Balancing efficacy and safety in the use of oral sedation in dental outpatients

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Craig Elice Date: 04/02/2010
Article title: Balancing efficacy and safety in the use of oral sedation in dental outpatients
Author(s): Dionne RA, Yagiela JA, Cote CJ, et al..
Journal: JADA 137: 502-16
Month, Year: April 2006
Major topic: Workshop evaluating safety of sedation
Type of Article: Opinion paper from workshop. Literature review
Purpose: This article reviews the recommendations from a group of experts in anesthesiology, pharmacology and sedation at a workshop for the purpose of reviewing the scientific basis and status of oral sedation in dentistry and to further recommend areas needing further research and to make regulatory changes to improve patient safety.
Overview of method of research: A review of the litereature indicates that there is both a need for use of anesthesia and sedation to manage fear and anxiety in dentistry and an demand for the services. The degree of invasiveness/ stress of the procedure is directly related to the demand for sedation. The clinical practice of pediatric dentistry has evolved into three main areas of managing a pediatric patient depending upon the behavior of the patient. These three areas include behavior management techniques, sedation such as nitrous oxide, midazolam, and lastly general anesthesia. Based on the data supporting the safety of enteral sedation, the following was noted. Much of the data is deficient in quantification of morbidity and mortality due to under-reporting of adverse effects, over-reporting of adverse effects with new drugs, and incomplete documentation, lack of overall usage rates and changing clinical practice. However, the following conclusions were drawn from this data. They include excessive single or repeated doses should be avoided, multiple drug regimens should be used with caution, and lastly an understanding of each drugs pharmacologic properties and its combined effect with additional local anesthetic should be understood. Morbidity and mortality studies were reviewed. Ninety-five cases were reviewed with 60 resulting in death or neurological injury and 35 requiring prolonged hospitalizations or no harm to the patient. The most common cause was related to drug interactions or overdoses. All routes of administration were associated with deaths with the most common event being respiratory depression followed by cardiac arrest. Dentistry was associated with 29 deaths followed by radiology and cardiology. Pulsoximetry resulted in fewer deaths in a hospital setting but not in a private practice environment. The studies indicated that morbitidy and mortality was more related to monitoring and resuscitative skills of the provider more so that the drugs used, route of administration and patient population. It is believed that delayed recovery after pediatric sedation has not been well studied. The data indicate that strict discharge criteria with objective measures for discharge readiness should be considered. Bispectral index monitor continuously evaluates the patients electroencephalogram and computes a score from 0 to 100 which correlates well with depth of sedation and anesthesia in adults and children. The workshop discussed the pharmacokinetic activity of benzodiazepines more specifically triazolam which is a short acting, short half life sedation agent. Titration of the medication used orally is very difficult and frequently leads to complications. The Dental organization for Conscious Sedation (DOCS) protocol of multi dosing with Triazolam with nitrous oxide was discussed along with morbidity and mortality findings were presented. The review demonstrated the relative safety of benzodiazepines and the wide margin between therapeutic doses and toxic doses.
Conclusion: the general consensus of the workshop participants was that there is a strong need and demand for entereal sedation indentsitry. The oral route is convenient and widely accepted in dentistry.Additional prospective studies are needed to better assess the safety of enteral sedation. Increased education is key in promoting safe measures for administering enteral sedation.. Enteral sedation should be regulated by state boards to insure that dentists are properly trained and guidelines are followed when sedating patients in the office setting. As it relates to pediatric sedation, the workshop attendees emphasized the need for specific discharge criteria including making sure the patient can maintain their airway unassisted and remain spontaneously awake without stimulation. Lastly the participants felt the need to further understand the pharmacokinetics of flumazenil as it relates to reversing the actions of benzodiazepines, and to be qualified to use it if necessary
Assessment of article: It seemed like a very broad topic for a symposium. The summary of the workshop was very scattered from the discussion.