Dentists: Is this letter too much to ask of a dentist before I allow treatment?

[ExtremeFear]

Dentists: Is this letter too much to ask of a dentist before I allow treatment?

I have had every bad experience possible happen for dental work when I was younger. As a result for years I suffered, not allowing them to use LA at all. Instead I just got Nitrous Oxide, and had them crank it up as much as possible. I could still feel everything during the procedure but since my mind was somewhere else I didn't react physically. They always HATED to do that though, they wanted to jab me full of needles and have me deal with the pain once I was out of their office (as in post op pain from the needle). Most of my issues stem from the needle though (i ahve LA injected into a vein, directly into a nerve, and had haematomas)...but I also hate the clamp (dam) as I feel like I am suffocating and worry if I start to vomit (from the extreme fear) will I aspirate, and the drill too. I would actually be happy if they would work without the clamp.

I finally agreed to LA but with some restrictions that they had to agree upon. But I have dentists twice now betray my trust... This time I am planning on bringing a typewritten letter to be placed on my file and signed by me. This way I am hoping it will be a legal binding document. I am allowed to refuse treatment after all. So my question is, as a dentist do you think that these 3 requests are unreasonable? Could you work with these, knowing that your patient is taking a huge step even getting treatment? I don't think they are unreasonable...

1: Sedation as deep as possible with anterograde amnesia effect such as IV for ALL dental work (ensuring it lasts the full appt). I don't wish to try and overcome the fear. Even if I were to overcome it, the experience is still very unpleasant and its better to just not be aware of it. I wish to just 'sleep' the appt away like it almost never happened. Problem is, I have had IV sedation wear off prematurely before, leaving me aware of the last 30 min of the appt. It was because initially, she used 2 meds in the IV, one which caused the anterograde manesia effect but she only titrated with the other one. It was horrible because I came to with the clamp still on my face and I panicked. She kept injecting more stuff into the IV but it didnt put me back into lala land. I want them to titrate with the one that causes the anterograde amnesia (or use another method that will ensure the amnesia effect lasts the full apt.) Edit: Or... another alternative I just read on here in another post is to combine oral sedation along with nitrous oxide so that there is a synergistic effect. I have had oral sedation before and it did last the apt, but I wasn't 'under' enough. Would they consider the addition of the nitrous oxide in addition to Halcion (triazolam) so that I am more deeply sedated?

2: NO Inferior Alveolar Block. I have had some pretty bad experiences with this painful injection, which include trismus and prolonged jaw soreness post op, which has always resulted in missed time from work due to calling in sick for a few days to deal with it. I will agree to Peridontal Ligament Injections as alternative. In fact, I have had to forcefully have my jaw reopened after IAB before. I had kept my jaw shut for a week due to the stiffness and soreness and then I could no longer actually open it at all anymore even if I tried. (Dont suggest that I should have gently moved it to keep this from happening, as I won't do something that hurts) They had to use tongue depressors to forcefully open my jaw over the next week or so. It was H*LL. I have had a dentist agree to PDL injections but then as soon as I was under nitrous oxide she jammed the needle into my jaw joint anyway. I tried to protest but the nitrous slowed my reaction time and she had it to the hilt before I could react. She just kep saying "You're doing great" meanwhile my jaw was on fire and in pain! Plus then I had to deal with hours and hours of a swollen droopy drippy drooly lip which I also can't handle... which brings me to point #3, along with the prolonged soreness and stiffness mentioned above.

3: No Epinephrine. I panic with the numb feeling in my face. In fact I have actually injured my lip before by biting it trying to get the feeling back quicker. (I didn't intend to bite it, I just didnt realize I was doing it that hard). I was trying to coax the feeling back like you do when your foot falls asleep. I just can't deal with the freezing feeling. It drives me insane. For me it's like chinese water torture... And it's like I just can't leave it alone... like I feel compeleld to try and get the numbness out as quick as possible almost to the point of panic. Therefore I would prefer the shortest acting LA possible. Mepivicaine without epi is an alternative that I KNOW exists! I would actually prefer it to come out prematurely than last for hours and hours after the apt. (I am under sedation anyway and would probably be ok even without adding more as I have had plenty of work done in the past without any LA at all uner just sedation, including a root canal). Also as mentioned above, PDL injections for mandibular work would help with this also, eliminating the dippy drooly fat swollen lip and tongue for hours thing.

