Sweaty Palms in the Dentist’s Chair?

Office-based mobile anesthesia services help alleviate fear of dental procedures

By Gregg M. White, MS, CRNA

For many of us, a trip to the dentist is top on the list of “things to avoid” (right there next to daily flossing). In fact, it’s estimated that half of the American public have some level of anxiety over visiting their dentist.

Whether triggered by a fear of needles, the noise of the dentist’s drill, an event in the past — or by nothing at all — for many people, the anxiety is debilitating enough to prevent them from seeking dental care, often causing severe problems.

For James S., even the process of having his teeth cleaned caused him to break out in a sweat. It wasn’t until he broke several teeth and was forced to go the dentist because of the pain that he realized there was an easier, safer way to alleviate his anxiety.

“My dentist told me he could arrange for a board-certified anesthesia provider to be there during the long process of fixing my teeth,” James said. “At first I was skeptical and didn’t want to risk the possibility that I would wake up during the middle of the procedure. But the more I learned about office-based mobile anesthesia services, the more comfortable I began to feel.”

Different types of sedation require different training and skills

A variety of medications — from the light sedation of “laughing gas” to deeper forms of sedation and general anesthesia — are used to help patients relax both before and during a dreaded dental procedure. Some make the patient groggy (though not truly asleep) while others involve deeper levels of unconsciousness. Your dentist will know which level is best for you based on the degree of your anxiety and the dental procedure involved.

In many cases, dentists handle minimal sedation by themselves using a combination of midazolam (Versed) and nitrous oxide, also known as “laughing gas.” When minimal sedation won’t do, most dentists — even those who have received some training in anesthesia procedures — may prefer to partner with board-certified anesthesia providers.

According to Shawn DeRemer, MD, executive medical director of Anesthesia Associates Northwest (AANW), a Portland, Oregon-based company providing mobile anesthesiology services to dentists, surgeons, physicians and healthcare facilities: “Partnering with a board-certified anesthesiologist or certified registered nurse anesthetist (CRNA) gives a dentist two advantages. First, it offers more choices by making more types of medications available to the patient. It also frees the dentist to concentrate on what he does best — the actual dental procedure — rather than having to monitor the patient while he or she works.”

“Our mobile service brings everything a dental office needs to support surgical procedures requiring anesthesia. The transportable equipment and services converts the office into a surgery center,” says Dr. DeRemer. “Safety is our primary concern. Services like ours deliver the safety of a hospital setting to the dental office.”

In addition to giving dentists and their patients more choices, board-certified anesthesia providers are able to use anti-nausea medications to prevent possible side effects (such as nausea or vomiting) from the anesthesia. They also have drugs available to them that are metabolized very rapidly to eliminate these types of side effects altogether.

By using board-certified anesthesia specialists to provide deeper levels of sedation, dentists have the capacity to work straight through and get all the work done without having to be concerned about the patient’s comfort level.

During long procedures, where dentists are trying to complete work that would normally take three or four visits, the anesthesia provider works alongside the dentist to constantly monitor sedation levels and other physiologic parameters.

Types of Sedation

Inhaled minimal sedation involves breathing nitrous oxide — otherwise known as “laughing gas” — combined with oxygen through a mask that’s placed over your nose. This type of sedation tends to wear off quickly, and it is the only type of sedation where you may be able to drive yourself home after the procedure.

Oral sedation is the type of sedation most commonly associated with sedation dentistry. It involves pills such as Halcion (similar to Valium) that provide minimal to moderate sedation, depending on dosage.

About an hour after you take the pill, you’ll be awake but very drowsy. Some people become groggy enough from moderate oral sedation to fall asleep during the procedure. They usually can, though, be awakened with a gentle shake.

IV moderate sedation goes to work more quickly because you receive the sedative drug through a vein. This method allows the anesthesia professional to continually adjust the level of sedation.

Deep sedation and general anesthesia make the patient almost unconscious or totally unconscious — deeply asleep. While under general anesthesia, you cannot easily be awakened until the effects of the anesthesia wear off or are reversed with medication.

Knowing if sedation is right for you

If you are avoiding needed dental care because of anxiety or fear, consider discussing sedation options with a dentist who regularly works with anesthesia professionals. But, if you have health problems, it’s wise to discuss your options first with a board-certified anesthesia provider.

Sedation dentistry may also be appropriate for people who:

• have a low pain threshold or very sensitive teeth
• can’t sit still in the dentist’s chair due to injuries or other reasons
• have a quick gag reflex
• need dental work that will take several visits to complete

Who should give the sedation?

Dentists who complete a training program in basic anesthesiology can administer minimal intravenous and inhalation types of sedation such as nitrous oxide and Versed. Each state’s dental board carefully regulates the use of sedation techniques. Many states require dentists to hold permits in order to perform even minimal sedation.

According to the American Dental Association, some dentists can perform more complex anesthesia techniques. But first they must complete the Commission on Dental Accreditation (CODA) program in deep sedation and general anesthesia. Because this training is extensive, the percentage of dentists with this training is small. (These dentists are typically oral and maxillofacial surgeons, not general dentists.)

Even CODA-certified dentists aren’t trained in all the emergency procedures that might be required if anything goes wrong, nor will they have all the necessary equipment. Because anesthesia is a medical specialty requiring extensive education, training, specific skills and equipment, many dentists prefer to use board-certified anesthesia professionals in their practice.

These professionals include medical doctors who have specialized in anesthesiology and CRNAs. (A CRNA is a registered nurse with an undergraduate degree and master’s degree in anesthesia. CRNAs receive about 1,800 clinical hours in anesthesia services during their training, after which they must pass a rigorous national exam.)

Do you really want your dentist to multi-task during your procedure?

There are many questions smart dental consumers might ask of their dentist before having anesthesia, but the most important consideration is this: Do you want your dentist providing the sedation? Or do you want your dentist working on your teeth? When your health is involved, multitasking might not have the best results!

About the author

Gregg M. White, MS, CRNA co-founded Anesthesia Associates Northwest (AANW) in 2005 and serves as the company’s executive operational director. AANW is a Portland, Oregon-based company providing mobile anesthesiology services to dentists, surgeons, physicians and healthcare facilities.