Abstract
Dental fear may be the most common reason for referral for intravenous sedation. Intravenous sedation offers many patients an opportunity to obtain needed dental care. However, intravenous sedation also has costs and may not help patients overcome their fear. Given a sample of 518 dentally-fearful patients in the USA presenting for dental care, this study examined the variables which predicted receiving intravenous sedation or not. About one-fifth of the patients received intravenous sedation, while the others received only cognitive behavioural therapy. Having more carious teeth, higher dental fear, more negative beliefs about dentists, lifetime diagnoses of panic disorder and/or generalized anxiety disorder, fewer existing coping skills, and a lower desire to cope with the dental situation were each predictive of having intravenous sedation. When the variables were considered simultaneously, only lower desire to cope contributed uniquely to the prediction. In a setting where psychological treatment for dental fear is available, patients’ desire to cope with their fear was the most important factor in determining whether they received intravenous sedation or not.
Background
Recently, a sample of 99 dentists in Northern Ireland stated that the most important factor in deciding which patients should be offered intravenous (IV) sedation was dental fear, yet only 2% used a standard dental fear measure to assess their patients’ fear1. The authors suggest that such an informal assessment of a patient’s need for IV sedation may mean that some patients are offered IV sedation when it is not necessary, and/or that others who might be ideal candidates are not offered this option.
Providing treatment recommendations for the fearful patient may not always be clear cut. On the one hand, while cognitive behavioural techniques for reducing dental fear are effective2, they require additional time and costs for psychological appointments, and they are not successful for all patients. On the other hand, while IV sedation has allowed many dentally-fearful patients to receive necessary dental treatment, it may have little effect on patients’ fear as they may remain convinced that they can only tolerate dental treatment if sedated3; furthermore, this modality entails its own costs and medical risks. Thus, a more nuanced examination of the determinants related to receiving IV sedation in a sample in which both IV sedation and cognitive behavioural techniques are available may be illuminating.
Existing literature suggests that there are several possible risk factors for referral for IV sedation. Greater dental needs, irregular attendance patterns, and higher levels of dental fear have each been identified as reasons for referral for IV sedation1, 4. Lower levels of trust of dentists and physicians is associated with not having a regular dentist5, which suggests that negative beliefs about dentists may also be related to the decision to refer for sedation.
Dentally-fearful patients often have other psychiatric diagnoses as described by the Diagnostic and Statistical Manual of Mental Disorders (DSM)6, although the literature is somewhat inconsistent in terms of which diagnoses are more common, due to sampling differences as well as whether the researchers examined current, prior, and/or lifetime (current and prior) prevalences. For example, Roy-Byrne et al.7 found lifetime histories of major depression, substance abuse, panic disorder, and additional simple phobias (i.e., other than phobia of the dentist) in 26%, 24%, 20%, and 45%, respectively, of fearful patients. These authors also found that 5% had lifetime histories of generalized anxiety disorder, but assessed this in a restricted manner which undercounted the number who would have otherwise been diagnosed. Hägglin et al.8 found that individuals with higher levels of dental fear were significantly more likely to have current major depression in one of two samples. Anttila et al.9 found that patients who were currently depressed were less likely to have regular dental attendance, but the relationship between being anxious and dental attendance was less clear. Pohjola et al.10 found that dentally-fearful individuals were more likely to have had major depression, social phobia, and generalized anxiety disorder in the prior 12 months, but were not more likely to have panic disorder. Locker et al.11 found that fearful individuals were currently more likely to have agoraphobia, social phobia, additional simple phobias, and/or conduct disorder, but were not more likely to have major depression or generalized anxiety disorder. In sum, it seems that dentally-fearful patients are more likely to have other psychiatric disorders, but the specific disorders vary from sample to sample. None of the studies examined risk factors for IV sedation. While Boyle et al.4 stated that there was no difference in “mental health” between the patients referred for sedation and those referred to a general dental clinic, the authors did not describe what this variable was. Therefore, it is unclear whether some psychiatric disorders are more predictive of receiving IV sedation or not.
A final set of factors which may be related to the recommendation for cognitive behavioural treatment vs. IV sedation are patient resources. Generally, patients with psychological resources such as higher levels of social support, a greater desire to cope, lower levels of stress, and greater coping skills are more likely to do well in cognitive behavioural psychotherapy12. Financial resources may also influence treatment recommendations, although this may be complicated because both psychological treatment and IV sedation incur costs, the costs may not be covered equally by patients’ insurance schemes, and some patients may require so many sessions of psychological treatment that it may be cheaper to have IV sedation.
