Sedation dentistry helps ease patients' anxiety

Mar. 9--Phil Letterman of Raleigh was 15 when he swore off the dentist.

After a bad experience getting a cavity filled, he just flat refused to go. But after three years of dodging the dentist, Letterman had sore teeth, aching jaws and chronic headaches. He fessed up about his troubles and his parents took him in for a marathon five-hour appointment at a Raleigh dental practice in December.

Letterman took a sleeping pill prescribed by his dentist, Dr. Dan Davidian, before the appointment and another once he got there. He remained calm as Davidian systematically filled the cavities he had in just about every tooth.

The best part? The next day, he didn't even remember getting treatment.

"It's completely changed my mind about dentists," said Letterman, now 18 and a senior at Sanderson High School. "I will go to [Davidian] until my teeth fall out of my head."

Even Mom and Dad are smiling, despite the $14,000 bill for Phil's extensive work, of which their dental plan will pay $1,500. The fee for sedation accounted for less than $300 of the total.

"I'm beginning to see a big difference in him, now that his teeth don't hurt," said Kay Letterman, Phil's mother. "He's getting back to his old, jovial self."

Sedation dentistry, in which patients swallow a pill to calm their nerves, was relatively rare for everyday dental care until recently. But it's fast becoming mainstream. Many dentists see the technique as a way to extend care to patients who might otherwise skip treatment entirely -- and to boost business.

Practices that offer sedation often use it as a selling point. At least a dozen Triangle dental practices promote that they offer oral sedation services.

"All you've got to do is look in the phone book to see," said Dr. Benjamin Brown, a Raleigh dentist who is president of the N.C. State Board of Dental Examiners, the body that licenses and regulates dentists.

The dental board recently established the state's first rules on oral sedation, in recognition of the technique's growing prevalence. Dentists must complete at least 18 hours of board-approved training in conscious sedation and perform a minimum of five supervised sedation cases to obtain a permit.

The board plans to inspect practices annually to ensure that dentists offering oral conscious sedation are properly trained and are correctly monitoring patients during treatment, although that system is not yet in place, Brown said. Dentists also must monitor patients' blood pressure, pulse and blood oxygen levels during treatment. A staff member who is trained in resuscitation and life support must be immediately available on site.

He said the rules are mainly about fairness. Other types of sedation used in dentistry, including intravenous sedation and general anesthesia, are regulated.

"We felt that it ought to have the same type of scrutiny," said Brown, who specializes in root canals and sometimes uses oral conscious sedation for patients in his own practice.

Oral sedation has been around for years. It got its start with dentists prescribing Valium to fearful patients. Today, many more sedatives are available to dentists.

The most commonly used drugs, sleeping medicines such as Ativan and Halcion, are favored because they are fast-acting and leave the patient's system quickly, cutting back on the "hangover" effect felt with other types of drugs.

Patients need to be driven to and from their appointment and will feel groggy for several hours after treatment, but done correctly, it is very safe, said Davidian, whose practice, Sedation Dental Care, focuses on fearful patients. Dr. Thomas Pezdek, a partner in the practice, has done sedation for more than 20 years.

Davidian said sedation helps patients not only by dimming their anxiety but by allowing the dentist to get a lot of work done quickly. A nonsedated patient can only endure so much.

"Once you get numb, we can go through and methodically take care of everything that needs to be done," he said.

Insurance typically doesn't cover oral sedation. Patients pay $200 to $300 for the service.

Some attribute sedation's rapid growth largely to a single group: the Dental Organization for Conscious Sedation or DOCS.

DOCS, which is based in Pennsylvania, was established in 2000 by Dr. Michael Silverman to raise awareness of sedation, train dentists to do it and help them market the service. About 100 dentists a month complete DOCS's 22-hour training course. The organization has trained more than 3,500 dentists nationally since it was established, Silverman said. "In 10 years, all dentists will do it and all dental schools will teach it," he predicts.

Sedation isn't for everyone, though. People with chronic health problems generally aren't treated with the method. And, under the new state rules, dentists aren't allowed to use conscious sedation on children younger than 13 without more specialized training.

Patients who have tried sedation can become quick converts.

Don McCarrick of Fuquay-Varina hadn't been to a dentist in five or six years until a friend recommended Sedation Dental Care.

McCarrick has a strong gag reflex that made dental visits unpleasant. In January, he went in for a sedated appointment that included multiple fillings and a root canal. Without sedation, the work would have taken several visits.

"They had a field day with me," said McCarrick, who owns his own landscaping business and appreciated being able to get everything done in one shot. "I'm self-employed, so the less time I can have away from work the better."

TYPES OF SEDATION:

--Nitrous oxide ("laughing gas"): Inhaling nitrous (most dentists use a mixture of pure oxygen and nitrous oxide) gives dental patients an almost immediate feeling of well-being and euphoria, allowing them to overcome anxiety. The effect wears off within minutes of stopping the gas and patients can drive home after treatment. North Carolina dentists do not need a permit to administer.

--Oral Conscious Sedation Patients: A prescription sleeping medicine is is taken an hour before an appointment. A second dose may be administered at the dental office. Patients may fall asleep during treatment or remain conscious but in a state of extreme relaxation. Patients can be woken up, move around and respond to questions. Many people have no memory of the treatment. Patients require an escort to drive them to and from the appointment. Since August, a permit from the state dental board is required. A dentist must complete 18 hours of training and perform five supervised sedations to get a permit.

--Intravenous conscious sedation: Similar to oral, but sedatives are administered intravenously, either by the dentist or a certified registered nurse anesthetist. A permit is required. In North Carolina, a dentist must complete 60 hours of training and instruction in the method and at least10 supervised patient sedations to receive a permit.

--General anesthesia: The deepest possible level of sedation. Patients are unconscious, unable to move and don't feel pain. Anesthesia may be administered through injections, inhaled gases or both. A permit and extensive training is required. Dentists must complete at least one year of advanced training in anesthesiology beyond undergraduate dental school or meet other training deemed appropriate by the state dental board.

Source: N.C. State Dental Board of Examiners, N&O research

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