Who are the patients?
Adults: Phobic adult dental patients come in all sizes, shapes and colors and are phobic for many different reasons, both psychological and physical. Often these phobias developed when they were young children for all the usual reasons children develop dental phobias, including traumatic dental treatments. In some cases, troubles start much later due to an especially difficult treatment, particularly if pain control was incomplete.
It has also been postulated that a few people lack active pain suppression systems or suffer from depressed pain suppression mechanisms, including descending pain suppression pathways from the higher centers of the brain, and suppressed endorphin production or receptor systems. These patients have a very difficult time with pain control. They are the ones who appear to have a complete anesthetic block but who experience pain once a procedure is started and, in spite of the most diligent efforts of their practitioner, continue to have mild to moderate pain for most dental procedures.
My feeling in the past had been if they would only relax, we would have better pain control. I was blaming their lack of anesthesia on their apprehensions. I now wonder if I should have been blaming their apprehensions on the fact that most procedures they had undergone were done with only partial pain control because of their lack of endogenous pain suppression systems. This brings to mind the age old question of "Which came first, the chicken or the egg?" - a question that can thankfully remain unanswered so long as the practitioner treats the patient's apprehension symptomatically and adequately. Once patients are relaxed, adequate pain control is almost always possible.
Unfortunately, most adults never completely free themselves of their apprehensions - but they will improve over time with careful treatment and good pain control. Many will be able to be treated with less potent forms of sedation, if they are seen regularly and have comfortable treatments. A few may even graduate to no sedation for their dental treatments. Other patients will be refractory to any attempt at treatment without profound sedation. We should accept all three types and be non-judgmental toward those who continue to need sedation to undergo dental treatment.
Children: Many children can be treated if sufficient time and effort is spent to communicate with them and if gentle, empathetic treatment techniques are used. However, the younger the child, the more difficult this task becomes. Below a certain age, most children will need some help if extensive treatment is required. Unfortunately, the younger child also tends to be the smaller child, and the smaller the child, the more careful we must be as their safety margin - the area between sedation and overdose - becomes narrower. These patients are often the ones that go from uncontrollable to unresponsive with minimal changes of sedation, i.e. kicking, screaming, biting, scratching one moment and unconscious and unresponsive the next, with concentration changes of nitrous of only a few percentage points. Our oral medications often come in unit dosages that are not easily divided to provide a more accurate dose for any given weight.
It also is amazing to me how many parents do not know their child's weight. Often when we ask them what it is, we are told "somewhere between 20 and 30 pounds." This is a 50% range; we like to be a little more than 50% accurate with our doses of medication. For this reason, it's a good idea to have a scale in the office to check the child's weight.
Unfortunately, most of the very young, small patients are those who need extensive treatment due to baby bottle caries. These children will tend to continue to need extensive treatment as they get older because of their oral conditions and, in many cases, their treatments will be further complicated by family dynamics. For instance, if a child is left on the bottle, it is sometimes because of a very permissive atmosphere in the family where the child's every qualm is indulged. These are the children that get all the candy they want, receive little discipline, and have overprotective, often first-time parents who themselves do not do well in new surroundings. If there is one patient we want to become a good patient, it's the one we'll be seeing on a regular basis for extensive work. These overprotective parents foster overly dependent, insecure children requiring enormous amounts of extensive dental care at a very early age. It is hard to conceive of a worse combination.
Somewhat older children are easier to treat from a sedation standpoint because their size and physiology offer a wider range of safe dosages. Often these children's fears are a result of peer or sibling descriptions of dental treatment ("The dentist has a needle th-i-i-s-s-s big"), cartoons or other TV programs (who can forget Curley chasing Larry and Mo around a dental chair with a syringe large enough to use on King Kong), and, occasionally, parental phobias or mistreatments. Here's some of a conversation I overheard in a supermarket, "If you do not stop that and behave, I will take you to the dentist and he will give you a shot!" How relieved I was that the family was not one of my patients!
Various forms of oral sedation have been used by dentists to help apprehensive patients. Patient comfort can be achieved by the practitioner who uses anxiolytics, opioids, and nitrous oxide to allay anxiety and apprehension. This also decreases the likelihood of stress induced medical emergencies. The difficulty of using oral agents, however, is the time it takes to get an effect.