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Read Dr. Dougherty’s Chapter from Inside Job


Everybody has a major fear of something.  This fear may be about an activity such as flying or heights, a critter like a spider, perhaps being alone in the dark or a multitude of other situations or objects.  The most universal response people have is to avoid the things they fear.  This may work well in most instances, but what if your fear is going to the dentist?  It is generally accepted that the fear of going the dentist ranks among the top ten most common fears. Half the population will avoid going to the dentist on an annual basis.  It is not uncommon for people to wait many years without receiving necessary care because of dental phobia. In my practice, new patients have usually postponed care for three to twenty years, but many have been without dental treatment well beyond one’s imagination.

Avoiding the dentist, unfortunately, allows small problems to become much larger.  A small cavity might require a simple filling, but if neglected, will continue to grow.  If the decay approaches the tooth nerve, it can become infected, causing considerable pain.  The once small filling becomes a larger filling, a root canal, or a crown.  Given enough time, this ever increasing decay may lead to the loss of the tooth.  Similarly, the gum tissue, which has an initial localized infection, if left unattended, can lead to progressive bone loss and eventually to loss of some or all teeth.  The patient is now faced with the need for more extensive and expensive care to replace these missing teeth. The additional pressure for more treatment and expense adds to the fear and furthers the avoidance of care. The cycle continues over and over.

Dental neglect does not only cause physical problems, but rather takes its toll on our emotions.  I have met many new patients who are very embarrassed because of their unhealthy mouth.  Some have lost self-esteem because they feel they have “allowed” themselves to develop avoidable problems. Other patients are ashamed to show their teeth.  With front teeth missing or blackened by decay, they avoid smiling or maneuver their lips so they do not show their teeth while speaking. Still, others will shield their mouths with their hands to avoid showing any glimpse of their teeth. In extreme cases, a patient does not ever leave their home except for necessities.

From where does this fear, of receiving dental care, arise? I have observed five major categories as a basis for this phobia. The largest group of fearful patients can relate back to a bad experience at the dental office.  For some this may have occurred in early childhood and they have been living with these memories for their whole life.  I have often been told by patients about being held down in the chair and crying while the dentist hurt them. Others describe the dentist who “had his knee in my chest” while attempting to pull a tooth. Some patients recall that every time they went to the dentist they always seemed to require extensive care. Regardless of the veracity of these memories, they are very real and vivid for that patient, and those memories keep them from seeking care. These apprehensions are also reinforced and compounded by friends, siblings and parents who seem ready to share their dental fears.

The second most common cause of this fear arises from the failure of local anesthetic injections to completely numb a patient.  As with all other drugs, anesthetics do not work 100% of the time in 100% of patients. Fortunately, there is a wide variety of different local anesthetics and an array of injection techniques that allow the dentist to achieve almost 100% success. Unfortunately, once a patient has experienced the pain from not being completely numb, they never forget. One of my patients explained that he had no particular fear of dental procedures, but that his previous experiences were not always pleasant because he was not completely numb.  Quite simply, he did not mind the actual procedures, but did not want to be hurt. Who can blame him?

People avoiding the dentist because of a strong gag reflex comprise the third group of fear patients. These patients often have no fear of the dentist at all but cannot tolerate things being placed in their mouth. The response to care may be a mild gag or a powerful reaction that ends in vomiting. Fortunately, a combination of sedation and auxiliary drugs can attenuate this response and allow a person to receive their necessary treatment.

The fourth group of patients is one that tears at you heartstrings.  These patients have suffered sexual abuse. One male patient in his thirties advised me that when he was ten years old, an uncle had orally raped him over the course of a year.  Another patient, a female in her fifties, told me that when she was young, a family member would cover her mouth and nose with his hand until she passed out and then would rape her. The positions a patient and dentist assume during care invade the “personal space” of an individual and can be quite threatening. Whether the horrific experience was rape or other trauma, it is easy to understand why these victims would not be comfortable laying back in a chair and having a stranger put things in their mouths.

The last major group is comprised of those patients with either physical or mental disabilities that do not allow them to receive care in a routine manner

What assistance can be provided to all those who dread a visit to the dentist? The most important first step is to find an office where the people and environment allow you to feel relaxed.  Often, this alone may not be sufficient and more help is needed to surmount this latent fear. For these patients, the various modalities of sedation are essential.  The three most utilized approaches are nitrous oxide, oral sedation medications and intravenous (IV) sedation.

Nitrous oxide (“laughing gas”) is a gas that is mixed with oxygen and inhaled through a small mask that fits on your nose. After breathing normally through your nose for a few minutes, the effects of the gas can be felt.  The goal is to make you feel relaxed and comfortable.  Some patients report feeling a bit light headed or having a tingling sensation in their arms or legs.  This drug modality is not intended to put you to sleep.  During the process you can communicate with the dentist and be able to respond to directions and requests or ask questions. The effects of the gas wear off after a few minutes once administration is completed and the mask is removed. Nitrous oxide is best suited for patients with only mild anxiety. An advantage to this type of sedation is your ability to perform normal functions after a brief waiting period, unlike other forms of sedation that put you to sleep and require you not to drive for twenty-four hours. The use of nitrous oxide is fairly common and so it is relatively easy to find a dentist who provides this service.

