Sleep Dentistry in Melbourne: three ways to relax in the dental chair

 

Would you rather endure the agony of a toothache or the embarrassment of poor dental health, than sit in the dentist’s chair? If so, you’re not alone. The sound of the drill… The smell of the dental office… The lack of control… The piercing pain… Those “school dental” memories… I’ve heard it all before.  A fear of the dentist and dental phobia can be debilitating, preventing many people from seeking dental treatment, and suffering through excruciating pain unnecessarily.

For those of us who are terrified of the dentist, sleep dentistry is not a luxury but a necessity. It’s the only way to face the inevitable visit to the dentist head on and address your dental problems.

Depending on the severity of fear, sleep dentistry can be used for anything from a simple examination and a clean, general dentistry, to more complex and invasive procedures.

It is worth considering dental sedation, if:

  • You have very sensitive teeth
  • You have a low pain threshold
  • You have dental phobia or anxiety
  • You have an overly sensitive gag reflex
  • You want multiple treatments in one appointment
  • You are undergoing an uncomfortably long procedure
  • You have had traumatic dental experiences in the pas
  • You are undergoing a particularly unpleasant procedure
  • You cannot stand the thought of having any dental treatment while you are awake
  • You have a needle phobia
  • You have difficulties keeping your mouth open for extended periods

Want to find out more about sleep dentistry?

How does Dental Sedation work?

Sleep dentistry is loosely applied terminology to describe several techniques used to alleviate anxiety and to make patients more comfortable during dental procedures. It includes intravenous (IV) sedation (also known as twilight sedation) as well as General Anaesthesia (GA).

It is usually administered either by a dentist ,who has received special qualifications in IV sedation, or a fully qualified anaesthetist who has the required expertise to carefully monitor you throughout the procedure, ensuring your comfort and safety.

At our studio, IV sedation and General Anaesthesia are administered by one of our highly trained, AHPRA-certified anaesthetists.

 

 

 

 

 

 

What are the different types of sleep dentistry?

Conscious sedation dentistry

Oral Sedation

Whilst oral sedation technically cannot be classified as “sleep dentistry”, it’s worth mentioning, as it’s often the easiest and the cheapest method of taking the edge off mild anxiety. A family of drugs namely benzodiazepines (Valium, Xanax, Halcion etc) have a long history of use in dentistry for treating anxiety. A tablet is usually taken half an hour to an hour prior to your procedure, allowing you to feel more at ease during an otherwise stressful dental visit. The tablet will not render you unconscious, but most patients experience sleepiness and tiredness until the effects wear off. Ultimately, you’re fully awake but less anxious. Oral sedation will leave you feeling a little drowsy and carefree after the procedure, so it is best to arrange someone to drive you home from the appointment. This option is suitable for somebody with mild anxiety, but it will not be effective if your anxiety is severe. Most people describe it as “taking the edge off my fear”. For somebody with more severe phobia, either IV sedation or General Anaesthesia is more appropriate.

Inhalation sedation/Nitrous Oxide

Laughing gas, who hasn’t heard of this magic drug? If anything, it’s history is particularly amusing, as with many discoveries, its history is filled with embarrassment and shame. The dentist by the name of Horace Wells, who first introduced it into his dental practice, was booed off the stage when he attempted to extract a patient’s tooth under the influence of Nitrous Oxide. In the failed demonstration, it was later discovered that laughing gas is not so effective in overweight patients and alcoholics. The patient in the demonstration was both. Despite its dark history, Nitrous oxide has become the ‘go-to’ of sedation medicine over the last few centuries. It has similar effects to benzodiazepines in that it makes you lightheaded, calm, and euphoric. You might occasionally break into happy fits of laughter, hence the “Laughing gas” title. Despite the benefits, it’s a nuisance to administer in a dental setting, a patient must wear a nosepiece, which can get in the dentist’s way performing the treatment. Another downside of Nitrous Oxide is that it can increase the risk of miscarriage and fertility issues in female staff members who work in offices where scavenging equipment is not used to safely extract anaesthetic gases from room. Some people can even develop sudden and unexpected nausea from the gas fumes. Few practices still offer this option, as oral sedation is a more practical alternative these days.

