Sedation in Vancouver, WA

Hello, my name is Dr. Roman at Pacific Park Family Dental. Today I'd like to discuss a subject that a lot of patients want an answer on, but there's not very many answers online. These are the most searched questions on Google that patients frequently ask. For your convenience, I'll explain everything here so you don't have to go anywhere looking for this information.

Why would somebody need IV sedation in dentistry?

In my practice, I do IV sedation, and a lot of times people need this service in order to feel comfortable and happy at the dentist. Some people come to my practice and as I'm talking to them, I can see them just melting into the chair. I know they're terrified, scared, and not only scared of dental procedures, but they're also afraid of me judging them as a person. What I can tell you is that it's not my place to judge. I see a situation that we need to address, and we're addressing that situation. You are here with me because you need help, and I'm here to give help, and that's as simple as that. Sometimes there is a barrier called "I'm nervous," or "I'm anxious," or "I'm scared of dentistry." How do we tackle this? Thank God there are so many tools in my toolbox that I can give you that will make dentistry easy, pleasant, and comfortable for you. This is as simple as it gets.

What kinds of sedation do we have in our office?

I've been doing sedation for a few years, and I found that nitrous sedation doesn't really work in my hands as well. I see it work, but I never get the result that I want, and my patients don't quite fully feel as comfortable as I want them to feel. So, I shifted away from doing nitrous sedation, but I do a pill form of sedation, a little bit of Halcion. What I do is one pill 1 hour before and another pill at the appointment. It's a little different than most dentists do, but I can do this because I have a lot of agents that can counteract an overdose. I'm licensed in IV sedation, so even if we have a little bit of over sedation with intraoral medication, I can always counteract it quickly. I'm not afraid that somebody will fall asleep in my chair; I can quickly remedy this situation. When a patient comes in and takes that second dose of oral sedation, it's easy for them because they don't remember anything, and it ends up being a comfortable experience. We can place implants, remove wisdom teeth, do root canals, and patients are happy. They fall asleep during the procedure and remember nothing; it's wonderful. For 90% of people, that really works. For the remaining 5% of people, we layer a narcotic on top of that, maybe an oxycodone, to get people into their happy place. We're not trying to put people to sleep; we're just trying to get them to be a little more relaxed so we can do procedures. I want patients to be readily responsive but not asleep. This means that if I tap somebody on the arm and say, "Hey, how you doing, Bob?" Bob will open his eyes, say, "Hey, I'm doing great, thank you for asking," and go right back to resting. I don't want a patient to be non-responsive during sedation; that is too deep for us. We want them to be nicely comfortable but not in deep sleep. The last form of sedation that I do is called IV sedation. This is when I need to control the medications in such a tight fashion that I can drip dose it into your vein. This is maybe 2 or 3% of my entire population that I have to sedate. When a patient is really nervous and I have to get them to this perfect place where they don't remember anything, are not exactly aware of any discomfort, but I can tap them on the shoulder and ask them to take a breath, and they will do that for me. The three types of sedations we do in our clinic are oral sedation with only Halcion, oral sedation with Halcion and a light narcotic added, which will give us a more exaggerated effect of sedation, or we do IV sedation.

Who is a good candidate for sedation?

If you were to come to me, how do you know that you are okay to be sedated? For sedation via a pill, almost anybody works. There are very few contraindications that we need to check before sedating you that way, but 99% of people will do okay being sedated this way. For IV sedation, which is a little heavier, I definitely want to know if everything is under control. Are we going to run into things? Do you have a history of strokes or heart attacks in the last year? I want to know if your doctor approves of me doing some IV sedation. In some cases, IV sedation would even be preferable because of how much less stress it would put on your body. We know that stress, especially emotional stress, can trigger a whole slew of things, and minimizing that really benefits and helps your health in the long run, especially if you have suffered things like a stroke or heart attack. A stressful situation can exacerbate these already problematic situations.

What is the difference between sedation and general anesthesia?

Sedation is not going to sleep. When we say "I want to be completely out and not remember anything," that is general anesthesia. We do not do that, and we don't have to do that to get the same response from the patient. Moderate sedation is good enough because when people wake up from moderate sedation, they don't remember anything. The medications we use will block the memory from forming new memories. As soon as the IV medication goes into the vein, it blocks the memory portion of the brain from creating new memories, meaning that anything that happens will be instantly erased from your mind. It's as if it never happened for you. The difference is we don't have to breathe for you; we don't have to respond for you. In moderate sedation, you're breathing, you're swallowing, you're coughing. If something gets in your throat, you'll cough it out. You have full control over your body; you just don't know it. In general anesthesia, you don't have full control over your body. Someone has to do that for you, and this is why intubation is so important in general anesthesia. We want to protect the airway and be able to control your body to such a degree that we can guarantee success in all aspects of this sedation or anesthesia. In moderate sedation, that is not so important because you, as a person, are doing everything. We are just helping you get through the procedure, and that's the key fundamental difference between those two.

