If there’s something strange, in your neighborhood (dental practice), who you gonna call? EliteDOCS!
Over the years, thousands of the nation’s most well-respected sedation dentists have shown that they ain’t afraid of the unknown. When they have a question about how to treat a patient who presents with an unusual medical or dental history, they turn to EliteDOCS for friendly, timely, and knowledgeable advice and support.
The complete EliteDOCS archives contain thousands of questions and responses divided among a dozen categories, including Pharmacology, Protocols and Case Studies, Patient Management, Regulations and Dental Board Meetings, Medical Emergencies, and even – for those times when dentists could use a good laugh after a long day – a Jokes category.
To ask a sedation-related question, send your email to [email protected]. Forum administrators and faculty will make every effort to respond in a timely fashion to your queries. Nonetheless, please allow up to 10 business days for a response.
(Note, the answers you’ll receive – like all the information contained on the EliteDOCS forum – should never be considered a proper replacement for necessary training and/or education regarding adult and pediatric oral conscious sedation. EliteDOCS is an educational and informational resource only. See the site and posts for additional disclaimers.)
What follows is a sampling of some of the posts and responses featured on EliteDOCS as selected by the forum’s administrators. See if you knew the answers or agree with them.
EliteDOCS Case Studies
- This 23-Year-Old Female Takes a ‘Cocktail’ of Medications
- What to Prescribe a Patient Who Has a Fear of Flying?
- Head Trauma and Sleep Apnea Combined
- A 67-Year-Old ‘Rule of 4’ Female
- A Diabetic Patient Requiring Three Hours of Treatment
- Your Patient is Going to Be a Hyporesponder
- This Patient Can’t Take Valium. Can We Substitute Lorazepam?
- This Patient Takes a ‘Laundry List’ of Meds
- Important Notice
This 23-Year-Old Female Takes a ‘Cocktail’ of Medications
Question: I have a new patient who sought out my care after her mom had a very positive experience with the sedation protocol. This patient is, however, much more complex.
She presents with a mental health history of anxiety, depression, mood dysregulation, and agoraphobia. This is a 23-year-old white female with a BMI of 23. She is 5'3" and 130lbs. She is otherwise healthy aside from her mental health issues. She has no known drug allergies. Her only other previous surgery was cholecystectomy. She is a non-smoker.
We had a very good conversation in the office as I was the first dentist in a while to not automatically dismiss her. I am concerned with the amount of regular medication she takes, and if an enteral conscious sedation protocol is even appropriate for her. Her current meds are:
- Ativan® 0.5 mg bid
- Effexor® XR 150 mg qd
- Gabapentin 300 mg bid
- Seroquel® 100 mg bedtime
- Wellbutrin® XL 300 mg qd
Although I have been providing enteral conscious sedation for a long time, this case concerns me with the multiple benzodiazepines and CNS depressants. Would it be worth a try with just nitrous oxide?
Reply: Patients on multiple CNS depressants present some of the greatest challenges to the success of oral conscious sedation. As a result of tolerance to CNS depressants, these patients hyporespond, taking longer and requiring higher doses to sedate.
Occasionally, these patients reach TOP Dose before they become comfortable, requiring another method of sedation, such as by IV.
You may choose to attempt sedation on this patient after a frank discussion regarding the possibility she may need another method of sedation. Reassure her that if she isn’t comfortable, the appointment will not proceed.
Original Posting: - https://www.docseducation.com/blog/sedation-patient-taking-multiple-c-and-d-interaction-medications
What to Prescribe a Patient Who Has a Fear of Flying?
Question: I have a 25-year-old patient of record. He has no significant medical history and is on no medications. His most recent physical was within the last 12 months.
He called and asked if I could prescribe him "something to relax him and take the edge off." He lives about 30 minutes from the airport and will be driving himself. The flight takes about two hours.
My thought is that I can prescribe him Zaleplon since it is short-acting and the sedative effects should have worn off by the time he lands if he takes it about 45 minutes to an hour before his flight.
I would love this group's feedback on what medication would accomplish his goal of "taking the edge off" and also would be out of his system quickly, with no after effects.
Reply #1: I would not do this. You have no dental reason why you are prescribing this medication. I understand wanting to help, and your familiarity with this patient, but where is the line? Protect your license and yourself by not doing anything.
Faculty Member Reply: I strongly agree. It is not within the scope of dental practice to prescribe anything for anyone who does not have a documented dental diagnosis. You would be risking your career and dental license if there would be any adverse outcome, no matter how insignificant. In short, this is illegal. Don't do it.
Head Trauma and Sleep Apnea Combined
Question: My patient is a 44-year-old male with a history of head trauma and a deviated septum. As a result of the head trauma, he suffers severe daily migraines and is taking the following medications:
- Gabapentin 400mg - 2/day
- Butterbur 75mg - 2/day
- Motrin - 1600 to 4800 / day as needed
- Immitrex® injection as needed
As a result of his sinus problems, which is caused by a deviated septum, he suffers from sleep apnea and is using a CPAP machine. This patient is normal in weight with an athletic build, and his baseline vitals from the pulse oximeter are: BP 122/65, SPO2 hovering around 96%.
