A Guide to Dental Sedation E-Book

Leonard B. Goldstein

• Herausgeber: Quintessence Publishing Co, Inc
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 285

Veröffentlichungsjahr: 2022

Beschreibung

Sedation is practiced in all areas of dentistry, and clinicians who want to offer sedation to their patients must have a thorough understanding of how to administer sedation safely and effectively. This concise guide bridges the gap between classroom instruction and the actual application of various methods of sedation. The considerations for each dental specialty are covered, with special focus on pediatric and special needs patients. Chapters summarize the medications used in sedation, including dosages, warnings, and reversal agents, and sections on nitrous oxide discuss how to administer it without harm to the provider. Minimizing pain and anxiety for patients is as important a goal in dentistry as providing a functional and esthetic smile, and this concise reference book provides best practices to achieve it.

Leseprobe

A Guide to Dental Sedation

© 2022 Quintessence Publishing Co, Inc

Quintessence Publishing Co, Inc

411 N Raddant Road

Batavia, IL 60510

www.quintpub.com

All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without prior written permission of the publisher.

Publishing Director: Bryn Grisham

Editor: Marieke Z. Swerski

Production and Design: Angelina Schmelter

Dedications

To my wife Shelley, whose love inspires and strengthens me.

Leonard B. Goldstein

To my late son Alfred. May his memory continue to inspire me.

Alfred Mauro

To my husband Bernie, whose support, encouragement, and pride for everything I do is unbounding. I am glad we are on this journey together and I love you.

To my parents, for always believing I can and forever being in my corner. Words cannot express how much I love and appreciate you both and all you do.

Lindsay M. Gilbert

Contents

Section I: Introduction to Dental Sedation

1. A Brief History of Dental Sedation from 1960

Fred C. Quarnstrom | Lindsay M. Gilbert

2. Understanding Dental Sedation

Anthony Charles Caputo | Stuart L. Segelnick | Mea A. Weinberg | Dena M. Sapanaro

3. Patient Assessment and Evaluation

Chase L. Andreason | Anthony Charles Caputo | Lauren Hanzlik

4. Sedation Strategies

Anthony Charles Caputo

5. Patient Monitoring During Sedation

Chase L. Andreason | Leonard B. Goldstein | Lauren Hanzlik | Alfred Mauro

6. Sedation Drugs

Chase L. Andreason | Leonard B. Goldstein | Lauren Hanzlik | Alfred Mauro | Stuart L. Segelnick | Mea A. Weinberg | Dena M. Sapanaro

Section II: Sedation in Specialty Practice

7. Periodontic Sedation

Stuart L. Segelnick | Mea A. Weinberg | Dena M. Sapanaro

8. Endodontic Sedation

Maria C. Maranga

9. Orthodontic Sedation

Jae Hyun Park | Dawn P. Pruzansky

10. Pediatric Dentistry and Sedation

Leonard B. Goldstein | John T. Hansford | Mana Saraghi

Section III: Other Considerations

11. Special Needs Dental Patients

John T. Hansford | David J. Miller | Mana Saraghi

12. Complications, Emergencies, and Emergency Management

Leonard B. Goldstein | Alfred Mauro

13. Animal-Assisted Therapy in the Dental Setting

Mai-Ly Duong

Preface

Dental sedation has improved substantially during the past decades, especially since the publication of the foundational textbooks on the topic. Over the years, many students and practicing dentists have requested a “desk reference” to describe the use of sedation in all the clinical specialties in dentistry, and that is what this book aims to do. We appreciate the opportunity to share this information and believe we have assembled an outstanding group of content experts and chapter authors who contributed to the topic of dental sedation.

Our intent is for this book to be used as a reference guide for both dental students and practicing dentists. We believe that it can help to bridge the gap between classroom instruction and the actual application of various methods of sedation in the different specialties.

We have had the honor and pleasure to work with many outstanding and renowned authors in the field of dental sedation and dental clinical specialties, and none of them has ever refused to exchange opinions, accept advice, or provide suggestions. To all of them, we give our most grateful thanks for agreeing to be part of this project, one of the most exciting in our professional careers.

