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Dentistry year 4 - Module 8 > Special Care Dentistry > Flashcards

Special Care Dentistry Flashcards

1
Q

what is conscious sedation

A

a technique in which the use of a drug or drugs produces a state of depression of the central nervous system enabling treatment to be carried out, but during which verbal contact with the patient is maintained throughout the period of sedation.

the drugs and techniques used to provide conscious sedation for dental treatment should carry a margin of safety wide enough to render loss of consciousness unlikely.

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2
Q

what are the types of conscious sedation used

A
  1. inhalation
  2. intravenous
  3. oral
  4. intranasal - not widely used
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3
Q

the consent process regarding conscious sedation must be in what?

A

writing

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4
Q

what is used for inhalation sedation

A

use of nitrous oxide and oxygen

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5
Q

inhalation sedation is used as a mild sedation for what

A

mild anxiety

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6
Q

what are the indications of inhalation sedation

A

ability to breathe through nose

do not have a cold on day of treatmet

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7
Q

a drug that has anxiolytic affect means what?

A

A drug used to treat symptoms of anxiety, such as feelings of fear, dread,

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8
Q

what type of suggestion has known to be present with inhalation sedation

A

post hypnotic suggestion

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9
Q

what are the characteristics of nitrous oxide

A
  1. inhaled gas
  2. sweet smelling
  3. colourless
  4. heavy
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10
Q

why is nitrous oxide called laughing gas

A

Taking nitrous oxide can cause: feelings of euphoria, relaxation and calmness; fits of giggles and laughter

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11
Q

what is entonox

A

Entonox is a well-established pain relieving gas mixture. It consists of two gases, 50% nitrous oxide and 50% oxygen and is more commonly known as gas and air. Entonox is used to control pain during some investigations and procedures.

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12
Q

what is the onset of Nitrous oxide

A

rapid

3-5 minutes

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13
Q

what barrier is crossed by nitrous oxide

A

crosses the blood brain barrier rapidly

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14
Q

what is the elimination speed for nitrous oxide

A

rapid

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15
Q

where is nitrous oxide metabolised

A

no significant metabolism by kidneys or liver

Nitrous oxide (a trace amount) is metabolized through reduction by anaerobic bacteria in the gut

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16
Q

nitrous oxide is not stored in the tissues thus having NO hangover effect

A
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17
Q

inhalation sedation overdose signs include?

A

headache
nausea
vomititng

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18
Q

what is hypoxia

A

Hypoxia is a state in which oxygen is not available in sufficient amounts at the tissue level to maintain adequate homeostasis; this can result from inadequate oxygen delivery to the tissues either due to low blood supply or low oxygen content in the blood

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19
Q

what is diffusion hypoxia

A

Nitrous oxide enters the alveoli far more rapidly than nitrogen leaves, causing dilution of the gaseous contents of the alveolus. This results in the dilution of oxygen within the alveoli of patients breathing air and may cause ‘diffusion hypoxia’

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20
Q

how do you treat diffusion hypoxia

A

100% oxygen administration should follow nitrous oxide cessation for 5 minutes

known as O2 flush.

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21
Q

what are the indications for inhalation sedation

A
  1. mild anxiety
  2. needle phobia
  3. patient not suitable for IV/GA
  4. straightforward dental treatment
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22
Q

what are the considerations for inhalation sedation?

A

Able to cooperate

  • age
  • learning disability
  • cognitive impairment
  • ability to tolerate mask

mask may impede access to anterior teeth

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23
Q

what are the considerations for inhalation sedation?

