A member of DOCS Education writes:
My 68-year-old patient has a history of sinus trouble. Other problems the woman reports are osteoarthritis and osteopenia. (She needs a right-hip replacement and so far has had two steroid shots there.)
Among the medications this patient takes are 200 mg Celebrex™, flexeril, oxycodone, fish oil, garlic pills, glucosamine, Q10, Vitamin C and Ca supplement.
The prospect of dental care makes this woman extremely nervous. She says she feels claustrophobic when work is taking place inside her mouth. She weighs 165 pounds and stands 4’11” tall. She is an ASA III. She snores and feels tired during the day. Her blood pressure measured 140/91; once it soared to 166/104 while she was still in the chair. Her oxygen saturation was 97 percent.
We performed a pulse oximetry test overnight. The woman posted 48 minutes of oxygen saturation under 88 percent and under 90 percent for two hours. We urged the patient to see her MD and take a sleep test. We contacted the doctor to make this recommendation as well.
My question is, do you advise 2.5 mg Valium™ the night before the dental appointment (we will be doing 4 crowns), and possibly up to 0.25 mg Hacion™ the day after? I am also planning to provide 100 percent oxygen during the treatment to promote relaxation.
Is it safe to sedate this patient? Should I wait for the MD to approve this treatment? I’m concerned about the possibility of an apnea episode during the treatment should she fall asleep and how we would control this.
Dr. Jerome Wellbrock, DOCS Education faculty, responds:
I question the wisdom of sedating this patient in your office. Definitely wait until you have the results of her sleep study as well as a diagnosis from the sleep physician. All indications point to this being a patient with at least obstructive (and possible central) sleep apnea. I do treat patients with sleep apnea but take extra precautions. For example, I never give them any sedation medications to take at home. All medications are administered in my office and under close observation. The patient is dosed slowly and carefully monitored.
I use both pulse oximetry and capnography monitoring on these patients. Age is another factor; she is over 65. Make sure she is in your comfort zone for in-office sedation. You may want to consider having separate anesthesia personnel perform the sedation and monitoring allowing you to concentrate on the dentistry.
