Oral Sedation Dentistry

Oral sedation allows you to relax both your mind and body, and focus on feeling peaceful rather than anxious

By Dr. Michael D. Silverman

Anxiety Just Melts Away

When you are afraid, your threshold for pain is much lower, you become hypersensitive to every sensation, prick, and noise. Fear and anxiety trigger the release of certain chemicals like adrenalin which put your “fight or flight” instincts on high alert. You anticipate that something is going to hurt and so you tense your muscles, even if it is subconsciously. In this heightened state of anxiety you experience more pain during and even after treatment. However this response can virtually be eliminated with oral sedation dentistry!

The whole purpose of oral sedation is to make you as comfortable and relaxed as possible. It allows you to let your guard down, relax both your mind and body, and focus on feeling peaceful rather than anxious. Your apprehension and hypersensitivity to pain melt away, yet you remain awake and in control.

Sometimes referred to as “comfortable” or “relaxation” dentistry, these terms are used to describe the feelings most people perceive during their dental visits, which are produced by oral sedation.

Safety and Effectiveness

Oral Sedation dentistry allows you the confidence and peace of mind to experience dental procedures in a whole new way. Hours seem to pass like mere minutes so that necessary dental treatment can be performed comfortably. When you are relaxed you allow your dentist to be able to work more efficiently by focusing on the work at hand, with the confidence that you are comfortable.

A variety of oral sedative and anxiolytic medications have been developed especially for these purposes. They have been subjected to rigorous research and testing and have a long safety record after decades of use. In addition several have “amnesic” properties, meaning that you remember little to nothing after treatment.

The safety of sedation medications is measured by pharmacists and health professionals on a scale called the “therapeutic index.” The larger the number is on the scale, the safer the drug. Oral sedatives and anxiolytics used in dentistry have the highest numbers possible on the therapeutic index, making them the least likely to cause an adverse reaction.

How to Ensure Safety — What to Let Your Dentist Know

It is critical to provide your dentist with a complete health history including:

• Medical conditions for which you are being treated
• Any and all medications prescribed by a doctor
• Over-the-counter medications, remedies and vitamins (including aspirin)
• Alternative or herbal supplements: Many people seek relief from depression and anxiety symptoms with natural remedies like St. John’s Wort and Kava Kava. These may have a mild interaction with oral sedatives, so it’s critical that you tell your dentist if you are taking them. The medications and dosages for your oral sedation treatment can be adjusted to compensate for any interactions.
• Certain foods: Even something as seemingly insignificant as drinking grapefruit juice can have an effect on sedation. The enzymes in grapefruit interfere with the systems that metabolize (break down) certain oral sedation medications in your body, so you should not consume grapefruit 72 hours prior to or immediately after a sedation procedure.
• Also be sure to tell your doctor about factors like smoking and alcohol consumption, since these can influence the effectiveness of sedation medications.

Administer the Medication Yourself

Oral sedation is a popular treatment option for many people because it does not require injection, so if you’re afraid of “needles,” you needn’t worry. In fact, once you’re comfortable with oral sedatives, it may even be easier to have local anesthesia (numbing shots in the mouth) to further facilitate the ease of dental procedures. Oral sedation is a popular treatment option for many people because it does not require injection, so if you’re afraid of “needles,” you needn’t worry. Medications are given orally (by mouth). They are either placed and dissolved under the tongue, or they can just be swallowed whole.

Many dentists prefer the sublingual (under the tongue) route which works even more quickly. Taken this way they are absorbed into the bloodstream more rapidly. Both methods are safe and effective and work in a matter of minutes. You can even try the medication the night before to see how it affects you and also ensure a good night’s sleep.

