November 2011
Volume 22, Number 11
EDITOR Arun K. Garg, DMD; Editor in Chief EDITORIAL ADVISORS Editor Emeritus: Morton L. Perel, DDS, MScD Renzo Casselini, MDT, Professor of Restorative Dentistry, Loma Linda University, Loma Linda, CA Leon Chen, DMD, MS, Private Practice in Periodontology, Las Vegas, NV Scott D. Ganz, DMD, Private Practice of Prosthodontics, Maxillofacial Prosthetics and Implant Dentistry, Fort Lee, NJ Zhimon Jacobson, DMD, MSD, Clinical Professor, Department of Restorative Sciences/Biomaterials, Boston University Jim Kim, DDS, MPH, MS, Private Practice of Periodontics, Diamond Bar, CA Robert E. Marx, DDS, Professor of Surgery, Chief, Oral & Maxillofacial Surgery Peter Moy, DMD, Private Practice, West Coast Oral and Maxillofacial Surgery Center and Center for Osseointegration, Los Angeles, CA Myron Nevins, DDS, Associate Professor of Periodontology, School of Dental Medicine, Harvard University, Boston, MA H. Thomas Temple, MD, Professor of Orthopedic Surgery and Director of University of Miami Tissue Bank, University of Miami School of Medicine Miami, FL
The official publication of the American Dental Implant Association
The Use of Sedation in the Dental Outpatient Setting: A Web-based Survey of Dentists Jason H. Goodchild, DMD Clinical Associate Professor, Department of Oral Medicine, University of Pennsylvania School of Dental Medicine; Clinical Assistant Professor, Division of Oral Diagnosis, Department of Diagnostic Sciences, New Jersey Dental School; Private Practice, Havertown, PA
Mark Donaldson, PharmD, FASHP
Director of Pharmacy Services, Kalispell Regional Medical Center, Clinical Professor, School of Pharmacy, University of Montana; Clinical Assistant Professor, School of Dentistry, Oregon Health & Sciences University.
There were 7,276 e-mail requests sent to dentists in the United States and Canada requesting participation in a short web-based survey to update earlier information regarding the use of dental outpatient sedation. Participants were questioned regarding their use of dental outpatient sedation, including the frequency of use, type of sedation used, route of administration, medications used, physiologic monitoring employed, and availability of antagonist medications and an automated external defibrillator. In comparison to earlier studies, the use of outpatient dental sedation continues to change. The use of enteral sedation may be increasing, but now is differentiated by minimal and moderate sedation with different training requirements. The use of parenteral sedation by practitioners also appears to be increasing. Introduction n-office sedation by dental practitioners is a popular subject, as highlighted by the passage of updated Anesthesia Guidelines by the American Dental Association (ADA) in 2007.1 In addition, during the past 10 years, dental enteral sedation has garnered renewed attention as a result of highly marketed continuing education courses targeting non-anesthesia-trained dentists (defined as receiving limited or no anesthesia training as part of a formal residency program).2-7 Safety concerns focusing on adequate training, patient selection, and emergency preparedness are ubiquitous regardless of the type of sedation or anesthesia provided.8-16 It is no surprise, then, that all 51 United States Dental Boards have specific rules and regulations to address the training required for the provision of in-office sedation and anesthesia.17 Definitions of the level of sedation are provided in Table 1.1
I
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74 Table 1: The Levels of Sedation1 Level of Sedation
Definition A minimally depressed level of consciousness, produced by a pharmacological method, that retains the patient’s ability to independently and
Minimal Sedation
continuously maintain an airway and respond normally to tactile stimulation and verbal command. Although cognitive function and coordination may be modestly impaired, ventilatory and cardiovascular functions are unaffected. A drug-induced depression of consciousness during which patients re-
Moderate Sedation
spond 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 is usually maintained. A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or
Deep Sedation
painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. A drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently
General Anesthesia
maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or druginduced depression of neuromuscular function. Cardiovascular function may be impaired.
Despite modern techniques and equipment, anxiety and fear of dental care remain pervasive throughout the general population.18-21 As a result, a large number of individuals may not seek dental care regardless of pain or infection. Studies have consistently shown that anxious or fearful patients may seek care if sedation was offered, and many current patients may prefer sedation if it were a treatment option.4,6 Non-anesDental Implantology Update™ (ISSN 10620346) is published monthly by AHC Media, a division of Thompson Media Group LLC, 3525 Piedmont Road N.E., Building Six, Suite 400, Atlanta, GA 30305. Telephone: (404) 262-7436. Periodicals Postage Paid at Atlanta, GA 30304 and at additional mailing offices. The statement of ownership will appear in the November issue.
