Pharmacological Techniques of Behaviour Management PDF

Pharmacological Techniques of Behaviour Management Presented By: dr.mohira Ezzeldin Behavior management : Is 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...

Pharmacological Techniques of Behaviour Management Presented By: dr.mohira Ezzeldin Behavior management : Is 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  Premedication  General Anesthesia Conscious Sedation : A minimally depressed level of consciousness that retains the patients 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. The ability to independently maintain ventilatory function may be impaired Premedication: is the prescription of a small anxiolytic dose of a sedative, to be taken by the pt. outside the surgery environment, to reduce the pt. anxiety about attending their appointment, or to aid sleep on the evening of the appointment. It is frequently an adjunct to a further form of sedation.  General Anesthesia : A drug induced loss of consciousness during which the patients are not arousable even by painful stimulation. The ability to maintain ventilatory function is often impaired.  Objectives of sedation in pediatric dentistry For the child 1. Reduce the fear and perception of pain during treatment. 2. Facilitate coping with the treatment. 3. Minimized physical discomfort and pain. 4. Controlled behaviour or movement so as to allow safe completion of procedure.  For the dentist 1. accomplishment of dental procedures. 2. Reduce stress in an unpleasant emotion 3. Prevent burn out syndrome. Indication 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  “Conscious sedation is 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. The level of sedation must be such that the patient remains conscious, retains protective reflexes, and is able to understand and respond to commands. The drug used should carry a margin of safety sufficient to render unintended loss of consciousness extremely unlikely.  Indications: Dental phobia and anxiety Traumatic and long dental procedures Medical conditions aggravated by stress such as angina, asthma and epilepsy Children more than 1 year of age Mentally challenged individuals Ineffective local anesthesia due to any reason Contraindication 1. Medical conditions affecting cooperation e.g severe learning difficulties. 2. Medical conditions affecting sedation e.g. any pt. rated ASA III or worse should not be sedated outside a specialist facility. 3. Dental contraindication to sedation: lengthy or difficult procedures are best managed under GA. 4. Psychological contraindication to sedation: pts who refuses to give their consent to sedation. The ideal qualities of a sedative agent are:  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: 1-Gases: nitrous oxide. 2-Antihistamines: hydroxyzine, promethazine,diphenhydramine. 3-Benzodiazepines: diazepam,midazolam. 4-Barbiturates:seconal, pentobarbital. 5-Chloral hydrate. 6-Narcotics: meperdine, fentanyl. Considerations:- -Age. -Degree of surgical trauma. -Anxiety. -Complexity of the procedure. -Medical status.  The routes of administration of sedative drugs used in clinical pediatric dentistry are: Inhalational.(highly effective , instantaneous absorption of agents, easily titrated ). Oral. intravenous (IV). Intramscular. transmucosal (e.g. nasal, rectal, and sublingual). Nitrous oxide inhalation sedation is considered to be the standard conscious sedation technique.  Inhalational Sedation Nitrous oxide:  Is sweet-smelling, colorless, inert gas (laughing gas). It has anxiolytic and sedative properties with varying degree of analgesia and muscle relaxation.  Affect both gamma-aminobutyric acid type A (GABA A) and N-methyl-D- aspartate (NMDA) receptors.. It involves the inhalation of an oxygen–nitrous oxide gas mixture in relatively low concentrations, usually 30–50% nitrous oxide. Although nitrous oxide gas is well noted for its mild analgesic and anaesthetic properties, LA is still required for dental procedures. It has rapid onset and recovery time. The operator is able to titrate the gas against each individual patient. Optimum concentration is 30-50% N2O. N2O is considered to be inert and nontoxic when it is administered with adequate O2. exhaled unchanged through lungs.  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 :  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 Nitrous oxide inhalation sedation equipment is used solely for dentistry and is either wall-mounted or portable. -The machine should be of the continuous flow design, with flow meters capable of accurate regulation. -A fail-safe mechanism with automatic shutdown if O2 falls below 20%. -Audible and visual alarm activated by O2 failure. -Colour coding for gases. -Efficient scavenger system. -Nasal hoods of good design and suitable sizes. Before starting sedation the following checks must be made: ‘in use’ and ‘full’ gas cylinders correctly identified and labelled; oxygen fail-safe system confirmed to be working; reservoir bag, tubing, and nasal hoods checked for leakage; scavenging and ventilating system switched on; emergency equipment and drugs available; other equipment (e.g. radiography equipment and dental instruments) to hand so that the dental nurse does not need to leave the surgery.  Preparation for Conscious Sedation Consent for treatment: Valid informed consent is necessary for all patients receiving dental care under conscious sedation, and this should be confirmed in writing 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. For pediatric patients, it is recommended that only the ASA Grade I patients are sedated outside a hospital environment. Fasting is not required for nitrous oxide–oxygen sedation.  Clinical Technique:  The mask of appropriate size should be introduced to the patient with an explanation delivered at the appropriate level of understanding, and carefully placed over the patient’s nose.  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.(prevent diffusion hypoxia) The patient should be allowed to remain in the sitting position for a brief period to ensure against dizziness upon standing.  The patient is then ready for discharge. 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 A phenomenon termed diffusion hypoxia may occur as the sedation is reversed at the termination of the procedure. Due to its insoluble nature N2O will rapidly leave the blood stream once the concentration is reduced, and if the inspired conc. Of N2O is high, then a large amount of the gas will escape into the alveoli with such rapidity that the oxygen present becomes diluted; thus the oxygen–carbon dioxide exchange is disrupted and a period of hypoxia is created. Environmental pollution There is concern about the effect of environmental pollution with nitrous oxide on dental staff:. Neurotoxicity.  sexual and reproductive problems. hepatotoxicity. renal dysfunction. So scavenging system is very important and those that incorporate a scavenging nasal mask are recommended.