Planning for Your Appointment

Once you and your dentist decide to use oral sedation for your next appointment, you will need to make some preparations:

• Your health history can affect your before-and-aftercare plans, especially for diabetics and smokers, so make sure your dentist knows about any medical conditions that you may have.
• You may be instructed to take oral sedation medication the night before your appointment to make sure you get a good night’s sleep.
• You should not eat or drink anything six hours prior to your appointment unless directed by your dentist.
• Be prepared to take time off from work following your appointment. For short appointments, only half a day may be necessary. If a longer appointment is planned, make arrangements to take the remainder of the day off.
• You will need a companion to drive you to and from your appointment; you should not drive or operate heavy machinery until the medication has worn off; this will vary depending upon what drug has been prescribed — follow the directions exactly.
• Be sure to stay hydrated and drink lots of fluids following your appointment.

Which Medication is Right for You?

While your dentist will decide which medications are appropriate for your treatment, being familiar with the different drugs available can be helpful for you. Knowledge about oral sedation is not only powerful — it is empowering.

There are several commonly prescribed medications, including, but not limited to Valium®, Halcion®, Sonata®, Ativan®, Vistaril® and Versed®. With the exception of Vistaril® and Sonata® they all belong to a class of medications called benzodiazepines. Benzodiazepines are prescribed for the treatment of anxiety, insomnia, agitation, seizures, and muscle spasms. Taken in small doses, they are highly effective at relieving the above mentioned conditions.

Each medication has a different duration of action (how long it affects you) and different half-life (how long it remains in your body). Dosages can vary greatly depending on whether swallowed whole or placed under the tongue in addition to the treatment protocols for which the sedation is being used. The drugs take effect anywhere from 20 minutes to an hour. Some varieties of the medication have “amnesic” properties, meaning that you remember little or nothing of your time in the dental chair after the procedure is completed.

Other Forms of Sedation Dentistry

• Inhalation Conscious Sedation is also known as “Nitrous Oxide/Oxygen Sedation.” Nitrous oxide, commonly and inappropriately called laughing gas, has been used by dentists for nearly 100 years. It is an excellent analgesic (pain reliever), but a less effective anxiolytic (anti-anxiety) medication. It is administered through a nasal hood, which is similar to a small cup placed over your nose. Nitrous oxide is extremely safe because it is mixed directly with oxygen to provide you with a feeling of euphoria or light-headedness. All bodily functions remain essentially normal. You may experience a tingling sensation from the use of nitrous oxide. However, its effects wear off almost immediately so there is no “hangover effect.”

In combination with an oral sedative, nitrous oxide allows your dentist to fine-tune the exact amount of sedation needed to provide you with the best possible experience.

• Intravenous (IV) Conscious Sedation also known as “Deep Conscious Sedation” is used by some dentists, and surgical specialists like oral surgeons and periodontists who must undertake specialized training and certification in IV use. With this type of sedation, medications are administered directly into the blood stream intravenously (intra-within, venous-vein). The main advantage of this method is that it works immediately and the level of sedation can be adjusted quickly and easily. There is a higher degree of risk associated with IV sedation since normal bodily functions especially heart rate, blood pressure and breathing can be altered necessitating specialized monitoring equipment. The drugs used for IV Sedation are more potent when given this way than when taken orally and amnesia may be more profound.

Finding the Right Dentist

Like any informed consumer, you will want to make sure that your dentist is qualified to provide sedation dentistry. It is a good idea to request information on your dentist’s training, credentials, and the techniques that may be used prior to an appointment.

You Are Not Alone

Talk to your dentist about your fears and concerns so that together you can decide on the best treatment for you. It’s important to remember that dentistry has come a long way. Years of research have been dedicated to studying and finding methods to alleviate pain and anxiety. There are safe and time-tested options available to ensure that you have a positive and painless experience. Step out from under the shadow of fear and into the calm of sedation dentistry. You are not alone and you don’t have to be afraid anymore.

Age One Dental Visit

By Dr. Joel H. Berg

When parents or caregivers mistakenly say, “They are only baby teeth, they are going to fall out anyway” they have the wrong impression. The Age One Dental Visit sets the tone for lifelong dental health. The fact is, primary teeth serve as the guides for the permanent teeth and are critically important to the health and function of their adult successors. What’s more, primary teeth are the child’s teeth for most of childhood — children don’t usually begin losing them until about age six, and the last primary teeth aren’t lost until around age twelve. It’s just as important to care for them as for the permanent teeth that come later.

