considerations of iv sedation - dentaltown€¦ · iv sedation. 3. know the history of sedation...

continuing education

An overview of bringing IV

sedation into the practice, with an emphasis

on anesthetic history and airway

management protocols

by Kenneth J. Polke, DDS, FAGD, DICOI

Dr. Kenneth J. Polke is a retired NFL quarterback and retired dentist. He is now a professional keynote

speaker and author. Polke is a graduate of Case Western Reserve

Dental School and University of Alabama IV Sedation Residency

Program before teaming up with the Rocky Mountain Sedation Group and Sedation Consult as an adjunct

clinical instructor. He’s also founder and CEO of The Polke Group, which is designed to help doctors through practice

transitions, management and marketing. In addition, Polke provides professional transitions and brokerage services

through Henry Schein Professional Practice Transitions.

10 Considerations of IV Sedation


Farran Media is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of this program provider are accepted by the AGD for Fellowship/Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 1/1/2016 to 12/31/2018.Provider ID# 304396

This print or PDF course is a written self-instructional article with adjunct images and is designated for 1.5 hours of CE credit by Farran Media. Participants will receive verification shortly after Farran Media receives the completed post-test. See instructions on page 103.

AGD Code: 340

Farran Media is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors nor does it imply acceptance of credit hours by boards of dentistry.

94 NOVEMBER 2018 // dentaltown.com


Disclosure:The author declares that neither he nor any member of his family has a financial arrangement or affiliation with any corporate organization offering financial support or grant monies for this continuing dental education program.

Course description This course identifies the advantages

of offering IV sedation to the general public as a routine procedure in the general dental practice and highlights its benefits to the administering practitioner.

Abstract Rare is it to find a dental patient who

does not have some type of apprehension toward an upcoming dental visit. Whether this apprehension ranges from a minimum nervousness to having a full-blown dental psychosis, the causes of these phobias are far too many to mention here.

It is estimated that this fear of the dentist afflicts 40–50 percent of the general public, and if the U.S. has an estimated 330 million people, then it is safe to say that millions of people are not seeking treatment until “it hurts.”

Whatever the reasons, it bears stating that there has got to be a better way for patient and doctor to survive these close, personal times together. This unfulfilled niche in the marketplace should represent a great growth opportunity for every doctor. IV sedation offers a myriad of benefits to these types of patients and their treating doctors alike. Regardless if it is the glowing songs of “not even remembering being in the dental office” or “that was the best dental visit ever,” these are hymns of praise from the typical IV-sedated patient.

Then, when you see new patients referred into your office as a result of these IV-sedated ambassadors of goodwill, the financial bottom line starts to look better and better every month.

Three root canals and three same-day crowns done all in six hours is a

productive day—not to mention the additional IV-sedation fees.

The icing on the cake comes in the form of a less stressful office when comparing a one patient all-day visit versus a day of running around like a chicken with your head cut off, performing “drill ’em, fill ’em and bill ’em”-style dentistry.

Educational objectives 1. Identify patients best served by IV seda-

tion and distinguish those at high risk.2. Understand the parameters and knowl-

edge foundation needed to practice IV sedation.

3. Know the history of sedation drugs, including current options and oral alternatives.

4. Understand current monitoring equip-ment and its usage in assessing patients.

5. Have a broader medical knowledge to apply to all patients.

6. Determine if IV sedation is a practi-cal option for your practice.

An old dental joke goes something like this:

After interviewing a new patient, Dr. Jones states, “Sally, I think that the next time we get together, one of us should take a pill ... and I think it should be you!”

Wouldn’t it be nice if we could offer this service for every patient who either wanted or needed this service? Now, I know there will be critics condemning my glib attitude toward our beloved dental patients who are “afraid” of the dentist, but for many of you, like myself, the glitter of day-to-day dentistry has dulled a bit.

dentaltown.com \\ NOVEMBER 2018 95

Another tool in the toolbox It would be fantastic if we had another

tool in our toolbox allowing us the ability to remove fear from our patients—even some of our more hypersensitive hygiene patients. Many veteran hygienists would welcome this service.

