My Analysis and Commentary

The Iowa Dental Board conducted an investigation and issued a report, which I carefully studied. In the report they alleged that Dr. Byrne had overdosed Beverly on triazolam, saying that he had given her twice the recommended dose. They submitted references stating that a typical dose of triazolam was 0.5 mg, and Dr. Byrne had given her 1.0 mg.

But, to anyone truly knowledgeable in sedation medication, such an assertion is ridiculous. To establish the safety of a medication, using the usual recommended dose is not very helpful because it gives no clue about the safety margin of the drug. Some drugs have a wide safety margin. Triazolam is such a drug. To determine the maximum safe dose, we need to turn to clinical data establishing what is called the LD-50. The LD-50 of a drug is the dose at which 50% of the animals in a clinical trial die. This dose is extremely high for triazolam. Tested on mice, its LD-50 is greater than 1,000 mg/kg (see Halcion data from the FDA). For a 270-pound woman (a little over 120 kg), that would work out to a dose of 120,000 mg. While mice data can’t be extrapolated accurately to humans, it does give us a rough idea of the safety.

Not only was the dose not an overdose, in my report I indicated that I didn’t find the dose to be unusual and even suggested that it was an under-dose. While a dose of 0.5 mg would be appropriate for a typical patient, Ms. Mazurenko weighed about double what a typical female patient might weigh, and, besides, she was extremely anxious and had a history of drug abuse. In those circumstances, given the extremely high safety margins with triazolam, it would seem reasonable to me to have given her even much more. Her behavior at the appointment seems to indicate that she was inadequately sedated. She walked into the operatory and for some time conversed with the staff and, by the clinical record, showed no sign of even being sedated.

Furthermore, it is of interest that the report of autopsy from the county medical examiner failed to establish a cause of death. In my report, I gave my opinion that Ms. Mazurenko died from an emergency precipitated by the stress of the dental appointment. Knowing what I know about the Iowa Dental Board at the time, I’m suspicious and wonder if they leaned on the medical examiner to not report a cause of death that would undermine their case. After all, the purpose of an autopsy is to determine the cause of death, so it’s puzzling why they didn’t do that.

In preparing my report, in order to validate my impressions, I shared details of the case with two dentists that I knew from other states who used conscious sedation in their practices. Both of them agreed with me about the cause of Beverly’s death.

So What Is Our Take-Home Lesson Here?

There are two.

First, there is what I consider an error in how many people, including professionals and people tasked with regulating professionals, think about sedation. They correctly view sedation dentistry as a treatment risk but fail to consider the possibility that properly administered sedation probably decreases the risk of dental treatment much more than it increases it. While there are some rare but famous instances of child fatalities from improper sedation, adult sedation with benzodiazepines like triazolam has a strong safety record. In my report I stated, “The most frequent cause of dental office emergency is stress. Many medical events can be precipitated by the stress of dental care, from simple syncope, to diabetic coma or insulin shock, to angina, and up to myocardial infarction and death.” In dental school, we were trained in the managing of office emergencies, and most of them were caused by the stress of the procedures. This can cause dentists to be so cautious about administering sedative medications that they under-medicate the patient. If I have a patient with dangerously high blood pressure or with serious heart disease, and there is essential dental care that can’t be put off, treating them without sedation, in my opinion, could be putting them at excessive risk. That seems to be the clear conclusion of this case. While in the zeal of the Iowa Dental Board they were accusing Dr. Byrne of overdosing Ms. Mazurenko, the ironic truth is that he actually under-sedated her. Had she been adequately sedated, I believe that she would have tolerated the procedure without the extreme stress that caused the emergency.

A second point I want to make about this case is the over-reaction of the Iowa Dental Board. At the time this incident occurred, dental politics in Iowa, in my opinion, was working to protect the turf of oral surgeons by clamping down on sedation practices, and only a handful of general dentists in the entire state were given sedation permits. By keeping sedation out of the offices of general dentists, I believe they were hampering the delivery of quality dental care in the state. Around this time, there was an article in a Dubuque, Iowa newspaper, about how patients could go across the border into Wisconsin and receive sedation dentistry that they couldn’t find on the Iowa side of the border.

– Dr. David Hall

Do you have a comment or anything else to add? We’d love to hear from you. Enter your comment below. Or click here to ask Dr. Hall a question.