Fear and anxiety regarding dentistry continue to persist despite the modern advances in local anesthetic agents.1-19 The majority of individuals admit they are fearful to some extent but many avoid dental care altogether.13,19 Using coping skills, most of the general public that have fears and anxieties are able to carry on with normal daily life. An individual with a “specific phobia” is defined as having a fear and anxiety that is so great it inhibits them from normal daily function.20 These patients present the greatest challenge for the dentist.

When looking at fear and anxiety towards dentistry, the majority of the general public have a low level of fear, but they are able to receive dental treatment through various coping mechanisms. A small, but significant portion of the public, have fears so great that it impedes their ability to properly maintain oral heath care.13,19 These are the patients with a high level of fear who probably do not seek dental care on a regular basis. Between these 2 groups are those with moderate levels of fear and anxiety. This group may be able to tolerate minor dental treatment but have a higher level of anxiety for more involved treatment. For example, they may tolerate hygiene appointments, but may not be willing to accept other, more invasive treatments, such as a crown preparation or a root canal treatment. Patients with a moderate to high level of fear and anxiety are more likely to miss, cancel, or avoid a dental appointment.2,7,10,13,19,21,22 The majority of these fearful patients can be easily and safely treated with oral sedatives (Table 1). Adults, in general, have few objections to taking medications by mouth. The oral route is widely accepted, easy, convenient, painless, and inexpensive. The use of sedatives to produce anxiolysis (minimal sedation) in healthy adults is typically safe and effective provided the appropriate dose is prescribed and adequate time is given to allow the drug to reach its peak effect.23

As with all techniques, oral sedation has its limitations, however. Oral sedation can help the majority of patients with mild to moderate levels of fear and anxiety but may be ineffective in patients with higher levels of anxiety.

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The practitioner must remember that a certain portion of the fearful public will not be successfully managed using oral sedation because empiric dosing is not an exact science. For these patients dosages must be titrated intravenously. Even with intravenous sedation, there are still those who will require deeper levels of sedation, deep sedation, or general anesthesia, if dental care is to be provided successfully. Levels of sedation progress as a continuum and each level can be achieved regardless of the route of administration.

Employing oral sedation does not guarantee that a patient will be in a state of anxiolysis, nor does it guarantee that the patient will not drift into deeper levels of sedation. For this reason, patients should be treated with the lowest effective dose of the sedative agent chosen to best suit their needs. When providing sedation, the airway is always of chief concern, regardless of the level provided. While it is unlikely that appropriate doses of the drugs commonly used for oral sedation produce significant respiratory depression, it is important not to get this confused with airway obstruction; obstruction and respiratory depression are not synonymous. For example, a patient’s airway may become obstructed by depressing the mandible during treatment. Until this occurs, a sedated patient may breathe normally, but may not initiate enough ventilatory effort to overcome this obstruction and hypoxemia can occur. This risk for obstruction is a consideration when using any central nervous system (CNS) depressant, regardless of its ability to actually depress medullary respiratory drive.

HISTORY OF ORAL SEDATIVES

By definition, a sedative drug decreases activity, moderates excitement, and calms the recipient.24 The evolution of sedative drugs started with the introduction of fermented beverages by the Sumerians circa 9000BC.25 Aside from nitrous oxide and ether, the modern age of sedative medications began in the 19th century with bromides and chloral hydrate. While the bromides were excellent drugs in their day, they were not often manufactured into pharmaceutically elegant products, allowing the incorporation of impurities. This worsened the already negative side effect profile of bromides which included frequent urination, sweating, visual disturbances, and electrolyte disturbances.26

Chloral hydrate (Noctec) was synthesized in 1832 by the German chemist, Justus von Liebig, and represented the first class of sedative agents to show longevity on the mainstream pharmacopeia. Chloral hydrate is a generalized CNS depressant that acts rapidly, and if given alone, is capable of inducing deep sleep in approximately 30 minutes. It was soon discovered that chloral hydrate worked more quickly in combination with alcohol and, when slipped into whiskey, it was the “knockout drops” of the underworld, also called a “Mickey Finn.”

The most popular sleeping pills of the early 20th were the barbiturates, although the progenitor of the barbiturates was actually discovered in the mid19th century. A Prussian chemist, Adolf von Baeyer, is credited with inventing and naming barbituric acid in the early 1860s. In 1903, a student of Baeyer’s, along with another German chemist, produced a new compound out of barbituric acid and a diethyl derivative. The new chemical, given the tradename Veronal (barbital), was an excellent sedative and sleep aid. Other researchers came up with more barbituric acid derivatives; the most widely used was phenobarbital. Many European and American pharmaceutical companies developed new barbiturates in the 1920s and 1930s. The Eli Lilly Company produced the widely used Amytal (amobarbital) and seconal (secobarbital), and Abbott Laboratories invented Pentothal (thiopental) and Nembutal (Pentobarbital).

Though the barbiturates are effective sleep aids, they are not without risks. Barbiturates support addictive behavior, can have a variety of unpleasant side effects, and their effectiveness is greatly increased when taken concurrently with other CNS depressants. In fact, barbiturate sleeping pills can quickly cause death when taken with alcohol due to their significant cardiovascular and respiratory depressant effects. It is this narrow margin of safety that prompted the development of safer sedative/hypnotic medications (eg, benzodiazepines) during the next few decades. Due to their unacceptable safety profile, the use of barbiturates for sedation can no longer be recommended in most clinical situations.

BENZODIAZEPINES

The benzodiazepines and their newer derivatives are the most widely used class of drugs for anxiolysis and sedation. This is for good reason. Their efficacy is equivalent to or greater than any of the other classes of sedatives and their safety profile is enviable.

Virtually all effects of the benzodiazepines result from their specific actions on the central nervous system. They promote the binding and influence of the major inhibitory neurotransmitter, gamma-aminobutyric acid (GABA) to the GABAA subtype of GABA receptors in the brain. GABA^sub A^ receptors are actually multi-subunit complexes closely associated with gated chloride ion (Cl^sup -^) channels within the cell membrane of neurons. When GABA activates its receptor, the channel opens allowing greater influx of chloride ions and a more negative resting membrane potential. This renders the neuron less responsive to excitatory stimuli.

