Kevin: Today’s topic; Sedation. Let’s start by beginning. Why do we even need sedation? First of all, the explanation is sedation, that I say every day in our practice because I’m still practicing full time as a general dentist, we offer oral sedation, inhalation sedation, intravenous sedation and general anesthetic sedation. I’d like to describe it to the lay public as; for them women, one glass of wine, three glasses of wine, a bottle of wine, a case of wine. It’s all wine, but the more wine we give you, the more we can have a dramatic effect on your consciousness. For the men, I typically say it’s one beer, three or four beers, a six pack of beer, a case or a keg of beer. Basically, we are altering your consciousness.
Who needs sedation? In general terms, after 35 years of providing dentistry to the public, I find that the special needs specifically can benefit from sedation. Today, almost it’s impossible for me to perform a complete day without seeing an individual who has autism, mental retardation, down syndrome, special needs patients depending on their severity. Sometimes, it is almost impossible to provide adequate dental care in an office setting without the sedations that I mentioned; oral inhalation, intravenous and general anesthetic. I do believe for the modern and contemporary dentist to be able to offer different levels of sedation in a safe, efficient and effective manner can offer tremendous advantages, not only to your practice in the building of your practice, but to your patient base.
Besides the special needs group of individuals, the second group that benefits from sedation many times are elderly patients. They many times have significant medical histories. They’re on multiple medications and many times their oxygen intake and their overall activity is limited. In many cases, sedation is a necessary part of care in treatment depending on the processes and procedures and clinical treatments that we’re providing.
The third group of patients, the one that we most commonly refer to in the sedation field, are those patients who have high anxiety, very low thresholds for pain and are generally fearful of the dental profession. They avoid dental care, and depending on your statistics, anywhere between 15 and 50 percent of the population avoid dental care because of severe anxiety and severe fear.
Some of my experiences with sedation with multiple patients in doing sedation for over 30 years is the misconception that sedation does not provide anesthetic. It is not a pain reducer. It alters the consciousness. But whether we’re doing oral inhalation, intravenous or general anesthesia, you will still probably be necessary to have that patient receive a local anesthetic either as in a block form or as a local infiltration or a combination of both. Once we get that patient comfortable with the specific level of sedation, they will almost always need some type of local anesthetic to provide an anesthetic effect to diminish or eliminate pain sensation.
When we talk about oral sedation, in most cases but not all cases, the most common oral esthetic or oral sedation would be Triazolam. Generally, it’s 0.25 milligrams, it’s put under the tongue and under the tongue it dissolves and activates quite quickly. This under the tongue Triazolam of 0.25 milligrams is generally taken the night before and an hour before the dental appointment and can offer the patient significant relaxation. I strongly urge the professionals using this that they be comfortable with the pharmacology. The drug will generally stay into the individual’s system for approximately five hours to seven hours. So I strongly recommend that they not drive, they not cook over an open flame, and they generally stay homebound until the entire effect of the medication is relieved.
When we talk about inhalation sedation, we’re generally talking about nitrous oxide or commonly referred to generically as laughing gas. In most cases, the contemporary nitrous oxide and oxygen monitoring system will never administer more than 70 percent nitrous oxide. Generally, we go anywhere from 10 to 70 percent and most patients are comfortable somewhere around 30 to 40 percent nitrous oxide and the balance of oxygen. They should be titrated over several minutes and on the completion of the procedure, the patient should breathe 100 of ambient air or oxygen for about three to six minutes to wash the nitrous oxide out of the system. Please keep in mind that in most cases after nitrous oxide is given, the patient is adequate from a conscious point of view to get in a car, drive and leave the procedure.
The third is intravenous. In most cases, the dentist will be using a drug called Versed. Generally anywhere from 5 to 15 milligrams intravenously will provide almost immediate onset to calm and relax the patient and put them in a sedative effect. My personal opinion for most dentists with the basic training in sedation is you should only be treating ASA type one patients. This means patients who are generally healthy. In most cases, I try not to treat children under the weight of 60 or 80 pounds. In my opinion, general anesthetic, in my particular background and training, should only be performed in a hospital setting in an operating room. I’ve been providing hospital dentistry now for over 30 years and in many cases, the ASA types 2, 3 and 4, in my personal opinion, should not be treated in an office setting.
Sedation can open up many opportunities to provide the level of care and service that patients are now avoiding because of fear and anxiety, because of significant medical history or because of special needs. I strongly advice our listeners to consider the various courses throughout the country to get trained in oral inhalation and intravenous sedation and perhaps consider augmenting their office with hospital privileges to provide general anesthetic for care.
Many times patients also will ask, “Dr. Coughlin, I only want my teeth cleaned.” “Dr. Coughlin, I only want one or two fillings done or one single extraction.” My experience isn’t necessarily what we’re doing, but how much time it’s going to take. Can we maintain an open airway and can we provide the care in a safe and efficient manner? In general, my recommendation would be to keep the procedures for 90 minutes or less. The shorter the procedure, generally the safer the guidelines will be and the less likely to have counter-indications.
As far as particular questions, there are some questions that I get on a routine basis and Doug, I understand you have a few questions.
Doug: Sure. One of the questions I’m really curious about is the connection between sedation and modern dentistry and how the two even came together. How did that get started?
