Sedation and special care

Question 1

Problems in providing dental treatment

Answer 1

• communication
• anxiety
• moving target
• perception or reality
• previous experience

Question 2

Which are the common patient groups

Answer 2

1. Involuntary movements
2. Learning difficulties (congenital and acquired)

Question 3

Congenital movement disorders?

Answer 3

• muscular dystrophy
• cerebral palsy
• MS
• parkinson’s disease
• huntingdon’s chorea

huntingdon’s chorea is a learning difficulty - can make sedation tricky
MD - breathing concerns with sedation

Question 4

Acquired movement disorders?

Answer 4

Head injury

Question 5

Congenital difficulties

Answer 5

Syndromic and non-syndromic

?

Question 6

Acquired learning difficulties

Answer 6

• Trauma
• Infection
• CVA
• Alzheimer’s

Question 7

considerations?

Assessment of patients with learning difficulties

Answer 7

1. Will behavioural management be possible?
   * many patients can be treated with TLC
2. Is pharmacological management needed?
3. Sedation or GA or both
   * patient understanding
   * patient’s pain experience

Question 8

considerations?

Assessment of patients with involuntary movements

Answer 8

• mental and physical status
• anxiety
• pain experience

Question 9

Considerations for consent?

Answer 9

• no one else can give consent
• patient competent to consent, but can’t write
• not covered by legislation
• verbal consent document in notes
• Adult incapacity act (2000) Scotland
  1. No one else can give consent for adult to have treatment
  2. If not competient to give consent:
  Medically qualified or appropriately trained dentists can complete form allowing treatment, lasts up to 36 months

Question 10

Different techniques used for conscious sedation?

Answer 10

• inhalational (NiO)
• Intravenous (Medazolam)
• Oral (Medazolam)
• Transmucosal (Rectal, Intranasal, Sublingual)

Question 11

What does your choice of sedation technique depend on?

Answer 11

• patient co-operation
• degree of anxiety
• dentistry required
• skills of the dental team
• patient’s previous experience
• facilities avaliable
• anaesthetist required?

patient co-operation - vital, need lots for inhalation
dentistry required - if v.invasive, IV as won’t remember it
patient’s previous experience - what sedation have they had before?

Question 12

Advantages for inhalation sedation

Answer 12

• useful for anxiety relief
• rapid recovery
• flexible duration

Question 13

Disadvantages of inhalation sedation

Answer 13

• keeping nasal hood in place
• less muscle relaxation
• coordination of nasal breathing when mouth open

Question 14

Features of inhalational sedation

Answer 14

• safe technique
• nasal breathing when mouth open
• understanding behavioural management
• cooperation

Question 15

Advantages of IV sedation

Answer 15

• good sedation
• less cooperation needed
• muscle relaxation

less cooperation needed although need to get a canula in
muscle relaxation - can stop involuntary movements

Question 16

Disadvantages of IV sedation

Answer 16

• baseline readings
• IV cannulation required
• assessing sedation level
• behaviour during recovery
• efficacy swallowing

assessing sedation level - non-verbal v. challenging
efficacy swallowing - if they already can’t swallow this could be dangerous, ask how well they eat food

Question 17

What are the different techniques for IV sedation

Answer 17

1. Midazolam
2. Propofol
3. Multiple agent

Propofol - anaesthetic, pump is fast acting, turn off pump recovery quick
Multiple agent - deeper sedation, in UK can only do conscious sedation i.e verbal contact must be maintained

Question 18

What safety measures have to be checked with sedation

Answer 18

• swallowing
• airway
• liver
• medication interactions
• ASA 1 or 2

swallowing and airway is vital
liver - essential for metabolism of drug
ASA complicated 2 or higher seen in hospital or specialist

Question 19

Advantages of Oral/Transmucosal sedation

Answer 19

• avoid cannulation
• can make induction more pleasant
• better cooperation
• better future behaviour

Question 20

Disadvantages of Oral/Transmucosal sedation

Answer 20

• baseline readings
• bitter taste/stinging
• lag time
• untitrateable
• difficulty in monitoring level of sedation
• behaviour in recovery
• takes 30 mins to work
• bolus dose (IV is better, more adjustable)

Intranasal - don’t need to wait for it to be absorved through the gut. More reliable and faster (around 7 mins)

Question 21

How does oral sedation happen

Answer 21

midazolam 20mg, drink in front of dentist

Question 22

What is used for transmucosal sedation

Answer 22

Atomiser (intranasal)

Question 23

What are some outcomes of sedation

nb differing levels of cooperation

Answer 23

• all needed treatment carried out
• some treatment can be carried out (rest needs GA)
• Exam, scale and polish (rest needs GA)
• other treatments

Not always possible to do all the treatment you need to but that doesn’t mean it’s not worth doing. Might allow an exam to stop or justify GA.
Also possible to do other things e.g. take blood, cut toenails, haircut etc

Question 24

Considerations for treatment planning

Answer 24

• pre-sedation exam may not be possible
• ability to cope
• complicated treatment? nb maintenance in future
• treat patient not the carer
• use sedation because of clinical need

Question 25

Considerations for maintenance of dental treatment

Answer 25

Oral hygiene i.e:
* will patient allow oral hygiene care?
* are carers interested in providing oral hygiene?
* are the carers capable of providing OH?

Question 26

Considerations on choosing GA or sedation

Answer 26

• safety (controlled airway with GA, difficult intubation)
• cooperation
• waiting lists and access to services
• pain
• MH
• still a need for GA