A middle-aged patient in excellent health has a strong gag reflex. While the dentist has worked around this problem through extractions, the man is now considering sedation. Given the length of time he’ll spend in the chair—up to five hours—is the best protocol single-dose or incremental?
A member of DOCS Education writes:
I have a question about protocol selection.
The case involves a 47-year-old healthy adult male with an extremely strong gag reflex. After several years of relying upon extractions as a form of treatment because of his gagging fears, we’ve convinced him to try sedation. The man weighs 185 pounds and is extremely fit.
The patient will be in the chair for 4 to 5 hours. The treatment plan includes two posterior crowns—numbers 30 and 14—and several small composites. The crowns will be done digitally using my Cerec system and seated that day. I plan on doing the composites while crown(s) are being milled to minimize the time the patient needs to be sedated.
Where the patient has no gagging fears this case would require significantly less time, probably 3 and 1/2 hours, with most of that spent for milling.
This is an unprecedented length of time for one of my patients to be in the chair. To this point I have only used triazolam and hydroxyzine in an incremental protocol. There have been unplanned times where I have had a patient in the chair longer than I anticipated when doing two crowns. While I've become more expert at managing my time, I misjudged a couple cases early on in my sedation history. Given that the patient has a strong gag reflex, I want to cover all the bases and use the most appropriate protocol.
Could you recommend a protocol for this man? I find it difficult to choose between a single-dose protocol using lorazepam, hydroxyzine and possibly nitrous oxide. I’m inclined to select the higher doses of diazepam 10 mg HS the night before. On the day of the appointment, my experience has shown with severe gaggers that 100 mg hydroxyzine seems to knock out that reflex the best. It then becomes a matter of deciding how much lorazepam is appropriate. In the past when I have gone below the maximum dose I may experience more difficulty in completing this type of case.
My initial thought is to sedate the patient with the following:
10 mg diazepam HS night before appointment
2 mg lorazepam PO one hour before appointment
Assess patient upon his arrival
Be prepared to give 2 mg lorazepam SL after assessment
If you can incrementally dose, then your best bet is incremental protocol #2 (triazolam and hydroxyzine). Triazolam is more efficacious than lorazepam, and given the duration of action and half-life of lorazepam, triazolam also has a higher safety profile than lorazepam. Therefore: 10 mg diazepam HS at bedtime (I assume the patient is taking no other medications) 0.25 mg triazolam loading dose an hour before the appointment Appropriate-sized dose of triazolam and hydroxyzine at initial assessment Appropriate-sized dose of triazolam at reassessment
Dose incrementally to effect and maintain effect using appropriate-sized doses at fitting time intervals. Use nitrous oxide with the appropriate protocol for short intervals during invasive procedures.