My Team Got a Bad Vibe from This New Patient
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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.

 

My Team Got a Bad Vibe from This New Patient

A member in Colorado Springs, CO, describes her office’s experience with a somewhat mysterious new patient who requested sedation dentistry and, when pressed, acknowledged that she had previously taken high doses of opioids and benzodiazepines for pain management, anxiety, and insomnia.

 

According to the dentist:

The 36-year-old woman, “Stephanie” was tiny and declined to have an ID photo taken of her. She arrived wearing large sunglasses and a wig.

Her intake complaint was a possible abscess, as she had a sore on her gums. An examination indicated a healing aphthous ulcer. She had a long history of medical issues, including a hysterectomy at 18 years old due to endometriosis; removal of her diseased thyroid, rheumatoid arthritis, and earlier this year was diagnosed with Sjogren’s syndrome, a disorder of the immune system whose two main symptoms are dry eyes and dry mouth.

Stephanie provided a list of her medications which included treatments for depression, nausea, eczema, allergies, and cold sores, as well as hormones and supplements.

“Stephanie states she is in between doctors and when she saw the name of her most recent Nurse Practitioner at the top of the list [she] crossed it out multiple times stating, ‘Do not call her,’” the dentist writes. “When I asked why, I was told, ‘Just don’t.’”

The dentist wonders, “What is the patient hiding?”

 

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

There are too many Red Flags with this patient. I would definitely be referring this patient out for IV Sedation. You don’t have to treat every patient that comes into your office for dental care or sedation. Trust your staff and your gut instinct.

 

Dr. Anthony Carroccia
Dr. Anthony Carroccia

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

Lots of issues here: I trust the "Spidey" sense/ gut feeling/ women's intuition/ patient radar. A patient who is not completely forthcoming is an unknown that could be trouble. Minimally, a long conversation and dissection of the history are in order with the patient. I might side with the team on this one. It may be better as a surgery center sedation or utilizing a dental anesthesiologist.

 

Original Posting: https://www.docseducation.com/forum/staff-gut-feeling-patient

 

Can Local Anesthetic Interact with the Prostate?

Was it coincidence or is there a possible connection, wonders an Auburn, NY, member between his treatment of a patient with non-cancerous prostate issues and that patient’s need to be catheterized in the ER that evening because he was unable to urinate.

 

Wrote the dentist:

I had an incident with a 47-year-old patient who, aside from some prostate issues (not cancer) is extremely healthy.

I prepared a maxillary tooth for a crown, giving him 36 mg lidocaine with 0.018 mg epinephrine in maxillary infiltration injection.

Later that night, the patient ended up in the emergency room unable to urinate. The patient is concerned that the local anesthetic is what caused the issue.

I never heard of this, but I have learned not to doubt anything before asking the experts. Could there be a connection between the local anesthetic and the inability to urinate, or prostate enlargement?

 

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

I once had a patient who had some extractions and presented two days later to the ER with abdominal pain.

Turns out she needed an appendectomy.

Much like my patient's appendix was a pre-existing condition, so is your patient's prostate. While there is a systemic effect of local anesthesia, the amount you administered would not be enough to do that. And the location is not even close.

If anything, perhaps, the extra water during the crown preparation made him need to urinate more, hence the issue.

Original Posting: https://www.docseducation.com/forum/local-anesthetic-interaction-prostate

 

Preventing Sedation-Related Nausea

A dentist in Pasadena, CA, has a patient who experienced severe nausea during her last sedation treatment. What can he do this time to help her avoid a repeat?

 

Jerome Wellbrock, DMD, MAGD
Jerome Wellbrock, DMD, MAGD

Wrote the dentist:

My patient is a 37-year-old female, approximately 5 feet 6 inches tall, and 120 pounds. On her last visit, following DOCS protocols, I gave the patient 10 mg diazepam the night before; .25 triazolam the morning of, and another .25 triazolam sublingual for oral sedation.

Although she made it through the procedure just fine, she experienced nausea to the point of dry heaving. I would like to know if there is a way to modify the dosage, or a different way of titrating the meds, to deter her nausea?

 

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

I would consider adding hydroxyzine to your protocol. There are other medications for nausea, perhaps the most popular being Ondansetron, which could also be given both pre-op and post-op.

 

Original Posting: https://www.docseducation.com/forum/nausea-during-past-proceedures

 

My First Cerebral Palsy Patient

A general dentist in Virginia has treated patients with special needs previously, for cleaning or for sealants. This 31-year-old male cerebral palsy patient will need six teeth restored with composites. She’s looking for input on the correct protocol.

 

Wrote the dentist:

The patient weighs 145 pounds, is 5 feet 4 inches tall, with a BP 123/76. SpO2 is 98. His last medical exam was in August 2018, within normal limits.

During the consultation, the patient sat on the chair the whole time, about 45 minutes, playing with the air-water syringe. He opened his mouth with a little resistant tongue and rigid cheeks, for seconds.

He’s taking Paxil 20 mg/day and Lipitor 40 mg/day. His mother brought x-rays from another office and said he was sedated with minimal sedation of one pill of diazepam. She wants all of the treatments to be done at once.

My question is how will he be with sedation – hypo/hyper responder? Should I treat him as I would a ‘normal’ patient?

 

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

With taking Paxil, an SSRI, there could be a tolerance making him a hypo responder. He also could be someone who sedates quite nicely and if the aforementioned one diazepam sedated him before, then he could hyper respond. I would advise to go low and slow, keeping in mind the tough tongue and cheeks. You may need more time than you think.

Typically, a patient like this is seen by pediatric dentists, as their training includes the compromised as well as the kids. Unless you have seen a number of special needs patients, I would consider the alternative.

Original Posting: https://www.docseducation.com/forum/cerebral-palsy-patient

 

Lindsay Olsen, our Membership Director
Lindsay Olsen

 

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?

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.

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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