This document discusses guidelines for conscious sedation during periodontal and implant surgical procedures. It defines different levels of sedation from mild to moderate. Guidelines are provided for patient evaluation, monitoring, and recovery for mild and moderate sedation using oral, inhalation, or intravenous routes. Common drugs used for mild oral sedation are discussed along with dosing guidelines. Moderate sedation techniques including oral, inhalation, and intravenous administration are outlined. Safety and monitoring are important to avoid deeper levels of sedation than intended.

1. Department of Periodontics
Conscious Sedation
Submitted by:
Benju Sharma
BDS 3rd
Batch,4th
Year
Roll no. 35
Guided by:
Dr.Dhirendra Giri

2. Contents
• Introduction
• Rationale for sedation during perodontal and
implant surgical procedures
• Definitions and level of sedation
• Clinical guideline
• Mild sedation
• Moderate sedation
• Sedation failure
• Conclusion

3. INTRODUCTION
• Periodontal surgeries should be performed
painlessly from the beginning to the end of
procedure.
• For a painless surgical procedure effective local
anesthesia should be administered.
• But some patients are apprehensive and should
be treated under mild to moderate sedation.

4. • Sedation is basically adopted in procedure that
require long time.
• Route for administration include inhalation, oral,
intramuscular and intravenous.

5. RATIONAL FOR SEDATION DURING PERIODONTAL AND
IMPLANT SURGICAL PROCEDURES
• Anxiety reduction in fearful patients who avoid need
for dental treatment compromising quality of life.
• Reduction in preoperative anxiety facilitate better
wound heeling by reducing stress.
• Less number of patients referred to periodontics
department will have anxiety.

6. ADA POLICY STATEMENT AND GUIDELINE FOR
CONSCIOUS SEDATION
• ADA Policy Statement for use of conscious sedation by
dentist states that the knowledge and skills required for
conscious sedation and general anesthesia are beyond
the scope of predoctoral and continued education.
• Only dentists who have completed advanced education
program accredited by Commission on Dental
Accrediation (CODA) are considered qualified.

7. DEFINATIONS AND LEVELS OF SEDATION
• Minimal sedation is drug induced state during
which patients respond normally to verbal and
tactile stimulation.
• Maximum recommended dose is the maximum
drug dose that can be used unmonitored at
home.

8. • Incremental dosing is administration of multiple doses
of drug until a desired effect is reached.
• Supplemental dosing is the single additional dose drug
being used to prolong duration of drug action used
during sedation.
• Moderate sedation is drug induced depression of
consciousness during which patients respond
purposefully to verbal stimulation alone or
accompanied by light tactile stimulation.

9. • Titration is administration of incremental doses of drug
until desired effect is reached.
• Deep sedation is drug induced depression of
consciousness during which patient cannot be easily
aroused but respond purposefully following repeated
or painful stimulation.
• General anesthesia is drug induced loss of
consciousness during which patients are not
arousable even by painful stimulation.

10. CLINICAL GUIDELINES FOR MINIMAL AND
MODERATE SEDATION
Patient evaluation:
> current health status of the patient is to be
evaluated.
>American Society of Anesthesiologist have classified
health status as;
ASA1- A normal healthy patient.
ASA2- A patient with mild systemic disease.
ASA3- A patient with severe systemic disease.

11. ASA4- A patient with severe systemic disease
that is a constant threat to life.
ASA5- A moribund patient who is not expected
to survive without the operation
ASA6- A declared brain dead patient whose
organs are being removed for donor purpose.

12. Preoperative physical examination:
> blood pressure and pulse
> oxygen saturation and respiration
> appearance and skin color
> alertness
> exercise tolerance

13. Personnel and equipment:
 At least one additional person trained in basic life
support should be available.
 Positive-pressure O2 delivery system for patient
being treated,
 Functioning inhalation equipment for O2 and drug
delivery
 Equipment to establish IV access should be
available.

14. Monitoring and documentation
A trained individual should remain in the operatory
during and after treatment to monitor the patient.
In case of moderate sedation a qualified dentist
administering sedation should remain in the
operatory.
Dentist must not leave the facility until the patient is
fit for discharge.

15. Monitoring instruments like sphygnomanometer,
suction O2 delivery system, fail-safe and scavenger
system, pulse oximeter etc should be available.
Level of consciousness must be continuously
monitored.
Color of mucosa, skin, blood should be evaluated.
Respiration is monitored by auscultation of breath
sounds, verbal communication with the patient.

16. O2 saturation should be monitored in case of
moderate sedation.
Appropriate time oriented anesthetic record should
be maintained with name and doses of all drugs
administered
The physiological parameters monitored should
also be recorded.

