MOH/K/GIG/5-2023(GU)

GUIDELINES FOR CONSCIOUS SEDATION

IN DENTISTRY FOR ADULT PATIENTS

Oral Health Programme

Ministry of Health Malaysia

2023
Published by:
Oral Health Programme
Ministry of Health Malaysia
Level 5, Block E10, Precint 1
Federal Government Administrative Centre
62590 Putrajaya, Malaysia

Copyright
The copyright owner of this publication is Oral Health Programme (OHP).
Ministry of Health Malaysia. Content may be reproduced in any number of
copies and in any format or medium provided that a copyright acknowledgement
to OHP is included and the content is not changed, not sold, nor used to promote
or endorse any product or service and not used inappropiately or misleading
context.

Perpustakaan Negara Malaysia Data Pengkatalogan-dalam-Penerbitan

GUIDELINES
CONSCIOUS SEDATION IN DENTISTRY FOR ADULT PATIENTS.
ISBN 978-969-98561-0-8

1. Dentistry. 2. Conscious sedation. 3. Conscious sedation--Technique.

4. Adulthood-- Dental care. 5. Government publications--Malaysia.
I. Malaysia. Kementerian Kesihatan. Program Kesihatan Pergigian.
617.6

Available on the following website: http://www.ohd.gov.my

STATEMENT OF INTENT

This guideline was developed in 2020 and revised in 2023 to ensure the best
service is given to the patient. It will be useful tools for specialist and dental
practitioners both in the government sector as well as the private sector, in
practicing conscious sedation in their daily practice. This guideline will also
serve as an initiative in improving the standard of dental practice in Malaysia.
Every care is taken to ensure that this guidelines is correct in every detail at
the tine of publication. However, in the event of errors or omissions,
corrections will be published in the web version of this document, which is
the definitive version at all times. This version can be found on the website
mentioned above.
Table of Contents
FOREWORD ................................................................................................................................. i
PREFACE ..................................................................................................................................... ii
1.0 INTRODUCTION ............................................................................................................... 1
2.0 PURPOSE OF DOCUMENT ............................................................................................... 2
3.0 GENERAL PRINCIPLES ...................................................................................................... 3
4.0 SCOPE .............................................................................................................................. 3
4.1 Conscious Sedation Techniques .................................................................................. 3
4.2 Patient Groups ............................................................................................................. 4
4.3 Treatment Provided ..................................................................................................... 4
5.0 SEDATION TEAM AND STAFFING ..................................................................................... 4
6.0 STAFF TRAINING AND EDUCATION.................................................................................. 5
7.0 SEDATION FACILITIES AND ENVIRONMENT..................................................................... 5
7.1 Space Requirement ..................................................................................................... 6
7.2 Dental Surgery ............................................................................................................. 6
7.3 Recovery Bay ............................................................................................................... 6
7.4 Storage Area and Consultation Room ......................................................................... 6
8.0 SEDATION TECHNIQUES .................................................................................................. 7
8.1 Inhalation Sedation (IHS)/ (Nitrous Oxide/Oxygen) .................................................... 7
8.1.1 Specialised Equipment for Inhalation Sedation and Requirement ...................... 7
8.1.2 Safety Features of the Nitrous Oxide Delivery Unit ............................................. 8
8.1.3 Indications for Inhalation Sedation ...................................................................... 9
8.1.4 Contraindications for Inhalation Sedation ........................................................... 9
8.1.5 Procedure for Inhalation Sedation ..................................................................... 10
8.2 Intravenous (IV) Sedation with Midazolam ............................................................... 12
8.2.1 Specialized Equipment for Intravenous Sedation .............................................. 12
8.2.2 Indications for Intravenous Sedation ................................................................. 14
8.2.3 Contraindications for Intravenous Sedation ...................................................... 15
8.2.4 Procedure for IV sedation .................................................................................. 15
8.3 Oral Sedation ............................................................................................................. 18
8.4 Intranasal Sedation (INS) ........................................................................................... 18
8.5 Flumazenil (Antagonist of Benzodiazepine) .............................................................. 18
9.0 MONITORING ................................................................................................................ 19
10.0 RECOVERY AND DISCHARGE ......................................................................................... 19
10.1 Criteria for Discharge ............................................................................................. 19
 10.2 Removal of Cannula ............................................................................................... 19
10.3 Discharge and Post-Operative Instructions ........................................................... 20
11.0 RECORD KEEPING .......................................................................................................... 20
11.1 Pre-operative ............................................................................................................. 20
11.2 Sedation..................................................................................................................... 20
11.3 Dental Treatment ...................................................................................................... 21
12.0 MANAGEMENT OF RELATED COMPLICATIONS ............................................................ 22
12.1 Respiratory Depression .......................................................................................... 22
12.2 Allergy .................................................................................................................... 22
12.3 Cardiac Arrest ........................................................................................................ 22
12.4 Hypotension........................................................................................................... 22
12.5 Cannulation............................................................................................................ 22
12.6 Hiccup .................................................................................................................... 23
12.7 Paradoxical Effect ................................................................................................... 23
12.8 Prolonged Recovery ............................................................................................... 23
12.9 Over Sedation ........................................................................................................ 23
12.10 Failed Sedation ...................................................................................................... 24
12.11 Sexual Fantasies ..................................................................................................... 24
13.0 CONCLUSION ................................................................................................................. 24
REFERENCES ............................................................................................................................. 25
APPENDICES ............................................................................................................................. 27
Appendix 1 ........................................................................................................................... 28
Appendix 2 ........................................................................................................................... 30
Appendix 3 ........................................................................................................................... 31
ACKNOWLEDGEMENTS ............................................................................................................ 36
FOREWORD

Assalamualaikum and Greetings,

As the leading authority for oral healthcare in Malaysia, the Oral Health Programme, Ministry
of Health Malaysia is committed to ensuring that every citizen receives the highest level of
oral health services, as it is their fundamental right.

The Guideline for Conscious Sedation in Dentistry for Adult Patients has been developed to
ensure the provision of optimal care for patients. With the increasing use of technology, it
becomes essential to have a reliable framework to rely on during the implementation of
conscious sedation. It is of utmost importance that conscious sedation is administered with
the highest standards of safety and quality at all times.

Our aim is for the practice of conscious sedation in Malaysia to offer a secure, top-notch,
affordable care, providing a pleasant experience for both the patient and the practitioner
involved.

We have high expectations that this document will serve as a comprehensive guide in
performing conscious sedation and will be advantageous to all its users. Dental specialists and
dental officers, in particular, have a crucial role to play in upholding the highest standards of
oral healthcare.

With this guideline in place, we envision a future where conscious sedation practices
contribute significantly to the overall well-being and satisfaction of patients and practitioners
alike.

Wishing everyone success in implementing these guidelines and ensuring the best possible
oral healthcare services for all.

DR NOORMI BINTI OTHMAN

Principal Director of Oral Health
Ministry of Health Malaysia

i
PREFACE

Sedation in dentistry has always been a debatable topic among dental practitioners regarding
its benefits and potential risks. On one hand, sedation plays a key role in alleviating fear in
dentistry and has been widely used worldwide. However, improper administration of
sedation, due to lack of training and knowledge, has the potential to cause harm. Considering
that the area being worked on is shared between medical and dental practitioners in one way
or another, the latter should especially understand the limitations in practicing sedation
techniques in dental procedures.

Conscious sedation has opened a new avenue in dental treatment. However, like any new
technology and practice, it requires caution and guidance to ensure the best treatment for
the patient.

As of today, there is no comprehensive guideline for using conscious sedation in dental

practice in Malaysia. Consequently, different styles are being used in conducting conscious
sedation procedures.

