times a year and it was packed!

What medications do we utilize for anxiolysis? The most common and the safest is nitrous oxide gas (laughing gas). It has a quick onset and is exhaled in the same form as it was inhaled with no metabolism in the body. It wears off rapidly and, with few exceptions, has no side effects. I use a lot of nitrous oxide but, as one who has to get his hands inside patient's mouths, I have to say that more often than not, the hoses and/or nosepiece gets in my way. Also, patients musts be able to breathe through their noses and often they bounce in and out of sedation due to aberent breathing patterns. By far the best sedative medications or members of the benzodiazapine family of drugs. These are the "drugs of choice" and the most common one is diazapem (Valium). Diazapem, however, has one property that makes it not as ideal as some of the other members of that family; several of its metabolites also cause sedation making its affects last a long time. For that reason, I like to use triazolam (Halcion) 0.25 milligrams taken one hour before the appointment (this can be taken at home but I prefer to have the patient come to the office where I can administer the medication). Triazolam has been described as near ideal anti-anxiety medication for oral sedation in dentistry. It is extremely safe and effective and it's sedative effects only last a few hours.

If you are one of the many up-tight patients, consider this regimen as it can make dental visits a whole lot more fun (well, maybe not fun but at least more tolerable).


posted by Steve at 6:57 PM