Together we hope that our efforts will be appreciated by the heterogeneous dental community of dental students, dental practitioners, and all dental specialists.

Acknowledgments

First of all, we want to thank our families for their constant support and encouragement during the preparation of this book. We also want to express our gratitude to all the chapter authors and content experts who have worked tirelessly on this project. Because this book is based on many years of combined experience, there are numerous friends, colleagues, and mentors who have contributed to the information contained in this text in some way, shape, manner, or form.

We want to thank Norman Gevitz, PhD, Senior Vice President of Academic Affairs at AT Still University, for his constant support during the preparation of this book. We also thank Craig Phelps, DO, President of AT Still University, for his support for our project. In addition, we thank and acknowledge the deans and faculty of the two AT Still University Schools of Dentistry and Oral Health (Mesa, Arizona, and Kirksville, Missouri) for their assistance. We also thank our friends and colleagues at the Schools of Dentistry at UCLA, Stony Brook, and the University of Illinois for their support.

The editors also acknowledge all of the researchers who have added to the extensive body of knowledge regarding dental sedation. And last, but not least, we thank Ms Bryn Grisham, Publishing Director at Quintessence Publishing USA, who has ushered this project from conception to completion, and everything in between, including during the COVID-19 pandemic when everything came to a halt.

Contributors

Chase L. Andreason,dmd

Private Practice Limited to Oral and Maxillofacial Surgery

Evansville, IN

Anthony Charles Caputo,dds, ma

Dentist Anesthesiologist

Private Practice

Tucson, Arizona

Adjunct Professor and Attending Anesthesiologist

Center for Advanced Oral Health

Arizona School of Dentistry & Oral Health

AT Still University

Mesa, Arizona

AEGD Program Director

Johnston Memorial Hospital

Ballad Health

Abingdon, Virginia

Mai-Ly Duong,dmd, mph

Associate Professor

Arizona School of Dentistry & Oral Health

AT Still University

Mesa, Arizona

Lindsay M. Gilbert,msm, msed, edd

Adjunct Faculty

Scottsdale Community College

Scottsdale, Arizona

Leonard B. Goldstein,dds, phd

Assistant Vice President for Clinical Education Development

Professor, Arizona School of Dentistry and Oral Health

AT Still University

Mesa, Arizona

Professor, Missouri School of Dentistry and Oral Health

AT Still University

Kirksville, Missouri

John T. Hansford,dmd

Pediatric Dentist and Dental Anesthesiologist

Private Practice

Former Chief of Dental Anesthesiology

Interfaith Medical Center

Brooklyn, New York

Lauren Hanzlik,dds

Private Practice Limited to Oral and Maxillofacial Surgery

Denver, CO

Maria C. Maranga,dds

Clinical Assistant Professor

Postdoctoral Residency Program

New York University Langone Dental Medicine

Brooklyn, New York

Alfred Mauro,md

Diplomate in Anesthesiology

Director Emeritus of Anesthesiology

Jersey City Medical Center

Jersey City, New Jersey

David J. Miller, dds

Chairman and Chief Administrative Officer

Department of Dental Medicine and Oral and Maxillofacial Surgery

One Brooklyn Health

(Brookdale/Interfaith/Kingsbrook Medical Centers)

