Pain and Anxiety Modules 1-9

Pre-Anesthetic Assessment Evaluation Includes

-Complete medical/dental history

-Physical exam

-Psychological exam

Medical/dental history includes:

-current conditions

-past conditions

-OTC drugs and supplements

-adverse reactions to meds

-problems with previous dental treatment

Concomitant medications

2+ medications taken on the same day

Physical exam includes:

-visual exam

-take BP

-take pulse and respiratory rate

-record patient's weight

BP of 140-159/90-94

Consider N2O for stress reduction

BP of 160-199/95-114

retake; refer for medical consult before treatment

BP of >200/>115

retake; refer for immediate medical consult

Acceptable HR for adults

60-100

Acceptable HR for children

75-100

Acceptable HR for toddlers

120-160

Acceptable RR for adults

12-20

Acceptable RR for children

18-30

Acceptable RR for toddlers

25-32

Overweight children have what effect on their MRD?

Lowered MRD

Psychological examination includes

-eval dental phobia

-clinical signs of moderate anxiety

-stress reduction protocol

Dental phobia

unfounded fear of dental treatment; associated with traumatic past dental treatment

Clinical signs of moderate anxiety

-stiff posture

-nervous play

-white knuckle syndrome

-sweating

-too cooperative

-nervous conversation

-quick answers

Stress reduction protocol

-adequate pain control

-decrease pain of an injection

-select LA of appropriate duration

Risk assessment ABCs:

A- antibiotics, anesthesia, anxiety, allergy

B- bleeding

C- chair positioning

D- drugs, devices

E- equipment, emergencies

What percent of people avoid the dentist due to fear?

6-14%

Fear

Short lived, disappearing when the threat or danger passes

Anxiety

Not eliminated easily and tends to be learned response from personal experience/experience of others

White knuckle syndrome is common amongst what group of patients?

Men

Men show ___ signs of anxiety while women express anxiety ____

physical; verbally

Iatrosedation

technique of communication between the dentist and the patient that creates a bond of trust and confidence

Nondrug psychosedative techniques

Hypnosis, acupuncture, audioanalgesia, etc

Minimal sedation

-Retains patient's ability to independently and continuously maintain and airway and respond appropriately to physical/verbal stimuli

-Ventilatory/cardiovascular functions are unaffected

-Margin of safety wide enough to never cause loss of consciousness

Moderate Sedation

-Patients respond purposefully to verbal commands, either alone or by light tactile stimuli

-Spontaneous ventilation is adequate but cardiovascular function is usually maintained

-Margin of safety wide enough so that unintended loss of consciousness is unlikely

-Repeated dosing before the effects of previous dosing can be fully appreciated may result in greater alteration of the state of consciousness

Deep sedation

-Drug induced depression of consciousness during which patients cannot be easily aroused but respond to repeated or painful stimuli

-Patients may require maintaining a patent airway but cardiovascular function is usually maintained

General Anesthesia

-Drug induced loss of consciousness where patients cannot be aroused

-Ability to maintain ventilatory function is impaired

-Require maintaining a patent airway and positive pressure ventilation because of depressed neuromuscular function

-Cardiovascular function may be impaired

Maximum ADA level of sedation of a licensed dentist

Minimal sedation

When is patient monitoring required for sedation?

For any level above minimal sedation

Most popular drugs for anxiety management in dentistry?

Benzodiazapenes

Drugs for anxiety management are all ____

CNS depressants

Most common oral anxiety management drugs

Diazepam and triazolam

Most common IV sedation agents

Diazepam (valium) and midazolam (versed)

What are diazepam and midazolam good choices for?

Moderate IV sedation for procedures 60 minutes or less

What drug has amnesic properties and lack of rebound effect?

Midazolam

Nitrous oxide documentation MUST include:

-informed consent

-percentage of N2O administered

-length of time patient was sedated

-flow rate of gases during administration

Nitrous oxide documentation SHOULD include

-indication for use of N2O

-patient response and tolerance

N2O rapid onset time

2-5 minutes

Nitrous's low solubility in blood causes

rapid onset

How is nitrous excreted through the lungs?

Unchanged because it is insoluble in blood

How does nitrous effect HR and BP?

No effect

Nitrous is equivalent to a therapeutic dose of ___

morphine

Can nitrous cross the BBB or placenta?

