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Text Elements
Non - Pharm management
Communication strategies
Use tools
xx
xx
Environmental Considerations
Television on ceiling - relaxing places
Ambient sound, music, headphones
Ambient Scents ver headsets?
Acupuncture :
- In 2003 WHO endorsed it for pain in dentistry
- Benefits shown in reducing anxiety, suppressing gag reflex, and reducing pain
two points cited for dentistry are: CV-24 and PC-6
Some alternatives are: low level laser stimulation instead of needling
- can use acupressure at the same point to suppress the gag reflex
ex. if patient is gagging just push on that cv24 spot for 60 seconds
Hypnosis
“I want you to imagine that you are going to let yourself relax and breathe out deeply. With each breath I want you to imagine yourself becoming more and more relaxed.
Professional hypnotherapy may play a role in managing severe dental anxiety and has been shown to hav ea positive effect on smoking cessation
Cognitive Behaviour Therapy
Requires refferal to specialized psych services
Evidence suggests that it can help , although with most patients there are better alternatives available
Pharmacological Management
Definitions
Minimal Sedation (aka anxiolysis)
Moderate Sedation
Oral agents
Inhalation agents
IV drugs
Oral + Inhalation drugs
Deep sedation
Level of independent breathing decreases
Stages of anesthesia
Stage I : analgesia (induction through to loss of conciousness )
Stage 2: Excitement (loss of conciousness to onset of automatic breathing)
Stage 3: surgical
Stage 4: over sedation
Relative anesthesia/inhalation sedation
ADA code 943
- first line for children, uses N2O
Acts in STAGE I of analgesia
Indicatoins/ Contraindications
-
Fear and anxiety
-
Pain control
-
Medical conditions made worse by stress
-
Gagging -Traumatic or complex dental procedures
-
Psychosocial:
- Claustrophobic patients
-
Lack of understanding of process -either age or learning difficultus
-
sever anxiety -complexity of dental treatment
Medical:
- Nasal obstructions - URTI
- ASA III -COPD
- Pregnancy (1st trimester)
- Severe psychiatric disorders
Dental:
- upper anterior procedures
Advantages and disadvantages
-
Safe
-
Rapid onset and recovery
-
Easily regulated
-
Drug not metabolized
-
No adverse effects on CVS, RS. Liver or kidneys
-
analgesic
-
limited amnesia
-
Special equipment required
-
large variation
-
Care if chronically exposed (staff)
-
Potential for absue
-
Limited amnesia
Risks of Chronic exposure
- Deactivation of B12 causing peripheal neuropathy
- Toxic hepatic effects
- Depression of leukocyte production
- spontanous abortion and other reproductive issues
Methoxyflurane
- used in emergency pain relief, not really used in dental procedures !
Oral bensodiazepines
Advantages/ disadvantages
-
Well accepted by patients
-
Cost effective
-
Easy to administer
-
Provides anisolysis prior to procedure
-
Slow onset and long duration of action (requires supervision post procedure)
-
variable response
-
titrated rapidly
-
used in caustion with certain patients (older, frail, cognitvely impaired, OSA)
-
Cannot be used ifp atient does not have an escort/carer to look after them
Indications/contraindications
-
Dental Anxiety -Short procedure (1-2 hrs max)
-
Prolonged procedures
-
Severely limiting heart, cerebrovascular lung liver or kidney disease
-
allergies or other adverse events
-
severe anxiety that has not been managed effectivley with minimal sedation
IV Sedation
Can only be provided by a suitably trainded person
- Must have at least 3 staff memebers present in the room (proceduralist, seditionist and assistant)
- facilities must allow for rapid access of emergency services if required
Drug of choice is midazolam:
- no pain on injnection
- working time of 45 mins -short half life clnical working time of 45 mins
- you can use flumaenil to reduce effects of midazolam
Other drugs include:
- propofol
- remifentanil
- xxx?
Advantages and disadvantages
- Operator can focus on dentistry
- Well tolerated
- suppresses gag reflex
- suppresses anxiety
Cost:
- if dnetist - 942 (sedation ive)
- anesthetist (949 more expensive)
- trained staff required
- requirements for facilities
- Procedural time significantly increased
Technique:
- Consent forms signed ahead of procedure
- Patient is fasted prior to attending
- person providing the sedation gains access (5 -20 mins)
- Required tx takes place (generally 20-40 percent longer than without sedation)
- Recovery - variable time 10-30 mins
- Discharged home with a responsible person who will look after them
General Anesthetic
Decision for GA base don:
- Procedural difficulty and ability to anaesthetise with LA
- Procedural length
- Procedure unpleasantness
- patient preference
Do I have the skills to perform the procedure
yes
Can the proceudre be done under local anaesthetic
Yes
Is the p/t happy to tolerate?
Yes
NO
Do under LA
treat as if unable to do under la
No
Element Links
btDXzi2A: L4 anxiety drugs table