Pain and Anxiety Week 1 Flashcards
The pre-anesthetic assessment consists of
1) complete medial/dental history
2) physical examination
3) psychological examination
List what should be included in the complete medical/dental history
1) current conditions
2) past conditions
3) OTC drugs, supplements
4) adverse reactions to meds
5) problems with previous dental treatment
What are concomitant meds?
2+ meds taken on same day which can alter efficacy and safety of LA’s
Physical examination includes
1) visual exam
2) BP
3) Pulse and RR
4) patient’s weight
The patient’s weight is used to determine the ____________ ____________ _________ of LA’s
maximum recommended dose (MRD)
What does stress increase?
Pulse rate
Respiratory rate
What do LAs increase?
BP
BP of 140-159/90-94
Consider N2O for stress reduction
BP of 160-199/95-114
Retake; refer for med consult before tx
BP of >200/>115
Retake; refer for med consult before tx
T/F: We have to decrease the MRD for children because they have immature livers
True
Acceptable HR’s for adults and children
Adult: 60-100
Child: 75-100
Toddler: 120-160
Acceptable RR’s for adults and children
Adult: 12-20
Child: 18-30
Toddler: 25-32
Unfounded fear of dental tx associated with traumatic, painful past dental tx
Dental phobia
What are some signs of moderate anxiety?
1) stiff posture
2) nervous “play”
3) “white knuckle” syndrome
4) sweating
5) “too cooperative”
6) nervous conversation
7) quick answers
What are 3 things we can do for stress reduction protocol?
1) adequate pain control
2) decrease pain of injection
3) select LA of appropriate duration
How does stress affect the body in regards to pain?
It decrease the pain reaction threshold
Risk assessment ABCDE
A → antibiotics; anesthesia; anxiety; allergy
B → bleeding
C → chair positioning
D → drugs; devices
E → equipment; emergencies
An unpleasant often strong emotion caused by anticipation or awareness of danger
Fear
What % of people in the population avoid dental care b/c of fear?
6-14%
Not eliminated as easily, tends to be a learned response from personal experience or from the experience of others
Anxiety
T/F: Fear is long-term
False! it’s short-lived
Anxiety is from ______________ or thought of dentistry
anticipation
Fear refers to the ___________ occurring in the dental office
rxn
What are the most relevant routes of drug administration in dentistry?
oral, topical, subcutaneous, inhalation
Technique of communication between the dentist and the pt that creates a bond of trust and confidence
Iatrosedation
Non-drug psychosedative techniques
Hypnosis, acupuncture, audioanalgesia
Which drug is most effective and most popular drugs for anxiety management in dentistry
benzodiazepenes
These are good for mild to moderate pre-treatment anxiety
Benzodiazepenes
Which benzos are the most common anxiolytic agents?
Diazepam and triazolam
Nitrous oxide documentation MUST include…
1) Informed consent obtained and documented in chart
2) Percentage of N2O administered
3) Length of time the patient was sedated
4) Flow rate of gases during administration
Nitrous oxide documentation SHOULD also include…
1) Indication for use
2) Pt response/tolerance
What are some features of nitrous that allow it to provide ideal sedation? (5)
-produces analgesic and anxiolytic effects
-rapid onset of 2-5 mins
-wide safety margin
-quick recovery
-no hangover effect
T/F: Nitrous has low solubility in the blood
True
T/F: Nitrous can’t cross the placenta
FALSE; it can which is why you need a med consult if you have a pregnant pt
At what % can nitrous oxide induce unconsciousness?
70% or higher
Nitrous oxide has no effect on….
HR and BP
What is nitrous oxide equivalent to?
Therapeutic dose of morphine
Nitrous oxide is excreted ____________ through the _________, so it is ___________ in blood
unchanged; lungs; insoluble
Indications for nitrous oxide
- Anxiety
- Tendency to faint
- Strong gag reflex
- Medically compromised pts (angina pectoris, post MI, most CVA)
- Long procedures
- Inadequate local anesthesia
Administration of drug increases the possibility of a life threatening situation
Absolute contraindication
(do NOT administer under any circumstances)
Administration of drug is preferably avoided due to possible adverse reactions
Relative contraindication
(administer judiciously)
Absolute contraindications of nitrous oxide
- Nasal Obstruction
- Vitamin B12 Deficiency (can render B12 inactive)
- Alcoholic / Recovering Addict
- Uncommunicative (disability or language barrier)
- Patient Refusal
Relative contraindications of nitrous oxide (9)
- Middle ear infection
- Balance disorder
- Susceptibility to Motion Sickness
- Claustrophobia
- Pulmonary Diseases (med consult)
- Immunocompromised (med consult)
- Pregnancy (med consult)
- Psychiatric Disorders/Bipolar (med consult)
- Marijuana or Hallucinogenic Drug Use
Most common side effects of nitrous
Nausea, vomiting, headaches
What are some risks of long term exposure to nitrous oxide?
