[AMJ 2016;9(2):25–32]

Techniques to administer oral, inhalational, and IV sedation in dentistry

Diana Krystyna Harbuz and Michael O’Halloran
School of Dentistry, University of Western Australia, Perth, WA, Australia

sedation in dentistry or medicine. The appropriate setting

REVIEW for sedation should be determined as there is an increased
risk outside the hospital setting. Patients should be
Please cite this paper as: Harbuz D, O’Halloran M. adequately assessed and medication titrated appropriately,
Techniques to administer oral, inhalational, and IV sedation based on individual requirements.
in dentistry. AMJ 2016;9(2): 25–32.
http://dx.doi.org/10.4066/AMJ.2015.2543 Key Words
Sedation, deep sedation, conscious sedation, dentistry,
anaesthetic agents, pharmacology, dental phobia
Corresponding Authors:
Dr Diana Krystyna Harbuz
What this review adds:
Bachelor of Medicine and Bachelor of Surgery, MBChB
Peel Health Campus 1. What is known about this subject?
110 Lakes Rd. Anxiety during dental treatment is a common issue, and
Mandurah, Perth, Western Australia, 6210 without the use of sedation, dental health may be
Email: [email protected] neglected.

2. What new information is offered in this review?

ABSTRACT This review offers succinct information and
recommendations for safe practice for sedation in dentistry.
Background
Sedation in dentistry is a controversial topic given the 3. What are the implications for research, policy, or
variety of opinions regarding its safe practice. practice?
From this review, implications for further policy include
Aims continuously updating guidelines and practice standards for
This article evaluates the various techniques used to sedation in all forms of health care.
administer sedation in dentistry and specific methods
practiced to form a recommendation for clinicians. Introduction
In his article, O’Halloran discusses a variety of sedation
Methods techniques, clinical indications for sedation, risks of
An extensive literature search was performed using sedation, and the importance of regulated training to
PubMed, Medline, Google Scholar, Google, and local library ensure safe practice.1 It is important to understand the
resources. forms of sedation that patients may require to accept
dental treatment and overcome dental anxiety and phobia.
Results Knowledge of the agents used and patient selection are
Most of the literature revealed a consensus that light essential for safe practice.2–4
sedation on low-risk American Society of Anesthesiologists
(ASA) groups, that is ASA I, and possibly II, is the safest Definitions
method for sedation in a dental outpatient setting.
Sedation is a continuum from minimal, moderate, to deep
as described by the American Society of
Conclusion 2,5
Anaesthesiologists. Anxiolysis is a decrease in anxiety
Formal training is essential to achieve the safe practice of

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when the patient responds normally to verbal commands the procedure should be postponed until after birth unless
without resulting in conscious sedation. This is usually it is an emergency. Dental emergencies for pregnant women
achieved with a single low dose or inhalational agent.6,7 should be performed in hospital. Patients with intellectual
or physical impairment should be assessed on a case-by-
Conscious sedation is when a medication is, or medications case basis.3–4
are, administered to result in the depression of
consciousness. The patient should not require assistance Appropriate discharge criteria are important to prevent
maintaining their airway, cardiovascular function, or complications after discharge from care. Both verbal and
ventilation, and should respond purposefully to commands, written pre- and postoperative instructions for fasting,
such as verbal and light touch, for the patient’s own safety transport, and postoperative supervision by a responsible
and to avoid deep sedation.7,8 adult are important for patient safety.9

