Omar Iqbal on Dental Sedation
Omar Iqbal BDS, MSc Dental Implantology (GDC 85632) qualified from the University of Glasgow in 2005, and with his partner he opened Complete Dental Care in Glasgow. Omar has a calming and caring nature and enjoys helping patients to overcome their dental fears. His main focus in the clinic is providing dental sedation to treat anxious patients. He works with a friendly team that are experienced in providing dental sedation, which can allow even the most phobic patients undergo dental treatment. They take referrals from other dental practices for treating anxious patients but patients can also contact them directly to register and join the dental clinic. Our DFC volunteer Nikoleta Gehrmann travelled to Glasgow to interview him.
Nikoleta Gehrmann: Can you tell me something about the approach you use to help nervous patients?
Omar Iqbal: Our main focus is on intravenous sedation. We don’t want to knock people out, rather it’s to make treatment easier for them. That being said it still comes hand in hand with taking your time. You can’t just give the sedative and expect things to work, it is still about being very gentle, very calm and explaining things in a very easy to understand way and avoiding scary terms. I find using a sedative such as midazolam works very well with the vast majority of the patients we have.
NG: Some people who are due to have sedation fear saying something stupid or acting inappropriately and there are a lot of YouTube videos strengthening this view…
OI: A lot of these videos are from America, where they commonly use multi-drug sedation and give several drugs in combination, which can make people act a bit strangely after. In the UK, the vast majority of intravenous sedation is with a single drug called midazolam. Some people do use multi drugs, but very very few. With midazolam it is extremely rare to have that kind of reaction but it’s not impossible. It is more likely to occur in a younger patient whose hormones have perhaps not fully settled following puberty.
NG: How do people behave when they have that kind of reaction?
OI: Generally midazolam will sedate you and make you relaxed. It will make you feel a bit sleepy and feel like you can sink down in the chair. Everything slows down, the breathing slows down, the movement slows down and everything is relaxed. In a small number of people, rather than getting relaxed, they get excited. So they get more chatty, they ask a lot of questions, they look around to see what’s happening. They become more aware of their surroundings rather than less aware, but it’s a very small number of people and more likely for teenagers.
NG: What do you do with patients who react in this way?
OI: I can recognise it quite early on. We very gradually give the midazolam so we can monitor how they react. If we think somebody is going to become excited, we try not to give them more midazolam as it will only make them more excited. We try to manage them through just talking and taking things slowly, which works well.
NG: Patients themselves have no memory of the sedation session, so can you tell us how do they act, how is the treatment for you?
OI: I think the amnesia is a very good side effect. It helps because a lot of people come in with a big phobia, whether it’s needles or the noise or just everything. If they leave and don’t remember, it’s a nice side effect. They leave, they remember talking to me, they remember me placing the cannula for the intravenous sedation and then they remember leaving happy. They leave with a happy attitude, and they don’t have any negative feelings. Generally we have people in the chair who just sit there, they don’t talk, unless we ask them a question. If you ask them “how are you?”, they say “I’m fine” and their mind wanders in their own little world. Most of them close their eyes, we do talk to them afterwards and ask them how did they find the treatment and many are surprised that we are finished. As they have amnesia, time passes very fast for them, and an hour feels like five minutes.
NG: There are some opinions against sedation with the premise that it doesn’t beat the anxiety because the person has no memory of the treatment. What is your view on that?
OI: It is best if you can get somebody to overcome their anxiety or their phobia, that would definitely be the ideal scenario. However it’s perhaps not always possible. I think if someone has a specific phobia, sometimes they simply cannot overcome this. We can try and work on techniques to work past this phobia but it can take many visits over a long time. If we have a situation where somebody has an abscess or pain or decay in their front teeth which looks very bad, and say it’s going to take six months or longer to overcome their fears, waiting this long could make the initial problem worse. Also if someone needs a lot of treatment, such as ten fillings, then it can be too big a mental barrier to overcome. I advise my patients that in the short term we can provide intravenous sedation to relax them and provide the dental treatment. Longer term we advise our patients to return for regular check ups so they are more used to coming and we can slowly work with them to beat their anxiety. Then if they need some simple treatment, it can be easier for us to try and get this done without sedation.
