Sedation dentistry: addressing caregiver concerns for safety.

You may have heard of a dentist who offers "sedation" or "sleep dentistry" with promises of a "pain free" or "relaxing" trip to the dentist. These claims may leave you wondering how to choose a healthcare provider for your loved one with special needs--and whether it's truly possible for this experience to feel relaxing. In my dental group, we start by explaining that sedation in dentistry is actually one of the many answers to the first important question: How do we keep a patient comfortable and safe? Before we learn the answer, we must ask all the right questions to lead us to the right approach.

Since anesthesia is an expected part of most hospital procedures, caregivers trust sedation or anesthesia as a compassionate means of managing fear and discomfort without physical struggle or physical restraints. But when is anesthesia used in dental procedures? What should people know to balance the complexities of sedation in dentistry against the medical risks usually present in the population of people with special needs? Is anesthesia the best way to safely accommodate a person's health and behavioral needs? What do you consider when making an informed consent, which permits your home dentist to use a mild form of sedation in their office? What is a mild form of sedation and what isn't?

Learning More

Caregivers of children and adults with special needs tend to build expert knowledge of their loved one's disabilities and medical conditions, and they meet their child's needs with the help of a team of doctors and specialists. But it's less common to find that work in close partnership with a dentist. Patients or parents will sometimes reveal that they have avoided the dentist for years because of fears, anxiety, and even limited local resources. To move past fear, people need to learn more.

If you already have a trusted pediatric dentist or home dentist for your family, this clinician already knows your loved one and can recommend an experienced dentist colleague--someone with extensive experience in sedation dentistry. If you don't have a home dentist, use the Internet to learn more about the meaning of sedation dentistry, the types of sedation available in dental offices or in hospital settings in your area, the definition of terms, and what you can expect a person to feel, sense, or remember. My dental group's Web site (www.drblende.com) contains in-depth information for the special patients we treat--and who are commonly treated by other special care dentists. One of the most valuable resources for parents and patients is The Consumer's Guide to Sedation and Sleep Dentistry. This tool helps explain the full array of sedation modalities, which include "sleep dentistry" and a deeper discussion of the sedation choices most appropriate to the special needs community.

Research the specific safety guidelines established by your state dental board since license, training, and equipment requirements vary by state. Follow this link to the Sedation Guidelines of the American Academy of Pediatric Dentistry (AAPD), which offer one extensive set of guidelines for all medical and dental practitioners regarding the administration of sedation during and after treatment. While these guidelines are intended for children, they make sense for persons of every age who are considering anesthesia, with safety as their number one concern. These guidelines can be found at http://www.aapd.org/media/Policies_Guideli nes/P_Sedation.pdf.

Treatment Planning

Before scheduling any procedure, schedule a conversation. Use your first appointment to get to know the dentist and the dental team. Gather everyone together and discuss the entire health history of the whole person, planning the safest approach according to the individual need and desired outcome. The dentist will want to understand other medical risks, current medications, the patient's ability to tolerate the procedure, and their capacity to care for their new smile.

In this meeting, the dentist will assess the patient's overall health and may even ask permission to consult with your medical doctor. The dentist might invite an anesthesiologist to consult on the case. The anesthesiologist and the dentist need to answer one of the first and most important questions: How healthy is the patient?

Dentists, doctors, and anesthesiologists use a common language called the ASA-PS classification system developed by The American Society of Anesthesiologists. It is a means of categorizing patients into subgroups according to their physical status prior to administering anesthesia. You may be familiar with these abbreviations from patient literature regarding treatment approach, health risks, and symptoms. We use four of the ASA categories as our sharing rating language in my practice and in our "Consumer's Guide to Sedation and Sleep Dentistry."

The Health Rating of the Patient Will Recommend the Safest Sedation Solution

The ASA-1 rating generally applies to people who are in very good physical condition with no medical complications and who are not overweight, pregnant, smoking, nor abusing drugs. This large category of people usually tolerate the most common in-office sedation solution of analgesia or a local anesthetic, commonly referred to as a Novocain (e.g., Xylocaine, Lidocaine) injection. Pediatric dentists regularly rely on local anesthetics to complete treatment in healthy children who are able to cooperate with treatment.

