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“When sedation is done well and tailored to the patient, it can be a very rewarding and enjoyable experience for the dental team,” Dr Vivian Mascarenhas says. “Dental sedation allows the dental team to focus their full attention on the technical dental work and minimises the circumferential issues of patient management.

“Please speak to your sedationist (especially if they are a dentist), as they have a wealth of information to be able to help make the procedure much easier and support you, your team and your patient through the process.”

If you are considering using the services of a sedationist at your practice, consider the following:

Who is suitable for a sedation service?

Dr Richard Kozlowski says IV sedation is a great option for a generally healthy dental patient. “The ASA Physical Status Classification System is a good guide to who can be treated – screen the patients and make sure that they fall into Categories I and II only,” he advises.

Along with their medical fitness, each patients’ level of dental anxiety and their expectations of IV sedation can affect their suitability. It’s important that phobias are assessed and time is taken to explain the nature of IV sedation, plus how it differs from a general anaesthetic.

Vivian says it is important to acknowledge that smooth, predictable, and especially safe sedation procedures start with careful pre-sedation patient selection. “The next noteworthy point is that there are significant differences in providing sedation in hospitals (and day surgeries) as opposed to the dental practice setting,” he says.

“As such, there are a multitude of factors that determine a patient’s suitability for IV sedation in a dental setting which in the end, are best assessed by the attending dental/medical sedationist. In saying that, there are some very good guidelines that help the dentist to assess a patient’s suitability for recommending IV sedation to assist in facilitating their dental treatment.

These broadly are:

Patient Age: 16-70 generally.

Medical status:

a) ASA status: According to the ASA classification (American Society of Anaesthesiologists classification of clinical status), only patients with an ASA I (normal, healthy) or ASA II classification (patient with mild systemic disease, that is medically well controlled) qualify for conscious sedation in a dental surgery setting.

b) BMI (20-30): Weight alone unfortunately does not tell us the whole truth about obesity. In general, we use the Body Mass Index (BMI) to tell us whether the patient is anorexic or obese, and the severity of obesity. This will give us an indication as to what the ASA classification should be. The BMI can be calculated by a specific formula: BMI = weight
(kg)/ height (meter2):

BMI < 20, patient underweight
BMI 20-25, normal weight
BMI 26-30, overweight
BMI 31-34, obesity grade 1, ASA 11
BMI 35-40, obesity grade 2, ASA 111
BMI > 40, obesity grade 3, ASA 1V

c) Fitness: (as measured in metabolic equivalents)

We can ask the patient if they can climb two full flights of stairs without getting out of breath. This provides an excellent measure of cardiovascular and respiratory status.

Oral and airway assessment:

Respiratory compromise under sedation is the largest category of adverse outcomes during procedural sedation. As dentists, we can very quickly assess the oro-pharynx for predictor of a difficult airway:

Maximum mouth opening >3 finger widths
Severe Class II malocclusion
Reduced OVD
Short thick neck
Limited neck extension
Mallampati score of 3 or more (can’t visualise the uvula at maximal opening)
Obesity and presence of a large tongue or tonsils
Presence/evidence of sleep apnoea (stopbang questions).

What is expected in terms of practice facilities and patient prep

Richard says practices must have easy access in case of an emergency, so facilities that only have stair access are unsuitable. “A large surgery can better accommodate the extra staff and equipment and makes for a more pleasant appointment,” he says.

He adds a parking space near the practice entrance saves a lot of time and effort when unloading and is always much appreciated.

Vivian says to ensure there is a peanut or u-shaped neck pillow and a blanket on hand for patient use. “In addition, if possible, have a clean dental tray, mask, gloves and hand sanitiser ready for the sedationist,” he says.

Vivian also recommends having an experienced dental nurse to assist the operating dentist. “Even if the DA is not experienced with sedation, the sedationist can help the DA to manage the water etc, so as to protect the airway,” he explains. “If the DA is inexperienced and has little knowledge of how to protect the airway, this can place the patient at risk and makes the sedation and dental treatment much more difficult.”

When it comes to the patient, Richard says it is helpful to have the patient arrive early so that all consents, payments, and other admin are completed. “This allows the appointment to start on time and helps avoid the stress of running late,” he explains.

