The South African Dental Association GUIDELINES on CONSCIOUS SEDATION in DENTISTRY Revised Draft 13th April, 20011 IntroductionMany professional organisations have established guidelines and standards of care for patientsbeing sedated for operative procedures. Of the approximately 2800 dentists in private and ininstitutional practice in South Africa, a considerable though undetermined number administerconscious sedation, probably most commonly by the inhalational technique; yet to date, theSouth African Dental Association has had no such guidelines.The guidelines below, compiled at the request of the Private Practice Committee of the SouthAfrican Dental Association, do not purport to be comprehensive, but only to offer broad adviceto the intending or to the practising dental sedationist.2 DefinitionConscious sedation is a state of altered consciousness induced by the use of oral, parenteralor inhaled drug(s). While the patient is in this state, treatment can be carried out withoptimal comfort, communication can be maintained, the patient can respond to commands,and should maintain stable vital signs, protective reflexes and an independent airway. Thedrugs and techniques used for conscious sedation must have a margin of safety sufficient tomake loss of consciousness very unlikely.Any technique that results in alteration of the state of consciousness beyond that envisioned bythe terms of this definition must be regarded as induction of general anaesthesia, with all theattendant risks, consequences and responsibilities.3 ModalitiesConscious sedation as defined above is appropriate for patients receiving treatment in the dentalpractitioner’s rooms.It is strongly recommended that conscious sedation administered in his or her rooms by a traineddental practitioner who also acts as the sedationist, be confined to inhalational or oral sedation,with a properly trained assistant (see 7 below) in attendance.Intravenous conscious sedation.should be administered by a practitioner skilled in sedation, whois not also the operator. Conscious sedation for children, by whatever technique, should beundertaken only by teams trained and experienced in administration of sedation for this agegroup.
24 Education and TrainingThe sedationist and assistant/s must undertake formal and ongoing education and training.Up-to-date training in cardio-pulmonary resuscitation is essential for any person who administersconscious sedation of whatever type, and for any person acting as the assistant to the sedationist.A sound knowledge of the drugs to be used is essential for any intending sedationist.Education and training in the theory, methods and techniques of conscious sedation can beprovided in academic institutions where conscious sedation is practised and taught; or in formalshort or more extended courses as may from time to time be offered. Dental practitioners mustensure that all training taken by them and by their assistants is recorded and documented, fortheir own and their assistants’ protection.Knowledge and skills require regular maintenance and updating by means of refresher coursesand/or continual assessment or review as a routine practice activity. Even for skilled sedationistsand their assistants, refresher courses should be attended at least annually. Updating must also beundertaken after any break in the practice of sedation of 12 months or more.5 Facilities and equipment: monitoringPremises suitable for the safe practice of conscious sedation must have an oxygen supply,suction, an emergency electricity supply, a pulse-oximeter, all necessary drugs, includingemergency drugs, a chair or table which can be tilted to the Trendelenburg position, a fail-saferelative analgesia machine which cannot deliver a hypoxic gas mixture, and resuscitationequipment.During conscious sedation the well-being and safety of the patient must be ensured by having asecond suitably trained person present (see 7 below) who will be responsible for constantlycommunicating with the patient and monitoring his/her vital signs. A pulse-oximeter is theminimum monitoring equipment for any conscious sedation procedure. A cardiac defibrillatorshould be available, and for parenteral/multi-drug techniques, must be available.6 DrugsIt is beyond the scope of this guideline to give details of drugs and their correct and safe usage inconscious sedation. The essential education and training mandated in section 4, above, mustprovide all the necessary detail.Drugs for conscious sedation should have the following general characteristics: a large margin ofsafety, a painless route of administration, rapid onset and rapid recovery, easy reversibility, andno side-effects. Unfortunately no drug or combination of drugs completely achieves all theseideals.The inhalational agent used for conscious sedation is nitrous oxide, administered in combinationwith not less than 30% oxygen.
3For orally or intravenously administered sedation (see section 3, above), the benzodiazepines arethe current drugs of choice, producing anxiolysis with varying degrees of sedation and amnesia.Midazolam is the most commonly used benzodiazepine for pre-procedural and for intra-procedural sedation, anxiolysis and amnesia because of its favourable pharmacokinetics andabsence of active metabolites.7 PersonnelStaff (another dentist or a trained nurse if possible, or an oral hygienist or a dental assistant)appropriately trained in monitoring and resuscitation (see 4 above) must be present formonitoring and to give assistance during the administration of conscious sedation. A trained staffmember or the sedationist must also be present after sedation so that patients are constantlyattended until recovery is complete.8 Pre-sedation Assessment and Patient SelectionThe patient should fill in a questionnaire designed to disclose any risk factors, or whether he/sheis taking any medicine that may necessitate modification of technique or drug dosage, or the useof special equipment.Patients who are fit and healthy qualify for conscious sedation. Those with disorders of thecentral nervous system, with anaemia, cardiac, pulmonary, and other systemic diseases, and themorbidly obese, are at increased risk and should not be subjected to conscious sedation in adental practitioner’s rooms. Pregnancy and the puerperium also bring with them particular risksfor conscious sedation.Children have different requirements to adults, so their conscious sedation should be undertakenonly by those trained and experienced in case selection and sedation of children, and in anappropriately equipped environment (see section 3 above). Provided these requirements arefulfilled, there is no reason why conscious sedation should not be administered to children in adental practitioner’s rooms.Careful pre-operative assessment will ensure that correct decisions are made regarding suitabilityof a patient for conscious sedation and for the proposed operative procedure.Pre-sedation questionnaires, clinical findings and checklists must become part of the clinicalrecord.9 Records, DocumentationThe clinical record for conscious sedation should include the reasons for conscious sedation, theevidence supporting the reasons, and the consent document.The clinical record must also include details of age, gender, approximate weight, health status,regular drugs, questionnaires, checklists, sedative drugs and dosages given, oxygenconcentration, duration of conscious sedation, and any unusual events and actions taken.
