Case• 40. An anxious patient
A 23-year-old student is referred to you for removal of her wisdom teeth. She is very anxious at the prospect of minor oral surgery and has been told that you specialize in treatment under general anaesthesia. Assess the treatment options and their suitability for this case.
She has no complaint at present.
History of complaint
The patient has had several episodes of pain, swelling and bad taste related to both lower wisdom teeth during the last year. Her general dental practitioner has diagnosed pericoronitis and prescribed local treatments, but the episodes are increasing in frequency and severity and the last required systemic antibiotics.
The patient has moderately well controlled epilepsy and suffered her last fit approximately 4 months ago. She is treated with phenytoin 300 mg daily. She also reports allergy to penicillin and co-trimoxazole (Septrin), both of which have caused rashes.
The patient has had only a few restorations placed since the age of 10 years. Her general dental practitioner has provided intensive preventive treatment because she is so nervous. She can tolerate regular check-ups but has required no active treatment for many years. Her last amalgam restoration had to be abandoned on two occasions because of acute anxiety and fainting.
Investigation and diagnosis
The patient has had episodes of pericoronitis and requires extraction of at least her lower third molars. Further details of the indications for removal of lower third molars and their radiographic and clinical assessment are found in Case 25.
The patient has mesioangularly impacted but relatively superficial third molars and you assess them as being relatively easy surgical extractions that will require minor bone removal but not tooth sectioning.
▪ What options are available for controlling patients’ anxiety? What are their advantages and disadvantages?
See Table 40.1.
|Method||Advantages and disadvantages|
|Behaviour modification||Simple to perform but time consuming. Methods include identifying causes of anxiety (which may be visual, auditory or olfactory), modifying anxiety using desensitization techniques and a ‘tell-show-do’ approach. Works well in mild or moderate anxiety and for routine dental treatment but is unlikely to be appropriate for surgical extractions.|
|Hypnosis||Requires trained clinician and several relatively time-consuming episodes of training prior to surgery. Can produce pain relief as well as anxiety suppression. If patient has already received hypnotherapy their suggestibility will be known and the preliminary episodes may not be necessary. No after-effects and no drugs required.|
|Preoperative oral anxiolytic drug||
Suitable for mild anxiety and restorative procedures but unlikely to be sufficient for surgical extraction. May be used in addition to other techniques if the patient is so anxious that they may not even attend for their appointment.
Unpredictable effect in children.
|Inhalational sedation||Can be combined with oral anxiolytic drug. Requires trained operator and team. Suitable for routine dental treatment in mild and moderate anxiety and especially useful in anxiety-related gagging reflex. Ineffective in nasal obstruction or if patient fears mask.|
|Intravenous sedation||Requires trained operator and team but relatively simple in comparison with general anaesthesia and easily administered in a general practice setting. Fast and with few medical contraindications or adverse effects. Patient remains conscious throughout procedure.|
|General anaesthesia||Never the method of choice for minor procedures because of the risk of fatality. Though very low, this risk is sufficient to contraindicate general anaesthesia for most dental treatment in normal individuals. General Dental Council regulations require general anaesthesia to be performed in a hospital. May be required for patients with severe disabilities or more complex surgical procedures. Indications for general anaesthesia for removal of lower third molars are considered in Case 25.|
After discussing the options the patient elects to have her extractions performed under intravenous sedation.
▪ What constraints are placed on the use of general anaesthesia for dentistry?
The current General Dental Council guidance on the use of general anaesthesia is contained in the Council’s document Standards for Dental Professionals (June 2005). Failure to comply would render a dentist liable to a charge of serious misconduct.