special care and sedation Flashcards
what is special care
SCD are those with a disability or activity restriction that directly or indirectly affects their oral health
what are the problems with providing dental treatment to special care patients
- Communication
- Anxiety
- Moving target
○ Patients who are unable to stay still or open their mouth - Perception of reality
- Previous experience
Often the same as providing medical care
what are the types of movement disorders associated and give examples
- Congenital / genetic
○ Muscular dystrophy
§ Concerns about breathing
§ Don’t want to use techniques that will impinge on respiration
○ Cerebral palsy
§ Helps relax the body movements to allow dentist access
○ Multiple sclerosis
○ Parkinson’s disease
○ Huntingdon’s chorea
§ Often has a learning difficulty element to it as well - Acquired
Head injury
why can movement disorders cause problems in sedation
There is approximately a 40 minute window with sedation to get treatment done
management of patients with involuntary movements
- Assessment
○ Mental and physical status
○ Anxiety
Pain experience
what are the 2 classes of learning difficulites and give examples
- Congenital
○ Syndromic
○ Non-syndromic - Acquired
○ Trauma
○ Infection
○ CVA
○ Alzheimer’s
Whole spectrum of conditions from mild to severe
what do you assess before carrying out sedation in patients with learning difficulties
- Assessment
○ Will behavioural management be possible?
§ Many patients can be treated with TLC
§ Ie if you can just spend more time with the patient to help them become more cooperative (safer option)
○ Is pharmacological management needed?
○ Sedation or GA or both
§ Patient understanding
§ Patient’s pain experience
who can give consent
- No one else can give consent
- Patient competent to consent, but can’t write
- Not covered by legislation
- Verbal consent document in notes
- Adult Incapacity Act (2000) Scotland
○ No one else can give consent for adult to have treatment
○ If not competent to give consent
§ Medically qualified or appropriately trained dentists
§ Can complete form allowing treatment
Lasts up to 36 months
what are the 4 types of conscious sedation techniques
- Inhalation
○ Nitrous oxide and oxygen - Intravenous
○ Midazolam- Oral
○ Drink midazolam - Transmucosal
○ Rectal
○ Intranasal
§ One we commonly use now
Sublingual
- Oral
what affects your choice of sedation technique
- Patient co-operation
○ Patient cooperation is vital
○ If you have no cooperation at all the patient probably needs GA because you need to be able to put a cannula in etc
○ If you have good cooperation inhalation sedation can be an option but it is probably the least helpful option for some patients because you need them to breathe through their nose which can be challenging for anyone and also need the patient to stay still - Degree of anxiety
○ Very anxious patient might not be enough to use inhalation sedation so possibly looking at an IV solution for that patient
○ For the less anxious, IS can be ideal - Dentistry required
○ Extremely invasive dentistry cannot use IV because they don’t remember it and you don’t want to increase future anxieties
○ IS you have a nose piece so if you needed complex treatment near to the nose piece for example working on the upper central incisor then it could be contraindicated - Skills of the dental team
○ Just because you don’t have the skills doesn’t mean that someone else in your area might so you can refer on to the public dental service for anaesthetist lead sedation or GA - Patient’s previous experience
○ If someone has had successful treatment with IV sedation then they are more likely to go for IV again because it worked - Facilities available
○ Need to be careful where the treatment is carried out
○ Often a hospital environment is better for more complicated patients - Anaesthetist required?
Patients with airway issues or severe medical complications then back up is always helpful
what are the advantages of inhalation sedation
○ Useful for anxiety relief
○ Rapid recovery
§ Works quickly and recovers quickly
○ Flexible duration
§ Can give sedation and turn it on and off - not just stuck with one sedation level
No injections involved so good for patients with needle anxieties
- safe technique
what are the disadvantages of inhalation sedation
○ Keeping nasal hood in place
○ Less muscle relaxation
§ And less cooperation
○ Coordination of nasal breathing when mouth open
Need to breathe through nose not mouth otherwise operator gets the gases and becomes sedated
what are the advantages of IV sedation
○ Good sedation achieved
§ Deeper sedation than IS
○ Less cooperation needed
§ Still need to be able to get the cannula in safely
○ Muscle relaxation
Stops involuntary movements
what are the disadvantages of IV sedation
○ Baseline readings
§ Need to check BP, pulse oximeter (?), possible respiratory
§ If your patient is so uncooperative that you cannot get these readings you need to consider whether you can continue or not
□ Can document that you were unable to get these and continue with treatment if you are experienced enough
□ Depends on how unwell the patient is
○ IV cannulation required
§ Can sometimes be too much for a patient
○ Assessing sedation level
§ If patient has learning difficulties and is non-verbal how can you maintain verbal contact? There are ways around this;
□ Just because someone doesn’t speak doesn’t mean they don’t communicate so you can use different forms of communication eg give a thumbs up, etc
○ Behaviour during recovery
§ Patients can become quite upset during the recovery period
○ Efficacy swallowing
§ If a patient cannot swallow we don’t want to be responsible for putting this drug that reduces the swallowing as well
□ Ie patient has difficulty swallowing and we put a drug in them that reduces this reflex even more then the patient is not safe
If patient is a swallowing risk question whether you should do IV
what drug is used for IV sedation
midazolam
