Our EliteDOCS® Forum Responds

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

 

Preventing Nausea in Oral Sedation Patients

Nausea can be a side effect of many medications. A nauseous dental patient may be responding to the anesthesia or perhaps the procedure itself, swallowing some of the dental fluids, etc.

 

A member in Olympia, WA asks:

I have been doing OCS from DOCS Education for a little over two years. It has been a great protocol and service for our patients. 

I recently had a consult with a patient who has had OCS multiple times with dentistry and medical procedures. She reports that in half of those appointments, she has felt great afterward and in the other half, she has gotten horrible nausea, vomiting, and sickness.

I have a doctor in my practice who has done OCS for a couple of years longer than me. He has treated this patient two times in our office.

The first time, she was just fine but the second time she got horribly sick. Both protocols were very similar. Triazolam was used, and it was about the same dose that was used in both cases.

My question is, is there a way that I can treat this patient under OCS in a way that I can reduce the chances of her getting sick afterward? Is there anything I can change in the protocol, or add to it (maybe an anti-nausea medication) to help her?

 

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

Dr. Jerome Wellbrock
Dr. Jerome Wellbrock

I would not change a protocol that is working for this patient. You could add the anti-nausea medicine Zofran/Ondansetron. It is available as an oral tablet. I would dose the patient prior to the procedure and following.

 

Be Very Careful. This May Be Fatal

Methadone is a synthetic opioid agonist. It is known—and has been used for 40 years— for its ability to treat moderate-to-severe pain, as well as narcotic drug addiction. As the National Institute on Drug Abuse notes, instead of controlling withdrawal and cravings, methadone treats opioid use disorder by preventing any opioid drug from producing rewarding effects such as euphoria.

 

A member in Hyannis, MA needs advice on treating a patient who has been addicted to opiates for decades:

I need to perform an emergency treatment on a patient. He is 52 years old. He became addicted to opiates after a severe back injury 30 years ago. He has been maintaining his sobriety on methadone (130 mgs every morning). This dosage was recently increased from 120 mgs. He suffers from chronic pain and depression, and smokes 1.5 packs of cigarettes per day.

Vitals are all within normal limits, except for resting O2 sat on room air of 94-95.

He also takes Baclofen (muscle spasms, back pain), Duloxetine (anti-depressant), and Trazodone (sleep). All of his meds have 'C' or 'D' interactions.

I was planning on using Triazolam with incremental dosing. The patient reports agitation when he takes Benadryl, so I was not going to use Hydroxyzine. Unsure if I should give Valium 5 mgs and hold his Trazodone, as he says it doesn't help much anyway, or just have him take his usual dose of Trazodone.

Unsure if I should hold the morning Methadone due to CYP3a4 inhibition. Worried about cravings and dis-inhibition from Triazolam. He receives his methadone through a clinic and has no flexibility on dosage or timing of when he can take it.

I could hold his midday Baclofen dose in the interest of decreasing the amount of CNS depressants on board, however, it is likely to impact our level of sedation due to pain. The patient’s appointment is in the early afternoon; I need to inform him how to proceed with his Methadone that morning.

 

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

Have you consulted with his pain clinic and physician? This has to be first and cannot be skipped, as it may be fatal.

You likely have a hypo-responder, considering his current medications and history. I would expect some respiratory depression, the scale/depth of which is unknown. With the stats he is showing, I would think about that.

Definitely skip the Diazepam if you go an oral route. Consider IV Midazolam, as well, instead of oral sedation.

 

Does This Case Call for Lorazepam or Triazolam?

Both Lorazepam and Triazolam are regulated Benzodiazepines, which work in the central nervous system. They are used for a variety of medical and dental treatments, including anxiety, insomnia, and panic disorder. Among their most common side effects is dizziness.

 

A member in Tustin, CA writes:

I am doing a procedure that will involve six implant placements and a chairside conversion of prosthesis. It may take four hours or slightly longer.

The patient is a very healthy male in his fifties with no significant medical history and only taking vitamins.

I have been using Triazolam successfully for more than 15 years.

I’m considering Lorazepam for this case because of the length of the procedure. I would appreciate your thoughts.

  1. Whether I should stick to Triazolam and just administer more?
  2. If you recommend Lorazepam, what is the protocol for using it?

 

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

Due to the time involved, Lorazepam is a good selection. You could use Triazolam as well. The more invasive part of the treatment, the surgery, would be conducted during the patient’s more sedated moments. By the time you are trying in the prosthetic and making adjustments, you may appreciate the increased alertness.

You can re-dose “low and slow” as needed, keeping in mind not to exceed the Top Dose (the maximum recommended dose or “MRD”).

There are several Lorazepam protocols: single dose, with and without Hydroxyzine, multi-dosing. You may wish to reread your binder from the Advanced Oral Sedation course to see which protocol may be best for you, given your permit level and/or state restrictions.

 

Misinformed

This Patient’s Doctor Appears to be Misinformed

As the DrugBank database explains, Epinephrine (adrenaline) is a hormone and neurotransmitter that has long been used in the treatment of hypersensitivity reactions. It is also commonly used to relieve respiratory distress.

 

A member in Silver Spring, MD, inquires:

I am seeing a 70-year-old patient who has a stent. Concerning the use of Lidocaine and Epinephrine, the physician’s medical clearance says that Epinephrine, “is not appropriate for this patient.”

What anesthetic solution can I use other than Carbocaine (Mepivacaine)?

 

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

I would guess the patient’s physician does not understand the limited use of local anesthetic with a vasoconstrictor.

A patient who has had a stent placed is not necessarily a contradiction to the use of local with vasoconstrictor.

Additional information on this patient would be helpful. Complete Medical History and History of any medical interventions and when they were done.

You should be able to consider the use of local with Epinephrine. If so, then two cartridges of 1:100,000 or four cartridges of 1:200,000. Avoid 1:50,000.

If you should happen to provide dental care without adequate local anesthetic, then the patient could possibly release more endogenous Norepinephrine, which would be more of a concern than using Epinephrine.

Vitals all within normal limits, except for resting O2 sat on room air of 94-95.

Lindsay Olsen
Lindsay Olsen

 

YOUR TURN:

Do you have pharmacology, protocol, practice management, equipment/drug, or regulatory questions you’d like answered? 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 Clinical Program Manager, 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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