By Genni Burkhart
This case study review is a recap of a recent DOCS Education webinar that was presented by Dr. Carol Wilson and Dr. Michael Silverman in the continuation of teaching the art of sedation dentistry, as well as showing how sedation benefits the dentist and the patient.
The addition of sedation to a dental practice allows dentists to perform multiple procedures on a daily basis while moving from nitrous to other sedation, particularly on patients with dental anxiety or fear. Regardless of the level of sedation needed, DOCS Education can train dentists at all levels to safely sedate patients.
- The high number of patients with dental fear.
- Anxiety towards restorative dentistry with only local anesthesia. Two-thirds of patients are anxious about having dental treatment.
- Some dental fears are more severe than others, such as phobias which can be debilitating – leaving patients with no rationality as to why they’re afraid. Dental fear comes in different forms; some can cope, others cannot.
- Dental fear has not decreased contrary to some beliefs. Actually, dental fear has increased with 36% of the general population now having some form of dental fear. This can be attributed to COVID-19 exacerbating anxiety disorders.
The purpose of dental sedation is to give full and proper dental treatment in a comfortable environment to restore health and function, and address any dental fear the patients might have by allowing them to not remember much about their procedure, and providing them with the comfort they need.
Case Study Examples – What’s the Right Choice for Each Sedation Patient?
Patient with Gag Reflex
This patient had previously put off two crowns on #18 and #19 due to a gag reflex and has dental anxiety. He didn’t know sedation was an option at his previous dentists, so when sedation was offered at Dr. Wilson’s office the patient was open to it. Patient followed pre-appointment protocol and underwent sedation successfully. Patient was able to maintain his airway on his own, stay relaxed, and had a good experience at the visit with the treatment accepted and completed.
Test Your Knowledge - What’s the Best Sedation?
This patient has a strong gag reflex, does not like injections, doesn’t care for the tooth polish as it makes him nauseous, and doesn’t want to have a driver as he needs to go right back to work right after the procedure. Medical history includes high blood pressure controlled by lisinopril to 130/85 and seasonal allergies. The patient has the beginning of periodontal disease in one quadrant. Appointment will be less than two hours but does require anesthetic as it might induce gagging.
The correct form of sedation for Mr. Smith would be nitrous oxide, as this procedure can be produced in under two hours. Nitrous allows him to be able to get back to work and not have a companion as he requested. By listening to the patient, Dr. Wilson determined this is the best drug of choice for his needs. This drug is also a vasodilator and will decrease his blood pressure as well as help to decrease gagging.
This patient wants some cosmetic dental work done and to keep his appointments around two hours max. He needs two crown preps with restorative in one quad, two extractions, wants teeth #1 and #16 moved due to biting issues, and had a negative childhood experience with dentistry and would like to not remember the appointment.
The best form of sedation for Nick would be oral single dose. As he is over 18 years old, he would receive pre-appointment triazolam and follow through before the appointment. For appointments lasting two hours, this has a great amnesia effect. Nick can go home and rest and be well-oriented while not remembering much about the procedure.
Ed has a #7 fracture beyond repair. He wants the procedure to stay under four hours and doesn’t mind dental treatment. His needs include endo, post, core crown prep of #8 and 9, and extraction of #7 with single implant placement on #7 with bone graft. Ed doesn’t have dental anxiety over restorative hygiene but has heard horror stories from his friends. As for the extractions and the implant placement, he’d prefer not to remember.
The best form of sedation for Ed would be oral sedation with multiple agents using incremental dosing. This will help keep him comfortable for longer appointments while not remembering much about the procedure.
Morgan is a 70-year-old who wants cosmetic surgery and needs lots of dental work due to time and budget constraints. His time off work is limited, he had a negative experience at a dentist as a child, and Morgan desires a smile makeover with a full arch cosmetic crown. He’s diabetic so his appointments need to start early and end by 1 pm, and he understands the procedures could last longer than four hours.
The best form of sedation for Morgan would be IV sedation. Due to his high dental fear and diabetes, IV combined with oral sedation is the best solution. The dentist can titrate for effect on a more anxious patient or hypo responder, provide emergency access for glucose, and analgesic medications for a longer procedure.
Melissa wants to update her look. She’s a 41-year-old female, #12 has a mesial hairline crack, and is cold sensitive. Melissa had to prevent procedures during COVID-19 shutdown, and she doesn’t like injections. Melissa is an essential worker, so she needs to go back to work right after the appointment.
The best form of sedation for Melissa would be nitrous oxide. This offers mild relaxation, and she can go back to work right after the procedure without a ride.
Bette is a 65-year-old with advanced periodontal disease and her lower anterior teeth are mobile when she speaks. She had a traumatic childhood experience and requires extraction of #12, mandibular teeth with a flap to smooth bone, and placement of bone grafts for future implants.
The best form of sedation for Bette would be IV sedation due to irrigation with multiple extractions and swelling that can occur. The water would rinse away oral medications used and create a need to titrate.
The webinar continues with guidelines and recommendations on how to choose the best type of sedation and the equipment needed to administer oxygen, nitrous, recording machines, monitors, a companion chair, and best practices on keeping track of all drugs used, as well as the benefits of Safe Sedate.
In addition, there are regulations to be aware of created by dental boards in every state in the U.S. For DOCS members, legal counsel is provided to help dentists meet the requirements in each state as well as adhere to various dental guidelines regarding sedation.
With continuing education as well as permit qualifying courses, DOCS membership includes access to legal counsel and the entire DOCS faculty. DOCS can also provide ACLS, BLS, and PALS training with recertification training that can meet you where you are by coming to your office to train your entire team, as well as provide certification at larger events.
For further information, DOCS members can access a recording of this entire webinar online by logging into their DOCS Education account dashboard.
Author: With over 12 years as a published journalist, editor, and writer Genni Burkhart’s career has spanned politics, healthcare, law, business finance, technology, and news. She resides on the western shores of the idyllic Puget Sound where she works as the Editor in Chief for the Incisor at DOCS Education out of Seattle, WA.