This patient is treatment planned for four fillings, and he has elected to pursue this treatment under conscious sedation due to fear. Gabapentin is a C interaction with diazepam and triazolam, and is already a CNS depressant.
Reply: The gabapentin will aid in the sedative effect of the benzodiazepines, but that is not your biggest concern. The sleep apnea and his preoperative O2 saturation is a significant concern.
You have stated his baseline saturation is 96%. When sedated and reclined, his oxygen saturation will drop significantly since he suffers from sleep apnea. Your goal would be to keep his sedation level very light to prevent any unsafe O2 levels. This might mean limiting him to a single dose protocol with nitrous.
Original Posting - https://www.docseducation.com/blog/sedation-athlete-repeated-head-trauma
A 67-Year-Old ‘Rule of 4’ Female
Question: I have a new patient, and below is my thought process. Please critique, and let me know if you would advise something different.
Please note that this patient has not been seen yet for a proper workup: I only saw the patient for a “free consultation.” As such, baseline vitals are not available.
She is a 67-year-old female of average weight who meets the “Rule of 4” with regards to medications: she is on four. She has general dental anxiety, and requires a difficult extraction of tooth #3. The appointment is expected to be two hours or less.
Buspar (buspirone) 10mg, bid for anxiety
- Used mainly to treat GAD (Generalized Anxiety Disorder)
- Central acting
- Pharmacology is NOT related to benzodiazepines (not a GABA receptor agonist)
- Metabolized mainly by liver, slightly by kidney
Remeron (mirtazapine) 15 mg, qd for anxiety and sleep
- Mechanism is unknown, but believed to enhance central noradrenergic and serotonergic activity
- Potent antagonist of H1 receptors, which may explain sedative effects
Benicar 40mg, qd for hypertension
Ursodiol 500mg bid for autoimmune biliary cirrhosis of the liver (non-alcohol related)
Preliminary Protocol Evaluation:
- Night-before Diazepam: NO! SKIP!!
- Insomnia drug at bedtime (Remeron). Refer to page V–4 of DOCS NYU manual.
- Same page of manual:
- ‘If 2 CNS depressants / day, use 2.5mg diazepam’
- I still say skip the diazepam, due to insomnia drug above.
- Triazolam 0.125mg:
- 1 pill at 7am.
- Arrive at office at 8am. Assess patient. Take vitals. If needed, provide second pill. Let patient sit. Assess. If ready, administer nitrous, administer local anesthetic.
Faculty Reply: I appreciate the thought and homework that went into your inquiry. Well done! My comments:
The ‘Rule of 4’ says that if four or more medications are used to treat the same medical condition, that medical condition is more fragile (more challenging to control, and therefore more likely to become out of control when challenged — e.g. stress).
Buspar's pharmacology is related to that of the benzodiazepines in that they are both CNS depressants. Therefore, the potential exists for both potentiating CNS depression or cross-tolerance. It’s more accurate to say, Buspar's pharmacodynamics are not the same as those of the benzodiazepines.
Since the Remeron is being used as a sleep aid prior to sleep, I would not use diazepam the night before. Even if the patient was not taking the Remeron, I would not use diazepam the night before due to the patient's age.
I agree with your loading dose of triazolam.
Of course you will need a comprehensive evaluation of the patient prior to final consideration of the candidate for sedation. Again, well planned!
Original Posting: - https://www.docseducation.com/blog/sedation-67-year-old-woman-taking-anxiolytic-medication
A Diabetic Patient Requiring Three Hours of Treatment
Question: I have a 62-year-old male diabetic patient who is coming to the office for the pre-sedation workup.
He is taking the following medications:
- Amlodipine benzilate 20mg /day
- Atorvastatin 10mg/day
- Bisoprolol fumarate 1.25 mg 2 tabs/day
- Omeprazole 40mg/day
- Bupropion HCL 150mg
- Metformin 500mg
- Claritin 2 / day
I intend to use incremental protocol 2, with the time of treatment being three hours. The needed treatment is four quadrants of scaling and root planing, two extractions (tooth #31 and #15) with bone graft, and a crown for #19.
Because of his schedule, he cannot arrive at 7:00 am; so he made the treatment appointment for 10:00 am.
Question #1: Can he still take diazepam the night before?
Question #2: Can he have a light breakfast at 7:00 am?
Question #3: I am planning to use 4 carpules of Lidocaine 2% with 1:100,000 epinephrine. In the extraction side, I will probably use 4 carpules of septocaine 4% locally.
Please give me your thoughts or any suggestions!
