INTRODUCTION:
Most patients are cooperative in the dental
environment, but dentists are often challenged by young, fearful, and uncooperative
patients. The Pharmacological agents are sometimes necessary to obtain a
quiescent, cooperative patient to perform quality dentistry [1].
Pharmacological techniques that induce cooperative, yet conscious states in
otherwise uncooperative children are most commonly [2] referred to as
techniques of conscious sedation. The first reported use of diazepam in general
dentistry was by Albert Davidau. It is a reliable agent for treating stress and
anxiety in adults. Diazepam has been used as a pre-operative medication [3-4]
to alleviate muscle spasm [5] , in psychiatry [6] in cardioversion [7] and as
an anaesthetic induction agent in dentistry(8). If the patient is awake during
treatment, it is much easier to monitor the depth of sedation and differentiate
con- scious sedation from deep sedation[9-10].
Uses of Diazepam:
Diazepam could alleviate muscle spasms to some degree
in cerebral palsy, for treating status epilepticus, as a psychotropic agent in
Psychiatry, and as a premedication for poor risk patients undergoing general
anesthesia. It appeared to have only minor effects on blood pressure and
respiration [11-13].
In the beginning of 1966, Foreman introduced the
combination of diazepam and methohexital into Dentistry [14-15].This
combination of drugs produced profound amnesia for periods of time without the
sustained loss of consciousness or the protective reflexes. Patients appeared
to experience a high degree of emotional relaxation with a loss of fear for any
operative procedures. The merits of this combination of drugs was a reduction
in the amount of Brevital needed to provide the dental services for emotionally
disadvantaged patients [15].
Diazepam, administered by the intravenous route, is an
increasingly popular method of conscious sedation technique for the dental
outpatient. When administered intravenously, diazepam produces a calming
effect, some relaxation of skeletal muscle and anterograde amnesia. It is
indicated and useful for the relief of tension and anxiety states, such as
those commonly encountered by the dental patient. Diazepam is a reliable agent
for treating stress and anxiety in adults [16-18].
Diazepam is a safe and effective agent when used to
sedate young children for dental treatment. Preoperative sedation by oral
Diazepam suppresses the anxiety and the Cortisol augmentation resulting from
surgery and stress [19]. Diazepam is superior to combination of an opiate plus
Atropine [20]. Diazepam can decrease stress and blood sugar increase of
surgical patients stress followed by Cortisol and Catecholamies secretion [21].
A calm and comforting environment was created.
The use of this drug is easy and quick and their
action controllable so that the patient can return home immediately after the
appointment. This procedure relaxes both operator and patient.
Adverse effects:
Although diazepam can be used for the majority of
patients, it is contra-indicated in infants, pregnancy, patients with a known
hypersensitivity to diazepam, and individuals with acute-narrow angle glucoma.
Diazepam is a relatively safe drug, but does have a
number of common side effects which may be considered over-extensions of its
therapeutic actions. These include drowsiness, fatigue, and ataxia.
Local reactions commonly reported from diazepam usage
are venous thrombosis or phlebitis at the site of injection. Idiosyncratic
responses, which are less frequently reported, include confusion, depression,
vertigo, dysarthria and tremors.
Other side effects such as nausea, constipation,
incontinence, headache, hypoactivity, and changes in libido have been reported [22].
Of the possible adverse effects of diazepam, most significant are those reports
of respiratory or cardiovascular depression [23]. Diazepam should be used with
caution in patients who exhibit compromized renal function, limited pulmonary
reserve, in the elderly or very ill, and in patients who are currently on other
sedative inducing drugs, such as phenothiazides, narcotics, and barbiturates [24].
In these patients there is the possibility that apnea and/or cardiac arrest may
occur [22].
Paradoxical reactions are sometimes encountered with
the use of diazepam. These reactions include acute hyper excitable states,
hallucinations, delirium, anxiety, increased muscle spasticity, insomnia and
rage. Paradoxical reactions are elicited under various circumstances of
diazepam administration. They have been reported in diazepam administration,
via the oral route, after a period as short as two weeks [25]. Paradoxical
reactions have also been reported after discontinuance of prolonged diazepam
usage, due to a withdrawal phenomenon [26]. There also was one occurrence of
vomiting in the patient after administration of
0.6 mg/kg of diazepam.
Diazepam causes depression and suicidal tendencies in
quite a high proportion of patients who are on long term oral diazepam therapy [27-28].
Diazepam in dentistry:
This drug decreases activity, moderates excitement,
and calms the recipient [30]. The drug effect will last about 21/2 to 4 hours.
If the treatment is not painless, a local anesthetic is necessary. The
impression given by this premedication is one of a patient under general
anesthesia, but who has the ability to talk, swallow, move and understand what
is said to him. He is not confused or disoriented, his reflexes are only showed
down. It is surprising that under these conditions, one is able to treat these
patients who feared any contact of the gingiva or the slightest pressure of a
bur or needle. The patient remains silent, the clinical procedure (drilling,
impression, etc.) is done rapidly, and the muscular hypotoxicity of the patient
enables the practioner to record good occlusal relationships. Minor oral
surgery can also be done. The patient does not have any idea of the time needed
for the treatment. A three hour appointment appears to him as only a 1/2 or 3/4
of an hour. After this painless experience, the patient will be more relaxed.
