Pain and anxiety Flashcards
(207 cards)
1
Q
What is conscious sedation?
A
A technique in which the use of a drug or drugs produces a state of depression of the central
nervous system enabling treatment to be carried out, but during which verbal contact with
the patient is maintained throughout the period of sedation. The drugs and techniques used
to provide conscious sedation for dental treatment should carry a margin of safety wide
enough to render loss of consciousness unlikely.
2
Q
What 3 things can someone under conscious sedation do?
A
- Remain conscious
- Retain protective reflexes
- Is able to understand and respond to verbal commands
3
Q
What must happen if a patient is unable to respond to verbal contact when fully conscious?
A
An effective means of communication must be maintained.
Need to understand what their normal way of communicating is and maintain this.
4
Q
What are 4 broad indications for inhalation sedation?
A
- Medical reasons = conditions affecting cooperation.
- Psychosocial
- Conditions aggravated by stress
- Dental
5
Q
Indications for conscious sedation as a potential adjunct for patient management include patients with: (SDCEP) (5)
A
- dental anxiety and phobia;
- a need for prolonged or traumatic dental procedures
- medical conditions potentially aggravated by stress (IHD, hypertension, asthma, epilepsy)
- medical or behavioural conditions affecting the patient’s ability to cooperate (movement disorders and learning difficulties, spasticity disorders, parkinson’s disease)
- special care requirements
6
Q
What medical reasons are indications for inhalation sedation? (4)
A
- Learning difficulties
- Spasticity disorders (multiple sclerosis, cerebral palsy)
- Parkinson’s
- Medical conditions aggravated by stress of dentistry - IHD, hypertension, asthma, epilepsy, psychosomatic illness, misc conditions (UC, Crohn’s disease) etc
7
Q
What psychosocial reasons are indications for inhalation sedation? (4)
A
- Phobia and anxiety
- Gagging
- Persistent syncope
- Idiosyncrasy to LA - lack of response to LA.
8
Q
What dental reasons are indications for inhalation sedation? (2)
A
- Difficult or unpleasant procedures, such as XLA of 8s and implants or ortho XLA.
- Traumatic procedures
9
Q
What is the definition of a phobia?
A
An irrational and uncontrollable fear related to a specific object or situation. It is persistent despite avoidance of the provoking stimuli, affecting the patient’s lifestyle.
10
Q
What can cause dental anxiety?
A
Environment
Surgery appearance
Staff continuity
Trauma (usually primary experience in childhood, often cumulative experiences)
Learned behaviour from parents or playground
Developmental (young and old patients, and those with learning difficulties).
Fear of criticism
11
Q
What are social factors that are contraindications to sedation? (4)
A
- Unwilling
- Uncooperative
- Unaccompanied
- Very old
12
Q
What are medical factors that are contraindications to sedation? (6)
A
- Severe or uncontrolled systemic disease
- Severe mental or physical handicap
- Severe psychiatric problems
- Narcolepsy
- Hypothyroidism
- Patient on many drugs –> reduced drug clearance, the use of sedatives should be avoided as coma is a risk.
13
Q
What are contraindications to use of benzodiazepine? (5)
A
- Intracranial pathology
- COPD - leads to lower O2 saturation
- Myasthenia gravis - weakens the respiratory muscles, benzos already cause respiratory depression
- Hepatic (liver) insufficiency - can’t break down and metabolise drug properly
- Pregnancy and lactation - will pass to baby.
14
Q
What are contraindications to nitrous oxide (inhalation sedation)? (3)
A
- Blocked nasal airway
- COPD
- Pregnancy and lactation
15
Q
What are dental factors that are contraindications to sedation? (4)
A
- Procedure too long for sedation
- Spreading infection - airway threatening (limits LA effectiveness)
- Procedure too traumatic (GA)
- Urgency of treatment - long waits
16
Q
What is important to assess before considering sedation?
A
- Drug history
- Allergies
- Previous exposure to sedation and GA
- Mobility
- Medical condition state (well controlled?)
17
Q
What are the 6 ASA grades?
A
ASA I = patient with no systemic disease
ASA II = patient with mild systemic disease that does not affect lifestyle
ASA III = patient with moderate systemic disease affecting lifestyle/pt with severe systemic disease
ASA IV = patient with severe systemic diseases, threat to life constant
ASA V = not expected to survive without the operation
ASA VI = clinically brain dead, awaiting organ harvest
18
Q
What is the relationship between blood pressure and fitness for treatment on the ASA scale?
A
ASA I = <140/<90, routine Rx
ASA II = <160/<95 recheck regularly
ASA III = <200/<105 recheck after 5 mins, refer to GMP
ASA IV = >200/>105 emergency Rx only prior to BP management
19
Q
What ASA is done in primary care, and which are carried out by specialist facility
A
ASA I/II = primary care
ASA III+ = specialist facility
- While many ASA grade III patients will need to be referred to secondary care, some may
be treated in primary care depending on the available facilities, knowledge, skills and
experience and on the current stability of the patient’s medical condition. - ASA grade IV patients requiring dental sedation should be referred to an appropriate
secondary care facility.
20
Q
What needs to be recorded as part of the assessment process to inform suitability for sedation (3) and what needs to be measured before?
A
- Blood pressure
- Heart rate
- Oxygen saturation (pulse oximeter)
For healthy pts (most ASA grade I and II) having inhalation sedation with nitrous oxide/oxygen, these measurements are not usually necessay
Weight, height, BMI - useful for reversal drug calculations
21
Q
Can general anaesthesia be carried out in primary dental care setting?
A
NO
22
Q
For sedation, how old is a A) child, B) young person, C) adult
A
A) A person under 12 years of age
B) A person aged 12-16
C) A person ager 16+
23
Q
What are recognised as standard sedation techniques? (also known as ‘basic’ techniques?
A
- For a child, young person or adult, inhalation sedation with nitrous oxide/oxygen
and
- For a young person or adult, midazolam by any route (intravenous, oral or transmucosal)
24
Q
What are recognised as advanced sedation techniques? (alternative techniques)
A
For a child, young person or adult:
- certain drugs used for sedation (e.g. ketamine, propofol, sevoflurane);
- combinations of drugs used for sedation (e.g. opioid plus midazolam, midazolam plus propofol, sevoflurane plus nitrous oxide/oxygen)
- combined routed of administration (e.g. oral plus intravenous)
and
- for a child, midazolam by any route
25
Who is in the dental sedation team?
Clinical staff involved directly in sedation, including dedicated sedationist (dental professional, medical practitioner, anaesthetist), operator-sedationist and dental sedation nurse (or other sedation assistant)
26
What are the responsibilities of the referring practitioner?
To make a thorough clinical assessment of the pt as possible.
To explore alternative methods of pain and anxiety management
To assess whether referral is absolutely necessary to enable delivery of dental care
To provide appropriate clinical info about the pt with the referral, as far as pt compliance allows.
To provide the pt with information about why they are being referred, likely options for care and what to expect.
To provide preventive oral health advice and to encourage the pt to seek continuing dental care
To record details of the referral
27
What other anxiety managements techniques are there apart from conscious sedation?
Non-pharmalogical behaviour management
--> (cognitive behavioural therapy (CBT), distraction, guided imagery, hypnosis, play therapy)
General anaesthesia
28
What adaptations in treatment plans an protocols could occur? examples
* a reduced drug dose for frail and/or older patients, with titration of smaller increments at increased time intervals;
* pre-operative recording of physiological data or intra-oral examination may not be
possible for some children or patients with special care requirements;
* non-verbal means of communication;
* the use of a dedicated sedationist.
29
What information should be provided to the patient and carer before the sedation?
Info on what to expect before, during and after sedation, including clear instructions about fasting and escort requirements.
