How may pain and anxiety be managed successfully and safely in the dental office? Pain associated with dental treatment is managed effectively through the administration of local anesthetics at the start of treatment. These chemicals prevent passage of the nerve impulse beyond the site at which they are deposited.

Although the tooth or soft tissues have received a noxious stimulus {e.g., drill, curette}. the propagated nerve impulse will travel only as far as the site at which the local anesthetic was deposited. The rapid influx of sodium ions into the interior of the nerve ( the process responsible for continued propagation of the nerve impulse} is prevented, the impulse is terminated. and the patient experiences no discomfort.

However. fear of pain is a major deterrent to the delivery of dental care today. Patients who are not in pain fear the visit to the dental office because they believe that at some time during their dental treatment they will be hurt. Fear of pain produces a heightened anxiety in these patients, a factor that may lead to the avoidance of dental care until they are truly in pain.

How can dentistry alter its image of being painful? It is a fact today that virtually all dental care can be completed without discomfort to the patient. With the availability of a variety of excellent local anesthetics, it is possible to achieve clinically adequate pain control in virtually all situations. The most difficult pain management problems usually occur in endodontically involved teeth and since the reintroduction of intraosseous anesthesia and the introduction of articaine HCI, only rarely in this situation ts effective pain control unattainable.

The administration of a local anesthetic is also considered to be a traumatic procedure by most patients and indeed by many dentists. Yet even this aspect of dental care need not be traumatic. Local anesthetic injections may be administered atraumatically anywhere in the oral cavity, including the palate.

Yet the possibility of pain and the "injection" of local anesthetics are not the only things about dentistry that induce fear in patients. Dentists with extensive clinical experience have probably heard patients express fear of almost every possible procedure that we are called upon to carry out.

How then can we manage these overtly fearful patients? The answer is to distract them, to take their attention away, from what is being done for them (the patient would consider that we are doing things "to them") in their mouths. This can be accomplished through non drug techniques, such as headsets with music, video, dark glasses, warrn blankets or through the administration of drugs that induce a state of consciousness (or, more precisely, an altered state of consciousness) in which a person is more relaxed and carefree.

Over the years. many names have been given to this drug included state. Names such as chemamsia, sedamnesia, twilight sleep, relative analgesia and co·medication have been used to describe the state of altered consciousness that is now called sedation. Or Intravenous Conscious Sedation (aka "IV sedation")

Many definitions of IV sedation have been put forth over the years; however, in 1971 following the Third Pain Control Conference sponsored by the American Dental Association (ADA), American Dental Society of Anesthesiology, and American Association of Dental Schools. the "Guidelines for Teaching the Comprehensive Control of Pain and Anxiety in Dentistry," were published. These guidelines established a standard for the training of dental personnel in this area of patient management. The guidelines have undergone revision on several occasions over the ensuing years, most recently in 2007 when the House of Delegates of the ADA passed two documents representing significant revisions of the guidelines, including modification of the terms used to define the various levels of sedation.

In previous iterations. levels of IV sedation were defined as follows:

Anxiolysis; a minimally depressed level of consciousness that retains the patient’s ability to independently and continuously maintain an airway and respond appropriately to physical stimulation or verbal command and that is produced by a pharmacologic or nonpharmacologic method or a combination thereof. Although cognitive function and coordination may be modestly impaired, ventilatory and cardiovascular functions are unaffected.

Conscious sedation: a minimally depressed level of consciousness that retains the patient`s ability to independently and continuously maintain an airway and respond appropriately to physical stimulation and verbal command and that is produced by a phammacologic or nonpharmacologic method or combination thereof.

Deep sedation: a drug-induced depression of consciousness during which patients cannot be easily aroused, but respond purposefully following repeated or 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.

General anesthesia: a controlled state ul unconsciousness accompanied by partial or complete loss of protective reflexes, including inability to independently maintain an airway and respond purposefully to physical stimulation or verbal command, and is produced by a pharmacologic or nonpharmacologic method or a combination thereof.