Patient Information
Patient name
Date of appointment
Date of most recent TBI / concussion
Number of concussions (total)
Mechanism of injury
Current medications
Treating neurologist / provider
Active symptoms
Cervical spine involvement (whiplash, neck injury, upper spine symptoms)
Post-traumatic seizure history (if any)
Agents with concerns — discuss before use
Epinephrine (adrenaline) in local anesthetic
Published side effects: rapid heartbeat, elevated blood pressure, trembling, anxiety, headache, sweating, palpitations. In patients with TBI, epinephrine can also elevate intracranial pressure and lower seizure threshold in those with post-traumatic seizure history. Questions to raise: Is an epinephrine-free formulation available for this procedure?
Articaine as local anesthetic (where avoidable)
Published side effects: articaine has the highest reported rate of persistent paresthesia (prolonged numbness or tingling) among dental local anesthetics; also dizziness, ringing in the ears, and confusion at higher doses. Articaine enters the central nervous system more readily than lidocaine — a consideration with TBI history. Questions to raise: Can we use lidocaine without epinephrine, or mepivacaine plain, for this procedure?
Nitrous oxide sedation
Published side effects: nausea and vomiting (common), headache, dizziness. With repeated use or existing B12 deficiency: nerve damage, numbness, weakness, and neurological decline. B12 is required for myelin repair — a concern specific to TBI recovery. If you choose to decline: ask your dentist to note this on your chart for future visits.
Topical fluoride treatment (varnish or gel)
Published side effects: nausea, vomiting, and stomach cramping from oral mucosal absorption; fluoride accumulates in the body with repeated applications. Questions to raise: What cavity-prevention alternatives are available during my recovery period?
Alternatives to discuss with your dentist
Mepivacaine 3% plain (Carbocaine) — no vasoconstrictor
Ask if mepivacaine plain is available for this procedure — no epinephrine, no vasoconstrictor.
Prilocaine 4% plain (Citanest) — if mepivacaine unavailable
Epinephrine-free alternative. Please review my full medication list before use.
Lidocaine 2% without epinephrine — if available
Ask if lidocaine without epinephrine is available — specifically without a vasoconstrictor additive.
Morning appointment scheduling
Cortisol is naturally highest in the morning, providing a degree of physiological resilience. Post-TBI fatigue accumulates through the day — morning appointments reduce cognitive and sensory load.
Cervical spine & chair positioning
Please avoid hyperextension of my neck in the dental chair
My injury involved the cervical spine. Extended neck positioning during dental work can aggravate upper cervical injury, restrict vertebral artery flow, and increase intracranial pressure. A small rolled towel under my neck or a slight incline is appreciated if available.
Please allow position breaks during longer procedures
Sustained reclined positioning with neck extension increases my symptoms. Brief upright breaks during long appointments are helpful.
Sensory sensitivity — post-TBI
TBI commonly causes heightened sensitivity to light, sound, and smell. A dental environment is high in all three. These sensitivities are neurological — not anxiety-based — and can cause symptom flares or cognitive fatigue that extends beyond the appointment.
I have light sensitivity — overhead operatory light is a concern; please use the lowest intensity needed or angle away from my eyes
I have sound sensitivity — high-pitched drill noise, suction, and ultrasonic scaling are significant triggers; please let me know before starting each
I may need a break if symptoms escalate — I will signal by raising my hand; please stop immediately when I do
Today's procedure — please note
Routine cleaning / exam — I'd like to discuss fluoride alternatives at this visit
Filling / restoration — I'd like to discuss epi-free anesthetic options
Extraction — I'd like to discuss epi-free anesthetic and nitrous alternatives
Amalgam removal — I'd like to discuss the SMART protocol before beginning
Unprotected amalgam drilling releases mercury vapor absorbed through the lungs and accumulated in the hippocampus and cerebellum. For a brain recovering from TBI, this is an additional neurological burden. SMART protocol: rubber dam, supplemental oxygen, amalgam separator, sectioning (not grinding), high-volume evacuation.
Other:
If sedation is needed
Published side effects of volatile inhalation anesthetics (sevoflurane, desflurane, isoflurane): post-operative nausea and vomiting, temporary confusion or agitation during recovery, malignant hyperthermia (rare but serious), and inorganic fluoride release during metabolism. Questions to raise: Given my TBI history, are IV propofol or regional anesthesia options for this procedure? Ask that the anesthesiologist review your full history before the procedure.
Discuss: IV propofol or regional anesthesia as possible alternatives
Note: if I have a history of post-traumatic seizures, please see the anesthetic considerations in the seizure disorder dental handout as well — available at theundoctored.com/seizures-dental-handout.html
Vasovagal & post-concussion awareness
TBI patients have heightened anxiety responses and autonomic dysregulation. A vasovagal response (rapid drop in blood pressure from anxiety, needle, or reclined position) can trigger cerebral hypoperfusion and post-concussion symptoms. If I appear pale, sweating, or become unresponsive: lower the chair, raise my legs, do not restrain. If symptoms do not resolve within 2–3 minutes, call emergency services.
If I become unresponsive or have a seizure in the chair
- — Remove all instruments from mouth immediately
- — Lower chair to flat or recovery position — do NOT restrain
- — Clear the area; do not put anything in mouth
- — Time any seizure activity
- — Most episodes resolve within 1–3 minutes without intervention
- — Call 911 if unresponsive beyond 2 minutes, or if seizure exceeds 5 minutes
- — My emergency contact:
- — My rescue medication (if prescribed): — follow instructions from my prescribing physician
My questions for this appointment
This document was prepared using research from theundoctored.com · Allie Johnson, DNM, DIM, PNM · Educational resource — not medical advice. For the full research basis: theundoctored.com/tbi-guide.html and theundoctored.com/dental-toxins.html
Patient signature: _______________________________________ Date: _______________