Behaviour and pain management Flashcards
List signs of anxiety in children
- Hiding
- Clinging to parent
- Stuttering/not speaking
- Nauseous or stomach ache
- Dizzy
- Going to the toilet
- Nail biting
List factors that influence anxiety in children
- Psychological make up
- Understanding of dentistry
- Previous exposure
- Influence from parents/siblings/friends
- Emotional development and ability to communicate
How to make the dental environment child friendly
- Light colours, toys and pictures, posters and stickers on the walls
- Hide equipment
- No PPE on first contact
- Good quality handpieces to minimise sound and vibration
List the ways we can improve behaviour and reduce anxiety in children
- Appearance of staff/environment
- Good communication
- Positive parental attitude
- Specific behaviour management strategies
Communication with children
- clear, direct instructions rather than questions
- Question for feeling during procedure
- Give feedback on behaviour
- Use children friendly language
- Eye contact
When is parental presence favourable
When the parent is taking on a passive role
In younger pts - better to prevent separation anxiety
When is parental presence unfavourable?
- Parents who are projecting their own anxiety to the child through words or behaviour
- Parents competing with dentist for child’s attention
List behaviour management strategies (8)
- Positive reinforcement
- Acclimation
- Tell, show, do
- Systematic desensitisation
- Voice control
- Role modelling
- Enhancing control / stop signalling
- Distraction
What is positive reinforcement?
Positive behaviour is rewarded with clear and immediate rewards e.g. praise (more effective) or stickers
What is acclimation
Introducing the patient to instruments/equipment before you plan on using them e.g. the appt before you plan on using it
What is tell, show, do
- Describing what the instrument does
- Showing them what the instrument does it positive/neutral terms
- Use the instrument
What is systematic desensitisation?
Hierarchy of anxiety provoking stimuli either in real life of imaginative.
Pt exposed to stimuli when instructed to relax
What is voice control?
Changing vocal tone to gain attention from patient
What is role modelling?
Presence of an older, well behaved patient e.g. sibling (e.g. observing sibling having treatment)
What is enhancing control?
Providing pt control over the dentist’s actions e.g. raise hand when you want me to stop
What is distraction?
Distracting patient from sensations
What is pain
Complex physiological and psychological (emotional) response derived from various stimuli
Define pain threshold
Level at which pain first becomes perceptible to an individual
Define individual ‘pain reaction’ -
Variation in response to the same stimulus when applied to different people
Factors that influence pain perception in children
- Stage of development/age
- Parental dental fear or influence from sibs/peers/media
- Previous experience (established fear)
- Emotional status
- If the pt has acute dental pain
- MH
What are two main categories of pharmacological pain control?
- Anaesthesia
- Analgesia
What is anaesthesia
Loss of all forms of sensations (pain, touch, temperature, pressure +/- motor function)
What are the methods of anaesthesia used in paediatric dentistry
LA
LA + inahaltion sedation
GA
What is analgesia
Loss of pain sensation unaccompanied by loss of forms of sensibility
Analgesics used in paediatric dentistry
Paracetamol
Ibuprofen
Calculating dose of analgesics
Dose by age
Consider weight/height of patient - if lower/higher than ideal for age then consider different dose
Contraindications for ibuprofen in children
Asthma, liver disease, renal failure and bleeding disorder
What do you have to consider when calculating dose of LA
- Age, weight and height
- Type of LA (2% of 4%)
Correct use of topical LA
Apply to dry mucosa in a localised area
Leave for 5 mins until mucosa wrinkled
What is an intrapupillary injection
Anaesthesia of the papilla used to prevent painful palatal infiltration
What is the “chasing technique”
After buccal infiltration, pass needle to papilla and follow into palatal tissue
When are intraligamental infiltrations required
- To supplement infiltrations (or blocks)
- Eliminates need for a block
- In permanent teeth only
Where to approach for an ID blocks in children
From contralateral primary molars
Where to approach for a mental block in children
Advance needle in buccal sulcus between apices of 1st and 2nd primary molars
What are the COMMON complications of LA
- Failure, bleeding, pain
- Psychogenic (syncope, hyperventilation, nausea, palpitations, mimicking allergy)
- Lip biting and soft tissue trauma
- Toxicity from overdose
What are the RARE complications of LA
Allergy
Drug interactions
Methomoglobineamia
Paraesthesia
What are the signs of toxicity from LA overdose
- Pt initially appears sedated - slurred speech, altered mood, diplopia and disorientated
- High blood pressure can cause tremor, respiratory depression and seizure
What are the severe effects of toxicity from LA overdose
Coma, respiratory arrest and cardiovascular collapse
What is methemoglobinemia and what LA is usually associated?
