Sedation Dentistry

If you feel that the right dentist and psychological techniques alone won’t do the trick for you, have a look at the available pharmacological options for coping with 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. Sedation is sometimes touted as “the solution for overcoming dental anxiety or phobia”, but in reality, many people don’t like the idea of sedation. Scores on dental anxiety tests bear little or no correlation to the need for (or desirability of) sedation.

❓ “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 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)

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”. In this case, IV sedation is the method of choice.
  • you want a little help to relax – “laughing gas” can give you a pleasant relaxed feeling
  • you have a “gut feeling” that sedation would help you and allow you to get work done which otherwise you wouldn’t be able to tolerate
  • 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
  • you perceive your fears to be completely irrational and not helped by either an empathetic dentist or psychological techniques
  • you have other mental health problems and you feel you’d benefit from sedation
  • your primary aim is “to get your teeth fixed” as quickly as possible, for example because you’re very busy or you’ve got an important social event coming up
  • it’s an invasive or unpleasant procedure such as more complex extractions
Sedation may not be a good option if:
  • control and trust are a major issue for you
  • you’re considering sedation to “make life easier” for your dentist, for example because you fear that they will get frustrated or angry with you
  • you feel you would benefit from a gentle approach which would involve being talked through procedures, going at your pace, and using stop signals
  • you feel you’re being “bullied” into accepting sedation
  • you have an intense dislike for or fear of the drugs used for sedation (or the psych pharmaceutical industry in general)
  • you’re worried that sedation will interfere with your judgment and your ability to communicate your concerns to your dentist

Types of Dental Sedation

The 3 most common forms of sedation on offer are:

  1. Inhalation sedation (also known as “laughing gas”, “happy gas”, nitrous oxide, “gas and air”, relative analgesia)
  2. Oral sedation (anti-anxiety pills or a liquid)
  3. Intravenous (IV) sedation (drugs administered into the blood-stream through a vein – that’s what “intravenous” stands for)

Click on the links to find out more about each of them.

None of these involve “being put to sleep”, even though advertisements for “sleep dentistry” sometimes refer to oral or IV sedation. Being put to sleep is called general anaesthesia, or GA for short.

“Sleep Dentistry” – Mixed Feelings

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 can pretty much eliminate your anxiety about discomfort 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 if you 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.

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 a treatment would be uncomfortable or distressing to you. It may be useful to talk to others who have experienced the treatment. For a few reasons you may want to have a friend or family member present during the procedure. This can ensure that your basic dignity and privacy are not compromised, if you are in any way worried about this. Also the dentist may relate useful information to them.

Some people feel empowered by using sedation, despite liking to be in control:

“I am an absolute control freak, I have to be in control, I’m just a domineering old bossy boots. However, by having IV sedation, I don’t feel I was not in control. Rather the opposite because it was my decision to have it because it ws the only way for me to deal with extreme fear of extractions. I like to be in control when I know what I am doing. When it comes to dental work, I am no expert, therefore I leave it up to the experts and hand over complete control to them while I take a back seat so to speak, under sedation. Therefore, by making that decision, I feel I was completely in control of my own destiny so to speak.”

The case for sedation

The case for sedation can be summed up in one sentence: “If it helps, why not?”. If you’re going to have a treatment that will not be painful, but might be uncomfortable, why not have sedation as part of the course and forget that it ever happened?

The case against sedation

Other dentists argue that relying on sedation does not allow you to overcome your fears, for a number of reasons. In the case of IV sedation, because you will not remember the treatment, you cannot learn that dental treatment is nothing to fear. Oral sedation can have the same effect because benzodiazepines can impair memory and interfere with the acquisition of new information and laying down new memories. Sedation may also make you believe that the only reason why you’re able to cope with treatment is the sedation, and you may not attribute your success to yourself, but to the drugs used.

So what’s the verdict?

The argument against sedation does appear to have some validity, judging from anecdotal evidence from both dentists and patients (although there is no real consensus).  This is not so much of a problem with laughing gas, because it doesn’t appear to affect memory in the same way as benzodiazepines (for example, people often recall warm fuzzy feelings or feeling amused, and these positive associations can help with overcoming fears). Also, both some dentists and some people with dental fears find that IV sedation does ease their fears long-term and that they were able to progress to having treatment without sedation. Anecdotal evidence suggests that this may be more likely if sedation is “tapered off” during the treatment, so that anything which could potentially be unpleasant is done under heavier sedation first, and lighter sedation is used towards the end of the appointment.

There is no right or wrong when it comes to dental sedation. Many dentists quite happily offer both psychological methods and sedation side by side, and together with you figure out what suits you as an individual. Other dentists have a strong preference for one or the other. If that is the case, make sure that the dentist you choose shares your own preferences!

Some thoughts on sedation

There’s 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 more condescendingly, “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 web 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 patient 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 may offer it because they don’t have the personality and/or skills needed to make frightened people feel at ease.

In this context, it is interesting to note what Stanley 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 sedation instead of, rather than as an adjunct to, a doctor or dentist who will try and relieve anxiety just doesn’t do the trick.