By: Mel Hawkins, DDS, BScD AN, FADSA, DADBA
“It is no longer enough that dentistry be technically competent, it must be humanely presented”
Dr. Wm. Dover, dentist, dentist/anesthesiologist
Modern dentistry. With its biomaterials, advanced implant techniques, cosmetic emphasis, state of the art laboratory procedures, beauty, function, pain control, pharmacology, drugs, patient management, smiles, local anesthesia sophistication, products, adjuncts, medical wonder drugs …Is one any more important than the other? Yes. But it’s not in this list. We dentists, dental hygienists, expanded duties practitioners, dental assistants, office managers, registered nurses must never lose track of the fact that we are treating real people, not actors, as in TV commercials.
Dentists approach me at the podium, by email or at a reception and state something like:
- “I’ve never needed to use sedation for my patients. I’m a gentle, patient, communicative person and use tender loving care (TLC) to get my patients through”
To get them through? Key phrase.
- “I’ve only ever referred one difficult to manage child in 30 years of practice.”
That’s admirable. Sooner or later if an individual practices long enough, a patient has an indication for referral.
- “I have a lot of senior citizens in my practice with a variety of heart problems, diabetes and physical and mental challenges. They just don’t need sedation”.
Stress of a dental appointment and myocardial compromise don’t go well together. Cardiac patients, high blood pressure individuals, and of course the apprehensive patient benefits from a reduced stress level.
I’m not here to sell sedation. I don’t need to. Some 85 million Americans avoid the dentist out of dread, according to the Journal of the American Dental Association (JADA).
The ADA has stated that a significant % of the population still avoids dental treatment due to fear. It’s ranked up there with public speaking, heights, flying, snakes, claustrophobia and crowds. As with any therapeutic treatment modality, patient management by sedative inhalational gases, oral or IV medications such as midazolam (Versed®) will or could help the patient feel better towards dentistry, help the appointment time pass faster or provide memory gaps of points in the appointment which really don’t need to be remembered.
Dentists who use sedation say it may be the only way to get certain patients into the dental chair at all. Mom’s and Dad’s who parent uncooperative, caries ridden children say it may be the only way their child can be managed.
So how does a practitioner deal with the major disadvantages of oral sedation, namely “guessing” at a dose because titration is impossible and what if you’re wrong? How does one minimize the time of onset? Doesn’t waiting for it to work just exacerbate the already existing apprehension?
MINIMIZING THE ORAL ROUTE DISADVANTAGES:
How do you choose a dose? The first appointment is in part a guessing game but the guesswork can be successfully reduced by employing a few practical (and rational) rules.
- Body weight: adult vs. child
- Level of apprehension.
- Drug experience, prescription drugs, OTC medications e.g. cough medication DM, tolerance, dependence, chronic prescribed medications (benzodiazepine history), liver enzymatic induction.
- Difficulty of dentistry and
- Time required (appointment length).
WHAT TO USE? Prototype: Triazolam – Halcion®
What do I mean “amnesia is conditional”? Isn’t that why a benzodiazepine is administered? Yes, but there are two overriding events that negate amnesia.
- Trauma / Pain
- Audio comments.
In other words, anything that stimulates a physical (pain) or emotional (anger, envy, insult) reaction from the patient, for example:
- Elevating a lower third molar which is not adequately anesthetized. “It’s just pressure, it’s just pressure”, while thinking, “they won’t remember it anyway”. Not. It hurts and they do.
- “Don’t you love my new Porsche? I’m going to Hawaii for a month”. Don’t say it!
There are many consents out there and sedation consent forms ( pardon the play on words) one more category. The first interview question should be, “Is English your first language?” or “Is English your preferred language of discussion?” If it’s not, it will be a very short appointment, ending now, for today. They must then arrange to bring an interpreter for the consultation and consent appointment. I have experienced occasions where during a consultation I believed that a patient while nodding “yes” at almost every point (as opposed to nodding off), ultimately had understood virtually nothing! Their first language was an East Asian dialect.
The most important point after communication confidence has been established is for the patient to 100% understand:
- Not to drive a motor vehicle, operate machinery or use sharp objects (i.e. in the kitchen, for example ) and not to make any important decisions for 24 hours. Yes, they may go back to work but must sign off on the above!
The most important points for the dentist to adhere to are:
- Although the initial question and answer format can initially be conveyed in the printed word, consent must be discussed verbally with an adequate time allowed for questions and answers. Note that obtaining consent is not a single event but rather a process that occurs over time.
- An oral sedative cannot be administered and then consent endeavored to be obtained in the belief (true fact but not legal) that because the onset of the drug effects will not occur for a few minutes, “we may as well not waste time”. Why do all the consents and then administer the tablets/pills/capsules and then wait even longer? Answer: Because you must.
- Never change the treatment plan while the patient is under the influence, i.e. extract a tooth that you said you would initiate endodontic therapy on, see what happens, you find a crack, the tooth is obviously doomed and you take it out without permission, or with “permission” from the intraoperatively sedated patient, or just as bad, the spouse, which of course is not permission at all.
What is the criteria for assessing a professional fee for the reimbursement of a 25 cent tablet (or two or three)? Of course, this is not about the cost of the medication. It is very much about the education and expertise of the dentist, the time and money expended to do so, the responsibility of administering and monitoring the drugs involved, per-op and post-op, the ability to manage side effects including a medical crisis, the challenge of managing not only an uncooperative child but also a parent or guardian who may be equally as challenging, demanding or sceptical. In other words, “what’s it worth?”…or “should it be free as it simply allows the dentistry to be more efficient?”
Sedation is a wonderful adjunct to the practice and delivery of modern day dentistry. Not only is the apprehensive individual a prime indication for consideration, but also longer, more sophisticated and intricate procedures necessitate a cooperative and relaxed patient. The relaxed dentist and dental office environment form the third point of the treatment triangle and as a comprehensive treatment plan is extended to our patients, perhaps a comfortable, safe an time efficient consideration should be offered simultaneously.
Dr. Hawkins is board certified as a Diplomate of the American Dental Board of Anesthesiologists and is a Fellow of the American Dental Society of Anesthesiology. He has over 30 years of private practice experience in sedation dentistry in Toronto, Canada. Mel has been lecturing throughout the United States, Canada, Mexico, Europe and Asia for 40 years.
Like what you read? Dr. Hawkins will be speaking as the 2016 Oregon Dental Conference! Register today! www.oregondentalconference.com