- (congenital or acquired) blood condition where RBC contain >1% methemoglobin
- Prilocaine, articaine and benzocaine
What LA is paraesthesia associated with
Articaine and prilocaine
What are the categories of anxiety management in dentistry
Behaviour management
Behaviour therapy
Conscious sedation
General anaesthesia
Define conscious sedation
Technique that produces a state of central nervous system depression to enable treatment to be delivered where verbal contact is maintained with the pt throughout.
What features are retained in a consciously sedated patient
Verbal communication
Protective reflexes allowing a stable patent airway
Aims of conscious sedation
Prevent/reduce dental fear, anxiety or pain
Facilitate pt cooperation
Promote positive attitude
Safe provision and completion of care with minimal disruptive behaviour
List examples of conscious sedation
- Inhalation sedation
- Oral sedation
- Transmucosal (nasal)
- Intravenous sedation
Indications for conscious sedation (in peadiatrics specifically - so we are thinking of IHS)
- Dental phobia or anxiety
- Manage gag reflex
- Special care requirements e.g. medically compromised or behavioural conditions
- Traumatic or prolonged tx
Contraindications for conscious sedation in children
- URT issues
- Blocked nose/nasal obstruction
- Pre-cooperative children
- Medical contraindications
- Pt unable to communicate well e.g. some behavioural conditions
MH contraindications for inhalation sedation
- Nasal obstruction or congestion
- Severe respiratory disease
- Middle ear infections
- Neuromuscular disorders
- Methotrexate
- Porphyria
- Chemo
What is used in inhalation sedation
Titrated dose of nitrous oxide in oxygen
Pharmacology of nitrous oxide
- Colourless and almost odourless
- Relatively insoluble
- Excreted rapidly by lungs
Effects of nitrous oxide on the body
- Eurphoria and CNS depressant (sedative)
- Mild analgesic
- Minimal effect on respiratory system
- Minor decr in cardiac output
- Slight increase in peripheral resistance
Nitrous oxide mode of action
- Analgesic - acting on opiod receptors
- Anxiolytic - acts on GABAA receptors
- Anaesthetic effect - acts on GABA receptors
What is required at the pre-operative assessment for IHS
- Full asessment to confirm the need for sedation
- Written consent from parent/pt
- Pre and post op instructions
- Height and weight
What are the pre-op checks before IHS is administered
- Check pt ate or if they need glucose
- Check for nasal obstruction
- Confirm MH
- If consent not taken, achieve now
- Record any pre-op analgesia
What are the increments nitrous oxide is increased by
5-10%
What gas is used at the end of the session
100% oxygen for 3-5 mins
Why is 100% oxygen used at the end of the session
Prevent diffusion hypoxia
What is recorded post-operatively
- Mask size
- Flow rate
- % of N2O and oxygen
- Time started and finished
- Type/amount LA given
- Dental treatment provided
- Recovery, post op medication and discharge
What are the signs of ideal sedation
- Slightly incr bp and heart rate (initially)
- Normal, smooth respirations
- Flushing of extremities and face
- Muscle relaxation
Symptoms of ideal sedation
- Lightheadedness
- Tingling/numbing of hands and feet
- Warm wave or vibrations
- Numb oral soft tissues
- Euphoric feeling
Why may IHS fail?
- Pt not breathing through nose
- Ineffective seal around nosepiece
- Pt too anxious and cannot cooperate
- Fault in machine
What are the advantages of INHS
- Non-invasive - good for needle phobic
- Titrated dose that can be altered
- Rapidly absorbed and excreted
- Reflexes maintained
- Some analgesic effect
- Cost effective and safer than GA
What is the onset of IHS
2-3 mins
How long does it take for recovery after IHS
Complete recovery within 5 mins
Disadvantages of IHS
- Lack of potency
- Requires psychological reassurance
- Nasal mask may impeded access of upper anteriors
- Nitrous oxide pollution
- LA still required
- Potential adverse effects
What are the adverse effects of IHS
- headache, nausea and vomiting
- Loss of consciousness
What are the occupational adverse effects due to chronic exposure
- Impaired RBC production and pernicious anaemia
- Avoid in first trimester and preg staff should opt out
What is the maximum conc of N2O exposure in 8 hours
100ppm
How to minimise N2O pollution
- Active scavenging systems
- Good ventilation
- Floor level extractor fans
- Good technique with pt
- Check equipment regularly
