Help for the Nervous Dental Patient: Nitrous Oxide Sedation
By Dr. Jeff Shnall
In this article we will discuss the topic of fear of dentistry: how common the problem is, who it affects, why patients are fearful and most importantly we will discuss many ways that reduce or eliminate the fear that you may have about dental treatment.
How common a problem is the fear of dental treatment?
Looking at U.S. to 75% of the population has some degree of fear of dental treatment ranging from mild to severe, while 5 to 10 % are so fearful of dental treatment that they will not go to the dentist unless they are in severe pain.
Why are people afraid of dental treatment?
1. Memories of bad dental experiences as a child or adult that was painful or unpleasant.
2. Some patients have anxiety issues in other areas of their life, not just towards dental treatment. For example these patients may suffer from panic attacks or may already be on anxiety medication for generalized anxiety.
3. Feelings of loss of control also make some patients nervous in the dental chair. Some patients feel very vulnerable during dental appointments
Earlier we spoke about some of the reasons people do not like coming to the dentist and why some people avoid going to the dentist. This raises the question: can having dental treatment be a painless experience and are there things your dentist can offer you to take the fear out of dentistry? The answer to both of these questions is a resounding yes!
Can going to the dentist be a painless experience?
Here are some things that can either reduce or eliminate pain and/or fear associated with dental treatment:
1. The first step towards a better experience is an honest, frank discussion with your dentist when you first meet him or her or at your next visit discussing your fears and/or apprehension towards dental treatment.
Some patients are too embarrassed to tell their dentist they are afraid.
I always ask new patients to tell me if they are nervous about having dental treatment and if so, what aspects of dental treatment are they afraid of. For example, is it just the freezing? Is it the sound of the drill or is it something else? Telling your dentist about past unpleasant dental experiences can help them avoid triggers that made you anxious in the past.
2. Understanding the nature of your dental condition, (that is whether you have a cavity, gum disease or an infected tooth,) and how the problem can be corrected can be helpful in reducing fear and can make your dental appointment easier for you. You should be told how long a treatment will take, and how many appointments will be required.
During an appointment I tell my patients what we are doing during each step so there are no surprises.
Dental treatment should not be painful…however it is not a perfect science, so before I start treatment I tell my patient:
“You shouldn't have any discomfort when we treat you today, however, if you feel anything at all or if you need me to stop what I am doing for any reason you just have to raise your hand right away and I will stop.”
And if their hand goes up I do stop. Using this technique builds trust between patient and dentist and also gives patient a feeling of being in control while they are in the chair.
Should dental treatment hurt? Is it truly painless?
The majority of treatments that I do in a given day are painless but there are times when my patients will raise their hand and stop me while I work. This is the nature of dental treatment.
If you are having treatment done e.g. a filling and you are still having discomfort, your dentist should stop right away if you raise your hand or otherwise let them know. Usually the sensitivity can be remedied by giving more freezing or by using special freezing techniques that deliver more anesthetic to the area where you are being treated (which occasionally may be required especially when treating the lower back teeth, i.e. the molars).
Most dental treatments can be delivered virtually painlessly and it is a myth that dental treatment is supposed to hurt.
Before the freezing I find it helpful to use an aesthetic spray or gel on the gums, and let it sit for a full minute. This pre-numbing can make the freezing quite painless.
Looking at U.S. to 75% of the population has some degree of fear of dental treatment ranging from mild to severe, while 5 to 10 % are so fearful of dental treatment that they will not go to the dentist unless they are in severe pain.
Why are people afraid of dental treatment?
1. Memories of bad dental experiences as a child or adult that was painful or unpleasant.
2. Some patients have anxiety issues in other areas of their life, not just towards dental treatment. For example these patients may suffer from panic attacks or may already be on anxiety medication for generalized anxiety.
3. Feelings of loss of control also make some patients nervous in the dental chair. Some patients feel very vulnerable during dental appointments
Earlier we spoke about some of the reasons people do not like coming to the dentist and why some people avoid going to the dentist. This raises the question: can having dental treatment be a painless experience and are there things your dentist can offer you to take the fear out of dentistry? The answer to both of these questions is a resounding yes!