Were it not for the fact you do offer this treatment option, you might gladly see them in your office instead of referring them down the street to the specialist to never be seen again. We must seriously ask ourselves why it is that for some of the simplest and most innocuous procedures performed by physicians, patients are routinely sedated (or so it seems). And yet, dentists who have a stronger need for such a skill set in our toolbox are relegated to second violin in this endeavor.

Historically speaking, we were the kings of anesthesiology. The evolution of anesthesia started first with inhalation anesthesia, followed by local and regional anesthesia and finally intravenous anes-thesia. The first general anesthetic agents were ether (1842), nitrous oxide (1844) and chloroform (1847). How did we lose this

coveted title to our physician brethren? It was a dentist who discovered the

surgical use of nitrous oxide—one of the first known general anesthetics. Although Joseph Priestly, a British engineer and chemist, is really credited for having discovered nitrous oxide in 1772, it wasn’t until 1848 that Dr. Horace Wells, a Hartford, Connecticut, dentist, publicized it as an anesthetic to extract molars on his dental patients.1

Prior to this, from 1772–1848, nitrous oxide was used as a party drug to entertain the rich, where it gained its more affec-tionate name of “laughing gas.” Sadly, Wells died after a prolonged period of self-experimentation to find the perfect anesthetic. He did not receive credit for his achievements in the world of anesthe-siology until 1864, well after his suicide.2 The ADA officially recognized Wells as the first to discover nitrous oxide as an analgesic/anesthetic in 1864. The American Medical Association followed suit in 1870. Is it possible that Wells’ suicide was a premonition for many in our profession?

A method to reduce our stressors Could our zeal to treat every patient to the best of our ability without regard for our

own stress levels and mental health lead to our own demise? Do the words “high suicide rate,” “high divorce rate,” “high drug addiction” and “high depression rates” ring any bells? Does it not make sense to use every advantage we have at our disposal to make every dental visit the most comfortable and stress-free for everyone involved?

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An overview of anesthetics

Today’s modern anesthetic drugs do just that. They can be lumped into two broad categories: Sedatives (anxiolytics),

drugs that reduce excitement and promote calmness without inducing sleep, and hypnotics, drugs that do induce sleep. Hypnotics in larger doses promote general anesthesia.3 The bridge

between nitrous oxide and today’s sedatives/hypnotics was covered through the use of alcohol containing laudanum followed by morphine in 1800, then

bromide in 1857.4 Finally came the introduction of barbital in 1903, within the family of drugs

known as barbiturates.5 Having served their purpose for a full century—were it not for their high dependency rate and low margin of safety—the use of barbiturates

gave way to the family of drugs known as benzodiazepines in the 1950s. Although Leo Sternback is credited with their invention, the widespread use of

chlordiazepoxide (1957), diazepam (1959), lorazepam (1971) and midazolam (1976) did not take hold until 30 years later.

As it became general knowledge that benzodiazepines took much higher doses than alcohols and barbiturates to produce CNS depression, the heightened efficacy, along with a vast increase in their margin of safety, brought these drugs to the forefront. Other benefits of benzodiazepines included less interaction with other drugs, no increase in sensitivity to pain, no loss of permanent short-term memory, very low levels of dependence and a specific antagonist drug—flumazenil—which relegated the barbiturates to a dinosaur drug.6

Another family of drugs within the sedative/hypnotic class, opioids, offered a unique set of properties while sedating patients. Opioids, unlike the “benzos,”

raised the patients’ pain threshold during surgical procedures, offering a new level of comfort.7 This raised pain threshold naturally led to a lower anxiety level, requiring lesser dosages of “benzos.”

