Anesthesia in periodontal treatment: a narrative review of modalities and advancements

Introduction

Background

Periodontal treatment relies on profound dental anesthesia, a fundamental component for procedural success and patient comfort. Proper intraoperative pain and anxiety management contributes to the technical aspects of treatment and significantly impacts the overall patient experience. Dental procedures are inherently painful and therefore require analgesics—either alone or in combination with anesthesia—both during and after the procedure to ensure adequate pain management (1). Yet, this has not always been the case; early periodontal procedures were often performed without effective anesthesia until the introduction of local anesthetics in the early 20^th century, which revolutionized pain control and expanded surgical options. A range of factors can influence a patient’s dental anxiety and pain response. Negative emotions and psychological distress can amplify a patient’s experience of discomfort, as demonstrated in both clinical and experimental settings (2,3). Consequently, the management of pain and anxiety in outpatient facilities has become a central focus that has led to the use of different strategies aimed at providing appropriate pain relief.

Periodontists are specialized in the diagnosis and treatment of periodontal disease, and in the placement of dental implants. Periodontal disease consists of chronic inflammatory conditions that impact the supporting structures of the teeth including the gingiva, periodontal ligament, cementum, and alveolar bone, which if left untreated could result in tooth loss and contribute to systemic inflammation (4). To halt the progression of this disease, comprehensive management of the periodontium is indicated. Periodontal procedures span a wide range of surgical and non-surgical treatment modalities aimed at restoring the health of periodontium. When non-surgical interventions do not improve the patient’s current state, periodontal surgical procedures may be required. These approaches include, but are not limited to, osseous surgery, guided tissue regeneration, and soft tissue grafting (5). The focus of these treatments is to restore lost tissue, correct defects, and debride areas to produce a sound foundation for teeth. Periodontists also perform a variety of dental implant related procedures, such as dental implant placement, sinus lift, and ridge augmentation. These procedures have greatly expanded the scope of care in periodontal practice.

Rational and knowledge gap

Appropriate pain control during the procedure provides effective manipulation of the area, particularly given the inflammatory nature of periodontal disease. Occasionally, it can be difficult to achieve adequate local anesthesia because severe inflammation can reduce the bioavailability of local anesthetic, hence reducing its efficacy (6). The selection of anesthetic should be based on the duration of clinical procedure and individualized to meet each patient’s needs. When comparing the duration of oral surgery procedures to that of periodontal therapy, a significant difference is observed, with periodontal surgical procedures ranging between 80 to 210 minutes, which is on average a longer duration (7).

For some patients, fear of pain associated with periodontal treatment is a significant barrier to receiving care. This is a compounding factor that can manifest as avoidance, anticipatory fear, fear of specific dental stimuli, and physiological arousal leading to problems tolerating treatment (8). The effective management of an anxious patient is needed for surgical procedures requiring high precision such as soft tissue graft, implant placement and sinus augmentation. These procedures are technique-sensitive and require careful execution to yield optimal outcomes (9). Thus, periodontists may need to incorporate anesthesia techniques beyond simple local anesthesia.

Several factors, including the nature of the procedure, can influence the decision to use local anesthetic, nitrous oxide, moderate sedation, or general anesthesia (1,2). Recent studies and technological advances have facilitated the development of new pain and anxiety management techniques. Despite these advances, the most comprehensive reviews date back to two decades ago, underscoring the new for an updated overview.

Objective

This review aims to discuss the current state, emerging trends, and advances in anesthesia for periodontal treatment. We present this article in accordance with the Narrative Review reporting checklist (available at https://joma.amegroups.com/article/view/10.21037/joma-2025-20/rc).

Methods

The current study is based on a review of the existing literature published on PubMed, Web of Science, Scopus, ScienceDirect, Embase databases, Google Scholar along with gray literature. The search focused on human studies exploring pain management techniques and various anesthesia modalities commonly used in periodontal surgery, published in English language. The search strategy employed terms related to various types of anesthesia combined with terms related to periodontal procedures (Table 1). For each type of anesthesia, indications, contraindications, techniques, and periodontal clinical applicability were retrieved. No time nor study design restrictions were applied. The search was conducted in December 2024 and January 2025.

