Forgetting the Drill; Sedation Dentistry Uses Pills, Gas to Calm Dental Phobics And Blur Their Memory. Some Experts Find That Scary.
Scott Barmby knew he needed dental work, but he'd been putting it off. First of all, he was too busy -- he only had one day a week off from the GM dealership where he sold cars. But beyond that, he knew what he was in for: "The dentist always says, 'This won't hurt,' and then the next thing you know, you're grabbing your chair" to keep from crying out.
Then one day, he touched one of his front teeth . . . and it fell out. Barmby had old caps on his front teeth that apparently weren't sealed properly, and he didn't realize that his teeth had been rotting away underneath.
Suddenly, the need for dental work was immediate. A consultation visit with a local dentist confirmed Barmby's fears: He needed a lot of dental work. His teeth were pitted from taking tetracycline as a child. In addition to an implant to replace the tooth he'd just lost, he needed bridge work, cap work and lots of porcelain fillings. He easily was facing 30 hours in the dentist chair.
A resident of Ijamsville, Md., Barmby decided that if he was going to invest that much time and money, he was going to shop around first. Internet research led him to Edward Dougherty in Bethesda, whose Web site introduced Barmby to the concept of "sedation dentistry." He went in for a consultation and decided that, even though Dougherty wasn't the lowest priced dentist, this was the place for him.
Using a combination of oral drugs and nitrous oxide (laughing gas), Dougherty sedated Barmby and worked on his teeth for hours at a time.
It was great, says Barmby: "You don't feel a thing; you don't know a thing; you don't remember a thing. Then you look in the mirror afterwards and. 'Wow!' "
Instead of 20 to 30 visits, all Barmby's dental work was completed in four or five. It was well worth the five-figure check he had to write, he says. But different approaches to sedation dentistry have caused a rift in the dental community, with each side claiming the other is taking unnecessary risks with their patients.
About a third of all U.S. dentists have laughing gas available in their offices, says dental anesthesiologist Joel Weaver, a professor at Ohio State University College of Dentistry and a spokesman for the American Dental Association (ADA). The gas is considered very effective for both adults and children who would like a little relief from anxiety during dental procedures. Once in the dental chair, the patient inhales a mixture of nitrous oxide and oxygen. Although the effect can vary with the amount given, most patients just feel happy after receiving it, says Weaver. It allows them to relax during the procedure, but because it doesn't subdue pain, it is typically used in conjunction with a local anesthetic like Xylocaine (lidocaine), Dougherty says.
But laughing gas isn't enough for everyone. An estimated 45 million Americans are "very nervous" or "terrified" about visiting the dentist, according to a study published in the Journal of the American Dental Association in 1998. Of those, more than half avoid dental care because of fear.
For many, of course, the problem then snowballs: The longer they avoid dental care, the worse their teeth get. And the worse their teeth get, the more extensive dental work they need, making them fear it even more.
The next step beyond laughing gas is for the dentist to prescribe a small dose of an anti-anxiety drug such as Valium (diazepam), explains Weaver. The patient can take a pill an hour or so before her appointment and by the time she gets to the dental office she'll feel more relaxed and less nervous. That's often sufficient for people with run-of-the-mill dental nerves.
Not so for the true nursing uniforms. Although some don't know exactly why they're so scared of the dentists, many can remember traumatic dental experiences as a child. Kathy Javadi of Gaithersburg remembers having four teeth pulled when she was a child in Iran.
"The doctor was a butcher. It was so painful," she says. The dentist used novacaine, "but I don't think it works very well on me." When Javadi had her wisdom teeth removed a few years later, the surgery was just as traumatic. After that, her fear of dentists became so profound that just the smell of a dentist's office would make her shake and cry.
For the truly fearful, a small dose of Valium before the appointment isn't going to cut it. They may have avoided the dentist for five, 10, even 20 years. They need more than a little something to take the edge off.
That's where the emerging field of sedation dentistry comes in. "Conscious sedation" is a term used for the zone between anxiolysis (diminution or elimination of anxiety, as is done with laughing gas or oral anti-anxiety meds) and general anesthesia, in which a patient is rendered completely unconscious, unable to breath on her own or respond to physical or verbal stimulus.
Under the oral-drug version of conscious sedation, the patient is given a larger dose of an anti-anxiety drug. He remains awake during the dental procedure -- although he may feel like he is sleeping -- and is able to respond to verbal commands and breathe unaided. He is, however, in a much deeper state of relaxation.
