A phobia is defined as an irrational fear of a certain situation, object or activity which leads the sufferer to avoid it at all costs. Dental phobias are serious problems and affect many people. In severe cases dental phobics will avoid going to the dentist even when they have developed serious oral health issues. Because of this avoidance, many dental phobics do not know how to properly care for their teeth and this can lead to a viscous cycle of problems. It is vital to visit the dentist at least twice a year so that any potential problems can be diagnosed before they become serious.
Causes of dental phobia
For dental phobics the thought of visiting the dentist can cause severe anxiety, panic attacks and a great deal of stress. No two cases are exactly the same. People experience anxiety towards dental check ups for a number of reasons; they may have had a bad experience early on in life, it may be the ‘clinical’ smell of the surgery. Some people are too embarrassed about the condition of their teeth and may be afraid of what the dentist may say to them or the treatment they will need to undergo to treat the problem. Some people experience a ‘gag reflex’ when dental instruments are placed into their mouths and a few patients may develop problems breathing.
Fear of Pain
You can simply be either more sensitive to pain or fearful of it, and the cause of the sensitivity can be psychological, but more often than not, it is infact a psychological reaction to the widely held misconception that a dental surgery is a place of pain. There is a cultural view that dentistry is something to be feared and in some cases this social norm can strike deeper, affecting people quite profoundly.
There can be many specific reasons for a phobia:
- fear of anaesthetic/needles
- fear of choking
- fear of diagnosis
- fear of the drill
- fear of pain
- fear of future dental work
It is also true that sometimes you simply do not know why you have a dental phobia or that you are unable to pinpoint a single reason or cause.
Realising you have a phobia is the first stage in defeating it. Your dentist can use a number of methods to help you overcome your fears. At Castle Dental Care we believe that explaining the procedure is very important, often just understanding what is involved can relieve some of the fear. We encourage patients to express their concerns and fears about treatment. It is important that you feel relaxed and comfortable with your dentist, you may need to see a different dentist if you don’t feel entirely comfortable. A lot of anxious patients just need more time and a gentle approach to treatment. For extremely nervous patients we offer Intravenous Sedation for dental treatment.
Intravenous (IV) sedation is when a drug is administered into the blood system during dental treatment to reduce anxiety and allow treatment to be performed comfortably.
What does it feel like? Will I be asleep?
In reality you remain conscious throughout the procedure. You will be able to understand and respond to requests from your dentist. However you may not remember much (or anything at all) about what went on because of two things;
- IV sedation induces a state of deep relaxation and a feeling of not being bothered by what is going on. Because you are completely relaxed, your dentist can perform more high quality dentistry in less time.
- The drugs used for IV sedation produce either partial or full memory loss (amnesia) for the period of time when the drug first kicks in until it wears off. As a result, time will appear to pass very quickly and you will not recall much of what happened. Many people remember nothing at all. So, it may indeed appear as if you are ‘asleep’ during the procedure.
Is it still necessary to be numbed with local anaesthetic? Will the dentist numb the gums before or after I am sedated?
The drugs used for IV sedation are not painkillers, they are anti-anxiety drugs. While they relax you and make you forget what happens, you will still need to be numbed. If you have a fear of injections, you will not be numbed until the IV sedation has fully kicked in. The sights, smells and noises around you will dissipate and you will feel relaxed and at ease. If you have a phobia of needles, you will most likely be relaxed enough not to care by this stage. Your dentist will then wait until the LA has taken effect before starting on any procedure.
How is IV sedation given?
IV means the drug is put into a vein. An extremely thin needle is put into a vein close to the surface of the skin in either the arm or the back of your hand. This needle is wrapped up with a soft plastic tube. It makes the entry into the vein, then is slid out leaving the soft plastic tube in place. The drugs are put in through that tube (correctly referred to as an indwelling catheter) but more commonly know by the tradename of venflon. The tube stays in place throughout the procedure.
Throughout the procedure your pulse and oxygen levels are measured using a pulse oximeter. This gadget clips onto a finger or earlobe and measures pulse and oxygen saturation. It gives a useful early warning sign if you’re getting too low on oxygen. Your blood pressure will be checked before and after the procedure.
EMLA topical cream can be applied to the site where the needle is to be placed. This makes the area profoundly numb before the needle is inserted.
What drugs are used?
The most commonly used drugs for IV sedation are short acting benzodiazepines. They have three main effects:
- they reduce anxiety (relax you)
- they make you sleepy
- they produce partial or total amnesia ie, make you forget what happened during some or all of the procedure.
By far the most commonly used drug for IV sedation is midazolam. This is the first choice because of it’s relatively short duration of action, meaning that it will be out of your system faster.
The drug is put into the vein at a rate of 1mg per minute. Because there are differences between individuals in how much of the drug you need in order to be sedated, your response to the drug will be monitored. Once the desired level of sedation is achieved, the drug is stopped.
The venflon is left in place during the procedure so that the sedation can either be topped up or so that the reversible agent (flumazenil) can be put in, in the unlikely event of an emergency.
Is it safe? Are there any contraindications?
IV sedation is completely safe when carried out under supervision of a specially trained dentist.
- known allergy to benzodiazepines
- alcohol intoxication
- Central nervous system depression
- some cases of glaucoma
Cautions (relative contraindications) include psychosis, impaired lung or kidney or liver function, advanced age and sleep apnoea.
What are the main advantages of IV sedation?
- IV sedation tends to be the treatment of choice if you don’t want to be aware of the procedure.
- The onset of action is very rapid and drug dosage and level of sedation can be tailored to meet the individuals needs. IV sedation is highly effective and highly reliable.
- Benzodiazipines produce amnesia for the procedure.
- The gag reflex is hugely diminished making IV sedation a suitable option for patients who tend to gag.
- With IV sedation the patients are conscious and can co-operate with instructions.
Are there any disadvantages?
It is possible to experience complications at the site where the needle enters eg, haematoma can form which is a localised swelling filled with blood.
While IV sedation is desired precisely because of the amnesia effect ie. Forgetting what happened while under the influence of the drug, there can be a downside to this. If you cannot remember that the procedure was not uncomfortable or threatening then you cannot unlearn your fears. As a result patients may rely on IV sedation and are less likely to receive regular dental care.
Recovery from IV sedation is not complete at the end of the dental treatment. You need to be escorted home by a responsible adult who must stay with you for 24 hours.
Cost can be another disadvantage, IV sedation is more expensive than treatment under local anaesthetic.
What will my first appointment be like?
Your first appointment will be a standard consultation. Your dentist will complete a medical history form and perform a thorough oral examination and take any necessary xrays. Your dentist will discuss your treatment needs and treatment options and will agree a treatment plan.
Your blood pressure, oxygen levels and heart rate will be measured. It is critical to tell your dentist about all medications and supplements that you are taking so that he/she can check for any potential drug interactions with the sedation medications that will be used.
Your dentist will then answer any questions that you may have and then fill out paperwork and obtain verbal and written consent from you for the treatment to be carried out.
After IV sedation
- Have your escort take you home and rest for the remainder of the day.
- Have an adult stay with you for 24 hours and until you are fully alert.
- Don’t perform any strenuous or hazardous activities and don’t drive a motor vehicle for the rest of the day.
- Don’t eat a heavy meal immediately, if you’re hungry eat something light eg. Liquids and toast. Drink plenty of water for the rest of the day.
- Don’t drink alcohol for the rest of the day.
- Take medications as directed by your dentist.
- If you have any unusual problems contact your dentist.