Pain mechanism

Pain transmission through periodontal ligament

Pain transmission through the periodontal ligament (PDL) is a complex process involving both nociceptive and mechanoreceptive pathways. The PDL is a specialized connective tissue that anchors the tooth to the alveolar bone. Periodontal pain is usually well localized due to the presence of proprioceptors and mechanoreceptors in the periodontium (10). Noxious stimuli in the PDL are detected and transmitted through free nerve endings of primary afferent sensory neurons (mainly A-delta and C-fibers), also referred to as nociceptors (11). Noxious and physical stimuli (including pressure and heat) are converted into electrical signals through the activation of ion channels [i.e., transient receptor potential (TRP) channels and voltage-gated ion channels] located on the cell membrane of the nociceptors (12). Activation of the TRP channels allows ions such as calcium and magnesium to enter the neuron, causing a localized depolarization. If the depolarization reaches a specific threshold (13), it triggers the opening of voltage-gated sodium channels, allowing sodium ions to enter the neuron and generate an action potential (14). This signal transduction enables nociceptors to detect and respond to noxious stimuli. A-delta fibers and C-fibers transmit different type of pain. While the myelinated A-delta nerve fibers convey fast-response, sharp, pricking, and localized aching pain, the unmyelinated C-fibers are responsible for slow, dull aching, burning, and diffuse pain (15). A-delta fibers mainly respond to mechanical and thermal stimuli; C-fibers, associated with polymodal nociceptors, respond to mechanical, thermal, and chemical stimuli (16). Once activated, the peripheral primary afferent nerve fibers synapse in the trigeminal subnucleus caudalis in the medulla (16). At the spinal cord, interneurons are responsible for pain modulation, in that pain transmission can be either inhibited or excited (17). Next, second-order neurons transmit the nociceptive signal to the brainstem through the trigemino-thalamic tracts, where it is further modulated by supraspinal structures (e.g., periaqueductal gray, rostral ventral medulla, central nucleus, paraventricular nucleus, parabrachial nucleus, locus coeruleus), and then relayed to the thalamus (18).

Pain perception

Once the nociceptive signal reaches the thalamus, it is relayed via third-order neurons to various cortical regions, including the prefrontal cortex, primary and secondary somatosensory cortex, and motor cortex. Within these higher brain centers, the incoming sensory input is processed, integrated, and ultimately interpreted as pain (15). This cortical processing not only determines the sensory qualities of pain (e.g., location, intensity, and duration), but also integrates emotional cognitive, and contextual factors. For example, nociceptive signals traveling through ascending tracts to the higher center can be potentiated and modulated through the affective pathway, mediating emotional, motivational, affective, and autonomic responses. Thus, anxiety or stress can exacerbate pain experienced by patients during dental procedures (19).

Mechanisms of action of anesthesia on pain transmission (Figure 1)

Figure 1 Mechanisms of action of anesthesia on pain transmission. This figure illustrates the levels and main mechanisms of action of various types of anesthesia on the nervous system: (A) Local anesthesia acts on peripheral nerves by blocking sodium channels, preventing sodium influx and the propagation of action potentials. This inhibits pain signal transmission. (B) Minimal to moderate sedation operates at the brain level by modulating neurotransmitter systems such as GABA-A and NMDA receptors, influencing motor coordination, consciousness, anxiety, and physiological parameters. (C) General anesthesia acts centrally at multiple levels, including the brainstem, thalamus, and cortex, enhancing inhibitory pathways and suppressing excitatory pathways. This results in unconsciousness, muscle relaxation, and reduced pain perception. GABA, gamma-aminobutyric acid; NMDA, N-methyl-D-aspartate.

Local anesthetics modulate pain transmission by reversibly binding to sodium channels, thereby inhibiting sodium influx into the neuron and blocking nerve conduction (20,21). This binding prevents the propagation of action potentials along the cell membrane, effectively halting the transmission of noxious stimuli (22). Only the lipid-soluble fraction of local anesthetics can penetrate neuronal membranes, a proportion dictated by the anesthetic’s ionization constant (pKa) (23). This process is delayed in environments with lower-than-physiological pH levels, such as infections (23).

An additional level of anesthesia includes minimal or moderate sedation (formerly referred to as conscious sedation). These techniques not only inhibit sensory input but also alter motor coordination, consciousness, anxiety, and physiological parameters (24). One commonly used agent for minimal sedation is nitrous oxide (N₂O), an inhaled anesthetic gas often combined with other agents (25). Its analgesic effects derive from antagonism at N-methyl-D-aspartate (NMDA) receptors, the release and stimulation of endogenous opioid peptides in the central nervous system, and its modulatory actions on neurotransmitters, including gamma-aminobutyric acid (GABA)-A receptors (24,25). The facilitation of GABAergic inhibitory pathways also underpins its anxiolytic properties (24).