A

Able to cooperate

  • age
  • learning disability
  • cognitive impairment
  • ability to tolerate mask

mask may impede access to anterior teeth

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24
Q

what are the contraindications of inhalation sedation

A
  1. COPD
  2. Recent eye or ear surgery - Nitrous oxide anaesthesia in the presence of intraocular gas can cause irreversible blindness.
  3. Mask Intolerance
  4. pregnancy - recommend 2nd trimester

Vit B12 deficiency (NO depletes the body’s store of vitamin B12)

methotrexate interaction - drug holiday (to much toxicity)

chemotherapy interaction

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25
Q

inhalation sedation requires the use of which equipment

A

RA (Relative analgesia) machine

gas cylinders or piped gases

Scavenging - is a means to collect and remove excess gases to prevent them from being vented back into the operating room.

monitoring for staff

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26
Q

what is the name of this equipment

A

Relative analgesia machine

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27
Q

what is the name of this equipment

A

inhalation mask

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28
Q

laughing gas users risk?

A

spine damage says doctors

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29
Q

possession of laughing gas to be

A

criminal offence

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30
Q

intravenous sedation is delivered as an injection most commonly which drug is used?

A

midazolam

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31
Q

what level of anxiety must you have to be considered for IV sedation

A

Mild-moderate

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32
Q

how is midazolam administered

A

administered in to the vein via cannulation

introduce a cannula or thin tube into (a vein or body cavity).

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33
Q

do you require a escort for Intravenous sedation

A

Yes

the escort is required to follow rules to keep patient safe

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34
Q

what is usually one of the side affects of IV sedation

A

Amnesia

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35
Q

what drug is required to reverse the use of midazolam

A

Flumazenil in a dose of 0.15 mg is a safe drug that reverses the sedative effect of midazolam

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36
Q

what are the indications of midazolam

A
  1. dental anxiety/phobia
  2. medically suitable
  3. social history
  4. unpleasant procedure
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37
Q

what are the contraindications for IV sedation

A
  1. needle phobia
  2. medical reasons
  3. social reasons
  4. pregnancy - sedation during the third trimester of pregnancy for surgeries not related to delivery of the baby
  5. poor venous access
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38
Q

what equipment is needed for IV sedation

A
  1. Midazolam
  2. Flumazenil
  3. Labels for syringes
  4. Saline - sedation usually accompanied by hypotension, which reduces the amount of sedation able to be employed. Blood pressure is restored by the infusion of intravenous normal saline.
  5. pulse oximeter
  6. BP cuff and machine
  7. Tourniquet
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39
Q

how many micrograms of midazolam is in 5 ml

A

5 mg

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40
Q

how many micrograms of flumazenil is in 5 ml

A

500 mg

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41
Q

what factors can affect reading on a pulse oximeter

A

nail polish (dark)/gel/acrylic nails

finger tapping/playing with pulse oximeter

breath holding

cold hands

fasting - varies between units

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42
Q

what are the signs of overdose with IV sedation (midazolam)

A
  1. loss of protective reflexes
  2. loss of consciousness
  3. decreased respiration
  4. decreased heart rate
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43
Q

flumazenil is a reversal agent and it must be held in

A

stock

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44
Q

flumazenil rescue is considered a

A

never event

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45
Q

what is flumazenil

A

it is a benzodiazepine

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46
Q

what medication is usually given as oral sedation

A

usually midazolam

delivered as a drink

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47
Q

is oral sedation considered pre-med

A

not the same as pre-med

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48
Q

what must you do before you have given a patient midazolam as a form of oral sedation

A

must still cannulate for safety - rescue/reversal

must be proficient in IV technique

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49
Q

how long does it take for the effects of oral sedation to work

A

Oral sedation means that the sedation drugs are swallowed as a tablet or liquid. It takes about 10 minutes for the effects of the drug to work. Once you are sedated, you will usually have a small cannula placed in the back of your hand or in your arm.