NG: You work with very nervous patients and once they’re hooked up they are fine, but how is their way from the door of your practice to the point of being sedated?
OI: Obviously I can’t go outside and drag them into the practice and force them to come, so it’s good if they have somebody with them to help them take the first step. Usually it’s a family member or a close friend they trust. Breaking that initial barrier can be very challenging, but once they come in, we do try to keep them in a very relaxed atmosphere. Everyone is very friendly, our practice is nice and airy. The atmosphere in the practice is very calm, we take our time and nobody is rushing them in and out.
I take my time chatting to the patient and to find out what makes them scared. Was it a bad experience, is it one thing, is it just needles, is it everything and is there anything we can do to make it easier. There is one thing with the sedation, as good as it is, if somebody has a particular phobia, even when they’re sedated, they still react. They don’t remember it, but they still react. For example, if somebody has a needle phobia, when they’re sedated, when you look at them you think, “OK, they are very relaxed” and as soon as you put the needle in the mouth they will be a bit upset. However, due to the amnesia from the sedation, once we are finished giving the anaesthetic they forget it very quickly and they get very relaxed again.
NG: That’s interesting. Do you know what happens with the needle phobia after that?
OI: If it will make it worse? That’s the thing with the midazolam, because of the amnesic effect, they don’t remember so the phobia doesn’t become any worse but at the same time it doesn’t get any better.
If someone has a specific phobia, no matter how much you sedate them, they pretty much always react to that phobia when you present it. When you take it away, within a minute or two they settle down, they calm down and they will very quickly forget they had it. So say the needle phobia is the thing. After I have sedated them, and when I start to numb their mouth, they may tell us they don’t like this, but once the anaesthetic is done, they become very relaxed and they are fine. And afterwards they have no memory of anything bad. So it doesn’t make the phobia worse.
NG: Why did you choose dentistry?
OI: At the time I had good grades at school and I enjoyed working with people. I enjoyed working with my hands as well and I also liked the medical field. When I was young, my neighbour next door was a dentist, we had an actual dental practice next door so I have quite good memories when I was young going to the dentist. For check-ups they would come to my door and call me for a check-up so I just went next door, as I was very small, with my night clothes on. He was a lovely dentist.
NG: And what made you want to work with nervous patients?
OI: I suppose I really enjoy helping people get past their fear. I have seen some patients are just so anxious about getting things done and it’s a shame and they will put up with a lot of pain, and they may put up with their teeth not looking very nice all because of their anxiety. It can make a really big change in someone’s life and it is nice to see how happy these patients are after we help them.
NG: What do you believe are the causes of phobia or anxiety?
OI: I think a big one is a bad experience, a very negative experience usually in childhood. In Scotland, certainly a lot of patients talk about the school dentist being rough and doing treatment when they were not properly numb so causing them a lot of pain and fear. So I think a lot of patients that I see had a very negative experience in their childhood and it just stays with them their whole life. Others have some specific phobia, especially needles, and it’s not just dental, it could be anywhere in the body, which can give us a bit of a challenge as there is a small needle required to place the cannula at the start of the sedation visit.
Dental phobias can have an impact on the whole family. So if a parent has had a very bad experience and is very uptight when seeing a dentist, they may pass it to the children. I see that sometimes a mother brings her children along and she is sitting in the corner of the room looking away due to anxiety.
NG: Can you share some tips on how you work with patients who have these fears? Like noises, needles, sensations?
OI: For needle phobia it is having a very good technique, I try to make it as painless as possible by using a topical anaesthetic first of all and actually giving the injection very very slowly. When I tell patients I will do it very slowly, they don’t like the idea and ask me to do it fast. Then I explain that if I do it very slowly, they will feel much less but if I do it fast there will be pain.
For noises, listening to music with headphones helps – it doesn’t block the noise completely, but it does help. A big thing is to take our time, not trying to do everything very fast or trying to do too much. If we take our time, letting the patient rest in between bits, it helps.
NG: Some dentists find that nervous patients are quite a difficult group to treat and some are even kind of scared of nervous patients. What do you believe, why is that?
OI: Yes, they are very difficult to treat and probably the biggest thing is that they need a lot more time. Before even looking in the mouth I spend a lot of time talking to patients to find out why they are scared, and what has made them come to get treatment now.
