Moderate Sedation with Nitrous Oxide and Benzodiazepine
Moderate sedation: Dentistry has long been associated with pain, fear and anxiety. Fortunately, most of the general population in North America are slightly to somewhat afraid of dentistry, but over 5.5% are highly phobic about dental treatments. 15% of the people are interested in having sedation during a dental visit.
We all know that anxiety affects pain perception, decreasing the pain threshold. The bottom line is that we try to make our patients at Affinity Dental Care feel more comfortable and painless.
How we make our patients more comfortable
The first step is to ensure our patients do not wait too long in our waiting area before seeing them in the treatment area. Our policy is that we do not make our patients wait longer than 10 minutes once they are in the clinic. In fact, 95% of our patients do not need to wait longer than 5 minutes. Besides valuing our patients’ times, we also know that the long wait in a dental office can increase anxiety during the waiting period due to the prolonged activation of the hypothalamic-pituitary-adrenal (HPA) axis in an increase in stress hormone like cortisol release. The longer the patient waits, the more cortisol is circulating in the body, further increasing the signs of anxiety like fast heart rate and heavy breathing.
The colour tone of our walls is calm and soothing. We have windows in all our treatment areas that allow natural light to come in and a nice view of the outside.
We like to tune in to lovely scenery of different countries or videos of fish swimming in the coral reef on our TV while playing soothing music instead of radio stations playing loud music.
Having patients take pain killers right before the appointment can positively reduce pain and soreness. We always apply a topical numbing gel to the injection site before freezing. The freezing technique is crucial, giving the freezing steadily, slowly with acupuncture/vibration, reducing or eliminating the pain from the needles.
We help our patients understand the process
Patients not knowing the treatment process and what to expect can add more anxiety to an already stressful situation. In light of this, a preoperatory consultation can help assess the patient’s medical conditions, previous history of dental treatments tolerance, and psychological conditions. The proposed treatment process can be shown and explained during the exact consultation. When the patients understand the process and feel confident about the dentist, they feel more comfortable and less anxious. It is equivalent to sitting in the dark versus in a well-lit environment.
Our office has no experience with and does not offer other anxiety-reducing modalities like acupuncture and hypnosis. According to our research, both are unpredictable in achieving the end goal – only works sometimes.
Notwithstanding the earlier armamentarium, certain patients may need moderate sedation either because they are petrifying with dentistry or have cardiovascular disease that cannot be stressed further during the dental procedure.
The cornerstone of moderate sedation
The use of benzodiazepine and nitrous oxide is the cornerstone of moderate sedation. We use one of those agents or both together to help to calm and sedate our anxious patients. Nitrous oxide, also called laughing gas, can be used alone to reduce stress and analgesic effect during the treatment.
The gas is non-irritating, sweet-smelling, colourless. It has a high margin of safety, and it is safe for patients who have impaired liver or kidney functions. The gas is delivered via a nose piece sitting on the patient’s nose. Despite its high safety level, there are specific contraindications for using the gas on some patients who are:
- Inability to tolerate a nasal hood for an extended time
- Un-cooperative children
- Claustrophobic patients
- Inability to breathe through the nose
- Patients with severe COPD (Chronic obstructive pulmonary disease)
- Pregnancy in the first trimester
- Bleomycin chemotherapy within the last past year
Oral sedation with a benzodiazepine can be used alone or in conjunction with nitrous oxide gas. The drug of choice in Affinity Dental Care is Triazolam (Halcion) for adults and Midazolam (Versed) for children. Both are sedative and anxiolytic (anti-anxiety). They both have a short effect and are relatively safe to be used in patients with compromised liver function.
The patients cannot eat or drink anything eight hours before the oral sedation. Because of that, we usually book the patients in the morning for sedation. The patient cannot drive or engage with activities with attention and sobriety for at least 24 hours after.
When both oral sedation and nitrous oxide are combined, the patients become very relaxed and can fall asleep. However, we only administer the medications to the level that the patients remain conscious when they are in the office. Besides following all the conscious sedation protocols closely, other safety measures like vital sign monitoring of the patients are on when the patient is under treatment.
At Affinity Dental Care, we want to ensure our patients are safe and have the least amount of anxiety during dental treatments.
