Sedation in Dentistry: How Far Should We Go and How Much Training Do We Need?

You're listening to the Phil Klein Dental Podcast. Today, we'll take a closer look at the different kinds of sedation that we as dentists can offer our patients. What types are available? What are the risks and benefits? And how much training do we need to administer sedation to our patients? To answer these questions and more is our guest, Dr. Stanley Malamed. Dr. Malamed is a world-respected dentist anesthesiologist and emeritus professor of dentistry at the Herman Astro School of Dentistry at USC, formerly the University of Southern California School of Dentistry. Dr. Malamed will be joining us in a second, but first, we all know that to achieve healthy, beautiful smiles, we sometimes need to align the teeth. And to do so, aligner therapy is a great option. So why not set your practice apart with 3M Clarity Aligners Flex, designed for comfort? Clarity Aligners Flex feature a thin, flexible design, yet they deliver excellent force persistence over a two-week period. Plus, they resist scratching and stains, and they're backed by a dedicated clinician team providing support every step of the way. With a variety of affordable case-type options, single or dual-arch, Clarity Aligners Flex offer a great value to your patients and practice. To learn more, visit 3M.com slash clarity dash aligners dash flex. Dr. Malamed, it's a pleasure to have you back on the show. Phil, nice to be back. Dr. Malamed, if you would, talk about sedation as far as the dental practice is concerned. What kinds of sedation are available to the clinicians and to our patients? And talk about some of the indications. Very specifically, two techniques, oral sedation versus intravenous sedation. So let's talk initially, what is sedation? And if you go to the dictionary, this is what it says, a relaxed calm, or sleepy condition that results from taking a drug called a sedative. And it's also number two, the act of giving a person a drug that causes calmness or relaxation. This is what we're doing. Why are we doing it? Well, I have over the years looked at many, many surveys of common fears. And sadly for us, dentistry is usually in the top 10. This one I picked, public speaking, is number one. This one, number two, is going to the dentist, fear of heights, fear of mice, fear of flying, and again, other fears. But dentistry, our profession, are we proud to be number two? I don't think so. I found this interesting. Jennifer D. St. George published a survey back, it was 2004, and it's a patient is seeking a new dentist. What are they looking for? This is what they want in their dentist. In 2016, there was a survey done in the United Kingdom, the top 10 reasons why people hate the dentist. On the left-hand side, things like the sound and the smell, the invasiveness, the drill, the anxiety. Number two is the pain. Number one is the needle. What do they want from a dentist? Number two, a dentist who doesn't hurt. and a painless injection. Same two things. People dislike what people want. They don't want to be hurt and they want painless injections. So what are our goals? The reason we're doing sedation is because people don't like going to the dentist for those very obvious reasons. So what are we looking for? What are the goals of sedation? And it boils down to this, the scared dental patient, everything we do for them, they're just overly aware of it. If you blow air in their mouth, I think everybody who's listening to us has had a patient, when you just blew air toward their mouth, they went, ow. When you touch them on your lip with your finger, they went, ow. They overreact. They overreact everything, which makes our life as a doctor more difficult, makes our treatment of that patient more difficult. So the goals of sedation, the primary goal of sedation, is to distract that patient. You take that patient's mind off of what we are doing in their mouth while they're in the dental chair. Take their mind away from it. In addition, what we're doing is taking a patient who cannot handle stress as well. So we're talking about the extreme dental phobic. We're talking about the medically compromised patient, a person who is stress intolerant, and we're allowing them to receive I would say high -quality dental care, safely and efficiently. And I think it's also important to note that we use sedation to reduce anxiety to prevent medical emergencies, which is something you've talked about for years. So let's take a look at that. This is part of a survey that an article I had published, it was way back in 1993, where I surveyed over 4,300 doctors in the U.S. and Canada. And I was asking them questions about their experiences with medical emergencies. So long story short, 4,300 dentists reported that in their career, they had encountered over 30 ,000 medical emergencies. The number one medical emergency by far, a little bit over 50% of all the emergencies in the survey was fainting, syncope. Now, very simple, happy people don't faint. Scared people faint. which