Can going to the dentist be a painless experience?
Here are some things that can either reduce or eliminate pain and/or fear associated with dental treatment:
1. The first step towards a better experience is an honest, frank discussion with your dentist when you first meet him or her or at your next visit discussing your fears and/or apprehension towards dental treatment.
Some patients are too embarrassed to tell their dentist they are afraid.
I always ask new patients to tell me if they are nervous about having dental treatment and if so, what aspects of dental treatment are they afraid of. For example, is it just the freezing? Is it the sound of the drill or is it something else? Telling your dentist about past unpleasant dental experiences can help them avoid triggers that made you anxious in the past.
2. Understanding the nature of your dental condition, (that is whether you have a cavity, gum disease or an infected tooth,) and how the problem can be corrected can be helpful in reducing fear and can make your dental appointment easier for you. You should be told how long a treatment will take, and how many appointments will be required.
During an appointment I tell my patients what we are doing during each step so there are no surprises.
Dental treatment should not be painful…however it is not a perfect science, so before I start treatment I tell my patient:
“You shouldn't have any discomfort when we treat you today, however, if you feel anything at all or if you need me to stop what I am doing for any reason you just have to raise your hand right away and I will stop.”
And if their hand goes up I do stop. Using this technique builds trust between patient and dentist and also gives patient a feeling of being in control while they are in the chair.
Should dental treatment hurt? Is it truly painless?
The majority of treatments that I do in a given day are painless but there are times when my patients will raise their hand and stop me while I work. This is the nature of dental treatment.
If you are having treatment done e.g. a filling and you are still having discomfort, your dentist should stop right away if you raise your hand or otherwise let them know. Usually the sensitivity can be remedied by giving more freezing or by using special freezing techniques that deliver more anesthetic to the area where you are being treated (which occasionally may be required especially when treating the lower back teeth, i.e. the molars).
Most dental treatments can be delivered virtually painlessly and it is a myth that dental treatment is supposed to hurt.
Before the freezing I find it helpful to use an aesthetic spray or gel on the gums, and let it sit for a full minute. This pre-numbing can make the freezing quite painless.
Nitrous oxide in use: Patient wearing a nasal mask
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Using Nitrous Oxide to Reduce Fear of Dental Treatment
Probably one of the most helpful tools I have in my office to help make dentistry painless and definitely take the fear out of having dental treatment done is the use of nitrous oxide-oxygen sedation, otherwise known as laughing gas. I will use the term nitrous oxide (N.O.) for short. The term laughing gas is really a misnomer. It doesn't really make you laugh when we use it although on rare occasions it can give patients a bit of the giggles. Nitrous oxide has been used in dentistry for over one hundred years. Nitrous oxide is always given with oxygen. In fact, when dentists use nitrous oxide-oxygen sedation their patients will also receive at minimum of 30% oxygen, which is more than the 20% oxygen present in the air that we normally breathe. Nitrous oxide sedation is very safe and can be used for both adults and children. |
What is nitrous oxide and how is it used in dentistry?
Nitrous oxide is an odourless, colorless gas. The way we use it is as follows: We place a small mask over our patient’s nose. You breathe nitrous oxide through your nose during the entire dental appointment.
The gas makes most patients feel quite happy and relaxed while they are having their dental treatment.
I have had patients tell me that nitrous oxide allows them to forget that they are in a dental chair during the appointment.
As mentioned, N.O. nitrous oxide works really well for patients of all ages, from very young patients to adults.
The way nitrous oxide (N.O.) is used is as follows:
We start to give our patient nitrous oxide by having them breath through the nose mask. We gradually increase the amount of N.O. they breathe in over the next few minutes.
During the first few minutes most patients, even young children do not feel any different. We then increase the amount of N.O. a little more and wait another minute.
We ask again if our patient notices any changes and if so are they pleasant or unpleasant. Early changes that people may start to notice as they breathe in the gas are tingling in their hands or feet or even throughout their body.
As the amount of N.O. used is increased you may feel like you’re floating slightly. Most patients like the feeling they get with N.O. Some patients report that they can forget they are in a dental chair as they are now feeling quite happy.