What is nitrous oxide and why do dentists still use it?

Nitrous oxide is a wonderful thing. It was discovered by a guy who was playing with gases and realized he could get "drunk" off this particular gas with no hangover. It comes quickly and evaporates quickly, and this is how nitrous oxide was discovered. It started being employed in dentistry a long time ago, and as a sedative agent, we've been doing this for decades now. A lot of dentists still use nitrous oxide because it is so great. It has a quick onset and quick release, and people can drive after that. In my hands, I've done nitrous oxide, and I wasn't really pleased with the results that I got out of it. It is much easier and cheaper for the patient just to have an intraoral type of drug sedation, and that way, they don't have to pay for it. The only cost that the patient incurs with this type of sedation is the cost of the pill, which is maybe five bucks at the drugstore.

How does oral sedation work in dentistry?

The way oral sedation works is that when you take that medication, it reaches your blood system over the course of about 30 minutes to an hour. When I have my patients come into the office one hour before, and they take that first dose of Valium, let's say, I can see after 30 minutes they're starting to get a little off balance. They're still responsive, but it looks as if they had a few glasses of wine to drink. Then, the second dose, when they have it an hour later, they really get comfortable. They're still plenty responsive, I can talk to them, and they are coherent. It's just that nothing bothers them anymore. They're not scared, they're not nervous, they're in more of a light-hearted mood. They joke around a little bit easier, and that's why the whole dental appointment goes a little bit smoother because things are not as serious all of a sudden, and they're not as terrified. There's no anxiety. For people that this approach doesn't really work yet, or they need a little bit more, we do recommend IV sedation, a moderate IV sedation, so we can add a few more drugs to this cocktail so they feel even more comfortable.

What is IV sedation in dentistry, and when is it recommended?

IV sedation, as we mentioned before, is when we install an IV into your arm and we're able to control the exact dosage. How do we know how much you need? There is approximately a standard dose that goes for height and weight. We calculate these parameters at the start. We don't put you all the way down until you are nonresponsive. No, we give you a little tiny dose that we know is going to get you relaxed but not fully sedated, and then we wait maybe five minutes. As these drugs start to work in your system, you will start slurring speech, getting more relaxed, your eyes will start to drift, and a lot of my patients say, "Oh, hey, the ceiling is moving," or "The room is spinning." When I hear these phrases, I know that we're so close. Once we're at that threshold, I know I just need to give them a tiny little bump, just a tiny bit, a drop of medication, and then pretty soon their eyes roll back, they're relaxed, they're breathing on their own. All I have to do to get them out of that nice daze is tap them on the shoulder and say, "Hey buddy, how you doing, is everything fine?" Typically, they look at me, they smile, and they go right back to relaxing. That's perfect. That's when I know that sedation has been done well. I can start my work, and typically, even if you pinch the patient or give them a shot, it's not noticeable. They don't really respond, they don't remember the discomfort, they're in their happy moment. You don't mess with it, you just do your dentistry, and it gets done well.

What kind of drugs do we use for IV sedation?

Principally, we use two drugs for moderate IV sedation. This is the bread and butter. We use a little bit of Fentanyl and a little bit of Midazolam. Fentanyl gets a bad rap. Why does it get a bad rap? Of course, Fentanyl is on the street killing people. What's happening? Yes, Fentanyl is so potent, it's such a potent drug that we don't measure it in milligrams. We measure everything in milligrams: antibiotics, other drugs, Midazolam, one of my sedation drugs. But Fentanyl, we measure in micrograms, which is a thousand times smaller than a milligram. Why? Because the effect it has on the mind, on the central nervous system, can suppress your breathing so quickly if you're not careful with it. This is something that people don't understand on the street; they just sell it like candy, and you can't. It's a powerful, powerful drug. You absolutely need to dose it right, and we've been trained how to dose it. This is why we don't overdose on these things. We know exactly how much to give. You give approximately 20, 30, 40, sometimes 50 micrograms and see how the person responds. What you're waiting for is a gentle relaxation, for the person to feel a little bit of euphoria, to feel relaxed and happy, and the nerves and the stress go away. You know that what you're doing is correct and it's working. Fentanyl is the "feel-good" drug, and Midazolam is the "forget your worries" drug. Once the Midazolam is administered, you will not remember anything that happened. But those two separate drugs, when mixed, create a synergistic effect. What that means is that if the effect of Fentanyl is this much, and the effect of Midazolam is this much, together it's more, without the suppression of your breathing. So, you will still breathe totally fine through sedation. But because those two drugs are working on different receptors in your head and in your central nervous system, you get a more profound relaxation and a more profound sedative experience. That's a wonderful way to do it, and this is why we do it this way, and we have fantastic success. Moderate sedation is one of the safest types of sedation to do. I don't think there are any deaths that have been recorded from moderate sedation, unless of course the dentist mismanaged the medications. That's a different story. However, from doing proper moderate IV sedation, I don't think there are any recorded deaths due to that.

