chapter 6 Nondrug Techniques: Iatrosedation and Hypnosis
In Chapter 3, the concept of sedation was described using the terms psychosedation, iatrosedation, and pharmacosedation. Definitions of these terms are presented at this time to provide groundwork for the remaining sections of this book.
The overall concept of sedation was originally defined as “the calming of a nervous, apprehensive individual, through the use of systemic drugs, without inducing the loss of consciousness.”1 Although this definition is essentially accurate, it requires further clarification. This is so because clinical techniques exist that act to diminish a patient’s fears and anxieties toward dentistry and surgery without the use of drugs. In addition, the term sedation, implying relaxation of the mind, is too broad of a term because it is possible to specifically “relax” or “sedate” the function of other organs (e.g., the heart [through the use of β-blocking drugs]). Therefore the more specific term psychosedation is suggested when discussing the management of fear and anxiety. The term psychosedative describes a drug capable of producing relaxation of the patient’s mind (e.g., central nervous system [CNS] depression). The two major categories of psychosedative techniques are iatrosedative techniques and pharmacosedative techniques.
Iatrosedation is defined in both a general and a more specific manner. The general definition of iatrosedation is those techniques of psychosedation not involving the administration of drugs. This chapter presents an introduction to these extremely valuable patient management techniques. The following are included in these techniques:
Iatrosedation and hypnosis are discussed in this chapter because they are both important components of the dentist’s armamentarium against pain and anxiety. The reader interested in the other techniques previously listed is referred to specific references cited for each: acupressure,2 acupuncture,3 audioanalgesia,4 biofeedback,3,5 EDA,4,6 and electrosedation.7
This definition of the term iatrosedation was formulated by Dr. Nathan Friedman, for many years the chairman of the Section of Human Behavior at the University of Southern California School of Dentistry. The word is derived from the Greek prefix iatro, meaning “pertaining to the doctor,” and the word sedation, meaning “the relief of anxiety.”8
The concept on which the technique of iatrosedation is based is rather simple: The behavior of the doctor and staff has a profound influence on the behavior of the patient. Other names have been applied to this concept, including “suggestion,” “chairside or bedside manner,” and “the laying on of hands.” The underlying premise of all these techniques is similar: One can use himself or herself to aid in relaxing the patient.
How important is iatrosedation in the overall concept of psychosedation? I have received extensive training in the administration of drugs for pharmacosedation and general anesthesia, yet I have received no formal training in any aspect of psychology or human behavior. It would appear therefore that I should have a strong bias toward the use of techniques requiring drug administration. When I first started my training in anesthesiology in 1969 this was true.
However, in the ensuing years, I have become acutely aware that iatrosedation is an integral part of the success (or possible failure) of every procedure that we in medicine and dentistry attempt. The success or failure of every pharmacosedative procedure also hinges on the use of iatrosedation.
Two classic studies illustrate the importance of human behavior in the control of pain and anxiety. In the first, Egbert et al9 demonstrated the value of the preoperative visit by the anesthesiologist to patients about to undergo surgery the next day. Patients were placed in one of three groups.
Group 1 received a preoperative visit from the anesthesiologist, but no preoperative drug for sedation before surgery. The purpose of the preoperative visit was to discuss the upcoming events with the patients and to answer any questions that they might pose to allay their fears. Group 2 received a sedative, pentobarbital, 1 hour preoperatively, but no preoperative visit from the anesthesiologist. Group 3 received both the visit from the anesthesiologist and the preoperative pentobarbital.
Results of the study demonstrated that patients in the first group were alert on arrival in the operating room, but were quite calm. They did not appear apprehensive. Patients in the second group were drowsy (the effect of the pentobarbital), but did not appear to be calm. They appeared quite concerned with the activities occurring around them. The third group, receiving both the visit and medication, were both drowsy and calm.
Patients in group 1 were not told about postoperative discomfort (pain) following abdominal surgery. Patients were told that analgesics would be available if they were required. Patients in group 2 (“special care patients”) were told that postoperative discomfort following abdominal surgery was quite usual and normal. The type of discomfort was described and its probable location. These patients were also told that analgesics would be available should they be required.
