Dental sedation calms patients, courts controversy

Pharmaceutical IndustryRoscoe VillagePersonal ServiceChemical IndustryMagnificent MileOld Town (Chicago, Illinois)Chicago Tribune

In a dental office overlooking the Magnificent Mile, Valerie Carlson teared up as she recalled traumatic dental surgery that left her filled with fear when she was a teenager.

On this day, she was to undergo preparatory work for dental implants. Normally patients who go through this get no more than a local anesthetic to numb the area.

But as Carlson settled into the dentist's chair, talking nervously, Dr. Kenneth Kromash of Great Chicago Smiles prepared her to receive a powerful intravenous sedative. Soon Carlson would be in a state of conscious sedation that would allow her to respond to Kromash's commands to open or close her mouth but would lessen the likelihood that she would remember any part of the procedure.

Even for a regular dental checkup, she opts to receive a sedative. "There is no other option for me. I need sedation just to get my teeth cleaned," Carlson said. "I can't even hear the instruments. It just makes my skin crawl."

Sedation is a common part of many major dental procedures, such as root canals or wisdom tooth extractions. But dentists are increasingly also offering it to people who might otherwise be too anxious to get checkups or other important care.

Depending on the dentist, options range from a mild anti-anxiety drug taken by mouth to deep sedation in which the patient cannot be easily roused.

The American Dental Association "supports the right of appropriately trained dentists" to use sedation or even general anesthesia to treat patients, saying it is safe and effective when properly administered.

But some anesthesiologists express concern that dentists without an anesthesia specialty might not obtain enough training or perform enough procedures to react well in an emergency.

"If you're a year out from taking that course, and you have an adverse event, are you equipped to handle it with the patient?" asked Dr. Andrew Herlich, chief anesthesiologist at UPMC Mercy in Pittsburgh.

Unexpected reactions to sedation are exceedingly rare events, he said, "but when there is an issue, it's pretty ugly."

The deaths of a 5-year-old Chicago girl in 2006 and a Skokie school principal in 2007 — the latter occurring just two months after the American Dental Association issued stricter sedation guidelines — gave pause to dentists who practice sedation and resulted in stiffer state regulations.

"It makes everyone pause and re-evaluate their protocols," said Dr. Peter Tomaselli of Chicago Smile Design in Old Town. "It makes everybody think."

To receive a dental sedation permit from the state of Illinois, dentists must now obtain at least 75 hours of training in addition to supervised hands-on sedation instruction. The Illinois Department of Financial and Professional Regulation can take disciplinary action, including fines and license suspensions, against dentists practicing sedation without a permit.

Sedation is divided into four categories based on a patient's ability to respond to external stimulation. Most dentists who offer sedation to anxious patients choose minimal or moderate sedation, preferring to maintain patient consciousness and avoid lengthy specialist training. Others may offer deep sedation and general anesthesia.

Kromash, who completed a two-year anesthesiology residency in addition to his general dentistry training, uses moderate, or conscious, sedation. Commonly achieved through a combination of sedative pills and an intravenous sedative, it creates a sleeplike state in which the patient's response to touch and sound is strong. Most patients who want IV sedation for dental procedures will pay for it out of pocket.

Relaxation dentistry, a term that describes the use of minimal sedation for anxious dental patients, has been a part of Tomaselli's practice for over 20 years. He says some patients are so afraid of the dentist that they will call the office multiple times before making an appointment.

Minimal sedation, which decreases anxiety while maintaining full consciousness, can be achieved through mild anti-anxiety medication or nitrous oxide and does not require a state permit. Tomaselli does not perform intravenous sedation, although it may be offered through a third party if a patient requests it.

"Sedation is a continuum," he said. "We stay very, very far to the conscious end of things and far away from the unconscious end of things."

Still, even minimal sedation has its risks, said Dave Marsh, director of government relations for the Illinois State Dental Society. "A combination of nitrous and oral medications could lead to a higher level of sedation," he said, calling it a gray area that is difficult to regulate.

Experts say patients undergoing any type of sedation should be monitored for dangerous changes in blood pressure, heart rate and oxygen levels. Sedation also poses respiratory risks that are not always predictable. One of those is aspiration, the process in which a foreign object is inhaled into the lungs.

People with serious health conditions could be better served in a hospital or an outpatient facility instead of a dentist's office. For example, using sedatives during dental procedures might not be a good idea for people who are pregnant or have certain heart, lung, kidney or liver problems, according to the American Society of Anesthesiologists. Someone with a history of respiratory or cardiac issues might react differently and be less able to tolerate issues like a decrease in blood oxygen levels, according to Kromash. But sedation is safe as long as a dentist has the proper training to handle emergency situations, he said.

Tomaselli said he sometimes turns away high-risk patients. "It's not an ego thing," he said. "It's what can you control, what are you prepared to manage and what's best for the patient?"

Tracy Bowman of Chicago Heights said she finally sought out a dentist offering sedation after two years of pain. Chemotherapy had ruined her teeth, and she had a mouth full of cavities, damage to her gums, gaps between her teeth and crowns that needed replacing.

Even though she was struggling to eat, the semiretired decorator and former model was hesitant to see a dentist, in part because the thought of sitting in the dentist's chair triggered feelings of claustrophobia that she had battled since childhood.

"At my age and with what I had just gone through, I didn't think I could withstand it awake to have all that work done," Bowman said. "I chose sedation because I knew that I wouldn't feel it as much and I wouldn't be as stressed."

Between March and May of this year, Bowman went to Dr. Timothy Dotson at Perfect Smile Dental Spa in Roscoe Village for multiple procedures to fix her damaged teeth.

"The greater risk is not doing anything," said Dotson, who brings in an emergency room nurse to assist with sedation procedures. "We don't chastise our patients for staying away. We compliment them for taking a step, facing what to them is a real fear."

Bowman says she is happy with her decision. "They gave me a pill to relax me, and then I had the IV sedation," she said. "I remember them starting it, and that was it."

Kromash said there are many ways to calm an anxious patient.

"I try to find out the source of the anxiety, the level of anxiety and then we talk about ways to manage that anxiety," he said. "Oftentimes patients just need a distraction."

Carlson, who lives in Roscoe Village, said the relationship she's developed with the dentist and his staff is key.

"I'll start going to this bad place in my head, and Dr. Kromash will take me to another place," she said. "He keeps my mind thinking about something else. He knows what I can handle, and he helps me to relax."

When Carlson, sitting in the dentist's chair, began to feel nervous about her impeding dental procedure, Kromash spoke with a calm assertiveness.

"Valerie, I don't think it's going to be that bad," he said. "You'll be fine."

Dental assistant Elizabeth Medina asked about Carlson's young daughter as the IV was prepared. The distraction worked, although Carlson grimaced as the IV site was numbed.

Moments later, the patient was back to chatting happily, although nervously, about her daughter's experience at sewing camp.

The doctor looked up. "Just to let you know, the IV is in," he said.

Carlson laughed.

"Then you probably won't hear the rest of this story," she said.

jmorrison@tribune.com

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