One drug popular among sedation dentists is triazolam (Halcion), which not only sedates the patient but also produces an amnesiac effect, so the patient remembers little or none of the procedure. Dentists may give a pill alone to induce the desired level of sedation, or use the oral drug in combination with nitrous oxide.
To monitor the patient's condition, a pulse oximeter is placed on one of his fingers to track blood oxygen; other monitors may be used as well. A dentist may receive training during dental school that allows her to practice this level of oral sedation, or may learn or review proper techniques through continuing education courses.
Another oral drug, hydroxyzine, is useful with patients with a heightened gag reflex, says Dougherty. Although not scared of dentistry, one of his patients had such an extreme gag reflex that she couldn't watch her own children brush their teeth, and had trouble brushing her own. She had to leave the movie theater if a scene with tooth brushing came on. So when her dentist needed to take X-rays, she was in a pickle. She couldn't bite down on a single piece of film to have an X-ray taken -- and she needed 16. With hydroxyzine, an antihistamine that also has an anti-anxiety effect and is sometimes used to treat nausea, Dougherty was able to take the full set of X-rays.
A still deeper level of sedation can be induced through intravenous drugs. The dentist who administers them, though, needs nursing uniforms -- a minimum of 60 hours of classroom education plus clinical practice on at least 20 patients.
"The beauty of IV-conscious sedation," says ADA's Weaver, "is that the dosage can be custom-tailored to the patient's needs. Some need more of a drug to get to the same level of sedation. [With IV- conscious sedation] the lag time between giving a dose and seeing its effect is very short -- usually within a minute or two. If that's not enough, one can give a little more, wait a couple minutes, give a little more, etc." That approach, called titration, "takes the guesswork out of how much to give," says Weaver.
The ADA is concerned that some dentists are putting patients at risk by trying to mimic the effects of IV sedation with oral drugs - - by giving a pill, waiting a while to see if it's sufficient, and if not, giving another, until the patient is sedated.
The problem with multiple doses of oral drugs, Weaver says, "is long lag time." Each person's rate of oral absorption is different. "There's much more variability [with oral meds than with IV drugs]. One person will get the maximum effect [of a pill] in 45 minutes, another in two hours. If I give a drug at 7 o'clock and at 7:30 it hasn't taken effect, do you need more, or is it still in your stomach? If you get a third dose at 8 o'clock and then all three hit between 8 and 8:15, there is a potential for overdose at that point."
And while there are drugs to reverse the effect of such an overdose, the proven effective way to administer them is via IV -- a technique that most dentists don't have the training to perform.
Michael Silverman, president and founder of the Dental Organization for Conscious Sedation (DOCS), disagrees. A dentist who practices in Broomal, Pa., he feels there's greater risk of overdosing a patient with a single dose of a drug, because the dentist will tend to give a higher dose to be sure the patient is "out of it. . . . The problem is, you don't know a patient's susceptibility." Just as three alcoholic beverages would make one person sick and another feeling little or no effect, the same holds true for anti-anxiety drugs.
DOCS, which offers memberships to dentists for $389 a year, teaches a technique in which the patient comes in an hour before the dental work is scheduled to start and is given oral drugs in small increments.
"The goal is to give the minimum amount needed to get the patient comfortable," says Silverman. "It makes a lot of sense, because it provides the least amount of drug necessary. You don't double the dose if they need more. You give smaller and smaller amounts each time," until the patient is sedated enough to undergo the procedure.
DOCS's 2,500 members have treated 450,000 cases with the incremental dosing technique over three year -- all safely, says Silverman.
(It should be pointed out that DOCS recommends using this technique only with adults. Sedating children is far more complex, says Silverman, and should be left to pediatric dentists who have gone through special training. The same goes for patients with nursing uniforms, who Silverman says should be referred to specialists.)
Still, DOCS's approach concerns many in the field. Dentist Jack Bynes of Coventry, Conn., says the group's "teachers are very knowledgeable. They advocate monitoring. But they're advocating the use of oral sedation and titrating. Oral sedatives cannot be titrated, only IV can. It's absolutely impossible" to do it safely.
"Eventually, somebody will get into trouble," perhaps a dentist who starts performing this type of sedation to add money to her bottom line and only takes some basic coursework, said Bynes, who runs the Web site www.dentalfear.com. He has started his own training program for conscious sedation; his approach requires dentists to complete a 10-chapter course -- and does not teach incremental dosing.
Bethesda's Dougherty feels both the incremental and single-dose sedation techniques are safe, and says he decides which approach to use based on the patient and the duration of the procedure.
