Anxiolysis Flashcards
What are the associated risks of anxiolysis?
Oversedation or loss of consciousness
Airway obstruction or respiratory depression
Cardiovascular depression
Drug interaction, adverse reactions or anaphylaxis
How do conscious and unconscious sedation differ?
Conscious induces a depression of consciousness where patient is still able to respond to verbal command or light tactile stimulation. (eg via propofol)
IV sedation and general anaesthesia induces a greater depression or loss of consciousness. Restricted to appropriately trained practitioners in accredited facilities.
What is the requirement of conscious sedation?
Should provide a margin of safety that is wide enough to render loss of consciousness unlikely.
What are the qualifications required for using conscious sedation?
Dental Board approved program of study leading to endorsement for conscious
sedation
Refresher course in dental sedation and medical emergencies to maintain
endorsement
How should patients be assessed for anxiolysis?
Nature of patient’s anxiety
Medical, surgical, dental and medication history, including allergies
Cardiovascular, respiratory and airway status
Exercise tolerance or functional status
Social circumstances, including intake of alcohol and psychoactive substances
Which patient groups are at increased risk of adverse outcomes from anxiolysis? (contraindications for anxiolysis)
- Younger than 2 years
- Elderly or frail
- Severely limiting heart, cerebrovascular, lung, liver or kidney disease
- Obesity
- Significant Obstructive Sleep Apnoea (OSA)
- Known or suspected impediment to endotracheal intubation
- History of acute gastrointestinal bleed
- Severe anaemia
- Risk of aspiration
- Previous adverse events
What are the most commonly used anxiolysis drugs in dental practice?
NO and Benzos
What factors are used to choose between the anxiolysis methods?
Patient factors (contraindications, DDIs and preferences)
Clinical settings
Dentist’s expertise
What are the pros and cons of benzos?
Pros: Well accepted and easy to administer
Cons: Slow onset, long duration of action, cannot be titrated rapidly, not suitable for children or adolescents
What are the pros and cons of NO?
Pros:
Rapid onset and offset of action
Easy to administer
Can be titrated rapidly
Suitable in children and adolescent
Cons:
Requires training
Requires specialised equipment
What are the adverse effects of benzodiazepines?
Impaired psychomotor performance
Impaired memory function
Delirium
Dry mouth
Blurred vision
Discontinuation symptoms
Rebound anxiety
NOTE: Warn patient that benzodiazepine can affect behaviour, coordination and ability to drive or operate machinery safely
How should patient be managed when using benzodiazipines for anxiolysis?
Advise patient of effects and adverse effects
Patient should consent to anxiolysis
Written instructions (dos and don’ts before and after appointment)
Monitor patient during procedure until recovered.
Use rubber dam to protect airway
Dental chair must be able to rapidly be positioned horizontally for CPR if needed
What dose should be used with oral benzodiazipines?
Lowest dose and do not use more than one drug concurrently.
Sedative-naive patients respond to low dose. Patients with tolerance due to cannabis, alcohol, opioids, and hypnotic usage may require higher dose.
Which benzodiazipines should be used most ideally?
Shortest duration of action and lowest dose.
Typically:
Lorazepam 1mg orally, 1-2 hours before procedure, administered at dental practice
Or
Oxazepam 7.5mg orally, 1-2 hours before procedure, administered at dental practice
Or
Temazepam 10mg orally, 1 hour before procedure, administered at dental practice
IF longer duration of action required diazepam 5mg orally 1 hour before procedure administered at dental practice.
How is NO administered?
Combined with oxygen and administered via a nasal mask.
