IV Sedation Versus Oral Sedation

By Dr. Binkowski

Not all sedation dentistry is equal, and consequently not all IV sedation dentistry is either. Many dentists that advertise themselves as “Sedation Dentists” are not providing true sedation, and in many cases are simply using oral sedatives in a way they are not intended to be used. Story City Dental provides true sedation (sleep) dentistry utilizing IV sedation. Currently, we are the only general dentistry practice in the area that offers IV moderate and deep sedation* in office. Both of these services far surpass the level of comfort and safety that can be provided compared to offices that simply use oral sedatives and “laughing gas” for “sleep dentistry”.

Read on to learn about how IV sedation can benefit extremely anxious patients.

ivsedation_ltblue

Your Anxiety Control and True Sleep Dentistry Options

Many people harbor fear for the dentist. We have seen countless patients neglect their dental health simply due to previous bad experiences. Usually these anxious patients come into our office when neglect of a simple dental problem has been allowed to grow and now the pain is preventing them from normally functioning on a daily basis.

There’s no reason to let pain grow to these levels of severity, though. There are many different options for anxiety control during an appointment to ensure a good patient experience.

Most dental offices offer two common types of anxiety control:

Nitrous oxide

(“laughing gas”)

Nitrous oxide is a vaso-dilator, which widens blood vessels and thereby increases blood flow. When the gas is inhaled, the body begins to relax and patients tend to experience euphoria and analgesia. The dentist administers nitrous oxide gas through a nasal hood. After the mask is placed on the patient, they will eventually start to feel tingling in their fingers and toes and sense relaxation. These sensations will continue throughout the procedure until the gas is removed. Once the procedure is over, the operator usually places the patient on 100% oxygen for five minutes to “flush” the remainder of the gas out of the blood stream. Afterwards, these effects disappear quickly and patients can resume normal activity. Under prolonged used at high concentrations, above 40%, the patient can experience nausea and vomiting. This is the least invasive of all the anxiety control options, is easy to titrate the mild effects, does not require much training and generally does not require any patient monitoring equipment.

Oral sedation

(AKA sleep dentistry, oral anti-anxiety medication or mild sedation)

Oral sedation involves anti-anxiety medication that a dentist will prescribe and a patient must fill at a pharmacy and bring with them to their appointment. Common drugs prescribed are benzodiazepines such as Halcion (most common), Valium, Zaleplon, Ativan, Xanax and Hydroxyzine. Generally the patient takes the recommended dosage the night before the appointment and a second dose one hour before the appointment (this varies). Unlike nitrous, the patient must be driven to and taken home from the appointment by an escort. Onset time and the effects of the drug vary from patient to patient. These medications help to reduce brain activity related to fear/anxiety, will cause drowsiness, and even cause some short-term memory loss. It is possible to titrate the effects of the drug when combined with nitrous, however, in many states this is considered two treatment agents and thus can require a moderate sedation permit. Oral sedation in many states (including Iowa) does not require advanced (or any) training to administer. If the dose of drugs given is being used to achieve a moderate level of sedation, a moderate sedation permit is required along with all associated monitoring equipment (ECG, w/BP-HR, ETCo2, SaO2). The onset of these drugs are slow as patients consume them and the doctor waits for the effects. The amount that actually reaches your bloodstream also varies due to “first pass metabolism.” Since the drug is taken orally, you can’t adjust the effects of it in real time (titration), making it possible for the operator to overshoot the desired level of anxiety control and roll into moderate or deep sedation. These drugs are reversible; however, with no IV access, the only way to reverse the effects is an intra-muscular injection (how would you like to get stabbed in the leg?). Due to the physiologic variation from person to person, the onset and duration are unpredictable. These drugs also come up short as they provide no pain control. This is what most all office in the local area are using when they advertise ‘sleep dentistry’, but the effectiveness of these drugs at producing a sleep effect couldn’t be farther from the truth.

A select few general dentistry offices in Iowa,
such as at Story City Dental, offer two substantially
more effective forms of sedation:

IV Deep Sedation*

(we offer the same thing oral surgery offices offer using our Certified Registered Nurse Anesthetist- CRNA)

