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If you reckon that the right dentist and the techniques described in the previous section alone won't
do the trick for you, have a look at the available pharmacological options for reducing dental anxiety.
These are not recommended for use instead of, but in addition to a caring dentist. Trust your gut instinct while figuring
out which methods might work for you.
Pros and Cons of Sedation
You can read about the different types of sedation available below. When deciding on whether sedation is for you and what
type(s) of sedation to go for, the following list of "Pros" and "Cons" might help you. They are pointers,
rather than hard-and-fast rules, and are largely based on personal observations.
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Pros
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Cons
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You tend to agree with the following statement: "If I could be worked on without knowledge of the procedure, pain
or memory of the treatment, then there wouldn't be much to fear".
You do not want to know what's happening. This would hold true for you even if you had a friendly dentist who could convincingly
offer pain-free treatment using local anaesthetic only.
Your primary aim is "to get your teeth fixed".
You want to be as "out of it" as possible. You "don't want to know" and don't want to remember the procedure.
You have a "gut feeling" that sedation would help you and allow you to get work done on your teeth which otherwise
you wouldn't be able to tolerate.
You want to get a lot of work done "in one go".
You need to get a lot of work done "in one go", because you're very busy or because an important social event
is coming up.
You're facing a long procedure which can't be broken down into shorter visits.
You're facing a procedure which would otherwise be uncomfortable or on the gory side (e. g. extraction of impacted wisdom
teeth, certain types of gum surgery - your dentist will advise you if things could become uncomfortable). In some cases of
complex oral surgery, a general anaesthetic may be required to make the procedure comfortable.
You need a little extra help to relax.
You suffer from persistent needle phobia which can't be controlled with behavioral methods. Even in extreme cases, it
is usually possible to get you relaxed enough to accept treatment by using laughing gas followed by IV sedation.
You have a bad gag reflex, and attempts at bringing it under control using behavioural methods have persistently failed.
In this case, laughing gas is the method of choice, and if that fails, IV sedation is an option. Both methods greatly reduce
the gag reflex.
You need extra painkillers administered into your blood-stream for whatever reason.
Your nerves are in very unusual places (very rare) and you can't find a dentist familiar enough with unusual local anesthesia
techniques to get you numb. With IV sedation, you will remember very little about the procedure because it causes memory loss,
and additional morphine-like painkillers can be administered into the bloodstream.
You need some extra help in calming your nerves to attend your appointment.
You have a fear of specific "dental procedures" rather than "dentists".
You've tried things like meditation or hypnosis in the past and found them to be quite effective in calming you.
Imagine the following scenario: you've met a person you immediately become friendly with. Turns out they're a dentist!
They're aware of the state your teeth are in (nothing to worry about on the embarrassment front) and invite you along to their
practice. You observe them perform some painless procedures on other people. You decide to let them treat you. In this situation,
you would prefer they give you anti-anxiety drugs beforehand, because you'll feel more relaxed about the whole situation.
You might want some sort of anxiety-reducing drugs during any procedures, because it would make you feel more comfortable
and relaxed.
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One of the major features of your phobia is a lack of trust in the dental profession, and a fear of loss of control.
You've had bad experiences with dentists not stopping when you were in pain in the past, or you have a history of sexual/physical/emotional
abuse.
Your primary aim is "to get your phobia fixed".
You need to know that your dentist will proceed "at your pace" and only do things you're comfortable with.
You're very scared of being sedated.
You don't approve of psychoactive drugs.
You're a "take-charge" person who likes to be in complete control of the situation at all times. The success
of pharmacological sedation is partly based on the person's desire to "let go" and relax. You may not only be unwilling,
but unable to release control of your mind to the drug/s being used.
Research suggests that the chances of overcoming dental phobia are much greater using behaviour modification compared
to using pharmacological methods alone, where fear has been found to return to baseline levels. This may be especially true
for forms of sedation which involve loss of memory for the procedure (it's difficult to learn a new behaviour if you have
no new memories which can replace frightening old memories), but not for inhalation sedation (which does not involve memory
loss).
Some dentists with poor people skills may use sedation instead of learning to manage people's anxiety properly. Sedation
may be seen as a "quick-fix" solution and pushed on the client without exploring alternatives.
