Clinical Research
An Analysis of Moderate Sedation Protocols Used in Dental
Specialty Programs: A Retrospective Observational Study
Madhavi Setty, DDS, MSD,* Thomas A. Montagnese, DDS, MS,† Dale Baur, DDS, MD,‡
Anita Aminoshariae, DDS, MS,† and Andre Mickel, DDS, MSD†
Abstract
Introduction: Pain and anxiety control is critical in
dental practice. Moderate sedation is a useful adjunct
in managing a variety of conditions that make it difficult
or impossible for some people to undergo certain dental
procedures. The purpose of this study was to analyze the
sedation protocols used in 3 dental specialty programs
at the Case Western Reserve University School of Dental
Medicine, Cleveland, OH. Methods: A retrospective
analysis was performed using dental school records of
patients receiving moderate sedation in the graduate
endodontic, periodontic, and oral surgery programs
from January 1, 2010, to December 31, 2012. Information was gathered and the data compiled regarding
the reasons for sedation, age, sex, pertinent medical
conditions, American Society of Anesthesiologists physical status classifications, routes of administration,
drugs, dosages, failures, complications, and other information that was recorded. Results: The reasons for the
use of moderate sedation were anxiety (54%), local
anesthesia failures (15%), fear of needles (15%), severe
gag reflex (8%), and claustrophobia with the rubber
dam (8%). The most common medical conditions were
hypertension (17%), asthma (15%), and bipolar disorder
(8%). Most patients were classified as American Society
of Anesthesiologists class II. More women (63.1%) were
treated than men (36.9%). The mean age was 45 years.
Monitoring and drugs varied among the programs. The
most common tooth treated in the endodontic program
was the mandibular molar. Conclusions: There are differences in the moderate sedation protocols used in the
endodontic, periodontic, and oral surgery programs
regarding monitoring, drugs used, and record keeping.
(J Endod 2014;40:1327–1331)
Key Words
Claustrophobia, dental anxiety, endodontics, gag reflex, moderate sedation, monitoring, oral surgery,
periodontics
P
ain and anxiety control is a critical part of endodontic practice. Fear of dental procedures in general is caused by factors such as past experiences, emotions, beliefs,
and expectations (1). Despite advances in oral health care, pain and anxiety continue to
be significant deterrents to dental care (2). Anxiety can be managed by pharmacologic
and nonpharmacologic means. A calm and relaxed environment can help reduce a patient’s response to, or awareness of, painful stimuli (3). Aromatherapy, acupuncture,
acupressure, hypnosis, and effective communication have been shown to reduce pain
and anxiety (4). Some of these nonpharmacologic methods require time and expertise
that may not be practical in a routine endodontic practice.
The current levels of sedation as defined by The American Society of Anesthesiologists are minimal, moderate, and deep. ‘‘Moderate sedation/analgesia’’ (‘‘conscious
sedation’’) is a drug-induced depression of consciousness during which patients
respond purposefully to verbal commands, either alone or accompanied by light tactile
stimulation. No interventions are required to maintain a patent airway, and spontaneous
ventilation is adequate. Cardiovascular function is usually maintained. ‘‘Reflex withdrawal from a painful stimulus is NOT considered a purposeful response’’ (5).
There are few studies in the endodontic literature that address the use of moderate sedation. It is reported that sedation increases the likelihood of success with local
anesthesia in anxious patients or for those who have a history of local anesthesia failures (6). Endodontic therapy and oral surgery procedures are ranked high on anxiety
rating scales by patients, and sedation is recommended for anxiolysis (7). One study
reported that oral triazolam (0.25 mg) was more effective than oral diazepam (5.0 mg)
for endodontic procedures (8); however, the doses recommended are meant to produce a minimal, not a moderate, level of sedation, and minimal sedation may not be
adequate to alter the efficacy of local anesthesia (9). It is well documented that sedation
is a continuum and not a static point that can be achieved with a specific drug or dose,
and it can vary from patient to patient or even for an individual patient (5). The level of
sedation that works for 1 patient to reduce anxiety may not be adequate for another
(10). Thus, there is the need for a deeper level of sedation at times. It is for this reason
that it has been recommended that moderate sedation be taught in graduate endodontic programs (11).
There are no studies in the endodontic literature regarding reasons for using moderate sedation, drugs used, monitoring protocols, anesthesia record keeping, complications encountered, additional procedural time, scheduling considerations, recovery
times, or other issues specific to endodontic practice. The purpose of this study was to
conduct a retrospective analysis comparing the moderate sedation protocols in the
graduate endodontic, periodontic, and oral surgery programs at the Case Western
Reserve University (CWRU) School of Dental Medicine (SODM), Cleveland, OH, and
From the *Private Practice Limited to Endodontics, San Jose, California; and the Departments of †Endodontics and ‡Oral and Maxillofacial Surgery, School of Dental
Medicine, Case Western Reserve University, Cleveland, Ohio.