Unconscious sedation/General anaesthesia

IV Sedation Dentistry

What is sleep dentistry I hear you ask? Let’s start with intravenous sedation (IV) dentistry, commonly referred to as twilight anaesthesia or twilight sedation, this type of anaesthesia is administered through a vein. IV sedation can be either conscious or unconscious. This technique is often referred to as “twilight sedation” because you will be in a dream-like state. Essentially, you are awake but not aware, and cannot recall anything that’s happened during the procedure. IV sedation can vary in its extent and can be classified as light, moderate and deep. Recovery can be slow or fast, and you will be monitored by an anaesthetist until it is safe for you to go home. Under IV sedation, patients often feel that the procedure took a couple of minutes when in reality it may have taken a couple of hours.

General Anaesthesia

General anaesthesia is in some ways like IV sedation however it allows the patient to remain completely asleep for the procedure. Like IV sedation, it is administered through the vein and takes the patient to a controlled state of unconsciousness that eliminates their movement, awareness and discomfort during the procedure. When people want to be “completely out”, general anaesthesia is the way to go. It’s magic – you go to sleep, wake up, and it’s all done!

What to expect before dental sedation?

All three methods of sedation have their application within dentistry. In your consultation with Dr Helen, she will help you determine the best option. Factors such as level of anxiety, length and complexity of the procedure and medical history will all need to be considered.

If you are undergoing Intravenous sedation (IV) or general anaesthesia, you will be asked to provide your medical history. This includes listing previous and existing medical conditions and any medications you are currently taking. You will also have a pre-procedure consultation with one of our anaesthetists. They will instruct you not to eat or drink for at least seven hours prior to your procedure, fasting reduces the risk of serious complications after surgery, such as aspiration pneumonia. A condition that can occur when food, saliva, liquids, or vomit is inhaled into the airways instead of being swallowed. When you wake from the procedure you will feel tired and drowsy while recovering, and a family member or a trusted friend will need to pick you up and accompany you home the day/night of the surgery.

What to expect during dental sedation?

Oral sedation is often referred to as conscious sedation because, as the name suggests, you are awake and aware. It simply calms you while the dentist works on your teeth. You arrive thirty minutes prior to your appointment and take a sedative tablet. Once the tablet takes full effect, your appointment will begin. You will be conscious, and able to respond to instructions but feel relaxed. Most patients describe feeling sleepy, carefree and a little ‘out of it’. It is not always possible to predict how effective it’ll be for you. Some people fall asleep on the couch while waiting in reception to be seen, and others report little effect. Everyone is different, and this form of sedation is only suitable for people who are a little anxious but can otherwise handle dental treatment reasonably well. However, if you have severe dental anxiety, I recommend considering either IV sedation or full General Anaesthesia.

Intravenous sedation (IV) is administered directly into the vein. The anaesthetist places an IV catheter at the start of the procedure and medications will be delivered painlessly through the IV port. When the sedative takes effect, you will be in a dream-like state of mind. This semi-conscious state is somewhere between half-awake and half-asleep. With a lighter form of sedation, you will be conscious enough to respond to the dentist, but unlikely to remember the procedure! With deeper sedation, you will be unresponsive.  The anaesthetist and anaesthetic nurse will monitor your vital signs and continue to deliver the IV sedation throughout the procedure until the procedure is finished, and you are ready to wake up.

General anaesthesia is also administered directly into the vein. While under general anaesthesia, you are in an induced unconsciousness. Like IV sedation, the drugs are administered through a catheter. You will be completely unresponsive and immobile during general anaesthesia, your functions and vital signs will be supported and monitored by an anaesthetist and an anaesthetic nurse. While this state is lovingly described as “sleep”, and it would be wonderful if you could experience sweet dreams like in the movies, it’s unlikely you will dream while under general anaesthesia.

