Dentaltown January 2020 - 83

Best practices when administering
benzodiazepines for dental procedures
There are many considerations when evaluating a patient for dental sedation. Appropriate
patient selection, availability of appropriate monitors, availability of appropriately trained
staff and medication selection are all key components to provide safe passage through dental
care. Here are some key points to consider when providing anxiolysis with benzodiazepines:15
* Obtain a thorough medical and medication history.
* Assess the patient's baseline anxiety/dental phobia(s).
* Appropriately classify patients with ASA classification.
* For first time anxiolysis treatment, schedule early morning, short procedures.
* Ensure there is a designated driver.
* Preprocedure: Obtain baseline vital signs.
* Document the time the medication was administered, the dosage that
was specific for your patient and the patient's response to the dosing.
* Postprocedure: Obtain vital signs, document the state of the patient,
the time of dismissal and the receipt of discharge instructions.

Contraindications and special considerations
There are special considerations and potential contraindications to any medication that
is administered; the same holds true for benzodiazepines. For all medications, administration
should be avoided for any known allergy to the medication, one of its components or metabolites.
Benzodiazepines work in the central nervous system. It's prudent to avoid compounding
CNS depression with the concomitant use of narcotic pain medications, antihistamines
and the acute ingestion of alcohol. This class of medications may have prolonged effects in
the geriatric and medically compromised populations. Caution must be exercised in these
populations and those with impaired kidney or liver functions.
There are certain disease processes that warrant avoiding specific benzodiazepines, including
triazolam and diazepam. Both triazolam and diazepam are contraindicated in acute narrow-angle
glaucoma. Triazolam is contraindicated in the neurological disease myasthenia gravis.15

Reversal of benzodiazepines with flumazenil
The greatest variable in sedation dentistry is the patient. Although great care is provided
in appropriate patient and medication selection, unintended overdose may occur. Any
administration of a sedative warrants that the practitioner is prepared to treat an unintended
overdose. The FDA monographs for each of the benzodiazepines discussed advocates for
appropriate patient monitoring, airway management and the potential administration of a
benzodiazepine-receptor antagonist such as flumazenil. This reversal agent provides partial
or complete reversal of the sedative effects of benzodiazepines.
Reversal of benzodiazepines with flumazenil can be achieved via the IV route. It is the
only route of administration, according to the FDA monograph. The typical vial of flumazenil
contains 5ml in a concentration of 0.1mg/ml. The initial dose of flumazenil is 0.2mg given
over 15 seconds. The dose of flumazenil may be repeated after 45 seconds. Subsequent doses
of 0.2mg may be repeated up to the maximum recommended dosage of 1mg. Dosage of
0.1-0.2mg provides partial benzodiazepine reversal; increasing dosage gives complete reversal.
The peak effect of flumazenil is 6-10 minutes.21
Resedation may occur after the administration of flumazenil, depending on the sedation
duration and the half-life of the specific benzodiazepine that was administered. The half-life
of flumazenil is 54 minutes. It is plausible that active components of benzodiazepines may
still be in a patient's system when the effects of flumazenil have worn off. This allows the
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Dentaltown January 2020

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