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While all benzodiazepines act as sedatives and anti-anxiety drugs, some are
more targeted at brain areas which control sleep and wakefulness, while others
are more specifically targeted at brain areas which control emotions such as fear.
The classification of whether a benzodiazepine is sedative-hypnotic or anti-
anxiety is to some extent an arbitrary one, as the boundaries are quite fluid. As a
rule of thumb, in higher doses benzos act like sedatives and may promote sleep,
while in lower doses, they simply reduce anxiety.
Benzodiazepines are Central Nervous System (CNS) depressants (for example,
there can be a decline in blood pressure and breathing – which is good, because
if your heart isn’t racing, you’ll feel calmer). They should not be mixed with other
CNS depressants such as alcohol. Don’t self-medicate and stick to the dose your
dentist or doctor recommends (which may be a higher dose than specified on the
drug package insert. Reason being that the package inserts recommend a dose
to induce sedation or sleep in a nonstress situation such as the home
environment). It is possible to overdose on these things, and overdoses could
lower your breathing to dangerously low levels, which could result in coma or
even death.
In case this sounds scary – unless you make a deliberate attempt to overdose,
it’s extremely unlikely for any dangerous symptoms to develop. The reason why
benzos are so widely used is precisely because they’re safe.
People for whom benzos have worked well describe them as “working wonders”,
as having a calming and relaxing effect, or as making you feel “out of it”.
Giddiness, confusion and saying silly things are also common. Benzos may
make you forget large parts of what happened while you were under their
influence, which can be handy if you don’t want to remember very much!
However, this effect is not reliable.
Dentists who offer oral sedation will have particular preferences, depending on
their experience (and experiences) with various drugs. Commonly prescribed
benzos include:
Temazepam (Restoril):
Temazepam is quite frequently used in the UK. In contrast to Valium, its half-life
is about 10 hours, so quite a bit shorter. It kicks in after about half an hour. The
recommended dose is 10 – 40 mg (with the most common one being 30 mg).
Why this huge range? In some people 40 mg of temazepam produces minimal
effects whilst in others as little as 10 mg produces profound sedation. This is a
problem with all benzos – there is no known method of identifying who is
susceptible and who is resistant to benzodiazepines.
Diazepam (Valium):
Diazepam produces a mild level of sleep and amnesia, and takes effect about an
hour after taking it. The average dose for an adult is 5 to 10 mg. The
disadvantage of diazepam is that it stays in the system for much longer than it is
needed (it has a half-life of 20-100 hours).
Lorazepam (Ativan):
Lorazepam can produce a higher level of sleepiness and memory loss than
diazepam. The usual dose is 2 to 3 mg. It kicks in after about one hour, like
diazepam, but its half-life is much shorter (12 to 14 hours).
Midazolam (Versed):
Midazolam is a short-acting benzo which can produce high levels of sleepiness
and memory loss. It is given as a syrup or mixed into a (non-alcoholic) drink. The
drink would usually be given at the dentist’s. It kicks in very quickly, after about
10-20 minutes.
Triazolam (Halcion):
This is not available in the U.K., but is hugely popular in the U.S. Unlike the other
benzos mentioned here, it is not so much used as a premedication, but as an
alternative to IV sedation in the dental office. This can work really well for some
people and many swear by it! But as with all benzos, other people find it has little
effect on them.
Controversies in Dentistry – Titration of Oral Sedatives
Occasionally, Halcion is used in the United States as an alternative to IV
sedation. One of the effects of Halcion is that it can induce amnesia (memory
loss) for what’s happening from the point the drug kicks in to the point it wears
off. (All benzos can have this effect to some extent, but Halcion somewhat more
so than others. However, the amnesia effect is unreliable – this also applies to
Halcion). If Halcion is given intermittently one hour before an appointment and
then during treatment at intermittent intervals, it can work well for some people as
a substitute for IV sedation.
However, in 2002 the American Dental Association came out in a position paper
against titration of oral sedation medication (titration means adding more of the
drug, i. e. giving extra pills until the desired effect is achieved). This statement
followed the rise of an organization called the “Dental Organization for Conscious
Sedation” (or DOCS for short) which was founded in 2000 by a DDS called
Michael Silverman and provides training in oral sedation. In 2004, DOCS had
more than 1,900 member dentists in the US. DOCS is where the misleading term
“sleep dentistry” (applied to oral sedation) was first invented. The training
courses also advocate titration of oral medication. Many dentists feel that this
practice is unsafe and/or that the training is not thorough enough. Even with
thorough training, many dentists believe that titration of oral medication is too
unpredictable. Oral medication can take up to two hours to absorb – so a patient
could swallow a pill and the dentist, not seeing the effects of the drug an hour or
two later, delivers a second pill. Meanwhile, the first pill is being absorbed and
the patient has ingested twice the amount he or she needs.
Because of the medical and legal situation, many dentists do not feel comfortable
with this method.
Can I take benzos as a premedication before IV
sedation?
Yes you can. You must however let your dentist know that you have taken them
and what dose (unless your dentist has prescribed them and knows anyway). Be
sure to inform your dentist beforehand, rather than on the day, because you may
forget to mention it otherwise.
Zolpidem (Ambien)
Ambien is a sedative/hyppnotic drug designed to relax you and help you fall
asleep. So it can be useful for the night before an appointment. It is chemically
similar to benzodiazepines. It is not a barbiturate (the traditional “sleeping pill”,
which thankfully has fallen out of favour).
Alcohol
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