What to expect after dental sedation

Oral benzodiazepines and Nitrous Oxide

Even though oral sedation is light in contrast to general anaesthesia, your coordination and judgement will be affected. You will feel tired, drowsy, and you shouldn’t be walking or driving home alone. Someone will have to take you home from your appointment. We advise patients against catching public transport, rideshare or taxi services even if you are feeling completely fine. You might be feeling OK, but your judgement will still be affected, so a trusted and reliable person will need to take you home.

IV sedation

When you undergo IV sedation time will seem to disappear. The anaesthetist will wake you and you’ll be surprised that it is over – hours can feel like minutes! When the procedure is completed, it is unlikely you will have any memory of it. Expect to feel tired and weak, it can take up to 24 hours for the sedatives to completely wear off, so make sure you have a trusted person to drive you home and to look after you for the remainder of the day.

General anaesthesia

With general anaesthesia don’t expect to be full alert immediately after waking; it generally takes approximately 45 minutes to an hour to recover from general anaesthesia. Although every patient has a different experience, you may feel slightly confused, drowsy, weak, nauseous, or cold and you may even want to go back to sleep. Most side effects are experienced directly after waking and subside quickly, however some patients take a day or so to completely recover. Someone will need to take you home and look after you for the rest of the day, and you will need to refrain from driving for the first 24 to 48 hours after receiving anaesthesia.

Is sedation safe?

As with any surgical procedure, dental sedation has its risks, particularly with people who have underlying health complications. Sedation dentistry can carry higher risk complications with patients who have liver, kidney, lung, or heart diseases. Other risk factors are obesity, certain neurological conditions, and substance abuse, or if you are currently pregnant. Age is also a factor that needs to be considered. If you are 80 years old or over, an anaesthetist will need to determine your state of general health before they decide whether it’s safe to administer general anaesthesia in a dental office setting.  Despite these precautions, sedation is generally a safe practice when administered by an experienced and registered anaesthetist. During your procedure, the anaesthetist and anaesthetic nurses monitor your vital signs every minute, including pulse, breathing and blood pressure, to make sure everything is normal, and you are perfectly safe.

What are the risks?

Now, this is the stuff you don’t necessarily want to hear. The scary stuff! Horror movie material. Waking up feeling and seeing everything during surgery and not being able to move!

The truth is, there’s no magic in medicine. Every procedure needs to be considered carefully and risks and benefits assessed. For most patients, the benefits of sleep dentistry well and truly outweigh the risks, and most healthy patients, tolerate IV sedation and general anaesthesia very well, with very few or no complications. The anaesthetist will discuss all the major risks with you and advise you on how to mitigate them.

Here is a thorough list of side effects and risks experienced when administered anaesthesia, keep in mind the vast majority of people escape unscathed:

Sore throat and or mouth injury – patients sometimes have a sore throat and hoarseness after having a breathing tube inserted into their throat. On very rare occasions, injury to teeth, lips, tongue and gums occur. The latter is uncommon and, both complications are resolved promptly.

Nausea and vomiting up to 30% of patients report some degree of nausea and vomiting in the first 24-48 hours after general anaesthesia. Although this response is not well understood, it usually resolves within a few days.

Awareness under anaesthesia – this is the complication most feared by people. However, this is exceptionally rare. 1-2 people in 1000 might experience brief moments of awareness of their surroundings, but no pain. Complete awareness is extraordinarily rare.

Allergic reaction – whilst also rare, allergic reactions range from skin rashes, hives, breathing problems to anaphylaxis. If under the care of an experienced anaesthetist, these complications can be dealt with promptly. If you have a family history of reactions to general anaesthesia, it’s important that you share this with your dentist and anaesthetist.

Malignant hyperthermia – whilst a severe reaction to general anaesthesia, malignant hyperthermia is astonishingly rare. Its incidence is not well known, but is estimated at a rate of 1:50,000 – 1:100,000. It is characterised by high body temperature, rigid muscles or spasms, a rapid heart rate, amongst other symptoms, and needs to be treated promptly. This condition often runs in the family, so if you have a familial history of it, it’s crucial that you share this information with the anaesthetist.