Objective of This Research
The objective of this study was to examine the roles that the previously-identified factors (dental needs, irregular attendance patterns, dental cognitions such as fear or negative beliefs about dentists, other psychiatric diagnoses, and patient resources) had on whether a dentally-fearful patient received IV sedation when both IV sedation and cognitive behavioural techniques were available.
Methods
Setting
The Dental Fears Research Clinic (DFRC) is a specialty dental clinic at the University of Washington in Seattle, USA, serving dentally-fearful children, adolescents and adults. Following psychological and dental examinations, the treatment team develops a plan that will best fit each patient. The goals are to help the patient obtain needed dental treatment, develop increased coping skills, and maintain a pattern of regular dental attendance. For most patients, the plan includes cognitive behavioural treatment without IV sedation. However, for others IV sedation is recommended.
Ethical Approval
The University of Washington IRB gave ethical approval for this study.
Data Collection
As part of a larger study, we extracted and coded chart data from fearful patients seen in the DFRC. For comparison purposes, inclusion in the data set was limited to those who had completed the same standard assessment of dental fear, namely the current 20-item version of the Dental Fear Survey (DFS)13. On this measure, patients are asked to rate how afraid they are of certain dental stimuli (such as the drill), what kinds of physiological responses (such as becoming tense or nauseated) they have during dental treatment, and how often they avoid dental appointments due to fear or cancel/become “no shows” for the appointment. DFRC began using the 20-item version of the DFS in late 1992. We reviewed charts of all current fearful patients, and all former fearful patients who were admitted to the clinic in 1992 or more recently, and selected patients if they had received the current DFS. Since no children, and very few adolescents, received this scale, the data set is primarily made up of adult patients. The IRB stipulated that only patients who were currently active or formerly active when we began the study could be included; therefore, the data set included patients who enrolled in DFRC from late 1992 through March 25th, 2009.
Each patient had been interviewed by a psychologist at intake to assess the nature and course of the patient’s dental fear, how long the patient had avoided seeing a dentist, what other psychiatric conditions the patient might have, and what coping and financial resources the patient had. In addition, patients completed questionnaires measuring dental fear and dental cognitions. The psychologist used this information to write up a summary of the patient’s psychological status, including psychiatric diagnoses. Patients also had radiographs and a brief dental exam to determine their dental needs. This psychological and dental information was used jointly by the psychologist and dentist to determine the patient’s treatment plan.
In addition to demographics, we extracted five kinds of patient data from the charts which we thought might be related to whether or not patients received IV sedation or not: (1) dental needs, (2) dental attendance patterns, (3) dental fear and other dental cognitions, (4) other psychiatric diagnoses, and (5) patients’ resources for dealing with dental treatment. These data were taken from radiographs, interviews, and questionnaires which were administered at the time of intake. We also examined the charts to determine which patients had received IV sedation.
Dental Needs
Since the charts didn’t always describe the patients’ dentition at intake in the same way, we approximated dental needs by examining the intake radiographs. Using these radiographs, one dentist rated each tooth for the presence or absence of decay. As a check on accuracy, radiographs from approximately 10% of the patients were rated twice, with very high agreement for the number of decayed teeth (Spearman’s rho = .915).
Dental Attendance Patterns
Dental attendance patterns were measured in three ways: the length of avoidance (if any) before coming to the DFRC, self-report tendencies of putting off or canceling dental appointments, and an assessment of the likelihood that the patient would cancel or not show up for dental appointments. At intake, patients had been asked when their last dental appointment was, and the psychologist entered the information as the number of years since the last appointment. (If the patient had been to a dentist within 6 months before entering DFRC, then the number of years was marked as “0”.) Self-reported tendencies to avoid appointments or cancel/not show up for appointments were measured by the scores patients gave for two items from the DFS which ask about these on a 5-point scale. After the interview, the psychologist rated whether the patient would be likely to present future problems with regards to canceling or not showing up.