You feel that being offered sedation would mean you're a "hopeless case".
Sedation is more expensive. Some forms of sedation (e. g. "laughing gas" and oral sedation, i. e. pills) are
only somewhat more expensive, while others (e. g. intravenous sedation) can be quite a lot more expensive.
In many areas, sedation is not widely available. You're limiting your choice of dentists.
Certain medical conditions can contraindicate the use of certain types of sedation drugs.
You're worried that taking an anti-anxiety drug such as Valium before your appointment will interfere with your judgment
and your ability to communicate your concerns to your dentist, or won't allow you to make informed decisions.
Forms of sedation other than "laughing gas" will prevent you from operating machinery - including cars. You'll
need an escort until the effect of the drugs has worn off, and you can't go straight to work afterwards.
You're "terrified of dentists" rather than of specific dental procedures.
You've tried things like hypnosis or meditation before and they didn't work for you. You may have been laughing or otherwise
"resisting" them.
Imagine the following scenario: you've met a person you immediately become friendly with. Turns out they're a dentist!
They're aware of the state your teeth are in (nothing to worry about on the embarrassment front) and invite you along to their
practice. You observe them perform some painless procedures on other people. You decide to let them treat you. In this situation,
you would prefer that they prescribe no anti-anxiety drugs, because you'd like to be in full control of the situation and
know of everything that's happening. You would prefer them to slowly "get you used to dentistry" by showing you
everything they do.
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The above are only rules-of-thumb which may help you to weigh up the pros and cons of sedation, in your particular situation.
They're not always mutually exclusive. For example, if you feel that more of the "cons" apply to you, you may still
want to choose sedation for a procedure which most people find uncomfortable (e. g. extraction of difficult-to-remove wisdom
teeth and the like), but you'll probably feel happier starting off slowly until you get to a point where you're no longer
scared and this seems feasible. On the other hand, if you feel happier with a pharmacological approach, your long-term aim
may be to get by with less or without the use of sedation.
Sedation is often recommended for "severe dental phobia". However, there is no consensus as to what constitutes
a "severe" phobia. Scores on dental phobia tests bear little or no correlation to the need for (or desirability
of) sedation. As a rule-of-thumb, sedation can be useful
if you don't want to be aware of what's happening during a procedure and you want to be "out of it", IV sedation
is the method of choice
if you want a little help to relax - "laughing gas" can give you a pleasant intoxitated feeling
if your fear is procedure-specific (e. g. needles, extractions), especially if you know that the fear would still exist in
the presence of an empathetic dentist and adequate pain-control
if you perceive your fears to be completely irrational, and/or
if you have other mental health problems and you feel you'd benefit from sedation.
Sedation may not be a good option
if you're "terrified of dentists" (as people)
if you fear "being assaulted" (in the broadest sense) or deliberately harmed
if control and trust are major issues
if you're considering sedation to "make life easier" for your dentist (more about this below), and/or
if you feel you would benefit from a gentle approach which would involve being talked through procedures, going at your pace,
and using stop signals.
There can be a conflict between your dental fears, on the one hand, and your need for control on the other. If you choose
sedation, this pretty much eliminates your anxiety about discomfort or pain from the dental procedures, if that's what you're
afraid of. Or, if you're afraid of a panic attack while sitting in the dentist's chair, sedation might eliminate that fear,
too (but see comments below on "wanting to please the dentist"). But if you want to be consulted if anything unusual
comes up, or if you're more generally worried about not being in control of proceedings, "sleep dentistry" may be
a hindrance rather than a help. It may be worth discussing inhalation sedation (laughing gas) with your dentist if you don't
like the idea of loss of memory for the procedure, and if some sense of control is important to you. What you choose will
depend on what you believe is most important.
Most people have some degree of ambivalence about being in control of, or aware during, a delicate or potentially painful
situation, medical or dental. You and your dentist should discuss whether the procedure would be uncomfortable or distressing
to you. It may be useful to talk to others who have undergone the procedure. For a few reasons it may be wise to have a friend
or family member present during the procedure. This may ensure that your basic dignity and privacy are not compromised. Also
the dentist may relate useful information to them during the procedure.
The two paragraphs above are partly based on the Mental Health Association of Greater St. Louis' "Open Mind" column ("Fear
of going to the dentist"): Sleep Dentistry - Mixed Feelings.
