Thoughts on oral/sublingual

titration with triazolam

 The prohibition of multiple dosing may have

unintended undesirable consequences
 Two smaller doses (2 x 0.25 mg) separated in time
are safer than one larger dose (1 x 0.5 mg)
 Multiple dosing can prolong effect duration
 Dose stacking can provide limited titration
 Faster onset, reduced variables with sublingual
triazolam enhance titration ability

USP Workshop
 Safeguards for oral sedation
beyond anxiolysis
 Continual monitoring of patient for
consciousness
 Continuous monitoring of pulse oximetry,
heart rate
 Continual monitoring of blood pressure
 Use of reversal agent if patient drifts into
unconsciousness and cannot be aroused
AGD White Paper
State Regulations for Adult
Oral Sedation
 Proposed Changes to ADA
Documents on Sedation
 ADA Policy Statement: The Use of Sedation and General
Anesthesia by Dentists
 Housekeeping
 Guidelines for Teaching Pain Control and Sedation to
Dentists and Dental Students
 Major changes in definitions, teaching of moderate enteral
sedation
 Guidelines for the Use of Sedation and General Anesthesia
by Dentists
 Major changes in definitions, performance of moderate enteral
sedation
 Proposed ADA Teaching
Guideline Changes
 Allows multiple dosing of triazolam up to 0.5 mg total dose
within definition of minimal sedation when full effect of
previous dose known
 Requires 16 hour course for minimal enteral sedation (may
include inhalation sedation as well)
 Allows multiple dosing of triazolam beyond 0.5 mg within
definition of moderate sedation
 Requires 60 hour course for moderate enteral sedation to
include management of 10 patients with IV access with
faculty/student ratio of 1/3
 Proposed ADA Use Guideline
Changes
 Requires dentist to be able to rescue patient “whose level of
sedation becomes deeper than initially intended”
 Requires ACLS or “appropriate dental sedation /anesthesia
emergency management course in addition to 60-hour course
for oral moderate sedation
 Requires time-oriented anesthesia record with vital signs
recorded continually
 Flumazenil
(Romazicon)

 0.1 mg/mL
 5 mL vials
 Flumazenil (2)

 Specific benzodiazepine receptor antagonist

 Causes rapid reversal of:
 Unconsciousness
 Sedation
 Amnesia
 Psychomotor dysfunction
 Flumazenil (3)

 Most patients respond to dose of 0.6 - 1.0

mg IV
 Resedation most common after large doses
of benzodiazepine and long procedures
 Monitor for up to 2 hr after administration
 Flumazenil (4)

 Adverse effects
 Nausea and vomiting, agitation
 Seizures in patients with epilepsy
 Drug interactions
 Benzodiazepine withdrawal
 CNS stimulation with tricyclic antidepressants
 Questions regarding flumazenil
reversal
 Rate of emergency progression with oral
triazolam
 Relative efficacies and onset times of
intravenous versus intramuscular, other
routes
 Safety of standard dosing versus titration
Flumazenil effects: influence of
route of administration in dogs
Route Reversal time
(sec)
IV 120±25 Heniff et al:
Acad Emerg Med
4:1115-8, 1997.
SL 262±95

IM 310±134

Control 1620
 Comparison of 3 Routes of Flumazenil
Administration to Reverse Benzodiazepine-
induced Desaturation in an Animal Model
 0.5 mg/kg midazolam IV to produce respiratory
depression (SaO2 to ≈90%) in anesthetized dogs
 2 minutes later given “reversal treatment
 No injection control
 0.01 mg/kg (0.12-0.17 mg) IV flumazenil
 0.2 mg SM flumazenil
 0.2 mg IL flumazenil
 Blood drawn at various times for flumazenil
measurements

Unkel et al: Pediatr Dent 28:357-62, 2006

Unkel et al: Pediatr Dent 28:357-62, 2006
Unkel et al: Pediatr Dent 28:357-62, 2006
 1 ?

