Mark Donaldson

Oral sedation: a primer on anxiolysis for the adult patient.

The use of sedatives has established efficacy and safety for managing anxiety regarding dental treatment. This article will provide essential information regarding the pharmacology and therapeutic principles that govern the appropriate use of orally administered sedatives to provide mild sedation (anxiolysis). Dosages and protocols are intended for this purpose, not for providing moderate or deeper sedation levels.

Comparison of International Normalized Ratios provided by two point-of-care devices and laboratory-based venipuncture in a pharmacist-managed anticoagulation clinic

PURPOSE The International Normalized Ratios (INRs) measured by two point-of-care (POC) devices were compared with those obtained via laboratory-based venipuncture. METHODS In an outpatient, pharmacist-managed anticoagulation clinic, 52 patients receiving oral warfarin therapy had their INR values measured using two POC devices, i-STAT PT/INR (Abbott Laboratories, Abbott Park, IL) and CoaguChek XS Plus (Roche Diagnostics, Indianapolis, IN). At the same visit, one venous blood sample was collected from each patient for INR measurement by the reference laboratorys instrumentation (STAGO, Diagnostica-Stago, Parsippany, NJ). Accuracy was evaluated by calculating the absolute difference for each set of INR values. Clinical correlation was defined as an INR measurement obtained by the POC devices that would have resulted in the same therapeutic decision as the INR value measured by the reference laboratorys instrumentation. RESULTS Accuracy was superior with the CoaguChek XS Plus device. The absolute difference (mean ± S.D.) in the INR measurements obtained using STAGO versus CoaguChek XS Plus was 0.28 ± 0.31 (p < 0.0001). The absolute difference in INR values measured using STAGO and the i-STAT PT/INR device was 0.51 ± 0.44 (p < 0.0001). For clinical correlation, 17 (33%) of 52 INR measurements with the CoaguChek XS Plus were sufficiently different from the STAGO-measured INR values to have resulted in a different therapeutic decision (p < 0.001), compared with 28 (54%) of 52 with the i-STAT PT/INR (p < 0.001). CONCLUSION INR measurements generated by POC devices exhibited positive bias, compared with laboratory-based venipuncture, for INR values at the high end of the INR range.

Evidence-based recommendations for analgesic efficacy to treat pain of endodontic origin: A systematic review of randomized controlled trials

BACKGROUND The purpose of this investigation was to identify evidence-based clinical trials to aid dental clinicians in establishing the efficacy for recommending or prescribing analgesics for pain of endodontic origin. TYPES OF STUDIES REVIEWED The authors prepared and registered a protocol on PROSPERO and conducted electronic searches in MEDLINE, Scopus, the Cochrane Library, and ClinicalTrials.gov. In addition, the authors manually searched the bibliographies of all relevant articles, the gray literature, and textbooks for randomized controlled trials. Two authors selected the relevant articles independently. There were no disagreements between the authors. RESULTS The authors analyzed 27 randomized, placebo-controlled trials. The authors divided the studies into 2 groups: preoperative and postoperative analgesic treatments. There was moderate evidence to support the use of steroids for patients with symptomatic irreversible pulpitis. Also, there was moderate evidence to support nonsteroidal anti-inflammatory drugs (NSAIDs) preoperatively or postoperatively to control pain of endodontic origin. When NSAIDs were not effective, a combination of NSAIDs with acetaminophen, tramadol, or an opioid appeared beneficial. CONCLUSIONS AND PRACTICAL IMPLICATIONS NSAIDs should be considered as the drugs of choice to alleviate or minimize pain of endodontic origin if there are no contraindications for the patient to ingest an NSAID. In situations in which NSAIDs alone are not effective, the combination of an NSAID with acetaminophen or a centrally acting drug is recommended. Steroids appear effective in irreversible pulpitis.