General anesthesia, a drug-induced reversible state of unconsciousness, muscle relaxation and loss of motor function, antinociception, and amnesia (21,26,27), exerts its effects at multiple levels of the nervous system via central mechanisms (27). Intravenous agents (e.g., propofol, etomidate) and volatile anesthetics (e.g., isoflurane) block pain signals transmission by enhancing inhibitory pathways (e.g., GABA-A receptor activity) hyperpolarizing neuronal membranes in the spinal cord horn, brainstem, thalamus, and cortex (27). Volatile anesthetics further stabilize neuronal resting membrane potentials by inhibiting presynaptic voltage-gated sodium channels, reducing neurotransmitter release and excitability (28). Conversely, drugs like ketamine attenuate excitatory pathways by blocking glutamate release at NMDA receptors in the spinal dorsal horn, thus reducing central sensitization (29). Additionally, general anesthesia modulates pain by inhibiting ascending nociceptive arousal pathways in the brainstem and reticular formation, inducing unconsciousness (27). It suppresses thalamic relay activity, thereby suppressing axonal conduction of sensory signals to the cerebral cortex and diminishing conscious pain perception (30). Further, cortical areas such as the somatosensory cortex, anterior cingulate cortex, and insula exhibit reduced activity, dampening pain processing and emotional regulation (31). Because general anesthesia does not directly inhibit peripheral nociceptor activation, combining local anesthetics with general anesthesia can effectively block peripheral pain signals.

In patients with complex analgesic needs, a combined approach targeting inflammatory, neural, psychological, and endocrine factors is often required (12). Thus, a thorough understanding of pain transmission mechanisms, particularly through the PDL, is essential for selecting optimal anesthesia modalities and pain management strategies. This ensures patient’s peri- and postoperative comfort and enhances procedural predictability and efficiency.

Local anesthesia

The American Dental Association (ADA) defines local anesthesia as the elimination of sensation, especially pain, in one part of the body by the topical application or regional injection of a drug (32).

Local anesthetics are one of the primary therapeutic agents utilized in clinical dentistry to alleviate discomfort, making them suitable for localized pain management during routine dental procedures and minor surgeries. They offer advantages, including their relative safety, effectiveness, and ease of administration (7). While no additional certification is required to administer, careful consideration should be given when selecting the appropriate drug based on the patient’s medical needs, required duration of action, past dental experiences, and potential adverse reactions.

Local anesthetics and vasoconstrictors

Local anesthetics can be divided into two categories: esters and amides (33,34). Ester local anesthetics are hydrolyzed in plasma producing, p-aminobenzoic acid (PABA) metabolites and while they exhibit greater vasodilation properties compared to amide local anesthetics, they are considered more allergenic (35). Due to this reason, ester local anesthetics are seldomly used in dentistry. Most incidents of adverse reactions associated with amide anesthetics are attributed to sensitivity to epinephrine, overdose toxicity, or vasovagal syncope (36).

Local anesthetics combined with vasoconstrictors are often preferred to improve hemostasis, prolong the duration of the anesthesia, and reduce systemic toxicity. The clinical efficacy of local anesthetics is influenced by the action of vasoconstrictors (37,38). The combination of a local anesthetic with a vasoconstrictor allows for optimal pain control primarily by reducing the local blood flow, which slows down the absorption of the anesthetic into the systemic circulation (39). In dentistry, epinephrine and levonordefrin are the most commonly used, while norepinephrine and phenylephrine have been removed from most formulations due to their risk for adverse cardiotoxic effects (38,40). When selecting the appropriate vasoconstrictor, considerations such as the duration of the periodontal procedure and the patient’s medical status should be assessed.

In dental anesthetic cartridges, epinephrine is commercially available in three different concentrations, ranging from 1:50,000 to 1:200,000 (40). In contrast, levonordefrin is used at much greater concentrations. A 1:20,000 solution of levonordefrin shows the same alpha-adrenergic activity to epinephrine 1:100,000 (37). Its potency and receptor specificity differ from those of epinephrine. In terms of vasoconstrictor activity, it is one-half to one-sixth as potent (37,38). To compensate for higher concentrations of levonordefrin, a combination with mepivacaine can be used as an alternative for patients who cannot receive epinephrine. The benefits of higher concentrations are that they provide enhanced hemostasis by constricting blood vessels, which minimize bleeding and improve visibility particularly in highly vascular sites.