So, if I was your patient, would you agree to those 3 things if it meant I would agree to treatment (a few fillings mostly but I might need a root canal in one).

Thanks for your time... I am not trying to be a difficult patient, but I am just beyond fear and since dentists have betrayed my trust before, that makes it even worse. Those 3 things would go a HUGE distance toward getting me the treatment that I should ahve to be healthy. I know if they don't agree to it, I will avoid getting the work done at all costs... at the very least they have to know I did my research on alternatives!

 

[snapper]

Re: Dentists: Is this letter too much to ask of a dentist before I allow treatment?

Hi, I'm not a dentist but I do have some issues of trust and control when receiving treatment.

I can feel your worry and anxiety when reading your post and some of your points I can identify with, however, from what I can understand, I think that dentists would be concerned whether they had scope to offer treatment.

I know it's not easy especially if you feel trust has been betrayed in the past and you sound like you've had some painful experiences. But if it were me, I would 'test the water' so to speak, to see how the dentist reacted to maybe one of the points on your list of concerns.

There's a lot of information that you want to get across, but sometimes less is better than more

Hope this helps a little!

 

[kittykat]

Re: Dentists: Is this letter too much to ask of a dentist before I allow treatment?

How long have you been with this dentist? I brought my list of stuff for my dentist the first time we met and he wanted to send me elsewhere. But I ended up staying with him, and I after awhile we had a good relationship and he really wanted to help me and ended up to agreeing to even more than the stuff that was on my list! Maybe don't spring this all on him at once. Have you gone to him yet and had an exam? If not, build a relationship through that first, and talk with him about your fears. I don't think your requests are ridiculous but I'm not sure how a dentist would feel if he got that letter from a person who he hasn't ever seen before.

 

[ExtremeFear]

Re: Dentists: Is this letter too much to ask of a dentist before I allow treatment?

How long have you been with this dentist? I brought my list of stuff for my dentist the first time we met and he wanted to send me elsewhere. But I ended up staying with him, and I after awhile we had a good relationship and he really wanted to help me and ended up to agreeing to even more than the stuff that was on my list! Maybe don't spring this all on him at once. Have you gone to him yet and had an exam? If not, build a relationship through that first, and talk with him about your fears. I don't think your requests are ridiculous but I'm not sure how a dentist would feel if he got that letter from a person who he hasn't ever seen before.

Problem is, I am in the military... and our dentists are somewhat of the mindset that if we are in the military we should be tough. We get a different dentist each time. None stay at a certain clinic very long. They get posted as we do. So every time, it's the same thing over again. And since dental exams are 'forced' on us each year, I have no choice. Somehow, I have still managed to avoid an exam for the last 3 years.

In the past they have allowed sedation but once I had a dentist there say he 'may or may not' allow it. I bolted. I cant do it without. Really its only 3 things I am asking for:

Deep sedation that wont wear off too early
No Inferior Alveolar Block
No Epi

Of the 3... deep sedation is the #1. I can suffer with the other 2 if they prescribe pain killers / muscle relaxants for the aftermath of the injections. Most dentists would not do this however. I have been told to just put warm compresses on it, and gently work the soreness and stiffness out. They underestimate the amount it affects me! However, I would also prefer to not have to explain to my supervisor (remember its military) why I called in sick and missed work for several days from getting a 'simple' filling done. Most supervisors would NOT understand the amount of pain, soreness and trismus I get from those injections! And I simply can not work if I am feeling rotten from excessive soreness and can't talk or open my mouth to eat properly.