Hallucinations and Delirium in the Dental Office Following Triazolam Administration

A rare and unusual case of hallucinations following triazolam administration is reported. A review of the literature suggests that hallucinations following triazolam are rare; this is the first report of such a reaction when triazolam was used for oral conscious sedation in dentistry. A discussion of dental implications follows with emphasis on complete medical history evaluation before administering oral sedatives. We conclude that the proper selection of oral sedation candidates, coupled with recognition and management of adverse events, is essential.

Dental considerations for patients taking weight-loss medications

BACKGROUND In this article, the authors examine prescription weight-loss medications and related dental considerations for oral health care professionals (OHCPs). The authors focus on the most common prescription weight-loss drugs and their potential interactions with medications frequently used in dental practice, and they include recommendations for modification in patient care. METHODS The authors reviewed the literature regarding interactions between weight-loss drugs and medications commonly used in dentistry, including patient-treatment considerations. They also address the interactions of greatest clinical concern that have a high-quality evidence-based foundation in either randomized controlled clinical trials or meta-analyses. CONCLUSIONS Dental treatment can be performed and medications commonly used in dentistry can be administered safely to patients taking orlistat, an inhibitor of fat absorption. The same may not be true, however, for other weight-loss medications that modify the central nervous system neurotransmission of norepinephrine, dopamine or serotonin. OHCPs should be aware of the potential theoretical and pharmacokinetic risks relative to the actual clinical and reported risks for hypertension and cardiotoxicity in particular. PRACTICAL IMPLICATIONS Recognition and avoidance of potential weight-loss drug interactions, especially those with medications commonly used in dentistry, can help clinicians optimize patient treatment while emphasizing patient safety.

Vitamin and mineral supplements Friend or foe when combined with medications

BACKGROUND Given the prevalence of vitamin and mineral supplement use among consumers and the potential for vitamin- and mineral-drug interactions, as well as oral and systemic adverse effects of excess consumption, oral health care providers (OHCPs) should ask all patients about their use. The challenges for OHCPs are how to recognize oral and systemic manifestations of these interactions and how to safely manage the care of these patients while avoiding potential interactions. METHODS The authors reviewed the literature regarding interactions between popular vitamin and mineral supplements and medications used commonly in dentistry. They used clinical databases and decision support tools to classify interactions according to their level of patient risk. They address interactions of greatest clinical concern with a high-quality evidence-based foundation in either randomized controlled clinical trials or meta-analyses. CONCLUSION Most medications used commonly in dentistry can be prescribed safely without regard to vitamin- and mineral-drug interactions. However, patients taking anticoagulants or cytochrome P450 3A4 substrates (such as clarithromycin, erythromycin, ketoconazole, itraconazole, midazolam and triazolam) in addition to specific vitamin or mineral supplements (vitamins D, E, K, calcium, fluoride, iron, magnesium, selenium or zinc) may face additional challenges. OHCPs need to recognize these potential interactions and know how to manage the care of patients who may be receiving treatment with these combination therapies. PRACTICAL IMPLICATIONS Recognition and avoidance of potential vitamin- and mineral-drug interactions will help clinicians optimize patient treatment while emphasizing patient safety.

New sedation and general anesthesia guidelines : Why the changes?

Jason H. Goodchild, DMD; Mark Donaldson, BSP, ACPR, PharmD, FACHE Editor’s note: In Dionne’s commentary (“Raise the Bar for Safe Sedation, Not Barriers for Access to Care,” on page 133) and in this commentary, the authors discuss the latest guidelines for using and teaching sedation and general anesthesia by dentists. Although the authors of both commentaries approach the subject of sedation and general anesthesia from different points of view, their main arguments focus on the concern for patient safety. Hopefully, providing both of these perspectives will afford JADA readers a better and more comprehensive understanding of the very serious issues involved and the challenges ahead.

Published material used without proper attribution: Lesson learned

A reader recently pointed out to the editors of AJHP that part of an AJHP article we published in 2010[1][1] was similar to a section of an article by Dorfman et al.[2][2] We are grateful to have had this observation reported. Although the article by Dorfman et al. appeared in our reference list, a