It is significant that benzodiazepines do not open the chloride channel. They bind to specific benzodiazepine (BZ) receptors on the GABAA complex, separate from the actual receptor for GABA. Activation of the BZ receptor enhances the chloride ion channel’s response to GABA, but no effect is produced if GABA is not present. A benzodiazepine agonist can only potentiate the body’s endogenous neurotransmitter. This concept is a likely explanation for the relative safety of benzodiazepines compared to chloral hydrate, barbiturates, or propofol. These other agents also have distinct receptors on the GABA^sub A^ complex, but actually open the chloride channel independently of GABA. High doses of these agents may be lethal, but death following overdose of benzodiazepines alone is virtually unheard of. This wide margin of safety (high therapeutic index) for benzodiazepines is illustrated using dose-response curves (Figs. 1 & 2). Unlike barbiturates, illustrated in Figure 1, the effectivedose curve and the lethal-dose curve for the benzodiazepines are separated by a very large margin. Even the high doses required for our “hypo-responder” patients are unlikely to cross over to the lethal dose curve. The safety and sedative efficacy of the numerous benzodiazepine formulations are virtually identical. Individual differences in the onset and duration of clinical effects are due to each drug’s unique pharmacokinetic profile. An understanding of these differences will enable the practitioner to select the right drug at the right dose for the right patient and for the right procedure.27

Diazepam (Valium)

Diazepam is often considered the prototypical benzodiazepine and the “grandfather” of the drug class; it has been available for over 42 years and continues to be widely used. It is a highly lipophilic molecule resulting in fast onset of action (usually within 20-40 minutes), and peak plasma levels 1-2 hours after oral administration. It has 100% oral bioavailability and doses range from 2-10 mg for adults. The long elimination half-life of diazepam (20-80 hours) is due to a number of active metabolites (desmethyldiazepam and oxazepam) which may contribute to the daytime drowsiness and “hangover” some may experience.28 Diazepam undergoes hepatic metabolism by oxidative reduction and both the parent molecule and active metabolites are particularly influenced by aging, hepatic dysfunction, and drug-drug interactions.29 Given these shortcomings, the use of diazepam for oral sedation has been largely supplanted by better benzodiazepine alternatives.

Lorazepam (Ativan)

Lorazepam is considered an intermediate-acting benzodiazepine given its elimination halflife of approximately 10-20 hours. However, this system of classification is actually misleading. Despite a half-life shorter than diazepam, the actual sedative effect is generally longer because it has lower lipid solubility which slows its redistribution from the brain.30 Lorazepam undergoes phase II hepatic metabolism via glucuronide conjugation to inactive metabolites that are rapidly excreted via the kidney, rather than phase I hepatic metabolism which is affected by competition by the cytochrome P450 enzyme system often resulting in active metabolites. Lorazepam is therefore less affected by variables such as advanced age, hepatic dysfunction, or drug-drug interactions. It has an oral bioavailability of 83 to 100% with peak plasma levels occurring 1-2 hours after administration. The onset of action following oral administration occurs within 60 minutes.31 Usual adult doses for dental sedation patients can range from as low as 0.5mg to 4mg depending on patient and procedural criteria.32-34

Triazolam (Halcion)

Triazolam is widely used for the short-term treatment of insomnia. Its rapid onset, short duration of action, and lack of active metabolites makes it a near ideal anti-anxiety medication for dental patients.35 It is short-acting with an onset of activity usually within 30 minutes, and with peak blood levels occurring after approximately 75 minutes. The oral bioavailability for triazolam is only 44% but can be increased to 53% with sublingual administration.35-37

The usual adult dose for oral sedation can range from 0.125 mg to 0.5 mg.27,38 Triazolam has no active major metabolites. It is metabolized by oxidative reduction via the hepatic cytochrome P45O 3A4 system and like diazepam, can be influenced by aging, hepatic dysfunction, and drugdrug interactions.39,40

Midazolam (Versed)

Midazolam is rapidly absorbed when administered orally either as a premixed syrup or by diluting the intravenous formulation in a pH-balanced, palatable, liquid vehicle (eg, apple juice). It has an oral bioavailability of 35 to 44% with an onset of action within 15-30 minutes, and peak plasma levels achieved within 20-50 minutes.41 Midazolam has largely replaced chloral hydrate as the medication of choice for pediatric sedation patients.35,43,44 Although, anecdotally, there have been reports of using the intravenous preparation of midazolam orally for short procedures on adults with doses at 0.25mg/kg with a cumulative maximum of 20mg being common, there have not been any published case series at this time to validate its effectiveness. Comparing pharmacodynamic effects, an oral dose of 0.25 mg of triazolam was found to be equivalent to oral midazolam in doses of 5mg to 8mg.45 Midazolam offers no advantage over triazolam for adult patients, unless they cannot swallow tablets. The actual niche for oral midazolam is for pediatric sedation and is not the focus of this article.

THE NONBENZODIAZEPINE GABA AGONISTS

Although the benzodiazepines have been touted as ideal sedative agents, the GABA^sub A^ receptor complex has many subunits that make up the macromolecular structure.35 The GABA^sup A^ receptor is composed of 5 subunits, with the ?1, ?2, ?3, and ?5 receptors thought to function as BZ receptor sites and mediate the clinical effects of benzodiazepines, including sedative, muscle relaxant, antiseizure, amnesic, and anxiolytic effects. However, the nonselective interaction between benzodiazepines and all of the GABA subunits may contribute to adverse drug effects, such as residual daytime sedation, cognitive impairment, rebound insomnia, and the risk of abuse. As research continues to clarify these receptor subunits, novel agonists will be developed that act more selectively. The socalled “nonbenzodiazepine” hypnotics are the product of this goal, but marketing strategies are currently well ahead of actual scientific confirmation.