And if i have excessive numbness I WILL panic and the only way I can get over it is to sleep it off with drugs. I just can't get how dentists expect people to go back to work with a drippy drooly fat swollen lips!!! And work normally like that! And then have to deal with the aching and pain from the injection site when it wears off... still at work! For me, a dentist apt with injections = several days missed work to recover from the injections! (I am talking mostly the block... upper isn't quite as bad however I would still NEVER be able to return to work the same day feeling like that!)

 

[kittykat]

Re: Dentists: Is this letter too much to ask of a dentist before I allow treatment?

Do you HAVE to go to a military dentist? I have heard that they are really rough.

Are you in a place that's not home? I know nothing about the military, but I'm not sure why it wouldn't be a problem to find a dentist in town??

 

[ExtremeFear]

Re: Dentists: Is this letter too much to ask of a dentist before I allow treatment?

Do you HAVE to go to a military dentist? I have heard that they are really rough.

Are you in a place that's not home? I know nothing about the military, but I'm not sure why it wouldn't be a problem to find a dentist in town??

Due to the fact that none of the military dentists at the clinic here used Nitrous Oxide, they did send me to a local dentist here last time. (There are only very few even civvie dentists here that seem to be qualified to use it) It was actually THAT civvie dentist that betrayed my trust and did an IAB when she promised not to. As soon as I was under the nitrous (which she dialed back since she thought I was too out) I felt her ram the needle into my jaw joint (which is the block) I tried to protest but the nitrous slowed my reaction time and she had it burried to the hilt before I could react. By then, she just kept saying "you're doing great" instead of stopping... since she was injecting fast in order to get it done before I could do anything about it, it was extremely painful!
Not to mention, the nitrous level she had me at was not adequate! I was too aware of everything.

I am not really fearful of loss of control at all... I'd rather be completely out if possible... But I am mad that she lied to me and betrayed my trust. ANd that little fiasco resulted in missed days from work and unnecessary pain from the injection site. I had to do the tongue depressor trick over the next week or so get my jaw opened again (it had locked from holding it shut for so long because of the pain)

So the letter on my file is to ensure the legality that it never happens again. Even if they 'think' I wont notice because of the sedation, I will... because bottom injections that are NOT IAB do not freeze your lips and tongue... if I come out of sedation with frozen lips and tongue I will know they did not follow my wishes. And with a legal written document on my file refusing that treatment (IAB) then they can be held legally liable (negligence?)

 

[kittykat]

Re: Dentists: Is this letter too much to ask of a dentist before I allow treatment?

I'm not sure about any legal things as I'm just a nursing student. I suggest you look on the internet to find a dentist that does nitrous! Can you drive like 30 minutes away? I really have no idea how the army works. It sounds like you're a prisoner?

 

[ExtremeFear]

Re: Dentists: Is this letter too much to ask of a dentist before I allow treatment?

Actually nitrous does not seem to put me under enough... that's why I'd like to try oral sedation and nitrous together. I don't know if they will go for it though. Oral sedation by itself also does not put me under enough. I am still too 'aware' with either method alone. But I read on here that used together, they can have a synergistic effect and since the nitrous is kept on the whole apt, then I am not as worried about becoming aware before the work is done. Point blank is I do not want to be aware at ALL during the procedure. Waking too early before from the IV sedation while the clamp was still on my face was horrible!

As for the injections, I am hoping that those two requests can be worked around... no epi (or use that stuff that takes it out quicker... as long as I am still under the sedation - what's a few more pokes once several have already been put in? The potential for soreness would probably be the same). And of course no IAB since I have such awful jaw issues!

 

[kittykat]

Re: Dentists: Is this letter too much to ask of a dentist before I allow treatment?

I've used lorazepam with nitrous. Never have done actual oral sedation, but I considered it as an option and they told me I would most likely be asleep the entire time. Maybe that's something you could try? I know those pills are expensive... that's why I ended up not doing that. But lorazepam and nitrous work really well. And, you'll be able to keep screaming "NO SHOTS THERE!!!!"

 

[ExtremeFear]

Re: Dentists: Is this letter too much to ask of a dentist before I allow treatment?