Brooklyn, New York

Jae Hyun Park,dmd,msd, ms, phd

Professor and Chair/Program Director

Arizona School of Dentistry & Oral Health

AT Still University

Mesa, Arizona

Dawn P. Pruzansky,dmd

Private Practice Limited to Orthodontics

Phoenix, AZ

Fred C. Quarnstrom,dds

Dentist Anesthesiologist

Affiliate Assistant Professor

Department of Dental Public Health Science/Oral Health Sciences

School of Dentistry

University of Washington

Seattle, Washington

Dena Sapanaro,dds, ms

Adjunct Clinical Assistant Professor

Department of Pediatric Dentistry

New York University College of Dentistry

New York, New York

Mana Saraghi,dmd

Director, Dental Anesthesiology Residency Program

Jacobi Medical Center

Assistant Professor

Albert Einstein College of Medicine

Bronx, New York

Vice President of Oral Exams

American Dental Board of Anesthesiology

Stuart L. Segelnick,dds, ms

Adjunct Clinical Professor

Department of Periodontology and Implant Dentistry

New York University College of Dentistry

New York, New York

Mea A. Weinberg,dmd, rph, msd

Clinical Professor

Department of Periodontology and Implant Dentistry

New York University College of Dentistry

New York, New York

Section I

Introduction to Dental Sedation

Chapter 1

A Brief History of Dental Sedation from 1960

Fred C. Quarnstrom, ddsLindsay M. Gilbert, MSM, MSEd, EdD

Since its development and advent in dentistry, anesthesia has had a complicated history encompassing both the tension between the fields of medicine and dentistry and the tensions among dental specialties. Public perception regarding the safety of sedation anesthesia in the dental office has also increased the pressure on all dentists to protect their legal ability to provide this important form of pain management for their patients. This historical reflection highlights key events over the past five decades that have greatly influenced the course of sedation anesthesia in dentistry and who performs it. See Box 1-1 for a list of relevant organizations and the acronyms they will be referred by.

Box 1-1 Organizations related to the history of dental sedation

AAOMS American Association of Oral and Maxillofacial Surgeons

ADA American Dental Association

ADBA American Dental Board of Anesthesiology

ADSA American Dental Society of Anesthesiology

ARRC Anesthesia Residency Review Committee

ASA American Society of Anesthesiologists

ASDA American Society of Dentist Anesthesiologists

CODA Commission on Dental Accreditation

NCRDSCB National Commission on Recognition of Dental Specialties and Certifying Boards

SCSOMS Southern California Society of Oral and Maxillofacial Surgeons

In 1960, the American Association of Oral and Maxillofacial Surgeons (AAOMS; then called the American Society of Oral Surgeons) Committee on Graduate Training published a statement paper called Essentials of an Adequate Training Program in Oral Surgery.1 At this time, the organization recommended 12 months’ worth of anesthesia training for oral and maxillofacial specialty students. By the late 1960s, there were many general dentists doing intravenous (IV) sedation bordering on general anesthesia with just 3 months of IV general anesthesia training. The American Dental Society of Anesthesiology (ADSA) was largely comprised of these general dentists. Very few oral surgeons were members of this organization at that time.

The Author’s Experience in Early Years

I finished my 1-year general anesthesia residency in 1967, the same year the ADSA initiated its fellowship examination process, which at that time was open to any dentist with a minimum of 1 year of operating room–based anesthesia residency training.1 I came home to Seattle with the intention of doing general anesthesia for general dentistry. I contacted the Chairman of the Oral Surgery Department at the University of Washington to see if my training would be of value to the school, because very few dentists had done a full year of anesthesia training. I had used IV diazepam (Valium, Roche) in my residency to achieve IV sedation for several procedures that were short but painful. At that time, diazepam was just coming to market. The chairman questioned me regarding this drug and my use of it, and we discussed it for several hours. He then told me, “Do not get in trouble. I will have to serve with the prosecution.” I asked why he would say that: I had a full year of general anesthesia training, whereas his residents only received 3 months. In fact, during my residency I had even supervised oral surgery residents as they rotated through the operating room.

For a new dentist just opening a practice, the climate for a general dentist doing general anesthesia in Seattle was at best hostile. I began providing IV sedation. Patients were awake and talking, but because of the amnesia caused by the diazepam, they did not remember the procedure and were well relaxed, making the procedure possible or at least easier. I only did this for severely phobic patients who simply could not tolerate dentistry because of their fear. For those who were mildly phobic, I use a combination of nitrous oxide oxygen (N2O-O2). They were awake and comfortable but had little, if any, amnesia.

I continued using IV sedation for about 20 years. Dentists could not advertise their services in the 1960s through the 1990s, so my patients came via referrals from other dentists or my patients. I did at least one case of IV sedation a week and used (N2O-O2) sedation on well over 70% of my patients. My practice was largely comprised of phobic dental patients who no one else wanted to treat. A difficult patient is better than a vacant chair!

