Anesth Prog 38:113 1991
CORRESPONDENCE Conscious Sedation and Desensitization
I wish to commend Drs. Moore, Peskin, and Pierce for their paper in the November/December 1990 issue of Anesthesia Progress. 1 I have advocated the integration of behavioral and pharmacologic approaches to patient management for many years as a means of achieving more effective anxiety control, along with decreased drug dosages and greater patient safety.24 In many cases, rupture of the fear cycle by a series of pleasant, painless conscious sedation experiences results in a progressive desensitization, leading to the patient's acceptance of routine dental treatment while in a fully conscious, nonsedated state. There is no question that the clinician's interpersonal and communication skills can exert at least as much sedative or calming effect on the patient as the sedative drug itself, as noted many years ago by Egbert et al.5 Furthermore, such an approach will dramatically enhance the placebo response, particularly when high levels of anxiety are present.6 The authors comment that methods for maximizing the efficacy of integrating pharmacologic and behavioral studies need further study. In my own experience, the use of a structured preparatory interview3 followed by carefully planned intraoperative management utilizing preparatory communications, positive suggestion, and a skilled, sensitive operating technique is highly effective.34 Postoperatively, knowledge and application of operant conditioning should be routinely employed.4 For exam-
ple, withdrawal of negative reinforcers (such as stressful surgery) should always occur in the doctor's presence, thus strengthening the desirable response with the doctor. Hopefully, the philosophy expressed by Drs. Moore et al. ,1 and shared by many others, will eventually be included in the undergraduate cuniculum of our teaching schools. It is one that can only benefit our patients and ourselves. Peter A. Foreman, BDS(NZ), FICD, FAGD, FADSA
REFERENCES 1. Moore PA, Peskin RM, Pierce CJ: Pharmacologic desensitization for dental phobias: clinical observations. Anesth Prog 1990;37:308-31 1. 2. Foreman PA: Behavioral considerations in patient management. Anesth Prog 1979;26:161-166. 3. Foreman PA: An integrated approach to the management of dental anxiety. Aust Dent J 1984;29:10-14. 4. Foreman PA: Practical patient management: the integrated approach. Anesth Prog 1988;35:19-25. 5. Egbert LD, Battit GE, Turndorf H, Beecher H: The value of the preoperative visit by an anesthetist. JAMA
1963; 195:553-555. 6. Janis IL: Psychological Stress: Psychoanalytic and Behavioral Studies of Surgical Patients. New York, John Wiley & Sons, 1958.
© 1991 by the American Dental Society of Anesthesiology
ISSN 0003-3006/91/$3.50
113
CORRESPONDENCE Conscious Sedation and Desensitization
I wish to commend Drs. Moore, Peskin, and Pierce for their paper in the November/December 1990 issue of Anesthesia Progress. 1 I have advocated the integration of behavioral and pharmacologic approaches to patient management for many years as a means of achieving more effective anxiety control, along with decreased drug dosages and greater patient safety.24 In many cases, rupture of the fear cycle by a series of pleasant, painless conscious sedation experiences results in a progressive desensitization, leading to the patient's acceptance of routine dental treatment while in a fully conscious, nonsedated state. There is no question that the clinician's interpersonal and communication skills can exert at least as much sedative or calming effect on the patient as the sedative drug itself, as noted many years ago by Egbert et al.5 Furthermore, such an approach will dramatically enhance the placebo response, particularly when high levels of anxiety are present.6 The authors comment that methods for maximizing the efficacy of integrating pharmacologic and behavioral studies need further study. In my own experience, the use of a structured preparatory interview3 followed by carefully planned intraoperative management utilizing preparatory communications, positive suggestion, and a skilled, sensitive operating technique is highly effective.34 Postoperatively, knowledge and application of operant conditioning should be routinely employed.4 For exam-
ple, withdrawal of negative reinforcers (such as stressful surgery) should always occur in the doctor's presence, thus strengthening the desirable response with the doctor. Hopefully, the philosophy expressed by Drs. Moore et al. ,1 and shared by many others, will eventually be included in the undergraduate cuniculum of our teaching schools. It is one that can only benefit our patients and ourselves. Peter A. Foreman, BDS(NZ), FICD, FAGD, FADSA
REFERENCES 1. Moore PA, Peskin RM, Pierce CJ: Pharmacologic desensitization for dental phobias: clinical observations. Anesth Prog 1990;37:308-31 1. 2. Foreman PA: Behavioral considerations in patient management. Anesth Prog 1979;26:161-166. 3. Foreman PA: An integrated approach to the management of dental anxiety. Aust Dent J 1984;29:10-14. 4. Foreman PA: Practical patient management: the integrated approach. Anesth Prog 1988;35:19-25. 5. Egbert LD, Battit GE, Turndorf H, Beecher H: The value of the preoperative visit by an anesthetist. JAMA
1963; 195:553-555. 6. Janis IL: Psychological Stress: Psychoanalytic and Behavioral Studies of Surgical Patients. New York, John Wiley & Sons, 1958.
© 1991 by the American Dental Society of Anesthesiology
ISSN 0003-3006/91/$3.50
113