Bone marrow suppression
Reproductive system disturbances (spontaneous abortion, premature delivery, infertility)
Neurological defects (numbness, difficulty concentrating, etc)
Hepatotoxicity
What color is oxygen on nitrous oxide equipment?
Green
What color is nitrous on nitrous oxide equipment?
Blue
When does the nitrous pressure gauge start to fall?
Once all the liquid is gone and only gas remains
Which button is used for over sedation and fills the reservoir bag?
Flush button
Name the safety feature:
N2O flow terminated if O2 delivery pressure falls
Oxygen fail safe mechanism
What is the minimum % of oxygen?
30%
What is the maximum % of nitrous oxide?
70%
Name the safety feature:
Allows atmospheric air in if flow of gases stops
Emergency air inlet
Name the safety feature:
Rapid delivery of high flow O2 to patient (over sedation)
Oxygen flush button
Name the safety feature:
Cannot inadvertently reverse tanks
Pin index safety system
Steps of nitrous oxide administration
- Select proper sized nasal hood
- Flush reservoir bag (start w/ 5-6 L/min flow rate of 100% O2)
- Place nasal hood; pt. adjusts for comfort; tighten
- Tell pt. to breathe normally; adjust flow rate
- Gradually titrate in 10% intervals; watching for signs of sedation
- Typical pt requires 50% N2O/50% O2
- When tx is over, put N2O to zero and increase O2; 100% O2 for 5 mins
- Document procedure
- NEVER leave pt. unattended!!!
Nervous system breakdown
-divided into CNS and PNS
-CNS and PNS divided into afferent and efferent
-PNS divided into somatic and autonomic
-Autonomic divided into sympathetic and parasympathetic
3 main functions of neurons
1) receive info
2) process info
3) send response
Structure of a neuron
Cell body, dendrites, axon
What is the terminal end of an axon that allows the impulse to travel to another neuron via NTs called?
Synaptic knob
T/F: Nerves are only found in the PNS
True
What is a nerve made up of?
Many axons, an artery, and a vein
CT around an axon
Endoneurium
Group of axons
Fascicle
CT around one fascicle
Perineurium
CT around group of fascicles
Epineurium
Which fibers are the largest and have the fastest impulse generation?
Type A fibers
What are the 4 subtypes of Type A fibers?
A alpha
A beta
A gamma
A delta
Which A fibers are the largest, fastest, efferent, and used for muscle movement?
Alpha
Which A fibers are afferent and used for proprioception, touch, and pressure?
Beta
Which A fibers are efferent and used for muscle tone?
Gamma
Which A fibers are afferent and used for pain and temperature?
Delta
T/F: Type A and C fibers can be afferent or efferent while Type B fibers are only efferent.
True
Where are Type B fibers found?
Preganglionic ANS
Vascular smooth muscle
Describe the myelination of Type A, B, and C fibers
Type A = myelinated
Type B = slightly myelinated
Type C = unmyelinated
Which are the smallest, most numerous, and unmyelinated fibers?
Type C
Which fibers are responsible for dull, achy pain?
Type C
What type of fibers are prevalent in the oral cavity?
Type A and Type C
Which fibers require more anesthetic volume? Why?
Type A (they’re larger)
Types of stimuli that trigger nerve impulses
Chemical
Thermal
Mechanical
Electrical
Neurons maintain RMP via?
1) Sodium-Potassium Pump
2) closed K+ channels
3) closed Na+ channels
What causes the absolute refractory period?
Inactivation of Na+ channels during repolarization
What causes the relative refractory period?
Hyper-polarization before RMP is established
T/F: An action potential cannot be generated in the relative refractory period
False! it can be if a larger stimulus is applied
2 types of synapses
Electrical and chemical
What are the 2 ways that LA’s cause reversible local anesthesia?
prevents generation and conduction of impulses
What do “membrane-stabilizing drugs” do?
Decrease rate of depolarization
Small/large diameter nerve fibers are less/more sensitive to LAs
small; more
Small/large diameter nerve fibers require less/more volume of LAs
Large; more
What are the 2 major routes of LA delivery?
1) topical
2) submucosal injection
T/F: Submucosal injections are more effective than topical
True
Topical requires _______ concentrations and causes _________ chances of toxicity
greater; greater
Which ion channels do LA’s bind to inside the cell?
Na+
