By Marc Gottlieb, DDS
I grew up anxious and afraid of the dentist. I never was a difficult or uncooperative patient but never comfortable in the chair as a child. That was the impetus for me to dedicate my 41 plus year career to treating the Apprehensive, un-manageable and medically compromised patient. As a trained general dentist and dental anesthesiologist I will cover and review some of my tools from Tender Loving Care (TLC) to General Anesthesia.
Here are some useful ideas to help calm your patients down. I assume every patient is at least a little anxious. Create a welcoming environment. Ensure that your office has a calm and comfortable atmosphere. Use soothing colors, play relaxing music and provide amenities like magazines or a television to help patients feel at ease. Eliminate temporary restorations that contain eugenol.
Be an active listener: Start by probing into your patients concerns and fears. Give them the opportunity to be honest with you and be empathetic. Make sure you communicate clearly using simple terms, analogies, and non-technical language to explain procedures, potential discomfort and, and the steps you will take to minimize pain. I often will explain how I am able to give a painless injection. It’s not about the length or diameter of the needle but the pH of the local anesthetic. My first step is to apply a small amount topical anesthetic. Every patient understands the concept of topical anesthesia and I will leave it in place for a full minute. Step two: Utilize a small amount of Citanest (Prilocaine) 4% without a vasoconstrictor. Citanest plain has a pH of 7. Without fail this tip will be your largest practice builder. No pain and immediate onset.
You can offer distractions but let them know they are always in control. Televisions and headphones will work to divert some of your patients but reassuring them there will be frequent breaks and they can always raise their hand if they want me to stop. This will work for the average or mildly anxious patient.
Then they ask; What are my sedation options? These can range from nitrous oxide to oral sedation or conscious intravenous sedation, depending on the patient’s needs and the procedures being performed. Minimal sedation: formerly classified as Anxiolysis. Many states do not require a special license or permit to utilize anxiolysis. Having the patient take their own Zanax, Valium or other benzodiazepine you prescribe for them are examples of minimal sedation. MD Anderson Guide to Anxiolysis for the non-anesthsiologist The ADA Guidelines recommends all medications be administered in your office under direct supervision along with additional training specific to that class of medication. I would suggest additional training that includes the use of monitoring equipment and airway management. Nitrous oxide used alone is considered minimal sedation but because of the potential to potentiate other medications along with drug interactions, many states require addition training and licensure for the dentist and hygienist. When nitrous oxide is administered in combination with any sedative / hypnotic then this technique is considered conscious sedation and will require significant additional training and licenses. A small percentage of my adult patients and even smaller number of my children utilize nitrous oxide. Nitrous oxide gives the patient a one or two beer buzz. Adult patients like the sensation they have when drinking alcohol so will request it to relax and calm them down for a procedure. Children don’t understand the high or buzz and it tends to disorient them. In low concentrations it tends to work and is utilized for the administration of local and then removed from the patient.
Oral sedation utilizes a class of medications that when taken by mouth may cause drowsiness and a degree of amnesia. The drugs tend to fall into the benzodiazepine class and limits the recall of the treatment. The intent of the provider is to keep them conscious, so the protective reflexes are always intact and they are easily aroused and respond to commands.
Intravenous or parenteral sedation is a deeper level of sedation; usually but not always given through an IV or injection. Medication reactions tend to come on slowly with oral sedation so you have time to prepare and reverse the patient if they become less responsive or unresponsive. Parenteral sedation can turn into general anesthesia with just a few drops of the medications. Complications can come on quickly and need to be treated immediately with reversal agents. Narcan if an opioid is deployed and flumazenil to reverse benzodiazepines..
Conscious sedation is very safe in patients of all ages and medical ailments. There are certain requirements for record keeping and monitoring in order to treat sick and older individuals but the inherent safety factor to conscious sedation is the patient’s ability to respond to simple commands, maintain their protective reflexes and can consciously override laryngospasm.
Deep sedation and general anesthesia utilizes the same medications as conscious sedation along with several others that are now reserved for oral surgeons and anesthesiologists.
Sedation dentistry can be beneficial for patients who have dental phobia, anxiety, a strong gag reflex or just have difficulty sitting in the dental chair.
Dr. Gottlieb will speak on this topic at the 2024 Florida Dental Convention on June 20-22 in Orlando. You can find more information on his courses at www.floridadentalconvention.com.