It is hoped that this guideline will be a useful tool for dental practitioners in both the
government and private sectors to improve their practice of conscious sedation. This
guideline also serves as an initiative to enhance the standard of dental practice in Malaysia.

Dentistry has indeed made significant progress in providing healthcare for the nation. It is
vital for dental professionals to practice at the highest possible quality to protect the public's
interest and continue improving the nation's overall health status.

ii
 GUIDELINE FOR CONSCIOUS SEDATION IN DENTISTRY FOR ADULT PATIENTS

1.0 INTRODUCTION

Conscious sedation could be defined as “A technique in which the use of a drug or drugs
produces a state of depression of the central nervous system enabling treatment to be carried
out, but during which verbal contact with the patient is maintained throughout the period of
sedation.”

The use of sedation in oral health began with nitrous oxide to facilitate dental extraction by
Colls and Wells in 1844. It was then followed by the administration of ether anaesthetic at
Massachusetts General Hospital by a dentist, William Morton. The first general anaesthetic
using ether was administered by a dentist from England, James Robinson on 19 December
1846. In the 1900s, it was reported that nitrous oxide was used for inhalation sedation for
dentistry. It was then followed by the use of intravenous barbiturates, hexobarbitone, in UK
dental practice in the 1930s. However, information regarding the care settings of sedation in
the yester years is lacking. Nevertheless, in the year 2000, after the publication of “A Conscious
Decision” which led to the cessation of general anaesthesia in dentistry in primary care
settings, more reports and guidelines have been published and have taken care settings
including environment and facilities, equipment, record keeping, training, referrals and
techniques for conscious sedation into consideration.

In the Western countries such as the UK and USA, conscious sedation can be provided at the
primary and secondary dental care settings. However, in the Ministry of Health Malaysia
facilities, conscious sedation is only provided in the hospital-based dentistry services such as
the Oral and Maxillofacial, Paediatric Dentistry and Special Needs Dentistry services.

As stated by several health departments in around the world, the drugs and techniques used
to provide conscious sedation for dental treatment should carry a margin of safety wide
enough to render loss of consciousness unlikely (minimal to moderate level of sedation). To
that extent, the Ministry of Health Malaysia refers to the guideline proposed by the College of
Anaesthesiologist Academy of Medicine Malaysia for the continuum of sedation depth as in
Table 1.

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 Table 1: Continuum of Depth of Sedation
Moderate
Minimal Sedation/
Deep Sedation/ General
Sedation Analgesia
Analgesia Anaesthesia
(Anxiolysis) (Conscious
Sedation)
Purposeful
Purposeful
Normal response response after Unarousable
response to
Responsiveness to verbal repeated or even with painful
verbal or tactile
stimulation painful stimulation
stimulation
stimulation

No intervention Intervention may Intervention

Airway Unaffected
required be required often required

Spontaneous May be Frequently

Unaffected Adequate
Ventilation inadequate inadequate

Cardiovascular Usually Usually

Unaffected May be impaired
Function maintained maintained

When conducting sedation, it is important to consider the risk it brings. This risk could be in
the form of depression of the respiratory function, that may lead to hypoxia, depression of
cardiovascular function which may cause bradycardia, hypotension and cardiac arrest. Apart
from that, the sedation technique/s used can cause the obtundation of patient’s protective
reflex and obstruction of airway leading to aspiration.

2.0 PURPOSE OF DOCUMENT

This guideline aims to provide a framework in which the conscious sedation can be delivered
in a safe, efficient and effective manner by a trained dental specialist/officer in the specific
technique of sedation especially in the Ministry of Health Malaysia. This can be achieved to
the highest standard of quality through education and training of the work staff. This standard
acts as a guideline and must be read concurrently with other documents in relation to laws,
regulations, ethical guidance and governance of any specific workplace where the service is
delivered. This document will be reviewed and updated regularly according to the current
requirement of the service delivery.

2
3.0 GENERAL PRINCIPLES1,2
To ensure conscious sedation are done to the highest standard for the Malaysian dental
services, principles as follows need to be adhered:

1. A registered dental officer or specialist must be appropriately trained to perform

conscious sedation
2. A thorough and concise medical history including blood pressure measurement, any
relevant investigation and identification of risk factors according to medical fitness
classification adapted from The American Society of Anaesthesiology (ASA)
Classification (Appendix 1) must be performed before the procedure
3. All patients undergoing sedation and/or carers must be given adequate information
about the procedure which includes written instructions for preparation of the
procedure, during recovery and discharge of the patient
4. Written informed consent for sedation and dental procedure must be obtained
separately before the procedure
5. Patients must be monitored throughout the procedure by trained staff members
6. An appropriate treating medical practitioner or specialist must be consulted if the
patient has any serious medical illnesses prior to planned dental treatment under
sedation
7. The sedation techniques, the dosage of the drugs, the timing of the administration and
the measurement of monitored variables must be recorded and kept appropriately in
patient’s file
8. Appropriate equipment for administration of the drugs, drugs monitoring and
emergency event must be available

4.0 SCOPE

4.1 Conscious Sedation Techniques

The sedation techniques that are provided include:

1. Inhalation sedation with Nitrous Oxide/ Oxygen
2. Intravenous (IV) sedation with Midazolam
3. Intranasal sedation with Midazolam
4. Oral sedation with Midazolam

** It has been proven that the provision of sedation with Midazolam via Oral and Intranasal routes
have improved the provision of oral health care of people with severe disability which enables
them to receive treatment without the need of general anaesthesia3.

3
4.2 Patient Groups

Patient grouping can be divided as follows:

1. Patients whose age is 16 years old and above and regarded by the referring clinician not
to be able to receive treatment in the conventional manner.
2. Patient who is categorized as ASA I and stable ASA II as Appendix 1 with BMI more than
18 or less than 30.
3. Patient who is categorized as ASA III and above should be referred to anesthetists for
further assessment of eligibility to undergo conscious sedation.

4.3 Treatment Provided

Wide range of dental treatment can be provided under sedation and depends on patient
cooperativeness as follows:
1. Oral examination
2. Scaling and polishing
3. Dental restorations
4. Dental extractions
5. Root canal treatment
6. Removal of impacted teeth
7. Biopsy of oral lesion
8. Enucleation of simple cyst
9. Minor oral surgery
10. Simple dento-alveolar procedures

** Any treatment which requires more than an hour to complete in a visit is not recommended to be
done under sedation. Complex and advanced restorative works may not also be included in the
care plan under sedation.

5.0 SEDATION TEAM AND STAFFING

An optimum sedation team consist of the following:

Table 2: Optimum Sedation Team

No Position Candidate for Position Role

1 Sedationist Dental Specialist or Dental 1. Conduct sedation process

Officer (proven to have 2. Monitor the patient throughout the
dedicated training in certain procedure in relation to
techniques of conscious cardiorespiratory function, breathing
sedation)/ Medical and consciousness of the patient
Practitioner/Anaesthetist
2 Operator Dental Specialist/ Officer Perform related dental operations
3 Assistant 1 1. Dental Officer Assist in related dental operations

4
 No Position Candidate for Position Role

2. Dental Surgery Assistant

(DSA)
3. Dental Therapist
4. Medical Nurse
4 Assistant 2 Dental Surgery Assistant Assist in related dental operations
(DSA)
5 Runner Dental Surgery Assistant Assist in other matters (not directly
(DSA) involved with the dental operations)

As a general principle, a sedationist and an operator should be a different person. However,

depending on the sedation techniques used such as inhalation sedation, the sedationist can
also act as an operator at the same time.

