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basic oral and dental care > pain and anxiety control > Flashcards

pain and anxiety control Flashcards

1
Q

What are some basic behavioural management strategies?

A 
Tell, show, do
Positive distraction- music, TV
Relaxation
Systematic desensitisation 
Hypnosis
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2
Q

What is MDAS?

A

Modified dental anxiety scale- 19 or above is high

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3
Q

How can pain be controlled?

A

Psychological techniques
LA- topical and injectable
Analgesics- oral, IV, IHS

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4
Q

How can anxiety be controlled?

A

Psychological
Drugs- anxiolytics- oral/IHS/IV (eg. Diazepam)
CBT/acupuncture/hypnosis/Pet therapy etc

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5
Q

What if someone has advanced behavioural problems?

A

Assessment
Refer to team specialising in dental phobias
Psychologists
Ask GP/local psychology team

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6
Q

How does sedation help?

A

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

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7
Q

What is the ideal sedation agent?

A 
Simple to administer
Rapid onset
Predictable action/duration
Rapid recovery
Rapid metabolism/excretion
Low incidence of side effects
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8
Q

What oral medication can be taken?

A

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

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9
Q

What inhalation sedation can be given?

A

Gas and air
Specialist equipment/training and surgery requirements

Patent nasal airway
Good for children
Minimal intervention
Analgesic
Hazards of chronic exposure

IDEAL

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10
Q

What IV sedation can be given?

A 
Pulse oximeter monitoring
Midazolam titrated according to response
20-30 mins
Anterograde amnesia
Muscle relaxant
Anticonvulsant 
No analgesic effects

IDEAL

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11
Q

What should be considered with regards to IV sedation?

A

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

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12
Q

What should be considered when administering sedation?

A 
Highly trained and efficient dental teams
Regular training in and out of house
Multidisciplinary care
Updated knowledge
Seek advice/second opinions
Refer if necessary
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13
Q

What are some medico-legal aspects?

A

Written consent
Escort requirements
Appropriate post op care

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14
Q

How is sedation regulated?

A 
GA only in hospitals
Poswillo report 1990- standards
Sedation only-
~registered and inspected premises
~appropriately trained staff
~appropriate equipment/drugs
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15
Q

What is pain?

A

Unpleasant sensory and emotional experience associated w actual or potential tissue damage or described in terms of such damage

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16
Q

What types of pain are there?

A

Inflammatory- eg. Post op pain
Neuropathic- eg. Trigeminal neuralgia, sciatica
Vascular- eg. Temporal arteritis (interrupted blood flow)

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17
Q

What analgesia is given for pulpitis?

A 
About the pain-
~Where- tooth 
~Cause- inflammation
~Acute
~Management- remove cause
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18
Q

What analgesia is given for a periapical abscess?

A 
About the pain-
~Where- perio tissues
~Cause- inflammation
~Acute
~Management- remove cause
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19
Q

What analgesia can be given for trigeminal neuralgia?

A 
About the pain-
~Where- nerve
~Cause- neuropathic
~Acute
~Management- Carbamazepine
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20
Q

What analgesia can be given for burning mouth syndrome?

A 
About the pain-
~Where- oral mucosa
~Cause- neuropathic
~Chronic over acute 
~Management- medication
21
Q

What analgesia can be given for TMJ problems?

A 
About the pain-
~Where- joint/muscles
~Cause- neuropathic
~Chronic w acute episodes
~Management- painkillers
22
Q

How can pain be reduced peripherally?

A

Remove cause
Anti-inflam tablets
LA

23
Q

How can pain be reduced centrally?

A 
Distraction
Relaxation
Cognitive restructuring 
CBT
Anticonvulsants
Antidepressants
NSAIDS
GA
24
Q

How can pain be managed?

A 
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
25
Q

What is the Arachidonic pathway?

A

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

26
Q

What do prostaglandins do?

A

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

27
Q

What can potentially happen if COX I is inhibited?

A

Stomach can’t protect itself from acid

Erosion and ulceration

28
Q

Where is COX I found?

A

Platelets, stomach, kidney

Constitutive

29
Q

Where is COX II found?

A

Kidney, brain, testicles, tracheal epithelia

Inducible

30
Q

What analgesics are in the DPF?

A 
Aspirin tablets
Diclofenac sodium tablets
Dihydrocodeine tablets 30mg
Ibuprofen tablets
Ibuprofen oral suspension
Paracetamol oral suspension
Paracetamol tablets (+soluble)
Carbamazepine 
Benzydamine
Diazepam
Lidocaine
31
Q

What are some OTC meds for dental pain?

A 
Aspirin
Aspro clear
Feminax ultra
Nurofen
Panadol (+extra)
Saridon
Solpadeine plus
Voltarol
32
Q

When shouldn’t you prescribe in disease?

A

Liver disease
Renal disease

Contact GP

33
Q

How should you prescribe in pregnancy?

A

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
34
Q

How should you prescribe in breastfeeding?

A

Insufficient research
Ibuprofen/diclofenac/paracetamol- not much concern
Dihydrocodeine- manufacturers concern
Aspirin- Reye’s syndrome risk or hypoprothrombinaemia if Vit K is low

35
Q

How should you prescribe for children?

A 
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
36
Q

What is paracetamol?

A

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

37
Q

How should paracetamol be taken?

A

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

38
Q

What are NSAIDs?

A

Non Steroidal Anti Inflammatory Drugs

Less side effects than steroids but other side effects

UK-
Annual prescriptions- 25 million
Admissions- 12000
Deaths- 2600

39
Q

What is Ibuprofen?

A 
Good efficacy in inflammatory pain
Anti-pyretic
Major side effects
Interactions 
Available OTC
Cheap
40
Q

How should Ibuprofen be taken?

A

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

41
Q

What is Diclofenac?

A 
Good efficacy in inflam
Antipyretic 
Major side effects
Major interactions (anticoagulants, haemorrhagic disorders, GI, asthma)
Similar to ibuprofen
42
Q

How should Diclofenac be taken?

A

75–150mg in a day- divided doses
Patients w heart conditions shouldn’t take
Not available OTC

43
Q

What is aspirin?

A 
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

44
Q

What are opioids?

A

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)

45
Q

What is Codeine?

A

Weak opioid, active at MU receptor, analgesic potency 50% morphine

1/2 life- 2.5-3hours
Above 65mg poorly tolerated

46
Q

What is co-codamol?

A

Codeine and paracetamol
Mild-moderate pain
Not used in dentistry really
Available OTC, however not prescribable on FP10

47
Q

How should co-codamol be taken?

A

1-2 tablets, 4-6 hourly (max 8/day)

Three strengths-
8/500- the only OTC
15/500
30/500

Constipation- common side effect

48
Q

What is Dihydrocodeine?

A

Mild-moderate pain
Not really used in dentistry
Prescribable on FP10
Liable to abuse (drug dependency risk)

49
Q

What are the costs of prescriptions?

A

NHS- £8.20 to patient
OTC- much cheaper (16-50p for 16 paracetamol/ibuprofen tablets)
Private- significantly more

basic oral and dental care (49 decks)

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