Sedation in Special Care Flashcards
What are some the problems in treating Special Care patients in dentistry?
Communication
Anxiety (due to lack of understanding)
Moving target
Perception of reality
Previous experience
Which congenital movement disorders can make dental treatment difficult?
Muscular dystrophy (breathing issues)
Cerebral Palsy
Multiple Sclerosis
Parkinson’s Disease
Huntingdon’s Chorea (learning difficulties)
What an be the cause of an acquired movement disorder?
Head injury
How are patients with involuntary movements managed?
Assessment:
Mental and physical status
Anxiety
Pain experience
What are the types of learning difficulties?
Congenital- syndromic/non-syndromic
Acquired- trauma, infection, CVA, alzheimers
What are the considerations for management of patient with learning difficulties?
Will behavioural management be possible?
-> Many patients can be treated with TLC
Is pharmacological management needed?
Sedation or GA or both- based on patient understanding/pain experience
What can be done if patient not competent to give consent for sedative treatment? (AWI 2000)
Medically qualified or appropriately trained dentists
can complete form allowing treatment (Lasts up to 36 months)
What are the types of conscious sedation techniques?
Inhalational
Intravenous
Oral
Trans-mucosal- rectal, intranasal, sublingual
What should be considered when choosing sedation technique?
Patient co-operation (if none- GA)
Degree of anxiety
Dentistry required
Skills of the dental team
Patient’s previous experience
Facilities available
Anaesthetist required?
What are the advantages of IS in special care?
Useful for anxiety relief
Rapid recovery
Flexible duration
No needles
Safe
What are the disadvantages of IS in special care?
Keeping nasal hood in place
Less muscle relaxation
Coordination of nasal breathing when mouth open (wont be sedated)
Requires cooperation and understanding of nasal breathing instructions
Less useful if very anxious
What are the ADV of IV sedation in special care?
Good sedation achieved
Less cooperation needed (still need to insert cannula)
Muscle relaxation
What are the DIS of IV sedation in special care?
Baseline readings required
IV Cannulation required
Difficulty assessing sedation level (esp non-verbal patients)
Behaviour during recovery- uncontrolled movements/patient upset
Not suitable for patients with swallowing difficulty
What can be used for IV sedation in special care?
Midazolam
Propofol- anaesthetic agent that can cause sedation
Multiple agents- can cause deep sedation (not in UK)
What are the features of propofol?
Uses pump
Fast acting
Can be topped up
Quick recovery
What must we consider to ensure sedation is safe in special care?
Swallowing
Airway
Liver
Medication interactions
ASA class
What is used in Oral/Transmucosal sedation?
20mg of midazolam liquid achieves same level of sedation as IV)
-> this is not premed
What are the advantages of oral and transmucosal sedation in special care?
Avoids cannulation
Can make induction more pleasant
Better cooperation
Better future behaviour
What are the disadvantages of oral and transmucosal sedation in special care?
Baseline readings required
Bitter taste / stinging
Lag time- 30 mins
Untitrateable- unrpredictable
Difficulty in monitoring level of sedation
Behaviour in recovery
Cannula still needed after sedation
Why is a cannula still needed in O/T sedation?
For easy access to allow for reversal
How is intranasal sedation delivered?
Very concentrated midazolam is given via syringe with atomiser
-> Absorbed via nasal mucosa
-> works in 7 mins- bypasses first pass metabolism
-> reliable level of sedation
What is the outcome of sedation based on and what are the options?
Degree of cooperation! Options:
All treatment completed under sedation (complicated treatment may even be possible)
Some sedation/some GA
-> exam, scale and polish- assess cooperation then refer for GA if required
Can enable other treatment from other disciplines
Why may extraction be easier than restoration in some special care patients?
Uncontrolled movements are more acceptable when doing extractions
What must we consider when placing restorations in special care patients
Will patient allow oral hygiene?
Are carers interested in providing oral hygiene?
Are the carers capable of providing oral hygiene?