Many sedation dentistry patients speak of it with the zeal of converts. One after another told a reporter how they cried talking by phone to staff -- out of relief to find someone who respected their fear and was able to reassure them help was available.
Indeed, in catering to fearful patients, a good sedation dentist's tools go far beyond drugs. The whole atmosphere of the office can be altered to reduce anxiety. No one in Bynes's office wears nursing scrubs or smocks, according to several patients who have been treated there. These people also say that the dentist's "uniform" consists of a long-sleeved shirt and bow tie. His staff members -- chosen for their people skills as much as their technical ones -- wear colored cardigans. Instruments are hidden behind panels. The dental chairs have built-in heat and massage features. Patients can listen to CDs through headphones that block the noise of the drill, or strap on a virtual reality headset and play a video game while their work is being done. Or they can look out the floor- to-ceiling windows at a waterfall (a real one -- Bynes's office is in a converted grist mill).
A more relaxed patient needs less sedation, says Bynes, and after using sedation at their first appointments, many are able to get by with just nitrous oxide at subsequent ones. But a setting like that doesn't come cheaply. Very few insurance policies pay for the sedation used in dentistry.
No one interviewed for this story knew of any sedation dentists who participated in provider networks organized by insurers. "You can't, in this type of practice" says Bynes, because insurers are not willing to compensate dentists for the extra time that sedation techniques require.
If a patient has an indemnity dental plan or a managed care plan that permits out-of-network treatment, the plan might pay its usual amounts toward the dental work, while the patient pays for the sedation, which can run from $100 to $500 per visit.
For the uncovered or those bound by a network, every penny has to come out-of-pocket.
A look at the DOCS Web site, www.sedation1.com, suggests that dentists' motives for providing sedation dentistry might not be entirely altruistic. Besides basic clinical information, the for- profit group teaches in its "Essentials of Sedation Dentistry" course for dentists:
"4 new ways to create passive income through higher levels of team participation"
"4 steps to closing high value cases" and
"3 ways to dramatically increase the value of each new sedation patient."
Many patients, though, don't seem to begrudge the sedation dentists their incomes.
Javadi, who had the traumatic dental work as a child in Iran, says she has friends today who are dentists and would do her work for free. Instead, she pays Dougherty, whose work on her, she says, has changed her life.
She used to be so ashamed of her teeth that she'd try not to smile, so no one would see that her gums had receded so badly that you could see space between the bottom of her teeth and the gums. After an expensive course of treatment, all done under sedation (Javadi chooses to have sedation even for routine cleanings) Javadi has her smile back.
Then one day, he touched one of his front teeth . . . and it fell out. Barmby had old caps on his front teeth that apparently weren't sealed properly, and he didn't realize that his teeth had been rotting away underneath.
Suddenly, the need for dental work was immediate. A consultation visit with a local dentist confirmed Barmby's fears: He needed a lot of dental work. His teeth were pitted from taking tetracycline as a child. In addition to an implant to replace the tooth he'd just lost, he needed bridge work, cap work and lots of porcelain fillings. He easily was facing 30 hours in the dentist chair.
A resident of Ijamsville, Md., Barmby decided that if he was going to invest that much time and money, he was going to shop around first. Internet research led him to Edward Dougherty in Bethesda, whose Web site introduced Barmby to the concept of "sedation dentistry." He went in for a consultation and decided that, even though Dougherty wasn't the lowest priced dentist, this was the place for him.
Using a combination of oral drugs and nitrous oxide (laughing gas), Dougherty sedated Barmby and worked on his teeth for hours at a time.
It was great, says Barmby: "You don't feel a thing; you don't know a thing; you don't remember a thing. Then you look in the mirror afterwards and. 'Wow!' "
Instead of 20 to 30 visits, all Barmby's dental work was completed in four or five. It was well worth the five-figure check he had to write, he says. But different approaches to sedation dentistry have caused a rift in the dental community, with each side claiming the other is taking unnecessary risks with their patients.
About a third of all U.S. dentists have laughing gas available in their offices, says dental anesthesiologist Joel Weaver, a professor at Ohio State University College of Dentistry and a spokesman for the American Dental Association (ADA). The gas is considered very effective for both adults and children who would like a little relief from anxiety during dental procedures. Once in the dental chair, the patient inhales a mixture of nitrous oxide and oxygen. Although the effect can vary with the amount given, most patients just feel happy after receiving it, says Weaver. It allows them to relax during the procedure, but because it doesn't subdue pain, it is typically used in conjunction with a local anesthetic like Xylocaine (lidocaine), Dougherty says.