Include details of
- escort responsibilities
- post-operative risks and possible
complications
- analgesia
- aftercare advice (including about the patient’s usual
medication)
- restrictions on post-sedation activities
- contact details for the care provider
- out-of-hours contact details for emergency advice and services.
30
What are pre-operative instructions for conscious sedation?
Food (light meal 2 hours prior) (check SDCEP?)
No alcohol
Medicine taken normally
Escort must be present
Consent, both verbal and written
31
What are post-op instructions for conscious sedation?
Escort (give all advices to them in written and verbal formats)
Try not to go home on public transport (London hard)
Diving, cycling and machinery risk
Return to work protocol (advise time off work)
Medication taken normally
Safety, practicality and pharmacology (not to be a sole carer for child or relative) (not signing any documents in next 24 hours)
32
What is the guidance of fasting before conscious sedation?
For conscious sedation, provide advice about whether or not to fast based on an
individual assessment of the patient and the nature of the sedation and dental
procedure.
(Expert opinion; Low quality evidence)
Following careful consideration of all factors for each patient:
* if there are no indications for fasting, advise a patient who is to receive conscious
sedation that they can eat and drink on the day of their appointment, avoiding
alcoholic drinks and large meals.
* if there is judged to be a significant risk of aspiration, or another indication, consider
fasting prior to sedation. The 2-4-6 fasting rule is a recognised fasting regime used in
anaesthesiaa
- Record in the patient’s notes the advice provided to the patient about eating and drinking prior to sedation and the justification for this advice.
- Confirm and record food and fluid intake on the day of sedation.
33
Do adult patients receiving inhalation sedation with nitrous oxide/oxygen require an escort?
According to SDCEP, they do not usually require and escort.
For inhalation sedation with nitrous oxide/oxygen it is standard practice that an adult does not require an escort unless there are other indications such as mobility issues.
It is the sedationist’s
responsibility to assess the patient and advise if an escort is required.
34
Do children require an escort after inhalation sedation?
Children and young people under 16 years of age do require an escort for inhalation sedation with nitrous oxide/oxygen.
35
What are the requirements for an escort?
For anything other than inhalation sedation, ensure the escort is aware of the need for a responsible adult to remain with the patient as a minimum for the rest of the day.
- for those sedated later in day, escort may need to remain overnight
- role of escort may be carried out by more than one person e.g. pt returning to care home or who requires two carers
- responsibility of escort extends to ensure pt takes normal prescribed medication and carries out the routines required to manage any concurrent chronic health condition
- wherever possible, pt and escort should travel home by private care or taxi rather than public transport.
- if either pt or escort appears to be unwilling or unable to comply with these requirements, conscious sedation must not be administered
36
What should be included in pt's records from the pre-sedation assessment?
Full medical history (including prescribed and non-prescribed drugs and any known allergies)
Blood pressure
BMI
Heart rate and oxygen saturation
Potential airway difficulties
ASA status
Dental history
Social history
Conscious sedation and general anaesthetic history
Dental treatment plan
Assessment of anxiety and any tools used
The selected conscious sedation technique and justification
Any individual patient requirements
Provision of pre- and post operative written instructions provided before treatment, including advice given on fasting
Written consent for conscious sedation and dental treatment
37
What should be included in the pt's notes for the visit for dental tx under conscious sedation?
- Presence of a responsible adult escort
- Time that food and drink were last consumed
- Arrangements for suitable post-operative transport and supervision
- Compliance with the pre-treatment instructions
- Presence of written consent for the procedure and reconfirmation
- Any changes in the recorded medical history or medication
38
What should be included in the treatment procedure notes?
- Dose, route and time(s) or administration of drugs
- Site of cannulation and/or attempted cannulation (for intravenous, oral and transmucosal sedation)
- Details of clinical and electromechanical monitoring (i.e. pre-operative, after drug titration, intra-operative and post-operative measurements, and in particular any significant events)
- Personnel present in surgery
- Patients reaction, sedation score and success of sedation
- Dental treatment provided
39
What should be included in the recovery notes?
- Monitoring - appropriate details of observations and measurements throughout
- Pre-discharge assessment by sedationist - appropriate discharge criteria met
- Written post-operative instructions given and explained to patient and escort
- Removal of cannula (for intravenous, oral and transmucosal sedation)
- Time of discharge
40
What can be prescribed as an oral premedication for anxiolysis?
A low dose of benzodiazepine can be prescribed as oral premedication for anxiolysis to assist with sleep the night before treatment or to aid an anxious patient's journey under close supervision to the treatment facility.
41
Can oral premedication be used as a standalone method for anxiety management?
Yes, it can be used as the standalone method without being followed by sedation at treatment.
42
What do higher doses of benzodiazepines count as?
oral sedation (not just premedication)
43
Can a premedicated patient give valid consent?
NO!
So consent must be achieved in pre-sedation appointment whilst patient has capacity.
44
Does a patient that is premedicated need to be escorted?
YES!
Advise the patient that when premedicated they will need to be escorted to and from the treatment facility and should not drive
45
When do you use standard sedation techniques compared to advanced?
Use standard sedation techniques, unless there are clear indications to do otherwise.
46
What is inhalation sedation?
Titrated dose of nitrous oxide with oxygen is standard inhalation sedation
It is a mild sedative agent that safely and effectively manages pain and anxiety during dental treatment for adults and children.
Always min of 30% oxygen used.
The success of the technique depends on appropriate titration of nitrous oxide
to the individual patient’s response and is supported by behaviour management techniques.
Dedicated inhalation sedation machines will not allow hypoxic levels of sedation.
47
Can inhalation sedation be used before intravenous sedation?
YES
Note that inhalation sedation with nitrous oxide/oxygen may be used before intravenous sedation to facilitate cannulation but, to remain a standard technique, would be discontinued prior to
administration of midazolam.
48
What does the success of intravenous sedation rely on?
Successful intravenous sedation with a wide margin of safety is dependent on titration of the drug dose according to the individual patient’s response and therefore the use of fixed doses or bolus techniques is unacceptable.
49
What is standard intravenous sedation technique?
Use of titrated doe of midazolam
Note that intravenous sedation of children with midazolam is considered an advanced technique
50
When do you remove the canula after IV sedation?
Maintain intravenous access by way of an indwelling cannula until the patient is fit for discharge
Oral premedication, topical local anaesthesia or inhalation sedation may facilitate cannulation for some patients.
51
How can midazolam be administered? (3)
Intravenous
Oral
Transmucosal (intranasal)
52
What technique can be used for patients with extreme needle-phobia?
Oral and transmucosal sedation with midazolam
53
Can oral and transmucosal sedation with midazolam be an advanced technqiue?
These techniques are also occasionally used in combination with other sedation techniques, in which case this would be considered advanced sedation.
Note that oral and transmucosal sedation of children are considered to be advanced techniques.
54
How does oral and transmucosal sedation with midazolam compare to sedation from titrated IV midazolam?
The state of conscious sedation resulting from oral or transmucosal sedation might be
comparable to that produced by the intravenous administration of drugs, but it is less controlled
and therefore less predictable.
55
Why do pts taking oral and transmucosal sedation with midazolam need to be cannulated still?
Cannulate asap due to the less predictable nature of either oral and transmucosal sedation. It is just in case the administration of a reversal agent is required.
56
Where do you administer oral and transmucosal sedation with midazolam?
At the sedation facility
57
When should advanced techniques be used?
Only use an advanced technique if the clinical needs of the patient are not suited to
sedation using a standard technique.
58
What do advanced techniques include?
- The use of certain drugs
- Combination of drugs and/or combined routes of administration
59
Why are advanced techniques more risky?
Drug combinations have less
predictable effects than single drugs, and some anaesthetic drugs and infusions used for sedation have narrower therapeutic indices.
