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Sedation of Phobic Dental Patients With an Emphasis on the Use of Oral Triazolam

by

Fred Quarnstrom, D.D.S.

F.A.G.D., F.A.S.D.A., F.I.C.D.

Diplomate, American Board of Dental Anesthesiologists


Published by

ANALGOTRONICS, INC. 3051 Beacon Ave. S. Seattle, Washington 98144

All rights reserved 1992 BY ANANGOTRONICS, INC.

No part of this manual may be reproduced by any mechanical, photographic, or electronic process, or in the form of a phonographic recording, nor may it be stored in a retrieval system, transmitted, or other wise copied for public or private use, without written permission from the publisher.


To my wife and best friend, Mariana, who tolerated my many evenings and weekends at the computer. and To my patients from whom I learn.


About the Author

Dr. Quarnstrom graduated from the University of Washington Dental School in 1964 and started his dental career as a dental officer in the United States Navy. He served with the Marine Corps and a Naval Construction Battalion the U.S., Okinawa and Vietnam. After the Navy experience, he spent a year at the Washington Hospital Center in Washington DC in the first year of a medical residency in anesthesia.

He has received fellowships in the Academy of General Dentistry, American Dental Society of Anesthesiology, and the International College of Dentistry. He has presented continuing education courses on nitrous oxide sedation, practice management, computer usage, electronic dental anesthesia, and I V and oral sedation. He has authored 20 papers and two manuals, produced a video tape and continues to do research in nitrous oxide sedation, electronic dental anesthesia, and Halcion oral sedation.

He has been in a private general practice in Seattle since 1967 and holds a the position of Clinical Assistant Professor in the Department of Dental Public Health Sciences at the University of Washington School of Dentistry and the Faculty of Dentistry at the University of British Columbia.


to the users of this manual

When reading this manual, it is important to remember I am a practicing general dentist. As you read it will become obvious why I do not make my living writing. If you understand how I got into the study of dental sedation, it will help explain the approach I take.

I graduated from the University of Washington Dental School at the tender age of 23. I was not ready to start a dental practice so I joined the Navy. I assumed the worst that could happen to me was to be stationed on a ship and get to see some of the world, which at the time was at peace. One year later, I learned the importance of reading the fine print on contracts; as I made an amphibious assault across the beach at Chu Lai, Vietnam as the dental officer of a Naval Construction Battalion attached to the Marine Corps.

The foot peddle powered drill and other short comings of military dentistry left me wondering if I had made a mistake when I chose dentistry over medicine. To this end, I took the first year of an anesthesia residency when I got out of the Navy. One of the challenges I had faced as a military dentist was apprehensive patients. My thought was that phobic patients could be better treated with general anesthesia. In practice, I found IV sedation was adequate, much less complicated, safer and much less exciting than general anesthesia.

About the time I started practicing, nitrous oxide began a resurgence in popularity with general dentists. I made some unfortunate statements about dentists using anesthesia that were not prepared for the potential complications of general anesthesia. Fortunately, no one paid me much attention. Once I saw how nitrous was being use; I realized this technique was very safe. For the next 17 years I used IV sedation, and nitrous oxide to control apprehension in my practice and presented workshops on the use of nitrous oxide.

My practice developed a significant number of patients who depended on IV sedation for their dental treatments. Over the years, malpractice insurance premiums to provide this service continually increased. It finally came to the point where, economically, IV sedation was impractical. It was at this juncture that I started looking for an oral sedative to use with my more apprehensive patients. Halcion was suggested and as of this writing I have treated 150 patients with this drug. I have found little if any physiologic changes, have found patients receptive to this treatment and all the patients have been able to tolerate their dental procedures with the aid of this form of sedation.

The biggest problem in using Halcion has been its use as a sleep aid. Very shortly after starting to use Halcion in my office, it became the topic of many local and national TV, newspaper and magazine stories. The amnesia effect I find very beneficial for dental patients can be a problem for some patients when they use the drug daily to aid sleep. The elderly, in particular, can be come very disorientated because of the cumulative amnesia effect if Halcion is continued for an extended period of time.

It is my firm belief that it is best to use a few drugs you know well. Using a combination of drugs to treat a patient can greatly complicate patient management because the combination may have unwanted side effects. Diazepam by it itself is quite safe, add alcohol and you can have devastating effects on respiration. I have found Halcion to be nearly an ideal drug for dentistry due to its short half life, amnesia, few unwanted side effects and the existence of a selective reversal agent.

It is my hope that this manual will get other dentists interested in using sedative techniques. This manual should be considered a starting place. With a little study, a yearly course in CPR, conservative dosages and a pulse oximeter most dentists should safely be able to treat the apprehensive patient who cannot be treated with nitrous oxide.

I owe thanks to many people. My staff and patients have been helpful in putting up with my research endeavors. Ms. Samone Welch took my manuscript and made it look like I passed 10th grade English. Dr. Ted Jastak, Dr. David Donaldson, and Dr. Peter Milgrom encouraged and helped me with my research and teaching. My wife put up with having me at the computer evenings and weekends for the last several years as I worked on manuals and research. To all of these I say thank you very much.

F.C.Q.


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