NEWS AND DENTAL EDUCATION

Oral Sedation – Anti-Anxiety Medication

Oral sedation dentistry is a medical procedure involving the administration of oral sedative drugs (usually in the form of a tablet), generally to facilitate a dental procedure and reduce patients fear and anxiety related to the experience. It is the most commonly used method in relieving anxiety before a dental appointment. An anti-anxiety or a sleeping pill can be taken the night before the appointment, an hour before going to bed can help with falling asleep and getting some rest; or it can be just taken an hour before dental treatment.

Anti-Anxiety Pills (Benzodiazepines or “Benzos”)

In dentistry, the most commonly prescribed drugs for anxiety belong to the “benzodiazepine” family (eg. diazepam, triazolam, zaleplon, lorazepam, and hydroxyzine). You’ve probably heard of them by their tradenames – for example, Valium, Halcion, Xanax, or Ativan.

Benzos decrease anxiety by binding with receptors in the brain which tone down activity in those parts of the brain responsible for fear.

Travel warning!

You shouldn’t travel on your own after you’ve taken benzodiazepines – make sure you have an escort, even if you’re walking there! It’s easy to become disorientated and miss your stop if going by bus or train, or walk straight in front of a car – or you might even forget that you’re on your way to your dentist’s clinic.  So find someone to accompany you. And please don’t pop pills and drive!

Benzodiazepines has two main fuctions:

1. Sedative-Hypnotics: drugs which induce drowsiness (“sedation”). In higher doses, they induce a state resembling physiological sleep (“hypnosis”).
2. Anti-Anxiety Drugs: drugs which act primarily to relieve anxiety and make you feel calm.

While all benzodiazepines act as sedatives and anti-anxiety drugs, some are more targeted at brain areas which control sleep and wakefulness, while others are more specifically targeted at brain areas which control emotions such as fear. The classification of whether a benzodiazepine is sedative-hypnotic or anti-anxiety is to some extent an arbitrary one, as the boundaries are quite fluid. As a rule of thumb, in higher doses benzos act like sedatives and may promote sleep, while in lower doses, they simply reduce anxiety.

Benzodiazepines are Central Nervous System (CNS) depressants (for example, there can be a decline in blood pressure and breathing – which is good, because if your heart isn’t racing, you’ll feel calmer). They should not be mixed with other CNS depressants such as alcohol. Don’t self-medicate and stick to the dose your dentist or doctor recommends (which may be a higher dose than specified on the drug package insert. Reason being that the package inserts recommend a dose to induce sedation or sleep in a nonstress situation such as the home environment). It is possible to overdose on these things, and overdoses could lower breathing to dangerously low levels, which could result in coma or even death.

People for whom benzos have worked well describe them as “working wonders”, as having a calming and relaxing effect, or as making you feel “out of it”. Giddiness, confusion and saying silly things are also common. Benzos may make you forget large parts of what happened while you were under their influence, which can be handy if you don’t want to remember very much! However, this effect is not reliable.

Dentists who offer oral sedation will have particular preferences, depending on their experience (and experiences) with various drugs. Commonly prescribed benzos include:

Midazolam (Dormicum):

We use this drug mostly to sedate our customers  for dental treatment.  Midazolam is a short-acting benzo which can produce high levels of sleepiness and memory loss (amnesia). It is given in tablet form (7.5mg for adult) by dentist usually half an hour before procedure. It kicks in very quickly, after about 10-20 minutes. The effect last 1 to 2 hours.

Diazepam (Valium):

Diazepam is another sedative drug widely used for dental treatment as well as in the hospital setup. It  produces a mild level of sleep and amnesia, and takes effect about an hour after taking it. The average dose for an adult is 5 to 10 mg. The disadvantage of diazepam is that it stays in the system for much longer than it is needed (it has a half-life of 20-100 hours).

Temazepam (Restoril):

Temazepam is quite frequently used in the UK. In contrast to Valium, its half-life is about 10 hours, so quite a bit shorter. It kicks in after about half an hour. The recommended dose is 10 – 40 mg (with the most common one being 30 mg). Why this huge range? In some people 40 mg of temazepam produces minimal effects whilst in others as little as 10 mg produces profound sedation. This is a problem with all benzos – there is no known method of identifying who is susceptible and who is resistant to benzodiazepines.

Lorazepam (Ativan):

Lorazepam can produce a higher level of sleepiness and memory loss than diazepam. The usual dose is 2 to 3 mg. It kicks in after about one hour, like diazepam, but its half-life is much shorter (12 to 14 hours).

Midazolam (Versed):

Midazolam is a short-acting benzo which can produce high levels of sleepiness and memory loss. It is given as a syrup or mixed into a drink. The drink would usually be given at the dentist’s. It kicks in very quickly, after about 10-20 minutes.

Triazolam (Halcion):

This is not available in the U.K., but is hugely popular in the U.S. Unlike the other benzos mentioned here, it is not so much used as a premedication, but as an alternative to IV sedation in the dental office. This can work really well for some people and many swear by it! But as with all benzos, other people find it has little effect on them.