Despite their benefits, vasoconstrictors—particularly epinephrine—may be contraindicated in patients with known allergies or comorbidities such as cardiovascular or liver disease, as these conditions may restrict dosing due to their risk for adverse effects (37). Reported complication include arrhythmias, chest pain, hypertension, palpitations, tachycardia, cerebrovascular accidents, ventricular ectopy, vasospasm, and tissue ischemia secondary to compromised perfusion (37,38). Short-acting anesthetics are often preferred for elderly patients and children due to their reduced duration of action. For individuals with a history of cardiovascular disease, local anesthetics that do not contain epinephrine, such as mepivacaine, are typically recommended. As a short-acting agent, mepivacaine minimizes cardiovascular stress while still providing effective anesthesia.

Although a rare event, another important consideration is the potential for paresthesia resulting from the use of local anesthetic (41,42). Garisto et al. support that 4% anesthetic solutions of prilocaine and articaine are associated with higher incidence of paresthesia than those of lower concentrations (41).

Applications in periodontal therapy

Intraoperative bleeding during periodontal procedures is a common challenge that can compromise treatment outcomes. Two primary goals in periodontal surgery are to eliminate or reduce periodontal pockets that often harbor dysbiotic microbial communities and to restore lost periodontal support (43). These objectives are typically accomplished through open flap debridement and regenerative procedures (43). Open flap debridement involves exposing the root surfaces of teeth and supporting alveolar bone to effectively remove diseased tissue that cannot be accessed by non-surgical treatment. In contrast, regenerative procedures require both a skilled clinician and surgical precision to effectively rebuild periodontal structures and promote the growth of new tissue.

Intraoperative bleeding during these procedures may seem significant to someone who is inexperienced; however, current reports of serious adverse hemorrhagic complications in the literature are scarce (44). McIvor and Wengraf reported blood loss ranging from a minimum of 0.5 mL to a maximum of 62 mL during periodontal surgery (45). Other studies have directly examined the influence of epinephrine concentration on intraoperative bleeding. For example, in a study comparing hemostatic and anesthetic efficacy of 4% articaine HCl with either 1:100,000 or 1:200,000 epinephrine, Moore et al. reported that the intraoperative hemorrhage ranged from approximately 55 [with a standard deviation (SD) of 36] to 70 (SD =53) mL which varied based on the concentration of epinephrine used (46). Higher concentrations of the vasoconstrictor provided improved visibility of the surgical field and less bleeding.

Beyond the management of intraoperative bleeding, an attempt to manage post-operative discomfort and improve the patient’s experience has led to the consideration of postoperative analgesics (47). Bupivacaine has a longer duration of action when compared to lidocaine, mainly due to its increased lipid solubility and higher protein-binding capacity, which allow it to remain close to neural fibers (48,49). These pharmacological properties have resulted in the wide use of bupivacaine in the management of postsurgical pain (50,51).

Techniques of local anesthetic administration

The method of local anesthetic administration can differ and have an influence over the duration and onset of anesthesia. Infiltration techniques are commonly used in the maxilla where the bone is more porous, they involve the deposit of anesthetic at or above the apex of the tooth being treated and normally result in a faster onset but shorter duration of action (52,53). In contrast, nerve blocks generally take longer to exert their effect. They involve the delivery of anesthetic near a main nerve trunk, affecting a larger area for a prolonged period of time (52,54). Overall, nerve blocks may be useful in periodontal surgeries that involve multiple teeth and large areas of soft tissue. Yet, possible complications include potential airway compromise and intramuscular hematoma, which are typically associated with inferior alveolar nerve (IAN) or posterior superior alveolar (PSA) nerve blocks in patients with bleeding disorders (38). Complications are rare at lower doses. Although clinicians are skilled in the use of local anesthetics, they must remain vigilant to address adverse events and ensure adequate dosing to minimize patient discomfort during procedures.

In many cases, clinicians routinely use a combination of block injections, local infiltration, and supplemental techniques. Supplemental injections such as PDL or intraligamentary, intraseptal, and intraosseous injections are useful when conventional methods are insufficient (53). An advantage of a PDL injection is that it only requires a small volume of anesthetic which is delivered under high pressure causing diffusion into the adjacent cancellous bone resulting in a quick onset (53). Localized anesthesia is achieved, making it successful for a single tooth procedure while minimizing the impact on the surrounding soft tissue.

