Just Relax You’re At the Dentist
March 7, 2008 by Kristina Chew, PhD
Filed under Health
Nitrous oxide? Oral sedation at the dentist office (including a Valium)? I’m not referring to our continuing efforts to help Charlie through dentist appointments but to relaxation dentistry:
In the last five years, thousands of dentists have been trained to administer drugs to anxious patients using medications that doctors say create a mild amnesia for patients who are awake, but not necessarily alert, and may forget the whole experience or have only vague recollections.
…….
“There are absolute dental-phobes who stay away, even to the point of trying to take their teeth out with pliers,” said Dr. Joel M. Weaver, a spokesman for the dental association and an emeritus professor at the College of Dentistry at Ohio State University. “Now dentistry has a real way to treat them. But we want to be able to treat them safely.”To bring the anxious patients out from their foxholes, a growing number of dentists have been marketing relaxation dentistry, or “oral conscious sedation” as it is also known, through television, newspaper and Internet advertisements, with enormous response.
Karen O’Hanley, 45, from Quincy, Mass., was so afraid of the dentist that she avoided the chair for four years, trying to scrape the plaque and stains off her teeth with tweezers.
Guess Charlie’s not the only one who needs to practice keeping his mouth open, hands down, and staying calm in the dental chair. (But glad for the reminder to keep the tweezers well hidden.)
Funny, I guess this bring up a kind of ‘if a tree falls in the forest’ question…
“using medications that doctors say create a mild amnesia for patients who are awake, but not necessarily alert, and may forget the whole experience or have only vague recollections”
So, if you don’t remember the experience, did the pain really happen? and how soon do you forget? do you remember the pain of a minute ago or is it then already gone?
Cheers, Nestor.
I wouldn’t give up the practice right away in favor of “conscious sedation”. Eleanor had a paradoxical reaction and rather than becoming sedated and calmed under the meds, became groggy but uninhibited, combative and unresponsive to request…and this with a progressive dosing that eventually skated on the verge of overdose. Her developmental pediatrician commented that this can happen.
This is the reason that we either do it cold turkey, or under general for significant work. It might be best to ascertain whether the particular person has the expected reaction or at least potential side-effects. I have had oral conscious sedation and it went as expected, but that is with additional numbing anesthetic so I can’t address pain without the shots. It took the stress off, but I recall some of the procedure but not all. I don’t recall pain.
Oral Conscious Sedation, “a minimally depressed level of consciousness produced by oral medication that retains the patient’s ability to maintain independently and continuously an airway, and respond appropriately to physical stimulation or verbal command.
Pediatric conscious sedation
http://www.mosbysdrugconsult.com/WOW/op041.html
O.K. – I am sure many of you think I am a horrible mother already but I take my kids to a dentist that puts them in a papoose. I cringed when I first took them but I then realized it was safer and they actually like it. My kids had horrible teeth but they are losing many of their baby teeth with fillings now and get regular dental checkups every 6 months. My youngest doesn’t even need the papoose but he enjoys getting in it now. He even knows Diego’s (his dentist) birthday.
@Jill, Whatever makes a child most comfortable through the experience—-that’s what’s the main thing—Charlie didn’t like the papoose. Soon as he could feel someone putting something in his mouth, he started pushing away; we’ve been practicing in advance with “playing dentist” to get him ready. We tried nitrous oxide for Charlie and it made him giggly and goofy, and he started to crawl all over the chair.
@Regan, I do think sedation will be in order if something more major might have to happen. Charlie has one permanent tooth on the top that came in crooked (he played with it) and it looks like he’ll have to have some kind of dental work or it’ll be uncomfortable, ultimately. And the dentist has already told us about an autistic boy he worked on who tried to pull off his braces.
@Translating Autism, But whether or not you remember or feel the pain, there is the difference in your teeth—-hopefully!
It took us months to get M to sit in the dentists chair. Now she does so much better. Scraping your teeth with tweezers? Ugh. The thought makes me cringe.
Kristina,
Don’t know why you brought this up, but this is something that I am extremely familiar with and competent to comment on.
There are three (sometimes four) levels of training (and certification) for administering anesthesia in a dental office. Requirements vary slightly for different states.
The highest level of training is certification to provide general anesthesia in a dental office. This requires formal training in a residency program after dental school of either a minimal 4 years in an oral and maxillofacial surgery program (that includes 1 full year of anesthesia training) or a dedicated dental anesthesia residency program of at least 2 years length. Those that are certified to provide general anesthesia may also provide IV sedation, oral sedation, nitrous oxide, or local anesthesia.