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50
Q

what is premedication

A

preliminary administration of a drug preceding a diagnostic, therapeutic, or surgical procedure, as an antibiotic or antianxiety agent

a drug administered for such a purpose = premed

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51
Q

what is a typical regimen for premedication with diazepam

A

5 - 10 mg Diazepam

Last thing at night on the evening before the appointment

On wakening on the morning of the appointment
60 - 90 mins before the appointment

Prescribe only what is required

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52
Q

diazepam is available in

A

2, 5, 10 mg tablets for oral use

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53
Q

diazepam has drug interactions with which drugs

A

Drug Interactions:-

Antibacterials - isoniazid inhibits metabolism. Rifampicin increases metabolism

Antivirals - Ritonavir

Proton pump inhibitors (PPIs) - Omeprazole

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54
Q

what are the indications for diazepam

A

Very anxious patients – may aid them attending the surgery or sleeping the night before

Patients when sedation is contraindicated:-

Medical reasons

Inability to get venous access – IV Sedation

Inability to breath through nose – RA

To “take the edge off” before more complex and prolonged procedures

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55
Q

what are the contraindications for diazepam

A

Hepatic impairment
Renal impairment
Pregnancy
Breast feeding

56
Q

what are the cautions for the use of diazepam

A

Avoid prolonged use

Reduce dose in debilitated patients

Reduce dose in elderly

Respiratory disease

Patient compliance – taking at wrong time!

57
Q

what benzodiazepines do we use for sedation

A

diazepam - premed

temazepam - predmed

midazolam - conscious sedation

flumazenil - reversal agent

58
Q

what are the features of benzodiazepines

A

Anxiolytic - low doses, can be subtle, not analgesic

Anticonvulsant - prevent and terminate convulsion

Sedation-

slight at low doses
intense at higher doses
decreased response to constant stimulus
reduced attention
will lead to sleep if left un-stimulated
dis-inhibition

59
Q

benzodiazepines have a amnesia affect on patients when is most intense

A

amnesia most intense with IV sedation

60
Q

what is anterograde amnesia

A

Anterograde amnesia (AA) refers to an impaired capacity for new learning.

61
Q

what are features of muscle relaxation of benzodiazepines

A

central effect

depression of spinal reflex activity

partly responsible for respiratory depression

reduces trismus

62
Q

what are the short term side effects of benzodiazepines

A

Drowsiness
Dizziness
Reduced concentration and coordination
Hypotension
Respiratory Depression
Sexual fantasy

63
Q

what are the long term side effects of benzodiazepines

A

tolerance

dependence

withdrawl symptoms

64
Q

what doses are needed for elderly people who require benzos

A

low doses

65
Q

what is a paradoxical reaction

A

A paradoxical reaction happens when a person experiences the opposite of what the drug is intended to do.

66
Q

Sedation standards and guidance

A

IACSDS

interollegiate
advisory
committee for
sedation in
dentistry
standards

67
Q

SDCEP Third Edition

conscious sedation in dentistry

A
68
Q

what is the definition of General Anaesthesia (GA)

A

A general anesthetic is a state of controlled unconsciousness,
affecting the whole body, so the patient does not move or feel
pain, with loss of protected reflexes.

69
Q

who carrys out GA

A

An anaesthetist uses a
combination of medicines to allow medical procedures to be
carried out, that would otherwise be intolerable to the patient

70
Q

what are the indications for GA

A

Lengthy or complex surgery

Very anxious / dental phobic patients who are unable to tolerate / cooperate with treatment under other modalities e.g. LA, oral, IV or nitrous oxide sedation

Patients with a profound learning disability who are unable to tolerate / cooperate with treatment under other modalities e.g. LA, oral, IV or nitrous oxide sedation

Multiple extractions in multiple quadrants

Severe trauma or acute dental infection

Cases where nitrous oxide or IV sedation is contraindicated or inappropriate

71
Q

what are the advantages of GA

A

Patient cooperation not required*

Patient unaware of the procedure taking place

Significant amount of treatment can be carried out in one attendance

May be able to co-ordinate interventions with other specialities

72
Q

what type of consent is needed when undergoing GA

A

‘Open’ consent often needed as cannot change the treatment plan half way through, or wake patient to discuss,

e.g. “EUA – examination under anaesthesia and dental treatment as deemed appropriate”. Some patients not happy to give ‘open’ consent which could result in e.g. more teeth extracted than first anticipated, or front teeth needing extraction