In intraosseous injection a small hole is drilled through the cortical bone to reach the cancellous bone, where the anesthetic solution is slowly delivered (53,55). To minimize discomfort, a small amount of anesthetic is first given via local infiltration to the adjacent gingiva prior to perforation (56). Although it is not typically used for routine periodontal procedures, it may be necessary for complex or surgical extractions. Similarly, intraseptal anesthesia involves injecting the anesthetic solution into the bone, in this case the interdental septum (53).

Table 2 offers an overview of the available local anesthetic agents utilized in periodontal treatments.

Innovations and emerging trends

Overall, while local anesthesia continues to be a staple in modern dentistry, its administration can be an unpleasant experience for patients. Pain may result from soft tissue damage at the injection site, the temperature of the anesthetic solution, its low pH, the properties of the anesthetic, or the pressure created as the solution spreads (57). To reduce the discomfort related to the low pH of anesthetic solutions, technical advances have made it possible to alkalinize dental anesthetic chairside (58). Sodium bicarbonate—commonly used for metabolic acidosis—is the most frequently used for buffering local anesthetics (59). Alkalinization accelerates the onset of anesthesia and allows for a reduction of injection-related pain, making the buffering of local anesthetics a helpful tool in improving patient comfort and anesthetic efficacy. Clinical recommendations for providers are to buffer each cartridge immediately before the delivery of the injection (60).

In addition to buffering, techniques involving the use of computer-controlled local anesthetic delivery (CCLAD) devices have been adopted. These devices not only regulate the injection speed but also consider the anatomical features of the area where the anesthetic is being injected. The Wand^TM (Milestone Scientific, Inc., Livingston, NJ, USA) gave rise to the first CCLAD systems in the late 90s, which were followed by the launch of similar products such as the Wand Plus, CompuDent^TM, and the Comfort Control Syringe (Dentsply International, York, PA, USA), among others (61). This system allows for superior needle control with more precise placement and delivery of anesthetic. The Wand and CompuDent^TM systems are foot-activated, with anesthetic flow rates regulated by a computer, while the Comfort Control Syringe differs in incorporating syringe-based controls for both aspiration and injection, offering five pre-programmed delivery speeds (57). These innovations offer promising benefits in patient acceptance, improvement in reducing injection-related pain, and enhancing anesthetic efficacy.

Another device that has improved patient comfort includes jet injectors, which can deliver local anesthetic as a high-speed stream with less tissue damage, faster drug absorption, and minimal pain (57,61). This is a needle-free technique that can be particularly advantageous for individuals with a needle phobia or for pediatric patients. The Syrijet Mark II [Keystone Industries (aka Mizzy), Cherry Hill, NJ, USA] has been available for over 40 years, while the MED-JET (Medical International Technologies, Montreal, QC, Canada), a more recent addition, delivers anesthetic through an orifice said to be seven times smaller than the tiniest commercially available needle (57). Once the liquid anesthetic is pushed through the small orifice, it forms a thin column of fluid that allows for subcutaneous tissue penetration without the use of a needle (57).

While patient comfort remains a priority, specialized devices for intra-osseous anesthetic administration have been developed to aid with the injection process and improve precision. Stabident (Fairfax Dental, Miami, FL, USA), X-Tip (Dentsply International Inc., Tulsa, OK, USA) and IntraFlow (Pro-Dex Medical Devices, Irvine, CA, USA), all focus on facilitating anesthetic delivery into the cancellous bone adjacent to the apex of the tooth (57). For example, the X-Tip combines the pilot drill and needle guide to allow for immediate anesthetic injection into the same access.

Alongside advanced injection systems, the use of topical anesthetic helps reduce pain caused from the needle insertion during anesthetic delivery or periodontal procedures such as scaling, contributing to a more comfortable experience and positive attitude toward dental treatment. Traditional topical anesthetics are available in various forms such as creams, sprays, gels and commonly contain active ingredients including benzocaine and lidocaine (62). Notably, up to 30% of patients have reported feeling pain during scaling and root planing, which has prompted efforts to develop a topical anesthetic that can be used during periodontal procedures (62-64). The HurriPak (Beutlich LP Pharmaceuticals, FL, USA) is a needle-free periodontal anesthetic kit that contains 20% benzocaine. It includes a plastic syringe along with a disposable tip which is gently inserted into the gingival sulcus with a rapid onset of 30 seconds and a short duration of 15 minutes (62). Due to its short duration, adjunctive anesthesia or re-administration is usually needed to maintain pain control throughout the procedure. Cetacaine (Cetylite, NJ, USA) is another topical anesthetic used for managing localized pain across all mucous membrane sites. It has a multi-agent formulation containing 14% benzocaine, 2% butamben, and 2% tetracaine hydrochloride and comes with an applicator tip that can access periodontal pockets (62). Similarly, Oraqix (Dentsply, Pennsylvania, USA) is a non-injectable anesthetic gel that contains 2.5% prilocaine and 2.5% lidocaine (57). It is intended to be administered into the gingival sulcus providing a localized anesthetic effect during scaling and root planing.

