IV conscious sedation is when a calming drug is given during dental treatment. IV stands for intravenous. This means that the drug is given through a plastic tube into a vein in your arm or hand. The drug relaxes you and makes you feel sleepy.
Table of contents
- What does IV sedation feel like?
- Will I be asleep?
- How is IV sedation given?
- Is it still necessary to have local anaesthetic (an injection in the gums)?
- What can I do if I’m terrified of the IV needle?
- Can I take valium tablets or other benzodiazepines beforehand?
- What about eating and drinking before IV sedation?
- What drugs are used? Are there different types of IV sedation?
- Is it safe?
- Are there any contraindications?
- What are the advantages of IV sedation?
- Are there any disadvantages?
- Is IV sedation available on the NHS?
- After IV Sedation
What does IV sedation feel like?
During IV sedation, you will feel deeply relaxed and your anxiety will be greatly reduced. You will be less aware of what is happening, and you may feel sleepy. You will, however, be able to understand and respond to requests from your dentist, and you can let them know how you feel. Afterwards, you may not remember much about the procedure. Many people remember nothing at all.
First-hand accounts of IV sedation (from our message boards)
Basically, it’s just a tiny pinch in the back of the hand and in goes the ‘stuff’. Nothing happens for several seconds and then you begin to feel light-headed (a little drunk) for a few moments, which is not unpleasant. Then instantly several hours have magically passed and everything has been done. It’s like the flick of a switch which turns your brain off for an hour or two. You feel fairly dopey and woozy afterwards where you may want to go and sleep it off.
Well, I DID IT!!!!!!!! … As I sat in the chair, I could feel my heart racing and remember telling the dentist that I needed to do this… I didn’t feel the IV being inserted, and as he was topping up the sedation level, he gave me the local injections. Now this should be freaking me out, but honestly, I only felt a scratch!! and me being needle phobic too! I NEVER felt it being extracted. Next thing I knew I was in the little recovery room with my partner.
I had IV sedation back in June, got 2 rotten and abscessed teeth extracted and a filling to a front tooth. I remember nothing at all from the IV going in, to being aware I was in my husband’s car asking for some water and telling him how I felt nothing!
IV sedation is the best!! I would not hesitate to use it again if I needed to. They numb your hand first, then they put the IV in and before you know it you are off to sleepyland. I really don’t remember too much, just bits and pieces of conversations.
Will I be asleep?
Some dental websites use terms like “sleep dentistry” or “twilight sleep” when talking about IV sedation. This is misleading because it suggests that IV sedation involves being asleep or unconscious. These terms are more descriptive of deep sedation.
Deep sedation isn’t common in the UK and would count as general anaesthesia (even though sedation occurs on a continuum).
You stay conscious and awake during conscious IV sedation. However, you may not remember much (or anything at all) about what went on. Here’s why:
- you will feel deeply relaxed and not bothered by what’s going on
- the drugs used for IV sedation will cause memory loss for when the drug first kicks in until it wears off. As a result, time will appear to pass very quickly and you won’t recall much of what happened. Some people remember nothing at all. So it may, indeed, feel as if you were asleep during the procedure.
How is IV sedation given?
The drug goes into a vein in the arm or back of the hand, using a cannula called Venflon. The Venflon has a very fine needle which is wrapped up with a tiny soft plastic tube. Once the Venflon has been inserted into the chosen site, the needle is then slid out, leaving only the thin flexible tube in place.
If you’d like to know more details, here is a description of how IV sedation is given.
Is it still necessary to have local anaesthetic (an injection in the gums)?
The drugs dentists usually use for IV sedation are not painkillers. While they relax you and make you forget what happens, you’ll still need numbing with local anaesthetic.
Will my dentist numb me before or after I’m sedated?
If you have a fear of dental injections, you won’t be numbed until the IV sedation has fully kicked in. By then, you’ll probably be so relaxed that you don’t care. Your dentist will then wait until you’re fully numb before starting on any procedure.
But how does the dentist know whether I’m numb?
You check the local anaesthetic has worked by asking the patient. Just because they’re sedated doesn’t mean they can’t answer you… in fact, they better be able to answer or they ain’t sedated, they’re anaesthetised! If they’re not numb enough they’ll soon tell you. But they won’t remember telling you of course because of the amnesia effect… – Gordon Laurie, BDS
What can I do if I’m terrified of the IV needle?
Make sure you discuss your fear with your dentist. They may have ideas for helping you with your fear.
If you worry about pain from the IV insertion, here’s a tip – get Ametop numbing gel to make the site where the needle goes profoundly numb:
AMETOP numbing cream. I have a mortal fear of needles, and I find injections unbearable. Every injection I’ve had in my life has been intolerable. However, my dentist managed to get the IV in without me even noticing. I actually just turned around and it was in. The stuff is that good. I did not even feel any pressure. You can get a tube of it from your pharmacist for a few pounds, and it needs to stay in the fridge. If you need proof, buy two tubes, and use one a couple of days before your operation, just to reassure yourself how deeply numb it makes you. – from our message board
Ask your dentist or oral surgeon where the IV will be going in (before the actual IV appointment), and try it out! You should apply Ametop 30-45 minutes in advance. The numbing effect remains for 4 to 6 hours. You will probably have to order it in, as it’s not usually in stock in pharmacies. So plan ahead.
