Introduction to pain and anxiety control

Question 1

How to combat pain and anxiety (5)

Answer 1

Behavioural techniques - routine practice
Combination of
-LA
-sedation: oral/ IHS/ IVS/ rectal
-general anaesthesia
Dependant upon pt/ tx factors
Awareness of other professionals skilled in management
Importance of team approach

Question 2

Difficulty of dental treatment (5)

Answer 2

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

Question 3

MDAS Phobia = (1)

Answer 3

19 or above

Question 4

Basic behavioural management trategies (5)

Answer 4

Tell, show, do
Positive distraction e.g. music, ipod, TV
Relaxation
Systematic desensitisation - gradual acclimatisation
Hypnosis

Question 5

Alternative management strategies (3)

Answer 5

Acupuncture
Drugs
-oral/ IHS/ IV sedation
But consider
-premedication
-diazepam is in DPF/ ask GMP

Question 6

Advanced behavioural management (3)

Answer 6

Pt selection
Professional skills
Assessment - refer to a team who specialise in dental phobia
Management may include psychologists
Ask GMP/ local psychology team/ SCD team

Question 7

Describe sedation (3)

Answer 7

Depress CNS to allow operative treatment with minimum physiological and psychological stress
Modify patients state of mind and allow communication and patients response to commands
Have good safety margin so that consciousness is maintained and airway protected

Question 8

Properties of ideal sedation agents (6)

Answer 8

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

Question 9

Sedation - oral premedication at home (4)

Answer 9

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

Question 10

Sedation - oral in the surgery with monitoring (1)

Answer 10

10-20mg Temezepam

Question 11

Inhalation sedation - ‘gas and air’ (6)

Answer 11

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

Question 12

Intravenous sedation properties (9)

Answer 12

 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 13

IV sedation (6)

Answer 13

 Good for epilepsy
 Movement disorders
 Stress related medical conditions
 Has a reversal agent - flumazanil
 Requires escort
 Requires cannulation and associated risks

Question 14

IV sedation side effects - drug related (6)

Answer 14

 Over sedation
 Cardiovascular depression
 Respiratory depression
 Specific drug interactions
 ?Tolerance
 Sexual fantasy

Question 15

Second appropriate person (4)

Answer 15

At All Times
A second person trained in sedation is required
for sedation to be undertaken, this may be a
DN/ dentist/ anaesthetist
Monitoring
Chaperone

Question 16

Team work (6)

Answer 16

 All sedation methods require highly trained and
efficiently functioning dental teams
 Regular training in and out of house
 Multidisciplinary care of patients
 Updated knowledge –courses and literature
 Seek advice/second opinions
 Refer if necessary

Question 17

Costs (4)

Answer 17

 Materials
 Staff
 Work time lost to patient/escort
 Other consequences

Question 18

Medicolegal aspects (3)

Answer 18

Same as any other treatments, additionally
 Written consent
 Escort requirements and
 Appropriate post operative care

Question 19

Regulation (3)

Answer 19

GA only undertaken in hospitals
Standards for sedation following Poswillo report
(1990)
Sedation only undertaken in
 Registered and inspected premises
 With appropriately trained staff
 Appropriate equipment and drugs

Question 20

GA stats (5)

Answer 20

 2.9 million per year in the UK
 death and persistent brain damage 1 per 180,000 GA’s
 Obesity is a major risk of airway complications
 Pre-op assessment important
 Sedation to be undertaken in preference to GA
wherever possible -Conscious decision DoH 2000