By DOCS Writing Staff
Meet John Dovgan, DDS, PC, of Phoenix, AZ, and Sabrina, a self-professed “dental phobe” and first-time sedation patient who wanted to get her oral health taken care of without the usual anxiety that accompanies it.
Dr. Dovgan, a practicing sedation dentist and examiner for the State of Arizona, is the nation’s foremost standard-of-care investigator (SCI). He has evaluated 1,200+ cases on behalf of state dental boards and has served as an expert witness in 120+ malpractice cases. As a DOCS faculty member, Dr. Dovgan uses an engaging and fun style to show dentists how to avoid legal and regulatory landmines.
DR. DOVGAN’S PERSPECTIVE: MEETING THE PATIENT
Sabrina is a 35-year-old healthy female who has worked in the medical field for years. She is an ASA I who is almost an ideal candidate for oral conscious sedation (OCS). Although she does have asthma, she only needs a rescue inhaler occasionally. No other medications were noted and fortunately, she hasn’t used her rescue inhaler for four months.
“In my practice, I enjoy treating patients who are young and healthy as well as patients over 65 with subsequent health issues.”
Sabrina truly has dental anxiety. She informed me that she generally has self-inflicted marks on her hands after any dental appointment.
Sabrina had to travel well over two hours to our practice from her home in Tucson, but it isn’t unusual for a sedation practice to reach a large geographic area. She obtained local lodging the night before our appointment and completed a health history and sedation informed consent form online, which was also reviewed with her in the office. Sabrina had her mother along to take care of her after the appointment.
When Sabrina arrived, we did a comprehensive exam with x-rays to determine a treatment plan. Unfortunately, the x-rays obtained from her previous dentist weren’t diagnostic enough for comprehensive treatment. Once her treatment plan in three separate quadrants was approved, we were ready to begin.
A pulse oximeter was placed with a baseline blood pressure, pulse, and Sp02. We were also very aware of her weight as total anesthetic amount is limited by the patient’s weight. This is especially important when doing OCS patients as we tend to do large treatment plans all at once. We figure the total amount of anesthetic carpules prior to beginning any case, and have my assistant place the used carpules into a cup. This avoids overdosing.
A rubber dam is always used when possible. Sabrina was placed on the pulse oximeter and given Triazolam .25 mg orally at 8:45 AM with Hydroxyzine of 10 mg. She was allowed to rest in the operatory while we waited for the medication to take hold. The patient said she reacts to Benadryl and it “puts her to sleep.” This indicated she might be a hyper responder, so I always dose low.
We factor this time in for patients that are from out of town, and I treat other patients while waiting for the medication to work. My dental assistant Michelle was in charge of monitoring Sabrina’s vitals during this time. At 9:40 AM we administered another .25 mg of Triazolam sublingually.
Within 10 minutes Sabrina was ready to have treatment as she had the “sedated” appearance. She was then placed on O2 for three minutes and administered 35% nitrous before being given the local anesthetic. We administered the local and placed her back on pure O2 for the remainder of the appointment.
Sabrina was properly sedated for the procedure, and it went very smoothly without complications. I truly believe we would not have been able to care for Sabrina without sedation, given her anxiety level. I especially enjoy giving patients the treatment they so desperately need when their fear and anxiety is properly taken care of. This is a win-win for everyone.
SABRINA: PERSONAL PERSPECTIVE OF AN ANXIOUS PATIENT
I’ve had dental fear most of my adult life, though not what I would consider severe. I’m generally fine for a typical 6-month cleaning. I may not enjoy it or fully relax, but I can get through the appointment and go about my day normally, before and after. If I need cavities filled or anything beyond that, I get very anxious.
“My heart pounds, nerves tingle up and down my arms and legs, and I sweat, almost as if I’m under attack or serious duress.”
My worst habit is poking “holes” in myself by digging my nails into my hands or arms to try to calm myself down. It’s not uncommon after dental appointments to have multiple wounds on my hands and arms that take a week or so to heal.
To top it all off, every single time I require more extensive treatment, I start crying. It takes 5-10 minutes to calm down enough for them to begin work. After the appointment, I’m exhausted and my mood is very low.
I tell myself that the anxiety is silly and there is nothing to be afraid of. I work in the medical field, for crying out loud! But no matter how logical I am, I get very anxious once I’m in the chair and it makes for a miserable experience. While I make sure to get my routine care done, I sometimes delay the more invasive work to the detriment of my oral health.
I went to my regular dentist in mid-2020 for a routine cleaning and found out that I had three or four small cavities that needed attention. However, with COVID numbers spiking again, I didn’t feel comfortable getting the work done at that time. Also, that dentist didn’t have nitrous oxide or sedation and I was very nervous about getting four cavities filled in one appointment.
During the next 6-month cleaning, they warned me that the cavities had gotten worse. This is the first time I’ve ever delayed treatment due to my anxiety, but I knew I couldn’t avoid it any longer, so I started looking for a sedation dentist.
Dr. Dovgan came highly recommended by my boss, who knew him personally and professionally. However, I also did my own due diligence. He was very highly rated online (close to a perfect 5-star score) and had been trained by and maintained certification through DOCS Education. There were dentists closer to me in Tucson who performed sedation dentistry, but none had the professional reputation or the reviews that Dr. Dovgan had. I was already nervous enough – I wanted to make sure that I had the best possible dentist available to do my sedation.
On the day of the appointment, they took a whole set of x-rays to make sure they got a good picture of what to expect. Dr. Dovgan introduced himself and we chatted about why I was looking to do sedation and would drive two hours to see him, specifically. I explained my desire to see a well-regarded sedation dentist in order to be absolutely comfortable with the procedure– well worth the drive.
He actually identified six cavities in various stages of severity. As someone who tries to take excellent care of their teeth to avoid this situation, that was heartbreaking. At this point, I began to cry. Dr. Dovgan gently and kindly spoke with me until I calmed down.
At about 8:45 a.m. they gave me two small pills to start the sedation. After about 45 minutes, Dr. Dovgan came back in and asked me a few questions about how I was doing. I must not have been loopy enough, because at that point he gave me a bit more sedation medication, but this time crushed into a powder and put under my tongue. I think at one point I asked for a blanket, but this is when my memory starts to get sketchy. Maybe 10 minutes later, they laid me back, put a nitrous mask on my face, and began their work. Other than them asking me at moments to adjust my bite or grind my teeth in a certain way, I don’t remember much.
Considering the amount of dental work, it felt like no time at all before it was all done. A little after 11:00 a.m., they rolled me out to my mother’s car. I slept most of the way home and didn’t have any numbness or pain by 4:00 p.m..
I was tired for the rest of the day and into the next, but otherwise felt completely normal. It was like I hadn’t just had six cavities filled the day before. And good news, no self-inflicted, anxiety-driven holes in my arms. I absolutely recommend sedation dentistry.
While I was still anxious going into the appointment, it would have been 1,000 times worse if I hadn’t had sedation. My regular dentist had actually wanted to break this work up into multiple appointments. I’m so glad I didn’t go that route.
Dr. Dovgan and his staff were wonderful. Overall, it was a comfortable and kind experience, and I would do it again–although I hope I never have to!