ASA-1 and ASA-2 patients are also candidates for conscious sedation or "procedural" sedation, which includes mild forms of sedation such as oral pills (e.g. Halcion, Valium) and inhaled gases (e.g. nitrous oxide, "laughing gas"). In conscious sedation, the patient will feel relaxed or even drowsy, but they will not be asleep. Even while some clinicians use the term "sleep dentistry," the patient is not actually sleeping but is aware, breathing independently, and able to respond to verbal commands. Ask your home dentist or pediatric dentist about their use of oral medications to understand if this sedation solution is right for your child and then decide under what circumstances you would feel good about approving their use.

The majority of patients with special needs fall into health categories that dictate unconscious sedation as the best sedation solution for dental treatment. Unconscious sedation is a medically-induced state of unconsciousness and involves the use of intravenous (I.V.) sedation or general anesthesia, which produce complete sleep. The patient is free of pain and will have no memory of the procedure. These sedation solutions offer the clinical team the greatest levels of control and predictability, allowing comprehensive completion of care, which is especially important for patients with special needs and other medical conditions. Recovery from unconscious sedation is quick. Patients can return home just hours after treatment or be admitted to the hospital for overnight observation when extensive dental work takes place. Pediatric dentists and general dentists commonly recommend unconscious sedation solutions for the dental treatment of children with special needs.

There are risks involved with any form of anesthesia, which is why unconscious sedation should be provided only in well-equipped environments by highly-qualified health professionals, including dental or medical anesthesiologists, certified registered nurse anesthetists, or specialist dentists like pediatric dentists or oral surgeons who have advanced education in anesthesia techniques. Some dental offices are equipped with the specialized equipment required for patient safety. Other dentists use the surgical facilities in a local hospital. Ask your dentist who will monitor the anesthesia while the dentist completes the treatment in the mouth. Ask about the qualifications and training of this person to better understand the safety net supporting this special patient with special needs. Get the answers you need for the safety of your loved one and for your own peace of mind.

Closing

As a caregiver of someone with special needs, a special needs dentist shares a common commitment to keeping your loved one safe and comfortable. He or she understands that you are putting trust in his or her ability to administer a special level of care, which considers your loved one's unique needs and abilities. You count on our expertise to help deliver a successful and stress-free outcome for your whole family. That's why special care dentists know that sharing information is one of the first steps toward answering the overarching question: How do we keep the patient safe and comfortable? It's by selecting the safest solution based on the health of the whole person.

RELATED ARTICLE: A healthy house means a healthy mouth!

It's at home where families and friends shape our lifelong health habits like scheduling regular visits to the dentist for routine cleanings, brushing after every meal, and flossing daily. Here are some other simple changes you can make to grow healthier habits in your home:

* Stand in the mirror and make brushing your teeth a family affair for children of all ages, starting with the first baby tooth, if possible. It's fun. It's silly. Your play helps your children easily adopt brushing after meals and snacks as an everyday habit.

* Use an alcohol-free fluoride mouth rinse every day. Before you assume your tried-and-true favorite will work for all ages, check the ingredient list and be absolutely certain alcohol isn't listed; it can be too strong for young taste buds.

* Adopt a ten glass-a-day habit and drink your tap water. Seventy percent of U.S. cities add fluoride to their water to build healthy teeth and bones and prevent tooth decay. Prevailing science proves that fluoride is a safe and important additive for most adults and children older than six.

* Avoid breath mints such as Altoids and Tic-Tacs, which are made from sugar (which can contribute to tooth decay). Talk to your dentist if you're chewing mints to mask bad breath or if you notice someone trying to cover the smell of cigarettes, which pose the biggest health risk of all.