73
Q

what are the disadvantages/limitations of GA

A

Preoperative assessment(s) medical and dental needed

Needs careful treatment planning / all work to be done in one visit,

Treatment often has to be more radical to be done in one visit

Does not help the patient get over their fear / build confidence

Pre-op fasting and after care required

Risk (morbidity and mortality) of GA

74
Q

From 1/1/2001: ALL dental GA’s could only be administered in hospital with intensive care facilities for support

due to landmark case - West Lothian, Scotland. Death of paediatric patient during GA for routine tooth extraction in October 1998

A
75
Q

Level of sedation

Minimal sedation:

A

Anxiolysis, retains patient’s ability to respond normally to stimulation and verbal command.

76
Q

level of sedation

moderate sedation:

A

Conscious sedation, depression of consciousness, patients respond purposefully to verbal commands

77
Q

level of sedation

deep sedation:

A

nearly unconscious, only has purposeful response to repeated and painful stimulation.

78
Q

Level of sedation

General anaesthesia:

A

completely unconscious, does not respond to any level of pain. The patient will require breathing assistance and cardiovascular function may be impaired

79
Q

when is amnesia the most intense with benzos

A

intense for first 20/30 mins

80
Q

how do benzos affect the spine

A

depression of spinal reflex activity

81
Q

how does patient recover from sedation

A
  1. Redistribution of the drug from CNS into body fat
  2. Uptake and metabolism of the drug by the liver and elimination by the kidneys
82
Q

Redistribution is responsible for the initial recovery from sedation, the alpha half-life, the time taken for the serum concentration to drop by

A

50%, followed by

Elimination of the remaining drug, the beta half-life, time taken to remove half the drug from the body.

83
Q

how do benzos defer Pharmacodynamically

A

affinity for receptors

half life

active metabolites

84
Q

benzos mechanism of action

A

Chloride ions enter the cell making the resting membrane potential more negative.

85
Q

what is the half life of diazepam

A

30 hours

86
Q

why is diazepam no longer used for IV sedation

A

The organic solvent caused vein damage: pain, thrombophlebitis, skin ulceration.

87
Q

why do we not use diazemuls (Emulsified into suspension of soya bean oil)

A

Long recovery period and possibility of rebound sedation means it is not well suited to short dental procedures

88
Q

what is the pH of midazolam

A

Water soluble

pH<4.0 and non-irritant to veins

89
Q

the use of midazolam by slow intravenous injection follows

Adult
Initially 2–2.5mg, to be administered 5–10 minutes before procedure at a rate of approximately 2mg/minute, increased in steps of 1mg if required, usual total dose is 3.5–5mg; maximum 7.5mg per course.

what is the maximum dosage we are allowed to use at the DDH

A

currently, 10mg maximum in the clinic

90
Q

what is the maximum course for midazolam for elderly

A

3.5mg per course

91
Q

what happens to midazolam once it is in the blood stream.

A

Once in the bloodstream it becomes lipid soluble at physiological pH.

this allows it to readily penetrate the blood-brain barrier

92
Q

what is the half life of midazolam

A

elimination half life of 1.9 hours +/- 0.9 hours

complete recovery quicker than diazepam

93
Q

why do you need slowly inject midazolam?

A

Too rapid injection can cause respiratory depression and apnoea

apnoea – where the muscles and soft tissues in the throat relax and collapse sufficiently to cause a total blockage of the airway; it’s called an apnoea when the airflow is blocked for 10 seconds or more

94
Q

Once reached end point don’t give any more midazolam why

A

Every time you add an increment of drug, the half-life starts again with that dose increment and a dangerous accumulation can build up.

