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B.28 CONSCIOUS SEDATION [if applicable for your clinic, Omit this section if Conscious Sedation is not used in the dental facility or retain only those procedures used in the facility]

Pharmaco-sedation is a necessary adjunctive procedure for many dental procedures, most often for behavior management and/or surgical procedures. Specific training is required, and these guidelines are not meant to be a substitute for that training. Sedative techniques are subject to [accreditation agency, if applicable] review and facilities may restrict techniques for a variety of considerations. These guidelines are based on guidelines developed by the American Dental Association and the American Society of Anesthesiologists and the practitioner is urged to review the most recent guidelines.

The goals for the management of Pharmaco-sedation in the ambulatory patient are:

  • Patient welfare

  • Control of patient behavior

  • Production of positive psychological response to treatment

  • Return to pretreatment level of consciousness by time of discharge

Definition of Terms
For the purpose of this document the following definitions shall apply:

  • ASA Classification:

ASA stands for American Society of Anesthesiologists. In 1963 the ASA adopted a 5 category physical status classification system for assessing a patient before surgery. The first 4 classes are:

          1. A normal healthy patient.

          2. A patient with mild systemic disease.

          3. A patient with severe systemic disease.

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

  • Anxiolysis: A dissolution or reduction of anxiety through the use of the hypnotic dose of a sedative agent, i.e., light sedation

  • Conscious Sedation: A drug induced depression of consciousness during which patients respond purposefully to verbal command, 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.

  • Deep Sedation: A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. .

  • General Anesthesia: A drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.

  • Moderate Sedation: Conscious sedation

  • Nitrous Oxide/Oxygen Analgesia: The relative reduction of fear, anxiety, and pain response through the controlled delivery of nitrous oxide and oxygen through a dental inhalation sedation delivery system.

  • Rescue: Rescue of a patient from a deeper level of sedation than intended is an intervention by a practitioner proficient in airway management and advanced life support. The qualified practitioner corrects adverse physiologic consequences of the deeper-than intended level of sedation (such as hypoventilation, hypoxia and hypotension) and returns the patient to the originally intended level of sedation.

General Considerations

  • Applicability: These guidelines should be considered as minimum guidelines. More stringent procedures may be required for individual patients.

  • Practitioners. According to the ASA 2006 Guidelines, “Only physicians, dentists or podiatrists who are qualified by education, training and licensure to administer moderate sedation should supervise the administration of moderate sedation. Nonanesthesiologist sedation practitioners may directly supervise patient monitoring and the administration of sedative and analgesic medications by a supervised sedation professional. Alternatively, they may personally perform these functions, with the proviso that the individual monitoring the patient should be distinct from the individual performing the diagnostic or therapeutic procedure.”

  • Local Anesthesia used in conjunction with pharmaco-sedation: All local anesthetic agents can become cardiac and central nervous system (CNS) depressants when administered in excessive doses. There is a potential interaction between local anesthetic and sedatives used in pediatric dentistry that can result in enhanced sedative effects and/or untoward events; therefore, particular attention should be paid to doses used in children. To avoid excessive doses, a maximum recommended dose in mg/kg or mg/lb. should be calculated for each patient and recorded prior to administration for all sedatives and local anesthetics used. (Table 1)

  • Candidates: A preoperative physical examination should be completed the day of treatment by a qualified practitioner for all patients undergoing sedation at levels deeper than anxiolysis. A medical consult may be appropriate. Patients who are ASA (American Society of Anesthesiologists) Class I or II may be considered candidates for conscious sedation or deep sedation. Patients in ASA Class III or IV present special problems and require individual consideration and should be treated in a hospital setting. General anesthesia requires consultation with an anesthesiologist, unless the person administering the general anesthesia has been adequately trained and privileged to assess the patient.

  • Responsible Adult: The pediatric patient should be accompanied to and from the treatment facility by a parent, legal guardian, or other responsible adult who should be required to remain at the treatment facility for the entire treatment period. A responsible adult must accompany adult patients who receive moderate, deep or general anesthesia. An adult who receives only nitrous oxide/oxygen or local anesthesia need not be accompanied by another adult.

