A DOCS Education member writes:
Last week I had a 21-year-old patient with an unremarkable medical history. However, the woman did report experiencing a very traumatic dental visit when she was only 12. She said she believes this encounter produced a state of dental phobia, and this sense of anxiety and fear remains with her today. The patient also indicated she received triazolam in the past for the placement of stainless steel crowns. The treatment required two fillings, two crowns and two impacted wisdom-teeth extractions.
Because of the woman’s appearance and her behavior, the possibility of ADHD was suspected (suggesting ASA I-II). But the patient denied ever receiving this diagnosis.
During the sedation consultation the patient demonstrated extreme agitation. She cried when she talked about the appointment. She last saw a medical doctor a year ago, and this physician indicated no concerns at that time.
The woman takes Ortho Tri-Cyclenâ„¢ for birth control and sometimes Aleveâ„¢. She occasionally consumes grapefruit juice. She eats four meals daily with one snack in between.
Her blood pressure reading was 138/83 (normally it is 110/70).
The patient reviewed forms and signed consent materials. Medications were dispensed as follows: 10 mg diazepine the night before and .25 mg triazolam on the day of the appointment. The top dose for this patient is 6.5 at .25 mg triazolam, so 1.625 mg triazolam.
The entire treatment was completed, and that was gratifying. Unfortunately the patient was slow to sedate. Work did not commence for 1.5 hours. Because the woman reported feeling nauseous we gave her hydroxyzine at the beginning of the appointment. Oxygen was delivered the entire time via nasal canula.
The patient vacillated between very sedated to somewhat alert during the entire appointment. As a result it took almost four hours to complete what should have been done in less than two hours. The woman also recidivated between bouts of hyperactivity and nausea. She complained that she was going to throw up. She vomited a number of times and initially expelled some solids. She repeatedly denied she had eaten anything.
Extraction of the wisdom teeth was left until last. We considered aborting this but the woman insisted she wanted the teeth removed. Extraction of the second and final tooth resulted in a high degree of emotion for her (and in all candor, for us). I resisted using the last 0.25 mg triazolam because the patient’s bouts of deeper sedation concerned me.
At the end of the 4-hour appointment, immediately following the period of high emotion, the woman entered another deeper sedation presentation. She was responsive but only barely so. I decided to reverse her with a sublingual injection of flumazenil 0.2 mg. After the injection she immediately began crying. Now she was more alert but once again she became more sedated, and once again she complained of nausea.
I next delivered glucose gel, which she fought because she was concerned about hypoglycemia.
It took another hour before we could safely dismiss her.
We did deliver 7.5 carpules of articaine over the course of the four hours.
I called the patient that night and she indicated was doing better. We prescribed gravol liquid, which appeared to be helpful.
The patient arrived at the office the following Monday and brought us flowers because she was so happy. She admitted that she had eaten two crackers before the appointment. My question is, could we have done better? While I think we made a positive impact the sedation was both tough and draining. I appreciate your response and suggestions.
Dr. Anthony Feck, Dean of DOCS Education Faculty responds:
Congratulations on a successful sedation appointment. You did a very beneficial thing for your patient, and she had a good experience, or you wouldn't have gotten flowers.
As far as how it could have been a better experience for you and your team, you don't indicate your dosing schedule before and during the appointment. Based on what you do reveal, you did everything appropriately.
Not all sedations proceed smoothly and without stress for the sedation team. Patients who have deep-seated psychological issues are likely to hyporespond to medication and hyperreact to any perceived threat (remember they are still conscious). The only way to completely eliminate this is through deep sedation or general anesthesia.
Take solace in the fact you met the most important definitions of sedation success: your patient got the dentistry done, was safe, and perceives you as great. Also recognize that while these difficult sedations happen to everyone, they are few and far between.