Is IV sedation safe and is it okay for everybody?

Is it okay for children? Let's say you have a 10-year-old you'd like to sedate. It is safe for children; however, in our practice, we stay away from children. Children are a totally different breed of human beings. We don't touch them with IV medications. They need to go to a specialist for that because they're young and precious, and we want to protect their health. I feel like there needs to be somebody more qualified to do it. I want somebody with experience to do it because the child's body is not like a small adult. They have a different metabolic rate, they have a different tolerance to drugs, and I want someone who can handle that better. I don't feel like I would want to take that on myself. That's why I give it to someone who is more qualified to do that. Anybody who's 14 and older, their bodies are more adult and their metabolic rates are more predictable. I know exactly how my drugs will react in their systems. I can do that totally fine.

How does pediatric sedation dentistry differ from adult sedation dentistry?

When we're sedating an adult, we know that all the systems have been developed and they work in a more predictable fashion. This is what makes moderate IV sedation dentistry or moderate IV sedation so predictable, easy, comfortable, great, and successful because adults more or less function within the same rate of metabolism. They all sort of work in a similar fashion. When it comes to kids, kids' bodies are so much smaller, and their reactions to medications can vary so much greater that it makes the sedation unpredictable. What you want for children's sedation is a specialist. You want an anesthesiologist to do that sedation because if that tiny body decides to throw a wrench in the works, we need someone who knows how to rescue that particular project. We want to know that someone is able to handle the situation. When a person is an adult, that almost never happens because the way an adult body works with medication is much more predictable.

Are there any risks or side effects associated with sedation dentistry?

Yes, there are always risks. There are always risks that a sedation medication will cause an opposite reaction. It has been documented that sometimes Midazolam causes more irritation. I have had doctors tell me that they injected a person with this particular medication, and they got really, really irritated and left. Was the sedation done inappropriately? No, sometimes the medications that we use cause a different effect, not a sedative effect. They cause a completely opposite reaction. It has been documented; that's one of the risks. Another risk is that if we have a small person and we dose them a little bit more, we can have over sedation. It means that we're going from moderate to a deeper form of sedation. The typical cure for that is to stop, observe the person, make sure they're breathing, wait 30 minutes, and everything will normalize. However, these risks, when they're accounted for, can be mitigated, well handled, and balanced, and things go great.

What can you expect during a dental procedure with sedation dentistry?

Typically, my sedation appointments run like this: a patient comes in a little bit nervous, so we banter a little bit, talk, and I ask them what I can do to make them less nervous. If I can get them some water, it's okay to have a little bit of water before sedation. It's not okay to eat, but it's okay to have clear liquids. So, we talk a little bit, and then I install an IV. This process takes usually five to 10 minutes, and once they're happy, they've asked all their questions, and they feel like I've answered everything, we inject some drugs into the vein and start our process. We start slowly, I give a little bit of medication and see how it works, see that everything is going according to plan. Once I see that smile, once I see that the nerves are gone and anxiety has ceased, I can start getting them to a place where they are not going to remember whatever I do. Once I know that they're there, the typical sign is complete relaxation, even breathing, and eyes rolling back into the back of their head, just kind of nice and relaxed. I know that we're okay to start, and I also know that the patient is breathing on their own and they're going to be totally fine. If they need to address something to me, I just tap them on the shoulder, they will tell me something if necessary, or they'll cough something up. Totally okay because they're in full control of their body; they're just not going to remember it. Once they're sedated, we do our dentistry, and then typically, once we are done, I can see them starting to move around a little bit more, we remove the IV, set them up, and say, "Okay, we're done." The typical response I get is, "Oh wow, when did we start?" That's how you know that they don't remember anything. Typically, that memory wipe medication actually works a lot longer than you expect, so patients actually come to my post-op appointments after sedation and say, "Oh, I only started understanding what's happening to me once I was home in my bed." That's it. I even had one patient whose wife took him grocery shopping after we removed his wisdom teeth and did a sedation appointment all at the same time. Everything went so great, the wife was like, "Oh, he's fine to go grocery shopping," and they went grocery shopping. It was very interesting to hear that he started understanding that he was in the middle of a grocery store, and that's how he came to, basically, in the middle of a grocery store. Imagine waking up being surrounded by people and produce. That's one interesting way to wake up.

How does laughing gas or nitrous oxide make you feel at the dentist?