Faculty Reply: Yes, diazepam the night before is ok. He should take a light non-fatty breakfast since he is diabetic.
Sounds like you have thought through this case and planned it out well!
Original Posting - https://www.docseducation.com/blog/unusual-scheduling-diabetic-patient
Your Patient is Going to Be a Hyporesponder
Question: I have a 41-year-old, 200-lb female patient who is being sedated by a medical anesthesiologist at my periodontist’s office. She will have all of her maxillary teeth extracted and eight implants placed.
I will be there to take impressions, and she will return to my office two days later to have fixed temporary teeth screwed into the implants. I would like to be able to give her local anesthesia, but she is extremely fearful of the dentist.
I am not looking to do conscious sedation, but just want to give her something to take the edge off. I plan to give her nitrous oxide prior to the local anesthesia. Her medical history is extensive.
She has a history of asthma, sarcoidosis, high blood pressure, and psychiatric treatment. She takes Keppra, Zyprexa, Xanex XR, Zoloft, Lamictal, Vivance, and an inhaler. Her psychiatrist suggests that I use 1 mg Xanax (non XR) or 0.25mg triazolam. I wonder if these will be enough and I am interested in your thoughts.
Faculty Reply: There's no way of knowing for sure until you try. But given her level of anxiety and the tolerance that she has developed due to multiple CNS depressants, the level of anxiety control is likely to be minimal with the doses of Xanax or triazolam that you mention. Combining those with nitrous will help, but this patient is going to be a hyporesponder.
The good news is that you will not be doing an invasive procedure, although your patient will need to be numb given her recent surgical procedure. If you want to be more confident of her anxiety control, then I would perform a regular oral conscious sedation.
In addition to the multiple CNS depressants she is taking and the associated tolerance, there is the issue of her psychiatric disorder. If it is schizophrenia, I would not use oral sedatives, but rather use IV sedation titrated to the appropriate level of effectiveness.
Original Posting - https://www.docseducation.com/blog/providing-anxiolysis-overweight-patient-multiple-medications
This Patient Can't Take Valium. Can We Substitute Lorazepam?
Question: We are trying to decide what to give the patient the night before her sedation. The patient states that she cannot take Valium because it makes her sick, but she can take Ativan (lorazepam). What do you suggest the patient take the night before sedation?
Faculty Reply: If the patient truly cannot take diazepam, then I wouldn't have her take anything the night before. Lorazepam is too efficacious, decreasing the safety margin for pre-operative sedation.
Follow-Up Question: What about having the patient take a Lorazepam one hour before her appointment?
Faculty Response: If you can do an incremental protocol, then taking a lorazepam loading dose is part of incremental protocols #3 and #4 (see your course workbook). If the patient can take triazolam, I would use a triazolam incremental protocol, which would be triazolam as the loading dose.
If you cannot do an incremental protocol, then a loading dose before the appointment on the day of the appointment is not allowed.
Original Posting - https://www.docseducation.com/blog/sedation-patient-unable-take-valium
This Patient Takes a 'Laundry List' of Meds
Question: I would like to know if I can use oral conscious sedation on a 62-year-old female patient. She is a nonsmoker. She is also pre-diabetic and not obese. She does have a slight gag reflex.
However, she has a laundry list of meds she is taking for arthritis, asthma, a heart attack in 2000, heart stint 2005, psychiatric issues, heart burn, daily pain meds (for back surgery), constipation, border-line diabetes, and acid reflux.
The long list of medication:
- Breo Ellipta®
- Fleet Enema
Do you feel like we can safely sedate this patient? I know she can come off of Nexium, and put her on Pepsid AC, but I am not sure how to address the class D reactions, with Ambien, Narco, Theophylline.
I understand that she has many medications listed but I feel like this may not be no-go, just because she is on so many medications.
Faculty Reply: This is a patient with multiple drugs for multiple medical issues.
Any time you see a patient on at least four meds for a problem, it is usually an issue that is not well-controlled. An example here is four meds for, I presume, asthma.
Also, she is on multiple CNS depressant meds including sedatives, sleep aids, pain meds, muscle relaxers, anti-depressants, and the list goes on.
It is not just a list of meds that determine if we should sedate a patient or not but also their medical health and status. The majority of the meds do have a "D" interaction with our sedation meds.
I personally would not expect to have a safe and successful sedation with this patient with oral conscious sedation. If she is sedated, it would be better controlled with IV sedation. Even with IV sedation, there are still many issues to overcome.
Remember we do not have to sedate everyone who wants sedation.
Original Posting - https://www.docseducation.com/blog/oral-sedation-not-extremely-ill-patients
The information contained in these EliteDOCS posts should never be considered a proper replacement for necessary training and/or education regarding adult and pediatric oral conscious sedation. This is an educational and informational piece only.
Regulations regarding sedation vary by state.
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EliteDOCS posts and replies in this article are edited for clarity.