Dental Cognitions
Dental cognitions were measured by scores on the DFS, the Revised Dental Beliefs Survey (R-DBS)14, and a measure of desire for control in the dental setting. The DFS scores can range from 20 to 100, with higher scores indicative of greater levels of dental fear. The R-DBS is a 28-item questionnaire assessing negative beliefs about dentists (such as whether dentists recommend unnecessary treatment, aren’t empathic, and insist on continuing treatment even if the patient indicates that he/she feels pain.) Possible scores can range from 28 to 140, where higher scores indicate more negative beliefs about dentists. Desire for control in the dental setting was assessed by the psychologist who carried out the intake interview on a 5-point scale, ranging from very weak to very strong.
Psychiatric Diagnoses
During the psychology interview, the psychologist asked patients about a number of DSM psychiatric disorders, and coded the patient as ever having the disorder or not on a check list. If a check list item was blank, the coding psychologist read the intake psychologist’s summary statement and the list of psychiatric diagnoses given there to determine if the patient had the diagnosis or not. Eleven diagnoses were included in the data set, including generalized anxiety disorder, panic disorder, specific phobia (other than phobia of the dentist; this disorder was formerly called simple phobia), obsessive-compulsive disorder, post traumatic stress disorder, major depression, dysthymia, bipolar disorder, substance abuse (including nicotine and substances such as alcohol, amphetamines, narcotics, and other substances), eating disorder, and schizophrenia. If the chart indicated that a patient had both major depression and dysthymia, for the data set the patient was coded as having depression only. As a check on accuracy, approximately 10% of the charts were coded twice for each of 11 diagnoses. The agreement was very high, with a mean kappa of .97 (range for all diagnoses = .89–1.00). With regards to the diagnoses referred to in the literature described previously, we chose not to include substance abuse because the DFRC charts did not distinguish between nicotine abuse and abuse of other substances such as alcohol, amphetamines, or narcotics. Thus, for this study we examined the impact of those diagnoses described in the literature which we had data on, namely major depression, panic disorder, generalized anxiety disorder, and other specific phobias.
Patient Resources
Most of the information about patients’ resources was rated by the psychologist who conducted the intake interviews, including social support from spouse/partner for the clinic activities, financial resources for needed dental and psychological treatment, existing coping skills, and the patient’s desire to cope in the dental situation. In addition, patients were asked to rate their current level of stress as a number between 1 and 100, where 1 is very low and 100 is “the highest stress you have ever experienced”. Finally, demographic information (age and gender) were given by the patient at intake.
Data Entry and Statistical Analyses
After abstraction and coding, data were entered into an Excel database using double entry for accuracy. Analyses were conducted using SPSS Version 14.0 (SPSS; Chicago, IL) and Stata Version 10 (Stata Corporation, College Station, TX). Univariate analyses included chi square for categorical variables and either student’s t tests or Mann Whitney for continuous variables (determined by whether the distributions were normal or not). The variables which were significantly related to group assignment (received IV sedation or not) were then entered into a logistic regression analysis using the Enter procedure. For each statistical analysis, only cases with complete data on the variables being analyzed were included. A p value of less than .05 was considered statistically significant, while a p value of .05 – .10 was considered a trend.
Results
Demographics
There were a total of 586 patients who were potentially eligible for this study. Of these, 66 were eliminated for various reasons, including having only had an assessment but never entered treatment (24), were children or for another reason had not received the DFS (31), had received previous treatment for dental fear as part of experimental studies conducted in DFRC (11), or for miscellaneous reasons (2), resulting in 520 potential cases. IV sedation data were missing for two patients, leaving a final sample size of 518. Table 1 includes the raw data for the patients who did or did not receive IV sedation expressed as means and standard deviations or percents. The patients’ mean age at intake was 41.6 years (SD = 13.0, range = 12–76), and 94.6% of them were aged 18 or older. Most (71.8%) were females. About one-fifth (112, or 22%) of the fearful patients had received IV sedation, while the other 406 (78%) had not. There were no relationships between age or gender and having had IV sedation.
Table 1.
