pain and anxiety control Flashcards
What are some basic behavioural management strategies?
Tell, show, do Positive distraction- music, TV Relaxation Systematic desensitisation Hypnosis
What is MDAS?
Modified dental anxiety scale- 19 or above is high
How can pain be controlled?
Psychological techniques
LA- topical and injectable
Analgesics- oral, IV, IHS
How can anxiety be controlled?
Psychological
Drugs- anxiolytics- oral/IHS/IV (eg. Diazepam)
CBT/acupuncture/hypnosis/Pet therapy etc
What if someone has advanced behavioural problems?
Assessment
Refer to team specialising in dental phobias
Psychologists
Ask GP/local psychology team
How does sedation help?
Depress CNS to allow operative treatment w minimal stress
Modified patients state of mind, allows communication and patients response to commands
Must have good safety margin so consciousness is maintained and airway protected
What is the ideal sedation agent?
Simple to administer Rapid onset Predictable action/duration Rapid recovery Rapid metabolism/excretion Low incidence of side effects
What oral medication can be taken?
Diazepam 2-5mg in morning
Temezepam 10mg night before
Temezepam 10-20mg in surgery w monitoring
Ask GP for advice/to prescribe
Reduces anxiety in advance- facilitates attendance
SIMPLE, PREDICTABLE, LOW SIDE EFFECTS
What inhalation sedation can be given?
Gas and air
Specialist equipment/training and surgery requirements
Patent nasal airway Good for children Minimal intervention Analgesic Hazards of chronic exposure
IDEAL
What IV sedation can be given?
Pulse oximeter monitoring Midazolam titrated according to response 20-30 mins Anterograde amnesia Muscle relaxant Anticonvulsant No analgesic effects
IDEAL
What should be considered with regards to IV sedation?
Good for epilepsy/movement disorders/stress related med conditions
Reversal agent- Flumazanil
Requires escort
Requires cannulation and associated risks
Side effects=over sedation, cardiovascular/respiratory depression, tolerance, sexual fantasy
What should be considered when administering sedation?
Highly trained and efficient dental teams Regular training in and out of house Multidisciplinary care Updated knowledge Seek advice/second opinions Refer if necessary
What are some medico-legal aspects?
Written consent
Escort requirements
Appropriate post op care
How is sedation regulated?
GA only in hospitals Poswillo report 1990- standards Sedation only- ~registered and inspected premises ~appropriately trained staff ~appropriate equipment/drugs
What is pain?
Unpleasant sensory and emotional experience associated w actual or potential tissue damage or described in terms of such damage
What types of pain are there?
Inflammatory- eg. Post op pain
Neuropathic- eg. Trigeminal neuralgia, sciatica
Vascular- eg. Temporal arteritis (interrupted blood flow)
What analgesia is given for pulpitis?
About the pain- ~Where- tooth ~Cause- inflammation ~Acute ~Management- remove cause
What analgesia is given for a periapical abscess?
About the pain- ~Where- perio tissues ~Cause- inflammation ~Acute ~Management- remove cause
What analgesia can be given for trigeminal neuralgia?
About the pain- ~Where- nerve ~Cause- neuropathic ~Acute ~Management- Carbamazepine
What analgesia can be given for burning mouth syndrome?
About the pain- ~Where- oral mucosa ~Cause- neuropathic ~Chronic over acute ~Management- medication
What analgesia can be given for TMJ problems?
About the pain- ~Where- joint/muscles ~Cause- neuropathic ~Chronic w acute episodes ~Management- painkillers
How can pain be reduced peripherally?
Remove cause
Anti-inflam tablets
LA
How can pain be reduced centrally?
Distraction Relaxation Cognitive restructuring CBT Anticonvulsants Antidepressants NSAIDS GA
How can pain be managed?
Remove cause- surgery/splinting Medication- eg. NSAIDs, paracetamol, opioids (morphine) Regional anaesthetic- eg. epidural infusion of LA and opioid Nerve blocks- eg. LA and opioid Physiotherapy Manipulation TENS Acupuncture Relaxation Hypnosis Psychoprophylaxis/CBT
What is the Arachidonic pathway?
Arachidonic acid is metabolised to produce inflammatory mediators (eg. Prostaglandins)
COX I and II convert ArA into prostaglandins
NSAIDs such as ibuprofen/aspirin/diclofenac inhibit COX I and II
Side effects of NSAIDS- GI irritation/bleeding/ulcers
Long term NSAIDS- bad side effects
What do prostaglandins do?
Protects GI tract, renal homeostasis, uterine function, embryo implantation and labour, regulates sleep-wake cycle, brings down body temp
E1 and E2- increase vascular permeability, causes inflam, reduces gastric acidity, contracts smooth muscle in uterus/gut/bronchi, increases hyperlagesia in sensory afferent nerves
D2- increases hyperalgesia in sensory afferent nerves, inhibit platelet adhesion
Thromboxane- increase vascular permeability, aggregate platelets
Prostacyclin- decrease vascular tone, reduce platelet adhesion
What can potentially happen if COX I is inhibited?
