A DOCS Education Member writes:
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 as a DOCS member, this case concerns me with the multiple benzodiazepines and CNS depressants. Would it be worth a try with just nitrous oxide?
Thank you for your help!
Dr. Anthony S. Feck, DOCS Education Dean of Faculty, responds:
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 they may need another method of sedation. Reassure them that if they aren't comfortable, the appointment will not proceed. If you and your patient do decide to move forward with OCS, then I recommend Incremental Protocol #2 from your DOCS course handbook.