INTRODUCTION
"A USA Today article quoted ADA figures detailing that '12 million Americans are dental phobics. Another estimated 12 to 24 million suffer dental anxiety.' Coping with the difficult-to-manage patient has long plagued the profession. The high cost of malpractice insurance, government regulations that dictate who can and cannot be hospitalized, and the threat of litigation have caused many dentists to avoid under taking dental treatment on all but the most cooperative and easily managed patients and to turn their back on 36 million Americans who want but, for reasons beyond their control, are unable to undertake dental care in a usual manner."
"A major problem that continues to have an impact on the teaching of anesthesia, pain, and anxiety control is the rising costs of liability insurance. In the 'real world,' annual premiums of almost $20,000 are required before the dentist can administer IV sedation."
Whether or not we provide various forms of sedation depends on our education, state regulations, costs of insurance, our competency, and equipment. IV sedation is seldom used because of insurance costs, the need for postdoctoral education and, more recently, regulations in various states as to who can perform this technique.
Do you really want to see phobic patients?
When deciding on using sedation in our practice we must ask some important questions. First and foremost, we must honestly evaluate ourselves. Do we have the temperament to handle phobic patients? (At best, these patients are very difficult in many ways.) Can we handle the stress of the potential problems that can occur with sedation? Are we adequately trained to handle potential problems? (At a minimum, we and our staff should all have a CPR course on a yearly basis.) Do we have an emergency response team within a reasonable distance from the office to assist if an emergency should occur?
In this discussion, considerable space will be spent referring to the patient who is unconscious (asleep) and explaining why I am in no way comfortable with such a patient. On the other hand, the patient who is awake will respond to verbal directions and is, therefore, a safe patient. So long as your patient remains conscious, you can relax and enjoy performing dentistry. With proper preoperative evaluation, careful use of the right drug and calculation of its dose, you should never have a patient lose consciousness, that is, go to sleep. Should this occur, however, all else should cease until the patient is again verbally responsive. Some states have regulations that go one step further and require the equipment and training necessary to administer general anesthesia if a patient is rendered unconscious. But it is a little late to start buying equipment and getting training when you find, through misadventure or miscalculation, that a patient is no longer verbally arousable.
Once we discuss Triazolam, it will become obvious that the chance of problems arising with this drug when it is used properly is very slight. But even if complications should occur, with the availability of a selective reversal agent -flumazenil - we'll all be able to breathe a sigh of relief. As you'll see later, flumazenil is reported to rapidly reverse the sedation of benzodiazepine drugs much as Naloxone does the opiate drugs.
Since there is a significant cost in lost productive time for training and purchase of equipment, both must be justified if one is going to start sedating patients. Because of the precipitous rise in malpractice insurance, several years ago many dentists who were qualified to administer deep sedation/general anesthesia had stopped offering this service. The phobic patient is left with the option of having teeth extracted at an oral surgery office under IV sedation or having restorative dentistry completed with oral sedation or nitrous oxide inhalation sedation. The purpose of this paper is to show that general dentists can provide these sedation services if they are interested, willing to take extra training and purchase some additional equipment, and will limit the drugs and the quantities of the drugs they use.