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thesia-trained dentists have historically dealt with procedural anxiety and fear by both pharmacological (e.g., local anesthesia, nitrous oxide and oxygen analgesia) and nonpharmacological means (e.g., iatrosedation). Recently, several surveys have tried to quantify the prevalence of outpatient sedation use by dentists.18,22-26 Additionally, the ADA conducted a survey on the use of inoffice sedation and published its findings in Subscription rates: U.S., $599 per year. Add $17.95 for shipping & handling. Students, $320 per year. To receive student/resident rate, order must be accompanied by name of affiliated institution, date of term, and the signature of program/residency coordinator on institution letterhead. Orders will be billed at the regular rate until proof of student status is received. Outside U.S., add $30 per year, total prepaid in U.S. funds. Discounts are available for group subscriptions, multiple copies, site-licenses or electronic distribution. For pricing information, call Tria Kreutzer at 404-262-5482. Missing issues will be fulfilled by customer service free of charge when contacted within one month of the missing issue date. Back issues, when available, are $100 each. For 18 continuing education units, add $96 per year. Opinions expressed are not necessarily those of this publication. Mention of products or services does not constitute endorsement. Clinical, legal, tax, and other comments are offered for general guidance only; professional counsel should be sought for specific situations. Copyright © 2011 by AHC Media. Dental Implantology Update™ is a trademark of AHC Media. The trademark Dental Implantology Update™ is used herein
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2008.27 In all cases, the results indicate that a large number of non-anesthesia-trained dentists are performing in-office sedation by various means. The purpose of our survey is to update the results from these previous studies examining the use of outpatient dental sedation. Methods Our survey questionnaire was designed to model the questionnaires used in previously published studies.18,22,26,27 The online survey site, www.Zoomerang.com, a subsidiary of MarketTools, Inc., was used to design the questionnaire, host the survey, and collect the responses. Potential respondents were asked via e-mail to participate in a short web-based survey focusing on dental sedation; participation was voluntary with no remuneration. All responses were anonymous. Respondents were asked to answer multiple choice questions pertaining to their use of outpatient dental sedation. Percentages were calculated based on the number of respondents to each question; in some cases, respondents could check multiple answers. For example, one of the questions read, “What type(s) of sedation do you use on patients in your primary dental practice? Check all that apply.” Limited demographic information was collected, including current office size, the primary practice state or province, age group, and year of graduation. Three separate e-mail blasts were sent throughout Canada and the United States to the same 7,276 dentists, each one week under license. All rights reserved. Reproduction, distribution, or translation of this newsletter in any form or incorporation into any information retrieval system is strictly prohibited without express written permission. For reprint permission, please contact AHC Media Address: P.O. Box 105109, Atlanta, GA 30348. Telephone: (800) 688-2421. Executive Editor: Shelly Morrow Mark, (352) 351-2587, (
[email protected]). Managing Editor: Leslie Hamlin, (404) 262-5416, (
[email protected]).
November 2011
75 Table 2: Prevalence of Sedation in Primary Practice Do you do use sedation on patients in your primary practice? Responses
Percentage
Yes
542
75.70%
No
174
24.30%
Total
716
100%
Table 3: Interest Level in Providing Sedation If you do not currently use sedation in your primary dental practice, are you interested in doing so? Responses
Percentage
Yes
46
26.44%
No
128
73.56%
Total
174
100%
Responses
Percentage
General Practitioner
396
73.06%
Oral Surgeon
46
8.49%
Pedodontist
40
7.38%
Periodontist
31
5.72%
Endodontist
20
3.69%
Dental Anesthesiologist
5
0.92%
Prosthodontist
4
0.74
Total
542
100%
Table 4: Types of Training Which of the following descriptions best defines your training?
