Dr. BERTRAND R. STUART DDS.
THE FEAR patients experience with a visit to the dentist is traditional as well as the fact that 
the mouth is really a special organ. Most people would not mind an injection on the hip/buttock area but expressions of anxiety and apprehension are always present when the injection is to be given in the mouth. This fact amplifies the neurological and psychological sensitivity of the oral cavity. In addition, the supine position in the dental chair gives a feeling of vulnerability. Notwithstanding, in reality, the mouth and face are richly innervated and heavily invested with emotional significance.
Although avoidance of regular dental care is often attributed to economic limitations, removal of these financial concerns usually exposes them as mere rationalizations for the patient’s fear and anxiety. A variety of helpful approaches is available to the dentist to help overcome his patient’s apprehensions. These range from honest expressions of empathy to suggestion, hypnosis, adjunctive medications, local and general anesthesia.
Dentists have become increasingly aware of the need for something to influence the psyche of the patient while the local anesthetic blocks the pain. Fortunately, the old, punitive, “sit still and take it” attitude is quickly fading from the practitioner’s routine.
While general anesthesia has been developed to a high degree primarily by oral surgeons in the US who have had advanced education and training in its use, they constitute a small percentage of practicing dentists and are obviously limited by their specializations to surgical procedures. For most dentists and for most patients, dentistry under general anesthesia would be ill advised and unnecessary. Nevertheless, some things are needed to enhance patient acceptance of dental treatment. Nitrous oxide/oxygen psycho sedation has been widely employed as a helpful modality for managing the conscious patient.
Expanding the dentist’s scope of patient management has also included the use of oral and intramuscular premedication. Both of these routes are subject to considerable variation in patient response, take longer to exert their effect and to wear off, and require, at best, an approximation of the appropriate dosage. The most reliable way to achieve the desired effect with a drug is to feed it slowly, directly in to the blood stream, anticipating objective signs and symptoms in the conscious, responding patient.
The ultimate aim in intravenous sedations is to achieve a level of relaxation and cooperation without oblivion and compromise of vital functions. It must be emphasized that there is no predetermined dosage and that each patient must be individually titrated to his or her own effect. The smallest dose administered which achieves relaxation and cooperation is the proper dose for that patient.
Local anesthetic must be administered for any anticipated painful procedure. It will be more profound in its effect because of the control of the patient’s anxiety by the intravenous agent. But incidentally, I’m still perplexed by a female patient who has extensive visible tattoos, and who has admitted to me she has a ring pierced through her clitoris but yet exhibited morbid fear of me numbing a molar for her extraction. Is it the fear of dental procedures or the fear of pain?
I am not aware of any local dentist who routinely uses general anesthesia in his office. All over the world such procedure is only permitted after specific Laws have been enacted. So then, how do we dispel the fear of the dental chair in local context? This is done by education, pre-medication or obligation.
Through education, which ideally should begin in early childhood, the individual must understand that dentistry is essential to health and wellbeing and that everything the dental practitioner does is in pursuit of this objective. Pre-medication involves the patient taking anti-anxiety drugs a few hours before visiting the dentist. Finally, in some countries, (and I can vouch for Cuba where I spent three years), a requirement by Law is that persons to be employed, to enter educational institutions, etc. must present a report from a dentist certifying a good oral health status. The State therefore forces the individual to restore his/her oral health. Should we do we do this here in Guyana?
