June 18, 2013 in Features, Health

Sedation eases dental procedures for panicky patients

Using drugs to ease anxiety, dentists say sedation allows panicky patients to get the care they need
By The Spokesman-Review
 

Sedation has eased dental procedures for Danyel Swenson, wearing an “elephant nose” delivering nitrous oxide and accompanied by her doll Grace at KiDDS Dental in Liberty Lake. The Spokane Valley girl, now 8, has had teeth pulled and cavities filled despite anxiety, her mother said – and wants to be a dentist when she grows up.
(Full-size photo)

Training rules vary

 The American Dental Association in 2007 adopted a policy statement asserting the “right of appropriately trained dentists” to use sedation and general anesthesia to treat patients.

 The association has also issued training guidelines for dentists who sedate their patients, calling on state dental boards to ensure that only qualified dentists use sedation and anesthesia.

 In Washington, rules modified in 2009 break down dental sedation into levels consistent with the ADA’s guidelines and apply different training requirements to each level, said Jennifer Santiago, program manager of the state Department of Health’s Dental Quality Assurance Commission.

 At the low end, dentists who provide “minimal sedation by inhalation” must have completed 14 hours of instruction. To provide general anesthesia and “deep sedation,” dentists must complete two years of anesthesia training, although dentists providing deep sedation before 2009 are grandfathered in if they meet continued- education requirements.

 Dentists don’t need state permits to minimally sedate patients at the low end, but moderate and deep sedation requires a permit.

Chuck Gamache’s wisdom tooth was impacted, growing sideways in his jaw. It had to come out. This was terrifying, considering Gamache’s dental history: the pain of a childhood in-line skating accident that broke his front teeth, a young adulthood marked by soda pop and neglect that made him self-conscious.

“When I got to the dentist, regardless of the situation, it would get to where I was almost hyperventilating, going into shock,” said Gamache, 31, of Spokane Valley. “I mean, I was freaking myself out.”

Before getting his wisdom tooth out, he asked his dentist, Dr. James Hood, about “conscious sedation” – the use of drugs to ease anxiety before and during dental procedures. They settled on a three-pill plan, two to be taken the night before his procedure and one in the morning.

“By the time I sat down in the chair and they did all their medicine checks to make sure I wasn’t over- or undermedicated – by that point you genuinely can’t care less what’s going on,” Gamache said. “They can talk to you, you can answer questions. You feel no discomfort whatsoever.”

Gamache first heard about dental sedation on a radio ad, and the message is online and on billboards, too: Scared of the dentist? There’s medicine for that. One earworm-inducing ad in Florida points patients to IWantToBeSedated.com.

Dentists say sedation eases visits for both the patient and the dentist, in some cases enabling people whose anxiety kept them from the dentist for years to finally be treated. It also boosts bills, extends appointment times and carries its own set of medical risks.

‘All good things in moderation’

Studies show more patients nationwide are opting for conscious sedation, said Dr. Jared Evans, president of the Spokane District Dental Society. Besides making panicky patients like Gamache feel calm during their treatment, sedation often also causes at least some amnesia, reducing the risk of trauma for people with anxiety – and making it more likely they’ll come back.

Evans, who owns KiDDS Dental in Liberty Lake, treats children. But many of his patients’ parents “avoid the dentist like the plague,” he said.

“They’re just way too nervous,” he said. “It’s sad to see the state they put themselves into by avoiding that routine dental care. But if you can eliminate that factor, and they know they’re going to be more relaxed and … they can get the work done, it changes their life.”

The risks are rare, but they can be serious.

“It hasn’t happened here, but nationally there’s cases where a doctor gave too much medicine,” Evans said. “They didn’t know the dose they gave or they readministered, and they overdosed a child.

“Death is always the ultimate risk,” he continued. “But if you can minimize those risks and the benefits outweigh those risks, it’s a worthwhile endeavor. Most studies show in about 1 in 1,000 sedations, there’s an adverse event.”

Deaths and cases of permanent brain damage among children constituted just over half the 17 sedation- or anesthetic-related “adverse events” reported to two insurance companies over a 14-year period, according to an article published last spring in the journal Pediatric Dentistry. Other sedation-related risks include vomiting and respiratory problems, including aspiration, in which the patient takes foreign matter into his or her lungs.