Next comes training to provide IV sedation in a dental office. This usually requires training in a residency program that includes a significant number of hours (on the order of 200 or so as a minimum) in providing deep sedation or general anesthesia to patients.
The next level is enteral sedation, or sedation provided through a natural orifice (by mouth, nasal, rectal). These practitioners usually only are required to take a 3 dayweekend course to qualify.
Finally comes administration of nitrous oxide and local anesthetics, which any dentist is qualified to administer.
Because of many factors (ease of overdose, lack of amount and rigor of training in pharmacology, lack of enough training in rescuing patients from inadvertant deep sedation, etc.) the most dangerous type of sedation to submit oneself to (usually) is oral sedation, which is sometimes marketed as “sleep dentistry”. In my town people go on the radio and advertise that “you only have to take a little pill” and you can have all of your work done in total comfort.
State dental boards have been slow to catch up with those who have marketed this dangerous practice to (mostly) general dentists. These courses “teach” general dentists to administer successive doses of benzodiazepines (like Halcion/triazolam) to patients until they are “suitably” sedated. Many dentists often combine this with administering nitrous oxide, which can further suppress respiration. No IV is started (which is easier for the dentist, as most aren’t even able to start one) which makes it harder to resuscitate a patient should it become necessary.
Some states write their laws differently, and instead of dividing certification/licensure by the route of administration of drugs, certify people by what level of sedation they are providing to patients. This is a much better way of dividing things up, and usually divides practitioners into those being able to provide anything up to general anesthesia or deep sedation, those able to provide only conscious sedation (a state where the individual follows verbal commands and there is no need to intervene to provide airway support), and those able to provide analgesia (nitrous oxide/local anesthesia) only.
Because of the lack of training, and practitioners not “knowing what they don’t know”, I would steer clear of anyone that is only certified to provide conscious sedation or enteral sedation. I would be a little hesitant when going to practitioners that could provide IV sedation, and generally confident when going to practitioners that were certified to provide general anesthesia/deep sedation.
Providing anesthesia in a remote location (such as an office) where there is little immediate backup should you need it necessitates that the practitioners that are providing anesthesia be very highly trained.
Also of note, providing anesthesia to pediatric patients is often more difficult than adults, so I would be doubly careful.
Sorry for the length of the post. This is something that I have very strong feelings about.
Joe
@Club 166,
I brought it up because the various types of sedation have been suggested for Charlie and we have had many, many reservations about it. He tends to have unusual reactions to medications and, of course, due to his limited speech, he can tell us very little about how he feels. That’s why we have been working so hard on trying to teach Charlie to sit in the chair, keep his mouth open, and keep his hands down.
Someone actually gave us a flyer for a dentist who practices in NJ and advertises that he does various types of sedation.
So more than thanks!
Kristina, I understand perfectly. Each child is unique and a method that works for one may not work for another one. As with everything, you keep trying different methods until you find one that works.
Regarding sedation, my oldest had to be sedated when he had an MRI. It turned out he was allergic to the medications – Fentanyl and Pentobarital. It was horrible, they had to put him on oxygen but he made it through. He had the worst behaviours during the next several days.
After Joe’s comment, I thought that I should clarify.
My statement “or under general for significant work. “, was in a hospital setting with an anesthesiologist. All the cleanings and polishings have been sans sedation.
Kristina,
Just to allay some concern–Eleanor just got braces, and she did “take it off-take it off-take it off…” and even got out the cuticle cutters to prompt me to do so (I thought of Charlie and your post about the loose tooth). I was worried, but after one day of gutting it out, she adjusted and they don’t bug her at all. Just to let you know that the adjustment can happen quickly, not necessarily that it will. You know best.
Regan,
I did not mean to imply that general anesthesia is not safe in an office setting. It can be very safe. It is imperative though that there are qualified people administering it.
Also, many individuals have dystrophic reactions to meds, where you get unexpected reactions (like excitation instead of sedation). Often the only way to tell is to try them.
Joe
Joe,
Forgive my ignorance on the subject of sedation but I was wondering if there was a way to find out how a person would react without actually trying it. For example, is there a way to maybe try out a smaller dose? I was just wondering because I do worry if my children have to have sedation and I am still a little weak and worried after my son’s experience with his MRI. I know there will be times in the future where they will need sedation. Thanks.
Jill,
If it’s oral sedation that’s going to be given, then a smaller trial dose could be given, but most practitioners probably wouldn’t want to do this, as once they gave someone any they’d have to have them sit around and watch them for a period of time. For IV sedation, it’s not really practical to start an IV just to give a test dose.