Sedation

While local anesthetics are effective for a broad range of dental treatments, individuals with high levels of anxiety may require additional forms of sedation, and providers should possess a thorough understanding of these agents. According to the American Society of Anesthesiologists (ASA), sedation is described as a continuum from minimal, moderate, to deep (63). Providers should be appropriately equipped to intervene if airway management or advanced life support becomes necessary. In instances of adverse physiological responses such as hypoventilation, hypoxia, or hypotension resulting from deeper than intended levels of sedation, prompt management is essential to restore the patient to the intended level of sedation (63). Continuous monitoring of cardiovascular and respiratory parameters is important in identifying signs of oversedation, allowing for a timely and appropriate response. The selection of the sedation technique and setting for sedation (outpatient or inpatient) is influenced by patient factors, including but not limited to renal, hepatic, respiratory function, and relative comorbidities (64). Hence, pre-operative assessments must be completed to evaluate the level of sedation needed for the procedure and the choice of agents that will minimize patient complications. In most cases, periodontists often collaborate with dental anesthesiologists or nurse anesthetists to manage sedation during lengthy or complex periodontal surgical procedures.

Appropriate case selection is imperative. Holtzclaw et al. emphasized that all patients undergoing sedation procedures should receive comprehensive evaluations (7). This includes a thorough preoperative assessment of the patient’s surgical and medical history, a complete list of medication, as well as review of their vital signs (7,65). Prior experiences with dental anesthesia, and any relevant laboratory tests, such as an electroencephalogram (EKG), pregnancy test, blood glucose test, and international normalized ratio (INR) tailored to the patient’s existing conditions and planned procedure should be documented. Observations such as the patient’s body mass index (BMI), oral range of motion, neck size, jaw size, Mallampati classification, cardiovascular and respiratory reserve, and ASA physical status classification, will also inform the decision-making process (65). Accordingly, an individual who is normally healthy or with mild systemic conditions falls under ASA physical status 1 or 2 respectively. A person with severe systemic disease, or a systemic disease that poses a constant threat to life, is classified as ASA physical status 3 or 4. Traditionally, clinicians have limited anesthesia delivery to patients classified as ASA physical status 1 or 2 but given the aging population and increasing prevalence of multiple co-morbidities, they are now faced with the challenge of treating patients classified ASA physical status 3 or 4 (65).

Again, the choice of anesthetic agent should then be based on the patient’s needs, co-morbidities, and medical history. For example, a simple dental implant procedure may be well managed with local anesthesia, but a patient’s high anxiety may require management with moderate sedation. The dental office-based anesthesia provider should be attentive to case selection, as prolonged procedures (longer than 2 hours), general anesthesia, and advancing age appear to be independent factors for increased morbidity (66). However, most injuries related to dental office-based anesthesia occur as a result of inadequate monitoring (67). Other factors associated with increased risk in the office setting include the use of unqualified providers, as well as a lack of appropriate equipment and training. In most cases, periodontists often collaborate with dental anesthesiologists or nurse anesthetists to manage sedation during lengthy or complex periodontal surgical procedures.

Minimal sedation

Minimal sedation is defined as a minimally depressed level of consciousness in which a patient maintains the ability to respond to verbal commands and can independently maintain their airway (67). This state of anxiolysis can be achieved through a low dose of enteral drug (Table 3) or inhaled nitrous oxide. Nitrous oxide can provide effective sedative effects and loss of awareness of pain for many patients. Triazolam (Halcion) is often used for minimal sedation because of its rapid onset, short half-life, and minimal residual drowsiness in part attributed to the absence of active metabolites (67). Patients are also able to medicate prior to the periodontal procedure. For example, diazepam (Valium) or triazolam may be taken the night before and 1 hour prior to the procedure.