These agents are chemically distinct from benzodiazepines. This allows them to be classified separately and be divorced from negative perceptions associated with benzodiazepines. However, they are BZ receptor agonists and their effects and clinical profiles are indistinguishable from benzodiazepines. Furthermore, their effects can be reversed using the benzodiazepine antagonist, flumazenil. They generally are claimed to have some selectivity for the ?1 subunit (BZ^sub 1^ receptor) described above which putatively reduces their potential for cognitive impairment and abuse.46 Whether these claims actually bear fruit remains to be seen.

Zolpidem (Ambien)

Unlike the benzodiazepines, zolpidem produces muscle relaxation and anticonvulsant effects only at doses much higher than the hypnotic dose.47 Zolpidem has a rapid onset of action, usually within 30 minutes, has a short elimination half-life and no active metabolites. This reduces the possibility of residual nextday effects from prolonged or excessive sedation. CNS depression with latent impairment of cognitive and motor function, commonly seen with barbiturates or long-acting benzodiazepines, is not common with zolpidem. Zolpidem is not contraindicated in pregnancy or in patients with narrow angle glaucoma; both are advantages over the benzodiazepines. The usual adult dose is 10mg, although 5mg tablets are also available and may be recommended for elderly patients or patients on other CNS depressants.48 Flumazenil (Anexate, Romazicon) will antagonize the sedative actions of zolpidem.49 Zolpidem received Food and Drug Administration (FDA) approval in 1993 and a supplemental new drug application was filed by Biovail Pharmaceuticals in January 2002 for approval of an oral disintegrating dosage form of zolpidem.

Sustained-release zolpidem (Ambien CR) was approved by the FDA on September 2, 2005 and although it has a specific role in the treatment of insomnia (“controlled-release” to address sleep latency), this new formulation would have no role for inoffice oral sedation.50

Zopiclone (Imovane)

Zopiclone is another nonbenzodiazepine that produces its hypnotic effects via selective stimulation of the ?1 subunit of the GABA^sub A^ macromolecular complex.51 While this medication is not available in the United States, the active S-enantiomer of this molecule, eszopiclone (Lunesta), has been marketed as a hypnotic agent in its own right. Zopiclone also has a rapid onset of action, usually within 30 minutes, and a short halflife (3.5-5 hours) and no active metabolites. This makes its pharmacokinetic profile very similar to zolpidem. The average adult dose is 7.5-15mg, and it is available as 5mg and 7.5mg tablets. Flumazenil will also antagonize the sedative actions of zopiclone.52

Eszopiclone (Lunesta)

Eszopiclone is one of the most recent additions to the nonbenzodiazepine class of sedative agents. As such there are very few data on its use in the dental realm. Its pharmacokinetic profile is similar to that of the parent compound, zopiclone, since eszopiclone is simply the S-enantiomer of the parent compound zopiclone. As such, flumazenil would also antagonize the sedative actions of eszopiclone.52 Eszopiclone was approved by the FDA in December 2004.53,54

Zaleplon (Sonata, Starnoc)

Zaleplon (Sonata, Starnoc) is a short-acting, nonbenzodiazepine sedative-hypnotic that also possesses anticonvulsant, anxiolytic, hypnotic, and myorelaxant properties. Zaleplon was FDA-approved in 1999 and has a faster onset of action and a shorter terminal elimination half-life than zolpidem. Zaleplon is available in 5mg and 10mg capsules and the usual dosing range is from 5mg to 20mg.55 In Japanese adults (and possibly other Asian populations), the maximum concentration in the blood (Cmax) as well as the total amount of drug absorbed from a single dose of zaleplon were increased 37 and 64%, respectively. This is likely due to differences in body weight or may represent differences in enzyme activities resulting from differences in diet, environment, or other factors. More conservative dosing of zaleplon in this patient population would be prudent. Flumazenil can also antagonize the sedative actions of zaleplon.56

Indiplon is from the same drug class as zaleplon and was being coproduced by Pfizer and Neurocrine Biosciences Inc to compete with Ambien and Lunesta.57 By early 2006, however, they had failed to win federal regulatory approval in the United States, yet literature citing this drug’s efficacy from other countries continues to populate the medical literature.58

Ramelteon (Rozerem)

Ramelteon is the first drug in the melatonin receptor agonist class of hypnotic therapies which has recently been FDA-approved for insomnia management and which works by a completely different mechanism than all the medications discussed thus far.59 The melatonin MT1 and MT2 receptors are thought to be involved in the maintenance of circadian rhythm, which regulates the sleep-wake cycle.60 Ramelteon has high selectivity and affinity for melatonin MTl and MT2 receptors which is believed to contribute to its sedation-promoting properties. Since its approval for the treatment of insomnia in 2005, ramelteon has been found to be very useful in treating patients having difficulty with sleep onset. The utility of this medication in the dental realm is slowly gaining interest, as this is the only sedative medication described thus far that is not a federally controlled substance.

The unique and targeted mechanism of action of this drug also limits its side effect profile; it is not associated with an abuse potential or “hangover” effect often found with other sedatives. Ramelteon has no measurable affinity for the GABA receptor complex, dopamine, or opiate receptors. Ramelteon is available as 8mg tablets and has an average onset of action of approximately 30 minutes and an elimination half-life of 2.6-5 hours.61 Ramelteon does not offer the benefit of anterograde amnesia found with benzodiazepines or other nonbenzodiazepine agents discussed thus far. Its action cannot be reversed by flumazenil.

THE ANTIHISTAMINES

While antihistamines are primarily used to manage allergic type reactions, they also cause sedation as a side effect. The strong calming and sleep-inducing effects of Atarax, Benadryl, and Phenergan in particular, led to these medications being marketed as sedative-hypnotics in addition to some of their other effects in preventing nausea, vomiting, and the adverse sequelae of allergic reactions. The actual sedative efficacy of these agents is generally less than that with benzodiazepines.