Ametop isn’t available in the U.S., but there is an alternative which also gets rave reviews from needle phobics: the Synera patch. This is just as effective. 1 In some European countries, but not in the UK, you can buy the Synera patch under the name Rapydan.
If you can’t get hold of either of these, use EMLA cream instead. For best effect, apply EMLA cream an hour or two beforehand.
Combining IV sedation with other forms of sedation or hypnosis
Many people find that having nitrous oxide or taking anti-anxiety medication beforehand helps them feel so relaxed that they’re able to go ahead with the IV. Alternatively, hypnosis can work really well.
Alternatives to IV sedation
IV sedation may not be suitable if you have an extreme needle phobia. In that case, you can take midazolam in a drink or even as a nasal spray. But usually, IV sedation is preferable because you can fine-tune the dose. This makes it more predictable and controlled.
Can I take valium tablets or other benzodiazepines beforehand?
Yes. You must let your dentist know about it though (unless your dentist has prescribed them and knows already). It’s best to do this in advance because you’re likely to forget to mention it on the day of the appointment.
What about eating and drinking before IV sedation?
Nowadays, many dentists are happy for you to eat and drink on the day of your appointment, as long as you avoid alcoholic drinks and large meals. Some dentists like to have people eat a light meal (some soup or a piece of toast with spread) an hour or two before they come in.
If there is any chance of oversedation (and the loss of protective airway reflexes), you may have to fast. This is more likely if the dentist or anaesthetist uses an advanced technique (see below), rather than standard single-drug midazolam IV sedation. There may also be risk factors that are particular to you, so follow your dentist’s advice on fasting.
What drugs are used? Are there different types of IV sedation?
In the UK, the standard technique is a titrated dose of midazolam. ‘Titrated’ means that the drug is given bit by bit until you get the desired effect.
1) The Standard Technique: Midazolam
Midazolam is a short-acting benzodiazepine, an anti-anxiety sedative. IV-administered midazolam has 3 main effects:
- it reduces anxiety and relaxes you,
- it makes you sleepy,
- and it makes you forget what happened during some or all of the appointment.
Midazolam is given at a rate of 1 mg per minute. The dental team will monitor how you respond to the drug. Interestingly, the amount you need doesn’t just depend on your size or weight – everyone reacts differently. Once you’ve reached the desired level of sedation, the drug is stopped.
The Venflon is left in place during the procedure. That way, the sedation can be topped up. It also means that if needed, a reversal agent for benzodiazepine (called Flumazenil) can be put in.
2) Advanced Techniques
In the UK, it is really quite rare to use anything other than straightforward midazolam. Advanced techniques are only used if “the clinical needs of the person are not suited to sedation using a standard technique” 2. Usually, advanced techniques are used in hospital environments only, and the sedationist has to be “suitably experienced”. Drug combinations have less predictable effects than single drugs and they don’t have the same margin of safety, so their use is uncommon.
One drug which is occasionally added on to midazolam is fentanyl (an opioid).
On the face of it, adding opioids might seem appealing, because of the pain-killing factor. But in the normal way, this would only come into play for post-treatment pain, because local anaesthetic will take care of any pain during treatment. Actually, where post-op pain is likely, you can simply give a long-acting local anaesthetic and take over-the-counter painkillers before the local anaesthetic wears off.
However, the addition of an opioid can be useful if the sedation for some reason isn’t effective enough. This is more likely if you’ve been using benzodiazepines for many years and have developed a high tolerance to them. In this case, adding an opioid may achieve the desired level of sedation.
As an alternative or in addition to midazolam, the sedationist may use propofol. Propofol is classed as a GA drug, because it’s very easy to tip over into GA (general anaesthesia) with it. In the UK, it can only be used in a hospital setting (although a few private dental clinics meet the standard of a hospital setting, and offer it as well). One advantage of propofol is the very rapid recovery time, less than 5 minutes.
Again, propofol can be useful for the small percentage of people for whom the standard technique doesn’t work.
How common is the use of multiple drugs?
In the U.S., the use of polypharmacy (multiple drugs) is much more common, possibly because IV sedation is taught at a high level. Also, there appears to be more of a liking for long IV sessions which require polydrug use. Long IV sessions may be driven by consumer demand, or maybe it’s a training issue. Many IV specialists in the United States don’t like using opioids for sedation, but there is a habit of using them ingrained in many practitioners. However, things appear to be changing as new dentists are coming through.
The general consensus among the experts in the field of dental sedation today is: the fewer medications are used, the safer and more predictable the treatment tends to be. Usually, this means one medication only. Midazolam tends to be the drug of choice. Advanced techniques can, however, be very useful where an experienced practitioner has tried midazolam and it didn’t have the desired effect.
Is it safe?
IV sedation is extremely safe when carried out under the supervision of a specially-trained dentist. In a recent review of studies looking at death rates related to dental anaesthesia, the studies looking at IV sedation reported a death rate of precisely zero 3.