While nitrous oxide can be administered in combination with oral sedative to reach a deeper level of anxiolysis (67), a positive pressure oxygen delivery system must be available in case of airway emergency. Additionally, a system that delivers at least 30% oxygen should always be in place in the event of a failure (67). A record of all drugs administered and vital signs must be maintained, and an additional person trained in basic life support should be present. More caution should be taken when treating pediatric patients as the same doses of medication can have varying effects. Contraindications for nitrous oxide include severe chronic obstructive pulmonary disease (COPD), severe asthma, upper respiratory tract infections, or women in their first trimester of pregnancy due to the potential risks to the developing fetus (68,69). Caution is advised, as nitrous oxide can induce nausea and vomiting due to its emetogenic properties (70). However, this is an effective option for those patients suffering from mild to moderate dental anxiety or phobia.

Moderate sedation

Moderate sedation is also referred to as ‘twilight sleep’ or conscious sedation. The ADA Guidelines for the Use of Sedation and General Anesthesia defines it as a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained (71). This form of sedation often refers to parental or IV sedation and is very effective in periodontal procedures. IV sedation involves administering sedative medications directly into a patient’s vein to achieve a relaxed state during dental procedures. IV sedation allows precise control of the sedation level through drug titration while the patient remains conscious. This method is often considered superior to oral sedation due to its faster onset and more predictable outcomes, but it requires advanced training and careful monitoring of vitals throughout the procedure (72,73). Benzodiazepines, opioids, ketamine, and propofol are usually the drugs of choice for intravenous sedation. In case of any complications (such as respiratory depression, hypoxia, hypotension, excessive sedation), reversal medications can be administered to counteract the effect of sedatives (74).

The use of moderate sedation is especially indicated in the presence of patients with dental anxiety and phobias, special need patients, and patients undergoing traumatic and complex dental procedures. The use of moderate sedation may also be based on the patient’s preference for a more relaxed dental experience (74,75). Midazolam and fentanyl are the most commonly used medications for sedative and pain control during periodontal procedures. Once the desired sedation level is achieved, surgeries may proceed under local anesthesia. During the surgical procedures, additional medications can be administered as needed to maintain the level of sedation.

A report by Holtzclaw et al., which involved a total of 964 patients who underwent intravenous moderate sedation for periodontal surgeries, found that the average procedural time was 138.3 minutes (range, 34–390 minutes) (7). Pre-surgically and post-surgically, it took an average of 16.4 minutes to obtain vitals, establish intravenous access and place patient monitors, while recovery time was 15.8 minutes (7). This underscores the need for moderate sedation methods in longer dental treatment duration, particularly within periodontics. The same study also noted that fentanyl and midazolam were the primary agents used for pain-control and sedation, with average dosages of 125.23 µg (range, 25–300 µg) for fentanyl and 9.69 mg (range, 3–28 mg) for midazolam (7). In certain cases, other medications were also administered, such as dexamethasone pre-operatively to reduce inflammation, and ketorolac postoperatively for pain management.

In this study, as in most clinical settings, the use of moderate sedation during periodontal procedures enhanced patient cooperation, improved pain control, and reduced intraoperative movement helping contribute to a more efficient surgical outcome and higher patient satisfaction. Moderate sedation alters the patient’s perception of pain, reduces anxiety, and induces a certain level of amnesia, often leaving no painful memories of the treatment. This can lead to a higher likelihood of treatment success within a shorter period of time (76). However, there are potential risks associated with moderate sedation, including respiratory depression, airway obstruction, nausea, vomiting, dry mouth, blood pressure fluctuations, and allergic reactions. Out of the 964 conscious-sedation procedures completed, a total of 18 complications (~1.6%) were reported (7). Most of them experienced episodes of restlessness; four involved episodes of nausea/vomiting; three were episodes of syncope; and one included intravenous infiltration. Reversal agents (flumazenil or naloxone) were not required, and no major complications occurred. These outcomes highlight the importance of well-trained staff with continuous hemodynamic monitoring of oxygen saturation, blood pressure, and heart rate to manage physiological changes as they occur.

It is also important to recognize the contraindications to moderate sedation, which include pregnancy, known drug allergies, myasthenia gravis, and angle closure glaucoma due to the risk of drug interactions. Additional complications can arise in patients with COPD or sleep apnea, kidney or liver disease, neurological conditions, and muscular dystrophy. Moreover, the lack of appropriate equipment and untrained personnel can further compromise the safe delivery of moderate sedation (77). Some patients do not enjoy the temporary memory loss post-treatment. Moreover, because there is a lack of direct feedback on intraoperative pain, there is an increased risk of traumatic injuries to the trigeminal nerve (42). While oversedation is always a risk, these complications can be minimized by administration from a trained professional (78).

