Dental Anxiety, is it common?

Dental anxiety is Commonplace!

You may feel that it affects only you but believe me, after treating patients now for more than 30 years, I can tell you, you are by no means alone in your dental anxiety.

Fear and dental anxiety may result from a bad dental experience as a child or even as an adult. It may just be one of those “illogical” phobias that people suffer from.  Some people fear spiders, others open spaces and others confined spaces.  But no matter what the cause, the fear or anxiety is very real and needs to be managed in an understanding and empathetic manner.  Many patients find that while they could cope with their being nervous when they were younger, as they become middle-aged, their anxiety levels seem to increase making dental treatment more and more difficult to tolerate.

Our Approach To Anxious Patients

Here at NQ Surgical Dentistry our first rule in treating nervous, anxious or phobic patients is to avoid being judgemental and to be understanding and supportive.

The starting point is to take a thorough history that will involve a detailed record of how the anxiety first began but also all the various factors affecting your dental health.  We will also want to know your medical history and will discuss your medications and any drug allergies you may have.  We will listen to the nature of your anxiety to see if there are specific fears that can be eliminated by careful patient management, avoidance of certain equipment, use of topical anaesthetic gel before injections, thorough explanations, and of course a liberal dose of TLC! For some patients however the only way they are going to willingly accept dental treatment is under sedation.  So first let’s look at anxiety and the effects of the drugs used to control it.

What Is Anxiety?

Anxiety is an emotional and physiological response to a situation mediated by chemical reactions in the brain.  The first thing to understand is that anxiety and fear can be eliminated by the use of drugs that are called “anxiolytics“.  These drugs reduce the “neuro-chemical” activity in the brain associated with creating the anxiety response.  An additional and separate useful effect of these drugs includes the loss of memory over the time the drugs remain active.  This is called “amnesia“.  Another effect of the drugs is to induce a relaxation, even a sleepy feeling that we refer to as the “sedative” effect.

The combination of the anxiolysis, amnesia, and sedation provides the patient with the equivalent to a relaxing twigh-light snooze.  This is why this treatment is called Conscious Sedation as opposed to the alternative of General Anaesthesia where the patient is unconscious, “out for the count”, and incapable of being woken up until the anaestheticdrugs are either reversed by other drugs or they are allowed to wear off once their administration ceases.  Sedation allows for complete elimination of fear, but leaves the patient able to maintain their own airway, breath normally and respond to firm touch to wake them to a more conscious level of awareness.

What Does Sedation Involve?

Conscious Sedation can be provided as Oral Sedation, Inhalation Sedation or Intravenous Sedation.

Oral sedation involves the ingestion of sedative tablets before the dental appointment to help the patient with their anxiety.  For the drug to be effective it must firm be released from the tablet or capsule in the stomach, absorbed across the stomach wall and then distributed to the point of action (brain). The absorption of sedatives in this way is unreliable and the dose required for any particular patient impossible to accurately calculate. Oral sedation may be successful only for the mildly nervous patient.  The practice of administering large oral doses of sedation to achieve effective sedation must be considered dangerous, unprofessional and indeed negligent particularly if the patient is not being monitored appropriately.  At NQ Surgical Dentistry we do not use such a technique.

Inhalation sedation requires the patient to breath through a small nasal mask that covers only the nose (the dentist needs to get into the mouth!).  The patient is provided with a combination of oxygen and nitrous oxide, the concentration being varied depending on the sedative effect achieved.  There are some problems with this technique when doing dentistry and generally it is used only for doing fillings.  The patient is lying down and must have their mouth open to allow work to be completed on the teeth and therefore they must be able to breath through their nose closing off their mouth with their tongue and soft palate.  Some people can do this easily while others find it difficult if not impossible.  Furthermore the expired air from the patient still contains unused (over-flow) nitrous oxide in sufficient quantity that it must be collected and removed from the surgery by a “scavenging unit” otherwise the dentist and assistant are likely to become sedated as well.  Not ideal!

