A MAN in a mask is wielding a drill that is so loud it makes you feel as if a bulldozer is plowing through your head.
A tube inside your cheek is vacuuming saliva. Water is sprayed across your teeth, and you are alternately gagging and having the strong sensation of drowning. The man is coming closer to your face with a needle that looks a lot like a sword from where you sit and, when inserted into your tender gums, will leave half your face paralyzed for hours.
What if you could forget you ever went to the dentist? What if the mask, the drill and the needle were mere blips in an incoherent dream and you could erase those images from your consciousness, something like an eternal sunshine of the spotless mouth?
And what if you were a dentist and could charge several hundred dollars for the promise of this glorious amnesia, tapping into a vast market of untreated patients hiding for years — their cavities unfilled, their crowns in disrepair, their gums a mess.
Enter relaxation dentistry, an appealing concept for the large number of people who dread and avoid the dentist. It is a fast-growing, hotly debated niche in the dental world that involves sedating adult patients with antianxiety drugs and sleeping pills for everything from routine cleanings and fillings to multiple root canals.
In the last five years, thousands of dentists have been trained to administer drugs to anxious patients using medications that doctors say create a mild amnesia for patients who are awake, but not necessarily alert, and may forget the whole experience or have only vague recollections.
But the practice has drawn mounting criticism from doctors and dentists who say it poses a dangerous risk of patients being oversedated by dentists who often have completed only a 24-hour training course and are not equipped to safely monitor the drugs.
Dentists and other medical professionals say the growth in relaxation dentistry is being driven by consumers’ increasing ease in using medications for everything from depression to erectile dysfunction and also by advances in sedation that mean patients can return to normal activities within a few hours of being medicated.
“Its been a big, big plus for millions of people who otherwise would have neglected their dental health, which in turn affects their overall health,” said Dr. Michael D. Silverman, a dentist who in 2000 founded the Dental Organization for Conscious Sedation, which offers 24-hour training courses, has more than 8,000 dentists as members and has spearheaded much of the marketing for oral sedation.
After warning that the rising use of oral sedation was not being adequately regulated, the American Dental Association published guidelines last year recommending that dentists undergo a minimum of 24 hours of training in sedating patients and 10 clinical experiences administering the medications, including three actual cases and one that involves bringing a patient back from deep sedation. The remaining cases can be simulated or watched on videotape.
Forty states, responding to reports of oversedation and other safety concerns, have either adopted those guidelines, developed their own that are more or less stringent, or are considering new regulations.
“There are absolute dental-phobes who stay away, even to the point of trying to take their teeth out with pliers,” said Dr. Joel M. Weaver, a spokesman for the dental association and an emeritus professor at the College of Dentistry at Ohio State University. “Now dentistry has a real way to treat them. But we want to be able to treat them safely.”
To bring the anxious patients out from their foxholes, a growing number of dentists have been marketing relaxation dentistry, or “oral conscious sedation” as it is also known, through television, newspaper and Internet advertisements, with enormous response.
Karen O’Hanley, 45, from Quincy, Mass., was so afraid of the dentist that she avoided the chair for four years, trying to scrape the plaque and stains off her teeth with tweezers.
“I was terrified, I was absolutely petrified,” said Ms. O’Hanley, describing anxiety-ridden visits to the dentist during which she sweated profusely. But last year, Ms. O’Hanley experienced relaxation dentistry, after hearing about it in a television advertisement. The procedure typically combines Valium and a sleeping pill sold under the brand name Halcion.
She said she had no memory of getting three fillings, a root canal, a bridge and a crown during one appointment.
The Valium is typically given the night before the appointment, while the sleeping pill is taken about an hour before the appointment. Adjustments are then made based on the patient’s response.
Dental appointments that involve oral sedation can take longer — on average about an hour, dentists say — because if the patient is not comfortable or adequately sedated, the dentist may administer more medication. But dentists who use the sedation say that patients could ultimately save time because they can get more work done in one appointment.
Now that Ms. O’Hanley has had one side of her mouth fixed last year, she said she would be willing to go back. She had no problem with the $400 her dentist charged for the sedation, on top of a $7,000 dental bill, only $1,500 of it covered by insurance.
“I don’t remember the needles, the gagging, the water,” she said “I certainly don’t remember being in the chair for five hours.”
Anesthesiologists say that the drugs used for sedation typically cause patients to lose some memory, even though they are conscious during the procedure. But memory loss is not guaranteed and it varies by patient depending on the dosages.
The side effects — drowsiness and fogginess — are considered moderate compared with the effects of undergoing general anesthesia, which is typically used for oral surgery and complicated procedures. But patients are told that they must be driven to and from the dental appointment if they are under sedation. The medications are also more potent in treating anxiety than nitrous oxide, or laughing gas, which is often used by dentists but is much shorter-acting, doctors say.
Many dentists can administer antianxiety drugs intravenously, a procedure that is often covered by insurance, dentists say, but that typically requires more training than oral sedation; the dental association guidelines recommend 60 hours of training and experience with 20 patient cases.
Some dentists say oral sedation is a dangerous trend that, if unchecked, could lead to serious risk for patients. The critics say that intravenous sedation is much more precise and therefore safer because pills take longer to absorb into the bloodstream, and dentists may keep giving more without knowing the full impact.
Dentists who practice oral sedation can use another medication, Flumazinil, which effectively reverses the sedative effects of the Valium and Halcyon in a relatively short period, doctors say, if they find a patient is oversedated.
Still, oral surgeons and dental anesthesiologists typically complete months or years of training in sedating patients, and many say the growing use of sedation by general dentists, who are not required to have advanced training in anesthesiology, is disconcerting.
“They are saying it’s no different than someone taking a sleeping pill before bed or popping a Valium if they are nervous, but these circumstances are different,” said Dr. Robert S. Glickman, chairman of the oral and maxillofacial surgery department at the College of Dentistry at New York University. “There is a lack of ability to evaluate the effect, to monitor it and a lack of ability to manage emergencies should they arise, and most people just do not have the experience in dealing with complications.”
Deborah Gorman-Sprague, who two weeks ago was sedated for a root canal, a crown and a surgical implant, said she had no safety concerns when her dentist, Dr. Robert Emami, suggested oral sedation. Her primary doctor, treating her for diabetes and high blood pressure, had given her the green light, she said.
Ms. Gorman-Sprague, 55, who lives in Randolph, Mass., surfed the Internet looking for dentists who offer a less painful experience, after suffering through implants that she said terrorized her and left her face swollen and black and blue. She chose Dr. Emami because he offered sedation.
“I felt like it couldn’t be worse than what I’ve been through,” she said. “I’ve been through so much pain. I feel like now dentists have finally caught up with today. It was like the dark ages before.”