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How many times have you dealt with an individual who is deathly afraid of having a dental procedure?  It is estimated that about 5 to 15 percent of people living in Western countries avoid going to the dentist because of fear.  Logically, the person knows that he needs to take care of his teeth.  If he does not do so, his teeth will develop decay and, ultimately, lose them all.  It makes sense to brush your teeth, floss, and go for regular dental checkups; right?  However, this reasoning does not hold true for this type of individual.  A reasonable person will conclude that he will spend less money, have better dental health and, generally, whiter teeth if he just go see his dentist.  For this individual, however, there is something stopping him.  What can it be?  It can be due to a bad experience when he was young.  So young that his communication skills and ability to reason are not quite developed yet which, in turn, caused the perceived trauma to go undiscovered and, eventually, became a permanent one that is now unconsciously imprinted on his brain. As he grew up, unaware of this experience, he outwardly manifests fear when he visits the dentist, a fear that becomes greater and greater on every visit.  Do you happen to have this type of patient?  You can’t miss him.  He is the patient with a high sympathetic outflow that presents itself as the classic “fight or flight” phenomena.  He walks into your office, white as a ghost, sweating profusely, with an increased heart rate, an elevated blood pressure and, my favorite feature, the look of “a deer caught in the headlights.”

Here he is.  The patient has mustered as much courage as he possibly can.  He has correctly rationalized that it is very important to take care of his teeth.  He has already overcome a major obstacle just by being in that chair.  Now, what are you going to do for him?  Do you have the courage to face a patient like this, a patient who is truly afraid of you for no logical reason?  Do you have the patience, compassion, and understanding to care for this type of patient, a dental phobic?

Unless you have a phobia of your own, it is very hard to understand what this person is experiencing. As human beings, we try to empathize with others but, unless you have similar fears, it is very difficult to understand what this person is actually experiencing.  Even so, we still are compelled, as healthcare professionals, to do whatever we can for this patient.  How can we help this type of patient deal with this crippling fear?

As an anesthesiologist, I have tried to come up with a system that will help the dental practitioner deal with this difficult situation.  Why, as a board certified anesthesiologist, would I want to be involved with anyone that has a dental phobia?  Because I believe I have an innovative solution to a very difficult and recurring problem.  In my specialty, I always deal with patient fears and anxieties.  Why?  Because medical and surgical procedures evoke some level of fear and anxiety in every individual.  Just imagine yourself needing to undergo a certain procedure.  The date is set.  If this is set for the next day, that’s great!  The patient has no time to think about what could potentially go wrong!  However, the reality is that these type of procedures are usually scheduled one to two weeks out and, sometimes, even further in advance.  This situation gives the patient all the time in the world to think about what could or could not happen.  That is anxiety!

Over the past 15 years, I have developed a great system for making patients feel calm and comfortable during their pre-anesthetic visit.  This visit normally occurs one to two weeks prior to the actual procedure.  What happens during this interview?  First, I obtain a history from the patient.  I look for any anesthetic problems which might have existed in the past with either the patient or his immediate family.  Second, we go over medications, allergies, and any past and present medical problems.  This interview helps me to determine whether the patient is medically optimized for the procedure.  What does medically optimized mean?  Even though the patient might have a medical systemic disease, i.e., hypertension, is he in the best health he can possibly be in for the procedure?  I cannot cure him of high blood pressure, but I can make sure that it is under control and has not damaged vital organs, such as his heart or his kidneys.

If I feel that the patient requires further tests, I will ask for those to be performed, such as a consultation with his cardiologist.  I will obtain an ECG within the last six months, as well as any further blood studies.  Our goal, as the medical team, is to make sure that the patient is safe during the upcoming procedure.

Once the anesthetic history is obtained, I then go through what the patient should expect to happen on the day of the procedure.  Does this help reduce anxiety and fear?  Yes. By how much?  I do not know.  But it is a process that definitely helps.  When a patient does not have any idea of what will happen on the day of the procedure, anxiety and fear goes up by about 50%.  This pre-anesthetic interview lasts for 10 to 30 minutes and is usually done one to two weeks prior to the procedure.  What does the patient do from the time I have the talk with him until the time of the procedure?  I believe this period of time is when fear and anxiety becomes manifest.  I also believe that, as a medical community, we should investigate how we can help these patients.  We need to help patients empower themselves, through their thoughts and actions, to reduce such anxieties and fears.  The medical community should be aware of the trauma caused by not addressing these issues. Remember that fear and anxiety cause significant increases in sympathetic outflow.  An increase in sympathetic outflow can cause an increase in heart rate and an elevated blood pressure.  What is the effect of an increased heart rate?  An increase in heart rate increases the amount of oxygen that the heart requires to function.  What does this do?  Due to the increased oxygenation demand, there is a need to increase the supply of oxygen to the heart.  When the heart is not supplied with enough oxygen, the heart starts to fail.  This failure of the heart is called an ischemia, which is the lack of oxygen to the heart’s tissues.  Ischemia can occur with the person unaware that it is already happening.  An increased heart rate can actually cause ischemia.  Will the patient feel the cause of the ischemia?  No, not always.  Thus, the patient can have an undetected problem due to fear and anxiety.