Means or Percents for Predictors of Receiving IV Sedation in a Sample of Dentally-Fearful Patients Seen in Seattle, USA between 1992–2009
| Factor | Variable | Had IV Sedation Mean (SD) or Percent |
Didn’t Have IV Sedation Mean (SD) or Percent |
|---|---|---|---|
| Demographics | Age: Years | 42.4 (13.7) | 41.4 (12.8) |
| Gender: % Female | 69.6% | 72.4% | |
| Dental Needs | D: Number of carious teeth | 6.5 (5.5) | 3.1 (3.8) |
| Dental Attendance | Length of avoidance: Years | 5.0 (7.5) | 4.6 (6.5) |
| Put off making appointment: DFS item on 5-point scale (higher = more likely) | 4.2 (1.3) | 4.2 (1.2) | |
| Cancel/no show for appointment: DFS item on 5-point scale (higher = more likely) | 2.7 (1.6) | 2.5 (1.5) | |
| Future cancel or no show: % rated as problems foreseen | 11.2% | 12.9% | |
| Dental Cognitions | DFS sum (higher = more fearful) | 76.8 (16.5) | 73.2 (16.7) |
| R-DBS sum (higher = more negative thoughts) | 85.6 (24.9) | 79.2 (24.9) | |
| Desire for control: 5-point scale (higher = greater desire) | 3.7 (1.1) | 3.9 (1.1) | |
| Psychiatric Diagnoses (Lifetime) | Panic disorder: % with diagnosis | 42.1% | 28.5% |
| Generalized anxiety disorder: % with diagnosis | 44.4% | 30.9% | |
| Other specific phobia: % with diagnosis | 42.5% | 40.3% | |
| Major depression: % with diagnosis | 51.1% | 43.0% | |
| Number of comorbid diagnoses | 2.5 (1.9) | 2.1 (1.6) | |
| Patient Resources | Social support: 4- point scale (higher = less support) | 1.7 (.9) | 1.9 (1.1) |
| Problems financing treatment: 3-point scale (higher = greater problems) | 1.6 (.8) | 1.5 (.6) | |
| Existing coping skills: 2-point scale (higher = worse skills) | 1.8 (.4) | 1.6 (.5) | |
| Desire to cope: 5- point scale (higher = lower desire) | 3.1 (.9) | 2.6 (1.1) | |
| Stress level: 1–100 scale (higher = more stress) | 49.8 (26.1) | 49.7 (24.9) |
Dental Needs
At intake, the fearful patients had between 0 and 24 carious teeth, with a mean of 3.8 (SD = 4.4). The patients who received IV sedation had on average about 3.3 more carious teeth than did those who did not; this difference was statistically significant (Mann Whitney = 13064.000, p < .001).
Dental Attendance Patterns
On average, the patients had not seen a dentist for 4.7 years (SD = 6.7; range = 0– 40). The patients who received IV sedation had been avoidant for about 5 months longer, compared with those who did not receive IV sedation (5.0 years vs. 4.6 years), but this difference was not significant. There were also no significant differences for the two items from the DFS which assess putting off or canceling appointments. Similarly, there were no significant differences on the psychologist’s rating of the patient’s likelihood of canceling or not showing up.
Dental Cognitions
The patients’ mean score on the DFS was 74.0 (SD = 16.7, range = 22–100). Nearly all (96.1%) had scores higher than 37, which delineates highly fearful patients13. Group comparison indicated that the patients who received IV sedation had significantly higher scores on the DFS, compared with the patients who did not (Mann Whitney = 13674.000, p = .035). Overall, the mean score on the R-DBS was 80.6 (SD = 25, range = 28–140). The patients who received IV sedation had significantly higher R-DBS scores than the patients who did not have IV sedation (t = 2.118, df = 398, p = .035). There were no significant differences on the measure of desire for control.
Psychiatric Diagnoses
The data for lifetime prevalences for the four psychiatric diagnoses revealed that 31.3% of the patients had panic disorder at some point in their lives, 33.7% had generalized anxiety disorder, 40.7% had one or more additional specific phobias, and 44.7% had major depression. Among the four psychiatric disorders, patients who received IV sedation were significantly more likely to have panic disorder and/or generalized anxiety disorder (chi square for panic disorder = 5.326, df = 1, p = .021; chi square for generalized anxiety disorder = 4.713, df = 1, p = .030). There was no significant difference for having another specific phobia, nor was there a difference for major depression. The mean number of additional diagnoses seen in the patients as a whole was 2.1 (SD = 1.7, range = 0–9) out of a possible 11. There was a trend for patients who received IV sedation to have more diagnoses, compared with the patients who did not receive IV sedation (Mann Whitney = 19290.500, p = .067).
Patient Resources
There were no significant differences between the two groups of patients on social support. There was a trend for the patients who received IV sedation to have greater problems financing dental and/or psychological treatment (Mann Whitney = 14123.000, p = .087). The patients who received IV sedation were rated as having significantly worse existing coping skills than the patients who did not receive IV sedation (chi square = 10.331, df = 2, p = .006). They were also rated as having significantly lower desire to cope in the dental situation than the patients who did not receive IV sedation (t = 4.547, df = 170.444, p < .001). Self-reported stress levels were the same for patients in both groups, at approximately 50 out of 100 for each group.
