A DOCS Education Member asks:
I would like input regarding a case that I am preparing on a 37-year-old male who has a fairly complicated medical history. I have successfully removed seven teeth and restored others for him in the past without sedation, over several visits. While awaiting a medical consult I am planning on sedating him with 10mg diazepam the night before and standard incremental dosing with triazolam on the day of his appointment. He needs 22 extractions, though I am anticipating removing only the remaining nine maxillary teeth on this visit.
He has recently been diagnosed with diabetes but after hearing that he does not own a device to check his blood sugar, I will assume he is uncontrolled despite taking his prescribed medications. Those medications are:
- Metformin 1000 mg
- Lantus® SoloSTAR®
- Meloxicam 7.5 mg
- Gabapentin 100 mg
- ProAir® HFA inhaler daily
- Benztropine 2 mg
- Bupropion
- Propranolol 20 mg
- Lorazepam 1 mg
- LATUDA® 40 mg
Assuming that I receive medical clearance from his physician, I am specifically concerned with the potential interaction of LATUDA® and the obvious amount of epinephrine that will be needed in the local anesthetic used. Additionally, a routine interaction check of his meds makes me wonder about the interaction of ProAir® (albuterol) and the Propranolol, both of which he takes daily. I welcome your comments and advice.
Dr. Jerome Wellbrock, DOCS Education faculty, responds:
Since we do not have additional information at this time I can only say that I would definitely put any sedation or dental treatment for this patient on hold. I am not a fan of blind speculation, but based on the limited information provided, we are dealing with the following: possibly an uncontrolled diabetic, Metformin, Lantus®, with neuropathy, gabapentin, meloxicam; respiratory issues, possibly asthma, ProAir® HFA, hypertension/heart/tremors, propranolol, schizophrenia/bipolar disorder, bupropion, LATUDA® and lorazapam.
Detailed information on his medical diagnosis and level of control of all conditions is needed before we can make a firm recommendation. Drug interactions are contra-indications to the use of local with vasoconstrictor. LATUDA® is a "X" interaction and propranolol is a "D" interaction with vasoconstrictor. Also ProAir® HFA and propranolol is a "X" interaction with themselves. You very well may get an “ok” from his physician but with this limited information I would not sedate this patient. Even oral surgery is a risk with his current meds and healing is an issue depending on his level of diabetes control. Let us know if you get more information. We appreciate you posting this case.
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