95
Q

why do you want to avoid Erythromycin/Clarithromycin (antibiotic): when taking midazolam

A

Markedly increase the exposure to Midazolam.
Severe. Avoid

96
Q

why do you want to avoid

Atazanavir/Darunavir/Fosamprenavir/Ritonavir (Antiviral, HIV):

A

Markedly increase the exposure to Midazolam. Severe. Avoid

97
Q

why do you want to avoid

Fluconazole/Isavuconazole/Itraconazole/Ketoconazole (Antifungal):

A

Markedly increase the exposure to Midazolam. Severe. Monitor the adverse effects and adjust dose

98
Q

why do you want to avoid

Imatinib/Idelalisib/Nilotinib/Rucaparib (Anticancer):

A

Markedly increase the exposure to Midazolam. Severe. Avoid or adjust dose

99
Q

Side effects of Benzodiazepines

A

Respiratory depression (particularly with high dose and IV use)
Ataxia and confusion (more common in elderly)
Depression
Dizziness
Drowsiness and Fatigue
Hypotension
Muscle weakness
Sleep disorder
Vision disorder
Tremor
Withdrawal syndrome

100
Q

benzos with breastfeeding

A

small amount present in milk-avoid feeding for 24 hours after administration

101
Q

in acute emergency how much flumazenil can be given

A

500 micro grams

102
Q

what is the maximum total dose of flumazenil

A

1 mg

103
Q

Local Anaesthetic creams for hands/arms

A

EMLA cream
Ametop gel

104
Q

it is estimated that it cost how much a year to tackle substance abuse in sctoland

A

2.6 bn

105
Q

what is scotlands 5 most common drugs used

A

 Cannabis
 Cocaine
 Ecstasy
 Amphetamines
 Heroin

106
Q

what percentage of adults use cocaine in scotland

A

3.8% the most in the world

2010

107
Q

what is Cocaethylene

A

cocaine mixed with alcohol taking it is greater than x3 alcohol consumption

108
Q

every time you take cocaine how many more times likely are you to have a heart attack

A

24

109
Q

drugs are categorised in to two groups based on function

A

stimulants (uppers)

depressants (downers)

110
Q

what drugs fall in to the stimulants drug categories

A
  1. caffeine
  2. nicotine
  3. cocaine
  4. amphetamine
  5. ecstasy
111
Q

what drugs fall in to the depressants drug categories

A
  1. alcohol
  2. solvents
  3. heroin
  4. morphine
  5. benzodiazepines
112
Q

what drugs fall in to the hallucinogenics categories

A

LSD
Magic Mushroom
Cannabis

113
Q

 Two main statutes relating to drugs in the UK

A

The Medicines Act, 1968

The Misuse of Drugs Act, 1971

114
Q

Misuse of Drugs Act, 1971
Class A drugs include

A

 Heroin
 Cocaine (including crack)
 Methamphetamine
 Ecstasy
 Methadone

115
Q

Misuse of Drugs Act, 1971
Class B drugs include

A

 Amphetamines
 Cannabis*

116
Q

Misuse of Drugs Act, 1971
Class C drugs include

A

Benzodiazepines
 Ketamine
 Anabolic Steroids

117
Q

where does heroin come from

A

heroin is a synthetic opiate

It is a chemical derivative of Morphine, the principle
ingredient of Opium

It is approximately 4 times more potent per gram than
Morphine

118
Q

what are the positive affects of opiates

A

 Initial euphoria
 Removal of Tension
 Tranquility
 Sense of Control
 Detachment from worries, fears
 Analgesia

119
Q

what are the negatives of opiates

A

 Itching
 Flushing
 Myosis
 Appetite Suppression
 Slurred Speech
 Slow Gait
 Depression
 Constipation

120
Q

whats the difference between neurosis and psychosis

A

neurosis - contact retained with reality

psychosis - contact lost with reality

121
Q

what is neurosis

Functional mental disorder, without
delusions or hallucinations. Behaviour is not
out with socially acceptable norms.