Consequently, advanced sedation techniques are likely to
have reduced margins of safety, potentially increasing the risk of adverse events.
60
What must be checked staff wise before doing an advanced technique?
If using an advanced sedation technique, ensure that its use is justified and record the
justification in the patient’s records.
Ensure that all members of the dental sedation team are specifically trained and
experienced in the use of advanced techniques for the patient groups being treated
Ensure that the facilities, knowledge and skills required for the prompt recognition and
immediate management of sedation-related complications and medical emergencies are
in place
61
When do you monitor the patient?
Pre-operative stage until discharge criteria are met
62
What are the clinical signs that should be monitored during sedation?
- Check level of consciousness/depth of sedation
- Airway patency
- Respiration (rate and depth)
- Skin colour
- Capillary refill
- Pulse rate, rhythm and volume
63
What should be monitored for all pts with inhalation sedation?
For all patients having inhalation sedation with nitrous oxide/oxygen, monitor the
patient’s clinical signs*.
* Additionally, non-invasive blood pressure (NIBP) monitoring may be indicated for some patients, for example, those with significant degrees of cardiovascular disease.
64
What should be monitored for adults and young people having an sedation (other than inhalation)?
For adults and young people having any sedation technique other than inhalation
sedation with nitrous oxide/oxygen, monitor as a minimum, the patient’s clinical signs*, oxygen saturation using pulse oximetry, and blood pressure.
65
What should be monitored for children having an sedation (other than inhalation)?
For children having any sedation technique other than inhalation sedation with nitrous
oxide/oxygen, monitor the patient’s clinical signs*, oxygen saturation using pulse
oximetry and, unless likely to prevent completion of the procedure, blood pressure.
66
When may you need to monitor ECG or capnography?
Monitoring by electrocardiogram (ECG) or capnography is not currently required for conscious
sedation for dental treatment.5
However, such additional monitoring may be appropriate for ASA grade III and IV patients.
67
What is the preferred conscious sedation technique for children?
Inhalation sedation with nitrous oxide/oxygen is the only standard technique for children.
A brief trial of nitrous oxide/oxygen at the assessment appointment may be helpful for
the psychological preparation of some children.
68
What are the preferred conscious sedation techniques for young people?
Use inhalation sedation with nitrous oxide/oxygen or intravenous
midazolam as the preferred techniques, unless these standard techniques are judged to be unsuitable for the patient and clinical need.
* Oral and transmucosal sedation using midazolam, while also considered standard
techniques for young people, are only appropriate in a minority of cases (e.g. for
patients with special care requirements or needle phobia).
69
Whose decision and responsibility is it to discharge the patient?
The decision to discharge a patient following any type of sedation is the responsibility
of the sedationist, although aspects of the discharge process may be delegated to a suitably trained member of the clinical team.
70
What is the discharge criteria?
The patient is orientated in time, place and person.
* Vital signs are stable and within normal limits for the patient. Respiratory status is not
compromised.
* Pain and discomfort have been addressed.
* Where relevant, haemostasis has been achieved.
* The cannula, where inserted, has been removed.
* The responsible escort is present and arrangements have been made for supervision as
advised by the sedationist.
* Written and verbal post-operative instructions appropriate for both the sedation technique and the dental treatment have been given to the patient and escort.
71
What are recognised training providers for sedation?
Validated training is training delivered by a recognised provider
(UK universities, Health Education England, NHS Education for Scotland, the Wales Deanery,
the Northern Ireland Medical and Dental Training Agency or Schools of Anaesthesia) or that is accredited through the dental faculties of the UK surgical royal colleges.
72
What critical incidents during sedation should be reported?
Choking, vomiting, over-sedation, emergency use of flumazenil or naloxone and medical emergencies.
73
What are the ideal sedative properties?
Anxiolysis - reduce patient anxiety
Analgesic - reduce pt pain
No effect on CVS or respiratory system
Not metabolised
Easy and quick to change level of relaxation
Reversible
No contraindictions with other drugs
Cheap
Long shelf life
74
What effects does benzodiazepine have?
Anxiolysis - first effect is at low doses, and high anxiety increases dose requirement.
Sedation - decreased response to constant stimulus
Anticonvulsant - sedative, and they terminate or prevent fits
Amnesia - IV administration gives anterograde amnesia. Most intense for 20-30 mins. Unpredictable duration.
75
What does anterograde amnesia mean?
Inability to form new memories.
76
Can benzodiazepines analgesics?
No, but they can effect the pain experience. They are not an analgesic, but they influence response to pain.
77
What is the pharmacology behind benzodiazepine?
BZD acts on receptors to enhance the effect of GABA (anticonvulsant and sedation)
BZD mimics effects of glycine (muscle relaxation and anxiolysis)
78
Where are GABA receptors and Glycine receptors found?
GABA receptors in the cerebral cortex
Glycine receptors in brainstem and spinal cord
79
What are the contraindications of of benzodiazepines?
Suspected allergy to BZD
Patient is epileptic
Patient dependant on BZD
Drug interactions
- Angina (Verapamil, Diltiazem)
- Anti-retroviral
- Anti-fungal (fluconazole)
- Anti-bacterial (erythromycin)
80
What drug interactions do benzodiazepines have?
Angina - verapamil, diltiazem
Anti-retroviral
Anti-fungal (fluconazole)
Anti-bacterial (erythromycin)
81
What are the side effects of benzodiazepines?
Depression of respiratory system and CNS
Muscle relaxation
Decreases cerebral response to CO2 - enhanced in patients with chronic bronchitis (COPD contraindication)
Cardiovascular effects
= HR increases via baroreceptor reflex
= Reduced blood pressure by decrease in vascular resistance
Drug interactions
- Increased respiratory depression with CNS depressant drugs
- Synergistic interaction with opioids
- Pharmacokinetic interactions (ketoconazole, erythromycin and midazolam)
Sexual fantasy
- reported in both male and female patients
- dose related (midazolam > 0.1 mg/kg)
82
What are negative effects of BZD?
Tolerance to oral BZD
Dependence
- long term BZD causes addiction, with withdrawal experienced
- Dependence activated by acute administration
- Acute withdrawal caused by BZD antagonists
83
What is midazolam?
A water soluble imidazobenzodiazepine, an active metabolite with half-life of 90-150 mintues.
- Water soluble pH <4
- Lipid soluble at physiological pH, crosses blood-brain-barrier
84
How does midazolam work?
Acts on the CNS receptors by blocking GABA receptors which causes an increase in the length of time for repolarisation to occur after a neurone has been depolarised. This has the effect of reducing the number of stimuli that reach the higher centers and results in sedation.
85
What are some characteristics of midazolam?
Lipid soluble at physiological pH, crosses blood-brain-barrier.
No rebound sedation
Midazolam is the BAD least affected by liver disease
5mg in 5ml concentration, easier to titrate.
86
How can you administer midazolam, where is it metabolised and how can it be excreted?
Administered by IV or IM injection.
It is metabolised in the liver and excreted via kidneys.
It has the most extra-hepatic metabolism of any BAD, acute administration not affected by renal disease.
87
What is flumazenil (anexate)?
Specific BZD antagonist, given by IV injection.
It is the reversal drug for benzodiazepines.
88
How does flumazenil work?
It has a high receptor affinity and low intrinsic action.
It completely displaces active BZD by competitive displacement of constituent receptors.
Elimination half-life of 53 minutes.
89
When is flumazenil used?
Not used routinely, only in specific emergency circumstances.
Essential emergency drug anywhere BZD is potentially administered.
It provides reversal of sedation, via residual sedation due to short half-life of 53 mins.
90
What are contraindications to flumazenil? (3)
Suspected allergy to BZD
Patient is epileptic
Patient dependant on BZD
91
How does nitrous oxide work?
