IV Sedation

When a drug, usually of the anti-anxiety variety, is administered Into the blood system during dental treatment, this is referred to as Intravenous Conscious Sedation (aka, "IV sedation"). Conscious sedation Is sometimes (incorrectly) referred to as "twilight sleep" or "sleep dentistry". These terms are more descriptive of deep sedation. Deep sedation isn't commonly used, and is more closely related to general anesthesia (even though sedation occurs on a continuum). This page answers the most common questions regarding conscious IV sedation. Please be aware that this page contains some explicit descriptions.

What does it feel like? Will I be asleep?
A lot of dental offices use terms such as "sleep dentistry" or "twilight sleep" when talking about IV sedation. This Is confusing, because it suggests that IV sedation Involves being put to sleep. In reality, you remain conscious during IV sedation. You will also be able to understand and respond to requests from your dentist.

However, you may not remember much about what went on because of two factors: firstly, in most people, IV sedation Induces a state of deep relaxation and a feeling of not being bothered by what's going on, Secondly, the drugs used for IV sedation can produce either partial or full memory loss (amnesia) for the period of time when the drug first kicks In until It wears off. As a result, time will appear to pass very quickly and you will not recall much, or perhaps even nothing at all, of what happened. So It may, indeed, appear as if you were "asleep" during the procedure.

Is It still necessary to be numbed with local anesthetic? Will my dentist numb my gums before or after I'm sedated?
The drugs which are usually used for IV sedation are not painkillers (although some pain-killing drugs are occasionally added, see below for a more detailed discussion), but_ anti-anxiety drugs. While they: relax you and make you forget what happens, you will still need to be numbed.
If you have a fear of injections, you will not be numbed until the IV sedation has fully kicked In, If you have a phobia of needles, you will very probably be relaxed enough not to care by this stage. Your dentist will then wait until the local anesthetic has taken effect (i. e. until you're numb) before starting on any procedure.

How is IV sedation administered?
"Intravenous" means that the drug Is put into a vein. An extremely thin needle is put Into a vein close to the surface of the skin in either the arm or the back of your hand. This needle is wrapped up with a soft plastic tube. The needle makes the entry Into the vein, and then Is slid out leaving the soft plastic tube In place. The drugs are put In through that tube. The tube stays In place throughout the procedure.

Throughout the procedure, your pulse and oxygen levels are measured using a "pulse oximeter." This gadget clips onto a finger or an earlobe and measures pulse and oxygen saturation. It gives a useful early warning sign if you're getting dangerously low on oxygen, although if your dentist and the nurses are paying attention they should see it before the machine does. The warning signs are unresponsiveness and slow breathing. Blood pressure before and after the procedure should be checked with a blood pressure measuring machine.

What are the drugs and what do the drugs do?
Good question!! For light conscious sedation the most commonly used drugs are benzodlazepines, or "benzos" for short. These are anti-anxiety sedative drugs. IV administered benzos have 3 main effects: they reduce anxiety/relax you, they make you sleepy, and they produce partial or total amnesia (i.e. make you forget what happened during some or, less frequently, all of the procedure).

By far the most commonly used drug for IV sedation is Midazolam (Versed). Midazolam Is the first choice because of its relatively short duration of action (meaning that It'll be out of your system faster).

For heavier sedation with a trained anesthesiologist, Barbiturates can be used and have one main advantage over benzos, and that Is that they can be used to provide more than 1 1/2 hours of conscious sedation (which is about the max with benzos). Some anesthetists use Propofol instead of benzos. The advantage of this is the very rapid recovery time, less than 5 mans. The disadvantage Is the drug must be continuously administered, so the drug Is pumped in using an electric infusion pump, the dose rate is set by the anesthetist.

Oploids such as Meperidine (Demerol) are strong pain-killers and be used as an add-on to either benzos (for procedures up to about 1 1/2 hours) or barbiturates (for procedures longer than 2 hours).

