Anxiety control in dental patient

Anxiety control in dental patientIntroduction Advances in the treatment of paediatric diseases has led to an increase in the number of painful or distressing diagnostic or therapeutic procedures for which many children will need effective sedation or anaesthesia.The choice between sedation and anaesthesia will depend on the type of procedure. Some procedures are very common and healthcare providers and practitioners need to understand under which circumstances either sedation or anaesthesia is most cost effective.Introduction The aims of sedation during diagnostic or therapeutic procedures include reducing fear and anxiety, augmenting pain control and minimising movement. The importance of each of these aims will vary depending on the nature of the procedure and the characteristics of the patient.Sedation in children & young peopleDefinitions Age ranges This guideline covers infants, children and young people under 19 years. Infants: children from birth to 1 year. Neonates: infants aged up to 1 monthSedation in children & young people Levels of sedationMinimal sedation: A drug-induced state during which patients are awake and calm, and respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected. Moderate sedation: Drug-induced depression of consciousness during which patients are sleepy but respond purposefully to verbal commands (known as conscious sedation in dentistry, see below) or light tactile stimulation (reflex withdrawal from a painful stimulus is not a purposeful response). No interventions are required to maintain a patent airway. Spontaneous ventilation is adequate. Cardiovascular function is usually maintained.

Sedation in children & young peopleConscious sedation: Drug-induced depression of consciousness, similar to moderate sedation, except that verbal contact is always maintained with the patient. This term is used commonly in dentistry. Deep sedation: Drug-induced depression of consciousness during which patients are asleep and cannot be easily roused but do respond purposefully to repeated or painful stimulation. The ability to maintain ventilatory function independently may be impaired. Patients may require assistance to maintain a patent airway. Spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.

Sedation in children & young peopleSpecialist sedation techniques Sedation techniques that have a reduced margin of safety and increased risk of unintended deep sedation or anaesthesia, accompanied by airway obstruction and/or inadequate spontaneous ventilation. Healthcare professionals using specialist sedation techniques need to be trained to administer sedation drugs safely, to monitor the effects of the drug and to use equipment to maintain a patent airway and adequate respiration.PREOPERATIVE EVALUATIONThe preoperative evaluation is an important interaction between the dentist and the patient. This process allows the dentist to carefully evaluate the patients overall health status, determine risk factors for sedation, educate the patient, and discuss the procedure in detail. Of utmost importance is a detailed medical history.The aim of the history is to identify issues that demand attention and caution. Items that must be addressed are:

Sedation in children & young peoplePREOPERATIVE EVALUATIONAbnormalities of the major organ systems: cardiovascular, pulmonary, renal, hepatic, and endocrine.Drug allergies, latex allergy, current medications, and potential drug interactionsHistory of stroke or transient ischemic attack (TIA) (certain oral sedation methods may trigger a TIANeuromuscular disorders (such as muscular dystrophy) History of tobacco, alcohol, or substance use or abuse Pregnancy Previous adverse experience with sedation/analgesia as well as general anesthesiaMONITORING Patients receiving oral sedation must be monitored before, during, and after their procedure. During the procedure, monitoring detects early signs of patient distress such as alterations in oxygenation, pulse, and blood pressure.Hospital-type monitoring equipment is not necessary but continuous monitoring of pulse oximetry, heart rate, and blood pressure is mandatoryA pulse oximeter measures oxygen saturation and enhances the assessment of respiratory status while the individual is sedated.The most common and the most serious adverse outcome of conscious sedation is respiratory compromise and its related consequences.Any decrease in the pulse oximetry less than 96% should be addressed immediately.True desaturation is defined as a pulse oximeter reading of SpO2 less than 95% while the patient is quiet and still.However, with oral sedation apnea is rarely seen with normal dosing in the absence of airway obstruction. When it does occur, it is easily managed with stimulation, positive pressure ventilation, and supplemental oxygen administration.Oral sedation is intended to produce only a minimally depressed level of consciousness, and this level of consciousness must be monitored continuously. Responses to verbal commands during the procedure serve as the guide to the patients level of consciousness. An appropriate level of consciousness implies that the patient can control their own airway and take deep breaths as necessary. After administration of the sedative medication, response of the patient to verbal commands may be delayed, and responses are frequently slowed or slurred. At times, light tactile stimulation may be required to get the patients attention. However, once aroused the patient should respond appropriately to verbal commands. Level of consciousness should be assessed every 15 minutes.Oral Sedation: Agents and TechniquesFor adult and teenage patients the agents used most frequently for oral sedation are triazolam (Halcion) and diazepam (Valim)For any effect to take place, these drugs must be absorbed into the blood stream and delivered to the site of action, usually believed to be in the central nervous system, in sufficient quantities to be effective. The time from ingestion to sedation is therefore important.

Triazolam (Halcion) is a benzodiazepine derivative drug that is primarily only used as a sedative. It has hypnotic propertiespossesses, anterograde amnesia, anxiolytic, sedative, and anticonvulsant properties.Because of its fast onset of action and short half-life (approximately 24 hours) it has become a useful agent for oral sedation in dentistry.

