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 three recent posts and responses from the EliteDOCS Forum. The posts and replies are edited for clarity and brevity.

 

This 9-Year-Old Patient Refuses to Sit in the Chair, Or Even Stand on Our Scale

A general dentist in Rochester, NY is struggling to find a way to treat a boy who is completely uncooperative. The child’s pediatrician says she is scared about the concurrent use of medications that the dentist proposes.

Wrote the dentist:

I’m a general dentist in New York State and have taken the pediatric sedation course at DOCS (which I highly recommend). I have a license in the State of New York and am trained in PALS and ACLS.

This nine-year-old boy, weighing 68 lbs, has been a patient since August 2011. I have treated him previously for an occlusal filling #3 and extraction, among other issues.

He returned in February 2018 and refused to be weighed or sit in the chair. I discussed the option of giving him oral sedation with his mother.

His current medications are Guanfacine and Zoloft.

I had sent a letter to the boy’s pediatrician describing the situation, and she responded that I should lower the doses I propose using and further suggested I try nitrous only. She also stated that the concurrent use of the medications I am proposing to use in the office frankly scares her.

I did use Lexicomp and what I proposed are considered C interactions.

Could you offer me an opinion on this case?

Roger Sanger, DDS, MS, DOCS Education’s Lead Instructor for Pediatric Sedation, responds:

Dr. Roger Sanger
Dr. Roger Sanger

You have a 9-year-old with what appears to be ADHD and other mental illness symptoms. The patient is 68 pounds, and in my opinion can be a danger to you, your staff, and himself physically. These are the most difficult patients to treat, even for radiographs, cleanings, and simple restorative work.

As the patient gets older, he will become even more of a danger as his physical reaction could cause serious bodily injury.

Although the meds you describe are within the limits of safe oral conscious sedation, I would not sedate this child with OCS but only in a surgicenter or hospital facility with intravenous sedation.

Could this be done in your office? No, not in my opinion, as it would require a team approach and a solo anesthesiologist. Without physical assistance, it still might be unsuccessful.

Don’t let parental pressure to treat this kid in your office under OCS place you in danger of physical confrontation and injury. It has happened and will happen when you least expect it.

 

With an Untreated Blood Pressure Reading of 172/113, is it Advisable to Treat This Patient?

A general dentist in Sherwood, AR has a patient with high blood pressure who is otherwise healthy. The patient needs endo, crown and bridge, and fillings.

Wrote the dentist:

His most recent blood pressure while in our office was 172/113. This was similar to numbers we recorded on his first visit. He saw his primary care physician recently and was advised to have additional treatment for his blood pressure, meds, but refused that because of an inherent distrust of physicians and a very strong belief that treatment is unnecessary because he routinely performs hard physical labor without any symptoms. Is it in any way advisable to treat this patient?

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

NO! With the stress of dentistry and the administration of both the sedation drugs and local anesthesia, this patient is at a higher risk for a cardiac event or cerebral event. Absolutely refuse!

 

Treating a 14-Year-Old with Lorazepam

Lorazepam

On referral from an orthodontist, a DOCS Education member in Fresno, CA will see a 14-year-old male for mucogingival surgery. The dentist wants to know the right oral sedation protocol for the teen.

Wrote the dentist:

The patient is 5'7", weighs 108 lbs, takes no medications and has no allergies or significant medical history. He is a Mallampatti Class 4. I plan to have him come to the office NPO on the day of surgery and will give him 1.0 mg of lorazepam upon arrival. I will reevaluate him 30 minutes later. My question is: What is the maximum dose of lorazepam for a 14-year-old of his stature?

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

You would use the TOP Dose calculation for this patient, the same as any patient. The patient’s weight divided by 25 (the quotient factor for lorazepam). You are going to round down.

So 108 divided 25 is 4.32 and I would round down to 4.0 mg of lorazepam. I would be concerned about the Mallampatti Class 4, since airway is always our greatest concern. I recommend using an incremental protocol. You can dose diazepam the night before and I would go low here. Dose lorazepam in the office; dose low and go slow, while constantly evaluating this patient.

As a reminder, you should always calculate TOP Dose for every patient you sedate with triazolam and or lorazepam.

 

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.

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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 106 Lenora Street, Seattle, WA 98121. Please print a copy of this posting and include it with your question or request.
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