At any circumstances when the patient does not respond to verbal command or stimulation
or spontaneous respiration and protective reflex are lost, dental treatment must be stopped
and the entire team members should focus on monitoring of the consciousness and breathing
while treating the patient until recovery.

Other medical or dental practitioners must be called to take responsibilities if the situation is
beyond the skill of management of the existing team members.

6.0 STAFF TRAINING AND EDUCATION

Training is required for all relevant team members as follows 4:

1. A dental specialist or officer must have completed relevant training with proven
qualifications or certificate of attendance for each sedation technique used. The
education and training must be continuous and updated and regularly monitored to suit
the current standard of practice.
2. The assistant should have attended a supervised clinical on-site training including theory
and practical management of patient under sedation to allow them to recover patient
and competent in monitoring patient consciousness.
3. All team members must have received necessary life support skills such as Basic Life
Support and Advanced Life Support / Advanced Cardiac Life Support training.

7.0 SEDATION FACILITIES AND ENVIRONMENT

While meeting the requirements of a general dental practice is essential, the sedationists must
ensure that each component in the practice is appropriate and complies with the national
guidance for sedation5, 6, 7.

5
7.1 Space Requirement

Generally, an operating room must be clinically fit for conscious sedation purposes and large
enough to accommodate all the necessities such as: equipment, wheelchair access and dental
care team. It should include appropriate lighting, ventilation and adequate access for
emergency services (e.g. direct pathway to Emergency Department), treatment area and
recovery area. This is to ensure that patient safety is guaranteed, and care can be provided
efficiently.

7.2 Dental Surgery

Due to limited space available, many dental practices may not be able to provide an enclosed
dental surgery with an en-suite disability friendly toilet as recommended. Nonetheless, as long
as the patient’s privacy is assured, and the size is reasonable to manage any emergency that
happens as in 7.1 is acceptable8, 9, 10, 11. The operating dental chair should be able to be
adjusted in the head-down tilt position in case emergency airway support is required at any
time during the sedation procedure as well as ensuring that all the equipment is in proper
working order prior to carrying out the sedation11.

7.3 Recovery Bay

Recovery bay should be separated from the waiting area and has direct access from the
surgery room. Therefore, the individual privacy of patients and accompanying person is
assured12, 13. The recovery chair must be capable to be lowered down to manage any
emergency event. This may allow a calm and smooth recovery process. Apart from that, the
area must be equipped with proper equipment for resuscitation. In case a dedicated recovery
bay is not available, a patient must be allowed to recover in the treatment area and can only
be discharged after adequate recovery is achieved with full support and guidance 14.

7.4 Storage Area and Consultation Room

The storage area should be specific and suitable for the items (e.g drugs, nitrous oxide
machine, gas cylinders, equipment for sedation etc) to be stored with regards to space,
temperature, humidity and ventilation. In addition, it must be in compliance with the current
regulations and guidelines15. A dedicated consultation room is optional though highly
recommended to maintain patient confidentiality and privacy throughout the process of
sedation.

6
 8.0 SEDATION TECHNIQUES

8.1 Inhalation Sedation (IHS)/ (Nitrous Oxide/Oxygen)

8.1.1 Specialised Equipment for Inhalation Sedation and Requirement

It is essential that the equipment for inhalation sedation is dedicated and is specifically
designed to administer the gas for dentistry purposes. It must conform to national safety
standards at all times and follow the maintenance guidelines provided by the manufacturer
with regular servicing documentation recorded15,16. Cylinders must be safely stored according
to current regulations to prevent injury15. The components of the system are as Figure 1, 2
and 3 the checklist for the equipment are as in Table 3.

Figure 1: The Gas Cylinders and Other Components

Flush button

Gas indicator
Patient
breathing
circuit
Reservoir bag

Nitrous oxide
tank Oxygen tank

Figure 2: Nasal Mask

7
 Figure 3: Head of The Machine

Nitrous oxide Oxygen flow

flow meter meter

Mixture dial

Flow control
knob

Table 3: Nitrous Oxide Machine Checklist

No Nitrous Oxide Machine Checklist [✓]

1 Cylinders: “FULL” and “IN USE”

2 Pressure gauges
3 All connections
4 Flow and mixture controls
5 Oxygen flush controls
6 Reservoir bag
7 Breathing system and range of mask
8 Scavenging system
**Adopted from Craig and Skelly, 2004

8.1.2 Safety Features of the Nitrous Oxide Delivery Unit

There is a need to ensure the following features are met:

1. Nitrous oxide cut-out: the nitrous oxide is automatically shut off if the oxygen runs out
and the patient will breath room air
2. There must be minimum of 30% deliverable oxygen and minimum oxygen flow is 2.5
L/min and maximum of 10 L/min of nitrous oxide
3. The machine is equipped with non-return valve to prevent re-breathing and reservoir
bag

8
 4. Active and passive scavenging mechanisms must be advocated and serviced regularly
(at least annually) and tested for fault/leaks
5. The dental surgeries must be well ventilated
6. All necessary precautions should be taken to minimize chronic exposure to nitrous
oxide

8.1.3 Indications for Inhalation Sedation17

The type of patients indicated for inhalation sedation are those with:
1. Mild to moderate anxiety
2. Unpleasant procedures for patients with minimal treatment experience
3. Patient with needle phobia
4. Patient with pronounced gag reflexes
5. Medically compromised patients
6. Other technique of sedations is contraindicated
7. As an alternative to GA

8.1.4 Contraindications for Inhalation Sedation17

The type of patients contraindicated for inhalation sedation are as follows:

Absolute Contraindications
1. Acute and chronic nasal obstruction
2. Pregnancy
3. Unable to cooperate or understand instruction due to cognitive impairment or age
factor
4. Access to the operating area is impossible with the nasal hood/mask placement

Relative Contraindications
1. Inability to breath nasally with open mouth
2. Severe chronic obstructive airway diseases or cardiac disease e.g patient who
experiences cyanosis at rest where the respiration is driven by low oxygen tension.
History of Bronchial Asthma.
3. Severe nasal or facial deformity
4. Severe psychiatric disease and nasal hood phobia
5. Severe medical conditions such as Myasthenia Gravis, Multiple Sclerosis, Motor Neuron
Disease or Parkinson’s Disease
6. Less than 3 months from ocular surgery because nitrous oxide has a mild risk to cause
intraocular pressure

9
8.1.5 Procedure for Inhalation Sedation17, 18

Procedures for inhalation sedation are as follows:

Pre-sedation Checks

1. Dental chair and all relevant equipment are working properly

2. Nitrous oxide and oxygen tanks are correctly attached
3. Fail-safe oxygen cut off system is checked
4. Nasal hoods, breathing circuit, reservoir bag, tubing, scavenging system are intact and
switched on
5. Emergency equipment and drugs are readily available
6. Other equipment required are available
7. Thorough dental, medical, sedation and social history have been taken with ASA status
recorded and level of cooperativeness has been assessed correctly
8. Accompanying adult available
9. Written and informed consent have been obtained
10. Correct size of nasal hood
11. No fasting is required

Procedure

1. Set machine mixture dial to 100% of oxygen

2. Set flow rate dial to between 5 and 7 litres/min for adults or 6 litres/min for children
3. Keep the equipment as unobtrusive as possible
4. Patient is reclined on the dental chair and well informed about the procedure to be
performed
5. Pass the nasal hood to patient to be placed on his/her own nose with 100% oxygen
running at the rate between 5 and 7 litres/min
6. Assist the patient to adjust the nasal hood for comfort and ensure a good seal is achieved
7. The position of the tubes behind the head is adjusted for comfort and seal
8. The patient is then asked to take some deep breaths and ensure that the reservoir bag is
moving properly and adequately filled
9. Inform the patient that the oxygen may feel cold
10. Reassure and check that the patient is comfortable
11. Steady conversation should be encouraged and maintained with only closed questions to
be answered with yes or no but discourage mouth breathing to maximize the effect of
nitrous oxide
12. Allow the flow of 100% oxygen for 1 minute
13. Then turn the mixture dial to 90% oxygen (administering 10% nitrous oxide)