Drug FactsThe main pharmacologic effects of triazolam are the enhancement of the neurotransmitter g-aminobutyric acid (GABA) at the GABAA receptor. It is lipophilic and is metabolized in the liver via microsomal oxidation or glucuronidation pathways and does not generate active metabolites. It has little effect on the circulatory or respiratory system, and several studies have shown no changes in blood pressure, pulse, or percentage of oxygen saturation and only a slight change in respiratory rate.Drug Facts Triazolam belongs to the pregnancy category X of the US Food and Drug Administration (FDA). This categorization means that it is known to have the potential to cause birth defects. Common side effects include coordination problems, dizziness, drowsiness, headache, light-headedness, nausea/vomiting, and nervousness.

Contraindications There are a few absolute contraindications to the use of triazolam; the main contraindications are hypersensitive to triazolam or other benzodiazepine drugs, patients with myasthenia gravis, patients with glaucoma, pregnant women, lactating mothers, and psychiatric patients.Office ProtocolNo alcohol or other sedatives should be consumed for 24 hours before the appointment.There should be no chance of young women being pregnant.The patient must have an adult escort to take them home after the appointment. They cannot drive, operate machinery, or undertake any activity that could be hazardous. No alcohol or other sedatives should be taken for 24 hours after the appointment. Use the nil-by-mouth guidelines The patient comes to the office 1 hour before the start of their dental procedure. Office ProtocolDosages range from 0.125 mg to 0.5 mg is administered (usually 0.25 mg). Have the patient observed by a trained staff member with instructions to alert the dentist if there are any problems or if the patient is snoring.If there is no sedation evident after 30 minutes, administer half the original dose.If even slight sedation is noted at 30 minutes, the patient has adequate sedation for the procedure. As the patient becomes drowsy, they should be casually walked to the treatment area. 75% of patients have amnesia from this point that lasts for 2 to 3 hours. It is common to this technique that the level of sedation may not seem adequate, but there is sufficient amnesia to allow them to forget most if not all of the appointment. Office protocolIf N2O-oxygen is to be used, it should be titrated to effect via a scavenged nasal hood system.Place blood pressure cuff and pulse oximetry probe.Administer local anesthesia slowly with a small-gauge needle at about 1 hour after administration of the initial sedative drug and wait for it to become effective.If a patient snores they may be oversedated and should be aroused by verbal commands or a gentle nudge.Try to limit the dental procedure to 1 hour.Keep the patient in the dental office until they are able to walk with a stable gait unassisted; have an adult take the patient home.

Diazepam (Valium)Diazepam, belongs to the benzodiazepine family and is a long-acting classic benzodiazepine. It is often considered the prototypical benzodiazepine and the grandfather of the drug class. As a rule of thumb, in higher doses diazepam acts as a sedative and may promote sleep, whereas in lower doses, it simply reduces anxiety without sedation. Diazepam possesses anxiolytic, anticonvulsant, sedative, hypnotic, skeletal muscle relaxant, and amnestic properties. It can be used in dentistry to reduce tension and anxiety and induce retrograde amnesiaThe pharmacologic action of diazepam enhances the effect of the neurotransmitter GABA by binding to the benzodiazepine site on the GABAA receptor, leading to central nervous system depression. The GABAA receptor is an inhibitory channel that, when activated, decreases neuronal activity and causes inhibitory processes in the cerebral cortex that have anxiolytic effects. When diazepam is administered orally, it is rapidly absorbed and has a fast onset of action (usually within 2040 minutes). The bioavailability after oral administration is 100%, and peak plasma levels occur between 30 minutes and 90 minutes after administration. It undergoes oxidative metabolism by demethylation and hydroxylation as well as glucuronidation in the liver as part of the cytochrome P450 enzyme system. Diazepam has several pharmacologically active metabolites. The main active metabolite of diazepam is desmethyldiazepam (also known as nordazepam or nordiazepam). Other minor active metabolites are temazepam and oxazapam. Because of these active metabolites, diazepam has a biphasic half-life of about 1 to 3 days and 2 to 7 days for the active metabolite

Because of these active metabolites, diazepam has a biphasic half-life of about 1 to 3 days and 2 to 7 days for the active metabolite desmethyldiazepam, which may result in prolonged action, causing daytime drowsiness and hangover for up to 48 hours. Advantages of diazepam are a rapid onset of action and high efficacy rates, like most benzodiazepines it also has a low toxicity in overdose. Diazepam by itself is safe, even in large doses.ContraindicationsUse of diazepam should be avoided in individuals with the following conditions: ataxia,acute narrow-angle glaucoma, severe liver deficiencies, severe sleep apnea, Myasthenia gravis, and anyone with hypersensitivity or allergy to any drug in the benzodiazepine class.Office protocolSame as outlined earlier.Dosages range from 5 mg to 10 mg (usually 5 mg, but 10 mg would also be acceptable for well-built men). Because of its long half-life (80 hours) the dosage should not be repeated.