CONCLUSION:
Understanding the patient's problem and supplementing
diazepam with the dentist's attitude is necessary for success. Dentistry has
long suffered a poor public image, and methods which allow for the proper
treatment of nervous patients and others, painlessly and safely, will do much
to improve this image. The use of diazepam to produce sedation and amnesia
appears to possess a high degree of safety and patient acceptance. Naturally,
proper training in anesthesia and related techniques are essential before
undertaking intravenous procedures. Unfortunately, this training is not always
easy for a dentist to obtain, but it is to be hoped that improved facilities
will be provided in the future (29).
REFERENCES:
1) Fields H,
Machen JB, Chambers WL, Pfefferle J C:Measuring selected disruptive behavior of the 36- to 60-month-old dental
patient. Part II: Quantification of observed behaviors. Pediatr Dent 3:257-61,
1981.
2) Creedon R L:Pharmacologic management of behavior. In: McDonald
RE: Dentistry for Child and Adolescent, 5th ed. St. Louis: CV Mosby Co, 1988.
3) Brandt, A. L. and Oakes, F. D. Preanesthesia medication: double
blind study of a new drug, diazepam. Anesth.and Analg. 44:125 Jan.-Feb. 1965.
4) Haslett, W. H. K. and Dundee, J. W.-Studies of drugs given
before anesthesia. XIV: two benzodiazepine derivatives- chlordiazepoxide and
diazepam. Brit. Jour. Anaesth. 40:250 (April) 1968.
5) Keats, S.-The role of diazepam in the comprehensive treatment
of cerebral palsied children. Westem
Med. 4 (Suppl. 1); 22 (Oct.) 1963.
6) Beerman, H. M.-A controlled study of diazepam in psychiatric
outpatients. Amer. Jour. Psychiatry 120:870 (March) 1964.
7) Kernohan, R. J.-Diazepam in cardioversion. Lancet 1:439, 1966.
8) Brown, S. S. and Dundee, J. W. Clinical studies of induction
agents XXV: diazepam. Brit. Jour. Anaesth. 40:108 (Feb.)1968.
9) Koenigsberg SR, Guelmann M, Shapira J, Kagan A, Holon G: Assess- ing diazepam sedation in children. J
Dent Res 67:128,1988.
10) Allen GD Kennedy WF Jr Everett G Tolas AG A comparison of the
cardio respiratory effects of methohexital and thiopental supplementation for
outpatient dental anesthesia Anesth and Analg 48:730 Sept 1969.
11) Khosla V Diazepam in oral surgery Oral Surg Oral Med Oral Path
28:671-679 1969.
12) Sohn D Valium Anes Prog 22:3 74-77 1975.
13) Foreman P Intravenous sedation Anes Prog 13:218 1966.
14) Foreman P Diazepam in Dentistry Anes Prog 15:253 1968.
15) Healy T The use of intravenous diazepam during dental surgery in
the mentally handicapped patient Brit Dent J 128:22-24 1970.
16) Healy T, Hamilton M: Intravenous diazepam in the apprehensive
child Br Dent J 130:25-27, 1971.
17) Flaitz C, Nowak A, Hicks MJ: Evaluation of the anterograde
amnesic effect of rectally administered diazepam in the sedated dental patient.
ASDC J Dent Child 53:17-20,1986.
18) Lundgren S, Ekman A, Blomback U: Rectal administration of diaze-
pam in solution. Swed Dent J 2:161-66, 1978.
19) Pekcan M. Middle East J Anesthesiol., 2005, 18, 421-433.
20) Kirvela OA, Kanto JH. AnesthAnalg., 1991, 73, 49-53.
21) Nishina K. Anesthesiology., 1998, 88, 922-927.
22) Valium Package Insert Nutley Hoffiman-La RocheInc 1973.
23) Lopez J Phvsostigmine reversal of diazepam-iniduced respiratory
arrest: report of case. J Oral Surg 39:539-41, 1981.
24) Sohn, D M Valium. Anesth.Prog., 22 (3):74-77, 1975.
25) Gardos, G Disinhibition of behavior by antianxiety drugs.
psychosomatics 21:1025-6, 1980.
26) Chandora, D B delaved diazepam withdrawal syndl (lrn) m: A case
of auditory and visual hallucination and (l seizures. J. Med. Assoc. Ga
69:767-70, 1980.
27) Rao S Sherbanivk R W Prasad K Lee S J K and Sproule B J Cardio pulmonary
effects of diazepam in ClinPharmacol 14:182189 1973.
28) Ryan H Merrill F B Scott G E Krebo R and Thompsoni B L Increase
in suicidal thoughts and tendencies. Association with diazepam therapy JAMA
203-13, 1137-1139 Marclh 1968.
29) Drummond-Jackson, S. L.-The Beach system of rational dentistry.
Intravenous Anesthesia-S.A.A.D. (1967).
30) Charney DS, Mihic SJ, Harris RA. Hypnotics and sedatives. In:
Brunton LL, Lazo JS, Parker KL, eds. Goodman and Gilman’s the Pharmacological
Basis of Therapeutics. 11th ed. Los Angeles, Calif: McGraw Hill; 2006:401..