10
14. The patient is informed that he/she may experience:
i. Light-headedness/ floating sensation
ii. Changes in visual and auditory acuity
iii. Tingling of hands, feet, around the mouth or lips
iv. Feeling warmth like being in a soft, feather bed
v. Feeling lightness or heaviness
15. Be positive, calm, pleasant and reassuring
16. Maintain the flow for one full minute and continue verbal reassurance
17. Adjust the mixture dial to 80% oxygen (administering 20% nitrous oxide) after 1 minute
18. Wait for one minute
19. Then introduce increments of 5% nitrous oxide at interval of one minute until the patient
appears relaxed and desired effect is achieved
20. Concentrations of nitrous oxide between 20% and 50% are typical for adults and
commonly produce a state of relaxation, sedation and analgesia without loss of
consciousness
21. At the desired level, the patient should be aware of the operative procedures but calm
and cooperative without fear
22. Local anaesthetic can be administered at this stage if required
23. Mouth prop is not encouraged to be used because if the patient cannot maintain mouth
opening, that may mean he/she could be deeply sedated (Refer to Signs of Sedation/
Signs of Over Sedation)
24. Treatment to be introduced slowly and progress to the next level in stages
25. When treatment is completed, continue administering 100% oxygen for 2 minutes before
removing the nasal hood to prevent diffusion hypoxia
26. Encouragement and praise can be given at this time for their cooperativeness and
acceptance of treatment
27. The patient can be asked to remove the nasal hood and slowly return the dental chair to
upright position
28. The patient can be transferred to recovery area when ready
29. Patient alertness and orientation must be satisfactory before discharging
30. Written and verbal post sedation instructions to patient and accompanying person must
be given

Signs of Sedation

1. Relaxation and acceptance of treatment without fear and anxiety

2. Slowed response and slurring of speech (reduced frequency of blinking)
3. ‘General detachment’ shown by less body and facial tension
4. Laughing/giggling/daydreaming – mood changes
5. Reduced pulse and breathing rate
6. Warmth, tingling and numbness

11
 Signs of Over Sedation

1. Unresponsiveness
2. Disorientation, apprehension
3. Irritability and hallucinations
4. Nausea (vomiting is rare)
5. Muscle rigidity, mouth closure

8.2 Intravenous (IV) Sedation with Midazolam17, 18

8.2.1 Specialized Equipment for Intravenous Sedation

The most ideal drug for IV dental sedation is Midazolam which has been widely used for many
years. As opposed to inhalation sedation, the equipment and drugs required for intravenous
sedation are much simpler and inexpensive. Generally, regardless of the drugs used for the IV
sedation, all the administration and monitoring devices must be available within the
treatment area. The equipment should be calibrated and maintained regularly for all types of
infusion techniques especially monitoring devices such as pulse oximeter and blood pressure
monitor19,20. In addition, it is required that supplemental oxygen is available at all times in case
the need for it arises, concurrent with the skills of delivering intermittent positive pressure
ventilation to patients.

Table 4 are the items required for administration of IV midazolam which is often used as a
drug of choice in dentistry for sedation:

Table 4: Materials and Equipment Required for IV Midazolam Administration 15, 19

Drugs/ Devices Description
Midazolam Drug used for IV sedation prepared in 5mg/5ml or 10mg/2ml
solution in a vial. The former preparation is more preferable as it
is easier to be titrated to prevent over-dosage and over-sedation.

Flumazenil Antagonist for midazolam presented in 500 micrograms in 5ml

12
 Drugs/ Devices Description
Syringes (5ml or The 5ml syringe is the most useful one as it can be used for both
10ml) midazolam and flumazenil. However, if a patient requires more
than 5mg of midazolam to achieve an optimal sedation, 10 mg
syringe is more appropriate to be used. Ensuring that the syringe
hub is compatible with both the drawing-up needles and the
cannula system is essential to allow smooth delivery of the
sedative agent.
Drawing up needles To draw up the midazolam into the syringe
(21 gauge)

Cannula system The currently used system is the Y-type cannula system as it allows
easy access to small veins and is less painful. It is best to avoid the
butterfly needles as it tends to develop blood clot within 5-10 min
after administration of the sedative agents and has the potential
to cut through the vein with the patient’s movement. It is
important to keep a flexible plastic cannula in a vein throughout
the procedure until normal recovery is obtained and the patient is
ready to be discharged.
Gauze Used to hold the drug ampoule while breaking it to reduce injury
to the operator’s finger.

Tourniquet Used (when indicated) in cases where the access to the vein is
difficult.

Antiseptic wipe Used to wipe the skin surface prior to venepuncture to prevent
infection and to get clear access to the vein.

13
 Drugs/ Devices Description
Stopwatch/ clock Used to monitor the drug titration rate.

Non-allergenic tape Used to hold the cannula in place and to hold the dressing over the
venepuncture site after de-cannulation.

Pulse oximeter Measures arterial O2 saturation and heart rate which is a

mandatory requirement during IV sedation of any techniques of
infusion. An alarm is incorporated in the device to indicate low
SaO2, tachycardia and bradycardia. It should be set no lesser than
90% of SaO2, 140 beats per min (bpm) for maximum limit of the
heart rate and 50 bpm for minimum limit of the heart rate.
Although the electronic device would give an immediate indication
of abnormality of the reading, clinical monitoring and justification
of the patient’s condition by the dental team remains crucial for
patient safety under sedation.
Blood pressure (BP) Used to measure BP before sedation starts, to get the baseline
monitoring device reading which should be within the acceptable therapeutic range
according to the patient medical conditions if any. It is also
measured during recovery to ensure the patient is discharged when
the BP returns to normal.

8.2.2 Indications for Intravenous Sedation

Intravenous sedation is indicated for the following cases:

1. Moderate to severe anxiety

2. Unpleasant procedures
3. Medically compromised patients (for certain conditions)
4. Patient with gag reflex
5. When other sedation methods are contra-indicated
6. Alternative to GA

14
8.2.3 Contraindications for Intravenous Sedation

There are some cases however, when intravenous sedation is contraindicated, as follows:

Absolute contraindications

1. Allergy to benzodiazepine
2. Develop adverse reaction to IV agents or benzodiazepine
3. Pregnancy and breast-feeding

Relative contraindications

1. Patient with severe psychiatric disease

2. Patient who is taking alcohol or drug abuser due to unpredictable effect of the IV agents
as a result of high dependency to alcohol which makes titration difficult
3. Renal or liver impairment
4. Needle phobia and fear of injections
5. Poor vein access
6. Potential drug interactions (opiate analgesic, hypnotic, sedatives, antiepileptic, drugs for
Parkinsonism)
7. Patient has other responsibilities which cannot be compromised e.g taking care of young
children or elderly, unable to take time off from work
8. Unreliable accompanying person
9. Poor past-sedation history

8.2.4 Procedure for IV sedation17, 18

1. Check the checklist for sedation procedure (Appendix 2) and ensure its availability.
2. Ensure the lay up for IV sedation is completed before the patient arrives and discretely
placed.
3. When the patients arrive, review and check the medical history.
4. Check and record the blood pressure, heart rate and SaO2 level.
5. Explain about the procedure to be done and confirm the treatment plan for that particular
session. Any enquiries must be dealt with before sedation is introduced.
6. Check if the patient has been fasting for at least 4 hours before sedation.
7. Check if a responsible adult accompanying person is accompanying the patient.
8. Check if the patient has emptied the bladder.
9. Check if the consent has been signed and understood.
10. Adjust the chair to supine position while patient is made comfortable to sit on the dental
chair. Ensure the leg is straight and uncrossed in order to prevent venous stagnation and
stability.
11. Select a suitable vein for cannulation. Any reasonably large veins can be used but the most
common veins chosen is at the dorsum of the hand or at the antecubital fossa.