If you become too drowsy, it is easy to give a drug (Flumazenil) that reverses the effects.
Are there any contraindications?
A contraindication is where a drug or procedure should not be used because it could be harmful. The main contraindications to IV sedation in general practice (out of hospital) are:
- being overweight with a high BMI (a common cut-off is a BMI higher than 35)
- high blood pressure with a diastolic pressure over 100.
- pregnancy and breastfeeding
- known allergy to benzodiazepines
- being drunk
- some instances of glaucoma.
Cautions (relative contraindications) include psychosis, impaired lung or kidney or liver function, advanced age, and sleep apnoea. Many people who have sleep apnoea don’t have an official diagnosis – if you’re overweight and you snore, do mention this.
Heart disease is generally not a contraindication to IV sedation.
If you’ve been taking benzodiazepines for many years, your tolerance may be high – so let your dentist know that you’ve been taking them!
Do I need to go to a hospital for treatment?
The Dental Sedation Teachers Group uses the following classification for making the decision if and where conscious sedation should be provided:
- I – Normal, healthy patient
- II – A Patient with mild systemic disease, e.g. well-controlled diabetes or epilepsy, mild asthma
- III – A patient with severe systemic disease limiting activity but not incapacitating, e. g. epilepsy with frequent fitting, uncontrolled high blood pressure, recent heart attack
- IV – A patient (usually hospitalised or bedridden) with incapacitating disease that is a constant threat to life
- V – A patient who is expected to die within 24 hours with or without treatment
If you’re in category I or II, you can normally be treated in general practice.
Those in category III should have treatment in a hospital-based clinic or a sedation clinic where medical support is available.
What are the advantages of IV sedation?
- IV sedation is the method of choice if you don’t want to be aware of the procedure.
- The maximum level of sedation with IV is deeper than with oral or inhalation sedation.
- It’s very effective and reliable. The level of sedation can be tailored to your needs. This is a huge advantage compared to oral sedation.
- Benzodiazepines produce memory loss for the procedure.
- You can do a lot of dental work in one fell swoop.
- If you have a very severe gag reflex, IV sedation can pretty much eliminate that.
- Unlike General Anaesthesia or Deep Sedation, conscious IV sedation doesn’t really introduce any compromises in terms of carrying out the actual procedures. That’s because you’re conscious and you can cooperate with instructions, and there is no airway tube getting in the way.
Are there any disadvantages?
- While people like IV precisely sedation because of the amnesia effect, there can be a downside to this. If you can’t remember that the procedure wasn’t uncomfortable or scary, you may be less likely to unlearn your fears. And if you are still anxious, you may slip into an avoidance pattern more easily. Other people argue that this is not a concern if IV sedation was readily available for everyone who needs it.
- Some dentists may resort to IV sedation too quickly. Sedation is not a replacement for TLC, painless dentistry and non-drug ways of helping. You should want IV sedation, rather than feel forced into it because your dentist isn’t keen on exploring other ways of helping you.
- IV drugs take a while to wear off. You must bring a responsible adult with you who will take you home after your appointment and look after you for the rest of the day.
- Occasionally, there can be bruising to your hand or arm at the injection site. But this should only last a few days.
- IV sedation is more expensive than other types of sedation.
Is IV sedation available on the NHS?
The NHS website‘s advice is to ask your dentist to refer you to an NHS sedation clinic. In Scotland, you can ask your GP or dentist for a referral to the Community Dental Service or Primary Care Salaried Dental Services.
After IV Sedation
- Have your escort take you home by car or taxi and rest (not public transport). No shopping trips, please!
- Have an adult stay with you for the rest of the day.
- Don’t drive or ride a bike for until the following day.
- Leave the cooking to someone else, and don’t operate any machinery. This includes domestic appliances and kettles!
- Avoid climbing ladders or similar.
- Don’t sign any contracts or make important decisions.
- Get another adult to look after children for the rest of the day.
- Stay away from the internet (especially shopping websites and social media sites…).
- Don’t drink alcohol for the rest of the day.
- Continue your usual medication as normal (unless your dentist says otherwise), and take any additional medications as directed by your dentist.
- If you have any unusual problems, call your dentist.
Standards for Conscious Sedation in the Provision of Dental Care (2015). The dental faculties of the royal colleges of surgeons and the Royal College of Anaesthetists.
Conscious Sedation in Dentistry – Dental Clinical Guidance Third Edition (2017). Scottish Dental Clinical Effectiveness Programme – NHS Education for Scotland.
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Sources of Information
- Ravishankar, N.; Howell, S. J.; Elliot, S.; Beardow, Z.; Mallick, A. (2012). A comparison of Rapydan® patch and Ametop® gel for venous cannulation. Anaesthesia, Vol. 67, Issue 4, pp 367-370. https://doi.org/10.1111/j.1365-2044.2011.07000.x
- Conscious Sedation in Dentistry, Third Edition, June 2017, Scottish Dental Clinical Effectiveness Programme
- Hamed Mortazavi, Maryam Baharvand and Yaser Safi. Death Rate of Dental Anaesthesia (2017). J Clin Diagn Res. Jun; 11(6): ZE07–ZE09.