A DOCS Education member writes:
My 57-year-old female patient desires sedation for the following treatment: eight extractions, two quads of SCRP and four fillings. Among the medications she already takes are Altace,â„¢ Estradiol,â„¢ Lortab,â„¢ Serzone,â„¢ Nexium,â„¢ Trazodoneâ„¢ and Xanax.â„¢ Her supplements include folic acid, calcium, vitamins D and B12.
The woman's medical history is positive for fibromyalgia, degenerative arthritis and anorexia nervosa. In 2009, in the inpatient setting, she was cared for by a psychiatrist. Apparently he only saw her once; at that time he prescribed the Serzone.â„¢ She reports that if she quits this drug she is likely to "go over the deep end."
I spoke to a different psychiatrist about Serzoneâ„¢ and he informed me it is a unique drug, one I probably don't want to discontinue.
I conducted a test appointment on her without sedation and extracted five teeth without incident. My primary concern is the potential of Serzoneâ„¢ to produce up to a five-fold increase in the serum concentration of the xylocaine used (2% 1/100). I limited her to 2.5 carpules and there were no problems.
Because Serzoneâ„¢ interferes with the metabolic action of benzodiazepines I will not use Valiumâ„¢ the night before; I know I must be very careful about oversedation.
Lorazepam, oxazepam and temazepam are more appropriate substitutes for triazolam. I have NO experience with oxazepam or temazepam and I don't even know whether they are reversible. In my experience, the amnesic properties of triazolam--as opposed to lorazepam--are valuable enough to warrant risking possible oversedation.
Once she's sedated with triazolam and Valiumâ„¢ I won't be able to carry out the rest of her treatment plan on such a small amount of anesthetic. Any suggestions on how I can finish this treatment plan in one visit without IV sedation?
Dr. Anthony Feck, Dean of DOCS Education Faculty responds:
Leave the patient on all her medications as usual. Use an incremental protocol involving lorazepam (incremental protocol #3), or lorazepam/hydroxyzine (incremental protocol #4). I prefer the latter. In either protocol you should omit the night-before diazepam.
As far as the interaction between Serzoneâ„¢ and local anesthetics, use what local anesthetic you need to make the patient comfortable, administering slowly and monitoring carefully.
Dr. Leslie Fang, DOCS Education Faculty responds:
The medication Serzoneâ„¢ is almost never used anymore, so I have to ask why the patient is on this drug. We need to be sure no element of psychosis exists in this patient. I doubt very many people have seen any patients on Serzone.â„¢
More than the effect of the local anesthetic I worry about a D interaction with both diazepam and triazolam. I would use the lorazepam protocol as Dr. Feck suggests. I would not brave the triazolam protocol just for the amnesic property. Adjust the patient's expectations accordingly: tell her she'll be comfortable and that the dentistry will be completed without anxiety. Don't tell her anything about amnesia.
The local anesthetic issue doesn't concern me once you are aware of the potential problem. You would be dosing low and titrating to efficacy.
