Special Care Dentistry COPY Flashcards
what is conscious sedation
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.
what are the types of conscious sedation used
- inhalation
- intravenous
- oral
- intranasal - not widely used
the consent process regarding conscious sedation must be in what?
writing
what is used for inhalation sedation
use of nitrous oxide and oxygen
inhalation sedation is used as a mild sedation for what
mild anxiety
what are the indications of inhalation sedation
ability to breathe through nose
do not have a cold on day of treatmet
a drug that has anxiolytic affect means what?
A drug used to treat symptoms of anxiety, such as feelings of fear, dread,
what type of suggestion has known to be present with inhalation sedation
post hypnotic suggestion
what are the characteristics of nitrous oxide
- inhaled gas
- sweet smelling
- colourless
- heavy
why is nitrous oxide called laughing gas
Taking nitrous oxide can cause: feelings of euphoria, relaxation and calmness; fits of giggles and laughter
what is entonox
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.
what is the onset of Nitrous oxide
rapid
3-5 minutes
what barrier is crossed by nitrous oxide
crosses the blood brain barrier rapidly
what is the elimination speed for nitrous oxide
rapid
where is nitrous oxide metabolised
no significant metabolism by kidneys or liver
Nitrous oxide (a trace amount) is metabolized through reduction by anaerobic bacteria in the gut
nitrous oxide is not stored in the tissues thus having NO hangover effect
inhalation sedation overdose signs include?
headache
nausea
vomititng
what is hypoxia
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
what is diffusion hypoxia
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’
how do you treat diffusion hypoxia
100% oxygen administration should follow nitrous oxide cessation for 5 minutes
known as O2 flush.
what are the indications for inhalation sedation
- mild anxiety
- needle phobia
- patient not suitable for IV/GA
- straightforward dental treatment
what are the considerations for inhalation sedation?
Able to cooperate
- age
- learning disability
- cognitive impairment
- ability to tolerate mask
mask may impede access to anterior teeth
what are the considerations for inhalation sedation?
Able to cooperate
- age
- learning disability
- cognitive impairment
- ability to tolerate mask
mask may impede access to anterior teeth
what are the contraindications of inhalation sedation
- COPD
- Recent eye or ear surgery - Nitrous oxide anaesthesia in the presence of intraocular gas can cause irreversible blindness.
- Mask Intolerance
- 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
inhalation sedation requires the use of which equipment
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
what is the name of this equipment
Relative analgesia machine
what is the name of this equipment
inhalation mask
laughing gas users risk?
spine damage says doctors
possession of laughing gas to be
criminal offence
intravenous sedation is delivered as an injection most commonly which drug is used?
midazolam
what level of anxiety must you have to be considered for IV sedation
Mild-moderate
how is midazolam administered
administered in to the vein via cannulation
introduce a cannula or thin tube into (a vein or body cavity).
do you require a escort for Intravenous sedation
Yes
the escort is required to follow rules to keep patient safe
what is usually one of the side affects of IV sedation
Amnesia
what drug is required to reverse the use of midazolam
Flumazenil in a dose of 0.15 mg is a safe drug that reverses the sedative effect of midazolam
what are the indications of midazolam
- dental anxiety/phobia
- medically suitable
- social history
- unpleasant procedure
what are the contraindications for IV sedation
- needle phobia
- medical reasons
- social reasons
- pregnancy - sedation during the third trimester of pregnancy for surgeries not related to delivery of the baby
- poor venous access
what equipment is needed for IV sedation
- Midazolam
- Flumazenil
- Labels for syringes
- 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.
- pulse oximeter
- BP cuff and machine
- Tourniquet
how many micrograms of midazolam is in 5 ml
5 mg
how many micrograms of flumazenil is in 5 ml
500 mg
what factors can affect reading on a pulse oximeter
nail polish (dark)/gel/acrylic nails
finger tapping/playing with pulse oximeter
breath holding
cold hands
fasting - varies between units
what are the signs of overdose with IV sedation (midazolam)
- loss of protective reflexes
- loss of consciousness
- decreased respiration
- decreased heart rate
flumazenil is a reversal agent and it must be held in
stock
flumazenil rescue is considered a
never event
what is flumazenil
it is a benzodiazepine
what medication is usually given as oral sedation
usually midazolam
delivered as a drink
is oral sedation considered pre-med
not the same as pre-med
what must you do before you have given a patient midazolam as a form of oral sedation
must still cannulate for safety - rescue/reversal
must be proficient in IV technique
how long does it take for the effects of oral sedation to work
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.
