March-April 2015 | Health

Sweet Dreams

Sedation dentistry is helping to coax terrified patients back into the dental chair.

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 A sedated patient receives treatment at Bethesda Sedation Dentistry.

Mildly sedated patients have control of their own breathing, says North Bethesda dentist Mary Ziomek. “They can respond to questions, and they can follow some directions,” she says. “If I tell them to take a deep breath, they can take a deep breath.”

Laurie Sheffield-James, executive director of the state Board of Dental Examiners, says about 300 of the approximately 5,000 licensed dentists in Maryland hold a permit allowing them to administer drugs to achieve moderate sedation. And only about two-thirds of those 300 dentists—including Schlossberg and Klotz—are permitted to sedate patients with drugs that are injected or given intravenously.

“The board takes giving a permit to dentists very seriously,” Sheffield-James says. Dentists seeking the permit must complete special training and pass an inspection of their office by the Board of Dental Examiners. Certification requires that dentists complete at least 24 hours of classroom training in administering and managing sedation and 20 supervised or simulated experiences with sedated patients.
“It’s always in the patient’s best interest to investigate the credentials, training and certifications of their dentist,” Schlossberg says.

Most Maryland dentists who offer sedation dentistry don’t need to obtain a state permit, according to the regulations, because they use only nitrous oxide through a mask or anti-anxiety pills such as benzodiazepine tranquilizers—Valium, for example—that are swallowed. Dentists have used nitrous oxide since the mid-19th century—it’s safe and wears off shortly after the mask is removed, according to the ADA. “It makes you feel like you drank a little bit of wine,” says Rockville dentist Dmitriy Itskovich.

Klotz has sedated moms who simply never took the time to care for their teeth. “Their kids were young, and they were busy. Next thing you know, it’s been 20 years since they went to the dentist. All of their back teeth are broken down. They’re just so ashamed,” she says.

That’s fine with 72-year-old Marian Goldbrenner, one of Itskovich’s patients, who has asked for nitrous oxide at all of her dental appointments for the past 35 years. “I am incredibly sensitive, and he cannot even clean my teeth without my using nitrous oxide,” says Goldbrenner, who lives in Potomac. “He checks my teeth and then says, ‘Let’s put the nitrous on.’ For me, it’s just disappearing from the present. I breathe it in, and I am no longer really aware of what’s going on. I’m floating a little bit.”

A patient’s apprehension about using nitrous oxide can counteract the effects of the gas, says Chevy Chase dentist Stanley Mayer. With very nervous patients, he’ll suggest making an appointment just to test how nitrous oxide makes them feel. They then make a follow-up appointment to get their dental work done.

Dentists need at least a “Class II” permit—there are three classes—if they want to sedate patients with IV medication, often a benzodiazepine such as Versed, which is also commonly given to patients undergoing an endoscopic procedure, such as a colonoscopy.

One benefit of benzodiazepines for fearful patients is that the drugs produce a loss of memory of events that occur right around the time they are administered.

Deeper sedation accomplished with benzodiazepine pills enables patients to stay in the dental chair for two or three hours, a real advantage if it’s been decades since their last visit, Itskovich says. Even with sedation, though, patients who haven’t seen a dentist in years usually need more than one appointment. “These people don’t have simple dental problems,” he says.

CONSIDERING HOW LONG it had been since he’d seen a dentist, Rourke got off pretty easy—no root canals, no teeth pulled due to neglect—although catching up on what he calls “25 years of dental roulette” required four appointments.

?At the second session, Klotz pulled another wisdom tooth. Again, Rourke has no memory of the experience. At a third appointment, Schlossberg pulled the two wisdom teeth on the other side of Rourke’s mouth. The dentist also was supposed to fill two cavities, but Rourke’s arrhythmia showed up on the heart monitor, so Schlossberg ended the appointment and scheduled another one.

Rourke, who still calls himself a “dental wimp,” is now using teeth whitening trays to try to erase the effects of drinking coffee and red wine for years. And he’s moved past requiring sedation. “I’m over that part,” Rourke says. He needed only a shot of a local anesthetic to numb his mouth when he got the two fillings.

Dentists hope that patients who request sedation in the beginning of their treatment process will, like Rourke, eventually feel comfortable enough to go without it. “My goal for you is to create as many positive experiences as you need, so that eventually you don’t need to be sedated anymore,” Ziomek tells patients. Sometimes, she says, that is accomplished in only one or two visits.

“A lot of what we do is establishing trust,” Klotz says. That means assuring patients that they are in control and can tell the dentist to stop if they need a brief break.

Fear of the dentist isn’t the only reason patients want to be sedated, Klotz says. She and her husband occasionally treat busy professionals who want to get as much work done in one visit as possible, and sedation enables them to sit in the chair longer. With IV sedation, Klotz says, she and Schlossberg have treated patients for as long as five hours. “Think about the amount of separate visits that might be for someone,” she says.

“They can’t see a regular dentist because they’re afraid they’ll be judged.”

She’s also seen patients who avoid the dentist because of a history of trauma to the head, neck or mouth. They become extremely anxious if someone wants to work on their teeth, she says. Bethesda Sedation Dentistry patient Teresa Rispoli fell off a table in the school cafeteria when she was 12. She broke her jaw and two top front teeth, punctured her lip and split open her chin. “I literally broke my face,” she says. She underwent plastic surgery to put her chin and lip back together, then had her jaw wired shut. Decades of failed attempts to fix her smile followed. The best any dentist could do was glue in temporary false teeth, leaving her unable to take a bite out of an apple or eat corn on the cob.

Every dental appointment brought more pain and disappointment. “For several years I didn’t even go to the dentist because it was such an awful, awful thing,” says Rispoli, 52. “I only went for a cleaning at random times.” A dentist once lanced an abscess in her gum without even numbing it, let alone sedating her. “The worst thing for me about the dentist is the needle,” Rispoli says. “It’s excruciatingly painful.”
Rispoli heard a commercial for Bethesda Sedation Dentistry late in 2013 and made an appointment, even though she lives in Frederick County, more than an hour away. Like Rourke, she was drawn in by the idea of being sedated.

Schlossberg agreed with Rispoli’s previous dentists that she was not a candidate for implants. But Rispoli says Schlossberg told her, “I can make you something, and I can promise you that no one is going to be able to tell it’s not your real teeth.”
She’s had several cleanings at the practice without any sedation and one marathon four-hour appointment with IV sedation. She has no memory of that session, during which Schlossberg prepared her mouth for a permanent bridge of porcelain teeth and made and placed temporary teeth. She got her bridge in January.

“For the first time in 40 years,” Rispoli says, “I’m smiling.”

Bethesda resident Rita Rubin is a longtime newspaper and magazine journalist. To comment on this story, email comments@bethesdamagazine.com