Controversies in Dentistry – Titration of Oral Sedatives

Occasionally, Halcion is used in the United States as an alternative to IV sedation. One of the effects of Halcion is that it can induce amnesia (memory loss) for what’s happening from the point the drug kicks in to the point it wears off. (All benzos can have this effect to some extent, but Halcion somewhat more so than others. However, the amnesia effect is unreliable – this also applies to Halcion). If Halcion is given intermittently one hour before an appointment and then during treatment at intermittent intervals, it can work well for some people as a substitute for IV sedation.

However, in 2002 the American Dental Association came out in a position paper against titration of oral sedation medication (titration means adding more of the drug, i. e. giving extra pills until the desired effect is achieved). This statement followed the rise of an organization called the “Dental Organization for Conscious Sedation” (or DOCS for short) which was founded in 2000 by a DDS called Michael Silverman and provides training in oral sedation. In 2004, DOCS had more than 1,900 member dentists in the US. DOCS is where the misleading term “sleep dentistry” (applied to oral sedation) was first invented. The training courses also advocate titration of oral medication. Many dentists feel that this practice is unsafe and/or that the training is not thorough enough. Even with thorough training, many dentists believe that titration of oral medication is too unpredictable. Oral medication can take up to two hours to absorb – so a patient could swallow a pill and the dentist, not seeing the effects of the drug an hour or two later, delivers a second pill. Meanwhile, the first pill is being absorbed and the patient has ingested twice the amount he or she needs. To be fair, it should be mentioned that there have been no adult deaths reported using the DOCS regime so far.

Because of the medical and legal situation, many dentists do not feel comfortable with this method.

Can I take benzos as a premedication before IV sedation?

Yes you can. You must however let your dentist know that you have taken them and what dose (unless your dentist has prescribed them and knows anyway). Be sure to inform your dentist beforehand, rather than on the day, because you may forget to mention it otherwise.

When not to take benzodiazepines (contraindications):

This varies from drug to drug. For example, some benzos are safe to take if you have liver problems, while others are not, and some are safe to take if you have heart problems, while others are not. You should be sure to inform your doctor or dentist if any of the following apply: known allergy to the drug, narrow-angle glaucoma, pregnancy, severe respiratory disease (COPD), congestive heart failure (CHF), impaired kidney or liver function, depression/bipolar disorder/psychoses, chronic bronchitis and some other conditions. Also if you’re taking other medications be sure to mention this.

Oral sedation – A hit-and-miss affair?

One problem associated with oral sedation is that it can be a bit of a hit-and-miss affair. Basically, you don’t know how well the drug will be absorbed from the stomach. Because the response to a drug is unpredictable anyway, you have to tailor the dose so that the 25% of people most susceptible to the drug won’t get an overdose. But that means that the 25% who are least susceptible won’t get enough… Body weight, height, or gender are not good indicators of how high the “ideal dose” should be, because the drug exercises its effects on the nerve cells in the brain. So, if you’re quite large, don’t take a little extra “just in case”. A standard dose might have virtually no effect on a petite female, but a large guy might be totally zonked after taking the same dose… you get the picture!

Other factors which may affect how well a benzo will work include whether you want it to work and your (and your doctor’s/dentist’s!) belief that it will work (the so-called “placebo effect”, which, BTW, has been shown to work even if you’re aware of it). If you don’t want the drug to work, for example because you’re scared of losing control, your brain may try and fight the effects of the drug. As a result, you may not experience much of an effect at all, or else experience the effect as unpleasant. In which case, oral sedation may not be for you.

What people said about benzos:

“My doctor prescribed me valium. I take one 30 minutes before my appt. It makes you a little sleepy and your anxiety disappears. It puts you in a “whatever” mood and helps you stop thinking about the pain or worries. ”

“I remember being taken to the chair and them giving me a vial of liquid Halcion…This stuff tastes like Peppermint Cherry…leaves a strong taste in your mouth, but no side effects… Everything around me went fuzzy and blurry, like I was in a dream or something. They moved me to the other room, where everything happened so fast!!! I don’t actually remember much, but I did feel bits and pieces… it wasn’t like a “Get me out of this chair now, feeling” but something that I could deal with… I remember them preparing the molds for my bridge and crown, but I didn’t quite care, and I didn’t even GAG! Which normally I would have!

I did have some amnesia, and I did feel somewhat calm and distant from the procedures, which made me feel good. The appointment was 2 hours, but it felt like I was in and out of there in like 15 minutes. I don’t remember walking to the car or the ride home.”

Zolpidem (Ambien)

Ambien is a sedative/hyppnotic drug designed to relax you and help you fall asleep. So it can be useful for the night before an appointment. It is chemically similar to benzodiazepines. It is not a barbiturate (the traditional “sleeping pill”, which thankfully has fallen out of favour).