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BENZODIAZEPINE AND OPIOID ANTAGONISTS IN DENTISTRY

Executive Summary

BENZODIAZEPINE AND OPIOID ANTAGONISTS IN DENTISTRY should be evaluated for use as reversal agents in dental sedation and anesthesia, the Natl. Institutes of Health (NIH) Consensus Development Conference panel on Anesthesia and Sedation in the Dental Office concluded at its April 22-24 session. The panel met to consider issues relating to the appropriate agents and indications, research directions, and personnel in the use of general anesthesia and sedation in dentistry, and to prepare a written statement summarizing their conclusions. The panel's first statement said: "Specific reversal agents for each class of drugs could revolutionize dental sedation and anesthesia techniques. Drugs such as the opioid antagonists and soon-to-be-available benzodiazepine antagonists should be evaluated for use in dentistry as they are being developed." Sedation in adults, the panel's report states, "is indicated to minimize stress in the presence of medical conditions (e.g., hypertension) and for complex procedures requiring an extended length of operating time. The chief contraindication to the utilization of sedative techniques is the presence of a medical condition that increases the risk to the patient." The panel's statement declares that "general anesthesia for healthy (ASA class I or II) [adult] patients may be indicated where there is greater complexity of the procedure, or higher degrees of preoperative anxiety, or a greater need for a pain-free operative period," or when local anesthetics are contraindicated. Unhealthy patients, the report states, "may require treatment in the hospital." The report declares that "the indications for use of sedation or general anesthesia for the geriatric patient are basically the same as for other adults." However, the panel report notes that sedation or general anesthesia may be contraindicated in geriatric patients with medical risk factors relating to the use of other drugs or pharmacodynamic and pharmacokinetic changes associated with advancing age. "Pediatric patients with extensive and complicated treatments needs, acute pain and trauma, and genetic or developmental disabilities, as well as those who are physically disabled or mentally retarded, may require sedation or general anesthesia," the report states. The panel statement adds that in children under three, general anesthesia "often is best managed in the hospital" and "in all children, severe compromising medical conditions contraindicate general anesthesia in the dental office." Max Goodson, DDS/PhD, Forsyth Dental Center, Boston, told the panel that "in a review of serious drug reactions occurring in dental patients as a result of drug administration, it is suggested that their most common cause is drug overdose, rather than idiosyncracy." Goodson said that "when combinations of drugs are used, each at their maximum recommended dosage, the combined effect is dangerously close to overdose." Overdose toxicity, Goodson suggested, "can be substantially reduced . . . by establishing and adhering to maximum dosage guidelines. The up side is that no one would ever suffer a fatality in a dental operatory due to overdose toxicity; the down side is that a given medication system would not likely be effective in all patients." Referring to soon-to-be-published laboratory data, Goodson told the panel that local anesthetics, when given in combination with a sedative anti-emetic and narcotic analgesic, can be toxic. He said that when a local anesthetic is given "together in combination with other drugs it [has] a systemic effect. The effect is not constrained to be local; its local effect is only there as long as it is local." The panel, based on data presented to it, stated that single agents are preferred over multi drug regimens to induce conscious sedation. The panel's statement declares: "Single drug techniques are generally preferred for conscious sedation unless a clear advantage can be demonstrated by the addition of other agents."
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