In combination, these drugs offer other benefits to patients, in particular those with mild to moderately high blood pressure. A raised pain threshold and a lowered

anxiety level create a patient with lowered blood pressure, due to less sympathetic stimulation. This sets up a lessened backdrop for a cardiac episode. Meanwhile, a patient

with the same underlying medical conditions subjected to only a local anesthetic is even more susceptible to a stroke, MI or cardiac arrhythmias.

What makes the latter situation even more dramatic is not being monitored by an EKG and any such changes going undetected. Similarly, a diabetic patient may best be treated by IV sedation especially for long surgical procedures. The author’s contention here is that a 5 percent dextrose solution used to transfer the “benzos” and opioids to sedate the

diabetic patient is a great advantage in helping to maintain their blood sugar level over this duration of time. A simple finger prick while sedated followed by a blood glucose

check can help to determine the rate of 5 percent dextrose flow.8

Naturally, the previously stated medical conditions and their appropriate strategies were predetermined by a thorough medical exam and presurgery testing.



See a growth in clinical confidence While you should always take a com-

plete medical history in your office, the necessity for a more exacting medical exam, and often consultations with cor-responding and treating physicians, will create an atmosphere for you that will command a respect by the rest of the medical community.

Knowing that you “have arrived” and advanced from the college ranks and are now playing in the NFL places you and your office on a different level.

Until your office is conversing on a routine basis with other medical offices you never feel as though you have come out of your cocoon.

Gain greater patient trust Your medical knowledge (staff ’s knowl-

edge included) will grow tenfold over the next couple of years by providing IV sedation.

Patients will immediately sense a silent but confident air about you and your staff when discussing their medical history and an elevated level of respect for your office versus the typical office norm of “throwing medical history forms” at the patient to be filled out.

Your medical exam will be the poster child for the adage of “the patient doesn’t care how much you know until they know how much you care.”

It is a true sign of respect when a new patient confides in you that they are using some questionably illegal drugs when they know that revealing this kind of information is in their best interest.

Build a well-trained, diverse team Allow me to be perfectly clear, before

going any further, to inform you that IV sedation is both an art and a science. The science comes from excellent training and the art only comes from experience. This concept applies to both doctor and staff. Until my staff was well trained in the area of upper airway management, we decided to outsource the IV sedation procedure to a CRNA provider.

Our experience while under the services of these CRNAs was frustrating at least and horrific at worst. Their use of propofol and their technique of bolusing by hand-syringe made for a roller-coaster ride for both us and the patient. Very little dental treatment

was accomplished, because we were either ventilating the patient through the use of a Bag-Valve-Mask because of oversedation or we were alternately then bolusing by hand-syringe again to get the patient sedated again.

And thus this cycle started again of oversedation to undersedation to overseda-tion and back again. Hence the roller-coaster ride. Finally, my staff refused to work with these CRNAs because of the stress levels they produced. I knew there was a better way and we expedited the upper airway management training needed. And we never looked back.

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A closer look at airway monitoring Pulse oximetry is a mandatory procedure

to measure oxygen levels in the blood, and a mandatory dental sedation monitor. Pulse oximetry depends on the observation that oxygenated hemoglobin and reduced hemo-globin differ in their absorption of red and infrared light. Oxyhemoglobin absorbs more infrared light (990nm), while deoxyhemoglobin absorbs more red light (660nm).

The pulse oximetry monitor can measure oxygen saturation, heart rate, approximate rhythm and approximate perfusion. Unfor-tunately, many patient factors and patient variables will contribute to the difficulty of this goal of well-oxygenated blood during sedation. However, new technology like capnography is making this objective and task easier. The capnography monitor determines the end tidal CO2 to confirm ventilation.

Samples of gas from the mouth and/or nose are continuously suctioned by aspiration capnographs into a cell within this monitor. So even if the pulse oxim-eter is recording well-oxygenated blood at the far extremities the capnography readings (what we affectionately refer to as “elephants”) are an early warning sign of

partial airway obstruction, which will soon lead to less oxygenated blood arriving into these same extremities.