I became rather adept at treating fearful patients. I often felt patients came in two varieties: those who were fearful and would admit their fear and those who were fearful and would not admit their fear. At that time, there was no other option for them but my practice. They could go to an oral surgeon and have extractions performed under general anesthesia, but I knew of no one else in the greater Seattle area who would do IV sedation for general dentistry. Later, in 1982, the University of Washington opened a dental fear clinic that could not only treat fearful patients with sedation but also had psychologists on the faculty to help patients address and conquer their fears.

In 1980, Cohen et al published a paper showing that male dentists and female chairside assistants who worked in dental offices and were exposed to nitrous oxide had higher incidence rates of liver disease, kidney disease, and neurological disease than those working in offices that did not use nitrous oxide.2 In the case of female chairside assistants with heavy exposure to nitrous oxide, the study also showed a 2.3-fold increase in miscarriages. It took several years for this research to make its way into dental schools. In response, companies developed scavenging techniques to remove the trace nitrous oxide gas from the air we breathe in dental offices. Dental schools discussed these hazards. The use of nitrous oxide dropped dramatically, particularly in the offices of female dentists and offices where dental staff were pregnant.

In 1983, anesthesia in dentistry received nationwide media coverage after a 37-year-old dentist in California named Tony Protopappas was arrested for (and later convicted of) the second-degree murder of three patients. The patients included a 13-year-old child and a 23-year-old dialysis patient whose primary physician has advised Dr Protopappas that she should not be given general anesthesia due to her medical condition. At the time of the patient deaths, Dr Protopappas was not licensed to administer anesthesia.3,4 Before the Protopappas case and the resulting media storm, clinicians in California could choose to undergo voluntary in-office anesthesia evaluations conducted by the Southern California Society of Oral and Maxillofacial Surgeons (SCSOMS). Afterward, this voluntary evaluation model evolved into a nationwide system of mandatory state board–regulated permits for the use of general anesthesia by dentists.1,3

In the mid-1980s, malpractice insurance costs for doing IV sedation skyrocketed. The increase for my practice was about $5,000 more a year. It was no longer practical to continue doing IV sedation unless I was doing several IV cases a week. I had taught nitrous oxide sedation courses and a couple of IV sedation courses since 1969. At the time, I had close to 200 IV anesthesia patients. I did some research for an alternative to IV diazepam. A dentist in Canada, whom I taught with, suggested I should try an oral medication with my fearful patients. Triazolam (Halcion, Pfizer) was a popular sleep aid that was reported to keep patients relaxed but awake. Patients had amnesia of the dental procedure while under the effect of triazolam. I started using oral triazolam on fearful patients on whom I had previously used IV sedation, and it worked far better than I expected. The most fearful patients were now able to have dentistry done while awake and talking. They did not remember the treatments yet they were awake and comfortable.

In 1990, I started presenting courses on oral conscious sedation using triazolam. In 2003, Dr Michael Silverman came to the American Dental Association’s Committee to present his case for doing courses in oral conscious sedation with his continuing education company, Dentists for Oral Conscious Sedation. Suddenly, there were courses for general dentists who wanted to go further with sedation than was possible with just (N2O-O2).

Conflicting Voices: The Many Interests of Dental Anesthesiology

The first national society for anesthesiology in dentistry, the ADSA, was formed in 1953 to protect, develop, and further the field of anesthesiology in dentistry.5 Most of the founding members were oral surgeons, but the organization soon attracted dentists outside the specialty with interest in anesthesiology, including general dentists. In 1954, then-president William B. Kinney made clear the ADSA’s main goal in a letter to all members published in the organization’s first news publication. That goal was to achieve specialty status for dental anesthesiology from the American Dental Association (ADA).5 As the group grew in both membership and influence, it began to tackle the issue of postdoctoral education opportunities in anesthesia for dentists. In the late 1980s, the ADSA began committing a significant portion of its financial resources toward funding and supporting dental anesthesiology programs throughout the country.6 During this period, the ADSA also developed a board examination, the American Dental Board of Anesthesiology, and began the specialty application process.7

