Enteral conscious sedation (ECS)�also called oral conscious sedation�has a lot of appeal on both sides of the dental chair. For the large population afraid to step foot in the dental office, swallowing a pill may be the difference between clean healthy teeth and painful oral health problems. For dentists, ECS is simple to administer, doesn't require much training compared to IV and other types of sedation, and often doesn't affect malpractice premiums. But ECS has caused controversy within the profession. Some dentists and dental associations have raised questions about the quality of ECS continuing education, as well as the safety and efficacy of ECS, according to an article in the February 2004 issue of AGD Impact .
Those skeptical about ECS in practice are worried about methods, especially incremental dosing, or titration. Critics say titration runs the risk of an untrained and ill-prepared dentist inducing deep sedation in a patient.
Enteral conscious sedation is primarily used to curb anxiety and fear in a patient without rendering them unconscious. Several polls and surveys suggest that fear of the dentist remains pervasive despite advancements in pain management, improved patient comfort techniques and various public-awareness campaigns. Ironically, sedation via a needle is a chief concern of more than half of all patients afraid of dental visits. According to a clinical article in the February 1998 issue of the Journal of the American Dental Association , one survey found that "25 percent of adults expressed a fear of injections, with one in 20 respondents indicating that they avoided, canceled or did not appear for dental appointments because of fear."
Prior to the 1960s, alcohol and barbiturates were used to relax patients. Once benzodiazepines hit the market, they became the drugs of choice for dentists. Triazolam is the benzodiazepine most commonly used by dentists because of its rapid onset, reported high margin of safety, and the availability of the antagonist flumazenil. Triazolam's popularity with dentists also stems from the drug's short half-life and duration.
Even with that training, some dentists believe that ECS is too unpredictable, especially with incremental dosing. Whereas the effects of IV or inhalation sedation can be observed within minutes, oral medication can take up to two hours to absorb. The scenario many opposed to ECS paint is a patient swallowing a pill and the dentist, not seeing the effects of the drug an hour or two later, delivers a second pill. Meanwhile, the first pill is being absorbed and the patient has ingested twice the amount he or she needs.