This is the most effective method for achieving rapid sedation, controlling dental anxiety and producing a sleep effect stronger than IV moderate sedation. You will achieve an even deeper level of sedation bordering on unconsciousness— which is why most oral surgeons turn to it for wisdom teeth extractions. Sleep is guaranteed and patients tend to fall into a “depressed level of consciousness” where they may or may not be able to respond to stimuli. No memory of the procedure will exist after completion of the surgery. The IV medications used for Deep sedation are Propofol and Ketamine with several other drugs that can be used in combination with them to produce certain desired systemic effects. The main difference between what we offer and what you will find in an oral surgery office is that our Certified Registered Nurse Anesthetist is responsible to patient monitoring and anesthesia thus Dr Binkowski can concentrate on the procedure (not do two things at once). Secondly we do not hand-dose the sedative, we use a drug infusion pump which allows us to keep a steady, safe level of deep sedation during the duration of the procedure. Action of the drugs is seen immediately in real time. Like IV moderate sedation the same pre-op appointment is required. In some cases consultation with the patients managing physician pre-op is required. A separate appointment is made for the dental procedure (with the IV sedation). Again, there are no same-day appointments for IV sedation at Story City Dental. The same patient exclusions apply for deep sedation that apply for moderate IV sedation. Deep Sedation uses the same monitoring equipment as IV moderate sedation with the difference only being the drugs used and the way they are administered (with a drug infusion pump). The patient must be driven home by their escort. The amnesic effects of the drug last for the duration of the procedure and some time afterwards. Patients we talk to at post-op ALL say they only remember falling asleep and waking at the end, nothing else and they wish they could have always done all their dental work under IV sedation.

IV moderate sedation

(AKA IV sedation or IV moderate sedation)

This is the a substantially more effective and safer method for controlling dental anxiety and achieving a moderate level of sedation (when compared to oral sedation) — which is why some oral surgeons turn to it for wisdom teeth extractions and most periodontists use it for soft tissue surgeries. While sleep is not guaranteed, patients tend to fall into a “twilight sleep state” where they are still able to respond to commands by the provider. Depending on the combinations of the drugs being used for the sedation, many patients describe a sensation of extreme relaxation to an intensely euphoric feeling with almost all reporting that they don’t remember anything or only bits and pieces of the time period encompassing the procedure. These effects are largely due to the titrated sedative drugs (Midazolam) or the opioid effects of the narcotics (Fentanyl or Demerol) used in combination with them. The most amazing thing we find with IV sedation is the ability to watch the drugs work in realtime.1A pre-op appointment is required in which a patient’s health history is reviewed and a simple physical evaluation is completed along with pre-op vitals (HR/BP, ECG, O2-Sat). A separate appointment is made for the dental procedure (with the IV sedation). There are no same-day appointments for IV sedation at Story City Dental. Not everyone is a good candidate for IV sedation. People who have an uncontrolled systemic disease, sleep apnea, a BMI over 40 or an inability to breathe through the nose (such as cold or cough) should not receive IV sedation. The day of the procedure, the patient will be connected to a monitor for heart rhythm, heart rate, blood pressure, oxygen saturation as well as breathing and CO2 output. An IV line is then started in either the hand or arm. All drugs used for the sedation are administered through a port in the IV line. Due to the speed of onset of these drugs, they can be titrated to achieve the desired depth of sedation in real time and reversed in the same fashion should an emergency arise. After a desired level of sedation is achieved, the mouth will be numbed with a local anesthetic for the planned procedure. Once the procedure is completed, and most of the sedative effects have worn off (relatively quickly since its IV), the patient must be driven home by their escort. The amnesic effects of the drug last for the duration of the procedure and some time afterwards. Almost all patients we talk to at post-op appoints tell us they remember nothing from the procedure, and if they could, they would have always done all their dental work under IV sedation.

Lastly there are is one other form of anesthesia, and it is usually done in an outpatient facility that has a ventilator and more complex monitoring equipment utilized by an anesthesiologist, or CNRA under a general anesthesia permit. This is:

General anesthesia

For the purposes of this article we will not cover the above form of anesthesia as they are rarely seen in a general dentistry office because it usually requires a state licensed surgery center.

IV Moderate and Deep Sedation Benefits Far Exceed Oral Sedation

IV moderate and deep sedation can benefit patients for a number of reasons:

  1. Rapid to Very Rapid onset
  2. Its titratable nature
  3. An IV access will already be present in cases of emergency
  4. Use of powerful IV painkillers during the procedure
  5. Ability to immediately administer non-narcotic painkillers post-op
  6. Ability to administer anti-emetics post-op
  7. A more highly trained operator1,2
  8. The use of a Certified Registered Nurse anesthetist (CRNA) to provide anesthesia makes the entire procedure safer (The surgeon is not also the anesthesiologist)
  9. Patient vitals are constantly monitored during procedure by the operator or the auxillary3
    During deep sedation there are two providers in the room who can provide ACLS

1 Iv Moderate sedation training requires 60 hours didactic training followed by 20+ solo cases by the dentist at an ADA approved training program as well as ACLS
2 IV deep sedation provided by a CRNA which has completed an anesthesia residency as well as ACLS and PALS training.
3 heart rate/rhythm, breathing/ EtCO2, spO2, and BP all monitored

Does this mean I don’t use oral sedation in my practice? Of course not. We use oral sedation with patients who require only a mild amount of anxiety control during procedures or we prescribe oral sedation to patients pre-op so that they can rest easily the night before their appointment.

With IV sedation, what used to take multiple appointments can now be completed in 1 or 2 long appointments with no memory of the procedure. Even the most dental phobic patients will find dental treatment pain-free and comfortable allowing them to take back control of their dental health.