It is a central nervous system inhibitor
- CNS depression without respiratory or vasomotor paralysis
- Confined to high centres, if oxygen administered.
- Enhanced GABA receptors = anxiolysis
Analgesia - 20:80 mixture of N2O:O2 produces same effects as 10-15mg morphine
92
What are the effects of nitrous oxide?
Euphoria
Analgesia and tingling - analgesia produced by same mechanisms as opioids
Time compression
Anxiolysis
93
What are the characteristics of nitrous oxide?
It is poorly soluble in blood
Least potent of all anaesthetic gases
First choice in children under 12 years old
Safe choice in elderly patients with moderate to severe cardio vascular diseases
Nitrous oxide eliminated by the lungs
94
What are the side effects of nitrous oxide?
Reproductive system, decreased fertility
Red blood cell synthesis via Vitamin B12
Neurological effects
Liver
95
What is the active metabolite, onset and half-life for each of these drugs a) midazolam, b) temazepam, c) diazepam d) flumazenil?
a) Midazolam
- hydroxymidazolam, 30 secs, 90-150 mins
b) Temazepam
- oxazepam, 45-60 min, prior to trx, 13 hours
c) Diazepam
- temazepam (13 hours), desmethyldiazepam (75 hours), 43 hours
d) Flumazenil
- BZD antagonist - 53 min half life
96
What are the indications for inhalation sedation? (6)
1. Anxious and phobic patients
2. Needle phobia
3. Gagging
4. Traumatic procedures (Orthodontic XLA)
5. Medication conditions aggravated by stress e.g. IHD, hypertension, asthma, epilepsy.
6. Unaccompanied adults requiring sedation.
97
What are contraindications to inhalation sedation? (6)
1. Common cold
2. Tonsillar and adenoidal enlargement
3. Severe COPD or sickle cell disease
4. First trimester of pregnancy
5. Fear of mask/ claustrophobia
6. Patients with limited ability to understand verbally/ severe learning disabilities
98
What equipment is needed for inhalation sedation?
- Gas cylinders filled with oxygen
- Flow control meter
- Reservoir bag
- Gas delivery hoses
- Nasal mask
- Scavenging system
- Safety features
99
What are the safety features of inhalation sedation equipment?
1. Pin index system to prevent the wrong cylinder being attached.
2. Diameter index system prevents cross connection of piping
3. Minimum oxygen is 30%, oxygen fail safe when oxygen pressure <40 psi
- Oxygen flush button for emergencies (35 L/min)
100
What are the advantages of inhalation sedation? (8)
1. Rapid onset (2-3 mins) and rapid peak action (3-5 mins)
2. Depth altered either way
3. Flexible duration
4. Rapid recovery independent on sedation duration
5. No injection
6. Drug not metabolised - exhaled
7. Some analgesia (better for ischaemic than inflammatory pain)
8. No amnesia
101
What are some disadvantages of inhalation sedation? (6)
1. Expensive equipment and gases
2. Not potent - will see and remember everything
3. Requires nasal breathing
4. Chronic exposure risk, especially if no scavenger system - long term neurological problems
5. Difficult to accurately determine actual dose
6. Staff addiction - drug of abuse
102
What are 10 signs of adequate sedation??
1. Patient relaxed and comfortable
2. Patient awake
3. Reduced blink rate
4. Lessened pain awareness
5. Paraesthesia - lips, fingers, toes, legs, tongue
6. Lethargy or floating feeling - "few pints"
7. Euphoria
8. Warmth
9. Altered awareness of time
10. Dreaming
103
What are 8 signs of overdose sedation?
1. Mouth repeatedly closing
2. Spontaneous mouth breathing
3. Nausea and vomiting
4. Irrational and sluggish
5. Decreased cooperation
6. Incoherent speech
7. Laughter and tears
8. Loss of consciousness
104
What will happen at the assessment appointment before sedation?
- Will not receive treatment
- Dental and medical history
- Observations - BMI, blood pressure, saturations
- Come up with most appropriate sedation technique
- Book in for tx
- Pre-op instructions.
105
What are the pre-op instructions for inhalation sedation?
Have a light meal before appointment
Take routine medications as usual
Children accompanied by competent adult
Adults accompanied at their first sedation appointment. May then attend alone.
Do not drink alcohol on day of appointment
Wear sensible clothing
Arrange care of children during and after your appointment
Plan to remain in clinic for up to 30 mins after treatment.
106
What is the inhalation sedation procedure?
1. Set up the machine
2. Select nasal hood (record size in notes)
3. Connect to hoses
4. Set mixture dial to 100% O2
5. Settle patient in dental chair and reinforce explanation of procedure
6. Set flow to 5-6 litres per min and position hood on patient's nose
7. Encourage nasal breathing and. check reservoir bag movements
8. Ask patient to signal when they begin to feel different
9. Titrate oxygen, initially reducing by 10% until getting to 80% then move down in 5% increments every 1 minute (it will take roughly 6 mins to reduce to 50%)
10. Constant reassurance and hypnotic suggestion
11. Adjust level of O2 as required, whilst monitoring signs of adequate sedation
107
What do you do if a patient is under-sedated?
If under-sedated decrease O2 in 5-10 increments until satisfactory sedation
108
What do you do if a patient is over sedated on inhalation sedation?
Increase O2 in 5-10% increments until satisfactory sedation achieved. Administer 100% oxygen for 2 minutes to prevent diffusion hypoxia
109
How do you do inhalation sedation recovery?
Gradually increase O2 by 10-20% per minute until 100%.
Administer 100% oxygen for 2 mins to prevent diffusion hypoxia.
Remove hood and turn gas flow off.
Return pt to upright slowly, give praise and reassurance.
110
How do success rates differ in inhalation sedation?
Differs across population 50-90%
Greater success for orthodontic extractions
Better success in children due to them more open to hypnotic suggestion and reassurance
Poorer in patients in pain and very anxious.
111
How is the potency of inhalation sedation expressed?
Potency expressed as minimal alveolar concentration 50 (MACSO)
MAC for Nitrous Oxide = 104%
112
What is the most commonly used drug used for intravenous sedation?
Benzodiazepines - midazolam and remimazolam
Inject sedative drug titrated against their response.
113
What are desirable effects of intravenous sedation?
anxiolysis, sedation, muscle relaxation and anterograde amnesia
114
What are undesirable effects of intravenous sedation?
Respiratory depression, paradoxical reactions (more agitated), hallucination and sexual disinhibition
115
When is intravenous sedation used in particular? Indications:
Higher levels of anxiety
Muscle relaxation - uncontrolled movements
Other techniques contraindicated
Amnesia wanted (don't want to remember what happened)
Only children above age of 12 and adults.
116
What are contraindications to intravenous sedation?
Allergy to benzodiazepines
Pregnancy and breast feeding
Severe psychiatric disease
Alcohol or drug abuse
Impairment of hepatic function
Phobia of needles and infections* (e.g. can overcome with inhalation sedation to allow cannulation)
Poor veins
Domestic responsibilties (e.g. care of children, elderly people)
Unable to provide suitable escort.
117
What is midazolam? how does it work? irritant? half life?
Benzodiazepine
Increased GABA receptor activity = anxiolysis
Non-irritant solution
Half-life around 2-4 hours
No clinically significant metabolites
Long duration of action
Reversed by flumazenil (benzodiazepine antagonist)
118
What is remimazolam? How does it work? Fast onset? How does it compare to midazolam
Benzodiazepine
Increased GABA receptor activity = anxiolysis
Faster onset, more rapid recovery, and lower incidence of post-operative side effects compared to midazolam.
Metabolised by non-specific tissue esterases so does not rely on the cytochrome-dependent pathways of the liver meaning dose adjustments are not required in patients with either hepatic or renal impairment.