During the postoperative recovery period, patients in group 1 required twice the number of doses of analgesics for their discomfort as the patients who had been prepared for the discomfort. It appears that when pain is expected and is considered normal, the patient is better able to tolerate it. Put another way, it might be stated that pain that is expected by a patient simply does not hurt as much as unexpected pain. A significant anxiety component is noted with unexpected pain, a reaction that is not present with pain that is expected (normal). It is this anxiety (the fear that the presence of pain means that something is wrong) that makes the patient experience even more and greater discomfort. A second interesting finding in this study was that patients in the “special care” group recovered from their surgical procedure more rapidly and were discharged from the hospital an average of 2.7 days earlier than the patients in group 1. This may be because of the diminished requirement for analgesic drugs in the second group, leading to a reduction in drug-related side effects and complications that might impede recovery and discharge from the hospital.
These two studies by Egbert demonstrate the power of communication. I have been witness to many such demonstrations during the use of sedative drugs in dental practice. Unfortunately, not all communication works to the benefit of the doctor. This next case illustrates this point.
Case Study 6-1:
The Power of Communication
A patient received inhalation sedation with nitrous oxide (N2O) and oxygen (O2) for root planing and curettage. The dentist performing the procedure was working with a dental assistant. The patient was receiving approximately 35% N2O, was quite well sedated, and had a degree of soft tissue analgesia. Treatment was proceeding well despite the patient’s earlier anxiety and sensitivity of the tissues. Approximately 20 minutes into the procedure the dentist, who had been conversing casually with the dental assistant throughout the procedure, made the comment, “Gee, I haven’t done one of these (root planing) in about 15 years.” Almost immediately the patient grabbed the nasal hood, pulled it off his nose, sat up, and told the dentist he wanted to go home. The patient did not want to be treated by anyone in whom he did not have confidence (even a dentist who was quite capable of doing the procedure well). An offhand remark, meant for the ears of the dental assistant, had destroyed the patient’s confidence in the dentist. This is another example of the power (albeit negative) of communication.
Case Study 6-2:
Lack of Communication
Yet another example of the power of communication, or the lack of communication, is that of a young man, 26, who admits to being quite uncomfortable with dental treatment. He stated that his previous dentist would walk into the treatment room, tell him to open his mouth, and immediately start treatment, without ever saying hello. The patient was very aware of this and became uncomfortable with his overall care. This dentist suggested that perhaps the patient would be more comfortable if he took a sedative before his next appointment. The patient told us that his treatment was even more uncomfortable than it had been previously because under the influence of the medication he was more acutely aware of the dentist’s lack of concern for him as a person. Following this treatment, the patient sought another dentist.
Communication is a powerful ally to the health professional. As these last cases illustrate, even when pharmacosedation is used, communication must never be ignored. Effective communication makes the drugs administered even more effective.
In the motion picture The Doctor,11 a successful surgeon falls ill and enters into the contemporary health care system as a patient experiencing, as never before, the trials and tribulations that befall patients every day in the hospitals and medical centers of America. Through his negative experiences, the physician learns the value of communication and the importance of empathy in dealing with patients. This award-winning and highly successful film was based on a true story. Incoming residents in family practice medicine at the Long Beach (Calif.) Veterans Administration Hospital begin their hospital career as patients admitted to the hospital, undergoing the routines all patients face (hospital gowns, blood tests, impersonal attitudes by hospital staff).12 Much of the commercial success of The Doctor was thought to be that audiences (all potential patients) believed that the message of the film struck home. The medical profession, to its credit, has recognized that the great emphasis placed in medical education upon the “scientific process” leads to the isolation of the physician from the patient and has begun to take steps to right the perceived wrongs. In a 1992 paper, Spiro13 states that “medical students lose some of their empathy as they learn science and detachment, and hospital residents lose the remainder in the weariness of overwork and in the isolation of the intensive care units that modern hospitals have become.” Medical schools have begun to modify their curricula, including in them new programs on communication and human behavior, designed to prevent the impersonalization of the physician.14
Similar programs have been in place for years in many dental schools throughout the United States and other countries. Yet in the highly competitive world that is dentistry today, it is often the patient who gets lost in the shuffle. I abhor the increasing use of the term client when discussing our patients. The importance of effective communication among the dentist and staff and patient can never be overemphasized. Interestingly, in the venue of continuing dental education, among the most popular programs offered are those in practice management—how to have a successful dental practice.15 The theme of communication is paramount in all these programs.