Your Anxiety Control Options
Many people harbor fear for the dentist. I have seen countless patients neglect their dental health simply due to previous bad experiences. Usually these types of patients come into my office when neglect of a simple dental problem has been allowed to grow and now the pain is preventing them from normally functioning on a daily basis.
There’s no reason to let pain grow to these levels of severity, though. There are many different options for anxiety control during an appointment to ensure a good patient experience.
Most dental offices offer two common types of anxiety control:
- Nitrous oxide (gas)
Nitrous oxide is a vaso-dilator, which widens blood vessels and thereby increases blood flow. When the gas is inhaled, the body begins to relax and patients tend to experience euphoria and analgesia. The dentist administers nitrous oxide gas through a nasal hood. After the mask is placed on the patient, they will eventually start to feel tingling in their fingers and toes and sense relaxation. These sensations will continue throughout the procedure until the gas is removed. Once the procedure is over, the operator usually places the patient on 100% oxygen for five minutes to “flush” the remainder of the gas out of the blood stream. Afterwards, these effects disappear quickly and patients can resume normal activity. Under prolonged used at high concentrations, above 40%, the patient can experience nausea and vomiting. This is the least invasive of all the anxiety control options, is easy to titrate the mild effects, does not require much training and generally does not require any patient monitoring equipment.
- Oral sedation (AKA sleep dentistry, oral anti-anxiety medication or mild sedation)
Oral sedation involves anti-anxiety medication that a dentist will prescribe and a patient must fill at a pharmacy and bring with them to their appointment. Common drugs prescribed are benzodiazepines such as Halcion (most common), Valium, Zaleplon, Ativan, Xanax and Hydroxyzine. Generally the patient takes the recommended dosage the night before the appointment and a second dose one hour before the appointment (this varies). Unlike nitrous, the patient must be driven to and taken home from the appointment by an escort. Onset time and the effects of the drug vary from patient to patient. These medications help to reduce brain activity related to fear/anxiety, will cause drowsiness, and even cause some short-term memory loss. It is possible to titrate the effects of the drug when combined with nitrous, however, in many states this is considered two treatment agents and thus can require a moderate sedation permit. Oral sedation in many states (including Iowa) does not require advanced (or any) training to administer. If the dose of drugs given is being used to achieve a moderate level of sedation, a moderate sedation permit is required along with all associated monitoring equipment (ECG, w/BP-HR, ETCo2, SaO2). The onset of these drugs are slow as patients consume them and the doctor waits for the effects. The amount that actually reaches your bloodstream also varies due to “first pass metabolism.” Since the drug is taken orally, you can’t adjust the effects of it in real time (titration), making it possible for the operator to overshoot the desired level of anxiety control and roll into moderate or deep sedation. These drugs are reversible; however, with no IV access, the only way to reverse the effects is an intra-muscular injection (how would you like to get stabbed in the leg?). Due to the physiologic variation from person to person, the onset and duration are unpredictable. These drugs also come up short as they provide no pain control.
A select few general dentistry offices in Iowa, such as at Story City Dental, offer a more effective form of sedation:
- IV moderate sedation (AKA IV sedation or IV moderate sedation)
This is the most effective and safest method for controlling dental anxiety and achieving a moderate level of sedation — which is why oral surgeons turn to it for wisdom teeth extractions. While sleep is not guaranteed, patients tend to fall into a “twilight sleep state” where they are still able to respond to commands by the provider. Depending on the combinations of the drugs being used for the sedation, many patients describe a sensation of extreme relaxation to an intensely euphoric feeling with almost all reporting that they don’t remember anything or only bits and pieces of the time period encompassing the procedure. These effects are largely due to the titrated sedative drugs (Midazolam) or the opioid effects of the narcotics (Fentanyl or Demerol) used in combination with them. The most amazing thing I find with IV sedation is the ability to watch the drugs work in realtime.1A pre-op appointment is required in which a patient’s health history is reviewed and a simple physical evaluation is completed along with pre-op vitals (HR/BP, ECG, O2-Sat). A separate appointment is made for the dental procedure (with the IV sedation). There are no same-day appointments for IV sedation at Story City Dental. Not everyone is a good candidate for IV sedation. People who have an uncontrolled systemic disease, sleep apnea, a BMI over 40 or an inability to breathe through the nose (such as cold or cough) should not receive IV sedation.The day of the procedure, the patient will be connected to a monitor for heart rhythm, heart rate, blood pressure, oxygen saturation as well as breathing and CO2 output. An IV line is then started in either the hand or arm. All drugs used for the sedation are administered through a port in the IV line. Due to the speed of onset of these drugs, they can be titrated to achieve the desired depth of sedation in real time and reversed in the same fashion should an emergency arise. After a desired level of sedation is achieved, the mouth will be numbed with a local anesthetic for the planned procedure. Once the procedure is completed, and most of the sedative effects have worn off (relatively quickly since its IV), the patient must be driven home by their escort. The amnesic effects of the drug last for the duration of the procedure and some time afterwards. Almost all patients I talk to at post-op appoints tell me they remember nothing from the procedure, and if they could, they would have always done all their dental work under IV sedation.
Lastly there are two other forms of anxiety control, and these are usually administered by an anesthesiologist, CNRA or oral surgeon that has a general anesthesia permit. These include:
- IV deep sedation
- General anesthesia
For the purposes of this article I’m not going to cover the above two forms of sedation as they are rarely seen in a general dentistry office.
IV Moderate Sedation Benefits Exceed Oral Sedation
IV moderate sedation can benefit patients for a number of reasons:
- Its rapid onset (it takes minutes)
- Its titratable nature
- It can be reversed (within 30-90 seconds)
- Use of a narcotic painkillers during the procedure
- Ability to immediately administer non-narcotic painkillers post-op
- Ability to administer anti-emetics post-op
- An IV access will already be present in cases of emergency
- A more highly trained operator2
- Patient vitals are constantly monitored during procedure3
Does this mean I don’t use oral sedation in my practice? Of course not. I use oral sedation with patients who require a mild amount of anxiety control during procedures or I prescribe oral sedation to patients pre-op so that they can rest easily the night before their appointment.
IV sedation can provide a safer, more pleasant dental experience for patients who pass the screening — and help everyone regardless of their comfort level realize excellent dental health.
1 After titration of the sedative and narcotic, the operator can literally watch a patient relax in real time (physically) and also watch on the monitoring equipment as their blood pressure and heart rate and breathing return to a relaxed, normal level (most anxious patients present with high heart rate and hypertension due to the stress of being at the dental office).
2 A note on educational and regulatory requirements to be able to provide IV sedation in Iowa:
Unlike oral sedation, IV sedation requires a permit and facility inspection by the state. The provider of the IV sedation is required to have received advanced training in IV sedation, usually in a post graduate residency program or an ADA certified course that includes advanced airway management (have experience at intubating a patient), as well as 60 hours of didactic course work and a minimum of 25 solo IV sedations. Providers are also required to have training in advanced cardiac life support (ACLS), which requires a refresher course with exam every two years. Dentists who do not practice IV sedation are only required to know BLS (CPR).
3 Patient monitors must include ECG, blood pressure, heart rate, end-tidal CO2 and O2 saturation.