Kevin: I think there’s been just a need. I know in most of the 60 dental schools in the United States, most of the new graduates are getting an orientation and training in sedation. The public is constantly demanding that there be a way to deliver care in a more efficient, effective and comfortable manner. I know I’m almost approaching age 60 and I’ve lost a kidney, broke an arm, broke a leg, had an appendix removed, but most of the young people that we deal with in the general practice, in most cases have had very little trauma in their life. Were wearing bicycle helmets, were wearing seatbelts, were in a much more safe environment and people are less traumatized than ever before and dental procedures can be extremely traumatizing to the public. As a profession, we’ve realized this and we’re looking at sedation to offer a level of care and service that previously was extremely difficult, if not, impossible to provide. Now we’ve offered many levels of different care and services.
Doug: I’m really curious as well in terms of the medical necessity for sedation. You mentioned, for example, someone who has anxiety about a procedure. Do you kind of have any guidelines about when it might be appropriate to try to just walk someone through — maybe try to walk them through that anxiety or do you just take it pretty much face value if someone says, “I really need sedation because I’m anxious.” Is that kind of the end of the conversation?
Kevin: I answer this question and answer it almost every day the same way. I have three children that are now young adults. I removed their wisdom teeth and my wife wanted me to sedate them and I chose not to. Although the chances of complications are very, very minor, I go on a healthy individual, why do I want to take any risk or chance at all? For those patients who are completely healthy and it’s only an anxiety and fear level, I try everything in my power to consider non-pharmacological treatments such as biofeedback, hypnotism, education, see, feel, touch, knowledge.
But in the real world, those patients who have been traumatized severely I find that it sounds good but in most cases, the only way we’re going to get them through the care and treatment is sedation. So they have to understand the risk, the benefits, the alternatives and the cost. In many cases, cost can be a factor because if there’s no medical need for the treatment, many times medical and dental insurance are saying, “Why are we providing a service and a fee for something where there’s no medical need?” Unfortunately, fear and anxiety many times don’t always meet the medical criteria for certainly general anesthesia or many of the other sedations that we discussed such as IV, inhalation and oral.
The take-home point is this isn’t candy. There is a risk and you have to understand the most significant risk with sedation is death. Although it’s extremely rare, it is a potential risk and in my opinion, those patients who don’t have medical necessity must fully understand that risk before they sign on the dotted line and approve the procedure.
Doug: I know you touched on this a little bit, but I thought maybe to go a little bit more into it. That’s for example the person who has anxiety, but obviously, sedation opens up the possibility for you to work on people who might not have been able to get dental care traditionally. Can you give some examples?
Kevin: After 35 years of practicing dentistry and still practicing full time, a day does not occur where I do not see a patient who is what we refer to as an ASA 2, 3, or 4, that needs significant dental care. Today, many patients who need a kidney transplant, a heart or lung transplant, knee and hip replacements, they many times have very, very poor dental conditions. These people are sick, they have a high likelihood of morbidity or mortality and I personally I’m not comfortable providing that level of care and service in an office. And my recommendation is most dentists would probably be better off not taking that risk either. So being able to provide hospital dentistry or to sedate these patients so that their heart and blood pressure doesn’t go through the roof offers a tremendous advantage.
And as we discussed, for whatever the reasons, and there could be many, autism today is extremely difficult on the dental profession. These patients have a high sensitivity to touch, sound and light. And if they require significant care such as dental restorations, extractions, root canals, crowns, minor orthodontic movement, I have found it almost impossible to provide a high level of care in a high fashion in an office setting without some type of sedation so that these patients are calm and are able to be treated in a humane and ethical type of procedure.
Doug: From a practice perspective, I’m curious about obviously if I’m a dentist and I’m going into the hospital, I would imagine that that’s time away from my office too. Can you say a little bit from a practice perspective about how you manage with that?
Kevin: For the smaller practices or I should say solo practices, this is a very difficult issue, hospital dentistry. Because when you’re away from your office, your office many times is not productive and it is difficult on patients who have emergencies because there’s no one there to watch your organization. I am a group practice, I have 14 dental offices, so I’m in a different situation that allows me to keep our offices open, our offices covered, and it allows me the ability to go to the hospital and provide a level of care and service and allowing my office to stay open.
I could tell you in my 35 years of experience, it is extremely rare that I go into one of the five hospitals that I’m currently on staff at and they are actually on time. There are many different reasons for this, but keep in mind, you don’t own the hospital and you are there as an employee or independent contractor for that hospital and there are many, many different moving parts. So to get anesthesia, nurse anesthetist, floating nurses, scrub nurses, sterilization, appointments, it’s not as easy as you would think. I would strongly recommend that you understand that if you think it’s going to take an hour to do a procedure, plan on three. It is a long, arduous procedure and obviously the patient safety comes first. But for those solo practitioners that don’t have coverage, you may want to consider making sure you have proper backup and support before you leave your organization.
That leads to a closing question that when you’re doing sedation in your office, it’s critical that you stay with the patient while they’re sedated. Many times, you are forced to see patients that walk in for emergency care, doing hygiene re-care visits, so you have to have the proper processes and procedures in place if you’re going to offer a high level of care, service particularly for sedation. But in the end, I think it could be a boon to your office, your organization and to your patients which is most important.
I hope you’ve enjoyed today’s podcast. You’ve been listening to Dr. Kevin Coughlin at Ascent Radio. You’re listening to Ascent-Dental-Solutions, with a focus on knowledge, education, development and training. Again, special thanks to Mr. Foresta and his company, Stand Out and Be Heard, who brings you these excellent podcasts week after week. I hope you enjoyed today’s topic and I look forward to speaking to you in the near future.