Education and Training
This facility adheres to the American Society of Anesthesiologist (ASA) guidelines for education and training for nonanesthesiologist sedation practitioners. According to the ASA’s 2006 guidelines:
“The nonanesthesiologist sedation practitioner who is to supervise or personally administer medications for moderate sedation should have satisfactorily completed a formal training program in: (1) the safe administration of sedative and analgesic drugs used to establish a level of moderate sedation, and (2) rescue of patients who exhibit adverse physiologic consequences of a deeper-than-expected level of sedation. This training may be a part of a recently completed residency or fellowship training (e.g. within two years), or may be a separate educational program. A knowledge-based test may be used to verify the practitioner’s understanding of these concepts. The following subject areas should be included:

  1. Contents of the following ASA documents that should be understood by practitioners who administer sedative and analgesic drugs to establish a level of moderate sedation:

    1. Practice Guidelines for Sedation and Analgesia by Nonanesthesiologists

    2. Continuum of Depth of Sedation—Definition of General Anesthesia and Levels of Sedation/Analgesia

  2. Appropriate methods for obtaining informed consent through pre-procedure counseling of patients regarding risks, benefits, and alternatives to the administration of sedative and analgesic drugs to establish a level of moderate sedation.

  3. Skills for obtaining the patient’s medical history and performing a physical examination to assess risks and co-morbidities, including assessment of the airway for anatomic and mobility characteristics suggestive of potentially difficult airway management. The nonanesthesiologist sedation practitioner should be able to recognize those patients whose medical condition suggests that sedation should be provided by an anesthesia professional.

  4. Assessment of the patient’s risk for aspiration of gastric contents as described the ASA Practice Guidelines for Preoperative Fasting: ‘In urgent, emergent or other situations where gastric emptying is impaired, the potential for pulmonary aspiration of gastric contents must be considered in determining (1) the target level of sedation, (2) whether the procedure should be delayed or (3) whether the trachea should be protected by intubation.’

  5. The pharmacology of (1) all sedative and analgesic drugs the practitioner requests privileges to administer to establish a level of moderate sedation, (2) pharmacological antagonists to the sedative and analgesic drugs and (3) vasoactive drugs and antiarrhythmics.

  6. The benefits and risks of supplemental oxygen.

  7. Proficiency of airway management with facemask and positive pressure ventilation. This training should include appropriately supervised experience in managing the airway of patients, or qualified instruction on an airway simulator (or both).

  8. Monitoring of physiologic variables, including the following:

    1. Blood pressure

    2. Respiratory rate

    3. Oxygen saturation by pulse oximetry

    4. Electrocardiographic monitoring. Education in electrocardiographic (EKG) monitoring should include instruction in the most common arrythmias seen during sedation and anesthesia, their causes and their potential clinical implications (e.g. hypercapnia), as well as electrocardiographic signs of cardiac ischemia.

    5. Depth of sedation. The depth of sedation should be based on the ASA definitions of ‘moderate sedation’ and ‘deep sedation’. (See above)

    6. Capnography—if moderate sedation is to be administered in settings where patients’ ventilatory functions cannot be directly monitored (e.g. MRI suite).

  9. The importance of continuous use of appropriately set audible alarms on physiologic monitoring equipment.

  10. Documenting the drugs administered, the patient’s physiologic condition and the depth of sedation at regular intervals throughout the period of sedation and analgesia, using a graphical, tabular or automated record.

  11. If moderate sedation is to be administered in a setting where individual(s) with advanced life support skills will not be immediately available (1-5 minutes; e.g., code team), then the nonanesthesiologist sedation practitioner should have advanced life support skills such as those required for American Heart Association certification in Advanced Cardiac Life Support (ACLS). When granting privileges to administer moderate sedation to pediatric patients, the nonanesthesiologist sedation practitioner should have advanced life support skills such as those required for certification in Pediatric Advanced Life Support (PALS).

When the practitioner is being granted privileges to administer sedative and analgesic drugs to pediatric patients to establish a level of moderate sedation, the education and training requirements enumerated in #1-9 above should be appropriately tailored to qualify the practitioner to administer sedative and analgesic drugs to pediatric patients.”

An individual trained and competent in the monitoring of sedated patients shall appropriately monitor any patient given a sedating agent in the clinic. Administration of agents with patients returning to the waiting room for onset of sedation is not acceptable. No medications for moderate or deeper levels of sedation should be administered outside of the clinical setting.