An increase in sympathetic outflow can increase blood pressure.  How does this happen?  The nervous system can actually constrict all the blood vessels in the body.  A constricted blood flow does not help in the healing process.  By constricting blood flow, the nervous system is inadvertently causing the pooling of blood in certain areas of the body.  Unfortunately, these are not the blood rich groups that aid in the healing process.  What are these?  Blood rich groups are composed of organs with enriched blood flow, such as the heart, lungs, liver, kidney, and brain.  In short, these are the organs that promote the healing process.  Are we then, in effect, slowing down the healing process when we increase anxiety and fear?  Yes!  If we are able to decrease anxiety and fear prior to the procedure, can we then improve the healing process?  Yes!  How do we do that?  We can help do so by simply listening to a CD that I have created.

This CD is called PreEmptive Healing.  Have the patient listen to the CD twice daily:  once in the morning upon waking up and once at night prior to falling asleep.  PreEmptive Healing is designed to be used from the time a dental procedure is scheduled to the date of the dental procedure.  I also suggest that patients be allowed to listen to the CD during the actual procedure.

During the testing of PreEmptive Healing, I noticed a decrease in the degree of anxiety and fear by 30-50%.  There is also less use of narcotics as well as a decrease in complications postoperatively.  The CD is designed to help reduce anxiety and fear both consciously and unconsciously.  How does it work?  The mind must be approached at all levels of consciousness in order to consistently and persistently lower fear and anxiety.  Simply stated, this is done through the conditioning of the mind.  Conditioning, by definition, is repeatedly going over something in order to have the thought imprinted.  In practice, instead of having the patient accept fear and anxiety, we are empowering his mind to destroy that fear and anxiety.  Conditioning is the only way to consistently and persistently free someone’s mind of the fear and anxiety in having dental work performed.

We have now taken care of the first part of the fear and anxiety a dental phobic has to deal with while waiting prior to the procedure.  How do we then take care of the fear and anxiety on the day of the procedure and during the procedure itself?

While on the way to the dentist, I suggest that the patient repetitively listen to the PreEmptive Healing CD in the car up to the time of the procedure.  Again, if allowed, it would be an excellent idea to listen to the CD while actually having the dental procedure.

How is the actual dental procedure done? The actual procedure is done by giving the patient anesthesia.  What kind?  I recommend heavy sedation.  Who are we?  Our company is called Mobile Anesthesia Service Concepts, LLC (MASC).  MASC is an anesthesia service that specializes in office-based anesthesia.  We can be found on the World Wide Web at www.masccares.com.

MASC provides outstanding anesthesia practices.  Our service is designed to provide increased efficiency, safety, and patient satisfaction.  MASC comes to the office prior to the case to make sure that we are able to provide safe and effective anesthesia.  Does the office need to provide any of the equipment?  No, we take care of those.  The only equipment not provided is oxygen.  Because oxygen is flammable, MASC does not carry oxygen in our vehicles.  The dental office is therefore required to provide it.

In the case of a dental phobic, heavy sedation works great.  What is heavy sedation?  Heavy sedation is an anesthetic technique using propofol, Versed, and local anesthesia.  The technique is called a total intravenous anesthetic or TIVA.  The procedure is as follows.  MASC will bring the patient in the room.  All consent forms are signed.  The patient arrives in sweat pants and sweatshirt to reduce the risk of being cold.  Why is this required?  Being cold under anesthesia increases oxygen consumption by the heart by up to 300%.  It also delays awakening after the procedure.  Once in the room, the patient is seated and a tourniquet is placed on the arm where the IV is going to be placed.  All the monitoring equipment are then put in place:  ECG, supplemental oxygen in the form of a nasal canula, noninvasive blood pressure cuff and pulse oxymetry, which measures the oxygen saturation of the body.  All the monitoring equipment has the same standard of care used in most operating rooms.  Once the monitoring devices are in place, the IV is placed and secured.  MASC is now ready to sedate the patient.

The four areas of anesthesia which must be employed to have a complete anesthetic are hypnosis, amnesia, analgesia, and surgical anesthesia.  MASC provides all four levels of anesthesia with heavy sedation.  We begin with 2-4 liters/minute of oxygen delivered via the nasal canula.  Then 2-4 mg of Versed to calm and cause amnesia.  Then a propofol drip is started to place the patient into a sleep state.  Once the patient is asleep and not moving, i.e., surgical anesthesia, the dentist then places a block with local anesthesia to provide analgesia intraoperatively and postoperatively.  Once all four levels of anesthesia are achieved, the procedure can begin.  The dental phobic patient is now asleep and will not remember anything regarding the procedure.  The dentist, on the other hand, has a calm and comfortable patient, thus making the procedure go quickly and smoothly.

Once the procedure is completed, the propofol drip is stopped.  In 10 to 15 minutes, the patient will awaken.  Following emergence from the sleep state, the patient will be monitored for 30-45 minutes.  This monitoring period is done in order to give time for the patient to recover from the anesthesia.  After the recovery period, the patient is walked to the car and sent home.  The patient will be advised not to make any major decisions or drive in the first 24 hours because it takes that much time for the propofol and Midazolam to be fully metabolized.  At home, the patient can relax and recover further from the anesthesia.  As far as meals after the procedure, from an anesthetic point of view, the patient will be able to eat anything.  Since no narcotics are used during the procedure, patients are less likely to have nausea and vomiting postoperatively.  Propofol also decreases the risk of nausea and vomiting.  Patients have been observed to do well with this anesthetic technique.  They recover rapidly with very few or no side effects.

I believe that this system is a win for the patient.  He has no recall of the procedure, which gives him a positive dental procedure experience.  This, in turn, starts to break down his fears and anxieties about going to the dentist.  The dental phobic can now take care of his teeth and have better oral hygiene in the future.  This system is also a win for the dental practitioner because, now, he has a solution for these type of patients.

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