Management of Anxious Patients by Kam Chana BDS

Exploring the benefits of intravenous sedation

by Dr Kam Chana

Many patients don’t enjoy dental visits. Surveys reveal that almost 50 percent of patients consider themselves anxious, and about 12 percent suffer from ‘extreme’ dental phobia. Such patients can be challenging to deal with, in terms of both psychological management and dental treatment.

As dentistry has evolved, so have the methods available to improve the patient dental experience. Anxious patients benefit from more time to build confidence and trust in a nonthreatening environment.A warm, friendly reception and the use of nonclinical settings, such as a consultation lounge, is helpful in putting patients at ease.

Initial visits need not even be with the dentist/ Having a patient care coordinator greet and discuss patients’ concerns is an excellent opportunity to build rapport and overcome anxiety faced by patients on their first visit.

Additional time spent by the dentist to understand the patient’s fears and their background, both dental and social history, helps to put the patient at ease.

Most patients will say they have a general fear of attending, but with many patients there are specific elements underlying their anxiety, often related to previous traumatic dental experiences. It’s important to listen to their anxieties and be mindful of those when examining and treating patients. They will let you know their limits!

If the extent of a phobia means conventional treatment is impossible, or if a procedure is particularly complex, such as multiple implant placement, the option of intravenous sedation is an excellent adjunct. This involves administering a benzodiazepine (midazolam) intravenously to rapidly induce a short-term state of conscious sedation. This allows patients to undergo treatment comfortably and with minimal psychological trauma.

There is also a high safety margin, because patients are not rendered unconscious and continuous monitoring is undertaken. The treatment time available under sedation may last 30–90 minutes, depending upon the patient’s anxiety level and physiological processing of midazolam.

Patients should be properly assessed for sedation following the 2015 Intercollegiate Advisory Committee on Sedation in Dentistry (IACSD) guidelines. If suitable, they can be treated safely in primary care or referred to secondary care. The dentist carrying out treatment can act as the sedationist with an appropriately trained second person present. Alternatively, a qualified sedationist may be willing to attend the appointment to provide sedation, allowing dentists to treat their own patients without referring them elsewhere.

Other forms of conscious sedation include oral sedation and inhalation sedation. Appropriate assessment allows the practitioner to determine what approach, if any, would be best for an individual case.

Offering conscious sedation provides a valuable service for patients and is a useful additional skill for practitioners.

It is a ‘practice builder’. Dentists wishing to provide conscious sedation must attend an accredited course and undergo a period of mentoring, as well as regular CPD and clinical governance.