Calm Fears and Build Your Practice With Conscious Sedation

Ever had a patient who shudders at the very sound of the handpiece? You know the one that I mean. The one who you are certain is fully anesthetized but almost jumps out of the chair when you merely touch the enamel with a bur. If you practice any dentistry at all, then chances are you have treated a patient like this. Dental phobia is a very common hurdle that we must clear on a day-to-day basis. However, adding conscious sedation to your toolbox can provide you with a powerful adjunct to your ability to treat this type of patient.

Nitrous Oxide

Many times, the simple administration of nitrous oxide is all that is needed to allay a patient's fears. It doesn't even need to be a high concentration. I start patients out at 40% nitrous oxide and then adjust accordingly from there. I only occasionally have to increase the dosage. The great thing about nitrous oxide is that after a thorough oxygen flush, patients are free to drive home on their own and there are no eating restrictions. If patients even slightly indicate that they would like to consider "laughing gas" or if they relate the fact that they are nervous about the upcoming procedure, I routinely offer them the use of nitrous oxide. Under no circumstances do I want a patient to have a bad experience. That can turn a mild case of dental phobia into a severe one and compound the issue for future visits.

Oral Sedation

Occasionally, there are patients for whom the use of nitrous oxide is insufficient for them to be relaxed in the dental chair. These patients can be good candidates for oral sedation. There are some very wonderful oral sedatives available today, and they are very safe to use at the recommended doses. Their use can make treatment times go much smoother. In fact, oral sedation can alter a patient's perception of time, which makes it great for lengthy procedures-even for those who are not extremely anxious. Furthermore, local anesthetic doses can be cut in half, making it possible to work in multiple quadrants without reaching the maximum limits. And the neatest thing is that patients' memories of procedures are limited at best, which makes for a much more pleasant overall experience.

I frequently use lorazepam (eg, Ativan^®) in my office. It is long acting, so it is great for long procedures. I prescribe two
2 mg tablets-one to be taken the night before and one to be taken 1 hour before the appointment. Because some patients have the unrealistic perception that they will be put to sleep, I caution them that "they will be awake and aware, but they won't care." I instruct patients to not eat or drink anything after midnight the night before the procedure and to not drive for 24 hours. There are occasions when patients can be sensitive to the sedative and become nauseous, so having them NPO makes life easier on everyone, not to mention much safer. There are also other oral sedatives available, such as diazepam (eg, Valium^®), triazolam (eg, Halcion^®), and zaleplon (eg, Sonata^®), that are shorter acting, which can be helpful if the patient has work or other errands to do later in the day.

I tell patients that once the initial dose has been taken, I do not recommend taking any further oral medication before the procedure. It is too unpredictable, and you may be unable to titrate to the proper level. The way that the state dental boards evaluate sedation nowadays is not by what method you use to obtain it but by the level of sedation that you ultimately achieve. Your goal is anxiolysis. Anything past that puts you in another category. Patients must be able to respond to commands and maintain their protective reflexes. If they are past that point, then you are required to provide airway management, and providing airway management requires another level of education and a specialized facility. Safety is of the utmost importance, so you would be walking a fine line by allowing additional doses. Check your state regulations concerning sedation very carefully. Many states permit the concomitant use of nitrous oxide and one oral sedative; however, combining more than one oral sedative usually requires advanced education.

IV Sedation

There are certain times when the use of a simple oral sedative is just not enough to relax a patient. This is where IV sedation can come into play. Providing IV sedation requires advanced education that includes actually sedating real patients, and the training can last up to a few weeks. Nonetheless, it can be well worth it because it gives you so much more flexibility in treating dental phobic patients. It enables you to better titrate the medication in order to achieve a safe, yet effective level of sedation. If a patient comes into our office having taken an oral sedative, and he or she is still too anxious to proceed, because we require NPO after midnight and a driver for oral sedation, we can go straight to an IV route and achieve a perfect level for the patient to be as comfortable as possible.

Patients for Life

Conscious sedation can be an extremely helpful addition to any dental practice. Relaxed patients are happy patients. And once you get fearful patients relaxed, many are able to conquer their dental phobias. This can keep them coming back for years to come and make them the most wonderful lifelong patients that you would ever want. And because they love to talk you up to their friends and family, they can be some of the greatest referral sources to boot.

About the Author

Richard P. Gangwisch, DDS, a master of the Academy of General Dentistry and a diplomate of the American Board of General Dentistry, is a clinical assistant professor at the Dental College of Georgia at Augusta University and practices in a Heartland Dental-supported office in Lilburn, Georgia.