Vivian recommends allocating enough time for both the dental procedure and for the induction and recovery of the patient. He says the practice should either ensure there is a spare room for recovery or leave a 30-minute pack down before the next patient. Scheduling and staffing should take into account that patients can take longer to recover, in some cases up to an hour.

He adds to ask the patient to ensure to follow all the sedation instructions provided, especially fasting and having a responsible adult available for 12 hours post op to collect the patient from the surgery and to look after the patient at home.

Dr Vivian Mascarenhas shares additional points you need to know:

Local anaesthetic is key

“Sedation is not a substitute for not using local anaesthetic (LA) or having ineffective LA,” he says. “It is in fact, absolutely integral to a safe and most importantly a smooth sedation. A smooth sedation is in everyone’s interest. A classic example is: ‘it’s only a clean (deep subgingival debridement with an ultrasonic) so I don’t need LA’. While that may be the case for a non-sedated patient who isn’t overly anxious, it’s not true for sedated patients as they lose their inhibitions and ability to control responses, still have a subconscious aversion and will respond given sufficient stimuli. This makes for a difficult sedation, and difficult treatment.

“In regards to LA, brush up on maxillary blocks (PSAB, MSAB, IOB) and alternatives to mandibular blocks (Gower-gates and Ankinosi blocks) as they provide much greater and more profound LA while minimising LA dosages,” he adds. “Additionally, review LA toxicity and maximum dosages for the different variants of LA and preparations (with and without vasoconstrictors) and remember that it’s the cumulative dosage for all the different LA’s combined, not the maximum of Prilocaine allowed plus the maximum of lignocaine.”

Sedation is not a GA in a dental chair

“Deep sedation actually makes dentistry more difficult because the patient will require far more intervention to both protect and maintain the airway from the dentist and nurse (which will make the treatment harder),” he explains.

Maintain a safe patent, protected airway

“The golden rule is: whoever is working in the airway is responsible for the airway, which means that this significant responsibility falls ultimately on the dentist,” Vivian says. “There have been many instances of a failure to protect the airway, which results in foreign body aspiration (especially water), which can have very significant consequences. Therefore, please ask for assistance if there is any doubt, as we are more than happy to help and show you how to best protect the airway.”

Other important considerations

Choose your sedationist as you would if you or a member of your family required sedation. Dentists should ensure the person that is providing the sedation is an AHPRA endorsed conscious sedation practitioner. This can be checked on the AHPRA registration page.
Understand the significant importance of patient (or guardian) consent for both the dental treatment and the sedation.
In many cases the treatment may well be complex, invasive, elective and/or expensive and it’s important that plans are reviewed so that the length of the appointments and type of treatment are appropriate to sedation. In general, if a treatment plan is going to take more than 1.5 hours, then this will need to be broken up into multiple appointments. Comprehensive clinical notes must reflect the discussions that occurred prior to the sedation appointment, including the likelihood of any scenarios that could occur whilst your patient is sedated that may give rise to a change to the proposed treatment.
Informed consent is essential for both the sedation, as well as the dental treatment plan. Its recommended that these are written and signed by both the patient and clinicians, and cover not just the primary treatment plan, but also any alternative treatments that may become necessary once they are under sedation and can no longer consent e.g. when there is a potential pulp exposure that will require endodontic treatment or extraction. Importantly the document must be clearly understood by the patient. It must be regarded as an adjunct to the verbal discussions, not a replacement.
A current certification in Provide First Aid Course (formerly known as Senior First Aid) for the dentist and all staff assisting during treatment and the patient recovery, should be regarded as mandatory for responding to medical emergencies.
Similar to pre-treatment, comprehensive clinical treatment notes, all information and instructions provided to the patient and the accompanying person and details of required post- treatment follow up, must be clearly documented, with the patient given adequate time to understand and discuss their responsibilities with their treatment team and support.
There must be no financial transactions with the patient until they have fully recovered from the sedation.
The accompanying person must clearly understand their responsibilities to the patient.
The dentist and sedationist must provide their after-hours contact details and fully expect to be readily available should the patient require assistance.
Check that your insurer covers this treatment and if you need to notify your provider.