February 3, 2016
by Derek Decloux, DMD
Performing minimal oral (enteral) conscious sedation on a healthy adult patient with a benzodiazepine is a safe, cost-effective way to treat certain patients with dental anxiety. Go through the ten statements below with the intent of determining whether each presented statement is fact or fiction.
NOTE: While many of the answers below make reference to regulations in Ontario, more than half of Canada’s provinces/territories have comparable or identical legislation guidelines regarding the use of sedation for dentistry. presiding over the realm of dental sedation. Please consult your local bylaws for exact rules and regulations about performing sedation for your patients.
Statement #1: Relative to higher deeper levels of sedation (like moderate sedation, deep sedation, and general anaesthesia), there is often a lower requirement of for perioperative patient monitoring when performing minimal conscious sedation.
FACT: In Ontario, a practitioner who intends to use a single drug to achieve minimal sedation must monitor patients by “clinical observation of the level of consciousness and assessment of vital signs which may include heart rate, blood pressure, and respiration” (Ontario’s Standards of Practice for the Use of Sedation and General Anesthesia in Dental Practice). If the practitioner were to change modalities of sedation or increase their sedative dosage with the intent of achieving moderate sedation, so too would the monitoring requirements increase (i.e. continuous pulse oximetry and continuous periodic vital sign monitoring become necessary).
Statement #2:. A patient will usually maintain his/her protective reflexes during minimal conscious sedation with a benzodiazepine.
FACT: A patient sedated with the appropriate dose for minimal sedation should be able to maintain his/her protective reflexes like coughing, sneezing, and blinking. A prudent practitioner should be capable of rescuing a patient from one level of sedation higher than is intended (e.g. rescuing from moderate sedation when performing minimal sedation). One should note that some patients may be hyper-responders to a drug dosage that would typically cause minimal sedation, hence the need to be able to rescue your patient from one level of sedation higher than is intended.
Statement #3: Consent for treatment can be obtained after a patient has taken a benzodiazepine, provided the dose administered was for only minimal conscious sedation.
FICTION: Patients may still experience anterograde amnesia after taking a benzodiazepine for minimal sedation (i.e. the patient will forget what happens after they have taken the drug) and may not be as clear-headed after the drug plasma levels have begun to increase. For these reasons, informed consent and post-operative instructions should be given in advance of benzodiazepine administration.
Statement #4: Minimal conscious sedation with a benzodiazepine still requires the patient to undergo a fasting period.
FICTION: Medico-legally, a patient is Ontario not required to fast for any amount of time if using only a single drug to achieve minimal sedation. This makes sense pharmacodynamically given that in conscious sedation, upper and lower esophageal sphincter tone should be maintained and the risk of aspiration should be close to non-existent. Regardless, this is an issue of debate among our profession and many seasoned practitioners would still recommend at least a two-hour period of both solid and liquid fasting prior to minimal sedation in order to ensure patient safety.
Statement #5: Certain benzodiazepines produce the effects of minimal conscious sedation for shorter or longer times than others.
FACT: Different benzodiazepines have different half-lives. For example, triazolam will hit peak plasma levels more quickly and for a shorter time than a drug like lorazepam, which has a longer onset but and a longer duration of action. This may also affect when you might decide to discharge the patient or what you might give to a patient as post-operative instructions (e.g. how long they may feel the effects of sedation, etc).
Statement #6: Patients are permitted to drive home after oral sedation with a benzodiazepine as long as it was an appointment where minimal conscious sedation was achieved.
FICTION: Due to the amnesic and sedating effects of benzodiazepines (not to mention certain side effects such as dizziness, confusion, and unsteadiness), patients are not permitted to drive themselves home after an appointment where they have been sedated with any dose of prescribed benzodiazepine. A general rule of sedation with any benzodiazepine is that the patient should not be driving or operating heavy machinery for at least 18 hours after discharge, or longer if dizziness or drowsiness persist.
Statement #7: Oral titration of a benzodiazepine is a safe means of achieving minimal conscious sedation.
FICTION: Unlike parenteral or inhalational sedation, it is extremely difficult, and therefore unsafe, to orally titrate a benzodiazepine to a patient based solely on their symptoms of anxiety due to variable delays between ingestion and rise of plasma levels of the drug. This technique is not recommended as it can lead to oversedation, overdose of the drug and acute benzodiazepine toxicity.
Statement #8: All patients should receive the same oral dose of drug X (a benzodiazepine of your choice) in order to achieve minimal conscious sedation.
FICTION: Patient factors such as weight, age, gender, drug/alcohol naivety, and organ function (to name only a few) will play a role in both the depth and duration of sedation when a benzodiazepine is administered. For those reasons, a detailed description of these patient factors should be taken into consideration when choosing a benzodiazepine dosage.
Statement #9: Minimal oral conscious sedation with a benzodiazepine is not appropriate for every single patient with dental anxiety.
FACT: Depending on a patient’s triggers for his/her dental anxiety, he/she may require more or less sedation than that provided by an orally administered benzodiazepine. Perhaps an anxiety reduction protocol with ample description of the events to occur will suffice for some patients. Alternately, some patients’ anxiety may be so severe that a higher dose of benzodiazepine or even a multi-drug parenteral regimen may be necessary to ensure a comfortable experience.
Statement #10: Certain benzodiazepines have fallen out of fashion for oral conscious sedation due pharmacodynamic reasons that can be deleterious to a patient’s safety.
FACT: Given our knowledge that certain benzodiazepines, such as diazepam, have both a variable half-life and active metabolites that can cause re-sedation after the procedure (when it could be harmful to the patient). Some examples of alternatives that do not produce active metabolites include triazolam for shorter appointments, temazepam for appointments longer than two hours, or lorazepam for appointments longer than hours. OH
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Derek Decloux obtained his DMD from the University of British Columbia in 2011. He spent four years as a Dental Officer (general dentist) in the Canadian Armed Forces before starting the University of Toronto’s M.Sc. with Dental Specialty Training in Dental Anaesthesia program.