Table 5: Frequency of Sedation Use in Primary Practice Compared to 2008 Survey27 How often do you use sedation on patients in your primary practice per month? Responses
Percentage
ADA 2008
Once or less often
114
21%
18.1%
2-5 times
166
30.6%
35.7%
6-10 times
84
15.6%
19.7%
11-20 times
64
11.8%
12%
21-50 times
69
12.7%
8.6%
More than 50 times
45
8.3%
5.9%
Total
542
100%
100%
apart. The list of e-mail addresses was compiled by the authors. The sample population was composed of ADA members, Academy of General Dentistry (AGD) members, and non-members, including both specialists and general practitioners. Data collection took place during the month of May 2009. Participants, limited by internet protocol (IP) address, could only complete the survey once. The study was submitted to the University of Pennsylvania Institutional Review Board and was granted exempt status.
Results Of the 7,276 e-mails sent, the total number of completed surveys was 716, for an overall response rate of 9.84%. When asked if the practitioner used sedation in their primary practice, approximately 76% (n = 542) answered “yes” (Table 2). Of the 24% (n = 174) who responded that they did not practice sedation in their primary practice, 74% (n = 128) were not interested in providing sedation to their patients (Table 3). General practitioners were the most common group using sedation, when broken down by level
November 2011
of training, accounting for 73% (n = 396) of respondents. Six other specialty groups completed the survey, listed by decreasing frequency: oral surgeons, pedodontists, periodontists, endodontists, dental anesthesiologists, and prosthodontists (Table 4). When asked to quantify the frequency of use, 30% (n = 166) of respondents noted using sedation 2-5 times per month. Table 5 shows the distribution of sedation type among respondents. The most common type of sedation provided was nitrous oxide and oxygen (77%), and the least common was general anesthesia, which was provided by only 10% of respondents (Table 6). Regarding route of administration, inhalation was the most common (75%) and parenteral (e.g., intravenous) was the least common (30%), as seen in Table 7. When asked what type of physiologic monitoring was used during sedation, the two most common responses were blood pressure monitoring (84%) and pulse oximetry (81%). Five percent of respondents reported using no physiologic monitoring equipment during sedation procedures (Table 8). An automated external defibrillator was available in the offices of 64% of respondents (Table 9). When asked about training, 67% responded that they had taken a training course specifically focusing on enteral (i.e., oral) sedation (Table 10). The most common drug class used for enteral sedation by respondents were benzodiazepines (90%). When asked to specifically list the most common drug used, the most frequent response was triazolam, as seen in Table 11. Relating to medications, 75% of respondents reported carrying antidotal drugs (e.g., flumazenil, naloxone) as a part of their medical emergency kit (Table 12). When asked to list memberships in dental organizations, the most common groups represented were the ADA (90%) and the AGD (46%). Table 13 lists all of the other member organizations reported by the respondents. Fifty-six percent of respondents were between the ages of 41 and 60 years of age (Table 14). Table 15 shows the number of operatories in the respondents’ primary practice. Our survey had respondents from Dental Implantology Update™
76 Table 6: Types of Sedation Employed in Primary Practice What type(s) of sedation do you use on patients in your primary dental practice? (Check all that apply) Nitrous Oxide & Oxygen
77%
Minimal Enteral
57%
Moderate Enteral
40%
Moderate Parenteral
22%
Deep Sedation
13%
General Anesthesia
10%
Table 7: Routes of Administration of Sedation Employed What route(s) of administration do you use for sedation? (Check all that apply) Inhalation
75%
Enteral (eg, Oral)
69%
Combination Enteral and Inhalation
44%
Parenteral (eg, Intravenous)
30%
Table 8: Types of Physiologic Monitoring Employed What types of physiologic monitoring equipment do you use during sedation in your primary dental office? (Check all that apply) Pulse Oximetry
81%
Blood Pressure Monitoring
84%
Capnography
9%
Co-Pulse Oximtetry
5%
Bispectral Index Monitoring (BIS)
2%
Electrocardiogram (EKG)
16%
Precordial Stethoscope
2%
None
5%
Table 9: Prevalence of AED Availability Do you have an AED (automated external defibrillator) in your office? Yes
64%
No
36%
Table 10: Prevalence of Enteral Sedation Training Have you taken a training course specifically focusing on enteral sedation? Yes
67%
No
33%
Table 11: Classes of Drugs Most Often Used for Enteral Sedation Focusing on enteral sedation, what class of drugs do you most often use? Benzodiazepines
89.6%
Opioids
4%
Barbiturates
0.4%
Antihistamines
3%
Alcohols (e.g., Chloral Hydrate)
3%
43 of 51 U.S. states and three Canadian provinces. The only U.S. states with no respondents were Alabama, Alaska, Hawaii, Louisiana, Mississippi, North Da-
kota, Rhode Island, and Vermont. The three Canadian provinces with respondents were British Columbia, Alberta, and Ontario.