At first glance, the use of oplolds seems appealing, because of the pain-killing factor. In reality, this usually only comes into play for post-treatment pain, because local anesthesia will take care of any pain during treatment. However, should the local anesthetic effect begin to lessen, an oplold will help to alter the experience of pain. However, what is often done instead is give a long-acting local anesthetic where post-op pain Is expected. When you take oplolds, even excruciating pain becomes tolerable - you can still feel the pain, but somehow you don't seem to notice It as much. Also, where barbiturates are used, an opioid must be added to counteract their pain-threshold-lowering properties.

Is it safe? Are there any contraindications?
IV sedation is EXTREMELY safe when carried out under the supervision of a specially trained dentist. Purely statistically speaking, it's even safer than local anesthetic on Its own!

However, contraindications Include pregnancy, known allergy to benzos, alcohol intoxication, CNS depression, and some instances of glaucoma. Cautions include psychosis, Impaired lung or kidney or liver function, and advanced age. Heart disease is generally not a contraindication.

What are the main advantages of IV sedation?

• IV sedation tends to be the method of choice if you don't want to be aware of the procedure - you "don't want to know". The alternative in the US Is oral sedation using Halcion, but oral sedation Is not as reliably effective as IV sedation.

• The onset of action is very rapid, and drug dosage and level of sedation can be tailored to meet the individual's needs. This is a huge advantage compared to oral sedation, where the effects can be very unreliable. IV sedation, on the other hand, is both highly effective and highly reliable.

• The maximum level of sedation which can be reached with IV is deeper than with oral or Inhalation sedation.

• Benzos produce amnesia for the procedure.

• The gag reflex Is hugely diminished - people receiving IV sedation rarely experience difficulty with gagging. However, If minimizing a severe gag reflex is the main objective, Inhalation sedation Is usually tried first. Only If that falls to diminish the gag reflex should IV sedation be used for this purpose.

• Can be Ideal for those with a phobia of dental injections.

• Unlike General Anesthesia or Deep Sedation, conscious IV sedation doesn't really Introduce any compromises per se In terms of carrying out the actual procedures, because people are conscious and they can cooperate with instructions, and there is no airway tube involved.

Are there any disadvantages?

• A needle has to be put In the arm or hand ("venipuncture"). If you have a general phobia of needles, this isn't much fun, If you cannot tolerate this, having Inhalation sedation ("laughing gas") before the venipuncture helps, because It relaxes you and produces a tingling feeling in arms and legs which distracts from the venipuncture.

• It is possible to experience complications at the site where the needle entered, for example hematoma (a localized swelling filled with blood).

• While IV sedation is desired precisely because of the amnesia effect (I. e. forgetting what happened while under the influence of the drug/s), there can be a downside to this: if you can't remember that the procedure wasn't uncomfortable or threatening, you can't unlearn your fears. However, it depends on the precise nature of your phobia and the underlying causes to which extent this may be a problem. Some people would voice a concern that some patients can't be "weaned off" IV sedation, as dental anxiety tends to returns to baseline levels. As a result, people who rely on IV sedation may be less likely to seek regular dental care. Other people would argue that this is not a concern if IV sedation is readily available to people.

• Recovery from IV administered drugs is not complete at the end of dental treatment. You need to be escorted by a responsible adult.

• You should WANT to be sedated. If, for any reason, you're unwilling to "let go", for example because you don't like not being in control, It will be more difficult to be successfully sedated.

Before IV Sedation:
Light Sedation: Do not eat or drink anything for 6 hours before you are scheduled for your procedure. This decreases the chance of nausea and vomiting during your procedure and the risks associated should that occur.
Heavier Sedation: Do not eat or drink anything for 12 hours before you are scheduled for your procedure. This decreases the chance of nausea and vomiting during your procedure and the risks associated should that occur.

After IV Sedation:
(1) Have your escort take you home and rest for the remainder of the day. (2) Have an adult stay with you until you're fully alert.

(3) Don't perform any strenuous or hazardous activities and don't drive a motor vehicle for the rest of the day.

(4) Don't eat a heavy meal Immediately. If you're hungry, eat something light, e. g. liquids and toast.

(5) If you experience nausea, lie down for a while or drink a glass of coke.

(6) ,Don't drink alcohol or take medications for the rest of the day unless you've contacted your dentist first.

(7) Take medications as directed by your dentist.

(8) If you have any unusual problems, call your dentist.