The aim is to achieve an optimum state without introducing Common techniques for sedation
additional risks of deep sedation or general anaesthesia. Oral sedation is reasonably safe, cheap, and generally well
Deep sedation is not recommended for dental procedures, 9 tolerated by patients. Disadvantages include a prolonged
as it is essentially not safe practice10 due to its associated onset and time to subside, an unreliable rate of absorption,
increased level of morbidity and mortality.11 and patient cooperation is required. There is an inability to
titrate and it is usually used in a dental setting as
General anaesthesia is defined as a drug-induced state in anxiolysis.1,3
which patients do not have a purposeful response to
stimulus, they lose their reflexes and their ability to protect Intranasal agents are absorbed directly into the systemic
their own airways, and there can be respiratory and circulation, which allows an efficient time to reach peak
cardiovascular depression.9 plasma levels.4 An advantage is intranasal administration
avoids first-pass hepatic metabolism and enteral
Sedation absorption.15
An optimum level of sedation should be achieved with the
view to avoid risks and complications.3 If performed safely Inhalation sedation is reasonably well tolerated, provided
and effectively, sedation may be acceptable in both patients can cope with the mask, and has a good analgesic
paediatric and adult populations.12 Patient selection for the effect. This is indicated for dental anxiety, needle phobia,
appropriateness of sedation assists with reducing risks. uncomfortable procedures, and suppression of gag reflexes.
Tailoring requirements on an individual basis can be based Contraindications include upper respiratory tract infections,
on degree of fear (mild anxiety or true phobia).3 For obstructive sleep apnoea, pregnancy, and young children.
example, if a patient is needle phobic, premedication or Limitations include a low potency, cooperation is required,
topical anaesthesia prior to IV cannula insertion will be and cost. In medicine, there are multiple uses for relative
useful.5 analgesia/nitrous oxide sedation such as simple emergency
procedures and labour.3,4
A history of previous dental procedures and methods used
for sedation, complete medical history, medications, and Intravenous administration is more commonly used for
allergies are essential for planning a safe procedure as this highly anxious patients, as it is the most efficient due to a
can affect the type of sedation used. Assessment of vital rapid onset, ability to titrate the medication quickly, and the
signs, oral examination, and clinical examination are effect of a long period of amnesia. Limitations include the
important to determine if they are fit for sedation in a need for patient cooperation and adequately trained staff.4
dental practice.3–4,13
Intramuscular and rectal administration are convenient,
The choice of sedation technique and location for sedation however, unsafe and not commonly used in dentistry due to
(inpatient or outpatient) depends on many factors, variable absorption rates and an inability to titrate.
including renal, hepatic, and respiratory function and Sublingual, transdermal, and subcutaneous also have
relative comorbidities (see Table 1: ASA Physical Status limited use in dentistry.4 Single-agent administration is safer
Classification6 with recommendations from this article).9,14 than multi-agent as using more than one agent is
Anxious patients have an increased risk of complications unpredictable, difficult to titrate appropriately with an
due to an increased sympathetic response. In pregnancy, increased probability of adverse side effects.6 Due to the

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unpredictable concentration of sedative in the blood with a Lignocaine and adrenaline can be added to prolong the
single or repeated bolus technique, it is preferable to effect.4,23
administer intravenous sedation with incremental titration
to the desired level clinical effect.3,4 Topical anaesthesia such as gels, sprays, or ointments like
topical amethocaine or EMLA cream can be used intraorally
There are two types of sedation managed by patients. or topically to the skin for topical anaesthesia prior to
Patient-controlled sedation (PCS) allows patients to self- cannulation.4
titrate their sedation; trials have shown patient satisfaction
is high and a lower requirement for a sedative with minimal Sedation outcomes
cardiorespiratory complications.16 Over sedation is rare.2 The aim is a balance between the appropriate level of
Patient maintained-sedation (PMS) is another method in sedation and avoiding using excessive quantities of
which patients can increase their own target concentration; sedation. If mixed agents are used there is an increased risk
PMS has proven effective for dental sedation.16 of drug interactions or additive effects causing adverse
outcomes.9
Paediatric sedation
The demand for paediatric sedation is increasing due to a Patients with pre-existing medical conditions and the elderly
growing population, and unfortunately not all specialties are are at more risk with sedation as this can change the
strictly regulated. The American Dental Association (ADA) physiology of sedation. The elderly require smaller doses of
recommends the use of the American Academy of sedation and the risk of haemodynamic instability, including
Pediatrics/American Academy of Pediatric Dentists desaturation is far greater.2 Sedation is not without risk,
Guidelines for children under 12 years old.17 adverse events are shown to be more common with
intravenous sedation in comparison to no sedation.
In the paediatric population there is no level I evidence
supporting sedation over general anaesthesia, however, There is a low incidence of paediatric deaths related to
sedation can avoid the requirement for a general sedation in a dental setting. Most deaths noted have been
anaesthetic which in itself is beneficial. 18,19 In paediatric in a dental outpatient setting with moderate/deep sedation
sedation it is recommended that only ASA I patients are and usually not following the appropriate guidelines. 24
sedated outside a hospital environment.13 Paediatric
dentists who use sedation are required to be adequately General anaesthesia
trained.20 If more sedation is required than expected, a general
anaesthetic is indicated as this is safer than titrating the
Adjuncts to sedation sedative to a point where the balance can be tipped
Non-pharmacological options include hypnosis, between conscious sedation and deep sedation.25 In very
acupuncture, iatrosedation, and electronic dental young children it may be more beneficial to elect for a
anaesthesia.4,21 The efficacy of these methods are patient general anaesthetic as opposed to sedation.26
dependent and not as predictable as pharmacological
methods.3 Behavioural management or cognitive Indications for general anaesthesia in dentistry include
behavioural therapy have been shown to decrease dental when patients are anxious, uncooperative, and needle
anxiety.21,22 phobic,4,27 certain paediatric cases, and patients with
intellectual or physical difficulties. These patients have an
Local anaesthesia must be used alone or in conjunction with increased chance of a vasovagal response due to increased
conscious sedation. Adequate local anaesthesia for the levels of autonomic activity, therefore, general anaesthesia
procedure must be provided and compensating for poor may be more appropriate.23 Specific paediatric cases include
local anaesthesia by deepening levels of sedation must be uncooperative or highly anxious children, significant
avoided because of the complications associated with deep procedures, to avoid emotional trauma, and emergency
sedation in dentistry. Local anaesthesia is the loss of pain cases.20
sensation to a specific area of the body by inhibiting nerve
function to the area for a certain amount of time. Potential Anaesthetists in dental cases should note the risk of the
side effects include pain during infiltration, post-injection shared airway. Blood and debris should be removed from
pain, nerve paralysis, visual or aural disturbances, the oropharynx before extubation. Throat packs are useful
intravascular injection, and the formation of a haematoma. at the onset of the procedure to prevent build-up of debris.