However, the ADSA Board of Directors discontinued the specialty application pursuit in October of 1991. This decision was influenced by two events. In June of 1991, the Anesthesia Residency Review Committee (ARRC) of the Accreditation Council for Graduate Medical Education threatened medical program directors with the loss of program accreditation if dentists were rostered as anesthesia residents.8 This decision was based on pressure by the American Society of Anesthesiologists (ASA), which was concerned by the number of dentist anesthesiologists in medical residency programs.1 The ARRC later allowed that dentists could participate in medical anesthesia rotations of up to 12 months but could not be considered residents.8 The AAOMS successfully negotiated continued anesthesiology rotations for oral and maxillofacial surgeons (OMS) residents, but non-OMS dentist anesthesiologists were left unmoored.1

The second event that directly caused the ADSA to abandon the specialty application was action taken by the AAOMS. Originally founded by oral and maxillofacial surgeons who supported the specialty formation, the ADSA had over the decades attracted a large proportion of non-OMS dentist anesthesiologists and general dentists interested in anesthesia. However, in the 1980s, an influx of oral and maxillofacial surgeons joined the ADSA, as they felt the additional board certification was in their best interest. By 1991, 70% of the ADSA membership consisted of oral and maxillofacial surgeons.7 The AAOMS did not support the ADSA’s mission to obtain specialty status for dental anesthesiology. The AAOMS has historically opposed the creation of an anesthesiology specialty out of concern that this would limit access to anesthesia for dentists outside the specialty, including oral and maxillofacial surgeons.9 Of paramount concern, also, was protecting the operator-anesthesia team model established by OMS. The AAOMS therefore exerted political pressure over the ADSA through an organized effort to reduce membership support for specialty formation by asking AAOMS members to discontinue their ADSA membership. Ultimately, in October of 1991, the ADSA Board of Directors voted to discontinue sponsorship of specialty recognition in order to preserve the organization, and in 1996, the ADSA House of Delegates voted for the organization to remain neutral on the issue of specialty formation.7,8

Back when the membership of the ADSA became populated by mostly oral and maxillofacial surgeons, this population change became mirrored in their education focus. Several dentist anesthesiologists became dissatisfied by the ADSA’s educational course offerings, which were largely designed to serve the oral and maxillofacial surgeon’s position as operator-anesthetist rather than dentist anesthesiologists. In 1980, Drs Larry Trapp and Ron Davies, two dentist anesthesiologist members of the ADSA, invited all ADSA members with 2 or more years of anesthesiology training to a meeting, and 17 dentists attended. Upon discussing their shared desire for more substantive continuing education on dental anesthesiology, they determined that the only solution was to start a new society designed for the benefit of dentists who were trained more extensively in anesthesia than the general ADSA membership. Members would be required to have 2 or more years of anesthesia training, this number being based on the length of training required to be board-eligible in medical anesthesia. The name chosen for the new society was the American Society of Dentist Anesthesiologists (ASDA).10

It was originally intended by the founders that the ASDA would be supplemental to the ADSA and that all would choose to be members of both societies; after all, the founders themselves were members of the ADSA.10 However, the ADSA leadership quickly made it known that they disapproved of the new society, perhaps in part because the 2-year anesthesiology education requirement excluded most oral and maxillofacial surgeons. However, the two organizations soon established a positive relationship based on the willingness of the ADSA Board of Directors to pursue specialty formation. When the ADSA gave up the gauntlet of specialty formation in 1991, the ASDA gladly took it up.

The ASDA submitted its first specialty application to the ADA in 1994 and, upon rejection, submitted again in 1997 and 1999. Each time, the AAOMS strongly opposed the application. After the 1994 application rejection, the ASDA leadership changed track. To bolster their next application, it was decided that they should demonstrate the ASDA’s ability to develop an independent board of anesthesia for dentistry. The ADSA had previously given up their efforts to establish a board upon surrendering the pursuit of specialty application, so the ASDA claimed the name and established the American Dental Board of Anesthesiology (ADBA). A revised specialty application was submitted in 1997 after establishment of the ADBA. However, it was rejected, as was the 1999 application.7