Hydroxyzine (Atarax, Vistaril) is an antihistamine (H1-antagonist) sedative which has an onset of action within 15 to 30 minutes. The maximum effect is achieved after approximately 2 hours, and drug effect wanes after 3-4 hours. The incidence of side effects with hydroxyzine is low. Other than drowsiness, hydroxyzine has minimal effect on cardiovascular or respiratory function. Usual adult doses range from 50mg to 100mg.62

Diphenhydramine (Benadryl) is an H1-antagonist of the ethanolamine class. Other members of this group include carbinoxamine, clemastine, dimenhydrinate (a salt of diphenhydramine), doxylamine, phenyltoloxamine, and others. Ethanolamine H1-antagonists have significant antimuscarinic activity and produce marked sedation in most patients. Diphenhydramine is a popular antihistamine due to its relative safety after oral or parenteral administration.

In addition to the usual allergic symptoms, the drug also treats irritant cough, although the airway drying effect may be counterproductive. Because of its anticholinergic properties, diphenhydramine is effective in the relief of nausea, vomiting, and vertigo associated with motion sickness.63

Diphenhydramine was originally approved by the FDA in 1946 as a prescription-only drug but was later changed to nonprescription, over-the-counter (OTC) status. Due to its ability to induce drowsiness, it is also promoted as an OTC hypnotic (Sominex). The onset of action following oral administration of diphenhydramine occurs in 15 to 30 minutes, with peak concentrations occurring in about 2 to 4 hours. Typical adult doses for sedation are 25mg to 50 mg.64

Promethazine (Phenergan) has been available since 1951 and although it has long been utilized as a sedative agent, it is a phenothiazine as well as an antihistamine. It has considerable anticholinergic, sedative, antiemetic, and some local anesthetic properties. In November 2004 the FDA directed manufacturers of promethazine to include a Black Box warning contraindicating its use in children <2 years of age given the increased risk for fatal respiratory depression in these very young children. Typical adult doses for sedation are 25-50mg.65

THERAPEUTIC CONSIDERATIONS

The most common use of oral sedation in adults is for the reduction of anxiety preceding and during the dental appointment. For some, the use of oral sedation the night before their appointment can ensure a more restful sleep leading to a more pleasant and relaxed patient for the dental appointment.66

Due to the varying recovery profiles of many different sedative agents available, the patient should be advised not to drive, make important decisions, or consume alcohol for a period of 24 hours after the appointment. This requires the patient to have an escort who must be a responsible adult. It would be ill-advised to allow a patient to leave the office unaccompanied.

On the day of the appointment, it would be prudent to administer the medication in the dental office where it is a controlled and monitored environment. Advantages of this protocol include the following:

1. The escort can be confirmed. Although a common scenario would be to have the patient take the sedative 1 hour at home prior to the start of the appointment, it may be beneficial to administer the medication at the dental office. Administering the medication in the office while supervised allows for the confirmation of the amount taken and can prevent the patient from self-medicating prior to arriving at the office and forgetting that an escort is needed, thereby driving unescorted to the dental office.

2. Written consent, if needed or required, can be obtained prior to administration of the sedative. Depending on the state or province, a practitioner may be required to obtain written informed consent that allows dental treatment while the patient is in an altered state of consciousness. If the patient were to take the oral sedative prior to arriving at the office, the informed consent must be acquired on a previous appointment.

3. Any change or confirmation of dental work that is or is not to be completed during the appointment can be confirmed prior to the administration of the sedative.

Selecting the Medication

It is important for the clinician to choose the sedative agent that will best suit the patient based on the patient’s age, weight, and medical history rather than solely based of the length of time required for the dental treatment. The choice of the drug also depends on the familiarity of the drug to the practitioner. The absolute contraindication of any medication is the lack of knowledge of the pharmacology of that drug.

Since all patients will react differently to medications, it would be prudent to start with a shorter appointment and with treatment that is not too invasive in order to gauge the appropriateness of the chosen sedative agent. The amount administered should always be the lowest effective dose.

For the first appointment, the dentist should consider starting with the lowest dose that is known to be effective. Discussions with the patient the day after the initial sedation appointment will help to determine if the oral sedative used is appropriate in dose and type. What the physician deems as an adequate or inadequate dosage may actually differ from the patient’s own experience of the appointment.67 If the initial dose proves to be inadequate, the amount given can be increased during subsequent appointments. Although the weight of the patient can be useful in determining the initial dose, the level of fear and anxiety may be a more accurate determinant. At this time, however, there are few data that correlate the level of fear and the appropriate dose of an oral sedative.

The myriad of benzodiazepines and related agents have comparable efficacy and the one selected is most likely predicated on its pharmacokinetic properties. These will predict an onset and duration most appropriate for the treatment session. The following are a few examples.

For short dental procedures (<1 hour), the use of zaleplon has been shown to be effective. A study by Ganzberg et al has shown good efficacy with the use of zaleplon (Starnoc, Sonata) in patients for third molar extraction. This study demonstrated efficacy comparable to triazolam and a faster recovery from the sedation in the zaleplon arm of the study.68 For very short dental appointments, zaleplon 10-20 mg given 1 hour prior to the procedure may provide adequate sedation.

For dental procedures of moderate length (1-2 hours), triazolam (Halcion), a short-acting benzodiazepine, in the dose of 0.125-0.5mg, can be given 1 hour before the procedure. Triazolam is a popular choice among clinicians due to its anxiolytic, hypnotic, and amnesic effects, which are desirable in dental patients. It has a relatively short half-life with little residual hangover effects the next day.

For longer appointments (2-4 hours), a longer acting benzodiazepine such as lorazepam (Ativan) may be prescribed. Oral lorazepam in the dose of 1-4mg may be given 1-2 hours prior to the dental procedure or 30-60 minutes prior for the sublingual preparation. The antihistamines have also been used as sedatives for short to long dental procedures. Diphenhydramine (Benadryl) may be prescribed in the dose of 50mg 1 hour prior to the dental procedure. Hydroxyzine (Atarax) with a longer half-life than diphenhydramine can be given in the dose of 50-100mg 1 hour before the appointment. Yet another antihistamine with a similar halflife as hydroxyzine is promethazine (Phenergan), and it is typically given in a dose of 25-50mg 1 hour prior to the procedure. Be aware that patients may experience anticholinergic side effects such as dry mouth; and for patients with angle-closure glaucoma, these antihistamines should be avoided.69

Geriatric Patients

The patient’s age is important in the selection of an oral sedative drug and dosage. For geriatric patients, many physiological and psychological changes take place with age such as decreased cerebral blood flow, cardiac output, renal and hepatic blood flow, and pulmonary function. Furthermore, these individuals tend to suffer from at least one chronic condition such as heart disease, hypertension, arthritis, osteoporosis, and noninsulin-dependent (type 2) diabetes mellitus, all requiring long-term control with drug therapy and occasionally surgery. In addition, there are also pharmacodynamic and pharmacokinetic differences in elderly patients.