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Stimulation of the trigeminal nerve during a dental Oral midazolam is slow onset, unreliable due to unknown
anaesthetic can lead to an increased chance of individual efficacy-related hepatic first-pass metabolism,21,34
arrhythmias.23 and patients have an increased chance of postoperative
nausea and vomiting. Intranasal and buccal midazolam
Pharmacology of important agents in dental avoid these complications.34 The intranasal route has been
sedation suggested in paediatric populations due to more rapid
onset, tolerance, and parent preference.20 Intranasal
Nitrous oxide
administration can be irritating to nasal mucosa.35
Nitrous oxide (N2O) is a sweet smelling, colourless gas2
inhaled in combination with oxygen. It is absorbed by
In a dental setting, it has been shown patients prefer
pulmonary circulation, has a rapid uptake, and is more
midazolam as a sedative to propofol when sedated with a
readily absorbed in areas with greater blood flow.3–4 The
single agent only.35 IV midazolam is an alternative to N2O
delivery units will not allow over 70 per cent N2O and
sedation in the healthy patient.18 In an outpatient setting,
therefore delivery of less than 30 per cent oxygen is not
midazolam has been shown to be safe and effective when
possible. The usual dose of N2O for dental sedation is often
used appropriately.35 Due to the anterograde amnesic
between 25–45 per cent, and should be titrated to effect. A
effects of oral midazolam, patients will require a period of
rapid onset of action and fast recovery is enabled by careful
observation and an escort home.3
titration. It has good analgesic and anxiolytic properties and
is useful for when patients have allergies to other
Adding fentanyl to midazolam has not shown to be of
agents.3,4,28
benefit for paediatric populations and studies have shown
more adverse effects such as respiratory depression.36
Patients usually maintain their laryngeal reflexes and
haemodynamic stability.29 High doses can lead to
Fentanyl
myocardial and respiratory depression.3–4 Chronic exposure
Fentanyl is a short-acting opioid, 60–80 times more potent
can lead to complications such as pernicious anaemia,
than morphine, and with a rapid onset of analgesia and
which is important to consider regarding staff. The
sedation. Duration of action is 30–60 minutes. Fentanyl can
technique should be used with adequate training3,4,29 and
be titrated with doses of 25–50µg after an initial bolus of
care needs to be taken if using other sedatives.30 N2O is one
50–100µg IV when using a single agent. If using multiple
of the most frequently used methods of paediatric
agents, a smaller bolus of 25–50µg is recommended.31,32,37
sedation.13
Fentanyl is metabolised in the liver and secreted in the
urine. Constipation, nausea, and vomiting are common side
Midazolam
effects of opioid use. Serious adverse outcomes include
Midazolam is a water-soluble imadazobenzodiazepine4
dose-dependent respiratory depression and occasionally
metabolised in the liver, and excreted in urine and faeces.
bradycardia.4,32
The pharmacokinetics are not as affected by liver disease
compared with other benzodiazepines.4, The rapid onset of
Propofol
action when given intravenously is beneficial and the
Propofol is also known as 2,6 diisopropylphenol and is a
elimination half-life is between 90–150 minutes.4
synthetic sedative hypnotic agent4 metabolised in the liver
and excreted in the kidneys.3 It is a potent hypnotic agent
Intravenous dosing is 1–2.5mg for adults or 1–1.5mg in the
and is commonly used for general anaesthesia due to
elderly. Oral/buccal dosing is 0.5–1mg/kg with a maximum
minimal postoperative confusion.38 With a rapid onset of
of 15mg. Intranasal dosing is 0.6mg/kg with a maximum of
action and rapid recovery, the offset time is faster than
10mg.31,32 Dosing for paediatric patients is 0.02mg/kg IV and
midazolam.2,4 Clearance is reduced in the elderly and
for adults 0.6–1mg titrated depending on the response.4,18,33
increased in patients with a high body mass index (BMI).
Older patients and redheads usually require less
The average dose for sedation is 0.5mg/kg or 1.5–
sedation.2,34 Due to the possibility of unusual responses, the
3mg/kg/hour maintenance. Paediatric dosing is 50–
antidote flumazenil should be readily accessible. 2
150µg/kg.30–32
Side effects include respiratory and cardiovascular
Propofol is a central nervous system depressant, a
depression and a paradoxical effect of excitement,
cardiovascular depressant resulting in hypotension and a
confusion, and agitation occasionally in paediatric and
decreased heart rate and, at anaesthetic doses, respiratory
elderly populations.4,34