17. Recovery and discharge:
- Level of consciousness, oxygenation, ventilation
and circulation should be determined before
discharge.
- Postoperative instructions must be given to both
patient and the caregiver.
- If a reversal agent used must be monitored until
recovery
*Reversal agent may have short duration of action
than that of sedative and may cause resedation of
the patient after discharge

18. MILD SEDATION
• Oral sedation:
– They mainly help in anesthetic failure and anxiety reduction
– Are cost effective and require minimal monitoring
– Drugs generally used include:
• Zaleplon
• Triazolam
• Lorazapam

19. Total anxiolytic dosing guidelines
Weight (lb) :
<100
150
200+
contraindicatio
n
Zaleplon
Age 41-64 yrs
5mg
10mg
10-15mg
Pregnancy,
liver
impairment,
severe renal
disease,
children
Triazolam
Age 41-64 yrs
0.250mg
0.375mg
0.500mg
Myasthenia
gravis, severe
COPD,
glaucoma,
mental
depression,
children
Lorazepam
Age 41-64 yrs
1mg
1.5mg
2mg
Acute angle
glaucoma,
hypersensitive
to drug,
lactation,
pregnancy,
renal
impairment

20. Onset of
hypnotic
effect
Peak plasma
concentratio
n
Duration of
action
Half life
Zaleplon
15-30 mints
1 hr
1 hr
1 hr
Triazolam
30 mints
<2hr
2-4 hr
2.5 hr
Lorazepam
30-60 mints
1-6hr
4-8hr
12-16 hr

21. • Dose in healthy adults under 40 yrs can be increased
by 25%.
• Dose for elderly and debilitated patients should be
reduced by 50% as they are more sensitive to
hypnotics.
• The systemic availability is increased by 27% when
administered sublingually compared to same dose
given orally.

22. • Inhalation sedation:
– By N2O technique
Advantage:
- Rapid onset of action and recovery
Disadvantage:
- Initial equipment cost is high
- Need of effective scavenging equipment
- Long term use can be hazardous to dental personal
Contraindications:
- COPD
- Severe emotional disturbance
- Early pregnancy

23. • Phases of sedation
Induction phase:
- 100% O2 flow started
- Correct flow rate is established of sedative.
- Scavenging system is checked for function and adjusted
- Initial N2O flow of 20% and titrated to 10% increments
every 60 seconds until patient feel relaxed and display the
signs.

24. Treatment phase:
- Once the ideal level of sedation is achieved, local
anesthetic is administered and procedure started.
- N2O flow can be reduced as patient gets comfortable and
can be increased if more local anasthesia has to be
given

25. Recovery phase:
- When N2O is no longer required flow is terminated and
100% O2 is given for 5 minutes until patient recovers.
- If the patient completely recovers is not required to be
escorted by other individual.

26. MODERATE SEDATION
• Requires more training for administration than mild
sedation
• Advanced cardiac life support and/or appropriate
training in dental anesthesia emergency management
required.
• Should satisfy all state laws and regulation for
provision of such service.

27. Oral sedation
Oral medication with supplemental dosing:
A typical regimen include a dose of triazolam 1 hr
before dental appointment followed by incremental
dose to achieve adequate level of sedation.

28. 24 hr max cumulative dose for triazolam for 200 pounds
healthy patient is 2 gm. Regimen include:
initial dose of 0.25mg
after 60 minutes 0.5 mg added
after 90 minutes 0.25mg added
Total dose of 1 gm.
Flumazenil is the reversal agent for triazolam.

29. Combined oral and inhalation sedation
• Combination of oral benzodiazepines with N2O
used.
• Minimal sedation dose of benzodiazepines and
then tittered N2O administered.
• Monitoring is required to avoid unwanted
overdose.

30. Intravenous sedation
• Desired end-point result is drowsiness,
tranquility, and loss of anxiety.
• Classic sign of drooping eyelid, response to
verbal commands, sign of relaxation and rest
with eye closed help prevent unwanted deep
sedation.

32.  Single benzodiazepine IV sedation technique
Midazolam technique:
Initial dose of 0.2 mg and then titrated at a rate of 0.5
mg/min until desired level of sedation achieved. Maximum
dose of 10 mg can be administered.
Diazepam technique:
Initial dose of 1mg given to determine any drug sensitivity
and then titrated at a rest of 2.5 mg/min until the desired
level of sedation is achieved. Maximum dose of 20mg can
be administered.

33. Combination IV sedation:
Is adopted to prevent sedation failure when
maximum safe dose of single sedative agent
produce little effect.
Administration of two or more sedatives reduce
dose of single drug and act synergistically.
Opoids are frequently combined with
benzodiazepines.

34. • Meperidine+diazapam/midazolam:
- benzodiazepine dosed as before
- meperidine is initially given to see any unusual
reaction it is titrated at a rate of 5mg/ min until
moderate sedation achieved.
-too rapid administration of meperidine may lead to
excessive sedation.

35.  Fantanyl + midazolam:
- Fantanyl is a rapid-onset, short-acting opoid.
- It has a longer respiratory depressant action than sedation.
- Initial dose of fantanyl 0.001mg/kg via IV infusion over
minutes
- The time taken by the drug to show its action is called as
lead-time.
- Midazolam is administered at a rate of 0.5mg/minute until
required level of sedation is achived.

36. • Combined oral and IV sedation:
- In this combination oral sedatives are mainly utilized to
reduce preoperative anxiety.
- Lorazapam is prescribed to the patient at minimal sedation
dose and is taken at home.
- Midazolam IV drip is started in office and the dose required
is reduced

37. Sedation failure
- It should be kept in mind that 100% sedation success
may not be achieved always.
- If the sedation is not adequate the procedure is
terminated and is rescheduled with new approach next
time.

38. CONCLUSION:
Sedation plays an important part in anxiety
reduction and is of great importance in long
duration periodontal surgeries and implantology.
Sedative selection should be done properly as
per requirement and the drugs used should not
be misused.

39. Reference
• Carranza’s 11th
edition.

40. THANK YOU