15
12. A tourniquet can be used to occlude venous return. Other option is maintaining a firm
steady grip at the proximal area of the intended point of cannulation by an assistant.
13. A small indwelling cannula (Venflon or Y-can system) is recommended to provide
continuous venous access.
14. Clean the intended cannulation point with chloroprep sponge (Chlorhexidine & Isopropyl
alcohol) or plain alcohol wipes.
15. Insert the cannula into the vein using aseptic non-touch technique (ANTT), retract the
needle halfway, then fully insert the cannula, support the needle before finally removing
it.
16. The correct positioning of the cannula is confirmed with the presence of flashback of
blood within the chamber of the cannula before the needle is fully retracted. (note: A
smooth entry is experienced. Resistance indicates a problem)
17. The cannula is secured using clear sterile dressing (Tegaderm).
18. Pulse oximeter must be attached to the patient’s finger at this stage and throughout the
procedure to monitor the SaO2 level. BP monitoring is recommended every 15 minutes.
Normal SaO2 should fall between 95 to 100 percent.
19. If SaO2 level falls below 95%, oxygen via nasal prong to be administered at 3L/min
throughout the procedure. However, if it continues to fall below 93%, procedure need to
be aborted.
20. A 5 ml syringe is used to withdraw the midazolam preparation (10mg/2ml). A 5ml or 10ml
syringe can be used if 5mg/5ml midazolam preparation is available.
21. The syringe is then attached to the cannula after ensuring that all air bubbles have been
removed from the syringe.
22. Patient should be informed that a cold sensation will be felt immediately following the
administration of the sedative agent and will pass shortly provided that the cannula is in
the correct position.
23. If swelling is observed and pain is felt radiating to the forearm or fingers, an injury may
have occurred to the artery, the administration of drugs should be halted immediately.

24. (a) For a medically fit adult patient, the following regime is appropriate for 5mg/5ml
preparation:
i. 2 mg (2.0 ml) of Midazolam within 30 seconds, wait for 90 seconds
ii. Observe the patient for any effects
iii. Give an increment of another 1mg (1.0 ml)
iv. Wait for 1 minute and observe the effects
v. An increment of 1 mg (1.0 ml) of Midazolam is further administered at an interval of
1 minute until desired sedative effects is achieved.
vi. For a prolonged procedure (> 30minutes) if indicated, further small increments (1 mg)
of midazolam can be titrated every 10 minutes against patient’s response.
vii. It is suggested that the maximum dose of midazolam for sedation which is 0.02-0.1
mg/kg dose not to be exceeded. If sedation is not achieved at this dose, sedation
should be abandoned until anaesthetist is available for airway protection.

16
 OR

24. (b) For an elderly patient (above 60 years old), a modified regime should be given for
5mg/5ml preparation:
i. 1 mg (1.0 ml) of midazolam given over 30 seconds
ii. Wait for 4 minutes and observe the effects
iii. Additional of 0.5 mg (0.5 ml) of midazolam is given every 2 minutes until the desired
effect is achieved.
iv. It is suggested that the maximum dose of midazolam for sedation which is 0.02-0.1
mg/kg dose not to be exceeded. If sedation is not achieved at this dose, sedation
should be abandoned until anaesthetist is available for airway protection.

25. The sedationist, operator and assistant should continuously observe and talk to the
patient while watching for signs of adequate sedation such as slurred speech, slowed
response and appears relax and calm. Signs of adverse reactions and respiratory
depression should also be observed.
26. Topical anaesthetic can be applied during administration of the sedative agents.
27. Local anaesthetic can be administered shortly after the adequate sedative effects is
obtained.
28. Usually 30 to 40 minutes sedation time is available. For a prolonged procedure, further
small increments (1 mg) of midazolam can be titrated every 10 minutes against patient’s
response.
29. A mouth prop may be placed with mouth opening as the sedative agent causes muscle
relaxation.
30. Protect the airway with effective aspiration or rubber dam. Eye protection equipment
should be used as well.
31. Once the procedure is completed, slowly move the chair to an upright position and
transfer the patient to the recovery area when she/he is ready with assistance. The
patient should be accompanied by the assistant or the accompanying person at all time
at the recovery area until patient is fit to be discharged. (Refer Recovery criteria at page
19)
32. The patient must only be discharged into the hand of a responsible accompanying person.
The dental assistant is responsible to give the post-op advice or instruction in relation to
sedation and dental treatment.
33. The sedationist is responsible to ensure the patient is fit for discharge.
34. The IV sedation procedure should be abandoned if:
i. Optimum sedation is not achieved within 30 minutes with midazolam at maximum
dose of 0.05mg/kg.
ii. Oxygen desaturation is below 93% despite on oxygen.
iii. Persistent hypotension >20% from baseline blood pressure.
iv. Patient develops allergic reaction eg skin rashes

17
8.3 Oral Sedation

The drugs that are often used for oral sedation is Temazepam and Midazolam. The dose for
midazolam is 0.5mg/kg to be taken 15-30 minutes before treatment. The maximum dose for
adults is 30mg for Temazepam and 20mg of Midazolam. Chloral Hydrate is still used for oral
sedation in paediatric patients.

Oral sedation technique helps to sedate patient with needle phobia and those who are unable
to cooperate such as people with intellectual disabilities. However, the effects of the drugs is
unpredictable due to variability in absorption which may lead to under or over sedation.

8.4 Intranasal Sedation (INS)

It is indicated for uncooperative patients or needle phobic patients prior to cannulation. It can
be used on its own for a short procedure as the sedation duration may be in 15 to 20 minutes
only. The drug used for this technique is 40 mg/1 ml Midazolam and administered in a syringe
connected to an atomization device (M.A.D). ½ the volume is administered in each nostril and
expected to have onset of action within 5-10 minutes after administration because it is directly
absorbed through the blood vessels of the nasal mucosa.

Side effects of this type of sedation includes:

1. Burning sensation
2. Stinging sensation
3. Coughing and spluttering the liquid at the back of the throat
4. Sneezing
5. Crying

8.5 Flumazenil (Antagonist of Benzodiazepine)

Flumazenil reverses the effects of midazolam such as sedative, cardiovascular and respiratory
depression. Flumazenil is not administered routinely but only when indicated such as those
who experiences slow recovery and has a difficult journey home or in any emergency
situation.

It can be administered by giving 200 micrograms (2 ml) over 30 seconds and continue giving
in an increment of 100 microgram (1 ml) at 2 minutes interval against the sedation effects.

18
9.0 MONITORING

Preoperative blood pressure and medical history checking are mandatory. A pulse oximeter
must be used to monitor the pulse rate and oxygen saturation of the patient throughout the
sedation procedure. Blood pressure, pulse rate and respiratory rate to be monitored every 15
minutes throughout the procedure. There is no electronic monitoring required for inhalation
sedation. Breathing rate and depth must be constantly observed together with skin colour and
level of sedation. (Refer Ellis Score & MoH Sedation Score).