A

 Anxiety
 Phobic
 Obsessional
 Hypochondriacal
 Depressive

122
Q

what is functional psychoses

A

Mental state involving loss of contact with reality. Delusions &
hallucinations are common. Patients may show changes in
personality, thought disorder & may exhibit strange behaviour. They
are likely to have difficulty in carrying out daily activities.

bi-polar
schizophrenia

123
Q

what is the most severe form of functional psychosis

A

schizophrenia

124
Q

what is pica

A

Pica is a feeding disorder in which someone eats non-food substances that have no nutritional value, such as paper, soap, paint, chalk, or ice

125
Q

NAME THREE EATING DISORDERS

A

Anorexia nervosa
 Bulimia nervosa
 Pica

126
Q

what are the oral effects of malnutrition (anorexia)

A

ulcers, dry mouth, infections and bleeding

127
Q

what are the oral effects of bulimia

A

dental erosion
oesophageal stricture - narrowing of oesophagus

128
Q

what are the oral effects of pica

A

fractured teeth, dentures and braces

129
Q

what is Principle 9: United Nations Basic Principles of the Treatment
of Prisoners

A

“Prisoners shall have access to
the health services available in
the country without
discrimination on the grounds of
their legal situation”

130
Q

what are the two types of homeless

A

roofless v homeless

131
Q

what is methadone

A

 Synthetic Opiate Analgesic

 Action on the CNS

 Absorbed from buccal mucosa & stomach

 Can lead to cessation of IV drug abuse – reduces risks of
Hep B, Hep C and HIV..?

132
Q

what is the methadone programme

A

Methadone is an opioid, like heroin or opium. Methadone maintenance treatment has been used to treat opioid dependence since the 1950s.14 The opioid dependent patient takes a daily dose of methadone as a liquid or pill. This reduces their withdrawal symptoms and cravings for opioids.

Methadone is addictive, like other opioids. However, being on methadone is not the same as being dependent on illegal opioids such as heroin:

It is safer for the patient to take methadone under medical supervision than it is to take heroin of unknown purity.
Methadone is taken orally. Heroin is often injected, which can lead to HIV transmission if needles and syringes are shared.
People are heroin dependent often spend most of their time trying to obtain and use heroin. This can involve criminal activity such as stealing. Patients in methadone do not need to do this. Instead, they can undertake productive activities such as education, employment and parenting

133
Q

methadone is a white powder that is mixed with a green syrup

this syrup is available in sugar free but not widely prescribed

the sugarfull alternative contains 50% sugar which is routinely prescribed however have implications on dental health

what are these implications

A

 High sugar content in syrup 50% = HIGH CARIES RISK

 Often Methadone ‘held’ in mouth to increase absorption
from buccal mucosa = HIGH CARIES RISK

 Opiate analgesic, therefore DECREASES salivary flow =
HIGH CARIES RISK

134
Q

70mls methadone contains how much sugar

A

35 gm sugar

135
Q

sedation and GA should be used with caution with drug users why?

A

potential for damage to heart, liver and kidneys

136
Q

what is disulfiram

A

Disulfiram is used to treat chronic alcoholism. It causes unpleasant effects when even small amounts of alcohol are consumed. These effects include flushing of the face, headache, nausea, vomiting, chest pain, weakness, blurred vision, mental confusion, sweating, choking, breathing difficulty, and anxiety

137
Q

what are the methadone taking advice

A

 Drink Methadone with a straw

 Try to take near a mealtime

 Swallow it immediately-don’t ‘hold’ in mouth

 Rinse with water afterwards

 Chew sugar free chewing gum to increase saliva

 Brush teeth BEFORE taking it! Or leave for a few hours
afterwards…

Dentistry year 4 - Module 8 (7 decks)

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