We continue to increase the amount of N.O. breathed in each minute until we find the amount that the patient is happy with. Every patient has a different amount of N.O. that is best for them so it does take a few minutes to find the amount that is right for you.
For some patients this may be a relatively low amount of N.O. while for others it might be the maximum amount that we can deliver, and it doesn't always depend on the size or weight of the patient.
If we turn the gas up a little too high for a patient it can start to feel a little unpleasant. So we turn it down a little, wait a minute and see if they are in their happy place again. If they are we should then be good to start treatment.
When your appointment is finished we turn off the N.O. and then have you breathe pure oxygen for 3 to 5 minutes before the mask is taken off your nose. This clears the N.O. out of you system and brings you back to normal sooner.
What are the benefits of using nitrous oxide-oxygen sedation for you dental treatment?
N.O. alters your normal sense of reality and makes most patients relaxed and happy.
It makes most patients feel so good that they don’t care if they are getting freezing or having dental treatment done.
N.O. causes tingling in the body it often can cause a numbing feeling in the entire mouth. So in many cases you won’t feel it when you are getting freezing.
This is really helpful when working on patients who are afraid of freezing and is particularly helpful in children. I have actually had children giggling a little while I give them freezing while using nitrous oxide.
N.O. does have an analgesic effect, which means that it does act as a pain killer, which can make dental treatment more comfortable for those with extra sensitive teeth and gums. There are patients that find dental cleanings very uncomfortable no matter how gentle dental hygienists can be…For these patients breathing in N.O. during their dental cleanings can be extremely helpful.
N.O. alters our perception of sound and can make the unpleasant sounds associated with dental treatment more tolerable (the main offensive sound being the dental drill).
N.O. also affects our perception of time…it actually makes time seem to pass faster. So an hour long dental appointment will seem to go by much faster, which can only be a good thing.
A big plus with N.O. sedation is that once the appointment is over and the N.O. is turned off, within a few minutes you are completely back to normal. You can drive a car right after using N.O. and you can go back to work or school. As we will soon see this is a huge benefit compared to other medications that can be used to reduce fear in dentistry.
Another huge benefit of N.O. is that it is very helpful in eliminating the gag reflex. Some patients gag very easily during dental procedures…i.e. during the taking of x-rays, or when models of their teeth are made (we call this impression taking).
N.O. can completely eliminate gagging during dental procedures or reduces it to a level where the procedure can be carried out easier for the patient and dentist.
So, for patients that are nervous about having dental treatment or who really find it very unpleasant to be in a dental chair, Nitrous Oxide sedation is definitely worth trying, providing you are a suitable candidate (see below).
Who is not a candidate for Nitrous oxide sedation?
There are very few people who might not be good candidates for NO sedation:
N.O. is not recommended for pts with: chronic obstructive lung disease which comprises the conditions: chronic bronchitis and emphysema N.O. sedation is best avoided in pregnant women in their first trimester if possible…as is the case with dental treatment in general (routine cleanings and emergency dental treatment are fine during pregnancy).
I would recommend consultation with your physician before considering the use of N.O. in your first trimester.
If someone has permanent and significant nasal obstruction N.O. sedation will not work as it will not be able to be breathe in through the nose and therefore will not be able to get the gas into their system.
Colds, allergies and Nitrous Oxide Sedation:
Occasionally, a patient may come in with the start of a cold or with allergies that make their nose stuffed up, so for these patients breathing Nitrous oxide through the nose will be difficult.
What works really well for these patients is a few sprays of Dristan Nasal Decongestant through each nostril before putting the nasal mask on. This clears up the nasal passages and allows the patient to breath fully though their nose during their appointment.
If an adult or child has a bad cold and is really stuffed up I would recommend delaying the dental appointment t if at all possible, especially if N.O. is to be used as it usually just ends up in frustration if the patient has trouble breathing in through their nose during the appointment, rendering the N.O. unusable.
Nitrous Oxide does have a few potential side effects:
Nausea in children or adults. There will be some patients who get nausea after breathing in nitrous oxide.
