A member of DOCS Education writes:
My male patient is epileptic and takes clonazepam. The man was advised by his medical doctor not to use triazolam. I conferred with the patient’s previous dentist; he said when triazolam was administered the man became oversedated and the dental procedure could not be continued. (That dentist was also urged by the same medical doctor not to combine these two medications.)
The treatment plan for this patient consists of extracting all remaining upper teeth and placing implants with an immediate fixed healing bridge. This procedure typically takes a few hours. When I contacted the patient’s medical doctor he advised me to increase the clonazepam.
How can I sedate this patient safely?
Dr. Anthony Feck, Dean of DOCS Education Faculty, responds:
There shouldn't be any interaction between the two benzodiazepines, clonazepam and triazolam, precluding either drug's use. The previous incident with triazolam most likely resulted from an excessive dose. Incrementally dosing to effect with small doses of triazolam at appropriate intervals should not be a problem for a patient taking clonazepam, or for that matter any other benzodiazepine.
Clonazepam is a benzodiazepine with a duration of action lasting 6 to 8 hours, similar to lorazepam, but with a much longer half-life, 19 to 50 hours. These qualities make it ill-suited for our needs to sedate dental patients in an outpatient setting.
Unfortunately, the process has now gotten more complicated. Not only has there been a previous sedation mishap, the patient's physician has gotten involved. He’s advising against a preferred protocol and urging a different one.
I recommend you have a conversation with the patient's physician. Discuss a preferred protocol that uses shorter-acting benzodiazepines for this patient, preferably an incremental approach with triazolam. At the very least it should be one that includes lorazepam, which has a shorter half-life than clonazepam. Stress that these are protocols taught and supported by one of the largest sedation groups in dentistry, and you will be using conservative doses. I would document the conversation. If you cannot gain consensus with the physician in this case, I would not use oral sedation, but rather nitrous oxide sedation/analgesia.
If you do proceed with oral sedation, in this instance I would not use diazepam the night before.