The norm expected are as follows:

Respiratory / breathing rate:

Normal: 12-20 breaths per minute

Heart rate
Maximum: 130 bpm
Minimum: 40 bpm

Oxygen saturation
Minimum: 93%

10.0 RECOVERY AND DISCHARGE

10.1 Criteria for Discharge

When the patient shows the following symptoms, they could be considered for discharge:

1. Patient should be orientated with time, place and person.

2. Patient is able to walk safely unaided without stumbling or wobbling
3. Patient’s vital signs such as blood pressure, heart rate and oxygen saturation level return
to the acceptable range as that before the procedure and Pain Score of < 4
4. No active surgical bleeding.

10.2 Removal of Cannula

Cannula should be removed before discharge as follows:

1. Wear gloves and eye protection with a cotton wool roll and dressing gauze in hand
2. Remove the ‘tegaderm’ dressing
3. The cotton wool roll is then held and pressed over the venepuncture site while removing
the cannula
4. Discard the cannula in a sharps bin while asking the patient to press on the cotton wool
at the same time

19
5. Ensure that there is no more bleeding on the venepuncture site before placing on the
adhesive dressing
6. Remind the patient that the dressing should remain in place for a few hours

10.3 Discharge and Post-Operative Instructions

1. Record the blood pressure, heart rate and SaO2 prior to discharge and record the
discharge criteria as outlined above
2. Post - operative instructions must be given:

i. Do rest at home and accompanied by responsible adults

ii. Do not drive
iii. Do not use machinery (e.g cookers, washing machines, power tools)
iv. Do not sign important documents
v. Do not drink alcohol
vi. Do come to Emergency Department for any complications. E.g active bleeding and
severe pain.

11.0 RECORD KEEPING

Apart from a standard format of keeping the patient’s details, special subheadings should be
used to record the sedation components. The subheadings recommended are:

11.1 Pre-operative

1. The presence of accompanying person and who is she/he

2. Consent (has been signed and informed)
3. Has patient taken any meal
4. Medical history has been checked and updated
5. Record the name of second appropriate person in charge of patient during sedation
6. Blood pressure
7. Oxygen saturation level (SaO2)
8. Pulse rate

11.2 Sedation

1. IV access site and time

2. Drug name(s) used
3. Batch number(s) of the drugs and expiry date
4. Minute volume of N2O
5. Ratio of percentage of N2O:O2
6. Any episodes of desaturation and the corrective action taken
7. Refer Sedation Score: (Table 5)

20
 Table 5: Sedation Score

Score Sedation level Clinical findings

0 None Patient is awake and alert

Occasionally drowsy, easy to rouse, and can stay awake once
1 Mild awoken
Constantly drowsy, still easy to rouse, unable to stay awake
2 Moderate once awoken
3 Severe Somnolent, difficult to rouse, severe respiratory depression
S Sleep Patient asleep

Table 6: Operating Conditions

Score Level Explanation

1 Good Patient fully cooperative with optimum degree of sedation

Minimal interference from patient due to over/ under
2 Fair
sedation
3 Poor Operating difficult due to over/under sedation

When Ellis Behavioural Score 4 & 5 or Sedation Score of 3 (e.g

4 Impossible
refer for GA)

Table 7: Recovery Rating

Rate Explanation

Normal Within the timescale expected

Rapid Sooner than normal – action taken

Prolonged Longer than normal

11.3 Dental Treatment

Dental treatment given must be recorded appropriately including any problems that arise
during the procedure.

21
12.0 MANAGEMENT OF RELATED COMPLICATIONS

12.1 Respiratory Depression

Causes Over-sedation by rapid administration of midazolam and overdose

1. SaO2 drops below 90% and recognized by pulse oximeter alarm

Indications
2. Patient turns blue if the oxygen drops significantly
1. Stop all treatment, ask patient to take deep breaths
2. If the patient fails to respond to the instruction, check the airway by
tilting the head and lifting the chin and administering the oxygen by
Management
positive pressure ventilation with inflating bags at 15L/min with
respiratory rate maintained >12/min.
3. If the patient still fails to respond, administer 500 mcg Flumazenil
(Maximum dose is 1mg).

**Tips:
1. Better suction as this can be due to blockage by water and debris
2. Supporting mandible during the extraction
3. Tilt the head and lift the chin during procedure.

12.2 Allergy

Allergy to midazolam is very rare but if it happens, it has to be further investigated.

12.3 Cardiac Arrest

Use standard basic life support.

12.4 Hypotension

All sedative agents may cause fall in blood pressure but usually does not cause any significant
problems during sedation.

12.5 Cannulation

Causes Fail to find the good veins and multiple cannulation

Indications Bruising and pain

Management Apply pressure and ice packing to the failed cannulation site

22
12.6 Hiccup

Causes Rapid injection of midazolam or oversedation

Indications Hiccups

Wait for them to pass if the dental treatment becomes difficult due to
Management
hiccups

**Tips:
1. Administer the midazolam slowly in the next visit.

12.7 Paradoxical Effect

Causes The sedative agent itself

Indications Uncontrolled behaviour, more difficult to manage, noisy

Stop treatment and reconsider, consider other alternatives such as GA,

Management
explain to the patient and accompanying person

12.8 Prolonged Recovery

Certain medical conditions or hypersensitivity to midazolam (difficult to

Causes
predict)
The patient does not show any signs of recovery after an hour of the last
Indications
increment of midazolam.

Management Administer titrating dose of Flumazenil

**Tips:
1. Patient at risk to be done early in the day

12.9 Over Sedation

Causes Inexperienced sedationist, under sedation ‘topping up’ of midazolam

Indications Unresponsive patient (over sedated). Sedation Score 3

Administration titrating dose of Flumazenil or adjusting the concentration

Management
of nitrous oxide level in inhalation sedation without removing the mask

23
12.10 Failed Sedation

Causes Inexperienced sedationist

Indications Patient remains anxious (under sedated)

Adjusting the concentration of nitrous oxide level in inhalation sedation

without removing the mask
Management
Titrate midazolam dose up to maximum dose.
Ensure functioning branula

12.11 Sexual Fantasies

Causes Administration of benzodiazepines

Indications Talk or act inappropriately relating to sex

Ensure that there are at least 2 persons with the sedated patient or the
Management
escort present throughout the procedure.

13.0 CONCLUSION

Conscious Sedation in Dentistry is currently on the rise and it is timely that a guideline exists
for the dental officers or specialists to conduct good practice and give the best treatment
possible to their patient. Through this guideline it is hoped that the dental services in Malaysia,
is able to achieve greater heights in healthcare for the nation.

