The Use of Conscious Sedation, Deep
Sedation and General Anesthesia in Dentistry
Introduction
Dentists have had both a historic and specific continuing
expertise in providing anesthetic, sedative and other
anxiety and pain control procedures for their patients.
The effective control of anxiety and pain has been an
integral part of dental practice since the early development
of the profession. Use of a wide variety of anxiety
and pain control techniques has enabled the profession
to extend oral health care to millions of individuals
who would otherwise remain untreated. Without effective
anxiety and pain control, numerous dental procedures
are virtually impossible and many patients do not seek
needed dental treatment. In addition, both anxiety and
pain control techniques are often essential for the
management of special patients, young children and the
mentally and physically challenged. The use of anxiolytic
sedative and anesthetic techniques by appropriately
trained dentists in the dental office and other settings
continues to have a remarkable record of safety.
Anxiety and pain can be modified by both psychological
and pharmacological techniques. In some instances, psychological
approaches are sufficient. However, in many instances,
pharmacological approaches are required.
Local anesthetics are used to control regional pain.
Sedative drugs and techniques may control fear and anxiety,
but do not by themselves fully control pain and, thus,
are commonly used in conjunction with local anesthetics.
General anesthesia provides complete relief from both
anxiety and pain.
This policy statement addresses the use of conscious
sedation, deep sedation and general anesthesia, as defined
in the Association's Guidelines for Teaching the Comprehensive
Control of Pain and Anxiety in Dentistry. These terms
refer to the effects upon the central nervous system
and should not be confused with any route of drug administration.
The use of conscious sedation, deep sedation and general
anesthesia in dentistry is safe and effective when properly
administered by trained individuals. The American Dental
Association strongly supports the right of appropriately
trained dentists to use these modalities for the management
of dental patients and is committed to ensuring their
safe and effective use.
Education
Dentists who have received appropriate formal education
in conscious sedation, deep sedation and general anesthesia
are qualified to use these modalities in practice. Training
to competency in conscious sedation techniques may be
acquired at the predoctoral, postgraduate, graduate,
or continuing education level. Dentists who wish to
utilize conscious sedation are expected to successfully
complete formal training which is structured in accordance
with the Association's educational Guidelines, "Part
One: Teaching the Comprehensive Control of Pain and
Anxiety to the Dental Student" and/or "Part
Three: Teaching the Comprehensive Control of Pain and
Anxiety in a Continuing Education Program."
The knowledge and skills required for the administration
of deep sedation and general anesthesia are beyond the
scope of predoctoral and continuing education. Only
dentists who have completed an advanced education program
structured in accordance with "Part Two: Teaching
the Comprehensive Control of Pain and Anxiety at the
Advanced Education Level" of the "Guidelines
for Teaching the Comprehensive Control of Pain and Anxiety
in Dentistry" or completion of an ADA accredited
post-doctoral training program (e.g., oral and maxillofacial
surgery) which affords comprehensive and appropriate
training necessary to administer and manage deep sedation/general
anesthesia, commensurate with the ADA document "The
Use of Conscious Sedation, Deep Sedation and General
Anesthesia in Dentistry" are considered educationally
qualified to use deep sedation and general anesthesia
in practice.
The dental profession's continued ability to control
anxiety and pain effectively is dependent on maintaining
a strong educational foundation in the discipline. While
many practicing dentists may elect not to use conscious
sedation, deep sedation or general anesthesia, it is
critical that those who wish to do so have access to
adequate training. The Association supports efforts
to expand the availability of courses and programs at
the predoctoral, advanced and continuing educational
levels which are structured in accordance with its educational
Guidelines in anxiety and pain control. It urges dental
schools to expand opportunities for predoctoral students
to receive training and clinical experience in conscious
sedation techniques. It urges continuing education sponsors
to offer comprehensive courses in accordance with the
Guidelines in conscious sedation techniques which include
sufficient opportunity for supervised clinical experience
to enable participants to achieve competency in these
techniques. Finally, it urges sponsors of advanced dental
education to develop programs at the postgraduate level
which are designed to train individuals in conscious
sedation, deep sedation and general anesthesia.
