By Jerome P. Wellbrock, DMD, MAGD
Choosing whether to sedate a patient with multiple medical conditions and medications is one of the most challenging decisions as a sedation dentist. Recently, I encountered a patient who fits this description. So let's take a closer look and explore how to decide whether or not to sedate with the patient's best interests in mind.
First, look at the patient's medical history of past and current health issues. Then look at the medications the patient may be taking and decide if and how to sedate this patient.
Regarding sedation, I will only look at the medical conditions and medications and not the details of this particular individual in terms of physical exams, particularly if the patient suffers from anxiety disorders with stress-induced panic attacks, major depressive disorder, hypoglycemia, hypothyroid disorder, and alopecia.
These current medications for these conditions include:
- Armour 60mg qd for hypothyroidism
- Klonopin-Clonazepam 0.25 mg PRN (a benzodiazepine) for anxiety
- Lexapro-Escitalopram 20mg, an SSRI (Selective Serotonin Reuptake Inhibitor) for depression
- Atarax-Hydroxyzine 25mg tid, H1-antihistamine for anxiety/depression
- Zofran-Ondansetron 4mg, a Serotonin 5-HT3 antagonist, antiemetic
- Marijuana (Cannabinoid) daily
Medications considered for sedation include Diazepam, Lorazepam, and Hydroxyzine.
Analyzing Drug Interactions
The best place to begin is to analyze drug interaction with a program like "Lexicomp" or another. Doing so will give us a listing of all the drug interactions for the patients and the suggested sedation medications. We will arrive with an extensive list of interactions in the D, C, and B categories. Our concern here is not just a particular interaction but also the number of interactions in any of these categories.
The following interactions increase CNS depression:
- Atarax-Hydroxyzine "D" interactions, with Klonopin, Lorazepam, Diazepam.
- Klonopin-Clonazepam, "C" interactions with Lorazepam, Diazepam.
- Lorazepam and Diazepam, “C” interaction.
- Lexapro-Escitalopram, "B" interactions with Hydroxyzine, a CNS depressant effect. Also an intermediate risk of prolonging QT segments.
- Lexapro-Hydroxyzine has a CNS depressant effect.
- Lexapro "B" interactions with Klonopin, Diazepam, and Lorazepam.
- The risk of QT prolongation associated with Hydroxyzine, Zofran, and Lexapro is moderate.
Lastly, we need to consider daily marijuana use. Cannabinoid of any service is considered CNS depressant and may deepen the effect of the sedation.
I need to address hypoglycemia. Any patient who experiences hypoglycemic events, whether diabetic or not, needs careful monitoring before and during the sedation appointment. The blood sugar should be checked before beginning the appointment and on the hour (every hour) after that.
The appointment should be less than 3 hours if glycemic control is difficult. You should have on hand a sugar supplement to elevate blood sugar if necessary. If you are doing oral sedation, it should be a sugary drink ( Coke, Orange Juice, etc.) If you are doing IV Sedation, you can add dextrose, etc., to your IV solution.
We tend not to take our patients off of their prescribed medications, but on occasion, it may be necessary to modify what they are taking or what we are planning to use for our sedation.
My recommendation is first to have a medical consultation with the patient's primary care provider and other current health care providers. Talk to them about possible upcoming sedation and get their assessment of the patient in terms of sedation.
While a PCP may say they don't see any problem with sedation, remember that you are the doctor providing both sedation and dental care.
You will ultimately be responsible for not just the sedation and dental care but for the overall safety and success of the patient.
“Always remember: Know your patient, know your patient, and know your patient. And again, dose low and go slow.” - Jerome P. Wellbrock, DMD, MAGD
Author: Jerome P. Wellbrock, DMD, MAGD, is a University of Louisville School of Dentistry graduate. After 39 years in private practice at Northern Kentucky Dental Medicine, PLLC, Dr. Wellbrock has joined Cincinnati Dental Services in Edgewood, Kentucky. He works three days a week, which affords him more time with DOCS Education and, of course, more time with family.
He has been a member of the AGD and ADA for over 30 years and has held positions as president at the Northern Kentucky Dental Society and LD. Pankey Study Club of Kentucky. Dr. Wellbrock is also a past vice president of the Kentucky Dental Association.