Supplemental oxygen is recommended for all sedated patients (not including anxiolysis).

Providers should demonstrate current competence via [insert facility’s competency evaluation procedures]

Table 1
Local Anesthetic Dosages
Max. Rec.

Generic Brand Conc. Dose Mg per

Name Name (%) (Mg/Kg) Carpule

Lidocaine Xylocaine 2 4.4 36

Mepivacaine Carbocaine 2 6.6 36

Mepivacaine Carbocaine 3 6.6 54

Prilocaine Citanest 4 7.9 72

Bupivacaine Marcaine 0.5 2.0 9


  • Medical support: The Dental Supervisor and the Clinical Director may limit the use and type of dental sedation performed based upon the availability of medical support. Utilization of some sedation techniques, e.g., IV sedation techniques, may require the prior notification of a physician present in the facility to assure that adequate medical support is available.

  • Staffing: The staff required to safely conduct a sedation procedure will vary with the technique used. (See education and training section above)

  • Armamentarium: Basic emergency diagnostic and treatment equipment and an emergency drug kit must be readily available. This should include the following: sphygmomanometer, stethoscope, oxygen source, positive pressure ventilator, adequate suction apparatus with tonsillar suction tip, oral and nasal airways, and IV kits. The equipment and supplies should be appropriate for both pediatric and adult patients. If narcotic drugs are administered, Naloxone must be available in the emergency drug kit. If Midazolam is administered, flumazanil (reversal agent) must be available. An Automated External Defibrillator will be available. Additionally, strong consideration should be given to having a crash cart.

  • Nitrous Oxide: See Section B.22.

Emergency Services
Back up emergency services should be identified. See Section B-18 (Medical Emergencies in the Dental Clinic).
Documentation Prior to Treatment
The practitioner must document each sedation procedure in the patient's record. Documentation should include the following:

  • Informed consent: Each patient, parent, or other responsible individual is required to be informed regarding benefits, risks, and alternatives to sedation and to give consent. The patient record should document that appropriate informed consent was obtained according to the procedures of the facility. (See Section B.12.—Informed Consent)

  • Instructions to parents or responsible individual: The practitioner should provide verbal and written instructions to the parents or responsible individual. Instructions should be explicit and include an explanation of pre  and post sedation dietary precautions, potential or anticipated postoperative behavior, and limitation of activities.

  • Dietary precautions: The administration of sedative drugs should be preceded by an evaluation of the patient's food and fluid intake. Intake of food and liquids should be as follows: (a) no milk or solids after midnight prior to scheduled procedure; (b) clear liquids up to 4 hr. before procedure for children ages 6 months to 3 years; (c) clear liquids up to 6 hr. before procedure for children ages 3 to 6 years; and (d) clear liquids up to 8 hr. before procedure for children aged 7 years or greater. No restrictions are necessary for anxiolysis or nitrous oxide/oxygen sedation.

  • Preoperative health evaluation: Prior to the administration of sedatives, the practitioner should obtain and document information about the patient's current health status as detailed in the following sections concerning the various sedation modalities.

  • Prescriptions: See Section B. 14.

General Requirements for the Monitoring and Documentation for Oral and Parental Conscious Sedation and Deep Sedation
The patient should be monitored from the time of drug delivery until discharge.

  • Vital signs: The patient's record should contain documentation of intermittent quantitative monitoring and recording of oxygen saturation (pulse oximetry), heart and respiratory rates, and blood pressure, as recommended for specific sedation techniques. Responsiveness of the patient should be monitored at specific intervals before and during the procedure and until the patient is discharged.

  • Drugs: The patient's record should document the name, dose and route, site, and time of administration of all drugs administered. The maximum recommended dose per kilogram or pound should be calculated and the actual dose given shall be documented in appropriate units (e.g., fentanyl is administered in microgram doses, not milligrams). The concentrations flow rate, and duration of administration of oxygen and nitrous oxide should be documented.

  • Patient immobilization: See Section B. 11.