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Discussion The current survey is a follow-up to earlier published studies investigating the use of outpatient dental sedation.18,22-27 The most recent ADA survey from 2008, in particular, served as a model to specifically reexamine some of the most pertinent questions for comparative purposes (see Tables 2, 3, 5, 6, and 7).27 Our results showed that 76% of respondents reported using sedation in their primary practice, as opposed to only 38% of respondents in the ADA’s survey. For those who responded that they did not do sedation but were interested in doing so, the results between the current survey and the ADA’s results were more congruent at 26% to 16%, respectively. The major difference between the two surveys is the response rate. The overall number of responses for the ADA survey was 2,131 vs. 716 for this study. In both cases, requests for participation were sent to ADA-member and non-member dentists, including general dentists and specialists. In our case, requests were sent via e-mail, yielding a response rate of 9.84% vs. the more traditional mailed survey methodology employed by the ADA, which yielded a 40.2% response rate. The most common respondent in this survey reported being a member of the ADA (90%), but no such data are available from the ADA survey. The respondents who reported using sedation in their primary practice were most commonly general practitioners. Although individuals from six other specialty groups completed the survey, the number of respondents in these categories was very low. Table 16 shows the type of sedation utilized by the different specialty groups. It is not surprising that the most common type of sedation used by dentists in the survey was nitrous oxide and oxygen (Table 6). Despite the ADA’s Anesthesia Guidelines, there are 40 United States dental boards that do not require an additional permit or training after dental school to provide nitrous oxide and oxygen.17 As regulations specifically addressing enteral sedation (minimal and moderate) continue to evolve, the use of oral sedatives has decreased, according to previously published information (Table 17). At the time this was written, seven U.S. states had no November 2011
77 Table 12: Prevalence of Pharmacological Antagonist Availability Do you presently carry antidotal drugs (e.g., flumazenil, naloxone) as part of your medical emergency kit?
Yes
75%
No
25%
Table 13: Membership in Professional Organizations Which of the following professional organizations do you belong to?
Responses
Percentage
American Dental Association
519
90%
Academy of General Dentistry
267
46%
American Dental Society of Anesthesia
70
12%
American Society of Dental Anesthesia
35
6%
American Academy of Oral and Maxillofacial Surgeons
47
8%
American Academy of Periodontology
27
5%
American Academy of Pediatric Dentistry
29
5%
American Association of Endodontics
19
3%
Dental Organization for Conscious Sedation
19
3%
Table 14: Age Demographics of Participants What is the age demographic in which you fit? 20 to 30 years old
4%
31 to 40
24%
41 to 50
28%
51 to 60
28%
61 to 70
13%
Over 70 years of age
3%
Total
100%
Table 15: Number of Operatories in Primary Practice How many operatories do you have in the office in which you primarily practice? 1-5
67%
6-10
29%
10-15
3%
16-20
1%
> 20
1%
Total
100%
regulations for the provision of either minimal or moderate enteral sedation, and only five had regulations for both minimal and moderate enteral sedation. When comparing other recent studies on the use of outpatient dental sedation, the use of nitrous oxide and oxygen appears to be stable (Table 17). This study may represent a change with respect to the use of enteral sedation (40% vs. 69%), and parenteral sedation, which has doubled (15% vs. 30%) in comparison to the ADA’s survey in 2007. While only 50% of respondents from the AGD sur-
vey in 2007 reported using oral sedatives, 67% responded “yes” to an earlier question in the same survey asking, “Do you prescribe sedative medication(s) for your patients to take before they come to your office?” Two questions later, respondents are asked, “Do you use oral sedatives?” Fifty percent responded yes and 38% responded no. This question, as written by the AGD in January 2007, can be interpreted differently and, therefore, may have been confusing to respondents. For example, the question may be interpreted as using oral sedatives for anxiolysis, oral
November 2011
