Putting a Cap on Anxiety
 
New Dental Procedures Aim to Tame Patient (and Doctor) Nerves

By Lindsay Holst

A cold, sterile room that smells of disinfectant and dental floss. Needles, drills and ratchets adorning a creaky tray. A dentist’s head, silhouetted ominously against the harsh, incandescent glow of overhead florescent bulbs. A patient’s white knuckles gripping the arms of a plastic-coated chair. The imagery encompasses the fear that some 95 million North Americans share: going to the dentist’s office. It’s the anxiety-ridden patient’s worst nightmare, and these days, it’s the dentist’s as well.

But it didn’t used to be that way. “Adults that are now older than 50 used to go to the dentist at a time when dentists weren’t so concerned about anxiety control,” says Dr. J. Daniel LaBriola, D.D.S., chief of oral and maxillofacial surgery at Inova Fairfax Hospital and oral surgeon at Northern Virginia Oral and Maxillofacial Surgery Associates (Annandale). “Back then it was, ‘I know you’re numb, sit there, let me do this.’ People started to get fearful that dentists wouldn’t listen to them and would proceed with something without adequate anesthetic.”

After such major milestones in dental care as fluoridated water and toothpaste, tooth decay decreased, and dentists realized that if they wanted to stay in business, they would have to take patients’ total needs into consideration, including anxiety control.

“Most dental anxiety starts when you’re a child,” says Dr. Daniel Cassidy, D.D.S., who has a family and cosmetic dentistry practice in Alexandria. “A lot of it is psychology. Hopefully we’re giving this generation of kids a positive experience so that they don’t have the negative association that some of the older generations have.”

New dental trends that stress anxiety control and pain management are helping doctors tame patients’ nerves better than ever before.

Anxiety control in patients doesn’t have to be rocket science. Sometimes, diverting dentist fears simply requires a different state of mind. In theory, if patients are made to feel as comfortable and calm as possible, they are able to relax to the point where they may even forget they are getting dental work done. Offices are beginning to offer dental work and spa-like amenities, such as manicures, pedicures and paraffin wax treatments, simultaneously.

Dr. Cassidy’s office offers add-on vibrating massage chair components that patients can control and iPods they can use to cut back on the sound of the drill. The Alexandria-based offices of Dr. Kim Kitchen, D.D.S and Associates, offer spa-like cuisine to patients who come in for consultations, further diverting the sterile, harsh environment typically associated with the dentist’s office. “We offer them water, juice, smoothies and freshly baked bread,” says Dr. Clifton Harris, D.D.S, who works alongside Dr. Kitchen.

When patients come in for procedures, they enjoy additional amenities such as hot towels, blankets, and DVD and CD players. “People are simply more comfortable when they have something else to focus on,” Dr. Harris says.

Sometimes patients’ stress can be exacerbated by something as seemingly minor as an office’s lighting. Dr. LaBriola’s office provides eye shades for patients with light problems, and the office also allows patients to bring in their own musical devices, though Dr. LaBriola prefers they keep the volume low so he can talk them through the procedure. If a patient is slightly anxious, he says, an explanation of the procedure can help tame nerves.

“I don’t give them gruesome details, but I let them know what sensations to expect,” Dr. LaBriola says. “With surgery, there can be intense sensations, though they’re not necessarily painful, and we want to be able to explain that to anxious patients. If they can’t hear me, they could develop more anxiety. In a surgical situation, it’s much more advantageous for the patient to know what’s coming.”

Slightly greater patient anxiety stems from a fear of pain, and basic relaxation techniques are not always sufficient in quelling worries. “What actually hurts in an injection is the medicine going into the tissue,” Dr. LaBriola says. “Newer tools can administer the local anesthetic at a slower rate, making the shot more painless; this way, people are more likely to have the procedure done.”

Patients with minor needle phobias can begin to relax, thanks to tools and procedures whose aim is to cut back on the dreaded burning sensation resulting from a too-quick injection. Sometimes, manual techniques alone can effectively divert the patient’s attention and cut back on injection-associated pain. When Dr. Cassidy gives an injection, he begins by numbing the gums with a topical anesthetic. He then applies pressure to and shakes the patient’s lip before administering the injection.

“They feel pressure before the stick,” Dr. Cassidy says. “The theory is that I’m stimulating the part of the nerve that feels pressure. Additionally, the shaking tends to distract the patient. “They’re still wondering what I was just doing, and I’ve already administered the anesthetic.”

The Wand, a tool Dr. Cassidy says has been around for a few years, uses a computer to administer the anesthetic very slowly through the mouth. The machine looks essentially like “a box with tubes coming out of it,” Dr. Cassidy says; out of concern that the machine’s appearance would be off-putting to patients, he trained himself to administer the local anesthetic slowly by hand. Another new tool, the Vibrajet, clips onto the anesthetic syringe and causes it to vibrate gently, which Dr. Cassidy says significantly cuts back on the sharpness of the injection.

For more severe forms of patient anxiety, more and more dental offices are offering sedation dentistry as an option. Kim Kitchen and Associates uses an oral-conscious sedation to put patients into a kind of “twilight zone,” sedating the patient and also acting as an amnesiac, so that the patient will not remember much of the procedure.

“We will have the patients take Valium, a longer-lasting sedative that calms your nerves down the night before,” Dr. Harris says. “They will get a good night’s sleep, and when they wake up the next morning, the drug will still be in their system; they will come into the office already quite sedated.”

When undergoing this type of sedation, the patient must be driven to the office. Upon arrival, the doctor will sometimes give an additional, quicker and shorter-acting drug that serves essentially as a sleeping pill, Dr. Harris says. Once in the chair, the patient is hooked up to a machine to monitor vitals, and the dentist commences the procedure.

Though sedated patients appear to be in a deep sleep, Dr. Harris notes, they are never in a situation where they’re in such deep sedation that they cannot be woken up by the dentist. “I did oral conscious sedation on a patient last week, and gave him 12 or 13 fillings,” Dr. Harris remembers. “He was here for about four hours, and he doesn’t remember the work at all; he just remembers essentially getting here and leaving. He got up twice during the procedure.”

When under oral-conscious sedation, patients are able to communicate to the doctor if they need to use the bathroom or take a drink; Harris says that he gives his patients a little Gatorade to stimulate them enough to get up and walk to the restroom and back. Afterwards, he says, they rarely recall anything.

Increased attention to patient anxiety has popularized another option in anesthesia. Many offices are turning to private anesthesiology practices that send a trained anesthesiologist to a dental office to perform the sedation himself. “People mistakenly think that the length of the procedure should dictate the level of the sedation,” says Don Mauney, M.D., an anesthesiologist at Horizon Anesthesia in Falls Church.

Practices like Horizon have relationships with area dentists or physicians, and anesthesiologists from the practice will deploy to different offices to perform sedation during procedures. The anesthesiologist will meet with the patient beforehand to review medical history, surgical history and other concerns such as medications and allergies.

On the day of the procedure, the anesthesiologist brings a small machine that can sedate patients and provide general anesthesia, as well as a machine that monitors such vitals as blood pressure, heart rate and end-title C02.

The type of anesthesia that Horizon provides is particularly useful for small children, extreme needle-phobics or those undergoing long and complicated procedures. “The alternative is to give the patient an IV with sedating medication, but with our machine the patient is able to breathe medication through a mask,” Dr. Mauney says.

“Safety is of paramount importance. Whether you’re having a 27-minute procedure or a six-hour procedure, you should be comfortable with the level of service.”

(April 2008)