An Ounce of Prevention

What really is prevention anyway? Prevention in the truest sense of the word means stopping an anticipated problem before it even starts. The importance of primary teeth and preparing for a lifetime of good oral health are the main reasons why parents should bring their children to see a dentist or pediatric dentist (children’s specialist), preferably before their first birthday. It’s more than just a casual visit: even a one-year old needs a comprehensive examination and even some preventive applications. Parents will benefit from the guidance of “Family Oral Health Education” including: risk assessment for decay; training (hands on) in teeth cleaning; nutritional counseling and use of cups for drinking; fluoride recommendations based on individual needs and important follow-up appointments for monitoring based on the level of risk determined by your dentist.

A baby’s first visit to the dentist sets the stage for lifelong oral health.

The Age One Visit may also reveal underlying conditions that may indicate future problems, and determine how often follow-up visits might be needed. Children with low risk for oral or dental disease might only be seen annually or semi-annually until the primary (baby) teeth are all fully erupted in the mouth and in occlusion (biting function). Children assessed at high risk might be seen as often as every two to three months.

Diagnosing and Treating Tooth Decay

One of the prime purposes for an Age One Visit is to examine the child for a number of forms of tooth decay that can affect babies and small children. For many years, health and childcare professionals have recognized a specific pattern of such decay, known as Baby Bottle Tooth Decay (BBTD). BBTD was believed to be primarily associated with the use of a sleep-time bottle that contains a liquid with natural or added sugars such as formula, juice or Kool-Aid. It generally occurs between the ages of twelve to eighteen months.

In recent years, similar cases of early and severe tooth decay have been found in children who do not fit the classic BBTD pattern of bottle use. The term Early Childhood Caries (ECC) is now being used to reflect a broader concept of the problem of tooth decay in infants and young children. ECC includes cavities associated with many causative factors, mostly sugars. These include continuous use of a “Sippy-cup,” at-will breast-feeding throughout the night, use of a sweetened pacifier or the regular use of sugar-based oral medicine to treat chronic illness.

For many years, health and childcare professionals have recognized a specific pattern of decay, known as Baby Bottle Tooth Decay (BBTD).

ECC develops rapidly — the progression from the hard, outer enamel layer of the tooth into the softer, inner dentin can occur in six months or less. It first affects the upper front baby teeth, which usually erupt at around eight months of age, followed by the primary molars (back teeth), which begin to erupt at about twelve months of age. At its most severe stage, ECC may then affect the lower front teeth.

The extent and severity of ECC can vary depending on culture, the child’s genetic makeup and socio-economic factors. On the other hand, ECC is really much like any other type of tooth decay, dependent on the presence of three conditions: specific bacteria in dental plaque on the teeth, unprotected teeth and the right mix of carbohydrates from food and drinks, such as natural or refined sugars.

“Here We Go Round and Round” — Breaking the Cycle of Decay

These conditions form a cycle of events, even in babies, that slowly unravel oral health: decay causing bacteria interact with the carbohydrates (sugars) to produce acid; the acid in continual contact with the teeth slowly demineralizes (dissolves) the tooth enamel; as demineralization continues, cavities form.

Because all three of these conditions must be present for a cavity to form, there are at least three opportunities for intervention: (1) eliminate or reduce the bacteria through oral hygiene; (2) reduce the presence and frequency of carbohydrates by dietary changes; and/or (3) make the tooth more resistant through the use of fluoride.

Until a child is about seven years old, an adult needs to brush the child’s teeth for them.

Age One Visits provide insight into these three opportunities for both the child and parents. For example, Age One Visits can help parents or caregivers learn the proper techniques for cleaning their children’s teeth. Until a child is about seven years old, an adult needs to brush the child’s teeth for them. Parents can allow the child to brush his or her own teeth, but at least once a day, preferably at bedtime, an adult should carefully and thoroughly brush the child’s teeth.