Reversed by flumazenil
119
How do you prepare IV sedation drugs?
Once patient arrived but before they enter the surgery
Midazolam drug of choice (water soluble BZD), half-life 90 mins
1mg/ml per ampule dose to begin with, maybe 0.5 if elderly or young.
120
How do you carry out intra-venous cannulation?
1. confirm position with test dose of saline
2. 22-gauge cannula used
3. cannot observe as swelling on the back of the patients' hand, attach cannula with tape or dressing
4. Attach monitor to measure oxygen saturation and pulp oximeter
5. Ready to give sedation
6. 2mg of midazolam is injected over 30 seconds
7. Titrate midazolam in increments of 1mg every 30 seconds until sedation judged to be adequate
8. Talk to patient and observe for any adverse responses, in particular respiratory depression.
121
What do you monitor during IV sedation? (5)
1. Consciousness (respond verbally)
2. Respiration
3. Pulse rate
4. Oxygen saturation (pulse oximeter)
5. Blood pressure
122
What is the pattern of sedation for IV sedation? How does this affect order of treatment?
Deepens for 10-12 mins
Gradual recovery
Useful sedation for 25-45 mins
- First 25 mins best quality
- Patient is constantly recovering, most invasive treatment to be done first.
123
What should be considered in a risk assessment prior to sedation?
- Nature, severity and stability of patients' medical condition
- Emotional state of patient
- Type of dental procedure required
124
When do you consider sedation for medically compromised patient? For patients that:
- Have dental anxiety or phobia
- Medical condition aggravated by stress
- Involuntary movements which compromise quality of operative care
- Require surgical procedure that LA is not advisable
125
Cardiovascular disease: sedation?
2-3 episodes of angina per week (ASA III)
Nitrous oxide recommended, reduces workload on CVS
- Increased oxygen
- Increased blood flow to the myocardium
Unstable Angina, must have medical consultation first
Post myocardial infarction, MI may be provoked by stress or pain
- Don't treat for 6 months
- If essential tx NsO-O2 sedation
Hypertension patients, oral, inhalation and intravenous sedation all appropriate
- Don't give too much LA as adrenaline is a vasoconstrictor, increases BP.
126
Respiratory disease: sedation?
Asthma --> acute exacerbation by stress, care with NSAIDS
IV and inhalation sedation provides anxiolysis with no airway irritation
COPD: reliance on hypoxic drive, sensitive to respiratory depressant drugs (no midazolam)
127
Endocrine problems: sedation?
Thyroid disorders: oral, inhalation and intravenous sedation all appropriate
Caution with adrenaline containing LA in hyperthyroidism
Caution with CNS depressants in hypothyroidism
Diabetes mellitus: no absolute contraindication with insulin
- Issue with retrograde amnesia and escort preventing overeating and insulin excess
128
Neurological problems: sedation?
Epilepsy: oral, inhalation and intravenous sedation all appropriate, ensure pt not hypoxic
Cerebrovascular disease: most CVA patients ASA II or III, severe or recent ASA IV
- Inhalation sedation most appropriate if patients' cognitive abilities allow
- Avoid hypoxia, to avoid TIAs
Myasthenia Gravis: avoid BZD
- N20-O2 sedation appropriate
- Easy fatigue and weakness of muscles, means muscle relaxants must be avoided.
129
HIV infection: sedation?
- Cross infection risk
- Drug interactions of protease inhibitors and ketoconazole (anti-fungal)
130
Renal disease: sedation?
ASA II-IV
Oral, inhalation and intravenous sedation all appropriate if in one off dose.
131
Hepatic disease: sedation?
ASA II-IV
Reduced biotransformation of many drugs
Inhalation sedation used
Due to significant extra-hepatic metabolism of midazolam, IV sedation can be used.
132
Anaemia: sedation?
Reduced ability to carry O2, due to iron deficiency.
Oxygen saturation done via %, needs to be investigated before sedation.
133
Special care in these cases, a) Porphyria, b) Malignant hyperpyrexia, c) Suxamethonium apnoea
a) Porphyria: avoid BZD
b) Malignant hyperthermia is a severe reaction to certain drugs used for anesthesia: care with Lidocaine, N2O-O2 sedation appropriate
c) Suxamethonium apnoea: care with articaine
134
What patients have involuntary movements? (4)
1. Muscular dystrophy
2. Cerebral palsy
3. Multiple sclerosis
4. Parkinson's
135
Which sedation is best for pt's with involuntary movements?
Inhalation sedation: useful for anxiety relieve, rapid recovery and flexible duration but less muscle relaxation and must keep nasal hood in place.
IV sedation: very good muscle relaxation but IV cannulation required and swallowing compromised.
136
Complication with conscious sedation: Cannulation issues?
Venospasm
= disappearing vein syndrome, collapse at attempted venepuncture.
- managed by time dilating vein (worse with more attempts), fewest attempts possible, warm water and efficient technique (slow skin puncture)
Extravascular injection
- active drug placed into interstitial space
- problems with delayed absorption of drug if accidental subcutaneous
- if cannula not placed corectly in the vein of the pt, then delayed absorption seen
- Prevent by good cannulation and test dose of saline
- Treated by removal of cannula, apply pressure and reassure.
Intraarterial injection
Haematoma
- Extravasation of blood into soft tissue
- Due to damage to vein walls
- At venepuncture and removal of cannula, be careful with elderly patients
- Prevent by applying pressure when removing the cannula
- Prevention by good cannulation technique and pressure applied post-operative
- Treated by time, rest and reassurance.
Fainting
- Manifestation of needle phobia related to venepuncture
- Worse if starved
- Inhalation sedation prior to cannulation useful prevention (vasodilation)
137
What are complications of IV drug administration?
- Hyper responders: deep sedation with minimal dose (1-2mg Midazolam)
= prevented by careful titration, such as 1mg increments with slow titration in elderly
- Hypo responders: little sedative effect with large doses
= check cannula is intravenous
- may be due to tolerance (BZD induced, cross tolerance, idiopathic)
- question technique above 20mg midazolam, taking 20 mins to sedate them
- Paradoxical reactions
= sedate normally but react bizarrely to various stimuli, then sedate when removed.
- check for failure of LA rather than the sedation
- Do not add midazolam, find other management technique.
- Over sedation
= Loss of responsiveness, respiratory depression, loss of ability to maintain airway
- manage by stopping procedure, checking ABC, REVERSE WITH FLUMAZENIL
- Keep pt airway, maintain ventilation until recovered.
- Respiratory depression management: check oximeter, stimulate patient and provide supplemental oxygen (2 L/min), reverse with flumazenil\
- Allergic reactions
-- extremely rare for sedatives, do not use flumazenil if potentially allergic
- latex and elastoplast much more common
138
What are the risks of undersedation?
Patient not relaxed enough for treatment
-- Psychologically distressing and no physiological protection
- Do not rely on amnesia
- Sedate properly or abort
139
What are advantages and disadvantages of oral sedation?
Advantages:
1. Patients are use to taking oral medication - although must be taken with professional supervision
2. Easy administration
3. No injection (cannula placed once sedated)
Disadvantages:
1. Long latent period (less with midazolam)
2. Erratic absorption from the GI tract
3. Inability to alter depth of sedation (cannot titrate to patient's response)
4. Prolonged duration of action
140
How does oral midazolam work?
Rapid onset, effective sedation, commonly available, water soluble.
However, no formulation available, bad taste, 50% 1st pass metabolism (low bioavailability), not titratable and has long lag time
Administered in drink form
- 20mg adults (0.5 mg/kg for anyone <40kg)
- Monitor and wait, attach pulse oximeter when able
- If necessary, top up with IV midazolam
- IV access once sedated
- Cannot give oral sedation unless the dentist is trained to use deep IV sedation
141
Transmucosal sedation?
