Pharmacological Techniques of Behaviour Management

Behaviour Management

• Definition: The means by which dental health team effectively and efficiently performs treatment for a child and at the same time instills a positive dental attitude. (WRIGHT, 1975)

Pharmacological Methods

• Conscious Sedation: A minimally depressed level of consciousness that retains the patient's ability to independently and continuously maintain airway and respond appropriately to physical stimulation or verbal command.
  • Minimal Sedation (Anxiolysis): A drug-induced state during which patients respond normally to verbal commands.
  • Moderate Sedation: A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation.
  • Deep Sedation: A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation.
• Premedication: The prescription of a small anxiolytic dose of a sedative, taken by the patient outside the surgery environment, to reduce anxiety about attending their appointment or to aid sleep on the evening of the appointment.
• General Anesthesia: A drug-induced loss of consciousness during which the patients are not arousable even by painful stimulation.

Objectives of Sedation in Pediatric Dentistry

• For the Child:
  • Reduce fear and perception of pain during treatment.
  • Facilitate coping with the treatment.
  • Minimize physical discomfort and pain.
  • Control behavior or movement to allow safe completion of procedure.
• For the Dentist:
  • Accomplishment of dental procedures.
  • Reduce stress in an unpleasant emotion.
  • Prevent burnout syndrome.

Indications for Sedation

• Fearful/anxious patient for whom basic behavior guidance techniques have not been successful.
• Patient unable to cooperate due to lack of psychological or emotional maturity and/or mental, physical, or medical disability.
• To protect patient's developing psyche.
• To reduce patient's medical risk.

Conscious Sedation

• Definition: A technique in which the use of a drug or drugs produces a state of depression of the central nervous system (CNS) enabling treatment to be carried out, but during which verbal contact with the patient is maintained throughout the period of sedation.
• Indications:
  • Dental phobia and anxiety.
  • Traumatic and long dental procedures.
  • Medical conditions aggravated by stress.
  • Children more than 1 year of age.
  • Mentally challenged individuals.
  • Ineffective local anesthesia due to any reason.

Contraindications to Sedation

• Medical conditions affecting cooperation (e.g. severe learning difficulties).
• Medical conditions affecting sedation (e.g. any patient rated ASA III or worse should not be sedated outside a specialist facility).
• Dental contraindication to sedation (lengthy or difficult procedures are best managed under GA).
• Psychological contraindication to sedation (patients who refuse to give their consent to sedation).

Ideal Qualities of a Sedative Agent

• Both sedative and analgesic effects.
• Easy and acceptable method of administration.
• Easy titration.
• Minimal cardiovascular side-effects.
• Minimal respiratory side-effects.
• Rapid onset of action.
• Rapid recovery.
• No accumulation in renal/hepatic dysfunction.
• Inactive metabolites.
• Inexpensive.
• No interactions with other drugs.

Agents Commonly Used for Sedation

• Gases: Nitrous oxide.
• Antihistamines: Hydroxyzine, promethazine, diphenhydramine.
• Benzodiazepines: Diazepam, midazolam.
• Barbiturates: Seconal, pentobarbital.
• Chloral hydrate.
• Narcotics: Meperidine, fentanyl.

Nitrous Oxide Inhalation Sedation

• Definition: A technique in which the use of nitrous oxide gas produces a state of depression of the central nervous system (CNS) enabling treatment to be carried out, but during which verbal contact with the patient is maintained throughout the period of sedation.
• Characteristics:
  • Sweet-smelling, colorless, inert gas (laughing gas).
  • Anxiolytic and sedative properties with varying degree of analgesia and muscle relaxation.
  • Affects both GABA A and NMDA receptors.
• Objectives:
  • Reducing or eliminating anxiety.
  • Reducing untoward movement and reaction to dental treatment.
  • Enhancing communication and patient cooperation.
  • Raising the pain threshold.
  • Increasing tolerance for longer appointments.
  • Aiding in the treatment of a patient with mental and/or physical disabilities or a medically compromised patient.
  • Reducing gagging.
  • Potentiating the effects of sedatives.

Contraindications to Nitrous Oxide Inhalation Sedation

• Common cold.
• Tonsillitis and otitis media.
• Nasal blockage.
• Patients with porphyria.
• Severe psychological disorders and nasal hood phobia.
• Maxillofacial deformities that prevent nasal hood placement.
• Inability to cooperate or understand.
• Myasthenia gravis and multiple sclerosis.

Equipment for Nitrous Oxide Inhalation Sedation

• Machine should be of the continuous flow design, with flow meters capable of accurate regulation.
• Fail-safe mechanism with automatic shutdown if O2 falls below 20%.
• Audible and visual alarm activated by O2 failure.
• Color coding for gases.
• Efficient scavenger system.
• Nasal hoods of good design and suitable sizes.

Preparation for Conscious Sedation

• Consent for treatment: Valid informed consent is necessary for all patients receiving dental care under conscious sedation.
• Pre-sedation checkup:
  • Patient's detailed history and examination are performed so as to classify according to the American Society of Anesthesiologists (ASA) classification.
  • Only patients who satisfy the criteria of ASA Grade I and II should be considered for sedation in dental surgery outside hospital.

Clinical Technique for Nitrous Oxide Inhalation Sedation

• Mask of appropriate size should be introduced to the patient with an explanation delivered at the appropriate level of understanding.
• Traditional behavior guidance techniques should be used.
• 100% O2 is delivered to the patient for 2-3 minutes at 4-6 liters per minute.
• Nitrous oxide can be introduced by slowly increasing the concentration in increments of 10% to 20% until the desired level is achieved.
• Encourage the patient to breathe through the nose with the mouth closed.
• Communicate with the patient throughout the procedure, paying particular attention to the rate and depth of breathing.
• Recovery can be achieved quickly by reverse titration.
• Once the flow of nitrous oxide is reduced to zero, the patient should be allowed to breathe 100% oxygen for 3–5 minutes to prevent diffusion hypoxia.

Signs of Sedation

• Tingling in the fingers and toes (parasthesia).
• Reduced body and facial tension.
• Reduced frequency of eye blinking.
• Slowed responses.
• Laughing/giggling.
• Glazed eyes.
• Relaxed feet.
• Euphoria.
• Warmth.
• Feelings of lightness and/or heaviness.
• Feelings of temperature change.
• Floating or melting sensations.
• Dissociation.
• Day-dreaming.
• Change of mood.