It usually makes you feel like you've had a glass of wine, but that's it. It's not going to help with any discomfort or pain. If you're feeling nervous, you're still going to feel a little bit nervous, but at least it's kind of muted, let's say.

How long does it take for nitrous oxide to wear off?

Within a minute, as soon as the gas stops, it wears off.

How long does it take for IV sedation to wear off?

It really is dependent on the dose that we give you. As long as the dose is within the normal range that we have given you, it takes about an hour to wear off completely. But the patient is responsive; they can walk, they can be totally functional right after we set them up. We don't give a lot of sedation for that specific reason. We don't want a patient to be completely out of it when we are done. We want the patient to forget what we've done but be sort of there and functional so they can get out of the chair, get to their car, and go home happily.

Can you request sedation for your dental procedure?

Yes, absolutely. We just have to know a little bit in advance. We have to know if we need to do any medical clearances, we have to instruct on how to do it. It's hard to do sedation the same day. We have done it in individualized cases where, let's say, somebody comes in, they haven't eaten today, and they want their wisdom teeth out, and it happens that the stars line up, they're perfectly healthy, and they're ready to go. Okay, that's totally fine, we can do it today. Usually, it happens very rarely, but if you tell us in advance, we can prepare you and get you in for a sedation procedure, and then whatever needs to be done alongside with that can be done.

Can sedation be used for all dental procedures?

Yeah, pretty much. You just have to let us know that you want this service. A lot of times, just to save people money, I tell them what I think. For example, let's say a person comes to me and they tell me, "Hey, I really want a cleaning, but I'm so terrified. I think I need IV sedation." I'll tell you outright, "Listen, I'm happy to sedate you. I just think it's a little bit of a waste of your money. How about we try the oral sedation? I'll give you some medications, you come in, I'll do a mild cleaning. If it works for you, boom, you saved a thousand bucks at least. That way, you can spend it on your next vacation. How about that?" Rather than treating everything as if you have a hammer, everything looks like a nail. I don't want to treat everything with a hammer. I don't want to sedate everybody. I want to use the right tool for the right cause. If you need something light and I know that it's okay to give you some oral sedation, that's the way we will go, and I will advise you to do that. I'll be honest with you. If it's something serious like wisdom teeth, multiple implants, or some heavy surgery that we have to do, and you are afraid, and I know that if we give you oral medication, it's not going to do as much as we need for you to be comfortable throughout the entire procedure, then I'll tell you that. First and most of all, I seek to be completely transparent with my patients. I'll tell them, "Hey, this is how it works, this is what I think, and this is what we should probably do. We can try out with something small and then see how you do further on. If we need to make adjustments, we'll make adjustments. It's not a big deal."

How do you prepare for a sedation appointment?

We tell people to always get a good night of sleep. Sleep is such an important thing. When people haven't slept before an appointment, it feels like my numbing medication doesn't work as well. Not being stressed and being well-rested is just so important for a good dental appointment. Let's say you're really nervous and now you're also nervous to the point that you can't sleep. Don't let it stress you out. We will work around whatever you bring to us in the morning, and we'll just go with it. We'll roll with the punches; it's okay, that's what we do. We want you not to eat anything before IV sedation. Clear liquids are okay. It's okay for you to have dinner, but about 8 hours before the procedure, we don't want you to have any milk, any yogurt, only clear liquids. Apple juice and water are okay, but no food, please. Also, we don't want you to smoke any pot. Some people do that, thinking it will give them a more pronounced sedative experience, but don't do that. It will just mess with my medications, and we don't want that. Also, don't drink. Please don't drink for a few days before you're getting your sedation. Alcohol really messes with my medications. I can actually tell when a person is a heavy drinker or a heavy drug user because it just takes so much more dosing just to get them to their happy place. So yes, don't do that, please.

What should you do if you have concerns regarding the safety of sedation dentistry?

If you have concerns regarding the safety of sedation dentistry, how it's done, or you just want to talk about it, you can always call me or come into my practice for a short consult appointment and ask these questions. These are the questions that people ask me every single time for sedation, and we discuss this with every single patient. We don't want this to be some sort of black magic thing that we do that you know nothing about. No, we want this to be easy, transparent, and nice. When you're going into it, you know exactly what you're signing up for and you know exactly what you're about to get. In the end, it's a positive experience for you, and that's the bottom line. Dentistry has to be pleasant, easy, and comfortable. If it requires IV sedation, it just requires IV sedation. It's not a big deal.

I hope I was able to lay some confusions to rest regarding IV sedation and IV sedation dentistry, how it's done, what it entails, and if there are any risks or not. If you would like to talk a little bit more about this, have any more questions, or just need to see me for any reason, do reach out to me at (360) 803-3546. Somebody will be with you, and I will make sure that this whole meeting happens. All right, take care.