I've used lorazepam with nitrous. Never have done actual oral sedation, but I considered it as an option and they told me I would most likely be asleep the entire time. Maybe that's something you could try? I know those pills are expensive... that's why I ended up not doing that. But lorazepam and nitrous work really well. And, you'll be able to keep screaming "NO SHOTS THERE!!!!"

I guess I should have mentioned, I have NO issues with needles anywhere else on my body... I still dont like the numb feeling (and as a result I have had stitches in a wound without) but I can handle it in other body parts... its only my face / mouth that I cant handle it. It's much harder to ignore there! And the pain / trismus in my jow is caused because the muscle that the block has to go thru is the one that opens and closes your jaw. So there is trauma to that muscle just from the very act of injecting... normally people experience only a very minor sore spot for a few days. Me however, that muscle goes into spasm, and stays like that for days. So I basically end up talking without moving my jaw. Any movement hurts, so I don't move it. Then after about a week, a few times I physically could no longer move it even if I tried. They use tongue depressors to force it back open... you put two together between your teeth, then force a third in between them. Its not fun! And yes it hurts too! That is why I flat out refuse IAB. PDL injections should be fine... even if they dont work as well as the block... I will be sedated on top of it, as deeply as possible... so even if it doesnt completely numb the tooth, I can handle it... I have actually had a root canal done years ago, with NO LA and only nitrous oxide, but at the time the nitrous worked much better on me and I was pretty much blacked out for the apt.

 

[kittykat]

Re: Dentists: Is this letter too much to ask of a dentist before I allow treatment?

A muscle relaxant may help?

 

[rob wain]

Re: Dentists: Is this letter too much to ask of a dentist before I allow treatment?

Hi
I can understand your extreme difficulty with accessing dental treatment but unfortunately some of your requests are counter productive - I'll try and explain.
Firstly the sedation - the definition of sedation is that the patient is able to respond, that is to say, they are still conscious. This is very important as it reduces the danger of injecting sedatives. If you become unconscious then it is called general anaesthesia and a much more complex level of training and supervision is required. This means that the dentist can't take you too deep.
Amnesia is a great side effect and a real blessing if you don't want to know what happened but it is difficult to 'guarantee' it.
Secondly the local anaesthetic - Sedation doesnt provide any pain relief and a sharp pain can often startle patients who were otherwise coping well with treatment. Adequate anaesthetic (numbing) is essential for a good sedation experience.
The good news though is that lower teeth can often be numbed without using an IAN - problem is that to do this you do need a local anaesthetic with epinephrine. However crestal or intra-ligamental infiltration with, for example, articaine (contains epinephrine) will often give adequate anaesthesia without a numb lip. You would need to discuss in advance of treatment what the dentist is to do if there is inadequate numbing of the teeth and he/she is unable to carry out the treatment.
You can stipulate that there be no IAN and you are quite within your rights to do so - the dentist should and indeed must respect your wishes.
However you should appreciate that your requests, taken together are almost impossible for any dentist to comply with. If you can find someone open to a discussion then they may be able to find the best areas for compromise to help you access some care. I've seen first hand how difficult it can be have treatment and I wish you luck

 

[ExtremeFear]

Re: Dentists: Is this letter too much to ask of a dentist before I allow treatment?

Rob, I think you missed where I said I never used to get LA at all!!! I have had numerous deep fillings and even a root canal performed with ONLY nitrous oxide. The level of nitrous oxide was such that time was really distorted and I was for lack of a betetr word 'somewhere else' but I still do remember feeling the work being done... and it was probably pain, I just didn't react to it physically. As long as I am able to remain still, the dentist shold not have an issue with how much pain I am willing to take up front to prevent lingering achy soreness for days afterwords. At least I didn't have to miss ANY work at all when I used to refuse LA.