Yes

Indications of use for nitrous:

-Patients with anxiety

-Patient with a tendency to faint

-Patients with a strong gag reflex

-Medically compromised patients (angina pectoris, post myocardial infarction, post cardiovascular arrest)

-Long procedures

-Inadequate LA

ABSOLUTE contraindication of nitrous:

-nasal obstruction

-Vit B12 deficiency

-alcoholic/recovering addict

-uncommunicative

RELATIVE contraindications to nitrous:

-ear infection

-balance disorder

-motion sickness

-claustrophobia

-pulmonary diseases

-immunocompromised

-pregnancy

-psychiatric disorders

-use of hallucinogenic/marijuana

Two most common side effects of nitrous

Nausea and vomiting

What can long-term exposure to nitrous cause?

-bone marrow suppression

-reproductive system disturbances

-neurological deficits

-hepatotoxicity

On N2O equipment green indicates

oxygen

On N2O equipment blue indicates

Nitrous oxide

What can the flush button be used for?

Fills reservoir bag with oxygen to provide quickly to combat over-sedation

What should you start with when administering N2O?

5-6L/min of 100% O2

After inflating resevoir bag what do you do next?

Place appropriately sized nasal hood and tighten

In what intervals do you adjust the flow rate to titrate N2O-O2?

10% while watching for signs of sedation

What typical titration does a patient require?

50% N2O - 50% O2

What do you titrate to once treatment is completed?

N2O to zero and increase O2 to 100% for 5 minutes to re-establish flow rate?

Why do you re-establish flow rate for 5 minutes after the treatment is completed?

Prevents diffusion hypoxia which causes the hangover effect

Can you leave a patient unattended when administering N2O?

NO

CNS

Brain and spinal cord

PNS

12 cranial nerves and 31 pairs of spinal nerves

How are CNS and PNS categorized

Afferent and efferent

What information is afferent

sensory

What information is efferent

Motor

PNS is divided into

-somatic

-autonomic

-sympathetic

-parasympathetic

3 functions of neurons

-receive information

-process information

-send information

Structural components of neurons

-cell body

-one axon

-1+ dendrites

Function of neuronal axon

Carries impulse away from cell body

Function of neuronal dendrites

Carries impulse to cell body

Synaptic knob

terminal end of an axon and allows impulse to travel to another neuron via neurotransmitters

Nerve

many axons, an artery, a vein

Where are nerves found?

PNS

How are nerves categorized?

-afferent

-efferent

-mixed

Endoneurium

connective tissue around an axon

Fascicle

group of axons

Perineurium

connective tissue around one fascicle

Epineurium

connective tissue around a group of fascicles

Saltatory conduction

nerve impulse jumping from node to node (only in myelinated cells)

Type A fibers

-largest fibers so fastest conduction

-myelinated

-afferent or efferent

Subtypes of type A fibers

-Aa (alpha)

-Ab (beta)

-Ay (gamma)

-Ad (delta)

Which subtype A fiber is the largest, fastest, efferent, controls muscle movement

A alpha

Which subtype A fiber is afferent and involved with proprioception, touch, and pressure?

A beta

Which subtype A fiber is efferent and associated with muscle tone?

A gamma

Which subtype A fiber is afferent and associated with pain and temperature?

A delta

Type B fibers

-slightly myelinated

-efferent

-preganglionic ANS and vascular smooth muscle

Type C fibers

-smallest and unmyelinated

-most numerous

-afferent and efferent

-responsible for dull, achy pain

The oral cavity has an increased number of what fiber types?

A and C

Which fiber types require more anesthetic volume?

Type A

What is the voltage gradient of the resting membrane maintained by?

Sodium-potassium pump

Another term for nerve impulses

action potentials

Can nerve impulses have different strengths?

No, generated by all or none

How do nerve impulses travel amongst neurons?

By crossing a synapse

How long does it take for a nerve impulse to pass through a neuron?

7 milliseconds

In resting state the membrane of a neuron is

polarized

The inside of the cell is (negatively/positively) charged

negatively

What kind of ions are there more of outside of the cell?

Sodium

Resting membrane potential

-70 mV

How does the neuron maintain RMP polarization?

-sodium-potassium pump

-closed K+ channels

-closed Na+ channels