Providing Anxiolysis to Overweight Patient on Multiple Medications

A Docs Education member writes:
I have a 41 year-old, 200 lb female patient who is being sedated by a medical anesthesiologist at my periodontist’s office. She will have all of her maxillary teeth extracted and eight implants placed. I will be there to take impressions and she will return to my office two days later to have fixed temporary teeth screwed into the implants. I would like to be able to give her local anesthesia, but she is extremely fearful of the dentist. I am not looking to do conscious sedation, but just want to give her something to take the edge off. I plan to give her nitrous oxide prior to the local anesthesia. Her medical history is extensive. She has a history of asthma, sarcoidosis, high blood pressure and psychiatric treatment. She takes Keppra, Zyprexa, Xanex XR, Zoloft, Lamictal, Vivance and an inhaler. Her psychiatrist suggests that I use 1 mg Xanax (non XR) or 0.25mg triazolam. I wonder if these will be enough and I am interested in your thoughts.


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

There's no way of knowing for sure until you try, but given her level of anxiety and the tolerance that she has developed due to multiple CNS depressants, the level of anxiety control is likely to be minimal with the doses of Xanax or triazolam that you mention. Combining those with nitrous will help, but this patient is going to be a hyporesponder.

The good news is that you will not be doing an invasive procedure, although your patient will need to be numb given her recent surgical procedure. If you want to be more sure of her anxiety control, then I would perform a regular oral conscious sedation. In addition to the multiple CNS depressants she is taking and the associated tolerance, there is the issue of her psychiatric disorder. If it is schizophrenia, I would not use oral sedatives, but rather use IV sedation titrated to the appropriate level of effectiveness.

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