Dealing with Nervous Patients [Part II]

In a previous article I discussed managing patients with mild to moderate anxiety. While the methods discussed previously will allow you successfully treat the majority of the patients, there are some that need more to ease their anxiety. For these folks you will have to take things farther with sedation.

While I know there are clinicians out there who successfully do this themselves with oral medications, my recommendation and comfort zone is to manage these patients with IV sedation administered by a dental anesthesiologist. My primary reason for using an anesthesiologist is the simple fact that I want someone there whose main job is to monitor the patient's vitals during treatment.

Beyond monitoring our patient's vitals, I have several reasons behind my recommendation for IV use. First, from a pharmacological standpoint; IV absorption is both more rapid and predictable. Secondly, heaven forbid you have an emergency during the procedure, which I have personally never had, you will be grateful to have an IV line in place to help facilitate a positive resolution.

While working on a patient under sedation helps assure a positive experience, it certainly presents some challenges. You can't ask the patient to change their position since you must move them yourself and additional steps will need to be taken to protect their airway since their reflexes are suppressed. When it comes to positioning, having an anesthesiologist present means there is one more person that can help you move the patient into the position needed for treatment. It's important to note that while you should be able to get your patient in a relatively good position, you need to be ready to accept the fact that it may not be as ideal as with a non-sedated patient and you may have to ergonomically stress yourself more than normal.

The importance of protecting the patient's airway from fluids and debris is something I can't stress enough—and failure to do so can lead to problems. My first line of defense is the use of a throat pack followed by an isolite. An isolite is a soft clear mouthpiece that not only acts as a bite block, but also provides high-volume suction and retraction of the patient's tongue and cheek. In addition to the suction provided by the isolite, we also use manual suction provided by my assistant.

The next step to consider in regards to airway protection is intubation. While intubation can be wonderful at helping protect the patient's airway, oral intubation can greatly impede completing treatment since there is a giant tube right where you need to work. Luckily, there is way around this with nasal intubation. While nasal intubation has its own set of risks, it's a wonderful way to greatly increase the protection of your patient's airway, as long as your patient is a candidate for it.

Again, it is critical that you adhere to the rules and regulations of the area in which you practice; some areas are friendlier than others regarding the use of anesthesiologists in your office.

John R. Carson, DDS, PC, Spear Visiting Faculty and Contributing Author [ www.johncarsondds.com ]