The child’s dentist can demonstrate the proper way to clean a child’s teeth, a procedure that usually takes less than two minutes with a very small child’s toothbrush or by simply wiping the teeth off with a wet cloth.

Dental professionals can also provide important information on the types of food and their frequency that promote a child’s oral health. At first glance, many foods like cereals, granola bars, and similar snacks may seem healthy and good for a child to have throughout the day. They aren’t — and neither are foods like raisins or fruit juices, even though they contain natural sugars and are full of vitamins and minerals. Carbohydrates in cereals, crackers, and granola bars will stick to the teeth where bacteria can easily interact with them over extended periods of time. And, regardless of whether the food contains processed or naturally-occurring sugars, bacteria metabolize both and form acid. Parents are advised to avoid giving their children sugary foods, especially in high frequency, that have any form of sugar listed as the first or second ingredient.

It’s not just baby drool; frequent snacking also inhibits one of the mouth’s most important cavity-fighters — saliva. Saliva neutralizes acid and supplies calcium and fluoride to protect and even reverse early decay. But it takes time — about two hours to neutralize the effects of acid. So, a snack every hour — which promotes the continual presence of acid in the mouth — won’t give saliva the opportunity to work effectively.

Breast Feeding, Baby Bottles and Other Practices

• Generally, breast-feeding is highly recommended for babies and doesn’t necessarily inhibit good oral health in young children. Breast milk by itself does not promote tooth decay any more than other forms of fermentable carbohydrates. On the other hand, once a child begins to consume foods or liquids in addition to breast milk, the combination of breast milk and other sugar-rich foods may potentially put the child at risk of developing ECC. Babies should be removed from the breast when they are finished feeding and children should not be allowed to nurse at will throughout the night.

• Baby bottles are frequently used by parents or caregivers to modify the child’s behavior by giving it during sleep time to stop fussing or crying. Other methods of improper bottle-feeding include propping the bottle or round-the-clock feeding. All these practices promote the constant production of acid in the mouth, so the use of baby bottles should be limited to meal-times.
• Pacifiers dipped throughout the day in a variety of different sweeteners, including jam, corn syrup or sugar, results in frequent exposure of the teeth to fermentable carbohydrates and promote higher acid levels in the mouth.

• Children with chronic illnesses or special health care needs may also be at increased risk of ECC if their medication contains sugar. Also, certain medications such as antihistamines may cause decreased saliva production causing mouth dryness and diminishing the protective effects of saliva. Daily oral hygiene care for these children is critically important.

• Every time bacteria are exposed to sugars, either refined or “natural,” they produce acid — so the more frequently a child eats sugar, the more frequently the teeth are exposed to acid. Frequent sugar exposures equals frequent acid exposures. Parents can therefore reduce the chances of their child developing cavities by limiting the frequency and amount of sugar their child consumes and not snacking on sugary products especially between meals.

Opportunity for Promoting the Entire Family’s Health

• A child’s oral health is closely related to the family’s overall dental health and hygiene practices. The Age One Visit can educate parents or caregivers on the importance of their own good oral hygiene.

• Children are not born with high levels of cavity-causing bacteria in their mouths. They acquire the bacteria from their caregiver, usually their mother, through close contact. These bacteria are transmitted through kissing, sharing eating utensils like a spoon or a glass, sharing food, or cleaning off a pacifier by mouth. The period when a child is most susceptible to acquiring the decay-causing bacteria is quite short, beginning as early as six months of age and continuing through approximately thirty-one months.

• There is mounting evidence that a child’s oral health is closely tied to his or her mother’s. This is why it is important that caregivers of young children promote their own oral health through regular dental visits and proper hygiene habits. The Age One Visit is a good reminder — and a learning opportunity — for proper hygiene and care.

• Diagnosis, prevention, education and treatment — the Age One Visit can cover a lot of ground for your baby’s first visit to the dentist. Most importantly, the immediate diagnosis and treatment of emerging dental problems, as well as the long-term attention to good oral hygiene, can help build a foundation of good dental health for your child — and your entire family — that will last a lifetime.