Sedation Dentistry
One of the reasons Dr. Hall has taken a special
interest in the dental patient with anxieties and fears is that
he is an anxious patient himself. He gets sweaty palms
whenever he sits in the chair for restorative work. In his case it comes from memories of
painful dental care as a child, with a dentist who didn't use novocaine or anything. Now,
when those anxieties come back, he has trouble getting numb. "I know there are some
dentists who say they don't believe it when patients tell them they aren't numb after a
novocaine injection," says Dr. Hall. "Not me. I believe those patients because
I'm one of them! I had an experience when I needed some orthodontic extractions, and in
spite of shot after shot, the dentist couldn't get me numb.
The novocaine hit the nerve, but it just
wasn't working. It was terrible! For my
root canal treatment it was the same way - the
dentist couldn't get me numb. I know what some of you go through."
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Options for treating dental fear:
Here are
some of the options dentists have at their disposal for treating anxious
patients, depending on the patient's level of anxiety and body chemistry:
 | stereo headphones (a distraction that
can help relax you)
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| nitrous oxide gas (for mild anxiety)
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| anti-anxiety premedication (for mild
and moderate anxiety)
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| conscious sedation or
sleep dentistry (for any level of
anxiety)
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| extra-strength novocain
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| or a pause when you need it - whatever it takes.
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"For my own treatment, I like the nitrous oxide gas," reports
Dr. Hall. "Give me a little gas, and then the novocaine works and I'm
wonderful!"
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Rationale for handling patients with dental fear:
Pain is a complex issue. There is a biochemistry of pain and a psychology
of pain, and you can't fully explain pain and its intensity without understanding both
fields of knowledge.
There is a pain receptor which transmits an impulse to the brain which the
brain receives and then interprets as pain. We can influence the pain receptor, the
transmission, the reception by the brain, or the brain's interpretation of the stimulus.
Past experiences influence the interpretation. Anticipation can greatly magnify a
response. There are times when mere gentle touching of a person can be interpreted as
pain, because of prior conditioning, past experience, level of anxiety, and other
psychological factors. There are also varying levels of pain tolerance from one patient to
another. Some patients can feel pain and yet it doesn't bother them, where others can feel
the same pain and not be able to tolerate it.
Additionally, there are interactions between hormones related to emotions
and the transmission of the pain. The dentist can give an injection of local anesthetic,
and, if the anxiety level of the patient is high enough, the pain transmission will still
occur, in spite of the fact that the local anesthetic is supposed to be blocking the
transmission. If we treat the anxiety level, then the local anesthetic works. Or, there
are times when the local anesthetic may work but because of anxiety, it wears off very
quickly - like in maybe five minutes. This anxiety is beyond the patient's control - he
cannot merely reason himself out of it. It is there, and he has to deal with it.
Without proper empathy, it is difficult for a dentist to fully treat pain
during treatment - there will be a lack of understanding of the emotional and
psychological aspects of the pain and its interpretation. The dentist may take the
attitude that "you're just being a difficult patient. I've done what I was trained to
do to handle your pain, and if that's not enough for you, it's your fault."
Therefore, he or she will make no further efforts to handle the situation and either
insist that you endure or otherwise refuse to treat.
Treatment options:
For low levels of anxiety, nitrous oxide gas works well. It brings the
level of anxiety down just enough for the local anesthetic to work and the treatment to be
comfortable.
For higher levels of anxiety, which occurs when there is a history of
traumatic dental treatment, orally medicated conscious sedation
may be indicated. In our office, we used diazepam (Valium®) and
meperidine (Demerol®)
for many years, which are excellent medications for lowering the level of
anxiety, for giving a feeling of euphoria that seems to be needed in erasing some of the
prior negative conditioning, or, if necessary, bringing about amnesia: forgetting the
entire appointment. Recently, oral triazolam (Halcion®)
has become very popular with sedation dentists. It also has a high level of
safety and wears off more quickly than diazepam, and thus is more convenient for
patients. In recent years, this has been termed
sleep dentistry, and many dental
practices are offering this option.
Sometimes, with very high levels of dental fear, patients, in spite of
very adequate levels of sedative, still cannot seem to endure the dental
treatment. However, after the appointment, they may not be able to remember the
appointment. The treatment then is successful in their mind and this successful experience
works for their benefit by reducing their anxiety in subsequent appointments.
Often, patients with memories of traumatic dental care, after a few
appointments with sedation, are able to move away from the sedation. With a few successful
dental appointments under their belt, the doctor can lower the level of sedation so that they
remember the appointments with greater and greater clarity, until they no longer need
sedation.
Oral sedation with the proper medications has
an excellent safety record. Valium® by itself is extremely safe, even in large doses.
Hoffman-LaRoche, the manufacturer of Valium®, has data on file showing patients who have
taken up to 2000 milligrams (that would be the equivalent of two full bottles of 10 mg.
tablets) in attempts to commit suicide, and no rescue medications or other rescue measures
were needed, because vital functions were not adversely affected.
Triazolam is of the same drug family, and is also extremely safe. Nevertheless,
as a precaution, most dentists using triazolam or diazepam employ monitoring
equipment.
Further information:
