Sedation Dentistry: An Application of Medical Histories and Observation

Records to Create A Protocol Aimed at Identifying High-Risk Patients

Ma#hew S. Bright1, James Cur6s, D.M.D.2, Mar6n Durkin, M.D., M.P.H3,
David Hicklin, D.M.D.2, Cynthia Nichols, D.M.D., M.S.2
1The University of South Carolina, South Carolina Honors College, Columbia, SC, USA

2Palme#o Health USC Medical Group, Department of Den6stry, Columbia, SC, USA

3Palme#o Health Research Compliance, Columbia, SC, USA

Introduction Objective
• Through retrospective medical record analysis at the Palmetto Health USC Medical Group
• Modern anesthesia found its basis in dentistry Department of Dentistry, this study aimed to evaluate patient outcomes when treated with the
• The Eirst successful demonstration of anesthesia was performed in 1846 sedative medications Midazolam, Fentanyl, Diazepam, and Meperidine, in the hope of identifying
• Intravenous diazepam, with or without additional agonists, has been utilized in dental sedation high-risk markers that will guide patient selection for in-ofEice sedative procedures
since the 1950’s
• Diazepam, although it may seem short acting, has a lengthy elimination period as active metabolites
remain in the bloodstream for approximately 20-80 hours (Greenblatt, Shader, Divoll, & Harmatz, Figures
1981) • Sedations utilizing Versed,
• Midazolam, a common sedation agent, is water soluble making it “virtually free of venous
Fentanyl, and
complications” (Flynn, 1984)
Diphenhydramine resulted in
• Fentanyl is a rapid onset agonist opioid that is 100 times more potent than morphine with a half life
of approximately 1-18 minutes (New Zealand) a tightly grouped locus when
length of procedure and

Materials and Methods

Table 1
length of recovery are
Summary of Linear Regression Analysis for Variables Predicting Length of Recovery
(Minutes) n=52 observed.
• All procedures were:
Coefficients Estimate Std. Error T-Value Pr(>|T|)
• Performed at Palmetto Health USC Medical Group,
Department of Dentistry Gender (Male) 1.70594 1.12469 1.517 0.1304
• Diphenhydramine is clinically
• Between the dates of: 07/01/2013-06/30/2016 Comorbidities (>1) 2.33337 1.12435 2.075 0.0388*
• Age ≥ 15 years at time of procedure utilized when a patient was
Age 0.07384 0.03534 2.089 0.0375*
• 298 procedures were included in this study
administered Versed and
• A linear regression model was created to include the the Drug Combination
Fentanyl - Versed -2.91851 1.88405 -1.549 0.1224

following variables when compared to the patients length Drug Combination

-4.81401 2.64049 -1.823 0.0693
Fentanyl, and yet needs an
Other
of recovery: Sex, Number of Co-morbidities, Age, Sedative
Morphine Milligram
additional agonist to achieve
Drug Combination, and Morphine Milligram Equivalents Equivalents per
Kilogram
21.92188 9.39675 2.333 0.0203*

per Kilogram Residual Standard

Error = 8.798
Degrees of Freedom =
297
Adjusted R2 = 0.04363 P-Value = 0.00366 full sedation. Lower length of
* if p < 0.05

recovery times could be due

Analysis to patient’s decreased
n=209
response to Versed and
• H0: The mean length of recovery time is not affected by the tested variables
Fentanyl
• HA: The mean length of recovery time is affected by the tested variables
• Since p=0.004 and p<0.05 there is signiEicant evidence that the linear regression model is
signiEicantly better than the intercept model with no tested variables, leading to the rejection of
• Sedations utilizing Versed

the null hypothesis. only tended to be short

• The adjusted R2 value of 0.043 is low, however it is representative of other similar studies procedures with fast recovery
involving retrospective analysis of human subjects times.
• An extremely low complication rate (approximately 3%), coupled with a highly variable patient
population lead to a inconclusive linear regression model that does not highlight an independent • Diazepam and Meperidine are
variable of interest used as an alternative to
• Data suggests that a patient’s age, number of co-morbidities, and combination of sedation Versed and Fentanyl.
n=16
medications could play a role in determining sedation outcome. Further research is needed to Sedations utilizing Diazepam
establish a connection and Meperidine were often of
intermediate procedure
Conclusion length and resulted in an
intermediate length of
• Fentanyl, although more potent than other sedative drugs, allows for shorter durations and
recovery when compared to
increased clinical control, resulting in a more predictable, shorter recovery time
other drug combinations.
• Improved quality of sedation and ease of recovery can increase patient satisfaction
• Data analysis can guide implementation of departmental policies that will guide patient selection for
in ofEice sedation vs. sedation in an operative setting
n=18
• Moderate sedation is a safe and effective manner to provide dental care to a medically compromised
population or to those who avoid treatment due to dental phobias Figure 1. Scatter plots relating variables of Length of Procedure (min) and Length of Recovery (min). Each data point
represents one sedation.
References:
Flynn, P.J., (1984). A comparison of midazolam and diazepam for intravenous sedation in dentistry. Anaesthesia, 39, 589-593.
Greenblatt, D. J., Shader, R. I., Divoll, M., & Harmatz, J. S. (1981). Benzodiazepines: A summary of pharmacokinetic properties. British Journal of Clinical Pharmacology, 11(Suppl 1), 11S–
16S.
New Zealand, BNM Group. (n.d.). Fentanyl Injection (Vol. 5).