Pharmacokinetically, oral absorption, hepatic metabolism, and renal clearance all decrease with age. Pharmacodynamically, oral sedatives and other CNS depressants tend to have a greater effect in the elderly. This, together with polypharmacy in this patient population, contributes to the lower dosages and shorter acting medications that are typically required in order to avoid oversedation.70

A suggested short-acting benzodiazepine such as triazolam in a starting dosage of 0.125-0.25mg given 1 hour before the dental appointment may be effective. For short appointments, another shorter acting (nonbenzodiazepine) alternative is zaleplon in a starting dose of 10mg, or zolpidem regular release in a dose of 5-10mg 1 hour prior to the appointment may be used. Alternatively, for longer appointments, a longer acting benzodiazepine such as lorazepam may be prescribed. Oral lorazepam in the dose of 0.5-lmg may be given 1-2 hours before or 30-60 minutes before the dental procedure for the sublingual preparation. Diazepam has a long half-life which is further extended in elderly patients; thus, its use in these individuals is not recommended. The antihistamines are typically longer acting and have anticholinergic side effects that are less desirable in geriatric patients, those at risk for falls, and especially those with glaucoma or evidence of dementia.

MEDICALLY COMPROMISED PATIENTS

Patients with underlying medical conditions will often benefit from oral sedation to minimize preoperative anxiety. Medical consultation is often recommended to understand the severity and stability as well as the treatment and control of any existing conditions prior to the administration of oral sedative drugs.

Cardiovascular Disease

Anxiety and pain increase heart rate and blood pressure, leading to an increased oxygen demand of the myocardium. With coronary artery disease, this increased oxygen requirement may not be met and episodes of angina and dysrhythmias can result. The use of sedation as well as excellent pain control both during and after the appointment are of increasing importance. These patients often benefit from oral sedation due to the decreased stress of the appointment especially during long or traumatic appointments. Excessive sedation can cause significant respiratory depression leading to hypoxia and subsequent myocardial ischemia. The use of supplemental oxygen should be considered even with mild sedation. Adequate pain control through profound local anesthesia as well as postoperative pain control with nonsteroidal antiinflammatory drugs (NSAIDs) and opioids are important for patients with cardiovascular disease. All of these considerations are also applicable to patients with hypertension.

Renal and Hepatic Disease

The benzodiazepines are generally safer than other anti-anxiety agents and short-term administration is effective. Because of the potential for drug or metabolite accumulation, chronic use of these agents is discouraged. For single doses used in oral sedation, dose adjustment of the benzodiazepines is required. Chloral hydrate, however, is renally cleared and its use should be avoided in these patients.71

Respiratory Disease

Minimal oral sedation in the usual doses is safe and beneficial for patients with asthma or chronic obstructive pulmonary disease (COPD). Stress can be a trigger for bronchospasm in patients with asthma as well as in patients with chronic bronchitis. The anticholinergic effects of the antihistamines may not only be desirable in these patients but may be of great benefit. The other oral sedatives such as the benzodiazepines can also be readily used.

Epilepsy

Minimal oral sedation may also be of benefit to this group of patients. The benzodiazepines have anticonvulsant activity and are often the drugs of choice for these patients. With unintentional oversedation, supplemental oxygen should be given to avoid hypoxia that can trigger a seizure. Some antiepileptic drugs (eg, phenytoin, carbamazepine, phenobarbital, valproic acid) are hepatic enzyme inducers that may increase the clearance of oral sedative drugs, thereby shortening their duration of action.

Diabetes Mellitus

Oral sedation can be used in patients with type 1 or type 2 diabetes mellitus. It is important to remind patients to maintain their caloric intake and their regular meals both before and after the appointment. If they sleep through a meal or do not eat their regular full meal due to the sedation, then the doses of their insulin or their oral hypoglycemic medication may need to be adjusted. Appointments for patients with diabetes should be kept short to prevent long periods of fasting. Keep in mind that signs and symptoms of hypoglycemia such as altered mental state and fatigue can be easily confused with an exaggerated response to CNS depressants.

Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) affects 2-4% of middle-aged adults.72 It is defined as apnea events lasting 10 seconds or longer that occur 5 times or more per hour during sleep.73 OSA can lead to hypoxemia, hypercarbia, polycythemia, systemic and pulmonary hypertension, and right ventricle failure. During rapid eye movement (REM) sleep, muscles that usually stent the airway open are relaxed. This results in significant narrowing of the airway.

Patients with OSA are extremely sensitive to CNS depressants and are at risk for upper airway obstruction even with minimal doses of these drugs.74 Treatment of patients with OSA using oral sedatives should be approached with caution as a loss of the airway can readily occur in this patient population. The use of supplemental oxygen is encouraged.

CONCLUSION

This overview is intended as an introduction to minimal oral sedation (anxiolysis) in the dental office and is not meant to replace continuing education taught by those with advanced training in this area. Using oral sedation techniques will allow patients to visit the dentist in a stressreduced state, where their fear and anxiety would otherwise impede their ability to seek and maintain proper oral health care. To date, this modality has been proven to be not only safe but very effective. Proper medication selection and patient management, however, are paramount to maintaining this safe practice.
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According to a study from Brazil, “Tooth avulsion is the complete displacement of a tooth from its socket due to intentional or non-intentional injuries. Treatment in these cases comprises tooth replantation.”