Unkel et al: Pediatr Dent 28:357-62, 2006

Observer Rating of Sedation Post Flumazenil (0.2 mg) Administration
5

4
Sedation Score

2
Tongue (n=5)
IM (n=3)
IV (n=2)
flumazenil
admin.
1
150 180 210 240

Time (minutes post-1st SL triazolam dose)

Jackson et al: unpublished data
 Bispectral Analysis Post Flumazenil (0.2 mg) Administration
100

90

80

70
Bispectral Score

60

50
tongue (n=5)
IM (n=3)
IV (n=2)
40 flumazenil
admin.

30
150 180 210 240
time (minutes post-1st SL triazolam dose)
Jackson et al: unpublished data
 Psychomotor Function Assessment
100 10 Minutes Post-Flumazenil

#569
80 #570
#571
DSST Score

#572
#573
#574
60 #575
#576
#577
#578

40
Flumazenil Admin:
Filled circles: IM
20 Filled triangles: SL
Open squares: IV

0
0 60 120 180 240
flumazenil
Time (minutes) (0.2 mg)

Jackson et al: unpublished data

 Rebound Sedation
at the Time of Discharge

Four subjects required an additional dose of flumazenil (0.2 mg, IV) 60 minutes
after the initial dose (as determined by the anesthesiologist’s discharge criteria):

• IV: 1 subject
• IM: 1 subject
• SL: 2 subjects
Jackson et al: unpublished data
 Lorazepam (Ativan)

 Dosage forms: injection: 2 and 4 mg/mL in 1 and 10 mL

vials and 1 mL Tubex; tablets: 0.5 , 1, and 2 mg
 Directions: IV, 1-2 mg at start of case; oral, 2 (1-4) mg 1
hr before bedtime or 2 hr before treatment
 Children: not recommended
 Clinical duration: 6 hr
 Recommendation: use for prolonged procedures or when
treatment is delayed
 Cardiac Disease and Dental
Treatment
 AHA/ACC Task Force on Perioperative
Evaluation of Cardiac Patients Undergoing
Noncardiac Surgery
 Dental treatment and hypertension
 AHA/ACC Task Force on Perioperative
Evaluation of Cardiac Patients
Undergoing Noncardiac Surgery

Need for noncardiac surgery

Coronary revascularization with 5 yr Yes

Operating room
and no recurrent symptoms or signs

Recent favorable coronary Yes

Operating room
angiogram or stress test

Postoperative risk
Clinical predictors stratification and risk
factor management

Major Intermediate Minor

 Estimated energy requirements for
various activities

1 MET Normal daily household activities

Walk a block on level ground at 2-3 mph

4 METs Climb flight of stairs

Walk on level ground at 4 mph
Heavy housework or moderate exercise (golf,
doubles tennis, bowling, dancing)

>10 METs Participate in strenuous sports (swimming, singles

tennis, football, basketball, skiing)
 AHA/ACC Task Force on Perioperative
Evaluation of Cardiac Patients Undergoing
Noncardiac Surgery (2)
Major clinical predictors

Consider delay or Consider coronary

cancel surgery angiography

Medical management Care dictated by findings

and risk factor reduction and treatment results

Major clinical predictors:

Unstable coronary syndromes

Decompensated CHF
Significant arrhythmias Wedon’t
Severe valvular disease
Recent MI with important ischemic risk
Unstable or severe angina treat these
 AHA/ACC Task Force on Perioperative
Evaluation of Cardiac Patients Undergoing
Noncardiac Surgery (3)
Intermediate clinical predictors

<4 METs or >4 METs and intermediate

High surgical risk surgical risk or low surgical risk

Low risk
Noninvasive testing Operating room

Consider coronary Postoperative risk

angiography stratification and risk
factor reduction

Care dictated by findings Intermediate clinical predictors: We may have

and treatment results to consult
Mild angina pectoris
Prior MI physician re
Compensated or prior CHF these patients
Diabetes mellitus
 AHA/ACC Task Force on Perioperative
Evaluation of Cardiac Patients Undergoing
Noncardiac Surgery (4)
Mild clinical predictors