410 Informed consentWritten informed consent is mandatory. The essential elements of informed consent forconscious sedation are the following:The patient, or in the case of a minor, the parent/legal guardian, must: 1. receive a full informative explanation of what is to be done. 2. be given clear, written pre- and post-operative instructions including instructions as to the period of abstinence from solid foods and fluids 3. sign a consent form acknowledging having received adequate information and explanation, and giving permission for local anaesthesia and sedation, as well as for the proposed dental treatment.Informed consent should be obtained at a visit before the day of the sedation/operation, as on theday, the patient may be too anxious, and thus be unable to make clear decisions for valid consent.11 Pre- and Post-sedation instructionsThe patient should be given both verbal and written instructions, including the instructions that: 1 regular medicines must be taken at the usual times. 2 a light meal may be taken 4 hours before the procedure under conscious sedation. 3 clear fluids or water may be taken in moderation up to 4 hours before sedation 4 he/she must bring a responsible person to escort him/her home and to care for him/her for the rest of the day.Instructions should also include advice not to drive, not to undertake any activity involvingmotor skills, not to drink any alcohol, and preferably not to sign legally binding documents or tomake important decisions for the rest of the day after conscious sedation.12 SafetyThe safety and well-being of the patient must take precedence over all other considerations. Themain factors governing safety are the knowledge and skill of the sedationist, who shouldtherefore take his/her responsibilities in this regard very seriously.In practices situated at high altitudes, the sedationist should be aware of the problems associatedwith lower atmospheric oxygen, and with the need for adequate oxygen flushing (5 minutesminimum), at the end of the sedation procedure.The drugs and techniques used for conscious sedation should have a margin of safety sufficientto render unintended loss of consciousness or loss of protective reflexes unlikely. All necessaryequipment and drugs to protect the patient from the effects of unintended oversedation, to rapidlyreverse such oversedation, or to deal with emergencies must be immediately available.
513 Recovery and AftercareRecovery from sedation progresses from the end of treatment to complete recovery anddischarge into the care of a responsible person.If recovery is not to proceed in the dental chair, the recovering patient should be moved toanother room suitably furnished and fitted for his/her comfort and well-being, and separate fromthe main waiting room, until recovery is complete. A trained person (see 7 above) shouldmonitor the patient throughout recovery, and the dentist or sedationist, and equipment and drugsfor dealing with emergencies must be immediately available.The minimum criteria for discharge of a patient who has been sedated include stable vital signs,the ability to walk without support, toleration of oral fluids, the ability to void urine, freedomfrom pain and no nausea. The patient must not be permitted to leave the surgery unaccompanied,and must not be allowed to drive himself/herself.14 Emergencies during sedationThis subject must be adequately covered in training courses. Written emergency protocols, andall the necessary equipment, drugs and materials must be available.15. Professional liabilityDental Protection Ltd has indicated that since the Health Professions Council of South Africaallows dentists to sedate their patients, they will indemnify those dentists who do so.Although the matter is constantly being reviewed, at present Dental Protection Ltd has nointention of introducing a higher subscription rate for South African dentists who practiseconscious sedation.16 Recommended reading16.1 Conscious sedation clinical guidelines. South African Medical Journal 87, 4: April 1997.16.2 Standards in conscious sedation for dentistry: Report of an independent expert working group: October 2000. The Society for the Advancement of Anaesthesia in Dentistry, 83 Wimpole Street, London, W1G 8YH, UK16.3 Sedation in dentistry. The competent graduate. The Dental Sedation Teachers Group, 2000. Dept of Sedation and Special Care Dentistry, Guy’s Hospital. London, SE1 9RT, UK16.4 Conscious Sedation. SA Dental Journal 55,3: March 2000; p168-169. James Roelofse.16.5 Conscious Sedation: Making our treatment options safe and sound. SA Dental Journal 55,5: May 2000; p 273-276. James Roelofse
616.6 Overview of pharmacological aspects of sedation Part I. SA Dental Journal 55,7: July 2000; p 387-389. James Roelofse16.7 Overview of pharmacological aspects of sedation Part II. SA Dental Journal 55,8: August 2000; p 441-442. James Roelofse16.8 ANY OTHER REFERENCES recommended by other committee members to be put in here at 16.8 et sequitur. Ad hoc committee responsible for compiling these guidelines: Professor J. Lemmer (Convener) Dr D Abramson (Dental private practitioner) Dr N Campbell (Executive Director, SADA) Dr C. Lundgren (University of the Witwatersrand, Johannesburg) Professor J. Roelofse (University of Stellenbosch) April, 2001E N D OF G U I D E L I N E S