A very good way to prevent nausea is to take a small amount of Gravol approximately 30 minutes before your dental appointment but do not do this without first discussing this with your dentist. For adults this is a 50mg tablet. For children should check the label as it is dependent on the age and weight of the child. If our patient remembers to take their Gravol before their appointment I find that nausea almost never occurs.
I always tell my patients to let me know if they are starting to feel nauseas during their appointment. If this happens your dentist can lower the amount of N.O. you are breathing in which can eliminate the feelings of nausea, or the can turn the gas off completely and have you breath in oxygen for a few minutes, which also usually helps the nausea pass.
It is recommenced that patients only have a light meal 2 hours before their appointment and then nothing to eat or drink thereafter so they are on a relatively empty stomach during their appointment. This can reduce the chance of nausea from developing and will also be a plus if the nausea should progress to vomiting which is a very uncommon event, especially if the patient takes Gravol before the appointment.
A quick comment about Gravol: Check with your doctor or pharmacist or doctor if you have pre-existing medical conditions before using any over the counter medications.
Does Nitrous Oxide Sedation work for everyone who tries it?
No. In my experience nitrous oxide works very well for the vast majority of patients, both adults and children. If I have a patient that is nervous about having dental treatment done I usually recommend they at least give nitrous oxide a try even for a minute or two to see if they like it.
Some pts who are nervous about dental treatment are also afraid to try N.O. but I find usually, if they give it a try they like it.
If a adult or child is extremely nervous N.O. may not be a powerful enough sedative and other methods would be recommended, for example having your dental treatment done under either IV sedation, which is a deeper form of anaesthesia than N.O., or even having your dental treatment done while you are completely asleep (general anaesthesia).
Some patient don’t like the thought of being sedated with N.O. as they are nervous about loss of control. The thought of being sedated with lowered awareness of their surroundings makes them anxious.
For patients fearing a loss of control I remind them N.O. does not put patients to sleep and if a patient doesn’t like the N.O. they can tell me or raise a hand to have it turned off or lowered at any time during the procedure.
Some patients cannot tolerate N.O. sedation as it makes them dizzy or feel unpleasant. Taking Gravol before the appointment help prevent this. When this happens I usually try to lower the amount of gas I use, but some patients are sensitive to N.O. and it unfortunately just doesn’t agree with them.
Some patients are afraid to try N.O. because they are afraid it will make them act silly say something inappropriate. In all the years I have used nitrous oxide with patients this has never been an issue, and patients have nothing to worry about in this regard.
Nitrous oxide sedation is a good way to allow a nervous patient to get used to having dental treatment done without pain and anxiety. I have patients who prefer nitrous oxide for all their dental procedures.
I have also had new patients who are initially very nervous about having dental treatment. Then, after having several procedures done with Nitrous oxide they feel relaxed or confident enough that we’re not going to hurt them that they no longer require nitrous oxide for their dental treatment.
Other Drugs that Reduce or Eliminate Dental Fear/Anxiety:
If you prefer not to use nitrous oxide sedation, another option that can be tried is to take a pill before your dental appointment to relax you.
There are a various medications that dentists use for this purpose. A few popular ones are:
- Lorazepam and Triazolam for adults
- Midazolam (which is a liquid) for children.
These medications work well for many patients. They are generally taken approximately 30 to 60 minutes before a dental appointment.
They relax you and sedate you (although you will still be awake) and usually do a good job relaxing patients who need dental treatment.
The main disadvantage of these drugs is that when you take them, their sedative effect can last for many hours, so if you’re in the dental chair for only one hour you will remain sedated for several hours after the appointment.
So going back to work or school will be out of the question. In fact, you will need a responsible adult to take you to your appointment and take you home after your appointment if you take one of these medications before your dental treatment.
You should definitely not drive after taking a dose of Ativan or Lorazepam that is strong enough to sedate you for dental treatment.
The fact that nitrous oxide allows you to go back to work and drive a car right after the appointment is a huge advantage over the oral medications.