The reason I can't do that anymore is that I think I have either become resistant to the nitrous oxide and it doesnt put me under much at all anymore... or they are just not using as much of a concentration. Either way, I am too 'aware' to go through an appt with just nitrous anymore and definitely too aware to do it without any LA. IV sedation works perfect, as long as they can titrate with the agent that causes the amnesia. But they didn't when I tried it. And I became 'aware' with the horrible clamp on my face still. I immediately had visions of alien abduction horror movies where people were strapped down and had things forced into their mouths with some clamp thing holding it open. I had both hands pressed on the seat arms and my knees were drawn up and I was ready to just bolt. The dentist had to rush to finish everything because I was grabbing at the clamp (dam) and the nurse kept injecting stuff into the IV but it wasn't working at all. I never got back into the amnesia state. That experience was very traumatic. I would go for IV sedation again if they could guarantee that wouldn't happen. Next time, if I become aware during a procedure I would bolt for sure whether the work was done or not. Another option is to not use the clamp!

But the fact still remains, I also need the LA to not last very long or I will panic and end up causing damage after the appt (I almost needed stitches once from btiing my lip). I would prefer to walk out with no numbness at all left remaining. I don't know if the military would carry that agent that counteracts it, or if they would even consider using it (or even if it works all that well). I would rather it wore out too quick than last too long (and I CAN keep still). I don't intend to cause myself damage as in bitten lip etc but I just can't leave the numbness alone until its out. The poking and biting at my lips tongue etc are constant until the feeling comes back. It's like I am not even consciously doing it. I can't emphasize enough how much that felling (or lack thereof) drives me absolutely batty insane. And its not even a fear thing... it's an annoyance thing, that ranks about the same as if someone placed me under a chinese water torture device and said "you'll just have to wait until the water runs out". So Epi is out... end of story. If they don't like it... then I can refuse treatment and just go without.

If they can do PDL injections vice IAB with an anesthetic without epi, then I would be fine with them reinjecting during the procedure if need be. But given my history of having work dome without any LA at all... and my ability to remain still even though I can feel it (kind of self hypnosis made easier by the sedation I guess) then the dentists should be ok with it too. Another reason I do NOT want Epi is that I have reacted to it injected into a vein before... and I never want to experience that again! I thought I was having a heart attack. As a medical responder I have to tell others of the side effects of epi pens etc. And knowing the side effects doesn't make it any easier to handle when it's YOU feeling it!

So Id like to try combo oral sed / nitrous. Even if the oral sed is only mild. The nitrous will last the full appt and the oral sed will cause more amnesia effect.

I flat out refuse Inferior Alveolar Blocks

I flat out refuse Epi.

...I can handle any temporary pain even if its intense... it's the lingering achy soreness gnarling pain that lasts for a week after an IAB that can't handle.


It's those 3 things or no go for me at all.

Hi
I can understand your extreme difficulty with accessing dental treatment but unfortunately some of your requests are counter productive - I'll try and explain.
Firstly the sedation - the definition of sedation is that the patient is able to respond, that is to say, they are still conscious. This is very important as it reduces the danger of injecting sedatives. If you become unconscious then it is called general anaesthesia and a much more complex level of training and supervision is required. This means that the dentist can't take you too deep.
Amnesia is a great side effect and a real blessing if you don't want to know what happened but it is difficult to 'guarantee' it.
Secondly the local anaesthetic - Sedation doesnt provide any pain relief and a sharp pain can often startle patients who were otherwise coping well with treatment. Adequate anaesthetic (numbing) is essential for a good sedation experience.
The good news though is that lower teeth can often be numbed without using an IAN - problem is that to do this you do need a local anaesthetic with epinephrine. However crestal or intra-ligamental infiltration with, for example, articaine (contains epinephrine) will often give adequate anaesthesia without a numb lip. You would need to discuss in advance of treatment what the dentist is to do if there is inadequate numbing of the teeth and he/she is unable to carry out the treatment.
You can stipulate that there be no IAN and you are quite within your rights to do so - the dentist should and indeed must respect your wishes.
However you should appreciate that your requests, taken together are almost impossible for any dentist to comply with. If you can find someone open to a discussion then they may be able to find the best areas for compromise to help you access some care. I've seen first hand how difficult it can be have treatment and I wish you luck