Cosmetic Dentistry and Sedation - Who is a Candidate?
(Resources for Sedation Alternatives)
Adults or young adults who:
· Want to have dental treatment completed in a relaxed, comfortable, safe setting with little memory of the appointment
· Have a high degree of fear of having dental treatment completed
· Phobic dental patients who have put off care for many years due to bad childhood or adult dental experiences
· Hate needles
· Have very sensitive mouths, gums, and teeth
· Hard time getting or staying numb for treatment
· Gags very easy, making dental treatment very uncomfortable
· Executive or marathon/special appointments for time challenged, such as business men and women, patients that need to have their treatment completed in as few appointments as possible due to hectic schedules. These clients cannot afford to take a lot of time off from work and can complete major dental care in a few "long" sedation appointments instead of many short appointments over many weeks, months, or years!
· Just do not like coming to the dentist and want to have their dental care completed easily, comfortably in a safe, professional environment, with little memory of the appointment
The most commonly asked questions and answers:
1. What kind of sedation dentistry do you offer?
Answer: We provide oral, I.V., I.M., and Nitrous Oxide or a combination of these options. Nitrous Oxide (relaxing air) helps you achieve a relaxed state where you are less apprehensive, stress - free, and are able to complete your needed care. Many patients who are apprehensive or fearful can complete their dental care comfortably with the help of nitrous oxide.
For phobic or fearful patients who want to be totally relaxed and have little memory of their appointment, we can provide I.V. (intravenous) or I.M. (intramuscular) sedation. By the time we start your I.V. you are already extremely comfortable and relaxed because you have taken an oral sedative pill dissolved under your tongue one hour prior to your appointment. In addition, you have been on Nitrous Oxide air, so starting the I.V. will not bother you at all. The I.V. provides your fluids during your sedation appointment. Through the I.V., we use .9% Sodium Chloride (normal saline) to keep you hydrated and provide the necessary medications to keep you very relaxed during your appointment.
Certain sedation medications can be given I.M. (intra-muscular) in an arm or leg muscle or even by drops in the nose (intra-nasal sedation). With any sedation method, we only use enough sedation medication to keep you safely comfortable throughout your appointment.
2. I hate needles and getting shots in my mouth, can anything be done?
Answer: First of all, when we need to numb an area of your mouth during your sedation appointment, you will be so relaxed and sedated that you will not even feel or perceive the injection. For regular, non-sedation appointments, a topical anesthetic gel is used on the gum prior to the injection. A topical, Tricaine, is a combination of three different strong numbing gels. We apply a generous swab of the blue Tricaine gel and leave it on for a full 5 minutes. It totally numbs the area so you do not feel anything, even a small pinch when the injection is given. The second thing we do to provide painless injections is to numb very slowly to avoid causing a pressure pain feeling as the anesthesia is placed. As your tooth starts to get very numb, the anesthetic is placed in other areas around your tooth, always letting the area get numb AHEAD of where we are going. Does this technique take additional time to provide for each and every dental injection? Yes, it does, but I've been using this very numbing technique on each and every patient since dental school.
3. Am I unconscious or will I feel pain?
Answer: No, you are not totally unconscious but you are extremely relaxed. You will be able to communicate with us and follow our directions but you will have little memory of the appointment, if any at all. This light type of sedation is termed "Conscious Sedation" and all of your protective breathing reflexes are intact. You are continually monitored with a sophisticated medical device during your entire sedation appointment. We use a Poet 8100 monitor from Criticare Systems. It monitors a 3-level EKG reading, blood pressure, respiration, and heart rate. A pulse oximeter reading of your blood oxygen content which is monitored through the nailbed of one of your fingers with a comfortable external finger monitor and an end tital volume CO2 (Carbon Dioxide) reading as you exhale through your nose. A permanent record is printed out every 5 minutes of all of these vital signs. We monitor your vital signs closely through out the entire sedation appointment. If during the appointment you become too sleepy, we can use a reversal medication to lighten your sedation level. You will not feel any pain during your sedation appointment as you will not perceive any pain or discomfort.
4. What Kind of Sedation Medicines Do You Use?
Answer: The oral medication that we use is an oral sedative called Halcion. It is a Benzodiazepine that relaxes you, causes drowsiness, and has effects to help you get a great nights sleep the night before your dental appointment. This sedative is placed under your tongue and dissolves, taken up immediately by your bloodstream. Its action starts much sooner and more effectively versus taking the pill by swallowing it. If swallowed, it must pass through your stomach where it is diluted and taken up much more slowly. This is also the reason I feel I.V. sedation appointments have a great advantage over oral sedation alone. Sedation medications that can be introduced by intravenous route (I.V.) go directly into the blood stream and the affects take place within minutes. We can titrate, or deliver, the sedation medications slowly and judiciously over lengthy sedation appointments lasting 4, 6, or 8 hours long safely and comfortably.
