Premedication and Oral Sedation

Photo of Gordon Laurie BDS
Written by the Dental Fear Central Web Team and reviewed by Gordon Laurie BDS, a specialist in Special Care Dentistry
Last updated on January 17, 2021

Premedication means taking a drug for anxiety relief before a dental appointment. You can take anti-anxiety medication the night before the appointment, an hour before going to bed. This will help with falling asleep and getting some rest. Or you may want some help in the hours immediately before an appointment.

In contrast, oral sedation means taking a pill or a liquid drug to make you feel relaxed during dental treatment. Oral sedation can be used as an alternative to inhalation sedation or IV sedation.

Choosing the right medication and dose should be based on your individual needs and medical situation and done under an expert’s care.



Premedication

Temazepam (Restoril)

Temazepam is now the most commonly used premedication among dentists who’ve had training in dental anxiety management. Part of a group of drugs called benzodiazepines, it was originally marketed as a sleep-inducing drug. But its short half-life (about 4 hours) makes it ideal for use as an anti-anxiety drug. It starts to kick in after about half an hour to an hour. A usual dose for an anxious, otherwise healthy adult of normal weight is 10 mg. For a more severely anxious adult, it’s 20 mg.

Temazepam works great for many people. A night time temazepam can help you get a decent night’s sleep before your appointment. And taking temazepam about 90 minutes before the appointment can help with pre-appointment nerves.

However, it doesn’t work well for everyone. In some people, 40 mg of temazepam doesn’t do much at all, while in others, as little as 10 mg produces profound sedation. This is a problem with all benzodiazepines – there is no known way of identifying who is susceptible and who is resistant to their effects. And the same person may react differently to them on different days.

Diazepam (Valium)

Because it’s so well-known, many dentists still prescribe Valium (another benzodiazepine). And over the years, we’ve had quite a few posters on our forum who found it useful for calming pre-appointment nerves. But temazepam’s faster onset of action and shorter duration of action make it the preferred choice for dental anxiety.

Diazepam comes in tablets of 2 mg, 5 mg and 10 mg. The dose depends on the individual and factors such as age and general health. As a rough guide, a dose between 0.1 mg and 0.25 mg per kg of body weight one hour before the dental procedure and after a light snack is recommended 1. One major 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.

Can I take temazepam or diazepam as a premedication before IV sedation?

Yes, you can. But you must let your dentist know that you are planning to take them and what dose – unless your dentist has prescribed them and knows anyway. Inform your dentist beforehand, rather than on the day, because you’ll probably forget to mention it otherwise.

When not to take benzodiazepines (contraindications)

This varies from drug to drug. For example, some benzodiazepines are safe to take if you have liver problems, while others are not. And some are safe to take if you have heart problems, while others are not. Let your doctor or dentist know if you have any of the following:

  • known allergy to the drug
  • neuromuscular disorders
  • narrow-angle glaucoma
  • pregnancy
  • respiratory diseases
  • congestive heart failure
  • impaired kidney or liver function
  • depression, bipolar disorder, or psychoses
  • chronic bronchitis
  • or other conditions.

Also, let them know about any medications, be sure to mention this.

Travel warning: Don’t drive or travel on your own after you’ve taken drugs in the doses mentioned here. Make sure you always have an escort, even if you’re walking to your dental practice or clinic. It’s easy to become disorientated and walk straight in front of a car.

Always read the label or talk to your doctor or pharmacist and make sure you understand the restrictions on things like alcohol intake, driving, operating machinery etc.

What people on our forum have said about anti-anxiety medications

My doctor prescribed me valium. I take one 30 minutes before my appt. It makes you a little sleepy and your anxiety disappears. It puts you in a “whatever” mood and helps you stop thinking about the pain or worries.

I did my first visit after 12 years today, basically, I had a valium (diazepam) before I went. It really helped. I used to panic and had fainted in the chair in the past but the pill I had today really relaxed. I just felt so much better.