conscious sedation, or both (updated terms as per the October 2007 ADA Guidelines for “anxiolysis” is now “minimal sedation”; “conscious sedation” is now “moderate sedation”). Similarly, if the respondents of the ADA survey, completed in 2007 and published in 2008, only performed anxiolysis (again, now termed minimal sedation), the question, “Do you use sedation on patients in your primary practice” may be confusing and yield a false-negative response. Anxiolysis, by definition, is the diminution or elimination of anxiety. It is not commonly considered sedation; however, it still can include the use of pharmacological means, such as oral sedatives. Comparing this study with the Dental Products Report (DPR) survey from 2003 and the AGD survey question, “Do you prescribe sedative medication(s) for you patients to take before they come to your office,” as described above, the frequency of enteral sedation use is 69%, 68%, and 67%, respectively. In addition, comparing the results from the AGD survey to this study concerning the use of combination inhalation and enteral sedation, the positive response rate was 46% to 44%, respectively, whereas it was only 24.4% in the ADA’s 2008 survey, as shown in Table 17. The two most common types of physiologic monitoring equipment used by the respondents are blood pressure monitoring and pulse oximetry. This is not surprising given that the most common types of sedation provided are nitrous oxide and oxygen, minimal enteral, and moderate enteral. In each of these situations, blood pressure monitoring, together with pulse oximetry, would be considered appropriate. Five percent of respondents reported using no physiologic monitoring equipment during sedation. For all types of sedation, with the exception of nitrous oxide and oxygen and minimal sedation, this is inappropriate and below the accepted standard of care. Although continuous physiological monitoring may not always be required for nitrous oxide and oxygen or minimal enteral sedation, pre-operative assessment of blood pressure and pulse is needed; pre-operative assessment of oxygen saturation, as measured by the pulse Dental Implantology Update™
78 Table 16: Relationship Between Training and Types of Sedation Employed Which of the following descriptions best defines your training?*
GP
OS
Endo
Perio
Pedo
DA
Pros
Total (N)
542
396
46
20
31
40
5
4
N2O
77.02%
82.57%
58.69%
85.00%
77.41%
92.50%
60.00%
100.00%
Minimal Enteral
57.37%
64.39%
26.08%
70.00%
48.38%
65.00%
60.00%
50.00%
Moderate Enteral
40.53%
43.18%
30.43%
15.00%
48.38%
60.00%
40.00%
50.00%
Moderate Parenteral
22.63%
19.44%
50.00%
20.00%
48.38%
17.50%
40.00%
25.00%
Deep Sedation
12.81%
6.06%
80.43%
5.00%
16.12%
10.00%
40.00%
25.00%
General Anesthesia
10.18%
3.78%
69.56%
0.00%
3.22%
17.50%
60.00%
0.00%
* GP = general practitioners; OS = oral surgeons; Endo = endodontists; Perio = periodontists; Pedo = pedodontists; DA = dental anesthesiologists; Pros = prosthodontists
oximeter, may be needed for certain medically complex patients. The availability of an automated external defibrillator (AED), while not a physiologic monitoring tool, is a piece of equipment vital to the rescue of patients during a cardiovascular emergency. It is encouraging that 64% of survey participants responded that they carried an AED in their office, despite the fact that very few dental boards require this of outpatient dental offices (e.g., FL, MA, WA). With the renewed attention on enteral sedation, the benzodiazepine triazolam has garnered renewed popularity. Triazolam was approved by the FDA in 1982, and early publications showed its promise as a medication suited for dental outpatient enteral sedation. Private continuing education organizations have further touted triazolam’s favorable characteristics for enteral sedation.28-33 Because of triazolam’s rapid onset, short half-life, lack of active metabolites, and the availability of a pharmacologic antagonist, it has been referred to as a “near ideal oral sedation agent.” 13 A large number of respondents reported taking a training course focusing on enteral sedation (Table 10), and when asked to choose the class of drugs used most often during enteral sedation, the respondents overwhelmingly indicated benzodiazepines (89.6%). Triazolam was also the most popular medication noted when participants were asked to specifically list their most frequently used drug. In fact, of the 53 open-ended responses indicating
which specific enteral drug was used most often, 37 respondents (68.9%) named a drug from the benzodiazepine drug class (Table 11). Almost 95% of respondents noted using either benzodiazepines or opioids most commonly for enteral sedation, and 75% reported carrying the antidotal drugs flumazenil and/or naloxone in their office. The other drug classes that can potentially be used for enteral sedation include barbiturates, antihistamines, and alcohols (e.g. chloral hydrate), none of which have pharmacologic antagonists. Approximately 6% of respondents noted using these enteral sedation medications, which have no available antagonist. This is specifically concerning, as the combination of chloral hydrate and hydroxyzine (i.e., an alcohol combined with an antihistamine) is still a popular pediatric sedation regimen.23,25 Our study shows a large increase in the use of parenteral sedation by dental practitioners when compared to earlier studies. Both surveys by Stan Goff specifically queried general practitioners. The AGD survey was posted on the home page of the AGD’s website (www.agd.org), but does not include data on specialist’s participation, and the ADA survey was sent to both general practitioners and specialists. Nineteen percent of the general practitioners of this study (Table 16) reported using moderate parenteral sedation, which when compared to earlier studies, is a more modest increase and consistent with earlier published results (Table 17).
