The 47-year-old woman takes several medications every day, including Percocet™ and OxyContin™ for chronic back problems. The patient has asked to receive oral sedation because of previous poor experiences in the dental chair. Her dentist is concerned about hyporesponse. Should the woman forgo her regular doses of narcotics in hopes of obtaining a more comfortable appointment?
A member of DOCS Education writes:
My patient requires sedation for operative procedures. She’s 47 and suffering from high anxiety due to a previous poor experience. She has also been diagnosed with Type II diabetes and hypertension, but both of these conditions are well-controlled.
The woman takes Percocet™ and OxyContin™ daily because of back problems. I know opioids can deepen the level of sedation. Is she less likely to over-sedate on account of the regular use? Do you advise special precautions, and if so, which ones?
Dr. Jerome Wellbrock, DOCS Education faculty, responds:
Not only does this present a difficult situation it is hard to predict how this patient will respond to your sedation. Due to her daily use of narcotic medications the woman may well hyporespond and require more drugs to adequately sedate.
Since she is also taking medications that are CNS depressants you should be careful not to over-sedate. This patient should be told to consider the first appointment a test sedation visit; you need to dose low and go slow. Accomplish this with oral sedation. However, IV sedation is easier for these purposes because you can titrate the least amount of sedation you need. Make sure reversal agents are on hand for both benzodiazepines and narcotics.
A member of DOCS Education responds:
Thanks. I am not IV-certified. I also practice in Ohio, where only single-dose protocols are allowed. If I am able to convince her to stop taking the narcotics the day prior to the appointment would that offer a wider margin of safety?
Dr. Anthony Feck, Dean of DOCS Education faculty, responds:
Removing your patient from the opioids she routinely takes will likely make things much worse. Not only will your patient now experience pain, she will suffer from withdrawal, as well. This will guarantee failure. I continue to seek reasons to take patients off medications they use to control medical conditions for purposes of oral sedation. I have yet to find a good one.