will lead us back into our program for today. Now, in addition to syncope, angina, seizures, asthma, hyperventilation, and the epinephrine reaction, these are called stress-related medical emergencies. A patient with angina comes into your office, they don't have chest pain, okay? But if they get scared, if they get hurt, their heart rate goes up. And when their heart rate goes up, they have... anginal pain. A person with asthma, they're not having an asthmatic attack when they're sitting in the chair, but if you hurt them, if they get stressed, they're going to have bronchospasm. So these are emergencies. These six emergencies on this list, again, are called stress-related. Now, if we add up the numbers, these emergencies add up to 75% of all the emergencies that we see in dental practice. Three quarters of all the emergencies are related to stress and anxiety, which means something. We can prevent up to three quarters of all the medical emergencies that do occur in the dental profession. So if you would, Dr. Malamed, talk about the different categories of sedation. How do we categorize it? Minimal, moderate, deep, and general anesthesia. Minimal sedation would be the use of oral medications alone. or nitrous oxide oxygen alone, minimal sedation. Moderate sedation is parenteral sedation, intramuscular, intravenous sedation. Moderate sedation is when you combine oral sedation with nitrous oxide oxygen. Now, there's one proviso here. Whatever state you're in, you need to go back to your state dental board requirements. Most states... that oral sedation alone is minimal, nitrous oxide, oxygen sedation alone is minimal. But once you combine the two, you need a permit for moderate sedation. So again, I would recommend strongly, whichever state you're in, check that out. Let's take a look quickly at what do we call the spectrum of pain and anxiety control. And this is just one version of it. What we have here on this horizontal line are the different levels of... The red vertical bar is very, very important. That is the point at which on the left-hand side, we have a conscious person. On the right-hand side, we have general anesthesia, requiring a totally different degree of training. But we start on the left-hand side. We'll discuss this briefly in a moment with iatrosed sedation, minimal sedation, and moderate sedation. The word conscious sedation is No longer used. It is outdated, even though some state dental boards still maintain that term. But we have minimal sedation and moderate sedation. We'll be right back with Dr. Malamed in a second. But first, if you're looking to raise the bar with your adhesive dental procedures, you should definitely be looking into Bisco. Bisco is a great company that has an unparalleled track record. I can unequivocally say... is their passion. They are genuinely dedicated to understanding and improving the ability to bond dental restorations. Bisco is a company that places tremendous value on research and scientific knowledge to benefit you and your practice. Being an endodontist myself, my favorite Bisco product is Theracal LC, which hands down is one of the best materials to use for direct and indirect pulp capping procedures. It not only seals the dentin, but offers significant calcium release, which stimulates hydroxyapatite and secondary bridge formation, which is exactly what we're looking for in these kind of procedures. So check out their entire product line of premium adhesive products at bisco.com. So Dr. Malamed, if you would share with us the techniques of sedation. The techniques of sedation are iatral sedation, which may or may not be a new term for some of you, and pharmacosedation, iatral sedation. It's very simply put, iatral means doctor and sedation means relaxation. So what we are dealing with is you. It's the way you behave in front of a patient, the way you speak to a patient. I came to USC Dental School to start teaching in 1973. I started out there to start teaching drugs, sedation, nitrous oxide, intravenous sedation and such. And they had a program at that time. The department was called Human Behavior. It was how to talk to a patient, how to handle yourself as a doctor in front of a patient. Chairside demeanor. We don't give shots. We don't poke needles into patients. We don't stick people. Those are terms that are very negative. They scare people. In Canada, when a dentist is going to be giving a local anesthetic to a patient, the doctor will say to the patient, I'm going to freeze you. Freeze you is a nice euphemism for shot. It's not a scary term. Other forms of viatral sedation include hypnosis, acupuncture. Audio analgesia is a fancy word for music, video, and more and more in today's world, primarily in pediatrics, the use of virtual reality. But this is, again, non-drug techniques of sedation. When we talk about pharmacosedation, which includes the use of medications, we have these four roots of administration, oral inhalation, intramuscular, and intravenous. So let me just interrupt for one second, Dr. Malamed, on the four