what is premedication
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
what is a typical regimen for premedication with diazepam
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
diazepam is available in
2, 5, 10 mg tablets for oral use
diazepam has drug interactions with which drugs
Drug Interactions:-
Antibacterials - isoniazid inhibits metabolism. Rifampicin increases metabolism
Antivirals - Ritonavir
Proton pump inhibitors (PPIs) - Omeprazole
what are the indications for diazepam
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
what are the contraindications for diazepam
Hepatic impairment
Renal impairment
Pregnancy
Breast feeding
what are the cautions for the use of diazepam
Avoid prolonged use
Reduce dose in debilitated patients
Reduce dose in elderly
Respiratory disease
Patient compliance – taking at wrong time!
what benzodiazepines do we use for sedation
diazepam - premed
temazepam - predmed
midazolam - conscious sedation
flumazenil - reversal agent
what are the features of benzodiazepines
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
benzodiazepines have a amnesia affect on patients when is most intense
amnesia most intense with IV sedation
what is anterograde amnesia
Anterograde amnesia (AA) refers to an impaired capacity for new learning.
what are features of muscle relaxation of benzodiazepines
central effect
depression of spinal reflex activity
partly responsible for respiratory depression
reduces trismus
what are the short term side effects of benzodiazepines
Drowsiness
Dizziness
Reduced concentration and coordination
Hypotension
Respiratory Depression
Sexual fantasy
what are the long term side effects of benzodiazepines
tolerance
dependence
withdrawl symptoms
what doses are needed for elderly people who require benzos
low doses
what is a paradoxical reaction
A paradoxical reaction happens when a person experiences the opposite of what the drug is intended to do.
Sedation standards and guidance
IACSDS
interollegiate
advisory
committee for
sedation in
dentistry
standards
SDCEP Third Edition
conscious sedation in dentistry
what is the definition of General Anaesthesia (GA)
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.
who carrys out GA
An anaesthetist uses a
combination of medicines to allow medical procedures to be
carried out, that would otherwise be intolerable to the patient
what are the indications for GA
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
what are the advantages of GA
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
what type of consent is needed when undergoing GA
‘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
what are the disadvantages/limitations of GA
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
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
Level of sedation
Minimal sedation:
Anxiolysis, retains patient’s ability to respond normally to stimulation and verbal command.
level of sedation
moderate sedation:
Conscious sedation, depression of consciousness, patients respond purposefully to verbal commands
level of sedation
deep sedation:
nearly unconscious, only has purposeful response to repeated and painful stimulation.
Level of sedation
General anaesthesia:
completely unconscious, does not respond to any level of pain. The patient will require breathing assistance and cardiovascular function may be impaired
when is amnesia the most intense with benzos
intense for first 20/30 mins
how do benzos affect the spine
depression of spinal reflex activity
how does patient recover from sedation
- Redistribution of the drug from CNS into body fat
- Uptake and metabolism of the drug by the liver and elimination by the kidneys
Redistribution is responsible for the initial recovery from sedation, the alpha half-life, the time taken for the serum concentration to drop by
50%, followed by
Elimination of the remaining drug, the beta half-life, time taken to remove half the drug from the body.
how do benzos defer Pharmacodynamically
affinity for receptors
half life
active metabolites
benzos mechanism of action
Chloride ions enter the cell making the resting membrane potential more negative.
what is the half life of diazepam
30 hours
why is diazepam no longer used for IV sedation
The organic solvent caused vein damage: pain, thrombophlebitis, skin ulceration.
why do we not use diazemuls (Emulsified into suspension of soya bean oil)
Long recovery period and possibility of rebound sedation means it is not well suited to short dental procedures
what is the pH of midazolam
Water soluble
pH<4.0 and non-irritant to veins
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
currently, 10mg maximum in the clinic
what is the maximum course for midazolam for elderly
3.5mg per course
what happens to midazolam once it is in the blood stream.
Once in the bloodstream it becomes lipid soluble at physiological pH.
this allows it to readily penetrate the blood-brain barrier
what is the half life of midazolam
elimination half life of 1.9 hours +/- 0.9 hours
complete recovery quicker than diazepam
why do you need slowly inject midazolam?
