Ensuring the comfort and safety of anxious patients
Ellen Meyer, MBA
Lack of access is a significant deterrent to receiving oral care, but some patients with the ways and means just can’t bring themselves to go to the dentist’s office—even for routine care—due to crippling anxiety related mainly to fear of pain. For these patients and others who can’t be properly treated with traditional pain, anxiety, and movement-control approaches, sedation or general anesthesia (GA) can be a blessing for them and their dentists.
Unfortunately, sedation dentistry has gotten somewhat of a bad reputation in the media, with high-profile reports of pediatric deaths calling its safety into question. According to our experts, when it comes to sedation dentistry, patient selection and clinician training are paramount to delivering a safe, predictable, high standard of care for adults and children.
Who Benefits from Sedation Dentistry?
Dental anesthesiologist Joel Weaver, DDS, PhD, of Columbus, Ohio, says the need for sedation and GA is growing for many reasons, including because procedures are longer and more involved than in the past.
He mentions two studies that establish the need for sedation or GA in dentistry for anxiety in adult patients1 and children.2 The adult study, a national telephone survey of 1,100 Canadians, found that among the 5.5% who reported having a high level of fear or anxiety, nearly half (49.2%) had avoided a dental appointment at some point because of it, and more than half (54.1%) were interested in sedation, depending on cost.1
Sedation can be especially beneficial for specific patient populations, says Morton Rosenberg, DMD, professor of oral and maxillofacial surgery and head of the division of anesthesia and pain control at Tufts University School of Dental Medicine and associate professor of anesthesiology at Tufts University School of Medicine. This includes adult patients who would “benefit from the ability to be sedated for their dental procedures because of physical disabilities such as Parkinson’s, Alzheimer’s, or pre-senile dementia.” It can also be critically important for safe and effective delivery of medically necessary dental procedures for patients who cannot cooperate due to mental health issues or cognitive disabilities.
Pediatric patients can also benefit, but their experience of anxiety may be different from an adult’s. Joel Berg, DDS, dean of the University of Washington School of Dentistry and professor of pediatric dentistry, explains that adults with dental phobia avoid dental treatment even though they know they need it. Young children, however, don’t understand the need for treatment. “It is a natural, self-protective instinct for them to feel afraid if their cognitive skills aren’t developed enough to understand their environment, especially when it is unfamiliar,” he says.
In Berg’s view, dentistry doesn’t use sedation/GA enough for children. In medicine, it is routinely used in procedures such as ear tube insertion that may actually be simpler than some dental procedures. “What concerns me sometimes is that GA or sedation may not be offered to children who should have it and that more aggressive behavior management methods are used, including restraints, so the operator can get the treatment done,” he says. “It’s not good for the psyche of the child, and it can affect the quality of the treatment performed.”
Rosenberg observes that for some children, the source of their fear is multifactorial. “A lot has to do with culture, the experiences of the parents and other family members, and what one sees in the media associating dentistry with pain.” To help put children at ease, he recommends getting children to a dentist early so they can understand and adapt to the environment.
Depending on the child’s age, anxiety level, and documented behavioral assessment, however, sedation or GA may be required for the dentist to achieve safe and effective care, particularly if the necessary treatment is extensive.
Raymond Dionne, DDS, PhD, is a research professor in the department of pharmacology and toxicology at Brody School of Medicine and in the department of foundational sciences in the School of Dental Medicine at East Carolina University in Greenville, North Carolina. He supports measures that make it more likely that patients will receive timely and effective treatment for dental problems. However, he also believes that just as every treatment plan should be individualized for the patient, so should the method of sedation. He says doctors should not use the one-size-fits-all approach of GA when the patient can be adequately treated with minimal or moderate forms of sedation that carry a far lower risk of adverse events. Dionne is concerned about the use of GA, which involves maximum levels of central nervous system (CNS) depression, in cases where the biggest benefit is for the doctor to make it easier to get the job done.
He says the method of sedation chosen should depend upon its goal. “In most cases, anxious patients just need something to take the edge off, not something that will render them unconscious; it’s like the difference between a cocktail and a drug overdose.”
Berg says he uses a kind of “decision tree” to determine whether sedation or GA is needed for children who may be difficult to manage. “A child who is cooperative enough to get x-rays done may or may not be cooperative enough to have treatment done in the clinic. Some 4-year-olds can tolerate four or five visits for extensive restorative dentistry without sedation, but we don’t know that until we conduct a proper developmental and behavioral assessment.”
Unless the decision has been made for GA in advance, New York-area dental anesthesiologist Mana Saraghi, DMD, who is qualified to perform all levels of sedation/anesthesia, makes the determination based on a conversation with the patient and the dentist. “We discuss what our goals are. Is it to have the patient completely motionless? For example, some patients who are very young (pre-cooperative) or have severe developmental delay (non-cooperative) may benefit from a more controlled environment, as with general anesthesia. Some need to be completely out, but most patients are willing to try a little sedation, as long as they don’t feel or remember anything.” Once the procedure is underway, she says, she can modify to reach “the ‘sweet spot’ that enables the dentist to get the job done while the patient thinks they are asleep but may in fact be responsive and breathing independently.”
Paul A. Moore, DMD, PhD, MPH, professor of pharmacology, dental anesthesiology, and dental public health at the University of Pittsburgh School of Dental Medicine, stresses the importance of determining whether the patient is even a candidate for sedation. This involves taking a thorough medical history using the American Society of Anesthesiologists (ASA) Patient Physical Status Classifications to rate the patient’s health and anesthesia risk (Table 1).3