In the past thirty-five years, I have encountered hundreds of patients who were petrified of sitting in a dental chair. When I reflect on this population of fearful patients, they all seem to have a fairly consistent profile. They are mostly above the age of fifty years old, they often have serious dental needs and they almost universally can recall one or multiple traumatic visits to the dentist as a child. The memory of the trauma or traumas has/have, it would seem, left an indelible imprint which is difficult, if not impossible to entirely expunge.
Fifty years ago, dentists often treated young patients like small adults. And, when the child’s response to unpleasant or unusual experiences was fear or poor control, the dentist often became frustrated, or impatient, or, in the extreme, brutal. Thankfully, this clinical approach has become increasingly rare. The specialty of pediatric dentistry has produced a group of dentists who have been taught to effectively and appropriately treat children. The result is a modern dental population which views dental care as a stress-free activity.
The child with memories of traumatic dental care becomes an adult who becomes, understandably, one who avoids dental treatment. This avoidance, in many cases, leads to increasingly greater dental needs. Through the years, I have seen a number of patients who have not had a routine dental visit in over twenty years. If it were not for extreme pain, or an inability to chew effectively, or a serious esthetic problem, they would never have arrived at my office at all.
So how does one begin the conversion of the dentophobic into one who voluntarily seeks and is able to sustain dental care? Well, all fearful dental patients seem to have a concern that they will be hurt in the chair and that they have limited ability to stop it. So, the first step is to demonstrate to a patient that dental care can be delivered without discomfort. In order to do this, modern dentistry offers a number of pain control strategies. Local anesthetics (Novocain) have been around since the 1950’s. In the past six decades, those sensation blockers, and the techniques of delivery, have become more effective. Nitrous oxide analgesic (sweet air, laughing gas) is a useful adjunct for dental care for the fearful patient. Nitrous oxide gas is mixed with oxygen and delivered through a nose piece. The precise way this gas works is not entirely understood, but when it is breathed, it causes relaxation and a temporarily altered perception of unpleasant stimuli. Once the nitrous oxide is flushed out, by breathing straight oxygen, the altered state is quickly reversed and the patient can drive away without residual effects.
Sedation techniques such as taking Valium prior to a dental visit is another effective strategy for some. Valium seems to produce a calming effect prior to a dental visit. Unlike nitrous oxide however, Valium, while rather short acting, cannot be reversed. Patients who take Valium prior to a dental visit should be driven to and from the dental office. In the past few years, a new technique called “Sedation Dentistry” has received a lot of publicity. Sedation dentistry involves taking a sedation drug called Triazolan prior to the dental visit. This drug has a number of effects including a chemically induced sleep-like period while the dentistry is performed. While this drug has a fairly good safety record, patients must be monitored during and after taking the drug because of documented instances of sleep walking, sleep driving and trance-like behavior.
Perhaps the most effective mechanism for helping the fearful patient is to establish trust. I have found that starting treatment with short, simple procedures is helpful. As trust is developed, longer, more complex procedures are more easily tolerated. The fearful patient slowly undergoes a conversion into a patient tolerant of dental care. So why, one must wonder, am I preaching to the choir? After all, patients reading this newsletter have demonstrated an ability to routinely participate in dental care. Well, many patients probably know friends or relatives who need care, but whose dental phobias prevent them from getting help. This may be an opportunity to assist them in eliminating pain or improving their ability to eat or to help them to look better. What a kind gesture!
Robert A. Hersh, DDS
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