Address requests for reprints to Dr Thomas A. Montagnese, Department of Endodontics, School of Dental Medicine, Case Western Reserve University, 2124 Cornell
Road, Cleveland, OH 44106-4905. E-mail address: [email protected]
0099-2399/$ - see front matter
Copyright ª 2014 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2014.05.015
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Moderate Sedation Protocols
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TABLE 1. Summary of Information Gathered in Each Program
TABLE 2. Drugs Used and Routes of Administration
Oral
Endodontics Periodontics surgery
Preoperative instructions
Name
Age
Sex
Fasting (nothing
by mouth) status
Escort
ASA classification
Mallampati
classification
Body mass index
Reason for sedation
Procedure
Tooth number(s)
Diagnosis
Specific procedure
Surgeon
Anesthesia
Anesthesia provider
Anesthesia type
Local anesthetics:
name, dosage
Venipuncture site
Angiocatheter size
Drugs: name,
dosage, time of
delivery
Intravenous fluid
Start and
completion times:
anesthesia and
procedure
Complications
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Periodontics
Oral
surgery
X*
X
X
X
Midazolam/oral
Midazolam/
intravenous
Diazepam/oral
Nalbuphine/
intravenous
Fentanyl/
intravenous
X
X
X
*Used only for pediatric patients.
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
used either 5% dextrose and water or 0.9% sodium chloride, the periodontic program used 5% dextrose and water, and the oral surgery program used lactated Ringer solution. The choice of intravenous fluid was
based on the program/course director’s preference. The drugs used
and routes of administration are listed in Table 2. Monitoring differences are shown in Table 3. Figure 1 shows the age range, which was
8–88 years. The mean age was 45 years. Figure 2 shows the percentages
of American Society of Anesthesiologists classifications for all programs.
Figure 3 shows the reasons for using moderate sedation; however, this
was only recorded in the graduate endodontic clinic.
Discussion
Materials and Methods
This retrospective cohort study was designed to address these issues. Approval was obtained from the CWRU Institutional Review Board.
Data were obtained from records of patients treated under moderate
sedation in the graduate endodontic, periodontic, and oral surgery programs at the CWRU SODM from January 1, 2010, to December 31, 2012.
Eighty-four records were used, consisting of 15 from the endodontic
program, 49 from the periodontic program, and 20 from the oral surgery program. The data collected consisted of blood pressure, heart
rate, respiratory rate, blood oxygen saturation, age, sex, American Society of Anesthesiologists physical status classification (12), Mallampati
classification (13), body mass index (14), reason for sedation, drugs
and dosages used, local anesthetics, tooth number, endodontic diagnosis (15), procedures performed, sedation failures, complications,
electrocardiogram readings (ECG), monitoring protocols, preanesthesia instructions, and duration of the procedure.
The data were entered into an Excel spreadsheet (Microsoft Corporation) and SPSS software was used for statistical analysis.
Results
Of the study patients, 63.1% were females, and 36.9% were males.
We found that there were differences in the information gathered in
each program. Table 1 lists data recorded in the sedation/anesthesia records of each program. Only the endodontic program anesthesia record
noted the intravenous fluid and amount used. The endodontic program
Setty et al.
Endodontics
X
X
to see if there was an association for the use of moderate sedation with a
specific tooth or endodontic diagnosis.
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Drug/route of
administration
Most patients requiring endodontic therapy in an endodontic specialty practice can be managed with local anesthetic alone. However,
there are instances in which moderate sedation can make otherwise
difficult and uncomfortable treatment experiences less so. Conditions
such as a severe gag reflex in which a patient is unable to tolerate the
dental dam, bite block, or x-ray sensor/film make it difficult, if not
impossible, to provide quality and comfortable endodontic treatment.
Temporomandibular disease can limit mandibular opening, making
treatment access difficult or impossible (16–22). These patients may
also have difficulty keeping their mouths open during prolonged
dental procedures and may not be able to tolerate a bite block.
Fibromyalgia can make it uncomfortable for a patient to keep still
and comfortable in the dental chair (23). A variety of phobias including
claustrophobia, which can make use of the dental dam and bite block
impossible; fear of needles; and fear of dental treatment in general can
be obtunded with the use of moderate sedation (1, 24–28). Patients
reporting a history of difficulty getting numb can be helped by using
sedation in conjunction with local anesthesia (3, 29). Special needs
patients can benefit from sedation as a patient management tool
(30). Certain medical conditions requiring stress reduction protocols
can be managed more safely by using sedation as an adjunct to local
anesthesia (23).
