Pharmacological methods of behaviour management

PHARMACOLOGICAL METHODS OF BEHAVIOUR

MANAGEMENT

Presented By- Yashkumar R. Shah

Final Year – II

Contents

Introduction

Definitions

Pharmacological Methods

Objectives of Sedation in Pediatric Dentistry

Indication and Contraindication

Clinical Guidelines for use of Conscious Sedation by Dentist

Routes of administration with drugs

Nitrous oxide sedation

Reversal agents

Premedication

General Anesthesia

Complications associated with moderate and deep sedation

Conclusion

References

INTRODUCTION

BEHAVIOR MANAGEMENT-

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)

DEFINITIONS

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

that is produced by a pharmacological or non pharmacological method or a combination thereof.

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.

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.

Minimal Sedation : (Anxiolysis)

A drug induced state during which patients respond normally to verbal commands

BEHAVIOUR MANAGEMENT

PHARMACOLOGICAL NONPHARMACOLOGICAL

PHARMACOLOGICAL METHODS

Conscious Sedation

Premedication

General Anesthesia

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. Facilitate accomplishment of dental procedures.

2. Reduce stress in an unpleasant emotion

3. Prevent burn out syndrome.

Indications Contraindications

Children with low coping ability Very young children

Behaviour management problems Intellectually challenged children

Dental fear and anxiety Hyper motive/obstinate children

A patient whose gag reflex interferes

with the dental care

Systemic diseases like respiratory

distress, Neuromuscular disorders etc.

Certain patients with special healthcare

needs

Clinical guidelines for use of conscious sedation by dentist(according to ADA,2012)

1. Patient evaluation.

2. Preoperative preparation.

3. Personnel and equipment requirements.

4. Preparation and setting up for the sedation procedures.

5. Monitoring during sedation.

6. Recovery and discharge.

ASA Physical Status Classification System

ASA Physical Status 1- A normal healthy patient

ASA Physical Status 2- A patient with mild systemic disease

ASA Physical Status 3- A patient with severe systemic disease

ASA Physical Status 4- A patient with severe systemic disease that is a constant threat to life

ASA Physical Status 5- A moribund patient who is not expected to survive without the

operation

ASA Physical Status 6- A declared brain-dead patient whose organs are being removed for

donor purposes

Preoperative preparation

Determination of adequate oxygen supply and equipment necessary to deliver oxygen under

positive pressure must be completed.

Baseline vital signs must be obtained

Preoperative dietary instructions.

Personnel and equipment requirements

Atleast 1 additional person trained in Basic Life Support for Healthcare providers must be

present in addition to dentist.

A Positive pressure oxygen delivery system suitable for the patient being treated must be

immediately available.

Preparation and setting up for sedation procedures

SOAPME

S – Size appropriate suction cathethers and a

functioning suction apparatus.

O – Adequate oxygen supply and functioning

flow meters

A – Appropriate size airway equipment

P – Pharmacy

M – Monitors

E – Special Equipments or drugs

Monitoring during sedation

Oxygenation

Ventilation

Circulation

Recovery and discharge criteria

Cardiovascular function and airway patency are satisfactorily stable.

Patient is easily arousable,

Patient can talk

ROUTES

DRUGS USED

N2O sedation

Horace Wells was an American dentist who pioneered the use of anesthesia in dentistry,

specifically nitrous oxide (laughing gas).

N2O sedation

INTRA VENOUS

INTRA MUSCULAR

ORAL

INHALATION

Inhalational Agents

Benzodiazepines

Other Agents With Sedative Properties

Nitrous oxide/oxygen has been shown to be an effective anxiolytic and sedative inhalation

agent for conscious sedation.

Nitrous oxide is a weak analgesic, most often insufficient to ensure painless dental

treatment.

Nitrous oxide /oxygen sedation and local anesthesia is an alternative to general anesthesia

Nitrous oxide/oxygen should be the first choice for paediatric dental patients who are unable

to tolerate treatment with local anesthesia alone and who have a sufficient level of

understanding to accept the procedure.

It may be offered to children with mild to moderate anxiety to enable them to better accept

treatment which may require a series of visits.

It can also facilitate the provision of more complex time consuming procedures and dental

extractions particularly for young children or anxious patients undergoing elective

orthodontic extractions.

Typically delivered through a mask over the nose, nitrous oxide is mixed directly with

oxygen and delivered as the patient breathes in and out regularly.

The patient is usually asked

to breath normally through the nose,and as the gas begins to take effect, the child will be

come more relaxed and less nervous.

The gas mixture shall contain a maximum 50% nitrous oxide.

•Nitrous oxide/oxygen is reliable in terms of onset and recovery as long as the patient

accepts the nasal hood and breathes through the nose.

•Nitrous oxide has minimal effect on cardiovascular and respiratory function as well as on

the laryngeal reflex.

Indications

A fearful or anxious patient.

Certain patients with special health care needs.

patient whose gag reflex interferes with dental care.

patient for whom profound local anesthesia cannot be obtained.

cooperative child undergoing a lengthy dental procedure.