Aspiration – most people already know that you will be asked to fast for at least 7 hours before the time of your surgery. Because under GA, the ability to protect one’s airway is reduced, this recommendation is to ensure that the food you’ve eaten is digested and moves from the stomach into the intestines, thus preventing stomach contents moving back up the digestive system, and being aspirated into the lungs, and subsequently causing a lung infection (aspiration pneumonitis).

Other remote risks may include:
Nerve injury
Respiratory depression
Stroke
Brain injury
Embolic event
Cardiovascular collapse, cardiac arrest
Death

Are you suitable for sedation?

It’s safe for most people to have sleep dentistry. However, some specific conditions increase the risk to the patient undergoing sedation, particularly IV sedation and general anaesthesia, such as:

  • Age
  • Obesity
  • Diabetes
  • Seizures
  • Allergies
  • Drug abuse
  • Sleep apnoea
  • High blood pressure
  • History of anaesthesia reactions
  • Medications that increase bleeding
  • Existing heart, kidney, or lung conditions

The ultimate decision determining the suitability of a patient for sedation is made by the anaesthetist administering the anaesthesia. While your sedation preference will be considered, the dental surgeon and anaesthetist will ultimately determine the most suitable sedation for you. It is essential that you share your previous and existing medical conditions and medications so that we can make the best and safest decision for you.

Will you feel pain with sedation?

Sedation is not a completely painless solution, but it can alleviate some of the pain associated with the dental procedure you’re undergoing. With general anaesthesia and IV sedation, you will not feel any pain since you are completely unconscious or unaware. With the help of anti-inflammatory medications, you shouldn’t experience much pain once the sedation wears off either.

With oral sedation, you will be awake, so you will also require local anaesthesia to numb your teeth so that you don’t feel any pain. It is normal to experience some slight pressure and vibration in the area being treated. You can inform your dentist of any sensation of pain during your treatment, and your dentist will administer a top up dose of local anaesthetic.

What are the side effects of sedation?

You may notice slight bruising at the injection site, but it’s largely unnoticeable. Following IV or GA sedation some patients experience temporary nausea, confusion, dizziness, sleepiness, muscle aches and a sore throat.

How much does it cost to be sedated at the dentist?

The cost will vary depending on the type of sedation used, and the duration of sedation. Oral sedation costs approximately $80 to $100 overall. Whereas the average cost of IV sedation and general anaesthetic costs approximately $800 to $1,000 per hour. General and intravenous sedation is partially covered by Medicare, so most patients are eligible for a rebate of approximately 30-50%. The rebate varies and depends on many factors, including but not limited to, the Safety Net limit (calculated by Medicare), and the combined annual household income of the patient. For instance, for a longer surgical procedure, you can reach your safety net of $2,184.30 in the first couple of hours, and for the remainder of the procedure, receive a higher rebate from Medicare. For instance, for a 6-hour procedure, you can expect to pay $6,500 and to receive $3,000 – $5,000 back from Medicare.

What are the alternatives to sleep dentistry?

Are there other ways to combat dental anxiety? Dr Helen shares some of her tips to feeling more calm and relaxed in the dentist chair:
Meditation. “Don’t ask me to teach you this valuable skill as I am not well rehearsed at it myself. However, I’ve witnessed several of my patients transport their minds to another place during dental treatment.

Perhaps to an imaginary sunny beach or to a rainforest. Our mind is a powerful tool. I’ve seen anxious patients meditate through a 6-hour procedure. When I ask them how they did it, they say “through practice” or with assistance of a qualified psychologist.”

A trustworthy relationship with your dentist. “I am far more rehearsed at this one. Knowing that you’re in control at times when you experience pain or discomfort and can signal to the dentist to stop is imperative. A respectful two-way relationship is incredibly valuable. When you know that the dentist has waited a sufficient time for the local anaesthetic to take effect, and that they will not persevere if you experience pain, you might even find that you can gather enough courage overtime to take small steps and have treatment done simply with local anaesthetic, opting out of full sedation.”

