Debby Maugans
Debby Maugans, food writer based in Asheville, North Carolina, and author of Small Batch Baking, Small Batch Baking for Chocolate Lovers and Farmer and Chef Asheville.
When some people think of going to the dentist, they flash on the torture scene from Marathon Man. As the character played by Dustin Hoffman squirms in the dentist’s chair, a Nazi-trained oral surgeon wields sharp instruments to “pry” information out of him. Just as Jaws emptied many a beach, Marathon Man offered one more compelling reason to avoid the dentist.
Going to the dentist is still a far cry from a day at the beach, but there are a growing number of options to help control pain and provide anxiety relief. One popular—yet controversial—new trend is sedation or relaxation dentistry. Medications help patients drowse their way through a dental procedure, technically awake but not aware, and sometimes with little or no memory afterward of drills or needles or discomfort.
I discussed this controversial new approach—fervently embraced by dental-phobes but viewed with angst by some safety experts—with Joel Weaver, DDS, PhD, RPH, a professor at the College of Dentistry at Ohio State University.
Sedation dentistry can be a tremendous boon to the many individuals who are so frightened of dental procedures that they completely neglect their oral health, says Dr. Weaver. Some are so desperate that they resort to yanking out their own teeth with pliers. However, Dr. Weaver stresses that dentists must be properly trained and experienced in sedation approaches. In untrained hands, respiratory distress and even death have occurred due to inadvertent oversedation or drug interactions.
Dr. Weaver explained the different types of sedation dentistry…
The conventional approach, also known as minimal sedation, consists of one oral dose of an anti-anxiety agent—most commonly diazepam (Valium)—shortly before a procedure to relax the patient. If someone has trouble sleeping the night before dental visits, the dentist might also prescribe a sleeping pill—most commonly triazolam (Halcion).
Safety concerns have arisen in recent years as many dentists have begun to take minimal sedation a step further, using the same drugs but in larger doses. Instead of a single pill, dentists gradually administer oral medication until a patient reaches a deeper level of sedation, called moderate sedation, more effectively reducing consciousness, and along with it pain, fear and anxiety. Patients usually have little or no memory of treatments and accompanying discomforts. With progressive oral sedation, resuscitation drugs must always be immediately available should there be a need to reverse the effects in the event of an emergency and the dentist must be trained and skilled in giving this drug intravenously.
Common side effects of any type of oral sedation include drowsiness and grogginess, and Dr. Weaver cautions that patients cannot drive themselves home afterward, or even take a taxi or bus. For safety’s sake, they must have an escort.
Unfortunately, the more a patient is sedated, the higher the risk of adverse events. People absorb and metabolize drugs at varying rates, some faster and others slower, says Dr. Weaver. Dentists must be certain that the first dose of an oral medication has fully entered the bloodstream and peaked before giving a person a second pill to swallow…or a third. However, this can be very difficult to determine, and requires considerable knowledge, skill and experience. Critics are concerned that accidental oversedation by practitioners can lead to serious health risks for patients. Safety statistics aren’t available about oral sedation, as there is wide variance on reporting adverse events. It is thought, however, that the dangers of oral sedation in dentistry are probably underreported.
The practice of sedation dentistry has become so popular so fast that it is outpacing its own regulation. In response to growing concerns about the potential dangers, the American Dental Association (www.ada.org) has issued voluntary guidelines recommending that dentists who administer moderate oral sedation have a minimum of 24 hours training in sedation, basic and advanced life support courses and at least 10 hours of supervised clinical experience. However, states are free to adopt these standards or not—most are introducing or considering regulation of sedation dentistry. At present, guidelines are voluntary, regulation is spotty, and consumers have their work cut out for them when it comes to choosing a safe and experienced “sedation dentist.” (More on how to go about this later.)
In intravenous or IV sedation, “soothing liquid medication” such as Valium passes directly into the bloodstream. The patient is technically awake but unaware. There are actually fewer safety concerns with intravenous than oral moderate sedation because an intravenous lifeline is already in place if emergency drugs are needed. Since the medication instantaneously enters a person’s bloodstream, there is no guesswork or time delay (as there is with oral sedation), the effects are easier to monitor, and, if needed, the reversal drug can be given immediately since the IV is already in place.
IV sedation is much more closely regulated than oral sedation—at least at present. ADA guidelines call for 60 hours of training and experience with at least 20 patients, and most states have boards that closely monitor and approve special training and certification. Dentists who use IV sedation in their practices are usually the most highly trained dentists of all. Some are specialists known as dentist anesthesiologists, who have extensive training in handling respiratory distress and in the use of resuscitation drugs.
If you have severe anxiety about dental treatments and feel that deep sedation may be the answer, Dr. Weaver cautions that you should make sure the dentist you consult is properly trained and experienced in the process of administering and reversing sedation. It’s important to confirm that the sedationist or dentist anesthesiologist will remain with you for the entire procedure and until you are ready to go home. You can find a dentist anesthesiologist in your area at the Web site of the American Dental Society of Anesthesiology (http://www.adsahome.org/patients.html) or the American Society of Dentist Anesthesiologists (http://www.asdahq.org/). Some of these specialists provide only sedation and anesthesia services but do not perform the dental work. In other cases, dentists work with a team of specially trained dental assistants whose role is to make certain the patient remains stable while the dentist simultaneously does the dental work. To avoid possible complications, inform your dentist about your complete health history (with special mention of any allergies or asthma), and all medications you take—both prescription and over-the-counter. Don’t forget to include vitamins and supplements.
If you choose a general dentist who also provides sedation dentistry, it’s a little trickier. While many are thoroughly trained and experienced, with regulations as they stand today, it can be hard to tell. First and foremost, Dr. Weaver emphasizes that consumers should undergo sedation only in the hands of dentists who perform a high volume of the particular procedure they require and have a good safety record overall. The best way to find out is to just ask the dentist. Before treatment, ask questions such as…
Some state dental boards provide some disciplinary action information to the public on their Web sites.
We’re learning more and more about the connection between oral hygiene/health and overall health. Translation? Avoiding dental work can destroy far more than your smile. With more palliative treatment options available today, you need no longer dread a visit to the dentist. Just be careful about what you do and where you do it.