A member of DOCS Education writes:

I recently had a consultation with a family of a nonverbal, mentally disabled 35-year-old man with history of epileptic seizures. He has seen the dentist routinely in the past with the aid of N2O, but for the last year he has refused to cooperate at his previous dental office. The patient does not exhibit any violent tendencies to dental treatment; however, he has refused to open his mouth. His medications are as follows:

  • Valproic acid (tid)
  • Topiramate 100 mg (bid)
  • Clonazepam 1 mg
  • Omeprazole
  • Diastat™ (if seizure is over five minutes or more than twice in a day)

The patient’s vitals are stable: BP: 117/81; SaO2: 96; Pulse: 86. I have requested a consultation with his physician due to some disagreements in memory with his parents over past seizure activity. Is this gentleman a candidate for oral conscious sedation (OCS) or better suited for IV sedation?

Dr. Anthony Feck, Dean of DOCS Education Faculty, responds:

Here are the items that deserve special attention: the patient's nonverbal condition; the valproic acid (which will have a [D] interaction with lorazepam); the likelihood of hyporesponse due to chronic use of a benzodiazepine (clonazepam); and the patient's seizure disorder.

Verbal interaction is the standard for determining levels of consciousness, so if the patient cannot respond verbally or physically to verbal stimulation, then the patient is not a candidate for oral conscious sedation.

If the patient is a candidate, then do not use a lorazepam protocol. He would be expected to hyporespond due to the daily CNS depression agents.

Again, if the patient is a candidate for OCS, then the sedation should be light as this patient is more prone to a seizure if the reversal agent is used. I would find out more about the frequency of seizures and what is most likely to cause them.

This is not a straightforward case, and it would be beneficial if you have extensive experience and participated in advanced training. IV sedation would be more predictable.

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The information contained in this, or any case study post in Incisor, should never be considered a proper replacement for necessary training and/or education regarding adult oral conscious sedation. Regulations regarding sedation vary by state. This is an educational and informational piece. DOCS Education accepts no liability whatsoever for any damages resulting from any direct or indirect recipient's use of or failure to use any of the information contained herein. DOCS Education would be happy to answer any questions or concerns mailed to us at 3250 Airport Way S, Suite 701 | Seattle, WA 98134. Please print a copy of this posting and include it with your question or request.
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