But laughing gas isn't enough for everyone. An estimated 45 million Americans are "very nervous" or "terrified" about visiting the dentist, according to a study published in the Journal of the American Dental Association in 1998. Of those, more than half avoid dental care because of fear.
For many, of course, the problem then snowballs: The longer they avoid dental care, the worse their teeth get. And the worse their teeth get, the more extensive dental work they need, making them fear it even more.
The next step beyond laughing gas is for the dentist to prescribe a small dose of an anti-anxiety drug such as Valium (diazepam), explains Weaver. The patient can take a pill an hour or so before her appointment and by the time she gets to the dental office she'll feel more relaxed and less nervous. That's often sufficient for people with run-of-the-mill dental nerves.
Not so for the true nursing uniforms. Although some don't know exactly why they're so scared of the dentists, many can remember traumatic dental experiences as a child. Kathy Javadi of Gaithersburg remembers having four teeth pulled when she was a child in Iran.
"The doctor was a butcher. It was so painful," she says. The dentist used novacaine, "but I don't think it works very well on me." When Javadi had her wisdom teeth removed a few years later, the surgery was just as traumatic. After that, her fear of dentists became so profound that just the smell of a dentist's office would make her shake and cry.
For the truly fearful, a small dose of Valium before the appointment isn't going to cut it. They may have avoided the dentist for five, 10, even 20 years. They need more than a little something to take the edge off.
That's where the emerging field of sedation dentistry comes in. "Conscious sedation" is a term used for the zone between anxiolysis (diminution or elimination of anxiety, as is done with laughing gas or oral anti-anxiety meds) and general anesthesia, in which a patient is rendered completely unconscious, unable to breath on her own or respond to physical or verbal stimulus.
Under the oral-drug version of conscious sedation, the patient is given a larger dose of an anti-anxiety drug. He remains awake during the dental procedure -- although he may feel like he is sleeping -- and is able to respond to verbal commands and breathe unaided. He is, however, in a much deeper state of relaxation.
One drug popular among sedation dentists is triazolam (Halcion), which not only sedates the patient but also produces an amnesiac effect, so the patient remembers little or none of the procedure. Dentists may give a pill alone to induce the desired level of sedation, or use the oral drug in combination with nitrous oxide.
To monitor the patient's condition, a pulse oximeter is placed on one of his fingers to track blood oxygen; other monitors may be used as well. A dentist may receive training during dental school that allows her to practice this level of oral sedation, or may learn or review proper techniques through continuing education courses.
Another oral drug, hydroxyzine, is useful with patients with a heightened gag reflex, says Dougherty. Although not scared of dentistry, one of his patients had such an extreme gag reflex that she couldn't watch her own children brush their teeth, and had trouble brushing her own. She had to leave the movie theater if a scene with tooth brushing came on. So when her dentist needed to take X-rays, she was in a pickle. She couldn't bite down on a single piece of film to have an X-ray taken -- and she needed 16. With hydroxyzine, an antihistamine that also has an anti-anxiety effect and is sometimes used to treat nausea, Dougherty was able to take the full set of X-rays.
A still deeper level of sedation can be induced through intravenous drugs. The dentist who administers them, though, needs nursing uniforms -- a minimum of 60 hours of classroom education plus clinical practice on at least 20 patients.
"The beauty of IV-conscious sedation," says ADA's Weaver, "is that the dosage can be custom-tailored to the patient's needs. Some need more of a drug to get to the same level of sedation. [With IV- conscious sedation] the lag time between giving a dose and seeing its effect is very short -- usually within a minute or two. If that's not enough, one can give a little more, wait a couple minutes, give a little more, etc." That approach, called titration, "takes the guesswork out of how much to give," says Weaver.
The ADA is concerned that some dentists are putting patients at risk by trying to mimic the effects of IV sedation with oral drugs - - by giving a pill, waiting a while to see if it's sufficient, and if not, giving another, until the patient is sedated.
The problem with multiple doses of oral drugs, Weaver says, "is long lag time." Each person's rate of oral absorption is different. "There's much more variability [with oral meds than with IV drugs]. One person will get the maximum effect [of a pill] in 45 minutes, another in two hours. If I give a drug at 7 o'clock and at 7:30 it hasn't taken effect, do you need more, or is it still in your stomach? If you get a third dose at 8 o'clock and then all three hit between 8 and 8:15, there is a potential for overdose at that point."
And while there are drugs to reverse the effect of such an overdose, the proven effective way to administer them is via IV -- a technique that most dentists don't have the training to perform.