Final thoughts
Being nervous about dentistry is quite normal and common. I have explained some of the ways that dentists can make going to the dentist easier for patients. This is truly a great time to be a dentist and to be a patient. As dentists we have excellent materials and techniques at our disposal that can deliver beautiful smiles. We can replace missing teeth with dental implants that never develop cavities and can provide a lifetime of service. We can get diseased teeth and gums back to a state of good health and function. But we can't do any of this if a patient is too afraid to walk through the door of a dental office.
Visiting the dentist regularly has many benefits:
Maintaining dental health, chewing ability, and appearance. The prevention of pain and tooth loss. i.e. catching cavities when
they’re small and easier and less expensive to fix.
Dental phobics should really be the most regular patients, for if they came every six months for checkups, we would catch problems when they’re early and they would need less complicated dental work that would stir up less anxiety in the chair. So it is ironic that many dental phobics won’t see a dentist until they are in pain. However, fear and avoidance of dental treatment is a common occurrence in many people.
Preserving your dental health has many other advantages:
People who lack teeth for chewing will tend to eat a softer diet with more processed foods, as they’re softer. They eat fewer coarse foods e.g. fewer raw veggies and fewer whole grain breads. This leads to poorer health as diets lacking these foods are lower in fibre.
Diets high in fibre promote health (i.e. have been shown to help prevent colon cancer).
Conversely, softer, highly processed foods may contain more white flour and sugar, both which can raise blood sugar and promote cancer and diabetes.
For a really interesting discussion of the link between cancer and diet I would highly recommend the book Anticancer, by Dr. David Servan- Schreiber.
Psychologically, teeth in poor state of repair or poor appearance can lower one’s self esteem and make one embarrassed to talk or smile. I have heard first hand accounts from some patients over the years of how they were so embarrassed about their smiles they would cover their mouths when they laughed …and how they would keep their mouth closed when they smiled for pictures. research has shown that your smile is the first thing that people notice about you so. Your smile does impact people’s first impressions of you, which could affect outcomes in social situations e.g. in dating or job interviews. People make unconscious assumptions about us simply from our appearance when first meeting us and having a nice smile can work both for while an unattractive smile can work against us in social arenas.
Maintaining healthy gums definitely is helpful in controlling blood sugar levels in diabetics. Put another way, diabetics who have poor oral health and unhealthy gums can have higher blood sugar levels.
Why? Bacteria at and under the gum line causes inflammation in the gums. Inflammatory agents produced by the body under our gums then get swept into our bloodstream and are circulated throughout the body. Theses circulating inflammatory agents make the cells of our body more resistant to the effects of insulin, which will increase blood sugar levels.
Dental phobics or people who find dental cleanings unpleasant may be less likely to attend the dentist for regular cleanings. This can lead to the build up of calcium deposits (literally chunks of calcium forming on the teeth above and below the gum line, which attracts more bacteria to the teeth and resulting in more gum inflammation, setting up the conditions for increased blood sugar described above.
These are just a few brief examples of how the health of your teeth and gums can impact your overall health:
If you are too afraid to even have your teeth and gums checked consider asking your dentist to use nitrous oxide for your first examination appointment at their office. You can even ask to simply try it out for a few minutes before you even commit to an exam just to see if you like it.
This will make the exam more pleasant. If you have very tender gums you will likely be a lot more comfortable when you have your gums checked if nitrous oxide is used.
One closing note: if you are one of those patients who can’t bring yourself to walk through the door of a dental office due to extreme fear, consider calling your province or state dental association and ask for the name of a dentist who can put you to sleep or deeply sedate you for your dental treatment.
You do not need to suffer with teeth or gums that bother you…and you don’t need to live with a smile that you are not happy with. Take that first step and make your dental appointment today. An ounce of prevention is worth a pound of cure. If you have a nagging dental problem that you have been reluctant to have checked or if you have too nervous to make a dental appointment in the past, sedation dentistry is something you owe it to yourself to explore.
If you have any questions or if you would like to book an appointment at our office we would be very happy to meet you! Our contact information is below:
Sincerely,
Dr. Jeff Shnall
Office tel:416-691-2886
Office reception email: BeechDental@gmail.com
Dr. Shnall’s personal email: Dr.Shnall@gmail.com