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
Once reached end point don’t give any more midazolam why
Every time you add an increment of drug, the half-life starts again with that dose increment and a dangerous accumulation can build up.
why do you want to avoid Erythromycin/Clarithromycin (antibiotic): when taking midazolam
Markedly increase the exposure to Midazolam.
Severe. Avoid
why do you want to avoid
Atazanavir/Darunavir/Fosamprenavir/Ritonavir (Antiviral, HIV):
Markedly increase the exposure to Midazolam. Severe. Avoid
why do you want to avoid
Fluconazole/Isavuconazole/Itraconazole/Ketoconazole (Antifungal):
Markedly increase the exposure to Midazolam. Severe. Monitor the adverse effects and adjust dose
why do you want to avoid
Imatinib/Idelalisib/Nilotinib/Rucaparib (Anticancer):
Markedly increase the exposure to Midazolam. Severe. Avoid or adjust dose
Side effects of Benzodiazepines
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
benzos with breastfeeding
small amount present in milk-avoid feeding for 24 hours after administration
in acute emergency how much flumazenil can be given
500 micro grams
what is the maximum total dose of flumazenil
1 mg
Local Anaesthetic creams for hands/arms
EMLA cream
Ametop gel
it is estimated that it cost how much a year to tackle substance abuse in sctoland
2.6 bn
what is scotlands 5 most common drugs used
Cannabis
Cocaine
Ecstasy
Amphetamines
Heroin
what percentage of adults use cocaine in scotland
3.8% the most in the world
2010
what is Cocaethylene
cocaine mixed with alcohol taking it is greater than x3 alcohol consumption
every time you take cocaine how many more times likely are you to have a heart attack
24
drugs are categorised in to two groups based on function
stimulants (uppers)
depressants (downers)
what drugs fall in to the stimulants drug categories
- caffeine
- nicotine
- cocaine
- amphetamine
- ecstasy
what drugs fall in to the depressants drug categories
- alcohol
- solvents
- heroin
- morphine
- benzodiazepines
what drugs fall in to the hallucinogenics categories
LSD
Magic Mushroom
Cannabis
Two main statutes relating to drugs in the UK
The Medicines Act, 1968
The Misuse of Drugs Act, 1971
Misuse of Drugs Act, 1971
Class A drugs include
Heroin
Cocaine (including crack)
Methamphetamine
Ecstasy
Methadone
Misuse of Drugs Act, 1971
Class B drugs include
Amphetamines
Cannabis*
Misuse of Drugs Act, 1971
Class C drugs include
Benzodiazepines
Ketamine
Anabolic Steroids
where does heroin come from
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
what are the positive affects of opiates
Initial euphoria
Removal of Tension
Tranquility
Sense of Control
Detachment from worries, fears
Analgesia
what are the negatives of opiates
Itching
Flushing
Myosis
Appetite Suppression
Slurred Speech
Slow Gait
Depression
Constipation
whats the difference between neurosis and psychosis
neurosis - contact retained with reality
psychosis - contact lost with reality
what is neurosis
Functional mental disorder, without
delusions or hallucinations. Behaviour is not
out with socially acceptable norms.
Anxiety
Phobic
Obsessional
Hypochondriacal
Depressive
what is functional psychoses
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
what is the most severe form of functional psychosis
schizophrenia
what is pica
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
NAME THREE EATING DISORDERS
Anorexia nervosa
Bulimia nervosa
Pica
what are the oral effects of malnutrition (anorexia)
ulcers, dry mouth, infections and bleeding
what are the oral effects of bulimia
dental erosion
oesophageal stricture - narrowing of oesophagus
what are the oral effects of pica
fractured teeth, dentures and braces
what is Principle 9: United Nations Basic Principles of the Treatment
of Prisoners
“Prisoners shall have access to
the health services available in
the country without
discrimination on the grounds of
their legal situation”
what are the two types of homeless
roofless v homeless
what is methadone
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..?
what is the methadone programme
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
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
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
70mls methadone contains how much sugar
35 gm sugar
sedation and GA should be used with caution with drug users why?
potential for damage to heart, liver and kidneys
what is disulfiram
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
what are the methadone taking advice
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…