<4 METs and >4 METs or intermediate

high surgical risk or low surgical risk

Low risk
Noninvasive testing Operating room

Consider coronary Postoperative risk

angiography stratification and risk
factor reduction

Care dictated by findings Minor clinical predictors:

and treatment results We often don’t
Advanced age have to
Abnormal ECG
Nonsignificant arrhythmia consult
Low functional capacity physician re
History of stroke
Uncontrolled systemic hypertension these patients
 Dental treatment and
hypertension
SBP DBP MRF Recommendation
120-139 80-89 Yes/no Routine dental care OK; discuss BP guidelines
140-159 90-99 Yes/no Routine dental care OK; consider stress reduction
protocol; refer for medical consult
160-179 100-109 No Routine dental care OK; consider stress reduction
protocol; refer for medical consult
160-179 100-109 Yes Urgent dental care OK; refer for medical consult
180-209 110-119 No No dental treatment without medical consult; refer
for prompt medical consult
180-209 110-119 Yes No dental treatment; refer for emergency medical
treatment
³210 ³120 Yes/no No dental treatment; refer for emergency medical
treatment
MRF: medical risk factor (e.g., history of MI, angina, high coronary disease risk,
recurrent stroke prevention, diabetes mellitus, renal disease.
From Merin RL: JADA 135:1220, 2004; after Herman et al: JADA 135:576-84, 2004.
 Obesity and sedation

 Two thirds of the adult population in the

U.S. are obese or overweight
 17% of children ages 2 to 19 yrs are
overweight
 Prevalence has tripled in the past 2 decades
 Obesity is a leading cause of restrictive lung
disease
 Body mass index

[Weight (kg)]
BMI =
[Height (m)]2

[89 kg]
Ex = 2 = 24.9
[1.89 m]
>25 overweight; ≥30 obese; ≥40 morbidly obese
Overweight
In
children
Dynamic lung volumes
 Recognition of Potential Airway
Difficulty

 Mallampati-Samsoon classification
 Thyromental distance
 Joint mobility
 Head and neck frontal and profile views
 Tonsilar separation/obstruction
 Mallampati-Samsoon
classification of the airway

 Class I - uvula, faucial pillars, soft palate

 Class II - faucial pillars, soft palate
 Class III - soft palate
 Class IV - hard palate
Mallampati-Samsoon Airway Classification
 Facial anomalies

 Maxillary hypoplasia
 Apert’s syndrome
 Crouzon’s syndrome
 Coronal craniosynostosis (Saethre-Chotzen
syndrome)
 Rubenstein-Taybi syndrome
 Facial anomalies (2)

 Mandibular hypoplasia
 Treacher Collins syndrome
 Hemifacial microsomia (Goldenhar’s
syndrome)
 Moebius syndrome (micrognathia 2O to
neuromuscular deficit)
 De Lange syndrome
 Robin sequence
 Sleep apnea

 Obstructive sleep apnea is most common

 Drugs with muscle relaxant properties can cause
loss of airway
 Drugs with respiratory depressant properties can
cause loss of respiration
 Sleep deprivation can increase chance for
oversedation
 Need for extended monitoring
 Sleep apnea (2)

 Repetitive episodes of upper airway obstruction

during sleep
 Accompanied by sleep disruption, hypoxemia,
hypercarbia, cardiovascular stimulation
 Often seen in obese or in patients with tonsillar
hyhpertrophy or craniofacial abnormalities
 Secondary cardiac and lung abnormalities

Do you want to treat these patients?

 Sleep apnea (3)

 Most patients undiagnosed

 Good questions to ask
 Do you snore nightly?
 Has anyone ever said that you stop breathing in your sleep?
 Do you feel tired and groggy on awakening?
 Do you fall asleep easily during the day?
 Do you frequently have headaches in the morning?
 Consider recommending sleep study for patients with
positive findings