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depression. Sedative doses usually have little or no effect on antidotes, medical equipment and facilities, monitoring
the respiratory system.4 equipment and resuscitation equipment in accordance with
the guidelines in ANZCA PS09.9,34
Sedative doses are not analgesic and a large proportion of
patients experience pain on injection. An antiemetic effect Conclusion
is described in a low number of patients. 4, Propofol can be When practicing sedation in the dental setting, awareness
used in subanaesthetic doses to improve sedation if of limitations is necessary. If the procedure is to be
patients are resistant to midazolam or midazolam combined undertaken with adequately trained staff in an area
with fentanyl, and can be used to prevent overuse of adequately equipped, then sedation in an outpatient setting
midazolam. Propofol does have an increased risk of deep should be safe provided appropriate patient selection is
sedation with respiratory depression and should therefore performed and patients have been sufficiently pre-assessed.
be used cautiously and by experienced, trained If this is not the case, then the possibility of adverse events
practitioners.9,29 and poor outcomes is increased. Single-agent
administration is preferable due to the ability to titrate
Current recommendations for sedation in adequately. The route of administration and agent used
dentistry in Australia should be decided on an individual patient basis.
The aim of conscious sedation in dentistry is to achieve the
optimum level of sedation with a wide margin of safety so References
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ACKNOWLEDGEMENTS
None

PEER REVIEW
Not commissioned. Externally peer reviewed.

CONFLICTS OF INTEREST
The authors declare that they have no competing interests.

FUNDING
None

ETHICS COMMITTEE APPROVAL

Not applicable

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Table 1: ASA Physical Status Classification6 with recommendations from this article9,14*
ASA I ASA II ASA III ASA IV ASA V ASA VI
Healthy patients Mild systemic Chronic Severe systemic Moribund Brain dead
disease conditions disease patient patient whose
organs are being
removed for
donor
purposes15,16
Candidate for Higher risk of Hospital Hospital Not appropriate Not appropriate
conscious complications environment environment for dental for dental
sedation with sedation, only only sedation sedation
safe if correct
precautions
taken
*Permission to reprint ASA Physical Classification System. Approved by Dr George Kendall, June 4, 2015.

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