Michael Silverman, president and founder of the Dental Organization for Conscious Sedation (DOCS), disagrees. A dentist who practices in Broomal, Pa., he feels there's greater risk of overdosing a patient with a single dose of a drug, because the dentist will tend to give a higher dose to be sure the patient is "out of it. . . . The problem is, you don't know a patient's susceptibility." Just as three alcoholic beverages would make one person sick and another feeling little or no effect, the same holds true for anti-anxiety drugs.
DOCS, which offers memberships to dentists for $389 a year, teaches a technique in which the patient comes in an hour before the dental work is scheduled to start and is given oral drugs in small increments.
"The goal is to give the minimum amount needed to get the patient comfortable," says Silverman. "It makes a lot of sense, because it provides the least amount of drug necessary. You don't double the dose if they need more. You give smaller and smaller amounts each time," until the patient is sedated enough to undergo the procedure.
DOCS's 2,500 members have treated 450,000 cases with the incremental dosing technique over three year -- all safely, says Silverman.
(It should be pointed out that DOCS recommends using this technique only with adults. Sedating children is far more complex, says Silverman, and should be left to pediatric dentists who have gone through special training. The same goes for patients with nursing uniforms, who Silverman says should be referred to specialists.)
Still, DOCS's approach concerns many in the field. Dentist Jack Bynes of Coventry, Conn., says the group's "teachers are very knowledgeable. They advocate monitoring. But they're advocating the use of oral sedation and titrating. Oral sedatives cannot be titrated, only IV can. It's absolutely impossible" to do it safely.
"Eventually, somebody will get into trouble," perhaps a dentist who starts performing this type of sedation to add money to her bottom line and only takes some basic coursework, said Bynes, who runs the Web site www.dentalfear.com. He has started his own training program for conscious sedation; his approach requires dentists to complete a 10-chapter course -- and does not teach incremental dosing.
Bethesda's Dougherty feels both the incremental and single-dose sedation techniques are safe, and says he decides which approach to use based on the patient and the duration of the procedure.
Many sedation dentistry patients speak of it with the zeal of converts. One after another told a reporter how they cried talking by phone to staff -- out of relief to find someone who respected their fear and was able to reassure them help was available.
Indeed, in catering to fearful patients, a good sedation dentist's tools go far beyond drugs. The whole atmosphere of the office can be altered to reduce anxiety. No one in Bynes's office wears nursing scrubs or smocks, according to several patients who have been treated there. These people also say that the dentist's "uniform" consists of a long-sleeved shirt and bow tie. His staff members -- chosen for their people skills as much as their technical ones -- wear colored cardigans. Instruments are hidden behind panels. The dental chairs have built-in heat and massage features. Patients can listen to CDs through headphones that block the noise of the drill, or strap on a virtual reality headset and play a video game while their work is being done. Or they can look out the floor- to-ceiling windows at a waterfall (a real one -- Bynes's office is in a converted grist mill).
A more relaxed patient needs less sedation, says Bynes, and after using sedation at their first appointments, many are able to get by with just nitrous oxide at subsequent ones. But a setting like that doesn't come cheaply. Very few insurance policies pay for the sedation used in dentistry.
No one interviewed for this story knew of any sedation dentists who participated in provider networks organized by insurers. "You can't, in this type of practice" says Bynes, because insurers are not willing to compensate dentists for the extra time that sedation techniques require.
If a patient has an indemnity dental plan or a managed care plan that permits out-of-network treatment, the plan might pay its usual amounts toward the dental work, while the patient pays for the sedation, which can run from $100 to $500 per visit.
For the uncovered or those bound by a network, every penny has to come out-of-pocket.
A look at the DOCS Web site, www.sedation1.com, suggests that dentists' motives for providing sedation dentistry might not be entirely altruistic. Besides basic clinical information, the for- profit group teaches in its "Essentials of Sedation Dentistry" course for dentists:
"4 new ways to create passive income through higher levels of team participation"
"4 steps to closing high value cases" and
"3 ways to dramatically increase the value of each new sedation patient."
Many patients, though, don't seem to begrudge the sedation dentists their incomes.
Javadi, who had the traumatic dental work as a child in Iran, says she has friends today who are dentists and would do her work for free. Instead, she pays Dougherty, whose work on her, she says, has changed her life.
She used to be so ashamed of her teeth that she'd try not to smile, so no one would see that her gums had receded so badly that you could see space between the bottom of her teeth and the gums. After an expensive course of treatment, all done under sedation (Javadi chooses to have sedation even for routine cleanings) Javadi has her smile back.