Alleviating anxiety during dental visits

 29 Sep 2015 - 0:00

 Alleviating anxiety during dental visits

By Christie Aschwanden

The thought of sitting in a dentist's chair has filled me with terror for as long as I can remember. It started with some painful dental work I had as a kid. A bike accident requiring jaw surgery and extensive dentist visits only made things worse. So when I heard about "sedation dentistry" and the promise that it would allow anxious patients like me to spend a dental visit relaxed and unaware of the unpleasant procedures taking place, I was intrigued.

Dental phobia is common, and it can prevent people from getting needed care, says Michael Kostrov, a dentist at Comprehensive Dental Care in Washington. "It's like a fear of heights: There's no rationale for the fear, so you can't just tell people not to worry." Different degrees of sedation can leave the patient merely relaxed or pushed to the edge of consciousness. "You wake up and have no memory of the visit," Kostrov says.

Sedation is usually achieved with a benzodiazepine drug given in a pill. Kostrov's practice normally schedules sedation visits for first thing in the morning, and the patient takes the pill at home, about an hour beforehand. (An unmedicated driver or escort is required to get the patient to and from the dental office.)

Oral sedation is safe, Kostrov says, and it's a good choice for a phobic patient who needs extensive work that will require multiple hours in the dentist's chair. (This type of sedation can last up to six hours. It does not replace local anesthetic painkillers.) Intravenous sedation, usually with a drug such as propofol, is another option that's more commonly used with short procedures, such as wisdom teeth extraction, Kostrov says.

Though both types of sedation are generally safe when properly used, intravenous sedation has a greater effect on breathing, Kostrov says, and requires more training on the dentist's part. What type of training a dentist needs to administer sedative drugs is governed by each state's dental board.

Before you agree to sedation, make sure you understand what drugs you'll be given and what their side effects and risks are, says American Society of Anesthesiologists President J.P. Abenstein. Ask how your vital signs will be monitored while you're sedated and who will be doing the monitoring. In rare cases, sedative drugs cause people to stop breathing, and you want to be sure that someone is monitoring your vital signs at all times and that there's an emergency plan in place in case something goes wrong. Ideally, the office should have a defibrillator and everyone on the medical team should have training in advanced cardiac life support, Abenstein says.

Other questions you should ask include: How have you determined the drug dosing? (You can check that the dose matches the one recommended in the drug's package insert, available at the FDA's Web site.) What will you do if I have trouble breathing? The medical team should use a pulse oximeter to continuously monitor your blood oxygen levels, says American Dental Association spokesman Joel Weaver. Benzodiazepines have reversal drugs that can counteract sedative effects, and the office should have these on hand. Even so, these drugs take time to work, Weaver says, so the office should have an emergency plan for treating airway problems or other serious side effects.

Some dentists learn to administer sedative drugs through a course that consists of only a classroom component. "So the dentist learns how to do it in classwork, but the ADA recommends that there should also be a clinical component where people get practice working directly on patients," Weaver says. Don't be afraid to ask your dentist what training he or she has received.

Before giving you any kind of anesthesia or sedative drugs, the clinician should take a complete medical history. Especially important are such questions as: Do you have a history of heart disease? What surgical procedures have you had previously? Do you have any allergies? "If you're not asked any of those questions, that's a red flag," Weaver says.

Kostrov's clinic schedules a consultation before the sedation visit to collect a medical history, discuss which procedures will be done and obtain consent for the treatment plan. "The patient won't have any memory of the process, so we do all consent ahead of time," Kostrov says.

Some health issues, such as heart problems, lung disease and obstructive sleep apnea, can make sedation more risky. If you have even a minor case of sleep apnea, then even a mild dose of sedative drugs may cause an obstruction of your airways, Weaver says. Also, the low blood pressure that can occur with sedation may increase the risk of heart attack or stroke in people who are already vulnerable.

Sedation dentistry is generally safe for kids, but you should ask lots of questions before allowing a dentist to sedate your child, says Sarat Thikkurissy, a spokesman for the American Academy of Pediatric Dentistry who practices dentistry in Cincinnati. The AAPD and the American Academy of Pediatrics have a joint set of guidelines for sedation in children, and you will want to make sure your dentist is familiar with them, Thikkurissy says. Also, some states require a special permit for giving sedation to children younger than 12. Any practitioner should be prepared to rescue the child from an adverse reaction. "That's where an emergency plan comes in," Thikkurissy says.

Regardless of the type of sedation you get, it will take some time for your body to return to normal. "Some patients can be foggy for several days," Abenstein says. You'll need someone to take you home after the visit, and you should plan to take the rest of the day off from work.

I'm overdue for a dentist visit, but after learning about what's involved in sedation - including the expense, which can be $400 on top of the cost of the dental procedure - I've decided I can live without it for the filling I need. As much as I hate the anxiety, I hate losing a whole day of brainpower even more, and I would rather spend the money on something enjoyable.

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