The objective of educating dentists to utilize conscious
sedation, deep sedation and general anesthesia is to
enhance their ability to provide oral health care.
Risk Management
Appropriate educational preparation, while necessary,
is not by itself sufficient to ensure safe and effective
use of conscious sedation, deep sedation and general
anesthesia. There is some degree of risk associated
with the use of any drug, even when administered by
trained individuals. Dentists who are qualified to utilize
conscious sedation, deep sedation and/or general anesthesia
have a responsibility to minimize risk to patients undergoing
dental treatment by:
- Using only those drugs and techniques with which
they are thoroughly familiar, i.e., understand the
indications, contraindications, adverse reactions
and their management, drug interactions and proper
dosage for the desired effect;
- Limiting use of these modalities to patients who
require them due to such factors as the extent and
type of the operative procedure, psychological need
or medical status;
- Conducting comprehensive preoperative evaluation
of each patient to include a comprehensive medical
history, assessment of current physical and psychological
status, age and preference for and past experience
with sedation and anesthesia;
- Conducting physiologic and visual monitoring of
the patient as needed from onset of anesthesia/sedation
through recovery;
- Having available appropriate emergency drugs, equipment
and facilities and maintaining competency in their
use;
- Maintaining fully documented records of drugs used,
dosage, vital signs monitored, adverse reactions,
recovery from the anesthetic, and, if applicable,
emergency procedures employed;
- Utilizing sufficient support personnel who are properly
trained for the functions they are assigned to perform;
- Treating high-risk patients in a setting equipped
to provide for their care.
The Association expects that patient safety will be
the foremost consideration of dentists who use conscious
sedation, deep sedation and/or general anesthesia. Dentists
who use these modalities should take all necessary measures
to minimize risk to patients.
State Regulation
State dental boards have a responsibility to ensure
that only dentists who are properly trained, experienced,
and currently competent are permitted to use conscious
sedation, deep sedation and general anesthesia within
their jurisdictions. For this reason, the Association
strongly urges state dental boards to regulate dentists'
use of these modalities. In addition to identifying
educational requirements which are consistent with the
Association's Guidelines, state dental boards should
evaluate and certify dentists who apply to administer
conscious sedation, deep sedation and/or general anesthesia
to ensure that the protocol, procedures, facilities,
drugs, equipment and personnel utilization meet acceptable
standards for safe and appropriate delivery of anesthesia
care.
The Association recognizes the existence
of office-based ambulatory anesthesia as an integral
part of the management of anxiety and pain control for
dental patients. It is important that state dental boards
be aware that ambulatory anesthesia services, will be
increasingly available from well qualified dentists.
It is in the best interest of the public and the profession
that access to this cost-effective service be widely
available.
States introducing regulation of conscious
sedation, deep sedation and/or general anesthesia may
elect to identify a period of time during which practitioners
without the specified educational qualifications may
apply and be evaluated for the use of these modalities.
These practitioners should have demonstrated competence
in the use of the regulated modalities over an extended
period of time as determined by the state dental board.
Research
The use of conscious sedation, deep sedation and general
anesthesia in dentistry will be significantly affected
by research findings and advances in these areas. The
Association strongly supports the expansion of both
basic and clinical research in anxiety and pain control.
It urges institutions and agencies that fund and sponsor
research to place a high priority on this type of research,
which should include: 1) epidemiological studies which
provide data on the number of these procedures performed
and on morbidity and mortality rates, 2) clinical studies
of drug safety and efficacy, 3) basic research on the
development of safer and more effective drugs and techniques,
4) studies on improving patient monitoring, and 5) research
on behavioral and other non-pharmacological approaches
to anxiety and pain control.
*Adopted by the American Dental Association house of
Delegates, October 1999
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