Intravenous sedation is the term for the injection or infusion of sedation drugs into the veins (normally in the arm or hand) and this achieves a much more efficient sedation and with experience, very good control of the depth of the sedation can be maintained.  The most common drug used for this is Midazolam also known as Hypnovel.  Some sedationists use other drugs with it for their additional pain-controlling properties.  Midazolam works very quickly, within a couple of minutes, and has a relatively short active life in the body so that once the patient is sedated to the appropriate level for the procedure they will receive regular small incremental doses of the drug to keep them at this level of sedation.  The drug can be reversed if necessary.

Monitoring

Throughout sedation, patients must be very carefully monitored.  This is performed by a combination of both clinical and technical monitoring.  Clinical monitoring is performed by both the dentist/operator and by the sedation nurse.  This involves checking the patients breathing by observing the regular rise and fall of the chest, and their colour around the hands, lips and ears to indicate adequate oxygen is being absorbed.  Their pulse can also be felt manually.  Further technical monitoring takes place using monitoring equipment that you would normally see in an operating theatre, recovery ward or in an intensive care unit.  This equipment measures (a) the breathing rate, (b) the pulse (heart rate), (c) the blood pressure including the Mean Arterial Pressure (MAP) by non-invasive blood pressure (NIBP) monitoring and (d) the expired concentration of carbon dioxide (capnography) to demonstrate that the patient is absorbing oxygen and using the oxygen successfully hence producing carbon dioxide.

The Benefits of Sedation for Anxiety 

Conscious sedation is a very useful additional procedure for anxious dental patients.  It means they can obtain their treatment in the dental practice setting without the need to have to be given a full general anaesthetic in a day surgery unit.  Sedation is safer than generalanaesthetic and has less potential side effects.  It is also likely to be less costly than having to be treated in a day surgery centre and have a consultant anaesthetist provide you with a general anaesthetic.  However, it can only be administered by appropriately trained and qualified medical or dental practitioners.  This means that if you are to receive this type of anxiety control, you will have to find out who provides this care in your location.  Sadly there are only a limited number of appropriately endorsed dental practitioners approved to offer intravenous sedation and to find them you can either contact the Australian Health Practitioner Registration Agency (AHPRA) online and ask them for the information or contact the Australian Society for Dental Anaesthesiology (ASDA) and contact the secretary asking for the details of your nearest sedation endorsed dentist.

Dentists Endorsed in Sedation

Training for dentists to offer this service is extensive.  They must have completed a clinical diploma in Sedation and Pain control and been examined to ensure they are both safe and proficient in the use of sedation techniques and in the management of numerous emergency situations to ensure patients can be cared for if they experience a medical problem while sedated in the dental practice.  Furthermore, every year these dentists must complete a prescribed course in managing emergencies in the dental setting run by a Consultant Anaesthetist that includes both theoretical and practical components.  This is to ensure they are up to date with the most recent advances and training in life support, airway maintenance and drug regimes.  They must also be assisted by trained and qualified nurses who have completed Advanced life Support courses and are re-certificated annually.  If you want to know if your sedation dentist is up to date ask to see their Annual Registration Certificate issued by AHPRA which clearly identifies if they are endorsed to offer sedation.

In Summary

Intravenous sedation is a highly successful method of controlling patient anxiety allowing them to willingly accept treatment that they would otherwise find themselves unable to accept.  It is safe and well tolerated and provided by a suitably qualified and experienced sedation team, will make dental treatment a pleasant experience.

At NQ Surgical Dentistry we employ a part-time Registered Intensive Care Nurse who has worked with Dr Colin Priestland in Townsville for 10 years and between them they have over 40 years experience of advanced life support, managing sedated and unconscious patients and both of whom continue to maintain regular professional continuing education.  Colin completed his sedation training in 1986 and has been active in the field since that time.

We want our anxious patients to know they are in safe hands, and that they can receive dental care in the friendly, safe and well-controlled environment at NQ Surgical Dentistry where we have all the most modern equipment, all the necessary emergency equipment and all the necessary training to give you the peace of mind to trust us to offer you the care you deserve.

contact the friendly team at NQ Surgical Dentistry today on (07) 4725 1656 or call in to see us at 183 Kings Rd, Pimlico QLD 4812