By Steven Krause, DDS Prepared by DOCS Education My patient is 66 years old; he presented with a wide range of dentition problems including pain, poor breath, copious food collection between his teeth, and heightened sensitivity. The man nonetheless delayed care because of significant fears provoked by both medical and dental visits. The patient’s experiences included a session during which he actually passed out and swallowed his tongue. When he regained consciousness a team was working on him. That sight prompted yet another round of panic. Medical history offers complex picture Further complicating the patient’s treatment is a complex medical history. He suffered a heart attack in 2000 followed by an aortic aneurysm in 2005. Other health concerns include high blood pressure, bruising, frequent urination and past chest pain. The man reported taking 10 mg Zetia®, folic acid, aspirin, 40 mg Simvastatin®, 25 mg atenolol, 4 mg doxazosin mesylate and 10 mg Uroxatral®. The oral examination revealed moderate-to-heavy plaque and calculus; we also noted periodontal pocketing and fracture lines on numbers 12, 14 and 29 (all with large alloys). Decay on number 20 was minimal but the buccal cusp was fractured. An existing fixed bridge affects numbers 3 to 5. Root canal filling had washed out of number 5 leaving the area sore. Oral cancer screening revealed no lesions or bumps. My subsequent diagnosis was periodontitis, fractured teeth, large leaking alloys, decay and a failing root canal on abutment of a three-unit bridge. The treatment plan incorporated the reduction of oral disease as well as cosmetic preferences. The patient was referred to an endodontist for retreatment of number 5. Because number 29 had the most extensive decay, he was scheduled for a CEREC crown and periodontal debridement (using conscious sedation). The access hole made by the endodontist would be restored with a composite in an effort to salvage the existing bridge. Financial concerns prevented the patient from addressing other teeth immediately. The patient received nitrous oxide during the periodontal probing to assess response; he expressed pleasure with this approach. He subsequently elected to have all treatment take place under oral sedation. We ordered medical consults, and once they were complete we conducted a presedation workup. We cross-referenced the patient’s medications with sedative drugs, preoperative blood pressure and heart rate. A pulse oximeter measured his oxyhemoglobin saturation. The patient’s cardiologist approved the use of diazepam, triazolam and hydroxyzine. We reviewed pre- and post-operative instructions with the patient and obtained his written consent. The appointment The night before the appointment the patient received 5 mg diazepam. When he arrived at the office the next morning, accompanied by his wife, he confirmed that in addition to this regular meds he took 0.25 mg triazolam at 5:50 a.m. The treatment schedule was reviewed with his wife and a phone number provided. The pulse oximeter was connected at 7 a.m., at which point the patient was provided another 0.25 mg triazolam and 30 mg hydroxyzine. Nitrous oxide was administered one hour later, followed by local anesthesia. The nitrous oxide was turned off but oxygen remained on low. Dentistry then started. The patient was very relaxed. About one hour into the dentistry he began to doze off into a light sleep. He still responded to frequent comments. The patient’s treatment was completed at 12:55 p.m. Ambulatory, he was given Gatorade™, and oriented times 3. He was able to stand up and sit down in a wheelchair. He was then instructed to drink plenty of fluids, eat light, and refrain from driving. The next day the patient reported that his experience with sedation had been very good. I consider this an interesting case because of the patient’s previous medical problems, numerous medications, and high blood pressure. Overall he was so agitated about the prospect of dental care that I think an attempt to treat without sedation could have risked a serious medical outcome.

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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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