The seven variables which were significantly different for patients who had or had not received IV sedation (D, DFS sum, R-DBS sum, panic disorder diagnosis, generalized anxiety disorder diagnosis, existing coping skills, and desire to cope) were entered into a logistic regression to predict receiving IV sedation or not. The initial model is shown in Table 2. The overall model was significant (Chi square = 24.36, df = 7, p = .001.) When the seven variables are considered simultaneously, more carious teeth and a lower desire to cope each contributed uniquely at significant levels ( p = .002 and p = .006, respectively).
Table 2.
Initial Logistic Regression Predicting Receiving IV Sedation in a Sample of Dentally-Fearful Patients Seen in Seattle, USA between 1992–2009
| Predictor | Odds Ratio | Standard Error | z | Probability | Lower 95% CI | Upper 95% CI |
|---|---|---|---|---|---|---|
| D | 1.130 | .045 | 3.07 | .002 | 1.045 | 1.221 |
| DFS | .986 | .014 | −.95 | .340 | .959 | 1.015 |
| R-DBS | 1.008 | .010 | .85 | .396 | .989 | 1.027 |
| Panic disorder | .546 | .232 | −1.43 | .154 | .238 | 1.254 |
| Generalized anxiety disorder | 1.665 | .719 | 1.18 | .238 | .715 | 3.800 |
| Existing coping skills | .980 | .471 | −0.04 | .966 | .382 | 2.513 |
| Desire to cope | 1.905 | .449 | 2.73 | .006 | 1.120 | 3.023 |
Further testing revealed that there was a significant interaction between D and desire to cope, but not between D or desire to cope and any of the other six variables. Therefore, a second logistic regression was carried out which included the initial seven variables and the interaction term. Table 3 presents the results of this analysis. The revised model was significant (Chi square = 25.36, df = 8, p < .002). In the revised model, only desire to cope remains significant (p = .007), while D drops to a trend for significance (p = .089). The results indicate that, when these variables are considered simultaneously, for each unit of being rated as less desirous of coping in the dental situation, a patient was 2.3 times more likely to receive IV sedation.
Table 3.
Final Logistic Regression Predicting Receiving IV Sedation in a Sample of Dentally-Fearful Patients Seen in Seattle, USA between 1992–2009
| Predictor | Odds Ratio | Standard Error | z | Probability | Lower 95% CI | Upper 95% CI |
|---|---|---|---|---|---|---|
| Interaction: D and Desire to cope | .947 | .050 | −1.03 | .302 | .855 | 1.050 |
| D | 1.341 | .231 | 1.70 | .089 | .957 | 1.879 |
| DFS | .986 | .014 | −.94 | .345 | .959 | 1.015 |
| R-DBS | 1.007 | .010 | .76 | .447 | .989 | 1.026 |
| Panic disorder | .528 | .225 | −1.50 | .133 | .229 | 1.215 |
| Generalized anxiety disorder | 1.764 | .769 | 1.30 | .193 | .751 | 4.146 |
| Existing coping skills | 1.001 | .486 | .00 | .998 | .386 | 2.594 |
| Desire to cope | 2.317 | .725 | 2.69 | .007 | 1.255 | 4.279 |
Discussion
Boyle et al.4 found that high dental fear was the strongest predictor related to whether patients in London were referred for sedation or to a regular dental clinic. This is consistent with Hunt et al.’s1 finding that northern Irish dentists rated dental anxiety as the most important factor in choosing sedation for a patient. Our USA data set allowed us to look at treatment modality in greater detail: given that all of the patients were fearful, what differentiated those who received IV sedation from those who did not?
The results of the univariate analyses indicate that variables from four of the five sets of factors predicted which fearful patients received IV sedation. In particular, higher dental needs (measured by D at intake), greater dental fear, more negative beliefs about dentists, lifetime diagnoses of panic and/or generalized anxiety disorder, poorer coping skills, and lowered desire to cope were each predictive of IV sedation. There were also trends for higher numbers of comorbid psychiatric diagnoses and fewer financial resources to predict receiving IV sedation. The only category which did not predict receiving IV sedation was dental attendance, whether this was measured by length of avoidance, self-reports of putting off or canceling/becoming a “no show” due to dental fear, or the psychologist’s rating that the patient was likely to present future problems with canceling or not showing up for appointments.
