A DOCS Education Member writes:
Recently a 26-year-old woman presented to my office for a new patient examination. She reported that she had only one area of anxiety. During her last few dental visits profound anesthesia was not achieved. It's her conviction that "I cannot get numb on my lower jaw."
The woman's mouth is largely in good health. She only needs some resin restoration for caries control. She stated that if nitrous oxide/oxygen sedation was sufficient to achieve numbness she would be fine with that.
The patient's health history includes Hashimoto's disease (hypothyroidism) for which she takes 125 mcg synthroid and polycystic ovarian syndrome for which she takes 500 mg metformin bid. She has no problems outside of these two conditions.
We scheduled restorative work without any sedation. I was confident I could adequately anesthetize her. The regimen was 30 percent nitrous oxide combined with a mandibular block (2 carps 3 percent lidocaine with 1:100,000 epinephrine) and infiltrated number 5 (1 carp 4 percent septocaine with 1:100,000 epinephrine).
Unfortunately, very soon after the woman received this medication, she fainted. My assistant called me back into the room immediately. We found the patient slumped to the side and pale in color. I quickly began speaking to her and shaking her shoulders, and almost immediately she regained consciousness. We placed her on 100 percent nitrous using a nonrebreather mask. Then we evaluated her vitals using our pulse oximeter, and placed a cold compress on her forehead. As soon as she regained consciousness, she asked, "did I have a seizure again?"
After further discussion, the woman described a "history of seizures" with painful injections. I feel that what I witnessed was vasodepressor syncope, not a true seizure. The patient did exhibit some compulsive movements during the syncope, which is likely why it has been described as seizure in the past.
She actually wanted me to continue with the work but I declined. My plan for the future is to use oral conscious sedation with diazepam the night before and 0.25 mg triazolam one hour before (I’ll administer additional doses as needed). I will be sure to keep her in a supine position. My assistant had raised the chair up after infections last visit. I also will advise that she eat a small breakfast to avoid hypoglycemia from the metformin. I also will utilize nitrous and do my best to provide minimal pain during injections.
Is there anything I am missing? Do you see any red flags?
Dr. Leslie Fang, a member of the DOCS Education faculty, responds:
Sounds like another fun day at the office.
I believe that it would be very prudent to inquire about the nature of the seizures. Here are some types:
- Grand mal seizure. These usually occur with tonic clonic activities and last from seconds to minutes. Patient would have loss of consciousness and experience a post-ictal period after the seizure when she would still be pretty confused and fuzzy.
- Petit mal seizure. In this case the seizure involves one part of the brain. It may not be associated with tonic clonic activities. Temporal lobe seizures, in particular, are associated with an "absence spell," where the patient would have transient loss of consciousness.
- Status epilepticus. Considered the most dreaded of all seizures. Prolonged period (exceeding 10 minutes) of tonic clonic seizures with resultant issues of hypoxemia and related injuries. This is a true emergency necessitating prompt transfer to a medical facility.
Regarding this particular patient, her clinical behavior suggests vasovagal syncope, which is usually associated with painful injections or blood draws. Patients typically develop transient hypotension and bradycardia with resultant syncope.They generally come out of these episodes rapidly and spontaneously and require no intervention.
Since the woman volunteered after the fact that she has a history of seizures, I urge you to discover the exact diagnoses for these. Clearly this patient's problems aren't serious as she takes no medications at all. If it proves that no diagnosis of true seizure disorder exists and she in fact has vasovagal syncope, we should be able to sedate her without issues.
Dr. Anthony Feck, Dean of DOCS Education faculty responds:
As Dr. Fang suggests, it would be prudent to inquire whether the patient has been diagnosed with a seizure disorder, and if so, why they are not being medicated for it. What you describe does appear to be either a vasovagal or hypoglycemic response. Was the patient NPO prior to the visit? I like your plan for the next appointment.
DOCS Education Member responds:
Thanks to both of you for this timely feedback. The woman was not NPO at the last visit. Still, at the moment I'm unsure as to what her diet was that morning. She indicated a tendency to get hypoglycemic when failing to eat routine meals. I agree it's prudent to discover whether a definitive seizure diagnosis was ever made, and I plan to do just that. Should that conversation produce further questions, I will post them. Thanks again.
