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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
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
26
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
27
What can potentially happen if COX I is inhibited?
Stomach can’t protect itself from acid | Erosion and ulceration
28
Where is COX I found?
Platelets, stomach, kidney | Constitutive
29
Where is COX II found?
Kidney, brain, testicles, tracheal epithelia | Inducible
30
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 ```
31
What are some OTC meds for dental pain?
``` Aspirin Aspro clear Feminax ultra Nurofen Panadol (+extra) Saridon Solpadeine plus Voltarol ```
32
When shouldn’t you prescribe in disease?
Liver disease Renal disease Contact GP
33
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 ```
34
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
35
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 ```
36
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
37
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
38
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
39
What is Ibuprofen?
``` Good efficacy in inflammatory pain Anti-pyretic Major side effects Interactions Available OTC Cheap ```
40
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
41
What is Diclofenac?
``` Good efficacy in inflam Antipyretic Major side effects Major interactions (anticoagulants, haemorrhagic disorders, GI, asthma) Similar to ibuprofen ```
42
How should Diclofenac be taken?
75–150mg in a day- divided doses Patients w heart conditions shouldn’t take Not available OTC
43
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
44
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)
45
What is Codeine?
Weak opioid, active at MU receptor, analgesic potency 50% morphine 1/2 life- 2.5-3hours Above 65mg poorly tolerated
46
What is co-codamol?
Codeine and paracetamol Mild-moderate pain Not used in dentistry really Available OTC, however not prescribable on FP10
47
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
48
What is Dihydrocodeine?
Mild-moderate pain Not really used in dentistry Prescribable on FP10 Liable to abuse (drug dependency risk)
49
What are the costs of prescriptions?
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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