Anxious or Phobic Dental Patients

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Pharmacological Sedation Techniques


atients who conquer their dental fears through the natural methods mentioned previously in this course will gain self-esteem and tools that can be used not only to squelch dental fear and anxiety, but in many other areas of their lives. Attempts should be made to cure the anxious patient of the root causes of their fears prior to considering sedation. However, some patients will not respond to these methods and will need varying degrees of sedation to allow dental treatment. (Some methods of sedation require additional education or permits)

The three main types of pharmacological anxiety control are: conscious sedation, deep sedation, and general anesthesia.

Conscious sedation is the lightest form of sedation. The patient still maintains an airway continuously and independently, and will respond to verbal commands and physical stimulation. Deep sedation is a controlled state of depressed consciousness. Protective reflexes are reduced, and the airway is not independently maintained. The patient will not respond to verbal commands. General anesthesia is a controlled state of unconsciousness. Protective reflexes are nonexistent, and the airway is not independently maintained. Sedation drugs are administered orally, intramuscular or intravenously, or by inhalation.

Oral drugs like Benzodiazepines (Diazepam and Oxazepam) can be administered one hour prior to the dental appointment. Triazolam and Flurazepam are useful when administered the night before treatment to assure a sound night’s sleep. Chlorohydrate with Promethazine or Hydroxyzine is used in pediatric dentistry.

Nitrous oxide is an effective anesthetic agent. Combined with oxygen, it is the safest and most controllable form of sedation available. It has few complications, and the patient has no side effects after the administration of pure oxygen. Hygienists must be licensed to use nitrous on patients. Dentists must be present when their patients are being administered nitrous. Some complain of residual headaches, and worst residual “highness” so it is important to make sure each patient receives enough time for 100% oxygen post-treatment for at least 5 minutes. Listen, too, if patients do not prefer Nitrous oxide. There exist other alternatives to it; fulfilling the same desired affect of relaxation, as mentioned in the previous paragraph.

Drugs that can be administered intramuscularly give a deeper effect and are most often used with uncooperative patients such as a child or the mentally handicapped. Adequate training is required for administration of intramuscular drugs. Training requirements are typically two years in a residency program in anesthesiology or completion of a residency in oral and maxillofacial surgery.

IV sedation is effective for many patients. The patient is still capable of responding to verbal commands and physical stimulation, but is essentially worry-free. Some of the drugs used in IV sedation can cause amnesia, so the patient doesn’t remember the experience at all. It is important to remember that in some states a dentist must obtain a permit in order to administer IV sedation or conscious sedation.

Referral to a Mental Health Specialist


any anxious patients will only visit the dentist in the case of a serious emergency. In these situations, the dentist must take the time to consider the treatment that will both fix the issue and be least traumatic for the patient. For example, if a patient is too anxious to receive treatment immediately for a true dental emergency, it may be necessary to prescribe antibiotics for pain and infection, and then work with the patient to eliminate the fear and anxiety before completing treatment. The prescription of antibiotics may not be a definitive treatment, but in conjunction with stress reduction instruction or therapy, it may increase the chances that an anxious patient will return for further treatment.

If all of the aforementioned treatments do not work to calm an anxious patient, it may be necessary to refer the patient out of the office to a mental health specialist, clinical psychologist (PhD), psychiatrist (MD), or a mental health center.

Dentists are not trained psychologists. If the patient is still too anxious for treatment, refer them to a mental health professional especially if the patient:

A psychotherapist can offer the patient treatment including relaxation strategies, biofeedback training, hypnosis, desensitization programs, or group therapy.

If referring a patient, choose a therapist who will give recommendations to you and with whom you feel comfortable. Ingersoll and Geboy suggest that the psychologist meet the patient in the dental office for the sessions during off-hours. This can be very useful, as the office will become a familiar setting for the patient.

University Dental Fears Clinics

University Dental Fears Clinics are another excellent option. Staffed by dentists and psychologists, they specialize in treating dental anxiety and phobias. Because many are affiliated with dental schools, they are not only places to refer patients but may offer continuing education courses for the dentist or auxiliary in the management of the anxious patient. Contact the Dental School nearest you for more information.
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