Department of Dental Medicine

Oral Sedation Guidelines

Sedation is a continuum that ranges from anxiolysis to general anesthesia.

Patients undergoing oral sedation or oral sedation+N2O need an ASC sedation
consult prior to scheduling an ASC procedure appointment.

Definitions (American Society of Anesthesiologists)

Anxiolysis – a drug-induced state during which patients respond normally to
verbal commands. Although cognitive function and coordination may be
impaired, ventilator and cardiovascular functions are unaffected.

Conscious sedation - a drug-induced depression of consciousness during which

patients respond purposefully* to verbal commands, either alone or accompanied
by light tactile stimulation. No interventions are required to maintain a patent
airway, and spontaneous ventilation is adequate. Cardiovascular function if
usually maintained.

*Reflex withdrawal from a painful stimulus is not considered a purposeful

response.

Department of Dental Medicine Facilities

Treatment rooms are of a size and design that permits access of emergency
equipment and personnel to allow effective emergency management, and
contains:
 A chair suitable for CPR or CPR board
 Lighting as necessary for specific procedures
 Suction equipment as necessary for specific procedures, including non-
electrical back-up suction

Equipment
The following is available:
 Positive pressure oxygen delivery system, including full face mask for adults
and pediatric patients
 Oral and nasal airways of various sizes

Date: 04/10/2015 UNM Dept. of Dental Medicine Written by: J. Flores, RN, DDS
  Blood pressure monitoring device
 Pulse oximeter
 Emergency drugs and equipment
 Written Protocols and Training
 Written emergency protocols

Prior to sedation
 A pre-operative evaluation must be performed.
 Resident must know Patient’s current written medical history; including
known allergies and previous surgeries and anesthetics must be reviewed.
 Focused physical examination consisting of pre-operative and post-
operative vital signs, auscultation of the heart and lungs, and evaluation of
the airway.

Please see Appendix A.

Patients undergoing sedation or anesthesia for elective procedures should not

drink fluids or eat solid foods for a sufficient period of time to allow for gastric
emptying before their procedure, as recommended by the ASA “Guidelines for
Preoperative Fasting” ingested material minimum fasting
period:
 Clear liquids 2 hours
 Nonhuman milk 6 hours
 Light meal 6 hours – (light meal ex.: 1-2pcs. dry toast/graham crackers, light
jelly spread can be permitted, black coffee, or water)

Faculty Supervision
The use of oral sedation must be approved by attending faculty.
Faculty must be present in the clinic throughout the procedure.
Resident must document current successful completion of basic life support (BLS).

Monitoring (16.5.15.10 NMAC)

For administration of nitrous oxide or enteral anxiolysis/analgesia, the patient’s
record should reflect evidence of appropriate monitoring of vital signs, including,
blood pressure, pulse, and respiratory rate during procedure and the effect of
medications.
Record must be reviewed by supervising faculty.

Date: 04/10/2015 UNM Dept. of Dental Medicine Written by: J. Flores, RN, DDS
Personnel (16.5.15.10 NMAC)
Staff, residents and faculty must be BLS certified and capable of assisting with
procedures, problems, and emergency incidents.

Dispensing Oral sedatives

Oral sedatives such as oral benzodiazepines or any oral medication that has
sedation as a profound side effect, i.e. diphenhydramine, is to be stored in the
appropriate areas within the Department of Dental Medicine and distributed to a
Resident with Faculty supervision after Faculty treatment consultation and
approval.

Oral sedatives that are deemed as “Controlled Substances” according to DEA

classification are to be dispensed by the Department at the time of the sedation
appointment for use within the Department only, under the supervision of
appropriately sedation permitted Faculty. Faculty should verify that last recorded
“Remaining Amount” match with the remaining drug volume in the bottle.
Controlled Substances used for sedative purposes during a procedure in any
Department of Dental Medicine facility should not be prescribed to the patient
and dispensed from an outside pharmacy. Currently, the Department stocks and
dispenses triazolam (Halcion) and oral Versed (midazolam syrup) for oral
sedation.

Oral Versed (midazolam syrup) that has an accompanying measurement strip,

needs to have strip placed on the bottle following Manufacturer’s instructions
prior to opening. Oral Versed (midazolam) should be dispensed rounding up to
nearest whole number. (ex. 3.5ml rounds to 4ml)

Faculty is responsible in assisting Residents to determine proper dosages for

sedatives dispensed and should stay with Resident during dispensing. Dispensing
should follow closely with Manufacturer Recommended Dosages (MRD).

Oral Versed (midazolam syrup) – 0.5mg/kg not to exceed 20mg/patient

Triazolam (Halcion) – 0.5mg/day, oral administration
If given sublingual (SL)(crushed and placed under the
tongue) SL administration should be noted in chart and
noted that this administration route has a greater and more
immediate therapeutic effect.