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Types of Sedation
While sedation can be administered in lots of different ways (including administration through the skin, nose, rectum, muscles,
under the tongue, or even through the nose - every bit as unpleasant as it sounds!), the 3 most common forms of sedation on
offer are:
1) Inhalation sedation (aka "laughing gas", "happy gas", nitrous, nitrous oxide)
2) Oral sedation (i. e. swallowing pills or a liquid)
3) Intravenous (IV) sedation (i. e. drugs administered into the blood-stream through a vein - that's what "intravenous"
stands for)
To find out more about each of these methods, click on the internal links below:
Inhalation sedation
Oral sedation
IV sedation
None of the sedation methods above involve being "put to sleep" - but note that advertisements for "sleep dentistry"
sometimes refer to oral or IV sedation. Being put to sleep is referred to as general anaesthesia, or GA for short.
General Anesthesia / Deep Sedation
Some thoughts on sedation
There is no doubt that sedation is a fantastic option for some people. Some dentists will opt for it for themselves when undergoing
certain procedures (I've even heard of one who'll have nitrous oxide for a simple cleaning!). But it's not for everyone -
and it shouldn't be pushed on people.
Nowadays, you'll come across quite a few websites which advertise themselves as "catering to the dental phobic"
or even "catering to cowards". Or they'll breathlessly announce "sleep dentistry" or "twilight dentistry"
as the solution to all your problems... but with some of them, all they seem to offer, apart from being not particularly unfriendly,
is sedation or even general anaesthesia. There may be blanket statements along the lines of "if you are terrified of
dentistry, sedation is THE answer". Of course, there isn't one answer that applies to everyone. And personally, I'd be
quite wary of any place which advertises itself in that way. True enough, often the website design is left to a professional
dental website design company, who simply inserts a standard piece of text. It's even possible that the owner(s) of the practice/office
are blissfully unaware of the marketing hype. I'm not saying that all dental offices which advertise themselves in this way
are bad - there are some great ones around that receive excellent feedback.
Perhaps the most disturbing aspect of the marketing hype for sedation is this: some people will agree to (or even request)
sedation even though they'd prefer not to be sedated - because they worry that the dentist is going to be upset with them
should they panic. They're worried that they'll inconvenience their dentist because s/he may have to stop what s/he's doing,
that their dentist will then get frustrated or angry with them, which in turn will cause them to react with more fear. This
reasoning is usually based on the assumption that no dentist will want to deal with someone who's "difficult" (i.
e. someone who needs more assurance than the average patient).
If that is the way you feel, please don't settle for a "put up and shut up" approach - instead, make an extra
effort to find a calm and understanding dentist who has the ability to put you at ease, even if this means meeting more than
one dentist (for a chat, initially) to see whom you feel comfortable with. Hey - you're worth it ;) !
It's also true that depending on where you live, sedation may not be widely offered - and it's more expensive. If you
suffer with dental phobia, it can be very disconcerting, if not scary, to read statements along the lines of "the only
way people like you can be treated is when you're sedated". Not true in most cases! So don't have a nervous breakdown
if you can't avail of it - generally speaking, pain can be controlled extremely well with the use of local anaesthetic, and
anxiety can often be controlled using psychological methods. However, if you have an instinctive feeling that behavioural
methods can't help you, make sure you seek out a dentist who offers sedation.
Many dentists who offer sedation simply do so as an adjunct to empathetic treatment, to patients who desire to know as little
as possible of the procedure or who want to get things fixed in the least amount of time possible. However, there are also
some who offer it because they lack the people skills needed to make frightened clients feel at ease.
In this context, it is informative to note what Stan Malamed, the author of "Sedation - A Guide to Patient Management"
(2003 edition) has to say on the subject:
"I have received extensive training in the administration of drugs for pharmacosedation and general anaesthesia, yet
I have received no formal training in any aspect of psychology or human behavior. It would appear, therefore, that I should
have a strong bias toward the use of techniques requiring drug administration. When I first started my training in anaesthesiology
in 1969 this was true. However, in the ensuing years I have become acutely aware that iatrosedation [i. e. the relief of anxiety
through the doctor's behaviour] is an integral part of the success (or possible failure) of every procedure that we in medicine
and dentistry attempt." (p. 79)
Malamed cites a classic study by Egbert et al (1963) illustrating the importance of human behaviour in the control of anxiety.