Dental Implantology Update™
The major limitation of the present survey may relate to the e-mail format vs. traditional mail for distribution and sampling. The 9.84% response rate in this study may be considered low because it was delivered via e-mail instead of standard mail utilized in more traditional survey methodologies. The questionnaire was designed to be short and concise; however, the inboxes on some e-mail providers may have been set up with filters that send e-mails from an unknown source directly to a junk folder. With so much spam e-mail populating computer inboxes, it is not surprising that approximately 90% of e-mail solicitations were either ignored or not received. In addition, the email requests were sent to individuals who were not acquainted with the authors, and sent from one of the author’s (JG) personal e-mail account, which may also account for low overall response. Our sampling population was composed of ADA-member, AGD-member, and nonmember dentists, including both specialists and general practitioners. There were no exclusion criteria. Participants needed only to be a dental school graduate and willing to complete the web-based survey. Individual e-mail addresses were compiled into a list and may have included dentists who previously attended a continuing education course taught by one or both of the authors. Although individuals completing the survey were anonymous, because the authors teach courses on dental outpatient sedation, the frequency at which respondents noted November 2011
79 Table 17: Comparison of Sedation Techniques from Recent Surveys Route of sedation administered by dentists, comparison of recent surveys
N
Inhalation (%)
Enteral (%)
Combination Inhalation and Enteral (%)
Parenteral (%)
DPR 2003 (ref. 18)
508
76
68
n/a
5
DPR 2006 (ref. 22)
357
57
56
n/a
9
AGD 2007 (ref. 26)*
1179
74
50
46
13
ADA 2008 (ref. 27)
2131
70
40
24
15
Goodchild/Donaldson 2009
716
75
69
44
30
*From AGD 2007 Survey: Question “Do you prescribe sedative medication(s) for your patients to take before they come to your office? 67% Yes, 31% No. Two questions later, respondents are asked, “Do you administer oral sedatives?” 50% Yes, 38% No.
their use of outpatient dental sedation may be severely biased. According to statistics provided by Zoomerang, the website received 990 visits, which yielded 716 completed surveys. Because the sample population was composed of a non-representative sample of individuals, it is difficult to draw rigorous conclusions about any specific group. The respondents were comprised mainly of general practitioners, although the intention of the survey was not meant to primarily represent this group. The stated purpose of the present survey was to update previously published survey results examining the current directions in outpatient dental sedation. Despite a lower total response rate than the AGD and ADA surveys, as shown in Table 17, and inherent sampling bias, the number of responses generated in this survey provides valuable information on sedation use among dental practitioners. It is possible that the variances between this survey and previously published studies may be due to factors, including chance, sample bias, and small sample size. Future surveys focusing on specific dental groups (i.e., general practitioners) with sufficient sample size are needed and will contribute to our understanding on the use of outpatient dental sedation. In addition, because outpatient dental sedation regulations vary widely among U.S. states, future research should target practitioners in individual states, both with specific training and use regulations and those without.
results of this survey show that the use of outpatient dental sedation continues to change. The use of enteral sedation may be increasing, but now is differentiated by minimal and moderate sedation, with different training requirements. The use of parenteral sedation by practitioners also appears to be increasing.
Conclusions In comparison to earlier studies, the
5.
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Dionne, RA. Gordon SM, McCullagh LM, et al. Assessing the need for anesthesia and sedation in the general population. J Am Dent Assoc. 1998;129:167-173.
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Silverman MD. Oral sedation dentistry: A safe and effective way to reduce visit anxiety. Dentistry & Oral Health, Vol. 2. Issue 2 at http://www.deardoctor.com/inside-the-
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