- Absorption of active agent across mucosal surfaces
- Avoids traditional parenteral routes (IV or IM)
- Avoids enteral route problems (first pass metabolism)
- Intranasal midazolam used as a sedative for children during laceration repair
- Midazolam 0.3 mg/kg, use 10mg in 2ml
- Squirt into nostrol, watch and wait and then apply pulse oximeter
- Cannula placed once patient sedated
- Very few paradoxical reactions, as well as no significant side effects
142
Why do you avoid IV sedation with children?
Children + BDZ = avoid IV sedation as narrow therapeutic margin and paradoxical reactions
143
What do you need to be wary of when using multiple agent sedation?
Risks of synergistic reactions. e.g.:
- 50 ug fentanyl = x% decrease in ventilation
- 6mg midazolam = y% decrease in ventilation
- 50ug fentanyl + 6mg midazolam = (x+y) x4
144
What is the most common multiple agent sedative?
Opioid + benzodiazepine
e.g.
- Opioid and ketamine = analgesia
- Midazolam = sedative
145
Fentanyl & alfentanyl?
Fentanyl & alfentanyl = rapid onset, short acting, very potent opioid agonist, controlled drug
- Naloxone (Narcan) = antagonist, must be readily available.
- Opioids produce sedation and analgesia
- Opioids first then midazolam titrated
- Produces respiratory depression (fentanyl) and nausea and vomiting (6%)
146
What can ketamine act as?
A useful analgesic -> neutral or stimulates respiration
- Ketamine does not affect cardiovascular and respiratory systems.
- Amnesia, short acting, with hallucinations in 25%
- Dissociative anaesthetic agent
147
When can ketamine and midazolam be used?
- Used in patients who become sedated by not anxiolysis
- Those that require high doses of midazolam
- Midazolam 0.2mg/kg + Ketamine 2mg/kg
148
Propofol
Licensed for use by those with a training in anaesthetic (synthetic GA induction agent)
Rapid onset and short acting with minimal accumulation
Less lag time between injection and effect
Faster recovery than with Midazolam
Continuous infusion initial bolus 1mg/kg for 1-5 mins, then infused 1.5-4.5 mg/kg/hr
Respiratory depressant in anaesthetic doses
Allows for patient controlled and maintained infusion
Propofol used for very long and very short procedures, when high doses of midazolam have no effect
149
Clinical experience of combination drugs
Different quality of sedation
Helps hypo responders to cope
No need for supplemental oxygen
Sedation window not very different
Recovery like midazolam on its own
Drug dose reduced for each patient.
150
What are advantages of continuous infusion??
Dose range narrow
Duration of sedation more flexible
Easily reversed if over sedation
Can give patient control of sedation
151
What are alternatives to nitrous oxide?
Volatile anaesthetic agent isoflurane and Sevoflurane
- Success of nitrous oxide may be reduced by fixed dose.
- No dedicated equipment
- Occupational exposure to anaesthetic volatiles
Combination of sevoflurane, nitrous oxide, oxygen and midazolam appears the best combination
152
What are implications of alternative sedation techniques?
- Sedationist must be trained and experienced in technique
- Must be able to justify use of technique
- Must have reversal agent (if one is available)
- Must have ILS skills
Potential complications same as for midzolam alone (respiratory depression and over sedation)
153
Who sets the standards for dental sedation?
IACSD
- Intercollegiate
- Advisory
- Committee for
- Sedation in
- Dentistry
SAAD = safe sedation practice scheme
154
What is the definition of anxiety?
A mental state characterised by an intense sense of tension, worry or apprehension, relative to something adverse that might happen in the future.
155
What is the definition of a phobia?
An anxiety disorder compromising of a marked and specific feat that is deemed excessive or unreasonable, and situations are 'avoided where possible'.
156
What is trait vs state anxiety?
Innate = the more enduring apprehension concerning dental treatment that a person generally feels when contemplating or engaging with dental treatment.
State = situation specific - the individual's degree of concern at a specific point in time when faced with a particular aspect of dental treatment.
157
What can cause dental anxiety?
Previous bad experience
Lack of control
Fear of pain
Specific anxiety - e.g. infections
Vicarious anxiety
Fear of the unknown
158
What are some physical signs of dental anxiety?
- Sweating, shortness of breath, dry mouth
- Shivering/trembling, inattention/inability to focus, pallor
- Avoidance of eye contact or excessive staring, aggression
- Closed body position (arms and legs crossed), pacing when standing
- Body focused movements (hand/foot tapping, rubbing hands, rubbing face).
- Stomach cramps, nausea, vomiting, frequent need for the toilet
- Avoidance of trigger (poor dental attendance)
159
What are 4A's of anxiety?
Ask about anxiety
Assess the level of anxiety
Acknowledge of concerns
Address specific fears
160
What is the modified dental anxiety scale? (MDAS)
5 point scale
Specific items relating to different aspects of dental treatment
The higher the score, the higher the level of anxiety
161
What are 4 ways we can manage dental anxiety?
Behaviour management
Behavioural therapy
Conscious sedation
General anaesthetic
162
What else do we need to consider when deciding which dental anxiety management technique? (4)
1. Urgency of tx - how can manage tx in meantime while on waiting list
2. Complexity/invasiveness of tx plan
3. Social history
4. Medical history - ASA
163
What patients lie in ASA classification 1
A healthy patient e.g.
- Healthy, non smoker, no/minimal alchol
164
What patients lies in ASA 2
A patient with mild systemic disease
e.g. Smoker, pregnancy, anxiety, well controlled diabetes, well controlled hypertension
165
What patients lie in ASA 3?
A patient with severe systemic disease
e.g. poor controlled diabetes, poor controlled hypertension, history of MI, COPD, CVA, TIA
166
What patient lies in ASA 4?
A patient with a severe systemic disease which is a constant threat to life
e.g. recent history of MI/CVA (<3/12), ongoing cardiac ischaemia, valve dysfunction
167
What patients lie in ASA 5?
Moribund patient not expecting to live more than 24 hours with or without an operation
e.g. ruptured aortic or thoracic aneurism, intra-cranial bleed with mass effect.
168
What is good about behaviour management?
Non pharmacological technique
Can be used as an adjunct to pharmalogical techniques
Aims to modify or change behaviour to lower level of anxiety
A low level technique suitable for all patients
Can be used by all practitioners
169
Name 6 examples of behaviour management?
1. Rapport building
- tell, show do. Empathy and time. More frequent recalls.
2. Environmental change
- waiting area, surgical space, lavender oil, musics.
3. Enhancing control
- use of stop signals, tell show do, involved in treatment planning
4. Managing physiological arousal
- breathing techniques, progressive muscle relaxation, applied tension (vasovagal episodes).
5. Retrospective control
- debrief after appointments. useful when things don't go to plan as helps patient understand why events may have happened.
6. Feedback positive coping
- praise, encouragement, labelling success. ask patient to identify positives.
170
How do you do controlled breathing exercise?
a. Sit in a comfortable position, with back upright. Let shoulders and jaw relax.
b. Put one hand low on belly. Take a long, slow, deep, gentle breath in through your nose and out through your mouth. Try to breathe right down into your belly, but do not force the breath. Just let your body breathe as deeply as is comfortable for you.
c. Do this for 5 breaths.
d. If possible, practice this exercise 3 times every day for a week.
171
How do you do applied tension technique?
a. This is a simple technique to increase blood pressure to a normal level again and avoid fainting.
b. Sit down somewhere comfortable.
c. Tense the muscles in your arms, upper body and legs. Hold this tension for 10 to 15 seconds or until you start to feel the warm rising in your face.
d. Release the tension and go back to your normal sitting position.
e. After 20 to 30 seconds, go through the tension procedure again until you feel the warmth in your face.
f. Repeat this sequence until you have practiced the tension 5 times.
g. If you can, practice this sequence 3 times every day for about a week.