The best recommendation I can give is to have a very experienced (and trained) individual administering the sedation. For kids (who can lose their airway easily) I would be very conservative, and only go to someone in an office setting that was certified to administer deep sedation/general anesthesia. Relative overdosing is not an uncommon scenario to occur when sedating individuals for procedures. This is not really dangerous in and of itself. It’s the failure to recognize the situation, and the failure of being able to properly respond that gets you into danger.
You’ll probalby have to pay more for this (but not as much as in a hospital-the biggest factor is the variability in getting insurance to cover it). It’s like getting major plumbing repairs done by someone who learned plumbing from their cousin Bob-they may know what they’re doing and do it right, or they may botch the whole job up. The only difference is, when giving anesthesia, there are often no “do overs” if you get it wrong the first time.
Joe
@Jill,
Charlie has had two MRIs and was sedated for both. He didn’t have too much of a reaction afterwards—-a friend’s son had to be sedated for some heavy dental work (an abcessed tooth) and he had a lot of trouble afterwards.
@Regan,
thanks for telling me about Eleanor and her braces! I guess those will be on our “next next” list.
@Joe,
As you may have guessed, if Charlie ever has to be sedated, I may be writing you some emails…..
My daughter does pretty well at the dentist, 3 good visits to every not so good one.
She hasn’t had any problems yet. The dentists has advised against local anesthesia, she’s afraid my daughter will chew her numbed lip or cheek.
I was in my 40s before I ever had a cavity filled without feeling it. Dentists would give me lidocaine but I would still cringe and feel pain. The dentists told me I couldn’t possibly be feeling anything.
Then I found a new dentist. He began to drill and I cringed, and he said “What’s the matter?” and I, after years of “training,” said “Oh, I’m just being a weenie,” and he said “Wait a minute. If you can feel it, you can FEEL it.” He simply numbed each ligament around the tooth (I’m pretty sure he said it was ligaments). It took more shots but the shots aren’t what bothers me. He then went back to drilling…
and I started crying, because for the first time in my life, a dentist was drilling my teeth and I COULDN’T FEEL IT. I suppose they were tears of relief (and maybe of disbelief!).
He says that I metabolize the lidocaine faster than he can drill my teeth. He knew about it because someone in his family has the same problem.
@Paula,
Thanks for sharing that—-I always suspect that Charlie might be feeling (and feeling pain) in ways that he doesn’t tell us and that he just endures. We’ve been lucky: He’s not had one cavity yet.
…He says that I metabolize the lidocaine faster than he can drill my teeth. …
I am glad that he found the right solution for you (ligamentous injections), but more than likely he gave you the wrong reason.
What you most likely have is anomolous innervation. The nerves innervating your teeth either take different pathways (and are thus missed when the normal locations are blocked by injections) or you have additional pathways other than the normal ones (less likely). If you just “metabolized faster” you would experience total numbing for a short period of time, which would then wear off. By blocking the pathways at the ligaments (right around the individual tooth) the dentist is blocking whatever nerves are entering the tooth.
So why don’t dentists always use this method to block the nerves? Because ligamentous injections hurt more than the usual ones.
Again, I’m happy that your dentist found a solution that works for you.
Joe
I was interested in your article primarily as a patient who hates the noise and pressure of surgical instruments hammering and buzzing in my head. I’m the daughter of a retired nurse anesthetist, as well as someone who has something to offer as an alternative. When I was at the oral surgeon’s office a few years back, having my gums sliced, with the blood running down my throat — I thought I’d faint; my knuckles were white from gripping the chair so tight — while hearing noises like someone was destrying a road outside with a jackhammer, only it was in my mouth! Ug!! — I decided to offer my dentist, who I’ve known from childhood, an option, free of charge, to try with his patients who are as fearful of the knife as I am. His automatic response (smiling, of course) was: “No thanks, I prefer drugs.” Give me a break! Disgruntled, I decided that all dentists must be addicted to drugs — not themselves, but on behalf of their patients. I sure hope that I’m wrong, but I have a feeling I’m not. I’m allergic to novacaine; it’s makes me sick, and too much anesthesia isn’t an option. I’m not preaching. All I want to do here is to invite those of you who are as much of a baby about surgery as I am (yes, I admit it), to bring your own copy of my Just Relax… CD to the dentist, along with your CD player (or your iPod) the next time you or your kids go in the dentist for a long procedure. I promise that you’ll thank me for it. Gail Seymour