Like millions of people in the U.S., Christopher
Dammer hates visiting the dentist. Haunted by memories of painful
experiences from childhood, he would go for long stretches
without seeking dental care -- a lapse that once led to a root
canal.
When he did get checkups, he was an onerous
patient to deal with, clenching his jaw, moving his head and
gagging, he says. "Every time I'm in the dentist chair
I start tightening up," says Mr. Dammer, a 55-year-old
mortgage banker from Scottsdale, Ariz.
Finally, after years of anxiety-ridden sessions,
his dentist, Scott Irwin, recommended a solution: "conscious
sedation." Last month, Mr. Dammer downed a series of oral
sedatives before a routine teeth cleaning and a filling. He
spent the session drowsy and relaxed. And now
"I have no memory about it," he says.
Dr. Irwin is one of a growing number of dentists
around the country offering so-called sedation dentistry, targeted
at the most fearful patients. The approach uses a variety of
medications to bring about a state of conscious sedation, in
which a patient isn't fully unconscious, but remains drowsy
and only semi-aware during procedures. Dentists trained in
the practice say the fastest-growing method involves oral sedatives
such as insomnia drugs, which they say offer more anxiety relief
than nitrous oxide (aka laughing gas). And because memory loss
is a common side effect of these drugs, patients typically
don't remember the experience.
The practice has spread as more doctors seek
training in administering sedating drugs. Some practices are
specializing in it and launching ad campaigns to attract patients
who otherwise avoid the dentist. Michael Silverman, founder
of the for-profit Dental Organization for Conscious Sedation
in Seattle, says nearly 8,000 dentists have taken his group's
courses in oral sedation since DOCS was founded in 2000.
But sedation dentistry -- sometimes called sleep
dentistry -- is also drawing criticism from some dentists,
spurring lawmakers and professional groups to address concerns
about the potential for over-sedation.
Oral sedatives, such as the insomnia drug triazolam,
sold under the brand name Halcion, are growing in popularity
in part because dentists can learn to administer them relatively
quickly. Intravenous drugs require more-specialized training.
However sedation experts say that even with oral sedatives,
practitioners must still be able to determine the proper dosage,
assess the level of sedation, assist a patient with breathing
if there are respiratory problems, and bring the patient out
of sedation with a reversal agent if necessary.
Since 2002, at least 20 states have amended
regulations or laws to address the use of anesthesia and sedation
in dentistry, according to the American Dental Association.
California, Florida, Iowa, Idaho, Minnesota and Wisconsin,
for instance, have adopted rules covering training, certification
and equipment.
Last week, the ADA released a draft update of
its guidelines on sedation and anesthesia. The updates, which
will be finalized in the fall, would change the ADA's definitions
for the levels of sedation to match those used in the rest
of medicine, among other changes. Joel Weaver, ADA spokesman
for anesthesia affairs, adds that under the new guidelines,
dentists would have to be able to pass a competency course
when receiving training. Several states that require certification
for dentists using sedation adhere to the ADA's guidelines.
Some dentists say that the addition of sedating
medication, which typically isn't covered by insurance, is
unnecessary. Eleanore Awadalla, a dentist in Toledo, Ohio,
and former member of Ohio's Dental Board, says "95% of
patients really don't need sleeping pills." She is concerned
that patients may misunderstand the sedation they are getting,
believing they will be completely unconscious under general
anesthesia. But she says conscious sedation isn't much different
from what she can achieve with traditional nitrous oxide --
which might be included in the covered cost of the procedure. "It's
all about what you sell," says Dr. Awadalla.
Nevertheless, many patients and dentists say
the technique is invaluable. Some 85 million Americans avoid
the dentist out of dread, according to the Journal of the American
Dental Association. And dentists who use sedation say it may
be the only way to get certain patients into the dental chair
at all. "The big draw is that it reduces the anxiety,"
says Dr. Irwin, who has been using oral sedation since 2004.
Dr. Silverman of the sedation-dentistry group
says that while each patient is different, a typical case works
like this: A nervous patient takes an oral sedative the night
before a procedure to help him or her sleep. The morning of
the dental appointment, the patient takes another dose and
is driven by someone else to the dentist's office. At the office,
the dentist may up the dosage, depending on the patient's level
of sedation. Dosages depend on the age, weight, health and
anxiety level of the patient.
Once the patient is adequately sedated -- nearly
asleep, perhaps with slurred speech, but still able to respond
to commands and breathe on his or her own -- an anesthetic
like Novocain is administered for the pain. The dentist then
begins the procedure. Afterward, the patient may remain sleepy
for several hours, and must be driven home.
The sedation "is not a euphoria or a high," says
Dr. Silverman.
Triazolam (or Halcion) is approved by the Food
and Drug Administration to treat insomnia, but doctors can
prescribe drugs
"off-label" for other uses.
John Yagiela, division chair for diagnostic
and surgical sciences at the University of California Los Angeles
School of Dentistry, says the oral drugs require strict training
to administer. Triazolam is "a very safe drug," Dr.
Yagiela says. But he notes that if multiple doses are given
before the first one has reached its peak, there is the chance
for over-sedation. The dentist needs to be trained in how to
spot over-sedation, manage any respiratory problems that may
arise, and use a reversal agent to bring the patient out of
sedation.
The reversal agent typically is an injection
of a drug called flumazenil. In a survey of 613 dentists trained
by the Dental Organization for Conscious Sedation, using triazolam
on 28,881 cases, there were 85 adverse cases -- 19 of which
involved the administration of flumazenil. None resulted in
the need for hospitalization, according to the study, which
was conducted by DOCS and presented at a 2003 conference.
Pfizer
Inc., maker of Halcion, says signs
of overdose may occur at four times the maximum recommended
dose, which is 0.5 milligram. This includes "somnolence,
confusion, impaired coordination, slurred speech, and ultimately
coma," according to the company's Web site.
The ADA's new draft guidelines recommend use
of no more than 1.5 times the maximum recommended dose, to
achieve what it calls
"minimal sedation."
Still, some dentists take extra precautions.
Kevin Sands, a dentist who practices in Beverly Hills, has
offered oral sedatives for the past six years, charging $800
and up. Dr. Sands says he uses an anesthesiologist to orally
sedate patients even though he has been trained to do so himself. "They're
experts at it," he says.