24
REFERENCES

1. College of Anesthesiologist Academy of Medicine Malaysia, Recommendations for

Sedation and Analgesia for Non-anaesthesiologists. 2012, Kuala Lumpur.
2. Dental Council of New Zealand, Sedation Practise Standards. 2017, Dental Council of
New Zealand: New Zealand.
3. Healey T J, Edmonson H D, and Hall N, Sedation for the mentally handicapped dental
patient. Anaesthesia, 1971. 26: p. 308-310.
4. SDCEP, Conscious Sedation in Dentistry Dental Clinical Guidance, S.D.C.E. Programmes,
Editor. 2017, Scottish Dental Clinical Effective Programmes: Scotland.
5. Department of Health, A Conscious Decision: A Review of the Use of General
Anaesthesia and Conscious Sedation in Primary Dental Care, Department of Health,
Editor. 2000.
6. Rooney E, NHS Reforms and the impact on dentistry, Department of Health, Editor.
2013.
7. Department of Health England, Commissioning Conscious Sedation Services in Primary
Dental Care United Kingdom, Department of Health England, Editor. 2007. p. 13.
8. Foley J, The way forward for dental sedation and primary care? British Dental Journal,
2002. 193(3): p. 161-4.
9. Wanyonyi KL, White S, and Gallagher JE, Conscious sedation: is this provision
equitable? Analysis of sedation services provided within primary dental care in
England, 2012–2014. BDJ Open, 2016. 16002: p. 1-9.
10. Morris AJ and Burke FJT, Health policy: Primary and secondary dental care: how ideal
is the interface? British Dental Journal, 2001. 191(12): p. 666-70.
11. Coulthard P, et al., Current UK dental sedation practice and the 'National Institute for
Health and Care Excellence' (NICE) guideline 112: sedation in children and young
people. British Dental Journal, 2015. 218(8): p. E14-E.
12. Ibbetson, R., et al., Standards for Conscious Sedation in the Provision of Dental Care,
T. Nikosvakia, Editor. 2015, Intercollegiate Advisory Committee for Sedation in
Dentistry.: United Kingdom. p. 115.
13. Holden, C., P. Howlett, and S. Hughes, A Quality Assurance Programme for
Implementing National Standards in Conscious Sedation for Dentistry in the UK 2015,
Society for the Advancement of Anaesthesia in Dentistry. p. 1-40.
14. Greening S and Jones V, Community Dental Service Referral Care Pathway for
Vulnerable Adults requiring Special Care Dentistry in ABUHB including Sedation and
General Anaesthesia, Board ABUH, Editor. 2015. p. 15.
15. Craig D and Skelly M, Practical Conscious Sedation, ed. Wilson NHF and Meechan J.
2004, London: Quintessence Publishing Co. Ltd.
16. British Dental Association, Conscious Sedation, B.D. Association, Editor. 2011: United
Kingdom. p. 13.
17. Clarke M, et al., National Course in Conscious Sedation for Dentistry, ed. B. C. 2016,
London: SAAD.
18. Department of Sedation and Special Care Dentistry, Diploma in Dental Sedation 2016.
2016, KCL Dental Institute: London.

25
19. Cote CJ and Wilson S, Guidelines for Monitoring and Management of Pediatric Patients
During and After Sedation for Diagnostic and Therapeutic Procedures: An Update.
Paediatrics, 2006. 118(6): p. 2587-602.

26
APPENDICES

27
 Appendix 1
_________________________________________________________________
ASA Physical Status Classification System
(Approved by the ASA House of Delegates on October 15, 2014, and last amended on December 13, 2020)

ASA PS Adult Examples, Including, but Pediatric Examples, Including Obstetric Examples,
Definition Dental Examples
Classification not Limited to: but not Limited to: Including but not Limited to:

A ‘normal’ healthy patient who is

A normal Healthy (no acute or chronic
Healthy, non- smoking, no or well able to tolerate physiological
ASA I healthy disease), normal BMI
minimal alcohol use stress. Has little or no anxiety
patient percentile for age
Is normotensive
Asymptomatic congenital
cardiac disease, well controlled
Mild diseases only without Normal pregnancy (well
dysrhythmias, asthma without
A patient Substantive functional limitations. controlled gestational HTN,
exacerbation, well controlled
with mild Current smoker, social alcohol controlled preeclampsia An extremely anxious patient.
ASA II epilepsy, non-insulin dependent
systemic drinker, pregnancy, obesity without severe features, refer MDAS scale
diabetes mellitus, abnormal BMI
disease (30<BMI<40), well-controlled diet-controlled gestational
percentile for age, mild/moderate
DM/HTN, mild lung disease DM)
OSA, oncologic state in remission,
autism with mild limitations

Uncorrected stable congenital

cardiac abnormality, asthma with
exacerbation, poorly controlled
Substantivefunctional limitations; epilepsy, insulin dependent
One or more moderate to severe diabetes mellitus, morbid obesity,
diseases.Poorly controlled DM or malnutrition, severe OSA,
Preeclampsia with severe
HTN, COPD, morbid obesity (BMI oncologic state, renal failure,
A patient features, gestational DM
≥40), active hepatitis, alcohol muscular dystrophy, cystic
with severe with complications or high
ASA III dependence or abuse, implanted fibrosis, history of organ
systemic insulin requirements, a
pacemaker, moderate reduction of transplantation, brain/spinal cord
disease thrombophilic disease
ejection fraction, ESRD undergoing malformation, symptomatic
requiring anticoagulation
regularly scheduled dialysis, history hydrocephalus, premature infant
(>3months) of MI, CVA, TIA, or PCA <60 weeks, autism with
CAD/stents severe limitations, metabolic
disease, difficult airway,
long term parenteral nutrition.
full term infants <6 weeks of age

28
 ASA PS Adult Examples, Including, but Pediatric Examples, Including Obstetric Examples,
Definition Dental Examples
Classification not Limited to: but not Limited to: Including but not Limited to:

Symptomatic Congenital cardiac

abnormality, congestive heart
failure, active sequelae of Preeclampsia with severe
Recent (<3 months) MI, CVA, TIA or prematurity, acute hypoxic- features complicated by
A patient
CAD/stents, ongoing cardiac ischemic encephalopathy, shock, HELLP or other adverse
with severe
ischemia or severe valve sepsis, disseminated intravascular events, peripartum
systemic
ASA IV dysfunction, severe reduction of coagulation, automatic cardiomyopathy with EF
disease that
ejection fraction, shock, sepsis, DIC, implantable cardioverter- <40,
is a constant
ARD or ESRD not undergoing defibrillator, ventilator uncorrected/decompensated
threat to life
regularly scheduled dialysis dependence, endocrinopathy, heart disease, acquired or
severe trauma, severe respiratory cong enital
distress, advanced
oncologic state

Massive trauma, intracranial

hemorrhage with mass effect,
A moribund
Ruptured abdominal/thoracic patient requiring ECMO,
patient who
aneurysm, massive trauma, respiratory failure or arrest,
is not
intracranial bleed with mass effect, malignant hypertension,
ASA V expected to Uterine rupture
ischemic bowel in the face of decompensated congestive
survive
significant cardiac pathology or heart failure, hepatic
without the
multiple organ/system dysfunction encephalopathy, ischemic bowel
operation
or multiple organ/system
dysfunction

A declared
brain- dead
ASA VI patient
whose
organs

29
 Appendix 2
_________________________________________________________________

PRE-PROCEDURAL CHECK LIST FOR SEDATION

Patient’s name: __________________________________ R/N No: _______________________

Sedationist: __________________________________ Dental Officer: __________________
Assistant 1: __________________________________
Assistant 2: __________________________________
Runner: __________________________________

Check List Availability

1 Another dentist present within an easy call

3 Trained sedationist, the operator and assistants present
4 Emergency equipment checked and located nearby
5 Sufficient Oxygen cylinder
6 Functioning Suction – dental unit
7 Functioning Suction – mobile/back up
8 Functioning Positive pressure ventilating bag (Ambu bag)
9 Functioning BP monitoring machine
10 Functioning Pulse oximeter
11 Emergency drugs
12 Sedation equipment and drugs
13 Dental unit and equipment
14 Patient and carer have been well informed and know about the plan
15 Written consent obtained
16 Medical and dental history checked
17 Routine medications taken
18 The time and type of last meal taken have been checked
20 ASA 1 or ASA 2
21 Accompanying person
22 Body weight recorded
23 Vital Signs recorded

30
 Appendix 3
_________________________________________________________________

PROCEDURE UNDER MIDAZOLAM SEDATION

Date of Procedure : _______________________

Sedationist : _______________________ Name:
Dental Officer : _______________________ NRIC:
Assistant 1 : _______________________ R/N:
Weight (kg):
Assistant 2 : _______________________
Height (m):
Runner : _______________________
BMI:
Accompanying Person : _______________________