“This accident is very critical as the success of tooth replantation is directly dependent on several factors, such as extra-alveolar period, storage of the tooth until replantation, type of retention employed, time of endodontic intervention, type of drug prescribed, oral hygiene status as well as general health. This trauma commonly occurs during sports practice, school, and leisure activities. The first measures are critical for the prognosis of the avulsed tooth. Several studies report lack of knowledge of the population, educators, sports professionals, and health professionals in the management of tooth avulsion. This study evaluated the influence of education on different groups of professionals, addressing the knowledge and prevention and emergency management of the avulsed tooth. The study was conducted on five different groups of professionals (elementary school teachers, physical education professionals, bank employees, dental doctors, and pediatricians) from the city of Brasilia, DF, Brazil. The professionals attended a lecture and were evaluated by a questionnaire applied twice, before and after the lecture. The results of the 479 returned questionnaires were analyzed. The difference between questionnaires before and after the lecture was statistically analyzed by the Wilcoxon test. There was statistically significant change in the performance of professional groups after information was provided (P < 0.0001),” wrote M.D.V. Frujeri and colleagues (see also <http://www.newsrx.com/library/topics/Dentistry.html> Dentistry).

The researchers concluded: “Education is extremely important to favor the knowledge on prevention and emergency management of an avulsed tooth, and may enhance the prognosis of tooth avulsion.”

Frujeri and colleagues published their study in Dental Traumatology (Effect of a single dental health education on the management of permanent avulsed teeth by different groups of professionals. Dental Traumatology, 2009;25(3):262-271).

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Most people know that smoking can cause heart disease, stroke, lung cancer or other respiratory diseases. But many don’t know that smoking causes tooth decay and gum disease.

Drinking beverages like sports drinks or soda and eating sugary, starchy foods are not the only culprits. Smoking affects the whole mouth–teeth and gums. Besides decay, it can lead to oral cancer.

Smoking contributes to tooth decay and gum loss. It compromises the flow, amount and function of saliva in the mouth. Saliva is important for cleaning the lining of the mouth and teeth. The flow of saliva helps to counteract mouth acids that cause decay and protects the teeth from wearing away. The calcium in saliva helps to prevent tooth decay. The calcium remineralizes (hardens) the surfaces of the teeth.

Studies show that smokers tend to have more tooth decay than nonsmokers. Some studies show that children who are raised in households where one or both adults smoke are more likely to develop tooth decay because of mouth, breathing and respiratory infections.

Smoking can cause gum disease, which leads to tooth loss. Smoking reduces blood flow to the gums and cuts the supply of vital nutrients. It can also reduce the vitamin C levels needed to maintain healthy gums. It causes receding gums. The gums wear away; the teeth become loose and fall out. The tooth roots are exposed, which also increases the risk of tooth decay. These two factors–reduced blood flow and vitamin C levels– make attempts to treat gum disease in smokers less likely to succeed.

Smoking also raises the mouth’s temperature, damaging and killing important cells and tissues in the mouth. The combination of high mouth temperature and cancer-causing compounds found in cigarettes (and cigars) can cause oral cancer, cancer of the mouth.

Smokers are two to 18 times more likely to develop oral cancer than nonsmokers. It depends on how heavily they smoke. Oral cancer strikes more Americans annually than some better-known cancers such as brain, thyroid, stomach, cervical and ovarian cancer. From 1997 to 2006, there were 110 cases of oral cancer among Department of Defense service members ages 20 to 24. For DoD service members over 40, oral cancer ranged from 116 to 122 cases per year.

The overall survival rate for oral cancer is low– nearly half of all oral cancer patients die within five years. More than half of all oral cancer cases are not detected until they reach an advanced stage. Early warning signs of oral cancer include:

A swelling, lump or growth in the mouth that does not heal. White or red patches inside the mouth that don’t go away.

Loose teeth for no apparent reason. Pain when swallowing. Persistent sore throat. Difficulty swallowing or in opening your mouth. A nagging cough or persistent hoarseness.

Unusual bleeding in your nose or mouth. Numbness or tingling in your lips or tongue. Getting an oral cancer examination at your annual dental visit is a way to screen for the risk of oral cancer. As a Soldier, it is very important to maintain good oral hygiene in the field to prevent tooth decay and gum disease. A Soldier’s risk of tooth decay increases in the field. Rations have a high amount of starch and sugar which bacteria use to produce acids that cause tooth decay.

A person’s best defense against tooth decay and oral cancer is to stop smoking.

Practice good hygiene by flossing and brushing daily. Perform an oral cancer selfexam every month if you are at risk for oral cancer.

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The Free Lance-Star, Fredericksburg, Va., story headlined “Ailing teeth and gums can affect whole body” (slug FB-Ailing-teeth-and-gums-can-affect-whole-body-THINGS-TO-WATCH-OUT-FOR-0208), moved by McClatchy-Tribune Regional News for Feb. 8, incorrectly reported in the fourth graf the job title of Misty Mesimer, a registered dental hygienist.

Feb. 8–We’ve long known that poor dental hygiene can lead to tooth decay, painful cavities and losing friends due to bad breath. But dentists say few people are aware that bad dental habits also can lead to serious conditions like heart disease.

A report issued by the surgeon general in 2000 detailed how poor oral health is highly correlated with oral cancer, diabetes, heart disease and, for women, premature or low-birth-weight babies. Subsequent studies have indicated that people with periodontal disease are at greater risk of suffering a heart attack.

There may not be a cause-and-effect relationship between poor hygiene and the diseases mentioned in the surgeon general’s report — the connection is still being studied.

But the correlation is important, said Misty Mesimer, a registered dental hygienist and local coordinator for the Germanna Community College dental hygiene program.

“We don’t know if poor dental hygiene leads directly to diseases, but having periodontal disease is not going to help your outcome of avoiding heart disease,” Mesimer said. “It’s one more infection that your body has to fight.”

Mesimer said the surgeon general’s report has shaped the way the dental program trains its students.

“In the curriculum at Germanna, students actually deal with patients with special medical conditions and observe the relationship between dental hygiene and other diseases,” she said.

Dental disease is the No. 1 preventable disease in America, Mesimer noted.

“Dental decay is more common than asthma, and unlike asthma, it can be prevented with dental hygiene and checkups,” she said.

