Triazolam

Drug Class: Benzodiazepine, sedative-hypnotic

Uses: Insomnia: unlabeled use: oral sedation of anxious dental patients

Side Effects:
“The most common side effects of benzodiazepine sleeping pills are related to the ability of the medications to make you sleepy; drowsiness, dizziness, light-headedness, and difficulty with coordination. Users must be cautious about engaging in hazardous activities requiring complete mental alertness, eg, operating machinery or driving a motor vehicle. Do not take alcohol while using triazolam. Benzodiazepine sleeping pills should not be used with other medications or substances that may cause drowsiness, without discussing said use with your dentist/physician.

How sleepy you are the day after you use one of these sleep medications depends on your individual response and on how quickly the product is eliminated from your body. The larger the dose, the more likely an individual will experience next day residual effects such as drowsiness. For this reason, it is important to use the lowest effective dose for each individual patient. Benzodiazepines that are eliminated rapidly, eg, triazolam, tend to cause less next day drowsiness…” (Pharmacia & Upjohn Company, April 2001).

Interactions With Other Meds:
“Triazolam tablets should not be taken with Ketoconazole, Itraconazole, and Nefazodone” (first two are antifungals and third drug is a antidepressant) (Pharmacia & Upjohn Company, April 2001)

Increase effects of erythromycin (antibiotic)

Increased sedation: Alcohol, CNS depressants, Opiod Analgesics, or anesthetics” (Mosby’s Dental Drug Reference, fourth edition, 1999)

“CYP3A3/4 Inhibitors:" Serum level and/or toxicity of some benzodiazepines may be increased; inhibitors include amiodarone, cimetidine, clarithromycin, erythromycin, delavirdine, diltiazem, dirithromycin, disulfiram, fluoxetine, fluvoxamine, grapefruit juice, indinavir, itraconazole, ketoconazole, nefazodone, nevirapine, propoxyphene, quinupristin-dalfopristin, ritonavir, saquinavir, verapamil, zafirlukast, zileuton…” (Drug Information Handbook for Dentistry, 8th edition, 2002)

Warning/Precautions:
“…hepatic disease, renal disease, suicidal individuals, drug abuse, elderly, psychosis, child e<15 yr old, acute narrow-angle glaucoma, seizure disorders.” (Mosby’s Dental Drug Reference, 4th edition, 1999)

Effects on Pregnancy:
“Certain benzodiazepines have been linked to birth defects when administered during the early months of pregnancy. In addition, the administration of benzodiazepines during the last weeks of pregnancy has been associated with sedation of the fetus. Consequently, the use of this drug should be avoided at any time during pregnancy.” (Pharmacia & Upjohn Company, April 2001)

*Patients should be advised to note the differences between drug names: generic vs. brand names. If you have any questions about your current meds and interactions of those meds with Triazolam, please consult your physician. An educated patient is the safest patient.

Updates in Dental Anesthesiology
Volume 1, Number 2, March 1997
Focusing in this issue on: Triazolam , EMLA, and Dental Phobia

Using Triazolam to Reduce Anxiety for Dental Procedures

Triazolam is a benzodiazepine that is chemically related to diazepam. Triazolam has a rapid onset, short duration of action and no active metabolites. These properties make it a near perfect anti-anxiety medication for dental patients. Clinicians and patients are sometimes reluctant to use triazolam because they are unfamiliar with the medication and uncertain about the drug’s effects. Triazolam is an excellent preanesthetic medication on the morning of a dental appointment, or the evening before. Doses as low as 0.25 mg of triazolam can relieve anxiety and induce sedation and amnesia before procedures. Studies have documented anxiety relief when 0.25 mg of triazolam was given in combination with 40 percent nitrous oxide. The effects were comparable to 19.3 mg of intravenous diazepam but with faster postoperative recovery.

The typical dose used in the dental office is usually 0.25 mg. Triazolam should be given to reduce anxiety when non-pharmacologic methods have not worked or are not practical. Oral triazolam in doses of 0.125 to 0.25 mg provides a safe alternative to parenterally administered drugs, especially for dentists not trained in parenteral sedation. Triazolam works well to reduce the emotional component of pain. It is beneficial for long crown and bridge procedures, implant or periodontal surgery.

Topical Application of 5% Eutectic Mixture of Lignocaine (xylocaine)and Prilocaine (EMLA) Before Removal of Arch Bars.
British Journal of Oral & Maxillofacial Surgery. 30 (3) : 153-6 , 1992 Jun.

Abstract: The analgesic effect of topical application of a 5% eutectic mixture of lignocaine and prilocaine (EMLA) was studied in 45 patients undergoing removal of oral arch bars used for the treatment of mandibular fractures . Employing a double-blind technique, either 4g of the eutectic mixture (EMLA group, n=15) or 4g of a similar emulsion containing no local anesthetic (placebo group,( n=15 ) was applied to the gingivae using a toothbrush with a standardized technique. In the control group (n=15), infiltration anesthesia with lignocaine was used only if requested by the patient during the removal of the arch bars. The patients in the EMLA group had significantly better analgesia (P less than 0.005) of the gingivae just before removal of the arch bars than patients in the control group. The number of patients who found the procedure pain-free with the placebo group was (2/15) (P less than 0.005). The plasma concentrations of both lignocaine and prilocaine were well below the toxic levels. Topical application of EMLA can be recommended for short procedures as an alternative to infiltration.

Assessing Abuse And Neglect And Dental Fear In Women
Edward A. Walker, M.D.; Peter M. Milgrom, D.D.S.; Philip Weinstein, Ph.D.; Tracy Getz, M.S.; Ralph Richardson, Ph.C.

Abstract: Little is known about how specific life stressors, such as sexual, physical and emotional abuse and neglect, might be factors in the establishment or maintenance of dental fears or might affect routine dental treatment. The authors collected data from 462 female members of a large urban health maintenance organization about their dental fear and histories of childhood and adult traumas. According to these data, a history of trauma appears to be significantly associated with elevated dental fear, although multiple factors play a major role in the establishment and maintenance of these phobias. Such patients frequently describe fundamental concerns for their safety. They report having fears of being trapped in the dental chair, feeling claustrophobic, being unable to breathe or experiencing choking or severe gagging that interferes with treatment. For these patients, a sense of helplessness and lack of control appear to be underlying problems.

Comments:
I have used EMLA with excellent results intra-orally as a palatal topical anesthetic. The area must be dried and isolated, and EMLA is applied for at least five minutes. This provides for relatively comfortable palatal injections. EMLA is useful for periodontal scaling. It will provide gingival, but not pulpal anesthesia. EMLA is well documented as a topical anesthetic for intravenous access. The patient feels little or no pain as the angiocath is placed. The skin is nicely softened by the EMLA, which reduces the resistance to the passing of the needle. EMLA makes starting IV’s easier for doctors and patients. Triazolam (Halcion, Upjohn) is a generically available short acting benzodiazepine. Use of triazolam is an underused modality in dentistry. Patients expect our best in all respects, particularly in anesthesia, pain and anxiety control. This is an easy to use addition to our repertoire that requires minimal training and adjunctive equipment. Patients are provided with a euphoric and comfortable association with our procedures. This medication works well in combination with nitrous oxide.

Patients with dental phobia do not feel safe in the dental environment. Patients who have suffered abuse or other traumatic experiences may not feel safe anywhere. Victims of abuse may have problems with trust in a professional relationship. Care must be taken to provide a secure environment in the office. Time should be given to develop a supportive rapport between the patient, dentist and staff.