Emergency & Reversal

As a group, benzodiazepines are the safest and most effective sedatives. Need for reversal has never been reported with standard oral doses of benzodiazepines in adults. The most common signs of overdosage are drowsiness, confusion, hallucination, and reduced reflexes. There are minimal effects on respiration, pulse, and blood pressure unless the overdosage is extreme.Management Flumazenil (Romazacon) 0.2 mg IV as initial dose; repeat 0.2 mg every 1-minute interval to a maximum of 1 mg.A single intraoral injection of flumazenil (0.2 mg) cannot immediately reverse oversedation with triazolam. A larger dose might be effective.12,13 There may be incomplete reversal by a single intraoral injection of flumazenil and the reversal may not persist. As a competitive receptor antagonist, flumazenil binds to the same site as the agonist triazolam. Although the clinical duration of triazolam administered as a single dose is comparable with that of flumazenil, research has shown that incremental dosing of this short-acting benzodiazepine results in long-lasting sedation that is dose-dependent13 and is not reversed with a single dose of flumazenil. Caffeine: 5 to 7 mg/kg for maximal effect. 50 to 100 mg produces a temporary increase in mental clarity and energy level and reduces drowsiness. Sources of caffeine are brewed coffee (a 6-oz [177-mL] cup is about 150 mg); Caffedrine capsules and NoDoz tablets (100 mg each); and Dexatrim and other diet pills have about 200 mg of caffeine in each pill. Give methylphenidate (Ritalin) 10 mg immediate-release tablet in severe somnolence. Repeat in 30 minutes if somnolence is prolonged. However, this strategy may increase hallucinations, precipitating Tourette-type syndrome. The half-life of Ritalin is 2 to 4 hours.Aside from overdosage, emergencies occurring during sedation almost always involve airway or respiratory compromise. An Ambu bag should always be available for assisting breathing, or some other device to administer positive pressure.The deeper the sedation, the higher the risk. The most common cause of airway obstruction is occlusion of the posterior oropharynx with the tongue. Simply lifting the chin to extend the head, stimulating the patient and telling them to breath most often resolves this issue. If the patient is very somnolent then supplementary oxygen may be given via a nasal hood.ORAL SEDATION IN CHILDRENOnly an appropriately trained and permitted dentist should administer oral sedation to children in an office setting. Sedation for children carries significant potential for adverse outcomes, and nearly all states require special training before a dentist can sedate a child. To be considered for oral sedation in the dental office setting, children should be only ASA 1 or ASA 2.The most serious adverse outcome of pediatric conscious sedation is respiratory compromise, which can lead to hypoxemia and predispose the child to a range of deleterious conditions. Because of this possibility, it is imperative that during the medical history special attention is paid to the respiratory system.\The most common acute medical condition affecting young children is the common cold (upper respiratory infection).The hypersecretion and edema associated with an upper respiratory tract infection can dramatically diminish the ability of the child to keep their airway clear, especially if they have received a sedative.In addition, N2O -oxygen administered via a nasal hood has little effect on the child with nasal congestion. In this instance, treatment should be deferred for 2 weeks from the cessation of symptoms. Apart from medical conditions, there are other issues that may not make the child a good candidate for oral sedation. The childs cooperative ability and willingness to take prescribed oral medication must be carefully assessed. Nausea and vomiting after oral intake of drug may occur and the sedation may be ineffective. To maintain safety and maximize the use of sedation time, the dentist should be able to complete the necessary dental treatment in less than 1 hour because sedation maybe effective for only 45 to 60 minutes.Midazolam is the ideal oral sedative for children. It is twice as potent as diazepam and is water soluble, making it easy to mix with juices for oral administration. Midazolam is also available premixed with cherry syrup. Unlike diazepam, midazolam has little if any hangover effect and its short half-life allows for a full recovery before discharge. Is a short-acting benzodiazepine and possesses most of the properties of the other benzodiazepines.It is available as midazolam hydrochloride syrup for oral administration to pediatric patients for sedation, anxiolysis, and amnesia and is intended for use only in monitored settings.Immediate availability of resuscitative drugs and age-appropriate and size-appropriate equipment for bag/valve/mask ventilation and personnel trained in their use should be assured. The dentist who uses this medication in pediatric patients must also be aware that the response to sedative agents in each child is variable and that regardless of the intended level of sedation a patient may move easily from light to deep sedation, with potential loss of protective reflexes.The recommended dose for pediatric patients is a single dose of 0.25 to 0.5 mg/kg, depending on the desired effect, up to a maximum dose of 20 mg.In general, it is recommended that the dose be individualized and modified based on patient age, level of pretreatment anxiety, and the level of sedation required. The younger (6 months to 6 years of age) and less cooperative patients may require a higher than usual dose up to 1 mg/kg. A dose of 0.25 mg/kg may suffice for older (6 to