172
What is cognitive behaviour therapy (CBT)?
a. CBT is based on the concept that your thoughts, feelings, and physical sensations and actions are interconnected, and that negative thoughts and feelings can trap you in a negative cycle.
b. CBT aims to help you deal with overwhelming problems in a more positive way by breaking them down into smaller parts.
c. You’re shown how to change these negative patterns to improve the way you feel.
d. Unlike some other talking treatments, CBT deals with your current problems, rather than focusing on issues from you past.
e. Short-term talking therapy
f. Tx typically lasts 6 to 10 sessions: usually around 1-hour in duration.
g. NICE advocates use for in specific phobias.
h. Strong evidence base for success in Dental Anxiety and Phobia.
i. Can be delivered by Registered Psychological Professionals or appropriately trained Dental Care Professional – in absence of mental health co-morbidities impacting on dental care.
173
What are positives of CBT?
- completed in relatively short period of time
- can be provided in different formats, including in groups, self-help books and online
- teaches useful and practical strategies that can be used in everyday life
- focuses on person's capacity to change themselves (their thoughts, feeling and behaviours)
- Can be effective in treating some mental health problems
174
What are cons of CBD?
- Commitment - need pt cooperation and attendance to appointments.
- Time - pt attends regular sessions and extra work between sessions
- May not have time if urgent tx needed
- May not be suitable for ppl with more complex mental health eneds or learning difficulties
- Access = long waiting list on NHS
- Cost of private therapy
175
What are 4 other techniques?
Distraction therapy
Acupuncture
Aromatherapy
Music therapy
176
What is the difference between oral pre-medication and oral sedation?
Oral pre-medication is the self-administration of a small dose of an oral sedative to alleviate anxiety. This usually takes place out of dental practice and is part of he dental formulary.
Oral sedation is the administration of a much larger dose of an oral sedative at the dental practice. Monitoring and discharge requirements for oral sedation are the same as for intravenous sedation. Only to be carried out by dentists trained and competent in intravenous sedation.
177
Where do benzodiazepines act and what do they result in?
All benzodiazepines act on the GABA (gamma-aminobutyric acid) receptors in the brain.
They act by facilitating the binding of the inhibitory neurotransmitter GABA at various GABA receptors throughout the CNS.
This results in:
i. Anxiolysis
ii. Sedation
iii. Amnesia
iv. Muscle relaxation
178
What is diazepam? available as? peak effect time? where metabolised? half life?
a. Anxiolytic benzodiazepine
b. Available as both a tablet and an oral solution
c. Peak effect at 30-90 minutes following administration
d. Metabolised by the liver
e. Active metabolite half-life of 2-5 days.
(Diazepam longer half life and more prone to interaction than temazepam)
179
What is temazepam? Available as? Peak effect time? Half-life?
a. hypnotic benzodiazepine
b. tablet of oral solution
c. peak effect 1hr-1.5hr (similar to diazepam)
d. half life 3.5-18.5 hours
Due to shorter half-life it is preferred to diazepam
180
Why is temazepam preferred to temazepam?
Temazepam has a shorter half-life of 3.5-18.5hrs compared to diazepams 2-5 days
181
How do you prescribe diazepam?
1 tablet, 5mg, take 2 hours before procedure.
Can be increased to 10mg if necessary.
Half adult dose for elderly or debilitated patients.
Not recommended for children because it has an unpredictable effect in children.
Advise all patients that they will require an escort and that they should not drive.
182
Why should diazepam not be prescribed for children?
Children can experience paradoxical reactions and the effects are unpredictable.
183
How do you prescribe temazepam?
10-20mg to be taken 1-2 hours before procedure.
Alternatively, 30mg to be taken 1-2 hours before procedure. Higher alternative dose only administered in exceptional circumstances.
184
Can temazepam be prescribed for children?
Yes, but nor first line.
Temazepam can be prescribed for older children (aged 12-17) using a dose of 5-10mg one hour before the procedure
Alternatives such as behavioural management techniques and inhalation sedation should be considered as first line for anxiety management in this pt group.
185
What is important to remember about consent when a patient is taking a premedication?
Patient who has taken a benzodiazepine may be deemed unable to give valid consent.
Therefore obtain valid consent in advance of the procedure.
Considered good practice to get written consent in cases involving pre-medication.
Include risks and benefits of pre-medication, including possible side effects.
186
What pre- and post-op instructions are there for pts prescribed oral anxiolysis?
Pre-op
- do not drink alcohol or take recreational drugs 24 hours before appointment.
- do not drive to appointment
- attend appt accompanied by responsible adult
Post-op
- For 24 hours after taking diazepam or temazepam, pts should not:
> drive or operate machinery
> make any important decisions or sign legal documents
> consume alcohol
> take recreational drugs
> post on social media
187
What are common side effects of pre-medication?
Dizziness
Drowsiness
Anterograde amnesia
Nausea
Headache
Hypotension
In high doses - respiratory depression
188
What are paradoxical reactions?
- Increased anxiety and agitation rather than anxiolysis
- Makes tx more challenging rather than less
- Unpredictable - could happen to any pt
- More common in children and the elderly
- Hallucinations rare side effect - consider 'chaperone' in surgery.
189
What are 5 patient factors that effect prescribing of anxiolytic medications?
1. AGE - often impaired metabolism and excretion in elderly - halve adult dose
2. POOR MOBILITY - increased risk of falls - consider alternative anxiolytic techniques, halve dose.
3. OBESITY - potentially slower onset of action and recover - prescribe standard dose with caution
4. PREVIOUS OR CURRENT BENZODIAZEPINE USE - may be particularly resistant to the anxiolytic effects of these drugs - prescribe standard dose but inform pt may be less effective
5. LIVER IMPAIRMENT - impaired metabolism - halve dose in mild to moderate impairment. avoid in severe impairment.
190
What are medical contraindications for anxiolytic medications? (8)
1. Acute pulmonary insufficiency
2. Neuromuscular respiratory weakness
3. Sleep apnoea
4. Poorly controlled COPD
5. Poorly controlled asthma
6. Severe liver disease
7. Acute narrow-angle glaucoma
8. Pregnancy
191
Name drugs that interact with benzodiazepines:
Tricyclic antidepressants - amitriptyline, nortriptyline
Opioids - tramadol, codeine, diamorphine, fentanyl
Sedating antihistamines - cyclizine, alimemazine, promethazine
Alcohol
Antipsychotic agents - chlorpromazine, haloperidol, olanzapine
Anti-epileptic agents - lamotrigine, levetiracetam, pregabalin, gabapentin, sodium valproate.
192
What effect do apalutamide, rifampicin, tocilizumab and carbamazepine have on diazepam?
Reduce effectiveness
193
What effect doe fluconazole, fluvoxamine, HIV protease inhibitors (ritonavir, indinavir, and nelfinavir), voriconazole, grapefruit have on diazepam?
Increase effectiveness
194
What is the definition of sedation?
a. A technique which uses drugs to produce a state of depression of the CNS which enables treatment to be carried out.
b. During which verbal contact with the patient is maintained throughout the period of sedation.
c. The drugs and techniques used need a margin of safety wide enough to render loss of consciousness v unlikely.
d. The level of consciousness must be such that the patient remains conscious, retains protective reflexes, and is able to understand and respond to verbal commands.
195
What is general anaesthesia?
A state of controlled unconsciousness
Medicines are used to send pt to sleep, so they're unaware of surgery and so do not move or feel pain while it's carried out.
Provided in hospital environment by qualified anaesthetists.
