Treating the Apprehensive Dental Patient ________________________________________________________
should be advised, as part of an informed consent process, that the use of any medication entails risks. In susceptible patients, medications used for sedation can cause anaphylactic reactions, adverse drug interactions, seizures, respiratory depression, and even death. While these reactions are rare, patients should be advised of their possibility. This section will focus on oral and inhalation sedation.
staff members are assigned a specific role increase the chance of an appropriate staff response and survival of the patient. Common Medications A universally ideal sedative medication does not exist; each sedative has its advantages and disadvantages, indications and contraindications. Benzodiazepines are most commonly used in dental practice for oral sedation. The agents used most often include diazepam, triazolam, and lorazepam. Diazepam Diazepam was invented in 1963 and was the successor to the first benzodiazepine, chlordiazepoxide [29]. Today, diazepam is approved for the treatment of anxiety disorders, acute alco- hol withdrawal, and skeletal muscle spasms. When diazepam is used to manage dental fear and anxiety, the dosage and schedule will vary according to the medical history, of the patient’s age and weight, the degree of sedation desired, and the concurrent use of any other medication. The usual adult dose is 2–10 mg the night before the appointment and 2–10 mg one hour before the appointment. Diazepam is a highly lipophilic molecule with 100% oral bioavailability. It has a rapid onset of action (20 to 40 minutes after administration), and plasma levels peak one to two hours after its administra- tion [30]. These favorable pharmacokinetic properties are countered by a long half-life, or the time required for the blood-plasma concentration of the medication to be reduced by one-half. The half-life of diazepam can range from 20 to 100 hours due to its production of active major metabolites, such as desmethyldiazepam [31]. This extended half-life can make patients feel sleepy for a few days after its administration. Patients should not drive, operate machinery, or perform any task that requires intense concentration or decision making during this period. Diazepam is metabolized by the liver, so hepatic dysfunction and older age can decrease its metabolism and prolong plasma concentration [32]. At the anxiolytic doses used for dental treatment, diazepam is a moderate tranquilizer that causes drowsiness and some loss of anterograde (short- term) memory [33]. Because of this effect, the patient may remember little or nothing of the dental procedure. Alcohol can potentiate the central nervous system (CNS) depressant effects of diazepam, so patients should be advised to refrain from consuming alcoholic beverages when this drug is being used. Diazepam has been assigned as pregnancy risk category D by the Food and Drug Administration (FDA), which indicates that there is potential for fetal harm if it is used during pregnancy. For these patients, a different agent should be used or dental treatment should be postponed until after delivery. Dental clinicians should avoid the simultaneous use of narcotic analgesics and diazepam, as the synergistic combination of these medications can potentiate CNS depression. Patients who have used diazepam should have a responsible adult drive them to and from their appointment.
ORAL SEDATION General Considerations
In recent years, the dental profession has advertised and marketed “sleep dentistry” as a means for patients with high levels of dental apprehension to receive dental treatment. In the United States, this is most commonly achieved by oral sedation [25]. Patients who receive oral sedation from a general dentist should only be titrated to levels of minimal-to-moderate sedation. Minimal sedation refers to a minimally depressed level of consciousness in which the patient can independently and continuously maintain a patent airway and can respond normally to tactile sensation and verbal commands [26]. Respi- ratory and cardiovascular functions remain normal, and there is no intent for the patient to lose consciousness. Moderate sedation is a deeper level of sedation in which the patient still responds purposefully to verbal commands but may need slight tactile stimulation to do so [27]. General dentists should not seek to place patients in a state of deep sedation, as the patient’s ability to maintain a patent airway can be impaired. Dental clinicians who use any medication to achieve patient sedation should be trained in the appropriate use, the initial and maximum dosage, and possible adverse effects of the drugs in use. Prior to administration, the clinician should take into account the patient’s medical history, age, weight, and con- current use of other medications. Certain medications (e.g., opioid analgesics, antidepressant medications, antipsychotic medications, antihistamines) can potentiate the effects of oral sedation agents. The use of nitrous oxide/oxygen inhalation sedation concurrently with oral sedation can also potentiate the effect of an oral sedative, and some states require a special permit if oral and inhalation sedation are combined. Individual state regulations and requirements vary as to the level of training required for dentists and dental staff involved in caring for patients who are given oral sedation. Some states require the use of equipment to monitor vital signs for the duration of the sedation. Further, training in cardiopulmo- nary resuscitation may be required at the Advanced Cardiac Life Support level (rather than the Basic Life Support level) for dentists and the entire staff. Most states require that an automated external defibrillator be present in the dental office and that all staff members be trained in its use. Staff members should be aware of the location of the emergency kit, used if a medical emergency occurs. The use of a medication that is appropriate for the given medical emergency is the responsi- bility of the dentist. Periodic mock emergency drills in which
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