Listening to music. “Although I can’t promise that the latest Drake track will knock you out, but your favourite music is a worthy distraction. The noise of the handpiece will recede into the background, distracting you from the moment.”

Why should you choose dental sedation? The verdict.

Dental sedation has revolutionised modern dentistry. If you are anxious or afraid of seeing the dentist, you can easily be treated in comfort and confidence. Given the potential implications of avoiding dental checks, tackling anxiety or phobias is important to avoid serious dental complications and dental sedation could be the solution for you.

In the hands of an experienced and compassionate dentist, you might desensitise to dental treatments. Our end goal is to help you become more comfortable visiting a dentist, and to develop a relationship of trust with your dentist, so that the necessary dental care is not so daunting. Sleep dentistry is a great adjunct to this master plan!

Other relevant questions

Can dentists put you to sleep for treatment?

Some dentists are qualified in IV sedation. In Australia to qualify to administer IV sedation, a dentist must undergo a two-year diploma in IV sedation. However, due to the intricacy of the skill required in administering general anaesthesia, a dentist would not be able to offer it. For your safety, an alliance with a registered anaesthetist is best practice. The dentist will perform the required procedure, while an anaesthetist will keep you comfortably and safely asleep.

Will dental sedation take longer?

On the contrary! Because a dentist can work without any interruptions, they can usually complete your procedure quicker.

Is there an age limit to who can have sleep dentistry?

Just like there is no age limit to the phobia of dentists, people of all ages can have sedation. However, it might not be safe to do it at a dental office if you are under the age of 5, over 70 or have a BMI of 35. These parameters do not automatically rule you out, so it is worth discussing your overall health with our anaesthetist. If it is not safe to have sleep dentistry at your dentist’s practice, there might still be an option to have it at a hospital, where a bigger team can supervise you.

Is there a chance I might not wake up?

This sounds scary, but it’s a very remote risk. Any family history of malignant hyperthermia, or any other complications with General anaesthesia should be discussed with the anaesthetist. Remember, a qualified anaesthetist with the assistance of an anaesthetic nurse will monitor your vital signs every minute to ensure you are safe. If there are any complications, they might decide to transfer you to the nearest hospital.

Is there a chance I might wake up during the procedure and feel everything?

The internet is saturated with scary stories. Yes, it is possible to slip in and out of the deep sedative state, especially during IV or twilight sedation. However, you are not likely to have any recollection of it. An anaesthetist can deepen sedation if necessary to ensure your comfort.

Can you have multiple sleep dentistry sessions?

Yes. However, to minimise the number of procedures and cost to you, we try to complete as much as possible in as few sessions as possible. You might want to consider being asleep for the bulk of your treatment or just for the surgical part of the treatment and opt for light oral sedation for follow up treatments to cement crowns, for instance, or to insert your new all on 4 teeth. Your dentist will help you plan it out.

How soon can you go home after dental sedation?

If you’ve had a sedative pill or Nitrous Oxide, recovery is quick, and you can go home immediately, provided somebody picks you up from the practice. With IV sedation and General anaesthesia, you will be recovering for at least an hour, before the anaesthetists releases you home safely, with a spouse or family member.

If you have a needle phobia, can IV sedation or General anaesthesia be administered any other way.

Unfortunately, no. However, if you discuss your needle phobia with the anaesthetist prior, they can give you an oral sedative prior to relax you so that the experience of the needle is nowhere near as harrowing as what you’ve anticipated.

Will you be in pain when you wake up?

Absolutely not! While you are asleep, the dentist will administer local anaesthetic, so that even if you wake up after a long surgery, you should experience no pain.

What is dental sedation like?

It’s like magic! You go to sleep, wake up, and it’s all done! What could be a better way to have your dental treatment? It’s a bigger deal though than your regular local anaesthesia. You would need to prepare in advance and allow yourself some time to recover before you can attend to your usual activities, however it is not as kind on your hip pocket as local anaesthesia. Other than that, it’s a wonderful way to ensure your dental treatment is manageable.

Dr Helen Voronina
Smile Consultation