After the 1999 rejection, the ASDA changed track again. Because CODA (Commission on Dental Accreditation) accreditation of postdoctoral training programs is so closely linked with ADA specialty recognition, it was decided that acquiring CODA accreditation for dental anesthesiology residency programs should be the next course of action prior to another specialty application. Of equal importance was the fact that the 1991 loss of space in accredited medical anesthesiology residencies for non-OMS dentists had left many practitioners without an accredited postdoctoral option. The ASDA leadership felt that CODA accreditation acquired separately from ADA specialty recognition would be a stop-gap measure that would provide and protect dental anesthesiology education until a specialty application could be successful. Additionally, the independent oversight and standardization of postdoctoral training programs in dental anesthesiology would strengthen the defense of anesthesiology’s place in dentistry.

In 2001, the ASDA submitted a request to the CODA asking for accreditation of postdoctoral training in dental anesthesia. Organizations that opposed CODA accreditation of dental anesthesiology programs included the AAOMS, the American Association of Orthodontics, and the American Academy of Oral and Maxillofacial Pathologists, as well as the ADA and its House of Delegates. Over the next 3 years, the CODA commissioners developed an application process to evaluate the merits of accrediting postdoctoral training programs in areas of general dentistry not recognized by the ADA House of Delegates or its Council on Dental Education and Licensure. In 2004, the ASDA formally submitted their application for accreditation of postdoctoral training in anesthesiology for dentistry, and in 2005 the CODA approved accreditation for dental anesthesiology postdoctoral programs.8,11

In 2012, the ASDA again applied for specialty recognition from the ADA. This application was once more rejected. In 1994, 1997, 1999, and 2012, the ASDA’s application passed the review process up until the final vote by the ADA House of Delegates.7 After the 2012 rejection, the ASDA removed language from its founding documents that specifically supported the OMS operator-anesthesia model.

At the 2017 Annual Meeting of the ADA, approval was granted to create the National Commission on Recognition of Dental Specialties and Certifying Boards (NCRDSCB). This board consisted of 19 members, and its purpose was to reduce bias or conflict of interest throughout the process of recognizing a dental specialty. The 19 members of the board included 9 general dentists and 9 specialists, one representing each of the 9 specialty areas recognized by the ADA. These members were appointed by the ADA Board of Trustees, under the leadership of President Dr Joseph Crowley. The last member was a public member who was not a dentist or specialist. The creation of the NCRDSCB paved the way for a fifth attempt to recognize dental anesthesiology as a specialty.12

In 2018, the ASDA submitted its fifth application to officially recognize dental anesthesiology as a specialty. Numerous updates were carefully made to the application, reflecting changes to ASDA membership requirements. A subcommittee of the NCRDSCB convened and determined that the application, just like the four previous applications, met all the ADA standards necessary to be recognized as a specialty. Following subcommittee review, there was a 60-day public comment period before the NCRDSCB met again to determine the outcome of the application. The commission approved the application, at last recognizing dental anesthesiology as a specialty area after 67 years and five application attempts.12

Currently, ASDA membership requirements include a minimum of 3 years of training in an ADA/CODA-accredited anesthesiology program, up from the original 2 years of training required at their founding in 1980. As part of that training, 2 years must focus on administration of clinical anesthesiology, with 6 months of that time focused on anesthesiology specific to dental patients. A minimum of 1 year of the 2 required years must be spent as part of a hospital rotation in an anesthesiology department. This is more than twice the required time for any other anesthesia rotation in a dental specialty program. A minimum of 800 deep sedation/general anesthesia cases must also be completed by dental anesthesiologists. Of these, there must be a minimum of 300 endotracheal intubations, with 59 nasal intubations and 25 other advanced airway approaches. There are also required minimums of 125 children under 8 years of age and 75 special needs patients, since dental anesthesiology specialists are likely to work with these patient populations.12

The Current State of Anesthesiology in Dentistry

In the past, the minimal training accepted by most states was a 60- to 80-hour didactic course and 20 clinical cases under supervision of a dental anesthesiologist, with 1 year or more of anesthesia residency or supervision of a medical anesthesiologist. These courses are very costly. Those doing IV sedation are still a small minority of dentists. In the interim, about 30% of dentists became qualified to do oral conscious sedation.

