First Case Using Single-Dose Protocol and Patient is Under-Sedated: What Next?

You get your sedation training, prepare for your first case, get the patient in the chair, but things just don't go as planned. The patient isn't adequately sedated but you're at your top dose; then the patient complains of pain and facial swelling the next morning. You've got another appointment on the books for this patient, so what do you need to do differently? Dr. Wellbrock advises.

A DOCS Education Member enquires:

I had my first sedation patient Monday and would like some feedback on my experience from some other dentists about the procedure.

Patient was a 54-year-old female wanting three new crowns on teeth #7, 8, 9 and a crown on 10. She is ASA I, but had elevated blood pressure when she presented the Friday before to dispense 10 mg of diazepam for her to take Sunday night. She takes Xanax® every night to help her go to sleep. (Previously, she had teeth #7, 8, and 9 prep and crowns inserted under IV sedation.)

On the day of appointment, I dispensed 0.5 mg triazolam sublingual and we waited. After an hour she said, “I feel no different. I feel like I could walk out of here and drive home." I waited 15 more minutes and BP dropped to 122/72. Started her on N₂0 and delivered anesthetic, 2*1.8 ml lidocaine 1:100k.

We had to work slowly because she said, probably 50 times, that she didn't feel any different, the sedation medication wasn't working, etc. After an exhausting couple hours of working to prep and temp #9 and 10, I delivered 2*1.8 ml lidocaine 1:100k. We started working on #8. She was moving around a lot; she said she wasn't in discomfort but the noise was killing her. I did add 1.7 ml Septocaine® 1:200k. I finished removing #8 crown and making the temporary.

Four hours in and I am getting as tired as she is and we called it quits. She stood straight up out of the chair when I told her we were done for the day. She seemed to walk fine; my assistant guided her to her ride car. (We have a companion chair but she didn't seem to need it.)

I called the patient that night and she thought the appointment went well, but was curious why we didn't get more done. I stayed positive and rescheduled her for another sedation appointment to finish preps and take impressions.

She called me the morning after the appointment at 6:50 a.m. and told me her entire face was swollen and she was having a lot of discomfort. When she presented, I didn't see much swelling, but she said she was "[expletive] miserable."

Finally, the questions: In your experiences, will she be better at her next appointment? What would you do differently? This is my first case; it didn't look anything like the videos.

She said she didn't sleep with the diazepam and wanted to take Xanax® instead the night before her next appointment. What do you guys think about that?

Dr. Jerome Wellbrock, DOCS Education faculty member, responds:

I would like to have more information on this patient, such as the date of her last physical; if she's taking any medications, herbals, over-the-counter medications; a smoker, recreational drug user; her sleep habits, snoring or OSA; her BMI, height, weight, vital signs at pre-sedation work-up and BP before beginning your sedation appointment, etc.

It sounds like she was most likely under-sedated and that she requires more sedation medications. I would let her take Xanax in place of diazepam the night before; I would most likely add hydroxyzine along with triazolam.

Are you able to incrementally dose or are you limited to single-dose?

It is possible that she was dehydrated after the appointment and did not hydrate enough resulting in her feeling so miserable the next morning.

The member follows-up:

Dr. Wellbrock, thank you for your response.

The date of the patient's last physical was almost one year ago. The only medication she takes is Xanax before bed each night. I don't know about OSA or snoring. She did tell me she usually only sleeps for 3 to 4 hours a night. She's a non-smoker; BMI is 24; height 5'4" and weight 140 lb.

Her BP two weeks before was 133/82; Friday before appointment 144/91 (she was visibly nervous). Her BP before the appointment was 146/91 and then 139/87. It dropped to the 125/82ish-range after the sedation medications started working, and stayed around there the entire appointment with minor fluctuations.

I am only able to use the single-dose protocol currently. I feel she was under-sedated, but I am currently at my limits.

Her chief complaint was the pain associated near injection sites. I would really like her to get a better night's sleep. Do you think she will do better with the Xanax instead of diazepam the night before?

Dr. Wellbrock advises:

Patients usually do better the night before if we do not change their normal medication schedule. Since she is taking Xanax at bedtime, I would not change that. Even with a single-dose protocol you can add hydroxyzine to that and that should help out with her sedation.

Member responds:

Dr. Wellbrock, thank you for your reply. I will try Xanax and hydroxyzine the night before.

I think she has such anxiety that she fights the sedation. She didn't remember much about the appointment, except that she thought it went well (but that's probably because I told her how well it was going every five minutes).

She has had most of her previous work under IV. She told me after her sedation appointment that her previous dentist gave her a steroid after every appointment. Once I gave her a Decadron® dose pack she felt much better in 12 hours. She will be leaving her next sedation appointment with a dex pack.

Thanks again.