Deep sedation

Deep sedation is defined as “a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation” (71). During deep sedation, patient’s ability to independently maintain ventilatory function may be impaired, and the patient may require assistance in maintaining a patent airway. Cardiovascular function is usually conserved during deep sedation (79). Compared to conscious sedation, deep sedation is less common in periodontics, but it may be an option for patients with severe anxiety. This technique is ideal for most short-duration oral surgery procedures, such as wisdom teeth removal. A common approach to procedural sedation and analgesia involves combining a short-acting benzodiazepine, such as midazolam, with an opioid like fentanyl (76). Careful titration and monitoring of these drugs is required to ensure an adequate depth of sedation while minimizing risks to the patient. Providers administering procedural sedation and analgesia must be skilled in monitoring airway patency and recognizing signs of obstruction, as well assessing ventilation adequacy through the evaluation of chest wall motion, pulse oximetry, and capnography (76).

General anesthesia

General anesthesia is occasionally used in periodontal care for patients undergoing extensive surgical procedures, those classified ASA 3 or higher, or individuals who cannot tolerate dental treatments under local anesthesia or sedation due to severe anxiety or special needs. This advanced method of behavior management carries inherent risks and should not be considered as the first-line approach to anxiety control (54,80). Considered a reversible pharmacologically induced state, under general anesthesia patients experience a complete loss of consciousness accompanied by an elimination of all responses to painful stimuli. Patients often require assistance in maintaining a patent airway through positive pressure ventilation and may experience impaired cardiovascular function (71).

General anesthesia is achieved through the administration of various pharmacological agents, including inhaled anesthetics along with intravenous or intramuscular medications to induce unconsciousness and analgesia. The concurrent use of sevoflurane with local anesthetics is preferred, due to its rapid onset, minimal risk of cardiac ectopy, and pleasant aroma (65). Depending on the case and provider preference, oral surgeons, dental anesthesiologist, or nurse anesthetist may opt to use intramuscular ketamine, maintained with parenteral propofol or inhalation (65).

This depth of sedation puts patients in a more compromised state; therefore, skilled professionals must be equipped to manage complications. Resuscitation medications should be accessible, and appropriate monitoring devices must be properly placed. Periodontists will often consult with oral surgeons, dental anesthesiologists, or other medical specialists. Given that each patient presents unique clinical challenges, careful case selection and thorough evaluation of needs are important when determining the appropriate treatment modality.

Finally, Table 4 summarizes indications, goals, risks, and complications for each type of pain control technique reviewed in this paper.

Strengths and limitations

This review provides an up-to-date summary of anesthetic and analgesic modalities in periodontal treatment, incorporating both established practices and recent innovations in pharmacology and delivery systems into clinical perspective. However, contrary to systematic reviews, narrative reviews are subject to potential selection bias and may not include all the available literature. Future systematic reviews are advocated to more rigorously summarize the effectiveness of each analgesic modality in periodontal treatment.

Conclusions

Anesthesia delivery for the management of pain and anxiety is an integral part of periodontal treatment. The efficacy of different techniques depends on good pre-operative patient assessment. Periodontists have been managing most patients in a dental office setting. Most procedures can be safely and effectively carried out with local anesthetics and minimal sedation. The growing array of delivery techniques and innovations, such as computer-controlled systems and needle-free injections, has significantly improved patient comfort and procedural efficiency. Intravenous moderate sedation is a safe adjunct for long periodontal surgical procedures or in patients with higher anxiety which may prevent the procedure from being accomplished. Depending on the case and provider preference, periodontists may employ anesthesiologists, dental anesthesiologists, or nurse anesthetists to reduce stress levels and improve surgical control. In summary, the choice of anesthesia modality, team, and location is left to the surgical providers and the patients.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://joma.amegroups.com/article/view/10.21037/joma-2025-20/rc

Peer Review File: Available at https://joma.amegroups.com/article/view/10.21037/joma-2025-20/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://joma.amegroups.com/article/view/10.21037/joma-2025-20/coif). L.S. serves as an unpaid editorial board member of Journal of Oral and Maxillofacial Anesthesia from June 2025 to December 2026. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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