On the NHS in Scotland, dentists are not paid for their time, rather they are paid for actual treatment they do. Anxious patients will usually take more time to treat and it can be split over many visits. When you factor in the costs for running a dental practice such as staff wages, heating & lighting etc… it can be very easy to actually make a financial loss when taking a lot of time treating patients. As we provide sedation for a lot of our anxious patients, we are able to carry out their treatment in a smaller number of visits and we can do quite a lot of treatment at each visit. This is good for the patients, as it means less visits for them and it allows us to make it work financially for us. It is a tricky balance and we sometimes still make a financial loss, although it is not too often.
Also it is very stressful for dentists treating anxious patients, as they can be a bit jumpy in the chair. For us to provide good quality treatment it is more difficult if the patient is moving. I don’t think patients realise how much stress dentists have when trying to make sure they are relaxed. These are the main reasons I think some dentists are anxious about treating these patients.
NG: Is there anything you feel nervous patients do wrong on their way to beating their dental fear, something you would like them to know?
OI: I think a big thing is finding a dentist you trust and that you like. I think a big part is also the fear of the unknown. A lot of people think things will be worse than they actually are, which is very common. Again a common fear is having an injection. A lot of patients imagine extreme pain and become very tense, which makes it more difficult for us. I understand that it can be difficult to trust someone that you have only met a few times but if you can let go and relax your body and trust your dentist then things will be more comfortable. Many times I will give an injection and when I am finished the patient will tell me they didn’t realise I did anything.
NG: If there was a dentist, fresh out of dental school who would like to start treating nervous patients, what advice would you give them?
OI: Talk to your patients, take the time to know your patients and to build a relationship. It’s very easy to fall into the financial thinking of “I need to try to work very fast”. You need to try to change the way you think and try to build rapport with your patients, whether they are anxious patients or non-anxious patients.
NG: Imagine a patient who would like to beat their fear with you and you are not able to help them. What would be the reasons for that?
OI: Unfortunately we can’t help everybody, and there are a lot of different personalities. The same way that the patient needs to be comfortable with the dentist, the dentist needs to be comfortable with the patient. It’s a two-way relationship, trust that works two ways. So the patient has to trust the dentist and the dentist has to trust the patient. I suppose that there are times where it’s not possible to build a good relationship. I think that’s the point where I wouldn’t be able to help somebody, as then I can’t build that trust and relationship with the patient, but it’s probably very rare. I do feel bad when I can’t help someone but nobody’s perfect and nobody can do everything perfect all the time.
NG: How do you decide whether to try to treat a patient with or without sedation?
OI: I don’t use any forms but I assess them subjectively when I talk to the patient about their fears. If it’s just one specific thing, like just needles, most times I can get past that without sedation, if I can get the patient to trust me enough. If there are many things, especially a very bad experience as a child, then most commonly I will need to provide some sedation. Trying to overcome many hurdles can perhaps be too difficult without sedation.
NG: How does a life after sedation looks like for patients? Are they able to attend for easier appointments?
OI: I believe the ideal scenario is if we see that something is complicated or if a patient needs a lot of dental treatment, then we will carry out the treatment with sedation. Then afterwards encourage them to come for regular check ups and in future trying to get them in for the easier things. Maybe next time is one filling and you can convince someone to try that one filling without sedation. For some people that will work, if they think “OK, I need just one filling, I can cope”, then get it done and it wasn’t too bad and then just maintaining that, that would be the ideal. It doesn’t work for everyone, some people need to be sedated every time they need treatment, whether it’s a lot of work or just to clean the teeth. At the end we can try to persuade them, but we can’t force them to get something. That’s the good and the bad thing about sedation, it works so well that once a patient has had treatment done with sedation it can sometimes be difficult to persuade them not to have it again.
NG: Would you mind sharing some special cases that really moved you or some stories you have in mind when you think of your successes?
OI: It is every week to be honest. A lot of patients are very anxious and at the first visit they’re maybe wondering “is this really gonna be good?”. Then they come back for the second time and they’re very happy and are ready to get all of their treatment done.
We have some patients that for their whole life, maybe thirty or forty years, have not been able to have dental work done. We help them and it can make a big change in their life. I get to see that every week. It’s truly nice.
Date of Publication: 26 December 2018