The type of dental disease that most frequently leads to health issues elsewhere in the body is periodontal disease. Periodontal disease occurs when bacteria in the mouth causes an infection in the gums and bone beneath the gums.

Fredericksburg dentist Dr. Cathie Butterworth said that 85 percent of people who have the disease don’t realize it.

“Periodontal disease doesn’t hurt, so only a dentist can tell you if you have it,” Butterworth said. “Some people don’t notice until their teeth are loose or their spouse says, ‘Your breath is killing me!’” Symptoms of periodontal disease include: tender gums loose teeth gums that bleed during brushing or flossing.

Patients often aren’t aware of the symptoms, Butterworth said.

“People come in and they say, ‘Nobody told me bleeding gums weren’t normal!’ Bleeding gums are not normal,” she said.

To prevent periodontal disease, Butterworth recommends brushing twice a day, flossing once a day, and using a germ-killing mouthwash like Listerine.

“The mouth is the dirtiest part of the body, and you need to clean it to keep bacteria from getting into the bloodstream and causing infections elsewhere in the body,” she said.

If Butterworth discovers that a patient has developed periodontal disease, treatment becomes more intense.

“We make them come in every 3 months for a cleaning,” Butterworth said. “We do the same with diabetics since they don’t fight infection as well and are more likely to get periodontal disease.”

Diabetics, Butterworth said, are one of the groups of people most at risk for the disease. She said smokers, the obese, older adults and people prone to bacteria because of genetics also have an increased risk for periodontal disease.

Fredericksburg periodontist Dr. Julie Schuster said patients undergo more serious cleaning when periodontal disease is discovered.

“We start with a deep cleaning,” Schuster said. “[The disease] starts as a localized infection in the mouth, but if the bacteria enters the bloodstream, it could reach the heart.”

If cleaning doesn’t work, Schuster might perform surgery to eliminate some tissue and bone around the teeth.

“If not treated, a person could end up losing their teeth,” she said.

Poor overall health habits may be one explanation for the link between bad dental hygiene and other diseases. People who neglect their teeth may also neglect their overall health.

Another theory, at least for the link between heart disease and dental disease, is that after oral bacteria enter the bloodstream, they may attach to plaque in the coronary arteries.

Whatever the reason for the correlation, Schuster said it’s important to pay attention to poor dental health.

“Periodontal disease can be an indication of unhealthy things elsewhere,” Schuster said. “If you have periodontal disease, chances are you have high blood pressure, poor circulation or another health issue.”

In the case of a pregnant woman, periodontal disease can affect not only the woman’s health, but the health of her child, as the disease is linked to premature birth.

To prevent periodontal disease, people need to practice good habits like brushing and flossing daily, and going in for regular dental checkups, Schuster said. The alternative is risking an unwanted diagnosis.

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UnitedHealthcare Specialty Benefits now provides coverage under all of its insured dental plans for a new oral cancer screening test for potential abnormalities inside the mouth, including premalignant lesions and oral cancer.

The test, which uses light-contrast technology, can improve a dentist’s ability to identify, evaluate and monitor lesions that are difficult to see using visual inspection under conventional lighting.

“Evidence shows that dentists can serve as a valuable ‘early warning’ system for patients who have signs of oral cancer,” said Dr. Michael Weitzner, vice president of clinical product development for UnitedHealthcare Specialty Benefits dental unit.

More than 34,000 Americans will be diagnosed with oral or pharyngeal cancer this year. The death rate associated with this cancer is particularly high – not because it is hard to discover or diagnose, but due to the cancer being routinely discovered late in its development. Studies confirm that survival does correlate with stage, making early diagnosis and treatment optimal for this disease and may have a positive impact on an individual’s medical costs (Journal of the American Dental Association, Vol. 132, Nov. 2001).

By covering this type of oral cancer screening, UnitedHealthcare Specialty Benefits dental unit is renewing its longstanding commitment to early detection of oral cancer. In addition to oral cancer screening, UnitedHealthcare Specialty Benefits dental plans have covered brush biopsies since 2005 when the American Dental Association first introduced a current dental terminology (CDT) code for the procedure. Screening is covered once a year for individuals, starting at age 30. UnitedHealthcare Specialty Benefits’ focus on wellness continues to build programs and plan enhancements that promote individuals’ ability to better manage their overall health as well as their future medical and dental costs.

About UnitedHealthcare Specialty Benefits

UnitedHealthcare Specialty Benefits offers a broad array of specialty benefits, including vision, dental, group and voluntary insurance, worksite individual insurance and non-insurance programs. UnitedHealthcare Specialty Benefits is a business unit of OptumHealth, the health and wellness unit of UnitedHealth Group, Inc. (NYSE:UNH). More information about OptumHealth can be found at www.optumhealth.com/.

Keywords: Women, Health, Dental, Oncology, Radiology, Other Health, Professional Services, Insurance, Consumer, Men, I, Technology, OptumHealth.

This article was prepared by Insurance Business Weekly editors from staff and other reports. Copyright 2008, Insurance Business Weekly via VerticalNews.com.

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More than 8,000 people die each year of oral cancer, and a Creighton University student group is trying to prevent some of those deaths.

The Creighton chapter of the Student National Dental Association held a walk along the Omaha riverfront this morning to call attention to oral cancer and raise money to fight it.

The hope is that people with the disease will be diagnosed earlier, said Erica Ross, a Creighton dental student and one of the event’s organizers.

People often don’t realize that symptoms of oral cancer, like bleeding in the mouth, are signs of a serious illness. By the time they try to receive treatment, Ross said, not much can be done.

“Early diagnosis is best,” she said.

Risk factors for oral cancer include tobacco use and alcohol consumption.

oral cancer

Jun. 28–More than 8,000 people die each year of oral cancer, and a Creighton University student group is trying to prevent some of those deaths.

The Creighton chapter of the Student National Dental Association held a walk Saturday along the Omaha riverfront to call attention to oral cancer and raise money to fight it.

The hope is that people with the disease will be diagnosed earlier, said Erica Ross, a Creighton dental student and one of the event’s organizers.