Nowadays, sedation anesthesia is very fragmented in general dentistry. We have dentists who only do local anesthesia, 30% or so who use (N2O-O2) sedation, another 30% who do oral conscious sedation in addition to nitrous oxide sedation, a few who do IV conscious sedation, and probably fewer than 300 dentists who are qualified to do general anesthesia. In order to provide general anesthesia, dentists are required to have a 1-, 2-, or 3-year general anesthesia residency, and oral and maxillofacial surgeons, who represent about 15% of the total dentist population, complete a surgical residency that includes some training in general anesthesia.

While sedation anesthesia in dentistry is a continuum of nitrous oxide, light oral conscious sedation, IV conscious sedation, and true general anesthesia, no single organization represents all aspects of this continuum. To an extent, each organization tends to lobby against the others as each organization tries to protect its own position in treating patients. There certainly is an overlap with other groups in many areas of practice. The operator-anesthesia model remains unique to dentistry, in contrast to our medical colleagues. No MD surgeon would both administer general anesthesia and do surgery. Only in dentistry is this commonly done.

References

1. Orr DL 2nd. The development of anesthesiology in oral and maxillofacial surgery. Oral Maxillofac Surg Clin North Am 2013;25:341–355.

2. Cohen EN, Gift HC, Brown BW, et al. Occupational disease in dentistry and chronic exposure to trace anesthetic gases. J Am Dent Assoc 1980;101:21–31.

3. Serna J. Dentist who killed 3 is paroled. LA Times. 10 July 2010. https://www.latimes.com/tn-dpt-0722-protopappas-20100721-story.html. Accessed 15 May 2019.

4. Cone M. $1.6 million awarded to 13 patients of convicted dentist. LA Times. 8 October 1992.https://www.latimes.com/archives/la-xpm-1992-10-08-me-1008-story.html. Accessed 15 May 2019.

5. The American Dental Society of Anesthesiology: 1953-1978. Anesth Prog 1978;25:9–30.

6. MacDonnell WA. Initial strategy for specialty recognition utilizing the American Dental Society of Anesthesiology. In: American Society of Dentist Anesthesiologists. History and Reflections for the Twenty-fifth Anniversary Celebration. Chicago, Illinois: American Society of Dentist Anesthesiologists, 2005.

7. Yagiela JA. My thoughts on the specialty effort. In: American Society of Dentist Anesthesiologists. History and Reflections for the Twenty-fifth Anniversary Celebration. Chicago, Illinois: American Society of Dentist Anesthesiologists, 2005.

8. Chancellor J. American Society of Dentist Anesthesiologists 25th anniversary: A brief overview. In: American Society of Dentist Anesthesiologists. History and Reflections for the Twenty-fifth Anniversary Celebration. Chicago, Illinois: American Society of Dentist Anesthesiologists, 2005.

9. Lew D. A Historical Overview of the AAOMS. Chicago: AAOMS, 2013:5–12.

10. Trapp L. The birth of the American Society of Dentist Anesthesiologists. In: American Society of Dentist Anesthesiologists. History and Reflections for the Twenty-fifth Anniversary Celebration. Chicago, Illinois: American Society of Dentist Anesthesiologists, 2005.

11. Chancellor JW. Accreditation as an alternative to specialty recognition. Tex Dent J 2002;119:248–251.

12. Weaver JM. The history of the specialty of dental anesthesiology. Anesth Prog 2019;66:61–68.

Chapter 2

Understanding Dental Sedation

Anthony Charles Caputo, DDS, MAStuart L. Segelnick, DDS, MSMea A. Weinberg, DMD, RPh, MSDDena M. Sapanaro, DDS, MS

It is common to discuss the administration of sedation for patients as a science as well as an art. The science of administering sedation is discussed throughout this textbook related to the various aspects of patient physiology and pathophysiology, available and indicated drugs for sedation, drug pharmacology and pharmacodynamics, and the combination of patient presentation with drug selection for the safe and successful treatment of the patient. The goal of this chapter is to combine the science with the art of sedation administration to understand that patient selection, sedation approaches, and successful treatment are as influenced by science as they are by the art of sedation administration. One is not more important than the other, but rather, they are equally dependent on each other for success.