Stomach can’t protect itself from acid
Erosion and ulceration
Where is COX I found?
Platelets, stomach, kidney
Constitutive
Where is COX II found?
Kidney, brain, testicles, tracheal epithelia
Inducible
What analgesics are in the DPF?
Aspirin tablets Diclofenac sodium tablets Dihydrocodeine tablets 30mg Ibuprofen tablets Ibuprofen oral suspension Paracetamol oral suspension Paracetamol tablets (+soluble) Carbamazepine Benzydamine Diazepam Lidocaine
What are some OTC meds for dental pain?
Aspirin Aspro clear Feminax ultra Nurofen Panadol (+extra) Saridon Solpadeine plus Voltarol
When shouldn’t you prescribe in disease?
Liver disease
Renal disease
Contact GP
How should you prescribe in pregnancy?
Don’t
1st trimester- congenital malformations (teratogenesis)
2nd/3rd- growth and functional development
Term/labour- adverse effects on labour/neonate
Avoid NSAIDS- ~haemorrhage risk ~closure of ductus arteriosus ~pulmonary hypertension of newborn ~delayed labour ~increased duration of labour ~increased blood loss in labour
How should you prescribe in breastfeeding?
Insufficient research
Ibuprofen/diclofenac/paracetamol- not much concern
Dihydrocodeine- manufacturers concern
Aspirin- Reye’s syndrome risk or hypoprothrombinaemia if Vit K is low
How should you prescribe for children?
According to weight 1st month Up to 1 year- 1/8 adult dose 1-5 years- 1/8 adult dose 6-12 years- 1/2 adult dose
What is paracetamol?
Well tolerated, anti pyretic, few side effects, few interactions, available OTC, cheap
Overdose potential
Oral ingestion (active after 11mins)
T 1/2 1-4 hours
Metabolised in liver
Works on COX II, TRPA-1 receptors
How should paracetamol be taken?
500mg-1g QDS, 4-6 hours hourly
No more than 4g in 24 hours
Multiple preps available
Tablets, capsules, elixir- sugar free
Overdose- nausea and vomiting, refer to A&E ASAP
20-30 tablets- lethal (liver failure- need transplant)
Antidote available- acetyl cysteine/parvalex
1998 laws- repacked nos
USA- methionine added
What are NSAIDs?
Non Steroidal Anti Inflammatory Drugs
Less side effects than steroids but other side effects
UK-
Annual prescriptions- 25 million
Admissions- 12000
Deaths- 2600
What is Ibuprofen?
Good efficacy in inflammatory pain Anti-pyretic Major side effects Interactions Available OTC Cheap
How should Ibuprofen be taken?
200mg-400mg TDS
No more than 2.4g in 24 hours
Multiple preparations available
Tablets, capsules, elixir- sugar free
Complications-
~asthma potentiation
~GI ulcer/bleed (worse w other NSAIDs)
~anti-thrombo-embolic efficacy (inc. bleeding)
~risk of MI (ibuprofen/diclofenac worst, naproxen best)
Don’t give to asthmatics/pregnancy/under 3months
Take care w elderly, people on aspirin/NSAIDs, renal/cardiac pts
What is Diclofenac?
Good efficacy in inflam Antipyretic Major side effects Major interactions (anticoagulants, haemorrhagic disorders, GI, asthma) Similar to ibuprofen
How should Diclofenac be taken?
75–150mg in a day- divided doses
Patients w heart conditions shouldn’t take
Not available OTC
What is aspirin?
Good efficacy in inflam Antipyretic Major side effects Interactions Available OTC Cheap
Other NSAIDs better for inflam
Don’t use under 12- Reye’s syndrome
Don’t use in Glucose-6-phosphate dehydrogenase deficiency- acute haemolytic anaemia
What are opioids?
Eg. Codeine, Tramadol
For moderate- severe pain
Not used in dentistry really
Used if NSAIDs contraindicated (eg. Already on NSAID, warfarin, GI symptoms/history of bleed)
What is Codeine?
Weak opioid, active at MU receptor, analgesic potency 50% morphine
1/2 life- 2.5-3hours
Above 65mg poorly tolerated
What is co-codamol?
Codeine and paracetamol
Mild-moderate pain
Not used in dentistry really
Available OTC, however not prescribable on FP10
How should co-codamol be taken?
1-2 tablets, 4-6 hourly (max 8/day)
Three strengths-
8/500- the only OTC
15/500
30/500
Constipation- common side effect
What is Dihydrocodeine?
Mild-moderate pain
Not really used in dentistry
Prescribable on FP10
Liable to abuse (drug dependency risk)
What are the costs of prescriptions?
NHS- £8.20 to patient
OTC- much cheaper (16-50p for 16 paracetamol/ibuprofen tablets)
Private- significantly more