The mean DFS sum in Boyle et al.’s4 sample of patients referred for sedation was 69.8 (SD = 18.9, range = 20–97), with 62% scoring over 37. In the current sample, the mean DFS sum was 74.0 (SD = 16.7, range = 22–100), with 96.1% scoring over 37. Clearly, the DFRC patients had high levels of dental fear. Thus, were the dentists from Hunt et al.’s1 study to consider the DFRC patients, presumably they would refer them for sedation. Furthermore, given the overall high level of dental fear seen in this sample, it would not have been surprising to find no significant difference in fear level between those who received IV sedation and those who did not. The fact that fear level was significantly different provides additional evidence for the importance of this variable in making decisions about IV sedation.
However, when considered jointly with the other variables which also predicted IV sedation in the univariate analyses, dental fear was not a significant factor in the regression analyses. In the final model, desire to cope was the only variable offering unique predictive ability, followed by a trend for the number of carious teeth.
The literature indicates that many dentally-fearful patients have other psychiatric diagnoses, as discussed above. The DFRC patients also showed high lifetime comorbidities for four other diagnoses. It is common for patients with one anxiety diagnosis (such as phobia) to have additional anxiety diagnoses (such as additional phobias, panic disorder, and/or generalized anxiety disorder); similarly, as major depression is a common disorder (occurring in up to 25% of females during their lifetimes, and perhaps 12% of males), it is also common for patients with anxiety disorders to also have major depression6. Indeed, an earlier study of 73 DFRC patients which included assessments of more psychiatric diagnoses than covered in this study found that 69% of the fearful patients had at least one other lifetime psychiatric diagnosis7.
Given that there is some evidence that higher levels of psychiatric dysfunction bode ill for psychotherapeutic treatment12, it may seem counterintuitive that, in this sample, IV sedation was not used with all patients with additional psychiatric diagnoses, according to the univariate analyses, and that comorbid diagnosis did not predict IV sedation in the multivariate analyses. Rather, low desire to cope with the dental situation was the only uniquely significant predictor for IV sedation. Desire to cope with a stressful situation is recognized as a positive indication for successful psychotherapy12, 15. Desire to cope entails motivation to change oneself to be better equipped to handle the stressful situation, a belief that one can in fact cope better, and a belief that one would be better off with better coping skills. Some medical situations (such as appendectomy) may be “one time only”, where it may not matter much that the procedure is carried out under sedation. However, inasmuch as optimal dental health entails repeated regular dental appointments, we believe that there is value in helping patients learn to cope with stressful dental stimuli so that they can undergo appointments without having to be sedated.
In this study, we were able to examine the charts of all fearful patients who presented for care at DFRC during the period of the study (late 1992 – spring, 2009). However, it is important to recognize potential weaknesses of the study. First, the data are based on patients who chose to attend one dental clinic (DFRC) in the US, and therefore may not be representative of patients attending other clinics. Second, since the data are from patients who chose to seek dental care at a clinic, they may not be representative of fearful patients in general, especially those who only seek emergency and/or episodic care. Furthermore, since insurance schemes are likely to vary in different locales, it is possible that the relative weight of patients’ financial resources for psychological and/or sedation costs would be different in other samples of fearful patients. Nevertheless, to our knowledge this is the first study to assess the various predictors of receiving IV sedation simultaneously, in a sample in which both IV sedation and cognitive behavioural options are available.
Conclusion
Among dentally-fearful patients seen in one US clinic, greater dental needs, higher dental fear, more negative beliefs about dentists, more psychiatric pathology, fewer coping skills, and lower desire to cope were associated with receiving IV sedation. When considered simultaneously, lower desire to cope was the most important predictor for receiving IV sedation.
Acknowledgments
This study was supported by grants TL1RR025016 and K32DE016952 from the National Institutes of Health.
Contributor Information
Trilby Coolidge, Division of Dental Public Health Sciences, Oral Health Sciences, University of Washington, Seattle, WA USA.
Scott P. Irwin, Joint Base Lewis-McChord, Tacoma, WA USA.
Kimberly A. Leyster, School of Dentistry, University of Washington, Seattle, WA USA.
Peter Milgrom, Department of Sedation and Special Care, King’s College Dental Institute, London.
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