Sedation and anaesthesia rules in Ontario

The four levels

The RCDSO's Standard of Practice describes sedation as a continuum, from feeling relaxed to being fully unconscious. It names four levels. Local anaesthetic, which freezes the area while you stay fully alert, isn't sedation at all, and it's used for implant surgery either way.

One detail surprises people: an oral sedative combined with nitrous oxide, at any dose, has to be managed under the rules for oral moderate sedation, not minimal.

What each level requires

The rules get stricter as the level gets deeper.

1. Any sedation, including nitrous oxideThe dentist must hold RCDSO authorization for that method. This has applied to minimal sedation since April 2020. Offices giving only minimal sedation don't need a facility permit but can be inspected at random.
2. Oral moderate and IV sedationThe dentist needs authorization for that level, and the office needs an RCDSO facility permit for it.
3. Deep sedation and general anaesthesiaOnly specific providers may give them: dentists with a specialty certificate in dental anaesthesiology, dentists who have completed a qualifying hospital or university anaesthesia program, dentists trained in oral and maxillofacial surgery, or physicians with recognized anaesthesia qualifications who have RCDSO approval. The office needs a permit for this level.

Facilities with permits are inspected before the permit is issued and re-inspected on a 36-month cycle. Authorizations and permits are renewed every year.

When a separate anaesthesia provider is involved

For deep sedation or general anaesthesia, the person giving the anaesthetic is sometimes not the person doing the surgery. A dental anaesthesiologist or a physician anaesthesiologist looks after the sedation and monitoring while the dentist operates. Under the standard, the operating dentist still shares responsibility for making sure the rules are followed.

This is one arrangement among several. Some offices provide only lighter options and refer patients who need more. The levels available vary from office to office, so ask rather than assume.

Screening comes first

Before any sedation, the standard requires a recorded medical history, a physical examination and an assessment of your overall medical risk using the American Society of Anesthesiologists (ASA) physical status classification. Your history is reviewed again at each sedation appointment.

• ASA I and II (a healthy patient, or one with mild systemic disease): the patients for whom sedation in a dental office is generally most appropriate
• ASA III (severe systemic disease), or other concerns such as a difficult airway: may not be suitable for a dentist qualified only in minimal or moderate sedation, and referral to a more qualified provider should be considered
• ASA IV and above: not acceptable for deep sedation or general anaesthesia in a dental office outside hospital

Sleep apnea, heart and lung conditions, allergies and every medication you take all feed into that decision. Being thorough here is a safety step, not paperwork.

Getting home

The standard is specific about discharge:

• Every sedated patient is assessed for fitness to leave before going
• After oral or IV sedation, deep sedation or general anaesthesia, you leave with a responsible adult
• You're told not to drive, operate hazardous machinery or make important decisions, and to avoid alcohol and other sedating drugs, for at least 18 hours, or longer if drowsiness or dizziness continues
• Nitrous oxide is the only method where the dentist may decide you can leave on your own, once you're fully recovered

For the practical side of surgery day, including fasting instructions and arranging your ride, see getting ready for implant surgery.

Is sedation worth adding?

Sedation is a tool for specific problems, not an upgrade. The standard lists anxiety about dental treatment, conditions that make treatment hard to tolerate, and long or extensive procedures among the reasons it may be used, alongside non-drug ways of helping you feel comfortable. For implant surgery that often means several implants or grafting in one visit, a strong gag reflex, or real fear of the chair.

It also brings things to weigh: fasting, a ride home, a lost afternoon or day, possible extra fees, and the medical screening above. Many single implants are placed comfortably under local anaesthetic alone. A reasonable aim is the lightest option that gets you through treatment safely and calmly.

How to check

The RCDSO public register at rcdso.org shows a dentist's sedation authorizations and the facility permits an office holds, along with a summary of any deficiencies found at a sedation facility inspection. Our guide to choosing an implant dentist in Ontario walks through using the register.