Rarely, mild sedative can have opposite-than-intended effects on children, Evans said: “Instead of getting them relaxed, it gets them ramped up.”

Hood, the Spokane Valley dentist who treated Gamache, said he most often sedates patients with nitrous oxide and commonly prescribed drugs such as Valium and Halcion.

Hood’s office is equipped with monitors that track patients’ oxygen levels, pulse and blood pressure.

“It’s like anything else – all good things in moderation,” Hood said. “People can get sick on nitrous oxide if you take it too far. … We monitor them all the time.”

That includes the patient’s trip back to their car, where office staffers make sure patients are buckled in – on the passenger side.

Gamache said he was glad he had a friend take him home after his wisdom tooth procedure. And he was glad his wife was around when he got there.

“The first thing I wanted to do when I got home was chop firewood,” he said. “I thought that was appropriate. My wife had to tell me it wasn’t.”

From ‘laughing gas’ to ‘deep sedation’

Dental patients have a continuum of sedation options, ranging from mild, or minimal, sedation to deep sedation and general anesthesia.

On the mild end: nitrous oxide, aka “laughing gas,” which dentists can turn up or down as needed and exits the patient’s system within minutes. The most commonly used dental sedative, the gas can ease mild fears, getting a patient through the delivery of a numbing local anesthetic, for example.

“That tends to be the hardest part – the four-letter S-H-O-T word,” Evans said.

A patient with more serious anxiety – or a child known to be “a little more squirmy” or potentially combative – might get a pill in the dentist’s office, usually Valium-based, that can be used in combination with nitrous oxide, Evans said.

“If a patient’s going to react, they’re going to react even if they’re lightly sedated at times,” he said. “But if that’s minimized, it can be easier to deal with and manage in the office, and the patient probably won’t have a full recollection of what happened, and that can get them through the experience.”

For debilitating anxiety, a dentist might suggest combinations of drugs or move into IV sedation, which “really borders on the threshold of (general anesthesia).”

Because IV sedation works instantly, it offers a greater degree of control than pills, which need time to work through a patient’s system, Evans said. But at the deep end of sedation, most patients with breathing or heart problems or other medical complications should be treated in a hospital, he said, where an anesthesiologist and dentist can work together.

“And for young children, you need more of a setting where there’s a breathing tube,” he said.

Some dentists are also anesthesiologists, and might offer general anesthesiology in their own offices or travel to colleagues’ offices to provide sedation, Evans added.

The cost of sedation depends on the form, and some insurers cover some forms. Nitrous oxide might run $20, Evans said, while a simple sedative pill might cost $50. IV sedation goes into the hundreds of dollars, while general anesthesia costs thousands, billed in increments of time. In a dentist’s office, an average general anesthesia bill might be $2,000, he said, while general anesthesia administered in a hospital – where it would likely be covered by medical insurance, rather than dental insurance – might cost $9,000 to $15,000.

Up front, at least, sedation also costs more in terms of time.

“It takes about an hour to get the patient to exactly where we want them,” before starting the dental work, Hood said.

But sedation might make it possible to do what might otherwise take several office visits in one long visit, he noted – reducing the total time a patient spends in his office. Sedation relaxes the body as well as the mind, meaning a patient is able to hold his or her jaw open for longer, for example.

‘Still loving the dentist’

Desi Swenson’s 8-year-old daughter, Danyel, was 6 when she got some teeth pulled to make room for new ones.

Diagnosed with hearing loss, Danyel had been visiting doctor after doctor, getting test after test, since birth and easily grew anxious.

A few minutes before her procedure, she took a small pill and put on the “elephant nose” that delivers nitrous oxide to patients at KiDDS Dental. While she was agitated during the procedure, she had no memory of it the next day, Swenson said.

When Danyel had to return for fillings, her mother opted for gentle sedation again. Danyel watched a movie with her doll on her lap as Evans worked on her teeth. After her fillings were in, she asked when the procedure would start.

“She really had no memory of having the filling done,” said Swenson, 35, of Spokane Valley. “Having the sedation was a huge difference. She came out of it still loving the dentist.”


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