Intro to pain and anxiety

Question 1

How to manage pain and anxiety?

Answer 1

Behavioural techniques
LA
Sedation: oral/IHS/IVS/Rectal
GA

Dependant upon pt/tx factors
Awareness of other professionals skilled in management
Importance of a team approach

Question 2

How to control pain and anxiety?

Answer 2

Important to facilitate tx and ongoing management
Failure of this = dental phobia 
Pt concerns/tx requirements
PHM/FH/SH
Professional training and support

Question 3

What makes dental tx difficult?

Answer 3

Co-operation
Anxiety/phobia
Med conditions/mental health issues
Involuntary movements
More complex tx/quadrant dentistry

Question 4

What to do if you do not have the skills to manage an anxious pt?

Answer 4

Know someone who does and refer pt for specialist advice/management

Question 5

Basic behavioural management strategies?

Answer 5

Tell, show, do
Positive distraction - music, TV
Relaxation
Systematic desensitisation
Hypnosis 

Pt selection
Professional skills
Team/environment

Question 6

Alternative management strategies for anxiety?

Answer 6

Acupuncture
Drugs - oral, IHS/IV sedation
Consider premedication, diazepam

Question 7

Advanced behavioural management?

Answer 7

Refer to a team who specialise in dental phobia
Management may include psychologists
Ask GMP/local psychology team/ SCD team

Question 8

What is sedation?

Answer 8

Depression of CNS to allow operative tx with the minimum physiological and psychological stress
Modify pt’s state of mind and allow communication and the pt’s response to commands
Have a good safety margin, so that consciousness if maintained and airway protected

Question 9

What makes an ideal sedative agent?

Answer 9

Simple to administer
Rapid onset
Predictable action/duration
Rapid recovery
Rapid metabolism/excretion
Low incidence of side effects

Question 10

Oral sedation types?

Answer 10

Oral premedication at home

• Reduces anxiety in advance of tx and facilitates attendance
• Diazepam 2-5mg the morning of tx/attendance
• Temezepam 10mg the night before
• Ask GMP for advice/to prescribe

Oral in the surgery with monitoring
- 10/20mg Temezepam

Question 11

Positives of oral sedation?

Answer 11

Simple to administer
Predictable action/duration
Low incidence of side effects

Question 12

Inhalation sedation features?

Answer 12

Specialist equipment/training and surgery requirements
Patent nasal airway
Good for children
Minimal intervention
Analgesic
Hazards of chronic exposure

Question 13

Positives of inhalation sedation?

Answer 13

 Simple to administer
 Rapid onset
 Predictable action/duration
 Rapid recovery
 Rapid metabolism/excretion
 Low incidence of side effects

Question 14

Intravenous sedation?

Answer 14

With pulse oximeter monitoring
Midazolam titrated according to response 
20-30mins good sedation, improved co-operation
Anxiolytic
Anterograde amnesia
Muscle relaxant 
Anticonvulsant
Min cardiovascular/resp depression
No analgesic effects

Question 15

IV sedation - who is it good for?

Answer 15

Good for epilepsy, movement disorders, stress related medical conditions
As has a reversal agent - flumazanil

Question 16

IV sedation features?

Answer 16

Has a reversal agent - flumazanil
Requires escort
Requires cannulation and associated risks

Question 17

IV sedation side effects?

Answer 17

Drug related:
Over sedation
CV depression
Resp depression
Specific drug interactions
?Tolerance
Sexual fantasy

Question 18

IV sedation positives?

Answer 18

Simple to administer
 Rapid onset
 Predictable action/duration
 Rapid recovery
 Rapid metabolism/excretion
 Low incidence of side effects

Question 19

What is needed for sedation?

Answer 19

A second trained person in sedation at all times
May be a DN/dentist/anaesthetist
Monitoring
Chaperone

Question 20

Why is teamwork essential for sedation?

Answer 20

Requires highly trained dental teams
Regular training in and out of house
Multidisciplinary care of pts
Updates knowledge
Seek advice/2ndry opinions
Refer if necessary

Question 21

Costs of sedation?

Answer 21

Materials
Staff
Work time lost to patient/escort 
Other consequences
LA vs GA vs sedation

Question 22

Medicolegal aspects for sedation?

Answer 22

Written consent

Escort requirements and appropriate post op care

Question 23

Where is GA only undertaken?

Answer 23

In hospitals

Question 24

Where is sedation undertaken?

Answer 24

In registered and inspected premises
With appropriately trained staff
Appropriate equipment and drugs

Question 25

What standards for followed for sedation?

Answer 25

Poswillo report 1990

Question 26

Risk of death and persistent brain damage per GA?

Answer 26

1 per 180,000
Obesity - risk of airway complications
= Pre-op assessment important
Sedation preferred to GA where possible