Date: 04/10/2015 UNM Dept. of Dental Medicine Written by: J. Flores, RN, DDS
Diazepam (Valium) – 2-10mg PO bid-qid (can be prescribed after consultation
with faculty)
Lorazepam (Ativan) – 2-6mg/day PO divided bid-tid (can be prescribed after
consultation with faculty)

Recovery and Discharge Criteria after Sedation

Recovery and discharge is the responsibility of the operating Resident under
Faculty supervision.
Department of Dental Medicine’s recovery areas are equipped with, or have
direct access to, appropriate monitoring and resuscitation equipment.
 Oxygenation should be monitored until patients are no longer at risk for
respiratory depression.
 Level of consciousness, vital signs, and oxygenation (when indicated)
should be recorded prior to discharge.
 An individual trained to monitor patients and recognize complications
should be present until discharge criteria are fulfilled.
 An individual capable of managing complications should be immediately
available until discharge criteria are fulfilled.
 Written post-sedation care instructions

Patients should be monitored until the following appropriate discharge criteria

are satisfied.
 Patients should be alert and oriented; pediatric patients’ mental status
should return to their baseline.
 Practitioners and parents should be aware that pediatric patients are at risk
for airway obstruction should the head fall forward while the child is
secured in a car seat.
 Vital signs should be stable and within acceptable limits
 Sufficient time (up to 2 hours) should have elapsed after the last
administration of reversal agents (naloxone, flumazenil) to ensure that
patients do not become re-sedated after reversal effects have worn off.
 Outpatients should be discharged in the presence of a responsible adult
who will accompany them home and be able to report any post-procedure
complications.

Date: 04/10/2015 UNM Dept. of Dental Medicine Written by: J. Flores, RN, DDS
  Outpatients and their escorts should be provided with written instructions
regarding post-procedure diet, medications, activities, and a phone number
to be called in case of emergency.
Please see Appendix B.
Appendix A: Pre-anesthesia Information & Chart Example

A. Pre-anesthesia assessment should contain:

1. Review of systems
2. Current diagnosis
3. Pertinent lab data
4. Pertinent physical examination findings
5. Allergies/sensitivities
6. Airway assessment
a. Anatomy
b. Dentures/teeth
c. Previous problems under anesthesia
7. Surgical/anesthesia history
8. Medication history
9. Social history
a. Smoking
b. ETOH use
c. Drug use
10. Family problems with anesthesia
11. Other
a. Disabilities
b. Communication problems
c. Prosthetics, etc.

Pre-anesthesia Chart Note Example

Patient is a 30yoF with a medical history significant for chronic back pain,
Degenerative Disk Disease, chronic periodontitis, and dental caries.
ROS:
Head: WNL
Heart: WNL
Lungs: WNL
Gastrointestinal: WNL
Urinary: WNL

Date: 04/10/2015 UNM Dept. of Dental Medicine Written by: J. Flores, RN, DDS
Hemotological: WNL
Muscle/Joint/ Nerves: lower back, bilateral leg pain due to DDD,
Allergies/Rxns: PCN, rash, no breathing problems
Previous surgeries: Back surgery in 2009
Surgical/anesthesia problems: no problems
Medications: prescribed medical marijuana, 3 cigs/day for 5+yrs and steroids,
20mg/daily
Social history: No tobacco, occ. ETOH use
Family problems with surgery/anesthesia: no problems
Disabilities/Communication /prostheses: Obese, Spanish-speaking only, translator
used
Airway assessment: Mal: 3, limited range of neck motion due to short, obese
neck, loose teeth, snoring/OSA during sleep
Patient level of anxiety: (calm, mildly nervous, extremely fearful)
Understanding/acceptance of anesthesia: (Discussed IV, oral, and N2O sedation.
Patient voices desire for oral/N2O sedation. Discussed
risks/benefits of oral/N2O sedation, and Patient voices
understanding and acceptance of sedation plan

Abbreviations:
PCN - Penicillin
ETOH – Ethyl alcohol
WNL - Within Normal Limits
CTAB - Clear To Auscultation Bilaterally
FROM – (neck) Full Range of Motion
MAL – Mallampati classification 1 – 4

Date: 04/10/2015 UNM Dept. of Dental Medicine Written by: J. Flores, RN, DDS
 Appendix B: Recovery and Discharge Information & Chart Example

A. Transfer of Care Information

1. What unit/personnel (PACU, recovery member etc.) is taking over care
2. Report given on
a. Allergies/reactions
b. Anesthetic type, drugs used
c. Fluids used
d. Complications, if any
e. Procedure performed
f. Vital signs (V.S.)
g. Pre-existing conditions/medications
h. Airway status/oxygen requirements

3. Post-anesthesia Note
a. Complications, if any
b. General status
c. Unanticipated patient responses/Emergency measures performed
d. Any deviations from standard of care and their rationale

Post-anesthesia Chart Note Example:

Post-anesthesia care transferred to RN.
Report given: Patient had 0.5mg oral triazolam, 2 divided doses
0.25mg 45mins apart/ 30% N2O sedation with no
complications) for extraction of #1, 16, 17, 28, and 32
Allergies/Rxns: PCN, rash, no breathing problems. No PCN given.
Fluids: 300mls NS given
Vital signs: B/P – 126/82, HR – 87, RR – 16, Temp 36.6, O2 Sat – 98%.
Medical history: chronic back pain, Degenerative Disk Disease, chronic
periodontitis, and dental caries.
Post-surgical condition: Patient currently has gauze packing at extraction sites,
voices no pain, is sitting upright, resting/breathing
comfortably, and responding appropriately to verbal

Date: 04/10/2015 UNM Dept. of Dental Medicine Written by: J. Flores, RN, DDS
 commands translated by Husband.
Husband, English-speaking, at bedside. Verbal and written post-operative care
instructions given to Husband.

Date: 04/10/2015 UNM Dept. of Dental Medicine Written by: J. Flores, RN, DDS