TABLE 3. Monitoring
Monitoring
Blood pressure
(continuously)
Heart rate
Respiration (visual)
Respiration (pretracheal
stethoscope)
Electrocardiogram
Capnography
Time oriented record
Oral
Endodontics Periodontics surgery
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
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Clinical Research
Figure 1. The age range.
This study shows the differences in the drugs used for moderate
sedation in 3 dental residency programs at our institution. In the graduate endodontic clinic, the most common reason for sedation was anxiety although other reasons included all of the conditions stated
previously. Personal communication with the graduate periodontic
and oral surgery programs found that the reason for sedation procedures was to manage anxiety. Oral surgery stated that sedation is
used to manage anxiety in general and also anxiety that may be caused
by pressures exerted during certain procedures, such as difficult extractions. Local anesthesia is the primary tool used for controlling pain
caused by dental procedures. Analgesics (eg, nalbuphine and fentanyl)
are administered specifically when a patient has a history of difficulty
getting numb (29). Oral, inhalation, and intravenous routes are all
used in the endodontic and oral surgery programs. The protocols
used in the graduate endodontic clinic are tailored to the specific needs
of the patient. Because the graduate endodontic clinic sees pediatric patients on a fairly regular basis, the course director feels that it is important for the residents to become familiar and comfortable with various
methods of behavior management, including sedation. The graduate
periodontic clinic uses only an anxiolytic for moderate sedation, and
it is administered intravenously. Moderate sedation is not used as
frequently as deep sedation/general anesthesia in the oral surgery clinic,
and that may be due to the degree of force needed to extract some teeth,
making it less experientially uncomfortable for a patient when a deeper
level of sedation is reached. The differences in the programs may be
related to the level of training of the faculty in each department and
the needs of the patient for specific procedures.
Monitoring protocols in all departments follow the rules of the
Ohio State Dental Board (31) and the American Dental Association
Guidelines for the Use of Sedation and General Anesthesia by Dentists
Guidelines (32). Differences appeared to be caused by the preferences
of the attending faculty. The attending faculty in the graduate endodontic
clinic requires ECG monitoring for all patients having mild or moderate
sedation so that residents will become familiar with the appearance and
sounds of various heart rhythms. The ADA Guidelines recommend that
‘‘continuous ECG monitoring of patients with significant cardiovascular
Figure 2. American Association of Anesthesiologists physical status classifications based on the combined total of all 3 programs.
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Figure 3. Reasons given for using sedation. This information was only documented in the endodontic program.
disease should be considered’’. An electronic wireless pre-tracheal
stethoscope is used by the attending faculty member as an adjunct to
monitor respiration.
We found that the most prevalent endodontic pathosis treated was
symptomatic irreversible pulpitis with symptomatic apical periodontitis
associated with a mandibular molar.
The difference in the number of sedation cases in each department
may be due to the fact that intravenous moderate sedation is a requirement for completion of the graduate periodontic program. The oral surgery residents are trained in deep sedation and general anesthesia and
have requirements regarding the number and types of cases they must
perform in order to complete their program. Most of their sedation
cases in the oral surgery program are deep sedations (personal
communication, D Bauer, Case Western Reserve University, School of
Dental Medicine, Cleveland, 2013). There is no requirement for intravenous moderate sedation in the endodontic residency program, and at
the time of this study, a formal course was not established.
Future studies that include the pediatric dental residency program
and exploring the reasons for the various protocols used in each program, would shed more light on this topic.
Conclusion
This study demonstrates the similarities and differences of delivering intravenous moderate sedation in the graduate endodontic, periodontic, and oral surgery programs at the CWRU SODM. The study was
undertaken by the graduate endodontic department to ascertain the reasons and conditions for using moderate sedation in endodontic practice
and to examine how sedation is practiced in other dental specialty programs. In order to provide endodontic services to those persons who
either avoid treatment or undergo treatment with needless discomfort,
either physical or emotional, the graduate endodontic program at
CWRU SODM has the goal of training the residents to provide moderate
sedation by the intravenous route. It is hoped that this will enable more
persons in need of endodontic services to have procedures done
comfortably.
Acknowledgments
Dr Setty was a Resident in the Postgraduate Endodontic
Program at Case Western Reserve University, School of Dental
1330
Setty et al.
Medicine. This article was based on her master’s thesis
research.
The authors deny any conflicts of interest related to this study.
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