Contraindications

Pre-co-operative children

Patients with upper airway problems as common cold, tonsillitis

or nasal blockage

Patients with sinusitis or recent ENT operations (within 14 days)

Patients in bleomycin chemotherapy

Psychotic patients

Patients with porphyria

PROCEDURE

Selection of an appropriately sized nasal hood should be made.

A flow rate of 5-6L/min generally is acceptable to most patients.

Introduction of 100%oxygen for1-2minutes followed by titration of nitrous oxide

in10%intervals is recommended.

During nitrous oxide/oxygen analgesia/anxiolysis,the concentration of nitrous oxide should

not routinely exceed50%.

Nitrous oxide concentration may be decreased during easier procedures(eg,restorations)and

increased during more stimulating ones(eg,extraction,injection of local anesthetic

During treatment, it is important to continue the visual monitoring of the patient’s respiratory

rate and level of consciousness.

The effects of nitrous oxide largely are dependent on psychological reassurance. Therefore,

It is important to continue traditional behaviour guidance techniques during treatment.

Once the nitrous oxide flow is terminated, 100%oxygen should be delivered for five minutes

due to risk of diffusion hypoxia.

The patient must return to pre treatment responsiveness before discharge

Clinical signs of sedation -

Objective Signs -

1. These signs recorded prior to and 5 minutes after administration .

2. The following signs were examined –

open or closed eyes, tears, smile, speaking, laughing, open or closed hands , limp legs,

abducted feet.

Subjective symptoms -

1. These are addressed the child’s perception of nitrous oxide effects.

2. Questions regarding the child’s perception of nitrous oxide effects on the head

,abdomen,fingers,toes,and overall condition were asked prior to 5 minutes after

administration.

3. The questions were how do you feel,do you feel different ,how does your head feel ,how do

your fingers feel.

Side effects

Over sedation

Nausea

Vomiting

Panics

Sweating

Headache

Restlessness

Dysphoria

Tinnitus

Desflurane-

It is a inhalational drug used for sedation.

Useful in outpatient surgery.

Produces direct skeletal muscle relaxation .

No hepatotoxicity ,No nephrotoxicity

Risks- Irritating to airway in awake patient and can provoke coughing,salivation,

and bronchospasm.

Sevoflurane-

It is inhational type drug.

Used in outpatient surgery

It is non Irritating to the airway

Concentration -2-4%

Does not produce tachycardia

No hepatotoxicity

ORAL route -

Diazepam-(5mg/5cc)

1.safe agent for mild to moderate anxiety particularly in children with cerebral palsy, mental

retardation.

2. Children less than 6 years of age

3. Oral absorption equally good as parental.

Limitation- multiple doses required to achieve sedation.

4. Not effective in severe anxiety when used alone.

Meperidine-

Dose-50 mg/5cc

Best used in combination for -

1. With promethazine or hydroxyzine

2.longer procedures with chloral hydrate.

Limitations -1.poor oral absorption

2. Contraindicated in children with COPD , hypothyroidism or liver dysfunction

Chloral hydrate –

Dose-500mg/5cc

It is a chlorinated derivative of ethyl alcohol that can act as an aesthetic when administered

in high doses.

Duration of action – 2-5hours.

Wide range of safety

Limitations - 1.Not recommended in children below 6 years of age.

2.Maximum dose not to exceed 1500mg

3.Contraindicated in children with heart disease, renal ailment.

Hydroxyzine-

Dose-25mg/5cc

It is a mild sedative along with antiemetic and anticholinergic action.

It potentiates narcotic and CNS depressants.

Better used in combinations with other agents.

Promethazine -

Dose -12.5mg/5cc,2.5mg/5cc

Better used in combination.

Mild sedative along with antiemetic and anticholinergic action.

Limitations – 1.for mild levels of anxiety only.

Intramuscular -

1.Ketamine-

Dose-10-50mg/ml

Ketamine was first synthesised by Parke-Davis scientist Calvin Stevens in1970.

It prevents the higher cortical centers perceiving visual ,auditary,painful,stumuli.

Potent analgesic.

It maintains cardiovascular stability as well as muscle tone.airway reflexes.

Chronic use may lead to cognitive impairment,including memory problems.

2.Midazolam-

Dose-1-5mg/ml

It possesses hypnotic ,anticonvulsant ,and muscle relaxant properties as well as being

antegrade amnesic and anxiolytic

Greater potency as compared to diazepam.

Rapid onset of action .

Limitations –Used mainly for short procedures.

Intravenous -

1.Propofol-

Also called as milk of amnesia.

Diprivan:2,6di-isopropophenol.

Dose-2mg/kg bolus IV for induction .

It is a fast acting sedative with a narrower margin of safety I.e. The dose required to produce

a sedative effect is close to that used to induce anaesthesia.

Limitation and risk-

1. Respiratory depression ,in particular is commonly associated with propofol use.

2. Rarely vomiting does occur and risk of aspiration.

2.Midazolam-

Most rapid onset of action

Permits titration and is easily reversible

Maintains a line for emergency drugs.