This early warning sign gives the doctor and staff more time to correct and head off the ensuing problem at the pass. My analogy of this relationship is that of a pilot who knows beforehand that his engine is about to conk out and has time to remedy the situation. Thus, your love affair with capnography begins. Hopefully this love affair doesn’t create any problems at home with the spouse. End tidal CO2 monitoring is now considered standard of care for moderate sedation and soon to be made mandatory by all state dental boards.

Much like capnography will keep you out of trouble, your prescreening format should do the heavy lifting in this regard. A major conclusion in your prescreening format should reveal that you and your staff can we manage a patient’s airway.

In other words, is this patient’s airway structure too difficult (too narrow or non- existent) to maintain a patent opening?

Class I–III Mallampati Score: Yes Class IV Mallampati Score: NoYour prescreening format will also reveal

any other medical issues to determine if the patient is medically stable and if preemptive measures should be taken before treatment.



More procedures, more money This expanded medical knowledge base will assist

you should you broaden your horizons into the areas of sleep apnea, implant placement and bone grafting, and not to mention treating older people, who typically present themselves to your office with a laundry list of meds and associated medical conditions.

It is certainly not the intent of this author to give a full IV sedation course in this article. I feel that while encouraging you to seek IV sedation training there are adversities to conquer while becoming competent in this endeavor. While I have cited some of the positives I would be remiss not to lay out some of the negatives.

First and foremost is the cost of training. Most states require 60 hours of didactic and 20 hours of clinical before one can be certified. Additionally, most

states require a physical office inspection along with emergency protocol role-playing before the go-ahead is given. One must include not only the cost of the courses needed but also the time away from the office, along with food, travel and lodging. This can be a sizable waste of money if your past performances have been to learn a new skill and then not promote it.

Marketing your new skill is not only crucial but is your second added expense. Another cost to consider is new equipment, supplies and drugs. Monitors, IV pumps and airway equipment are just some of the required investments to consider. While all of these things can be a daunting task to accumulate, it has been this author’s experience that word of your new-found skill travels fast and your budget can be recovered quickly, sometimes in as little as six to eight months.

Create a referral system unlike any otherThere is a plus side to all of this,

which will not become known to you until you have been providing this level of service for a while. It never ceased to amaze this author how many patients came to our office after seeing a “sedation dentist.”

When asked what was done at the other offices, their typical reply was “nothing” because just taking a pill or

two did “nothing” for them. Their complaint was all that time

wasted and they never were “sedated.” Oral sedation can have a low success rate. Plus, scheduling for oral sedation patients is a nightmare, as you never know when or if a patient will become sedated. The downtime surrounding these patients is a logistical burden.

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6Master a new skill set Upper airway management training

is crucial for both the doctor and staff for successful IV sedation. The primary duty of the doctor and staff uppermost and foremost during IV sedation is to establish and maintain a safe airway for the patient. Optimal vigilance requires

a full understanding of monitors. Now considered old school but still very useful, the observation of skin color, flush lips, conjunctiva and capillary refill have given way to pulse oximetry to determine signs of blood oxygenation necessary by the tissues of a sedated patient.



Practice in peace So, the moment of truth has arrived, and it is time to sedate your patient for a possible

implant placement or perhaps four wisdom teeth extractions or even a periodontal soft tissue graft.

The ease of which you will be able to perform certain surgical procedures on patients under IV sedation versus just local anesthetics will amaze you once you have taken certain precautions, since the sedated patient does not have protective reflexes.

Throat packs tied to floss strings, continuous high speed suction and the use of Isolite retraction are all necessary for the patient’s safety. Much like the use of rubber dams they were a pain to place and required extra effort but once secured they were most definitely facilitators, lifesavers and timesavers.