PRE-OPERATIVE CHECKLIST:

No Item Yes No
1 BP and SpO2 monitor
2 Oxygen cylinder
3 Midazolam
4 Flumazenil
5 Canulation tray/set
6 Dental materials and instruments

SURGICAL SAFETY CHECKLIST:

No Item Yes No
1 Patient identity confirmed
Correct tooth/teeth/surgical site identified by clinician, patient and
2
carer/parents
3 Medical history reviewed
4 Current medications
5 Any known allergies
6 Possibility of pregnancy
Risk of ORN (osteonecrosis) or MRONJ (Medication induced osteonecrosis of
7
the jaw)
8 Risk of prolonged bleeding
9 Is the patient immunocompromised
10 Consent confirmed and signed
11 What was the last time patient eats/drinks
If patient has not eaten, have appropriate measures been taken (Glucose
12
Drink)

31
Medical History:
……………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………

ASA STATUS:

Level Explanation Current Status

I A normal healthy patient
II A patient with mild systemic disease
III A patient with severe systemic disease
IV A patient with severe systemic disease that is a constant threat to life
A moribund patient who is not expected to survive without the
V
operation
VI A declared brain- dead patient

Plan: Name/Relation to Patient Date

Informed consent: _________________________ ______

Pre-OP instructions reviewed with: _________________________ ______
Post-OP instructions reviewed with: _________________________ ______

PRE-OPERATIVE RECORDINGS:

Blood Pressure: …………………. Pulse Rate: ………………….. SPO2: ………………..%

Venous Access Site: ……………………………………………. No of Attempts: ………………………………………
Type of Midazolam Preparation
IV BN: ………………………………………………………….. Exp Date: ………………………………………
Intranasal BN: ………………………………………………………….. Exp Date: ………………………………………
Oral BN: ………………………………………………………….. Exp Date: ………………………………………

MIDAZOLAM RECORDINGS:

Maximum dose: 0.05mg/kg =_______________

Loading Increment dose Total final

dose/Bolus mg/time/ Elis Behavioural Score/MOH Sedation Score dose

32
VITAL SIGN MONITORING:
To be taken every 15 minutes
Time Blood Pressure Heart Rate SPO2

ELLIS BEHAVIOURAL SCORE:

Ellis score used to grade the behavioural characteristics of patients under intravenous sedation.

Level Explanation Status

I No uninvited limb movement; total co-operation and no restlessness.

Small amount of uninvited limb movement; still total cooperation and no
II
restlessness
More uninvited limb movement; small degree of restlessness and anxiety.
III
Patient less co-operative; still able to perform all dental procedures.
Considerable degree of limb movement; perhaps also unhelpful head
IV movements; co-operation poor; patient quite restless and anxious; able to
perform only basic dentistry; advanced, delicate work not possible.
Restlessness, anxiety and limb movements severe; impossible to perform any
V
dentistry.

SEDATION SCORE:
In the event of midazolam oversedation (Score of 3) indicated for Flumazenil usage (to refer the MoH
sedation score below)

Score Sedation level Clinical findings

0 None Patient is awake and alert

Occasionally drowsy, easy to rouse, and can stay awake once
1 Mild
awoken
Constantly drowsy, still easy to rouse, unable to stay awake
2 Moderate
once awoken
3 Severe Somnolent, difficult to rouse, severe respiratory depression

S Sleep Patient asleep

33
OPERATING CONDITIONS:

Score Level Explanation Current Status

Patient fully cooperative with optimum degree of
1 Good
sedation
Minimal interference from patient due to over/ under
2 Fair
sedation

3 Poor Operating difficult due to under sedation

When Ellis Behavioural Score 4 & 5 or Sedation Score

4 Impossible
of 3 (e.g refer for GA)

OPERATIVE NOTES:

Local Anesthesia (LA) Yes /No

Type of LA: BN: Exp date:

DENTAL TREATMENT DETAILS:

Failed Sedation? Yes / No

Reasons?
……………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………

Was Clinical Holding Used? Yes / No

By whom?....................................................................................................................................

34
POST-OPERATIVE CARE:

BP: …………………………… SPO2: …………………………………. Pulse rate: ………………………….

Patient Assessment:

Can the patient walk unaided or with minimal support? Yes / No

If the patient on a wheelchair, does the patient look alert? Yes / No
Accompanying person present? Yes / No
Cannula removed Yes / No
Written and verbal instructions given to patient & accompanying person? Yes / No
Active bleeding Yes / No

Other complication, if any:

……………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………

RECOVERY RATING:

Rate Explanation Current Status

Normal Within the timescale expected
Rapid Sooner than normal – action taken
Prolonged Longer than normal

Flumazenil Use? Yes / No

BN: ……………………………………….. Exp Date: ………………………………………….

Dose: …………………………………….. Time of administration: …………………….

Reason for reversal?

……………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………

Time of Discharge

………………………………………………………………………………………………………………………………………………………..…

SEDATIONIST (DENTAL OFFICER/ SPECIALIST) SIGNATURE AND STAMP:

………………………………………………………………………....…

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ACKNOWLEDGEMENTS

Author:

Dr. Siti Zaleha Hamzah

National Head of Service and Consultant Specialist in Special Care Dentistry
Ministry of Health Malaysia

Contributors:

Asst Professor Dr. Farah Natashah Mohd Dr. Sofiah Mat Ripen
Specialist in Special Care Dentistry Secretary
International Islamic University of Malaysia Malaysian Dental Council

Dato’ Dr. Shah Kamal Khan Jamal Din

Ex National Head of Service and Consultant Oral Surgery
and Maxillofacial Surgeon
Ministry of Health Malaysia

Dr. Syed Iqbal Syed Husman

Consultant Oral Surgery and Maxillofacial Surgeon
Ministry of Health Malaysia

Dr. Ganasalingam a/l Sockalingam

National Head of Service and Specialist in Paediatric Dentistry
Ministry of Health Malaysia

External Expert Reviewer:

Dr. Melor @ Mohd Yusof Mohd Mansor

Ex National Head of Service and Specialist in
Anaesthesiology and Intensive Care
Ministry of Health Malaysia

Dr. Shamsuriani Md Jamal

Lecturer and Medical Emergency Physician
Universiti Kebangsaan Malaysia

Dr. Zalina Abdul Razak

National Head of Service and Consultant Specialist in Anesthesiology and Intensive Care,
Hospital Kuala Lumpur

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Dr. Amiruddin Nik Mohd Kamil
Consultant Specialist of Anesthesiology and Intensive Care
Hospital Kajang

Dr. Haslinda Abd Hashim

Consultant Specialist and Head of Department of Anesthesiology and Intensive Care
Hospital Selayang

Dr. Intan Zarina Fakir Mohamed

Specialist in Anesthesiology and Intensive Care
Hospital Tunku Azizah

Dr. Muralitharan a/l Perumal

Specialist in Anesthesiology and Intensive Care
Hospital Tengku Ampuan Rahimah, Klang

Dr. Darlina Mohd Dhari

Specialist and Head of Department in Anaesthesiology and Intensive Care
Hospital Kajang

Secretariat (Oral Health Programme):

1. Dr. Natifah binti Che Salleh

2. Dr. Fauziah binti Ahmad
3. Dr. Rapeah binti Mohd Yassin
4. Datin Dr. Nazita binti Yaacob
5. Dr. Muhamad Faris bin Muhamad Noor
6. Dr. Ku Amirah binti Ku Haris
7. Ms. Azirah binti Muhammad
8. Dr. Faris Abd Rahman Ismail (Medical Developmental Division, MOH)

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