The condition of the patient and the time of discharge from the treatment facility should be documented in the record. Documentation should include that appropriate discharge criteria have been met. The record should also identify the responsible adult to whose care the patient was discharged. (Table 2)

Table 2: The Modified Aldrete Scoring System for Determining when Patients are Ready for Discharge from the PACU. A Score = 9 was Considered Necessary for Discharge

Activity: Able to move voluntarily or on command

4 extremities


2 extremities


0 extremities



Able to deep breathe and cough freely


Dyspnoea, shallow or limited breathing





BP +/- 20 mm of pre anaesthetic level


BP +/- 20 to 50 mm of pre anaesthesia level


BP +/- 50 mm of pre anaesthesia level



Fully awake


arousable on calling


not responding


O2 Saturation

Able to maintain O2 saturation>92% on room air


Needs O2 inhalation to maintain

O2 saturation>90%


O2 saturation<90% even with O2 supplementation


Aldrete JA The post anaesthesia recovery score revisited. (Letter) J. Clin. Anesth. (7) 1995 89-91

Sedation Techniques, Specific Criteria

-Documentation of training and pharmacology in the form of dental school transcripts or a letter attesting to training from the institution. Where anxiolysis was not taught, training should be [requirements according to IHS guidelines or State dental practice act].


-No additional staffs beyond those needed for the routine dental procedure are required


-No additional armamentarium beyond the normal dental procedure set-up is required

Pre-op evaluation

-Only a review of the dental medical history form is required.


-No additional monitoring beyond visual and verbal monitoring is required


-Documentation should include drug and dose used and its effectiveness.

Moderate Sedation

See Education and Training section above.

-[Requirements according to State practice act, additional requirements of facility]


-The dentist should have at least two dental assistants present for proper monitoring and support, one to assist in the dental procedure and one to monitor the patient. At least one assistant must be certified in basic life support.

-The practitioner responsible for the treatment of the patient and/or the administration of drugs for conscious sedation must be appropriately trained in the use of such drugs and techniques, must provide for appropriate monitoring, and must be capable of managing any reasonably foreseeable complications. (See Education and Training section above)
-In addition to the operating practitioner, an individual trained to monitor appropriate physiologic parameters and to assist in any supportive or resuscitation measures required should be present. Both individuals must have training in basic life support, should have specific assignments, and should have current knowledge of the emergency cart (kit) inventory. (See Education and Training section above)

-The operating facility used for the administration of conscious sedation should have available all facilities and equipment previously recommended. The minimum monitoring equipment for sedation shall be a pulse oximeter. A precordial/pretracheal stethoscope is highly desirable. ECG monitoring equipment should be considered but is not required.

Pre-op evaluation

-Health history

-Review of systems

-Vital signs, including heart rate, respiratory rate, and blood pressure.

-Risk assessment (ASA guidelines)

-Evaluation of airway patency

-Evaluation of the respiratory and cardiac systems is needed

-Whenever drugs for conscious sedation are administered, the patient should be monitored continuously for responsiveness and airway patency. There should be continuous monitoring of oxygen saturation by pulse oximetry and of heart and respiratory rates. Respiratory rate alone may not be a reliable guide to oxygenation, especially when the rate is hard to determine and respirations are shallow. ECG monitoring is once again encouraged. A precordial/pretracheal stethoscope also may be used for obtaining additional information on heart and respiratory rates and for monitoring airway patency. Restraining devices should be checked periodically to prevent airway obstruction or chest restriction. The patient's head position should be checked frequently to ensure airway patency. A trained individual from the time the sedating agent is administered until discharge from the facility must constantly observe a sedated patient.


-Oxygen saturation and heart and respiratory rates should be recorded intermittently on a time based record throughout the procedure and until the patient is discharged.

-After completion of the treatment procedures, vital signs should be recorded at specific intervals. Postoperative monitoring, of blood pressure, heart rate, pulse oximetry, and possibly ECG is prudent. The practitioner shall assess the patient's responsiveness and discharge the patient only when the appropriate discharge criteria have been met.
General Anesthesia
Policies and procedures for the provision of general anesthesia are the prerogative of the Medical Staff Committee or Anesthesia Department of the facility. The dental practitioner should make himself/herself aware of all applicable provisions. A qualified person on appropriate patients without medical consultation may administer General Anesthesia in an adequate facility, with provision for recovery. The dental practitioner will follow all Policies and Procedures of the facility regarding General Anesthesia.

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