The second method of sedation is achieved by taking oral medications prescribed by or dispensed by your dentist. These drugs will have a more profound sedative effect than nitrous oxide.  The quantity of drug is controlled by the dentist so that you remain awake but very relaxed and calm.  This conscious sedation technique is best suited for mild to moderate anxiety.  The dentist will have you either swallow a pill or let one dissolve and be absorbed under your tongue.  In approximately an hour or less, the effects of the drug will be felt.  The patient may become quite drowsy but will still be able to respond to directions and requests.  The drug may diminish your memory of the dental procedures. The patient cannot leave the office alone after this type of sedation.  You must not drive or operate dangerous equipment for twenty four hours after being sedated, but you will be able to return to your normal activities the following day. Another potential downside is that the sedative effects of the drugs can diminish during the dental procedures.  This is attributed the different rates at which drugs will be metabolized in different patients.

The third form of sedation is intravenous (IV) sedation. This is considered to be the gold standard by which all other forms of sedation techniques are compared.  The technique employs a small flexible catheter that is placed into a vein usually on the back of the hand or in the arm.  Because the catheter is so small, the patient rarely feels the insertion.  A line is then attached through which the sedation drugs are administered.  The drug is administered in small doses (tittered) until the desired level of sedation is achieved.  Because of the precision involved in the dosing, many consider this to be the safest and most predictable sedation experience.  Drugs administered in this manner are more effective than the same drugs given orally. The patient is very comfortable throughout the dental treatment.  Most of the IV sedation drugs cause amnesia, and so the patients are not aware of their care and feel like they were sleeping throughout the entire visit.

Dentists who administer IV sedation have received special advanced training in hospital programs. They are evaluated by their State Dental Boards who will certify them based upon their training, credentials, training of support staff and medical equipment available in their office.  Because of the advanced, specialized nature of this technique, few dentists provide this service. A listing of those trained in IV sedation can be obtained through the State Dental Board.

The need for sedation-trained dentists is well beyond the availability of this care. It is my hope that sedation dentistry training will become more readily available for professionals serving the over 50% of the population that say “I hate the dentist”.


When should I look for a sedation dentist?

The simple answer is before you need one. My experience is that most fearful patients wait until there is an emergency dental need.  The emergency pain or infection has finally motivated them to seek care. Unfortunately, trying to find a stranger with whom you will be comfortable when you are afraid and in pain merely adds to the fear.

Is the dentist qualified to perform sedation dentistry? 

All states require dentists who perform sedation to have a special permit from their State Dental Board of Examiners.  Ask the dentist if he has one and check with the State Board.  Some dentists will prescribe a minor tranquilizer (which is permitted) and then claim to be a sedation dentist (which they are not) in their advertisements and websites.

What type of sedation training does the dentist have?

Dentists who are trained to provide IV sedation have had extensive training in a hospital based program. These programs are very comprehensive and require extensive operating room experience.  Dentists who provide oral sedation only receive on average three days of education in a non-hospital environment.  The most popular of these programs is provided by the Dental Organization of Conscious Sedation (DOCS). It is also important to ask if the support staff is trained in ACLS (advanced cardiac life support).

How often does the dentist provide sedation? 

Some dental practices are focused on meeting the needs of a sedation patient.  In these offices, the dentist will be providing sedation services daily and will develop considerable experience.  In other offices, a dentist may only occasionally provide this service in response to a patient’s request

What type of sedation does the dentist offer? 

The various routes of administration have been previously discussed.  They included IV sedation, oral sedation, and nitrous oxide.  The individual needs of each patient will determine what is appropriate and therefore which office meets their needs.

What type of dental services does the dentist provide? 

Be certain the dentist you chose is trained in the services that you need and performs them on a regular basis. You do not want to awaken from a sedation appointment and be told you will need to go to another office because the dentist was unable to provide a particular treatment.

Have they taken Continuing Education?

Do not hesitate during your interview of the dentist to ask how often they and their staff receive recurrent training and continuing education in anesthesia. The fields of pharmacology and medicine are constantly changing and all doctors need annual training to remain current.

Is the patient a child or adult? 

Sedation anesthesia is different for children and adults, and the training required for the doctor is different.  Again, match the dentist’s training to your needs.

How do I find a sedation dentist? 

First step is to call the Dental Board of your state.  They will have on file a list of dentists with sedation permits.  Next, go to the web and search for “sedation” or “sleep dentists”. Here you will be able to find web sites for sedation practices.  You will also find some websites that publish patient evaluations and comments about their dental experiences.

How do I begin?

Finding a dentist who understands your fears and anxieties will make you feel more comfortable. You can ask to schedule an appointment to meet the dentist without having any care provided.  This gives you the opportunity to determine if you are comfortable with the doctor, the staff, and the office environment (be prepared to pay a small fee for this visit). If the office thinks this is a weird request, then move on as this office will not be right for you.