People often don’t realize that the symptoms of oral cancer, like bleeding in the mouth, are signs of a serious illness.

By the time they try to receive treatment, Ross said, little can be done.

“Early diagnosis is best,” she said.

Risk factors for oral cancer include tobacco use and alcohol consumption.

Krystal Willie, one of about 50 participants in the walk, said she liked that the event focused on preventing a type of cancer that doesn’t usually receive much attention.

“People forget about oral cancer,” said Willie, a Southern Utah University senior doing a summer enrichment program at Creighton.

Ross said she expected the group to raise about $2,300 through sponsors and registration fees from the walk, which began at Miller’s Landing.

Some proceeds will be donated to the Oral Cancer Foundation. The rest will be used toward the Creighton group’s outreach and education projects.

oral cancer

New research, ‘HuR is exported to the cytoplasm in oral cancer cells in a different manner from that of normal cells,’ is the subject of a report (see also <http://www.newsrx.com/library/topics/Oral-Cancer.html> Oral Cancer). According to recent research published in the British Journal of Cancer, “HuR, a ubiquitously expressed member of the Hu protein family that binds and stabilizes an AU-rich element (ARE)-containing mRNAs, is known to shuttle between the nucleus and the cytoplasm via several export pathways. When normal cells were treated with heat shock, HuR was exported to the cytoplasm in a chromosome maintenance region 1 (CRM1)-dependent manner.”

“However, in this study, we demonstrate that HuR is exported to the cytoplasm in oral cancer cells even if the cells were treated with the inhibitor of the CRM1-independent export pathway. Immunohistochemical and biochemical analyses showed that HuR existed in both the cytoplasm and the nucleus in oral cancer cells, such as HSC-3 and Ca9.22, but existed entirely inside the nucleus in normal cells. AU-rich element-mRNAs were also exported to the cytoplasm and stabilised in the oral cancer cells, which were inhibited by HuR knockdown. This export of HuR was not affected by at least 7 h of treatment of leptomycin B (LMB), which is an inhibitor of the CRM1-dependent export pathway,” wrote H. Hasegawa and colleagues, Hokkaido University.

The researchers concluded: “These findings suggest that HuR is exported to the cytoplasm in oral carcinoma cells in a different manner from that of normal cells, and is likely to occur through the perturbation of a normal export pathway.”

Hasegawa and colleagues published their study in British Journal of Cancer (HuR is exported to the cytoplasm in oral cancer cells in a different manner from that of normal cells. British Journal of Cancer, 2009;100(12):1943-8).

For additional information, contact H. Hasegawa, Hokkaido University Graduate School of Dental Medicine, Dept. of Oral Pathology and Biology, North 13 West 7, Kita-ku, Sapporo 060-8586, Japan.

The publisher’s contact information for the British Journal of Cancer is: Nature Publishing Group, 345 Park Avenue South, New York, NY 10010-1707, USA.

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New methods and technologies have changed nearly everything about going to the dentist. But the connection between the patient and dentist is still what matters most. That’s what makes East State Dental Care unique. Dr. Angela Coleman offers her patients the latest in comprehensive dental care, while building a professional relationship with her patients. Armed with an array of the latest innovations, she and her team of  dentalplans professionals treat patients of all ages. With high standards and integrity, her skilled team is dedicated to ensuring their patients’ dental experiences exceed their expectations.

“Dentistry is advancing rapidly,” Coleman says. “My team and I are committed to staying up-to-date on the latest advancements in dental technique and technology so we can give our patients the best care available.”

Coleman sees dental care as an important part of treating her patients’ overall health.

“We offer a complete exam because dentalplans problems in and around the mouth can cause or indicate other concerns,” she says. “For example, periodontal disease has been linked as a possible contributing factor to heart attack, stroke and diabetes. If the gums are inflamed, it means the body is always under attack and that needs attention. We also look at the neck and thyroid for problems using an oral cancer screening. Our patients develop an understanding about the connection between dental health and overall health.”

Digital radiography is now used at East State Dental Care to help detect cavities and other abnormalities. This technology is far more precise than traditional x-rays and provides approximately half the radiation in less time. Some of the other advancements include FDA-approved ViziLite Plus. ViziLite Plus is an oral cancer screening that identifies abnormal oral lesions at their earliest stage of development, even cells on the path to cancer not viewable by the naked eye. This screening consists of a combination of mouth rinse and a glow stick that illuminates irregular cells.

“We use ViziLite Plus because it is a pain-free screening that takes only five minutes, and it has been proven to save lives,” Coleman says.

The latest cosmetic procedures dentalplans and whitening treatments are offered at East State Dental Care, too, including veneers, Lumineers and Zoom! in-office whitening. Another recent advancement in dentistry is Invisalign, invisible clear braces. With Invisalign, teeth can be straightened without traditional wires and brackets by using clear, removable aligners instead.

Some people approach dental appointments with anxiety. At East State Dental Care, these worries are addressed with several options for anesthetics or medication, such as sedation dentistry. Even children can put their fears aside.

“We have TVs in the patient rooms and kids can wear headphones and focus on cartoons or their favorite show instead of the dental procedure,” Coleman says. “It’s a great experience for them and they want to come here. Even the adults enjoy the TVs in the rooms. If children enjoy going to the dentist, they will be more likely to continue to go regularly as adults.”

Coleman sees good dental care as improving the lives of her patients. She wants people to understand the value of what she calls “Lifetime Care” – a philosophy centered on preventative care throughout the patient’s lifetime.

“After their appointment, our patients have an understanding of the importance of dental health, and they appreciate being treated like family,” Coleman says.

East State Dental Care

A proud Member of the Heartland Dental Care Family

Address: 2828 East State Boulevard, Suite A Fort Wayne, Indiana 46805

Telephone: (260) 484-9248

Dentist: Angela M. Coleman DDS, general dentist

Website: www.EastStateDentalCare.com

Number of employees: 8

Years in business: 9

Products & Services: General Dentistry, Gum Disease Treatment, Digital X-Ray, Invisalign Invisible Braces, Oral Cancer Screening, Cosmetic Dentistry and more.

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