* Adults and children over six years old should chew gum made with sugar-free sweeteners such as Xylitol and Sorbitol. These artificial sweeteners are proven to prevent tooth decay by reducing bacteria in the mouth while alleviating the symptoms of dry mouth.

* Ditch the sweet drinks! Check the ingredient labels on the drinks you buy for your family and be certain you're not quenching their thirst with sugar. Diet sodas, sports drinks like Gatorade[TM], caffeinated drinks like Red Bull[TM] and even fitness waters like Vitamin Water[TM] all contribute to tooth decay.

* Document every pill, tonic, or supplement that goes into your mouth and share this list with your doctor and dentist. They will want to watch out for the compounding reactions these remedies might have with other drugs or medications.

* Safeguard young teeth with sealants (which can be easily applied by your child's dentist), which are an easy and affordable way to protect the hard-to reach teeth in the back of the mouth. This treatment pays off quickly since it isn't painful to your child or your budget.

By David Blende, DDS

Dr. David Blende is Chief of the Dental Division at California Pacific Medical Center hospital in San Francisco. A graduate of University of Southern California Dental School, Dr. Blende has practiced special needs dentistry for more than 20 years. He is a member of the Special Care Dentistry Association, and the former Chairman of the California Dental Association's Council on Scientific Affairs and Research. For more information, call Dr. Blende at 800-575-3375 or visit www.drblende.com.

Sedation Modalities
                          Conscious Sedation:
                          Awake and Aware

                                             Oral Conscious
                          Nitrous Oxide      Sedation (pills)

Benefits patients with:   Minimal fear or    Mild fear
                          anxiety
                                             Mild gag reflex

                                             Shorter cases

Medical Considerations:   Age 18-65          Age 18-65

                          Healthy patients   Healthy patients

                          ASA I & II         ASA I & II

                                             High blood pressure,
                                             controlled

                                             Diabetes, controlled

                                             Smoking

                          Unconscious Sedation:
                          Asleep and Unaware

                          I.V. Sedation           General Anesthesia

Benefits patients with:   Moderate to severe      Severe fear or
                          fear                    phobia

                          Medically compromised   Medical conditions
                          or uncooperative,       as treated with
                          such as:                I.V. Sedation, plus:
                          * Down syndrome         * Complex medical
                          * Autism                conditions
                          * Alzheimer's disease   * Morbidly obese
                          * Developmentally       * Combative or
                          disabled                non-compliant
                          * Parkinson's disease   * Need for extensive
                          * Cerebral palsy        and/or complex
                          * Severe gag reflex     treatment, involving
                          * Difficulty getting    more than one
                          numb                    specialist
                                                  * Allergy or
                                                  intolerance to local
                                                  anesthesia

                          Shorter cases < 4       Longer cases > 4
                          hours                   hours

Medical Considerations:   Age 2-80+               All ages, including
                          ASA I, II & III         frail over age 80
                                                  ASA II, III & IV

                          Concerns regarding:     Significant Concerns
                          * High blood pres-      regarding:
                          sure, controlled        * Taking more than
                          * Heart disease,        4 medications
                          stable                  * High blood pres-
                          * Diabetes,             sure, uncontrolled
                          controlled              * Heart disease,
                          * Cancer                significant
                          * Bleeding disorders    * Angina, frequent
                          * Smoking / COPD        * Recent heart
                          * Asthma                attack or stroke
                          * High cholesterol      * Congestive heart
                          * Obesity,              failure
                          significant             * Arrhythmias
                          * Recent history of     * Respiratory
                          drug abuse              conditions,
                          * Psychiatric           significant
                          conditions              * Diabetes,
                                                  uncontrolled
                                                  * Liver disease,
                                                  significant
                                                  * Seizure disorder

ASA-1 A normal, healthy patient.

ASA-2 A patient with mild systemic
disease.

ASA-3 A patient with severe systemic
disease.

ASA-4 A patient with severe systemic
disease that is a constant threat to
life.

Table courtesy of Blende Dental Group (c) 2008