When I had my extractions, my dentist gave me Temazepam to take the night before and the morning of. That put me into a sort of ‘slow motion’ feeling before I even got into the surgery. I then had IV sedation which was brilliant.

Alcohol

Photo of a Gin and Tonic

Alcohol’s use as a sedative in dentistry has never been popular 😞. Still, alcohol has long been used by apprehensive patients as a means of self-medication before dental appointments. Some people find that a G&T or a small glass of wine before their appointment does the trick:

I’m one of those people who does not respond well to anti-anxiety meds because they either knock me right out, even in the smallest dosage, or the side-effects just compound my problems.

So, I find that ONE (not a whole bottle) small glass of wine works wonders in just relaxing me enough to get some relief, without any of the horrible side effects of medication. And I honestly don’t understand why everyone gets up in arms when you talk about using a TINY bit of alcohol to self-medicate responsibly. – from our message board

Don’t go overboard, though! You’re not doing your dentist or yourself any favours by stumbling in reeking of beer and whisky. If at all possible, alcohol should be avoided before any actual treatment:

The trouble with whisky as a “premed” is that it will cause the local anaesthetic to be less effective due to the vasodilation effect. It also opens up blood vessels quite effectively and will make a big difference to post-op bleeding. There’s also a big question over consent to treatment when you’re impaired through alcohol. – Gordon Laurie, BDS

Herbal Alternatives

No, not THAT herb! We’re talking about rescue remedy

Rescue Remedy

It may be a placebo effect, but many people swear by Rescue Remedy. It is readily available in pharmacies and natural health stores.

CBD Oil

There’s no real evidence that CBD oil does anything much for anxiety in quantities that can typically be bought for personal use. But the placebo effect is a very powerful thing, so if you think it would help, why not?


Oral Sedation

Versed (liquid midazolam)

A glass of orange juice

Midazolam, the drug used for IV sedation can also be used for oral sedation. It produces sleepiness and memory loss.

It is given as a drink, usually mixed with orange. This can be useful for people with extreme needle phobia. It can be used either as an alternative to IV sedation or to allow you to relax enough to accept IV sedation.

Temazepam

Temazepam can be used not only as for premedication but also for oral sedation in adults when used in higher doses such as 30-40 mg 1.

Triazolam (Halcion)

This is not available in the UK and Europe. But it’s hugely popular in the U.S. as an alternative to IV sedation. You can search our forum for first-hand accounts.

How common is oral sedation?

In the UK, oral sedation on its own is only rarely used for conscious sedation. Inhalation sedation and IV sedation are more common. The level of sedation that can be safely achieved tends to be lighter, and it’s nowhere near as predictable and reliable as IV sedation.

Oral sedation – A hit-or-miss affair?

One problem associated with oral sedation is that it can be a bit of a hit-and-miss affair. Basically, you don’t know how well the drug will be absorbed from the stomach. Because the response to a drug is unpredictable anyway, you have to tailor the dose so that the 25% of people most susceptible to the drug won’t get an overdose. But that means that the 25% who are least susceptible won’t get enough… Bodyweight, height, or gender are not good indicators of how high the “ideal dose” should be, because the drug exercises its effects on the nerve cells in the brain. So, if you’re quite large, you can’t take a little extra “just in case”. A standard dose might have virtually no effect on a petite female, but a large guy might be totally zonked after taking the same dose.

When using IV sedation, the effects are almost immediate. So it’s easy to give more midazolam until you reach the desired level of sedation. This isn’t the case with oral sedation, where you have to wait about 10-20 minutes to see how the drug affects you. Seeing how IV sedation is so much more predictable and reliable, oral sedation is only really used when someone doesn’t want or cannot have IV or inhalation sedation.

Visit our dental phobia forum for mutual support, advice, and discussion!


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Sources of Information

  1. N. M. Girdler, C. M. Hill, K. E. Wilson (2017). Conscious Sedation for Dentistry. John Wiley & Sons Ltd.[][]