Best for invasive procedure of short duration.

Limitations- Requires extensive armamentarium training.

Precautions to be taken in significant hepatic and thyroid disease.

Rectal,Submucosal,Or Subcutaneous are rarely used .

Reversal agents-

Specific reversal agents exist for benzodiazepenes and opioids.

1. Flumazenil –

. It can be used to reverse the effects of benzodiazepenes and should be immediately

available when using benzodiazepenes for sedation.

Dose-0.01mg/kg 4times as needed.

2. Naloxane-

It is a opioid antagonist and given intravenously mostly .

Dose-0.1mg/kg for children under 20kg.

Children over 20kg is 2mg.

This drug is incredibly effective in reversing the depressive effects of the opioids.

Side effect.- nausea

Complications.

Airway obstruction

Anaphylaxis reactions

Aspiration

Nausea

Vomiting

.PREANESTHETIC MEDICATION:

It refers to the drugs which use before anaesthesia to make it more pleasant and safe.

Objectives:

1. Relief of anxiety and apprehension preoperatively and facilitate smooth induction.

2. supplement analgesic action of aesthetics.

3. Decrease acidity and volume of gastric juice so that it is less damaging if aspirated.

4. Antiemetic effect extending to the post operative period.

Some commonly used drugs for preanesthetic medication:

Opioids: morphine (10 mg )

. Pethidine (50-100mg)IM

Anticholinergic:Atropine0.6mg IM,IV

Sedative antianxiety drugs :

Diazepam--(5-10mg)oral

Lorazepam(2mg)IM

H2 blockers : Ranitidine(150mg) oral

General Anaesthesia:

Definition:

It is defined as a controlled state of unconsciousness accompanied by a loss of protective

reflexes, including the ability to maintain an airway independently and respond purposefully to

physical stimulation or verbal command.

Indications:

1. Patients with certain physical,mental,or,medically compromising condition.

2. Patient who have sustained extensive orofacial trauma.

3. Patient wherein local anaesthesia is not effective or the patient is allergic to it.

4. Fearful,uncooperative,anxious Patient with no expectation that behavior will improve.

Procedure:

Chairside general anaesthesia –

Their are 3 common reasons for the use of general anaesthesia are-handicapped or mentally

retarded children , uncooperaative

child, and inability to come for frequent visits.

Team includes-1 . Anaesthesiologist

2. pedodontist

3. Dental surgery assistant

4. Anesthesia technicians

Pre-procedure-

Observations and recording of child behavior.

The parents are instructed to come for admission one day before the GA procedure.

Informing parents about necessity of chairside GA and obtaining verbal consent.

Day1 -

Patient comes to pedodontic clinic.

Concerned doctor send child for preanesthetic check up.

Patient comes back to pedodontics department with report.

If aesthetist accepts the case,patient is admitted.

Basic investigation are done.

Written consent form is signed by parents.

Premedication given to patient

Day 2:-

Child is brought to pedodontics opds with hospital file.

Child is accompanied by the parents to the procedure room and is present till induction is done.and

then asked to leave.

Induction is usually done using inhalation route.

Once the child is ready under GA the aesthetist hands over the patient to pedodontist.

Treatment is performed using four handed dentistry.

Radiographs also taken for treatment plan.

After completion of treatment dentist handover Patient to anesthetist.

He administer reversal drugs.

Child is shifted to ICU .

Day 3:-

Check up in pedodontics opd.

Then discharge the patient after payment is done.

The doctor concerned fixes a follow up appointment.

Commonly used parental anaesthetic agents-:

Opioids –morphine

. Fentanyl

Benzodiazepenes –Diazepam

. Midazolam

Triazolam

Barbiturates -: Methohexitol

. Thiopental

Complications of general anaesthesia:-

During anaesthesia:-

1.Respiratory depression

2.Salivation,respiratory secretions

3.Cardiac arrhythmia

4.Laryngospasm,convulsions

5.Fall in blood pressure

After anaesthesia:-

1.Nausea and vomiting

2.Organ toxicities –liver,kidney damage

3.Pneumonia

4.Persisting sedation

Masks for induction:-

1.Shape of mask:-

For the children, induction is generally carried out by the use of inhalation.The shape of mask is

modified to make it acceptable to the child’s.

E.g.balloon mask ,Mickey mouse with a wide open mouth.

2.Scented mask:

. To disguise the odors of the inhalation agents includes addition of drop of fruit extract on the mask.

Also vapourizing volatile fruit flavours into the anaesthetic gas mixture is acceptable.

Conclusion:-

Pharmaccologic behaviour management is necessary for children with lack of psychological or

emotional maturity

Mental , Physical or Medical disability

One should remember the risks during pharmacologic behaviour management

References:-

Textbook of Pedodontics –Shobha Tandon

. 2 nd edition

Textbook of Paediatric Dentistry –Nikhil Marwah

. 3rd edition

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