The I.V. medication we most commonly use that has the best results and safety record is a Benzodiazepine called Versed (Midazalam). It is a Valium like medication that has a shorter half-life than Valium so it wears off by the end of your sedation appointment. It gives you a wonderful feeling of peace and well being, takes anxiety and apprehension away, and produces amnesia. It is kind on the veins, has a stellar safety record and is widely used in the medical profession during out patient procedures for a number of invasive medical exams such as colon, heart, G.I. procedures to name a few.
If you become too sleepy and relaxed, we can quickly and easily wake you up a bit by using a reversal agent in the I.V. such as Romazicon (Flumazinil). This medicine takes up the sites of action of the Versed, thus waking you up enough for us to continue your care. You will be unaware you are more alert, but if needed as your appointment proceeds, we can again use more Versed to ensure you are comfortable.
A second I.V. medication we commonly use is a synthetic morphine called Fentanyl. It is 10 times stronger than morphine and is classified as a central nervous system (CNS) pain blocker. It is used in conjunction with the Versed to block out the pain receptors in your mouth and body in general to keep you relaxed, pain free, and sedated even during difficult dental procedures.
If need be, the Fentanyl can be reversed, and its effects reduced by the I.V. reversal agent for narcotics which is called Naloxone. Naloxone competes for the action sites of the narcotic (Fentanyl), thus reducing its effects.
During a lengthy sedation appointment, we want to reduce oral secretions (Saliva) to prevent water build up and to have a dry, clear working field while we complete your dental care. This is done through the I.V. as well with the use of an anti-sialogog called Glycopyrrolate that dries up your oral salivary glands (the Parotid, Submandibular and Sublingual glands) that secrete saliva into your mouth for normal function. As an aside, normal salivary flow is extremely important to keep your mouth moist and to start the digestive process. Saliva also washes off food and bacteria from the teeth and exposed roots of your teeth. When salivary flow is reduced or completely stopped due to infections or medical treatment (i.e. radiation treatment for oral cancers), it can present a problem with increased dental decay since you have less saliva/water to wash away food, sugars, and bacteria that collect on your teeth. If you cannot brush your teeth after eating, the next best thing is to rinse out your mouth with water after eating or drinking items containing sugar.
5. What is the process like?
Answer: First, after your call with our front desk team who have helped many fearful and phobic patients, we have an appointment to meet to discuss your concerns, review your dental goals, and to ensure you feel comfortable at our office. We know making that phone call to our practice for phobic or fearful patients is one of the hardest first steps to take. For most, it has been many years since they have been to a dentist and may have a great deal of fear and apprehension about bad past dental experiences. When you come for your initial sedation consultation, we understand you may be phobic, fearful or embarrassed about your dental condition. We understand this and all of our dental team members are here to help you overcome your fears and phobias to be able to complete your needed care. We are non-judgmental, empathetic, professional and honored that you have chosen our Team to help you with your dental care.
We do a complete dental and medical review, which includes the necessary dental radiographs and any other needed diagnostic materials. If our sedation patient is too fearful or has a bad gag reflex, we complete the examination and x-rays and treatment plan during a sedation appointment.
Prior to your sedation appointment we complete a medical consult with your primary care Doctor(s) or specialist(s) to determine the best way to provide your care safely.
Before the appointment, your dental treatment plan sequence and the investment for your care is completed and discussed with you in detail.
The night before the sedation appointment there is nothing to eat or drink after midnight. You take a sedative sleeping pill to get a good nights rest. You will take a second sedative pill one hour prior to your appointment.
When your designated driver brings you for the appointment, we seat you, start your Nitrous Oxide and set up the monitor to check your critical vital signs throughout the appointment.
Your I.V. is started if we are going to use it, and your planned care is completed. Someone will be with you at all times during your treatment. Your treatment is completed while you are comfortably relaxed.
When your treatment is completed, you will receive any needed prescriptions and post treatment information before you are driven home to relax for the rest of the day.
6. I know I need a lot of dental treatment. How can I pay for it?
Answer: Since you may have been away from dentistry for many years, you can understand that your financial investment can be substantial. We do have a relationship with Care Credit and Capitol One Health Care Finance (new name for Dental Fee Plan) that can assist you with your financial commitment. Your dental care can be phased over time if need be. Although Dental Insurance does help somewhat, it is limited by your employer negotiated benefits and by the maximum annual allowance of your coverage. These annual maximums have not been increased much, if any, since 1960! We will make every effort to help you comfortably get your needed care completed, and to help you work out your financial commitment.
Ronald Briglia, DMD
845 West Chester Pike
West Chester PA 19382
(610) 692-4440
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