Can have either gas or IV induction
Often last resort
196
What are indications for dental general anaesthetic? (3)
1. When other methods of pain and anxiety are inappropriate or have failed.
2. Allergy to local anaesthetics
3. Lengthy or unpleasant surgery
197
What are some contraindications for general anaesthetic?
a. Some specific conditions increase the risk to the patient undergoing general anaesthetic, such as:
b. Obstructive sleep apnoea
c. Epilepsy
d. Heart, kidney, or lung conditions.
e. High blood pressure
f. Alcohol use disorder
g. Smoking
h. History/family history of reactions to anaesthesia
i. Medications that can increase bleeding
j. Drug allergies.
k. Diabetes
l. Obesity.
198
What are some benefits of general anaesthetic?
Pt is unaware - no pain during procedure
Amnesia - will not remember what's happened
Muscle relaxation
Secure airway
With modern GA, serious side effects are very uncommon
199
What are some risks of GA?
Short-term effects include nausea, vomiting, headache, sore throat, dizziness and mild mild allergic reaction: these usually resolve in 48 hours but can take up to a fortnight.
200
What are more serious complications of GA?
Severe allergic reaction, accidental awareness, confusion after GA, and post operative infection e.g. chest infection.
201
What is the risk of life-threatening problems of dental GA?
1 in 400,000
202
When is dental general anaesthetic commonly used?
Most commonly used in paediatric dentistry in pre-co-operative patients where other pain and anxiety management techniques are inappropriate of have failed.
Special care dentistry
Oral surgery and OMFS
Adult exodontia where other pain and anxiety management techniques are inappropriate or have failed.
Rarely - implants.
To avoid repeat GAs, often tx planning more radical.
Some treatment may not be offered routinely under GA.
203
Case: Background: You are asked to see a 7-year-old patient who has pain associated with a carious ULD. The child has not seen a dentist before and comes into the dental surgery holding onto mum. He is reluctant to sit in the dental chair but does so with encouragement.
P/C Intermittent pain from ULQ, worse on hot and cold. Not disturbing Sleep currently.
MH: Fit and Well
DH: This is his first Dental Visit
SH: attends a local primary school, lives with mum, dad, and 3 younger siblings
Examination: Grossly carious ULD, no swelling or sinus. Non mobile, sore to air spray.
Radiograph shows caries to pulp ULD with Interradicular PDL widening What would you do?
Tooth has pulpal involvement and needs to be extracted.
Avoid dental extractions on children in their first visit as might create negative dental experience.
ART technique to try and excavate out a little bit of caries and get corticosteroid paste in there to calm down the pulp and then try and dress it.
Warn pt and mum that although there doesn’t seem to be swelling or infection or sinus at the moment, sometimes if there is infection and put in the dressing can block the infection and cause a swelling. Post op instructions. Analegesic use.
At next appointment, with local anaesthetics (topical first) and behaviour techniques, try an remove tooth.
o Positive reinforcement.
o Use of stop signals
o Enhancement of control
o Avoid tell show do with extraction
Inhalation sedation may be appropriate but there is a waitlist so would need to manage pain in the meantime. Try and dress the tooth using behaviour management techniques.
3 younger siblings – ask if they have seen dentist. As brother has caries, they are at higher risk. Try and get them in to acclimatise.
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Case 2
Background: A 52 year old man attends your practice as a new patient. He reports he is aware of a number of broken teeth, though he isn’t in any pain
MH: Stable Angina, Hypertension, Type II Diabetes Mellitus
DH: Hasn’t seen a dentist in 15 years, negative past experience with dentist.
SH: Smoker 10 x day, ETOH>14 units a week. Lives with wife who he is the registered carer for.
Examination reveals a number of carious but restorable molar teeth, and a chipped UL1. However, it is difficult to examine the molars fully or get bitewings due to patients very strong gag reflex when the mirror is near the tongue or back of the mouth
What would you do?
How to manage exaggerated gag reflex.
Get dental history and ask what has caused gag reflex to be more exaggerated.
How have other dentists managed gag reflex?
Was there negative trauma which induced the gag reflex as a protective response?
Looks like gag is triggered when mirror is in back of mouth by the tongue.
Look to start anteriorly to build up rapport and trust of the pt using behavioural management techniques.
Repair UL1, then maybe do a clean and see when gagging starts.
Look at referring for behavioural therapies. CBT?
Also could try acupuncture or finger pressure in area under lower lip, in that dip.
Could also try a small amount of salt on tongue e.g. if needing to take bitewing.
Referral if can’t manage with non-pharmacological techniques.
o Inhalation sedation (with acupuncture) has good success with managing gag reflex. Won’t mask hypoglycaemic attack.
o Intravenous sedation for exaggerated gag responses and could help with angina if it’s triggered by stress. Although could mask signs of hypoglycaemic attack.
If referring for intravenous sedation, make sure there are other arrangements for his wife.
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Case 3
Background: 22 year old patient attends your practice as a new patient, complaining of all her teeth being ‘rotten’. She is in no pain currently but reports a history of recurrent facial swellings.
MH: Schnizophrenia- under community mental health team, previously under MH section, depression and generalized anxiety.
DH: Hasn’t seen the dentist since she was 16, when she left home
SH: IVDU (Heroin), Smokes Cannabis and Crack Cocaine, No fixed abode, recently moved to this area
Examination reveals gross caries affecting entire dentition- will likely need full dental clearance What would you do?
Try and recover from heroin, would take methadone. Methadone is disgusting without being in a sugar syrup, so meant that her teeth suffered. All retained roots in this case.
Manage in staged extractions under local anaesthetic and behaviour management techniques if you could. Be honest that it is a lot of treatment, and lots of extractions. Extractions may be difficult if high bone levels. In this case, discussion as to whether she is appropriate for referral for tx under sedation or general anaesthetic.
If sedation, consider length of time she can be sedated for, for both inhalation and IV sedation. Would still be looking at multiple appointments. The mental health conditions mean her response to conscious sedation is quite unpredictable. There are also lots of interactions with antipsychotics and midazolam.
IVDU means that IV access may be quite challenging.
No escort, and no regular place of abode.
Went for general anaesthetic because of the extent of tx needed. Had GA for full dental clearance. Then inpatient overnight as she had nowhere to go afterwards. Discharged next day and then saw as outpatient to make dentures.
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Case 4
14 year old attends your practice having not seen a dentist since they were 8 and had a dental GA. Reports pain from all 4 quadrants of mouth though worse on the top right.
MH: Autism, ADHD, Anxiety
DH: Has all primary molars removed under GA at 8 years old, found this to be very traumatic and has refused to attend the dentist since
SH: lives with mum, attends a local secondary school, receives support from CAMHS.
Examination reveals deep caries in all four 6s, with the UR6 pulpally involved and apical pathology evident.
Girl will need at least 3 filling and probably a molar endo or an extraction.
Has previous negative experience that’s resulted in non-attendance.
Look at behaviour management techniques and treatment under local anaesthetic.
Would be worth knowing more about her autism and what she finds to be more difficult and what reasonable adjustments she would like to be taken into consideration with their care.
Don’t treat automatically like she has a learning disability.
Behaviour management techniques should be carried out by a trained professional as she is already taken care of by the adolescent mental health service already and you don’t want to go against anything they’ve do with her. Ask about CBT and coping strategies to see if they will work for dental anxiety.
Stage tx and see how she copes on smaller fillings and go from there.
Consider referral for inhalation sedation or IV sedation (she is over age of 12).
o Would more likely have U6 removed if IV sedation, as wouldn’t offer molar endo under IV sedation.
Could end up on GA pathway – but look at other pathways before.
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What is rebound sedation?
It is when the reverser drug has a shorter half life than the original sedative, meaning when it wears off the patient is sedated again.
This is an issue in diazepam due to long half life.