ways you just talked about, oral, sedation, inhalation sedation, which is nitrous, IM, intramuscular and IV. How does that break down for the GP as far as what they're using on their patients? So these are three surveys, three surveys that were published by the ADA in 2008, the Academy of General Dentistry in 2007, and by Goodchild and Donaldson in 2011. And virtually all of these, the doctors responding to these surveys were general dentists. You see that inhalation sedation. Nitrous oxide, far and away the most used sedation technique, well above 70% on all three of the surveys. Oral sedation, enteral sedation, between 40 and 70%. Parenteral sedation, which is, again, intramuscular, intranasal, intravenous, anywhere from 15% to about 30%. And again, the numbers you see here are primarily going to be general dentists. And I know you have some information about specialists as well with their utilization. If you could share that with us. The American, this is a little bit dated. It goes back to 2008, but it's the most recent information I could find. This is from the American Dental Association. And it talks about the use, utilization of sedation, minimal and moderate by specialty. So if we look at pediatric dentists, they all use nitrous. All of them do. 65%, two-thirds of pediatric dentists are using oral minimal sedation, but the use of parenteral sedation is not used very often in the pediatric dental office. Endodontists, again, nitrous oxide, oral sedation, with some, about 20%, using parenteral sedation. We go to periodontists, 75%, three-quarters of them, 77% are using nitrous. Not a lot of use of oral sedation by periodontists, but about half of all periodontists are using parenteral, in most cases, intravenous sedation. So it's pretty clear that general dentists, for the most part, are not using IV sedation on their patients. But those who feel that it's necessary to do this obviously need some training. So let's talk about the training for IV sedation. What are we looking at there? Every state. And if we have any Canadians listening in to us, every province, your dental regulatory agency requires you to obtain a permit from that province or state to administer IV sedation. You have to go through certain training. I am involved in two courses. I taught for 40 years at the University of Southern California, and I taught continuing education courses in intravenous sedation. I am now involved with the Oregon Academy of General Dentistry IV sedation course. And these courses run in excess of 100 hours. 100 hours, didactic, but the most important part of these courses is the clinical component. So again, intravenous sedation requires some rather vigorous training. What about inhalation sedation like nitrous oxide? Essentially, and there may be one or two states that are different. But you graduate dental school in the United States or Canada, and you are allowed to administer inhalation sedation with nitrous oxide oxygen. And I've given hundreds of lectures over the years on sedation. I believe that nitrous oxide oxygen should be the starter technique. You learned it in school. You should be doing it in private practice. What about oral sedation? What kind of training do we need there? Until about 10, I'm guessing maybe 10 years ago, no state had any, California did, but no state other than California required a permit for you to administer oral sedation. Well, that's changed. It's changed because more and more doctors are being trained to use oral sedation, unfortunately, sometimes in continuing education programs that are not exactly the best. And problems happened. Patients died from oral sedation alone. They died or suffered permanent brain damage. So again, depending upon what state or province you're in, please, you have to check with your dental regulatory agency to determine if a permit is required. Now, the state of California, where I am, has always, easily going back 15, 20 years, a permit. for adults, oral sedation for adults if you were 13 years of age and above. And now, and not now, but they've also had a permit for pediatric oral sedation, which is oral sedation for any patient who is under the age of 13. So again, please check with your dental regulatory agency to find out what regulations will affect you. Thank you, Dr. Malamed, for the tremendous information you provide us on this podcast and taking the time to be with us. We look forward to having you on more. It's always an honor and pleasure to be with someone with your expertise, knowledge, and integrity talking about such an important issue that affects all of us who provide sedation to our patients. Thank you so much. Phil, thank you very much. It's been a pleasure again. Thank you. If you're enjoying this podcast and have an Instagram account, please follow us, Phil Klein Dental Podcast. Every week we'll be adding high quality relevant content. And to support this program, please leave a review on your favorite podcast platform. It really does make a difference. Thank you so much for listening. See you next time.