Sedation and SCD Flashcards
SCD for
those with a disability or activity restriction that directly or indirectly affects their oral healthy
problems with providing dental tx to SC pts
- Communication
- Anxiety
- Moving target
- Perception of reality
- Previous experience
Often the same as providing medical care
2 common issues for SC pts getting dental tx
involuntary movements
learning difficulties (congenital or acquired)
duration of IV drug operating window approx.
40mins
5 possible congenital movement disorders
- Muscular dystrophy – slight concern on airway
- Cerebral Palsy
- Multiple Sclerosis
- Parkinson’s Disease
- Huntingdon’s Chorea – often has a learning difficulty association, tricky
possible acquired movement disorder
due to head injury
3 aspects in assessment needed for management of movement disorder
mental and physical status
anxiety
pain experience
possible causes of learning difficulties in SC pts
- Congenital
- Syndromic
- Non-syndromic
- Acquired
- Trauma
- Infection
- CVA
- Alzeheimer’s – often Elderly, additional complication e.g. drug metabolsim
3 assessment aspects for SC pts with learning difficulties
- Will behavioural management be possible?
- Many patients can be treated with TLC
- Is pharmacological management needed?
- Sedation or GA or both
- Patient understanding
- Patient’s pain experience
most important aspect of assessment for all SC pts
GET TO KNOW THE PT
what they do/don’t understand
triggers
consent key points
Adult Incapacity Act (2000) Scotland
No one else can give consent for adult to have treatment
- If not competent to give consent
- Medically qualified or appropriately trained dentists
- can complete form allowing treatment
- Lasts up to 36 months
- Patient competent to consent but can’t write.
- Not covered by legislation
- Verbal consent document in notes
4 concious sedation technqiues
- Inhalational N2O
- Intravenous - midazolam
- Oral sedation with midazolam (drink), can also get premed (milder)
- Transmucosal
- Intranasal
- sublingual
- rectal
7 considerations for choice of sedation technique
- Patient co-operation
- None ->GA
- Good -> IHS, but need them to stay still and breathe through nose – challenge
- Degree of anxiety
- Dentistry required
- Extremely invasive – IV, won’t remember
- Upper central operated on – nose piece for inhalation may inhibit?
- Skills of the dental team
- Patient’s previous experience
- Successful tx of sedation in past, likely go for that again
- Facilities available
- Hospital environment better in more complex pt, just in case
- Anaesthetist required?
inhalation sedation
consists of
Safe technique
- Nitrous oxide and oxygen combination through nasal hood
- Mild anxiety
- Rapid – both sedation and recovery
- Sedated before injection – good for needle phobia
- Flexible – can titrate, turn off on demand
need to be able to
- Nasal breathing when mouth open.
- Understanding Behavioural management
- Cooperation
IHS for
mild anxiety only
IHS pt need to (3)
- Nasal breathing when mouth open.
- Understanding Behavioural management
- Cooperation
3 adv of IHS
- Useful for anxiety relief
- Rapid recovery
- Flexible duration
3 disadv of IHS
- Keeping nasal hood in place
- Less muscle relaxation (not as deep) (need pt stillness)
- Coordination of nasal breathing when mouth open
IV sedation where
cannula in back of hand od antecubital fossa
3 techniques for IV sedation
- Midazolam (majority)
- Propofol – anaeshtestic agent at correct level becomes sedation, pump – adv pump off recover quickly, discharge quicker than midazolam
- Multiple agent - deeper sedation, not allowed in UK for conscious sedation
5 safety considerations for IV sedation to consider prior
- Swallowing
- Airway (needs to be stay patent)
- Liver (metabolism of drug)
- Medication interactions – check BNF
- ASA
3 adv of IV sedation
- Good sedation achieved (deeper than IHS)
- Less cooperation needed – need to get cannula in but after that fine
- Muscle relaxation (can stop involuntary movements)
5 diadv of IV sedation
- Baseline readings
- BP, pulse oximeter, resp count but if pt uncooperative and unable to get them, need to consider pt health as a whole and your experience before proceeding
- IV Cannulation required
- Assessing sedation level
- can be hard, may need hand signs/blinking etc, establish before
- Behaviour during recovery
- get upset, challenging after tx
- Efficacy swallowing
- vital; if pt cannot swallow don’t want to put a drug in that decreases the swallowing reflex further
- check how they eat diet before – do they need soften food? Swallowing risk on MHx? CONCERN for IV
- vital; if pt cannot swallow don’t want to put a drug in that decreases the swallowing reflex further
process for oral sedation
- Baseline recordings and pulse oximeter on
- Midazolam pull up 20mg, get them to drink in front of them
- Same safety as IV – aim is as sedated as IV but oral
- NOT PREMED – small dose benzodiazepine (diazepam or temazepam??) taken 1hr before dental appt, mild sedative to get them in
- 30mins to take action from drinking
- Bolus
- not as good as IV as not adjustable
- unpredictable
intranasal sedation
- V concentrated midazolam in a syringe with atomiser at end of syringe
- Squirt up nose
- Fine mist attaches to nasal mucosa
- Popular
- No first pass metabolism
- More reliable
- No waiting for it to be absorbed through gut
- 7 mins for nasal mucosa
- No inital cannulation
- No first pass metabolism
4 adv of intranasal sedations
- Avoid cannulation
- (not completely – once sedated, need to put cannula in so have easy access in case need to reverse in oversedation)
- Can make induction more pleasant
- Better cooperation
- Better future behaviour
6 disadv of intranasal sedation
- Baseline readings
- Bitter taste / stinging
- Lag time
- Untitrateable
- Difficulty in monitoring level of sedation
- Behaviour in recovery
possible outcomes for sedation pts
All needed treatment carried out
- Some treatment can be carried out
- Precision drilling not possible if the pt can move slightly
- Need to remain conscious
- XLA maybe easier than filling
- Exam, Scale and polish
- Can be essential – can assess further tx needed and plan
- Avoid unnecessary GA
- Can be essential – can assess further tx needed and plan
- Refer to GA for treatment
- Other treatments
- E.g. cannula in for sedation – get bloods
tx planning for possible sedation pts
- Pre sedation exam may not be possible
- Ability to cope
- Complicated treatment?
- Maintenance in future
- Treat patient not the carer
- Use sedation because of clinical need
maintenance of oral hygiene considerations for SC pts
- Will patient allow oral hygiene?
- Are carers interested in providing oral hygiene?
- Are the carers capable of providing oral hygiene?
GA or sedation?
- Safety
- Controlled Airway with GA
- Difficult intubation
- Co-operation
- Waiting lists and access to services
- Pain
- Medical history
- Still a need for GA
