Sedation for Nervous Patients

In reality, you remain conscious during conscious IV sedation. You will also be able to understand and respond to requests from your dentist.

However, you may not remember much (or anything at all) about what went on because of two things:

1. IV sedation induces a state of deep relaxation and a feeling of not being bothered by what’s going on
2. the drugs used for IV sedation produce either partial or full memory loss (amnesia) for the period of time when the drug first kicks in until it wears off. As a result, time will appear to pass very quickly and you will not recall much of what happened. Many people remember nothing at all. So it may, indeed, appear as if you were “asleep” during the procedure.

The drugs which are usually used for IV sedation are not painkillers (although some pain-killing drugs are occasionally added), but anti-anxiety drugs. While they relax you and make you forget what happens, you will still need to be numbed.

If you have a fear of injections, you will not be numbed until the IV sedation has fully kicked in. If you have a phobia of needles, you will very probably be relaxed enough not to care by this stage. Your dentist will then wait until the local anaesthetic has taken effect (i. e. until you’re numb) before starting on any procedure.

“Intravenous” means that the drug is put into a vein. An extremely thin needle is put into a vein close to the surface of the skin in either the arm or the back of your hand. This needle is wrapped up with a soft plastic tube. It makes the entry into the vein, then is slid out leaving the soft plastic tube in place. The drugs are put in through that tube (which is correctly referred to as an “indwelling catheter”, but more commonly known by the tradename of Venflon). The tube stays in place throughout the procedure.

Throughout the procedure, your pulse and oxygen levels are measured using a “pulse oximeter”. This gadget clips onto a finger or an earlobe and measures pulse and oxygen saturation. It gives a useful early warning sign if you’re getting too low on oxygen, although if your dentist and the nurses are paying attention they should see it way before the machine does. Blood pressure before and after the procedure should be checked with a blood pressure measuring machine (a tongue-twister called “sphygmomanometer”, which for obvious reasons is referred to as “sphyg”).

The most commonly used drugs for IV sedation are benzodiazepines, or “benzos” for short. These are anti-anxiety sedative drugs.

IV administered benzos have 3 main effects: they reduce anxiety/relax you, they make you sleepy, and they produce partial or total amnesia (i. e. make you forget what happened during some or, less frequently, all of the procedure). Total amnesia is more common with midazolam compared to diazepam.

By far the most commonly used drug for IV sedation is Midazolam, but occasionally Diazepam can be used.

Midazolam is the first choice because of its relatively short duration of action (meaning that it’ll be out of your system faster). Valium is (marginally) cheaper but longer acting and a bit “harder” on the veins, so you may feel a burning sensation on your arm/hand when the drug first enters. Local anaesthetic solution can be mixed in with Diazepam to make things more comfortable. The latest IV Diazepam is an emulsion which is claimed to be easier on the veins.

The drug is put into the vein at the rate of 1mg per minute for Diazepam or 1 mg every 2 minutes (followed by an extra 2 minutes to evaluate the effect) for Midazolam (because Midazolam is stronger in terms of the dose needed to achieve sedation). Because there are differences between individuals in how much of the drug you need to be sedated, your response to the drug is monitored. Once the desired level of sedation is achieved, the drug is stopped.

The Venflon is left in place during the procedure so that the sedation can either be topped up or so that the reversal agent for benzos (Flumazenil) can be put in in the unlikely event of an emergency.

IV sedation is extremely safe when carried out under the supervision of a specially-trained dentist. Purely statistically speaking, it’s even safer than local anaesthetic on its own!

However, contraindications include

• pregnancy
• known allergy to benzodiazepines
• alcohol intoxication
• CNS depression, and
• some instances of glaucoma.

Cautions (relative contraindications) include psychosis, impaired lung or kidney or liver function, advanced age, and sleep apnea. Many people who have sleep apnea haven’t been officially diagnosed – if you are overweight and you snore, do mention this.

Heart disease is generally not a contraindication.

If you have been taking benzodiazepines for many years, your tolerance may be very high – so let your dentist know that you’ve been taking them!

The Dental Sedation teachers group uses the following classification for making the decision if and where conscious sedation should be provided:

• I – Normal, healthy patient
• II – A Patient with mild systemic disease, e.g. well controlled diabetes or epilepsy, mild asthma
• III – A patient with severe systemic disease limiting activity but not incapacitating, e. g. epilepsy with frequent fitting, uncontrolled high blood pressure, recent heart attack
• IV – A patient (usually hospitalised or bedridden) with incapacitating disease that is a constant threat to life
• V – A patient who is expected to die within 24 hours with or without treatment

source: American Society of Anaesthesiology Classification of Physical Status (ASA)

If you are in category I or II, then you can normally be treated in a general practice.

If you are in category III, it is best to be treated in an environment where more experienced support is available (a hospital-based clinic or a sedation clinic where medical support is available).

• IV sedation tends to be the method of choice if you don’t want to be aware of the procedure – you “don’t want to know”.
• The onset of action is very rapid, and drug dosage and level of sedation can be tailored to meet the individual’s needs. This is a huge advantage compared to oral sedation, where the effects can be very unreliable. IV sedation, on the other hand, is both highly effective and highly reliable.
• The maximum level of sedation which can be reached with IV is deeper than with oral or inhalation sedation.
• Benzodiazepines produce amnesia for the procedure.
• The gag reflex is hugely diminished – people receiving IV sedation rarely experience difficulties with gagging. However, if minimizing a severe gag reflex is the main objective, inhalation sedation is usually tried first. Only if that fails to diminish the gag reflex should IV sedation be used for this purpose.
• Unlike General Anaesthesia or Deep Sedation, conscious IV sedation doesn’t really introduce any compromises per se in terms of carrying out the actual procedures, because people are conscious and they can cooperate with instructions, and there is no airway tube involved.

• It is possible to experience complications at the site where the needle entered, for example hematoma (a localized swelling filled with blood).
• While IV sedation is desired precisely because of the amnesia effect (i. e. forgetting what happened while under the influence of the drug/s), there can be a downside to this: if you can’t remember that the procedure wasn’t uncomfortable or threatening, you cannot unlearn your fears. However, it depends on the precise nature of your phobia and the underlying causes to which extent this may be a problem. Some people would voice a concern that some patients can’t be “weaned off” IV sedation, as dental anxiety tends to returns to baseline levels. As a result, people who rely on IV sedation may be less likely to seek regular dental care. Other people would argue that this is not a concern if IV sedation is readily available to people.
• Some dentists may resort to IV sedation too quickly, without exploring alternative options such as iatrosedation and psychological techniques in enough detail first. Sedation should not be used as a substitute for these techniques, but as an additional tool if other techniques alone don’t work, or if it is a potentially traumatic procedure.
• Recovery from IV administered drugs is not complete at the end of dental treatment. You need to be escorted by a responsible adult.
• You shouldwant to be sedated. If, for any reason, you’re unwilling to “let go”, for example because you’re terrified of not being in control, it will be more difficult to be successfully sedated.
• Cost is another disadvantage – IV sedation is more expensive than other sedation options.

1. Have your escort take you home and rest for the remainder of the day.
2. Have an adult stay with you until you’re fully alert.
3. Don’t perform any strenuous or hazardous activities and don’t drive a motor vehicle for the rest of the day.
4. Don’t eat a heavy meal immediately. If you’re hungry, eat something light, e. g. liquids and toast.
5. If you experience nausea, lie down for a while or drink a glass of coke.
6. Don’t drink alcohol or take medications for the rest of the day unless you’ve contacted your dentist first.
7. Take medications as directed by your dentist.
8. If you have any unusual problems, call your dentist.