References 1. Jacobsohn, P. H. “Horace Wells: Discoverer of Anesthesia.” Anesthesia Progress 42.3-4 (1995): 73–75. 2. “Suicide of Dr. Horace Wells, of Hartford, Connecticut, U.S.” Provincial Medical and Surgical Journal 12.11 (1848): 305–306. 3. Johns, MW. “Sleep and Hypnotic Drugs.” Drugs. (1975) 448-478.4. Balme, R. “Early Medicinal Uses of Bromide.” J Royal Coll Physic. 1976; 10: 205-208.5. Ayd, FT. “The Early History of Modern Psychopharmacology.” Neuropsychopharmagology. (1991) 5:71–84.6. Mehdi, T. “Benzodiazepines Revisited.” British Journal Of Medical Practitioners. 2012. 5(1):501.7. Becker, D. “Pharmacodynamic Considerations for Moderate and Deep Sedation.” Anesthesia Progress. 59(1): 28-42.8. Cornelius, B. “Patients with Type 2 Diabetes: Anesthetic Management in the Ambulatory Setting.” Anesthetic Progress. 64 (1) 39-44.

Help those in most need IV sedation will increase your bottom

line by allowing you to not only increase all your fees but the additional sedation fees will significantly increase your hourly rate.

Even state Medicare paid significantly more to help one special needs patient presented to our office by his social worker. This young man entered our office wearing a football helmet and for good reason. As I approached him he became violent by punching himself in the head and face—hence the helmet. We also found out that he had not been seen by a general dentist for 20 years. Upon further discussions and permission from his social worker, who had power of attorney, we devised a

plan for her to occupy his attention while seated in the dental chair. I snuck up from behind with a 50mg IM dose of ketamine through his shirt and into his rear deltoid. This calmed him down enough to start the IV sedation. We later found out from the social worker that no general dentist was willing to treat this young man for any simple dental procedures because they did not know how to best handle his medical condition. The goodwill created by seeing and treating this young man for some simple dentistry was priceless. We all went home that day with our heads held high (plus some publicity and lots of referrals).

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1. Which of the following does not pertain to moderate IV sedation?

A. This added service can be very rewarding

both emotionally and monetarily.

B. Training in IV sedation usually opens the door

to more advanced dental procedures.

C. IV sedation can reduce the stress levels for

patients, doctors and staff.

D. No special training is required for IV sedation.

2. Dental phobics typically are ...

A. Great ambassadors to the office.

B. Fearful due to childhood experiences.

C. Requiring much needed dentistry.

D. All the above.

3. One of the first general anesthetic agents used in dentistry was ...

A. Narcan.

B. Developed by British dentist Dr. Joseph Smith.

C. Flumazenil.

D. Also known as “laughing gas.”

4. Those patients best served by IV sedation on an outpatient basis ...

A. Have a Mallampati Class I airway.

B. Have uncontrolled high blood pressure.

C. Have sleep apnea.

D. Have a Mallampati Class IV airway.

5. While 60 hours of didactic training and 20 hours of clinical training

are required by most states, which of the following is not required

of IV sedation?

A. Special state board certification.

B. Acceptance of Medicare/Medicaid patients.

C. Office inspections.

D. Emergency protocols.

6. Moderate IV sedation has all the following advantages

over oral sedation except ...

A. Greater titration control to desired effect.

B. Faster onset.

C. Cost effectiveness for patients.

D. Addition of additional drugs for postoperative

pain control and postoperative nausea.

7. Moderate IV sedation has all of the following advantages

to my dental practice except ...

A. Increase patient referral.

B. Increase bottom line.

C. Verbal backlash from the medical community.

D. Expert status in community.

8. True or false: The broader medical knowledge gained from

IV sedation training will have no benefit should an unrelated

IV sedation medical emergency occur in the office.

A. True.

B. False.

9. Monitors used in IV sedation are used to determine

all the below except:

A. Blood oxygenation levels.

B. End tidal CO2.

C. Heart rate.

D. Suspected diabetes.

10. Pulse oximetry is used to determine:

A. End tidal CO2.

B. Ventilation.

C. Blood oxygenation levels.

D. Blood sugar levels.

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