Protocol in our office
It should be stressed that we do not want a patient who is asleep. If a patient sleeps they are over-sedated and should be kept awake by verbal commands. We do not worry if the patient is disappointed by their level of sedation because the amnesia that is common to this technique will allow them to forget most if not all of the appointment. It should be emphasized with children that they may still cry during the appointment. If they are controlled enough to allow dentistry to be safely done, they are adequately relaxed and crying, although distracting to the practitioner, is an indication of adequate ventilation.
Because dental sedation is a new, unreported use of triazolam, I feel we should be extremely cautious. I suggest not treating any person who has any medical problem, however slight.
At a pre-appointment interview, we review medical history to determine that there are no contraindications. At that time, I review with the patient the following points:
They are to have no alcohol or other sedatives for twenty-four hours before the appointment.
There should be no chance that they are pregnant.
They have none of the other contraindications.
They will have an adult take them home after the appointment and stay with them that evening.
As with all sedatives, they cannot drive, operate machinery or undertake any activity that could be hazardous. This includes such activities as walking unaided, climbing stairs, etc.
They should not undertake positions of responsibility, care of children, etc.
They should not make important decisions, legal or monetary, etc., for the rest of the day.
They should not have alcohol or other sedatives for twenty-four hours after the appointment
The Procedure
The patient comes to the office one hour before we wish to start their dental procedure. I determine the appropriate dose and have them take the triazolam at that time. Many authors have reported on the appropriate dosage for sleep enhancement. Suggested dosages range from .125 mg. to .5 mg.
I administer a dose that is lower than I think will be adequate the first time I treat a patient. An assistant stays in the operatory with them for the next hour taking vital signs, blood pressure, pulse, and respiration every 15 minutes with instructions to alert me if there is any change. The assistant is instructed to talk with them to assure that they remain awake. I check to see if there is any sign of sedation at thirty minutes. If there is no sedation evident, I will administer one half the original dose. If even slight sedation is noted at that time, we normally will have adequate sedation for the procedure. (Many patients will be disappointed at the end of the forty minutes by the relative lack of sedation. They are assured that this is normal and they will be adequately sedated by the time we start.) I have found that about 75% of patients have amnesia from this point which lasts for 2-3 hours. All patients have had some amnesia of the appointment.
The dental procedure is started at 45 minutes to 1 hour after administration of the drug. I continue to monitor vital signs and talk to the patient to be sure they are awake.
Once the appointment is complete we keep the patient in the dental chair until they are able to walk and I determine they are able to safely leave the office. Post operative instructions, the same as were given to the patient in the pre-appointment interview (see above), are reviewed with the adult who is going to take the patient home and watch over them the rest of the day. In addition, my home phone is given to this adult who is encouraged to call if they have any questions or problems. Finally, an assistant accompanies the patient out to the car supporting the patient so there is no chance of a fall.
It should be noted that the second appointment will normally be easier than the first. It has never been necessary to use a higher dose if the first dose was adequate. Also, as this is a class IV drug, it is necessary to keep careful accounting records on its use.