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 is a recent post and two responses from the EliteDOCS® Forum. The post and replies are edited for clarity and brevity.
A Pot-Smoking Patient Who is Difficult to Sedate
A member, practicing in Kelowna, British Columbia, has a patient who smokes marijuana daily and is difficult to sedate. The patient doesn’t want to try IV sedation. Additionally, the dentist wonders if it’s appropriate to provide her patient a smoke break over the course of a four-hour appointment.
Wrote the dentist:
This is my first time posting. I have been doing okay over the past years but I have this one patient. Any advice would be appreciated.
The patient takes Cymbalta, lamotrigine, Paxil and Synthroid. She weighs 245lbs and smokes a minimum of a pack a day (of cigarettes), and now smokes pot a couple times a day.
Last time we had her in, I followed the protocol: 10 mg diazepam. We maxed out the triazolam according to the patient weight ratio, and I used 100 mg hydroxyzine. I had her smoke before she came in.
It took 1.5 hours for the meds to kick in. She would be okay for a bit and then her eyes would be wide open and she’d say, “I’m not sedated enough.” Ten minutes later she’d be okay.
This would keep happening. Nitrous did nothing. We didn’t get to complete the treatment because she kept ‘waking up.’ It was very stressful and I don’t understand what was going on.
The patient wants to come back, but she doesn’t want to do IV sedation.
Should I have her smoke a joint and a cigarette before her appointment? How often do you take people out for a smoke break over the course of a four-hour appointment?
DOCS Education Faculty Member, Jerome Wellbrock, DMD, MAGD, responds:
I don't think you will have any success with this patient with oral sedation. She would be better managed with IV Sedation. My advice would be either to refer her to someone who does IV in office, or you could possibly have an anesthesiologist or CRNA come to your office to do the sedation while you do the dental procedures.
Dr. Anthony Carroccia, of St. Bethlehem Dental Care in Clarksville, TN, a long-time DOCS Education member, Diplomate, and EliteDOCS administrator also responds:
You have a hypo responder.
She had the maximum dosage of diazepam and triazolam and hydroxyzine. It took longer than usual for it to start to affect her and still it was not significant. If you try it again, you will likely do the same and max out the meds and probably have the same result.
I know she doesn't want to do IV, but it may be a better approach considering you had nothing left to give. You may even wish to consider a surgery center for deep sedation/general anesthesia.
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?
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