Definition of Terms

Numerous sedation/analgesia terms that are encountered in articles, conversation, and written guidelines should be defined before going into depth in the chapter.

•Analgesia: The loss of the ability to feel pain while conscious. It is not sedation but rather the diminution or elimination of pain.1

•Titration: The administration of incremental doses of an intravenous or inhalation drug until the desired therapeutic effect is reached, which is important for patient safety.1 Titration allows for maximum patient comfort while using a minimum amount of sedative. Titration is unpredictable with oral drugs, often resulting in oversedation.2 Usually, subsequent doses are given before the first dose is fully absorbed and exhibiting a therapeutic effect.

•Enteral route of administration: Technique of administration whereby the drug is absorbed from the gastrointestinal tract into the general circulation. Examples include oral, sublingual, and buccal (ie, drug is applied to buccal mucosa and absorbed).

•Parenteral route of administration: Pharmacologic agents are administered that bypass the gastrointestinal tract. Examples include the intravenous (IV), intramuscular (IM), subcutaneous (SC), and intrathecal routes.

•Inhalation route of administration: Pharmacologic agents are administered via the lungs (eg, nitrous oxide-oxygen and volatile anesthetics).

•Combination inhalation route of administration–enteral moderate sedation: Obtaining moderate sedation with inhalation and enteral agents.

•Transmucosal route of administration: A technique of administration in which the drug is administered across mucosa such as intranasal, sublingual, or rectal.

Behavioral Assessment

When determining the appropriate sedation approach, one should give particular focus to the behavioral assessment of the patient.1 This is directly influenced by how we interpret and process pain. The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and/or emotional experience that is associated with actual or potential tissue damage.”3 The key words in this definition are emotional and potential. It is important to appreciate that pain is an emotional experience that is influenced by the potential for injury. Clinicians must often make a critical assessment of a patient who presents with fear or phobia to dental treatment. We are well aware of the patients who have had a traumatic dental experience and become fearful for future dental treatment, though we must also appreciate the patients who present with fear or phobia based on their overwhelming concern that something bad will happen to them during dental treatment. As compassionate and sympathetic health care providers, we must allow ourselves to identify and understand the patient’s fear or phobia regarding dentistry whether it is based on an actual experience or not. Related to this is the understanding of the dual nature of pain involving pain perception and pain reaction (Box 2-1).

Box 2-1 Pain perception and pain reaction

Pain perception The physiologic and anatomic process by which pain is received and transmitted. The actual process by which the body perceives pain.

Pain reaction The manifestation of the perception of pain. Involves psychologic factors including age, sex, past experiences, and emotional state.

Effectively, how a person perceives pain is influenced by their reaction. Therefore, it is completely understandable that a person can be phobic of dental treatment without ever having had treatment provided or have a very strong response to planned treatment based on previous poor experiences. This is why the behavioral assessment of the patient before any treatment is provided is so important. Identifying that a patient would benefit from sedation before planned treatment can facilitate a successful treatment appointment as well as tremendously benefit the patient’s response to dentistry overall. Involved with the behavioral assessment is the identification of how strongly the patient feels about dental treatment and how they feel about proposed sedation approaches. Central to this process is the patient’s acceptance of sedation as a treatment approach and understanding what that level of sedation will mean to them based on what the dentist can provide.

To have this discussion with the patient and have them agree with the planned sedation approach, you must know the definitions of the available levels of sedation and anesthesia. The document to utilize as a primary resource is the American Dental Association (ADA) Guidelines for the Use of Sedation and General Anesthesia by Dentists. This document was most recently revised and adopted by the ADA House of Delegates in October 2016.1 Within this document, there are definitions provided for each level of sedation or anesthesia that an appropriately trained dentist can administer to a patient in the dental office setting. The new guidelines place more emphasis on the levels of sedation than on the route of drug administration. Three major changes are