One of the many privileges of DOCS Education membership is access to our EliteDOCS® Forum, an exclusive 24/7 online community where there are always fellow dentists and faculty members happy to respond to requests for advice and support.

What follows are some recent posts and responses from the EliteDOCS® Forum. The posts and replies are edited for clarity and brevity.

 

My Patient’s Physician Gave Me a Green Light

A general dentist in North Andover, MA, has a 77-year-old male patient who needs ten simple extractions. In consultation with the patient’s physician, this DOCS Education member learned that her patient has mild COPD without CO2 retention.

The physician gave the dentist a green light to sedate the patient using a short-acting benzodiazepine during multiple brief appointments. The question is, should she?

Wrote the dentist:

I know that COPD is a red flag but does it automatically push my patient from ASA III to ASA IV, since it’s mild and without retention?

If oral conscious sedation is an option, I’m thinking about sticking with a low incremental dose of triazolam only; with no diazepam the night before because it is long-acting, and no hydroxyzine because of the risk of drying out his airway and causing bronchospasm.

In reading here on EliteDOCS and reviewing my DOCS course notes, it seems that COPD is a relative (not absolute) contraindication. Would it be okay to use 30% N20 since he has no CO2 retention?

I’m also confused about nitrous.

Dr. Anthony Carroccia, of St. Bethlehem Dental Care in Clarksville, TN, a long-time DOCS Education member, Diplomate, and EliteDOCS administrator responds:

Mild COPD is still COPD; prolapse is still prolapse regardless of regurgitation; pregnancy is still pregnancy regardless of complications.

Dr. Anthony S. Feck, Dean of Faculty for DOCS Education, responds:

DOCS does not recommend ever treating a patient with COPD using oral conscious sedation in an outpatient dental setting. The fact that your patient is also 77 years old is another red flag. You can, however, use nitrous oxide titrating appropriately – and local anesthesia – while monitoring the patient carefully. Nitrous oxide is not a contraindication

The Massachusetts dentist followed Dr. Feck’s recommendation, posting this reply:

I will stick to nitrous only. Thank you.

Original Posting: https://www.docseducation.com/forum/ocs-or-refer-77yo-male-emphysema-and-mild-copd

 

To Gas or Not to Gas?

Nitrous Oxide

A general dentist in Loomis, CA, writes:

I just attended the DOCS Education San Francisco seminar (February 2018) and would like to get started. I do not have nitrous oxide in my practice. I know it can be beneficial at the time of anesthetic delivery and to extend a session if the medication is wearing off. How necessary is it to use nitrous oxide to be an effective sedation dentist? Do many dentists practice sedation without it?

Dr. Anthony Carroccia, of St. Bethlehem Dental Care in Clarksville, TN, a long-time DOCS Education member, Diplomate, and EliteDOCS administrator responds:

Nitrous oxide and oxygen are not necessary for all sedation cases. In some instances, nitrous oxide alone can be a sufficient sedative.

The American Dental Association states, “[n]itrous oxide/oxygen, when used in combination with sedative agent(s) may produce minimal, moderate, deep sedation, or general anesthesia.”

This drug is one that can allow a dentist to give a lower dose of sedatives or other drugs and keep your sedation treatments safer.

To answer your question, you will be a more effective sedation dentist having the ability to use another modality that allows for true titration. Most dentists have nitrous oxide but may or may not use it, as each case is different.

Original Posting: https://www.docseducation.com/forum/nitrous-oxide-1

 

Triazolam for Teens Under 18 Years Old?

Teen patient - stock photo
Stock Photo

A general dentist in Newport News, VA, writes:

I’m getting ready to do a consult with a 16-year-old female and her parent. The teen requires composite restorations in all four quadrants.

The length of the appointment will be approximately 2 ½ to 3 hours. The patient isn’t on any medications and has no medical conditions. All vitals are good. The patient, who is slightly heavy but certainly not obese, wants to be sedated.

I have done hundreds of sedations on adults, but 18 has been the youngest. I would like to use a standard single dose of triazolam 0.5mg with hydroxyzine 25 mg.

Will this dose of triazolam be okay or would you cut the dose?

DOCS Education Faculty Member, Jerome Wellbrock, DMD, MAGD, responds:

Legally, triazolam is not approved for any patient under 18 years of age. You need to use a lorazepam protocol. You can use diazepam the night before.

Make sure you calculate Top Dose for the lorazepam before the appointment even though you most likely will not reach it.

Original Posting: https://www.docseducation.com/forum/sedation-16-year-old-female

 

YOUR TURN:

Do you have pharmacology, protocol, practice management, equipment/drug, or regulatory questions you’d like answered? Likewise, would you like to lend your voice and experience to help fellow dentists from around the country?

Membership Director, Lindsay Olsen
Membership Director, Lindsay Olsen

EliteDOCS forum members are connected to one another – and to our faculty – 24/7. There are always friendly and knowledgeable fellow dentists online who are happy to respond to requests for advice and support.

To join our DOCS Education community of professionals serving at the forefront of dentistry, and receive all of the privileges to which membership entitles you – including access to EliteDOCS – visit us online here, or contact Lindsay Olsen, our Membership Director, at 206-812-7712.

Subtitle
Just as Pregnant is Pregnant, COPD is Still COPD, No Matter How Mild
The information contained in this, or any case study post in Incisor, should never be considered a proper replacement for necessary training and/or education regarding adult oral conscious sedation. Regulations regarding sedation vary by state. This is an educational and informational piece. DOCS Education accepts no liability whatsoever for any damages resulting from any direct or indirect recipient's use of or failure to use any of the information contained herein. DOCS Education would be happy to answer any questions or concerns mailed to us at 3250 Airport Way S, Suite 701 | Seattle, WA 98134. Please print a copy of this posting and include it with your question or request.
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