In this study, patients about to undergo surgery the next day were placed in one of three experimental groups. Participants
in group 1 were visited the day before by the anaesthesiologist who explained the upcoming events to them and answered any
questions the patients had in order to allay their fears. Those in group 2 received a sedative one hour before the operation
but no visit. Those in group three received both the visit and the pre-op sedative.
The results showed that patients in group 1 were alert upon arrival in the operating room but quite calm and didn't appear
to be apprehensive. Those in group 2, who had received a sedative only, were drowsy - but apprehensive. People in the third
group were both drowsy and calm. This example demonstrates that using pharmacosedation instead of, rather than as an adjunct
to, iatrosedation just doesn't do the trick.
Anyway, what I'm really trying to get at is: as a dentist, explore if and what level of pharmacosedation is required first,
paying particular attention to the issues mentioned above.
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"What's the story with sleep dentistry? Are there certain procedures which would be too painful otherwise?"
"I don't recommend sedation for procedures, but for patients. Some patients require sedation for almost any treatment,
others prefer it for long duration of treatment or something that they find unpleasant.
As a rule of thumb, IV is for people who want to know nothing about the treatment and be as "out of it" as possible.
The disadvantage is that they need escorted home and watched for at least the next 6 hrs. Nitrous Oxide (or RA in "dentist
speak", short for Relative Analgesia) is for people who are a bit nervous, it calms them down nicely and is a fairly
effective painkiller. It's fantastic for older children and properly done almost guarantees painless dentistry.
I sometimes combine nitrous with IV for proper needle phobics, for whom desensitisation doesn't work.
GA is a last resort. There are many procedures that can't be really be done under GA and there is always the risk of death.
I always get a bit nervous before a GA clinic and I've been doing them for a long time now." (Gordon Laurie, BDS)
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"I'm far too scared to see a dentist, but I know I have to go, I'm in soo much pain... Of course, my preference would
be to be unconscious, an ambulance picking me up at home, and waking up with everything done, but that's not going to happen...
Which anti-anxiety medications do you recommend to get me to the dental office (arrrghhhh)? Help!"
"The typical anti-anxiety meds given in the dental office; or at least the ones I give are valium, ativan, or even nitrous
oxide.
When we are considering any mind altering drug we must consider a few things such as: benifits vs. side effects, how long
the drug will last ie. valium has a very long 1/2 life vs. ativan with valium you still may be filling the effects 2-3 days
later with ativan maybe 1-2 days. The nice thing about nitrous after 2 minutes of breathing the gas you are at full potency
and 2 minutes off the gas you are completely free of the gases effects; this is one reason we like N202 so much. Also consider
with Nitrous you can drive home after the appointment with the others you can not.
What I suggest to you more than drug therapy is find a dentist that makes you comfortable. One that you trust, that takes
the time to explain things to you and relieve your fears rather than rush right in. This way you are already calm and relaxed
therefore, the need for drugs will decrease.
For example, I seen a new patient about 3 weeks ago; she hadn't seen a dentist in over 10 years due to bad experience
in the past and phobia. I had to give her ativan just to get her in the door for a 30 min new patient exam. The very 1st procedure
I had to to to her was the a root canal *of all the bad luck it couldn't be something quick and easy, nope a 2 hour RC - her
dental insurance was ending at the end of the month. I would of Loved to of waited, I could of gave her some antibiotics and
perhaps, pain killers delayed txt, started off slow and gentle but we where in a time crunch. To add to my dismay I had to
do it with no premed b/c her husband couldn't come with her to drive her home this time.
So I proceeded, my fear was if somehting went wrong or I scared her I would never see her again; and this would of been
tragic b/c she definally needed txt.
To make a long story short, by the end of the appointment she was in tears, she told me, " This was the best dental
visit she had ever had." I left work that day with a stomach full of butterflies, I felt all aglow, and I gained a patient
for life. This is how the dentist/patient relationship should be.
One final comment, these drugs mentioned above all come by prescription only and you remain awake the entire time. Do
not confuse these with general anath. or sleep anath." (Dr Silverfill, DDS)
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