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7/26/2019 Introduction to Pain and Anxiety Control
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Kyle J. Kramer, DDS, MS
7/12/11
7/26/2019 Introduction to Pain and Anxiety Control
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! Inhalation Minimal Sedation! 14 hours of instruction
! Clinical competency
!
Enteral and/or Combination Inhalation-EnteralMinimal Sedation! Current BLS
! 16 hours of instruction
! Clinical competency
!
Experience compromised airway management
Note: Guidelines do not pertain to sedation of pediatricpatients
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!
Moderate Enteral Sedation! 24 hours of instruction
! 10 adult patient case experiences*
"
Enteral" Enteral-Nitrous Oxide
! Clinical competency
! Management of compromised airway
Note: Guidelines do not pertain to sedation ofpediatric patients
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!
Moderate Parenteral (IV) Sedation
! 60 hours of instruction
! 20 adult patient case experiences
!
Clinical competency
! Management of compromised airway
Note: Guidelines do not pertain to sedation ofpediatric patients
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! Successful completion fulfills didactic requirements! 14 hours ACLS
! 10 classes over next 5 weeks" Lectures
"
Midterm"
8/1 to 8/8
" Final exam"
8/15 to 8/22
" Labs"
IV placement/IM injections"
Preoperative evaluation and ASA Monitors
!
2 sessions"
Airway Lab (2 half-days w/ Dr. Kramer in OMS clinic)
! Competency Evaluation" Case review and presentation/oral evaluation
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!
Define and describe pain, anxiety and fear
!
Review historical, philosophical andpsychological aspects of anxiety and pain
control!
Define consciousness and levels ofsedation! Minimal sedation
!
Moderate sedation
! Deep sedation
! General anesthesia
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! 40% of population doesnt receive routinedental care! Apprehension given for most common reason
! Mild apprehension of dental treatment! Very common: 75% of population
!
Severe anxiety leading to avoidance oftreatment! Less common: 6-20% of population
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! In the US an estimated6-14% of thepopulation avoidsdental care due to fear
of dentistry! 14-34 million
! Anxiety and fearremain significant
roadblocks to patientcare! Despite advances in pain
control
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n = 400
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Problems
1. Poor oral health
2.
Patients are fearful of dentaltreatment
3.
Inadequate access to care1. Few dental sedationists
compared to number of patients2. Remains a problem despite
improvements
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Fear continues to besignificant barrier to
patient care! Public Speaking 27%! Dentists 21%! Heights 20%
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Our Goals
! Improve access to care!
Improve patient care andcomfort
!
Our professional obligation todo better
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Methods of improving access tocare
!
Non-pharmacologic! Verbal guidance and reassurance! Distraction (listen to music, watch a
movie)!
Hypnosis
!
Pharmacologic! Anxiolysis! Minimal sedation! Moderate sedation! Deep sedation! General anesthesia
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!
An unpleasant sensory and emotionalexperience associated with actual or
potential tissue damage, or described in
terms of such damage InternationalAssociation for the Study of Pain
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!
Neural processes of encoding andprocessing noxious stimuli
! Afferent activity blocked by local anesthetics
!
Autonomic process
! Consciousness not required
!
Intraoperative and postoperative
importance! An absolute must for all types of sedation
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!
Activation of the sympathetic nervoussystem
! Release of epinephrine from adrenal glands
!
Fight or flight response
! Emotional responses
" Crying, scared, etc.
!
Physical responses" Tachycardia, hyperventilation
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! Short-livedphenomenon,disappearingwhen theexternal danger orthreat passes
! Autonomic responsedependentof thethreat! If the threat (a spider) is
present
activation of thefear response
! Once spider is gone, thefear response resolves
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1.
Fear of pain*
Is it going to hurt?
2.
Fear of the unknown
3.
Fear of helplessness and dependency
4. Fear of bodily change and mutilation
5.
Fear of death
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! Arise from many
sources
! Past traumatic
experiences! Observation of others
! Concerns or worries
! Exposure to anecdotal
stories
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1.
Fear of pain*
Is it going to hurt?
2.
Fear of the unknown
3.
Fear of helplessness and dependency
4. Fear of bodily change and mutilation
5.
Fear of death
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!
Both groups had
similar fears
!
Dentists can
eliminate sometriggers
! What do patients
care about?
! No pain!
! Work quality???
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! A specific unpleasurable state oftension which indicates thepresence of some danger to theorganism Weiss and English
! Autonomic response
independentof the threat! Memory of the spider -> activation
of fear response
! Can arise with anticipation of thetriggering event
! Usually a learned response
! Can lower pain thresholdsignificantly! Innocuous stimuli -> interpreted as
pain
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! Several types of anxiety Generalized anxiety disorder
Panic disorder
Obsessive-compulsive disorder (OCD) Social anxiety disorder
Specific phobias (arachnophobia)
Post-traumatic stress disorder (PTSD)
Situational stress anxiety****
Note: May often have additional diagnosis ofdepression
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General Anxiety Situational Anxiety
!
Mood disorder! Anxious but dont know why
! Biochemical changes in theCNS
! Treatment modalities
!
Pharmacotherapeutics
" Mood stabilizers
" Antidepressants
" Anxiolytics
! May require larger doses
!
Anxious secondary to anevent (dental visit)
! Treatment modalities
! Non-pharmacotherapeutics
" Iatrosedation
"
Hypnosis! Pharmacotherapeutics
" Nitrous oxide
" Anxiolytics
! May respond to smaller
doses
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Similarities Differences
!
Autonomic response! Physical
! Emotional
! Learned response?
! Requires consciousness
!
Threat present/not present
! Learned response?
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!
Goals of Pharmacologic Management
! Induce an altered state of consciousness
" Relative analgesia
"
Co-medication
" Twilight sleep
" Chemamnesia
! Reduce/eliminate stress and anxiety
Sedation
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!
Analgesia:
! The diminution or elimination of pain
!
Local anesthesia:
! Elimination of sensation, especially pain, in one
part of the body
" Predictable and reversible
! Via topical application or regional injection ofa drug
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Minimal Sedation (Anxiolysis, Stress reduction):
! Minimally depressed level of consciousness
" Modest impairment of cognitive function and
coordination" Respond normally to tactile stimulation and verbal
command
! Independently and continuously maintain own
airway" Airway reflexes intact
! NOcardiovascular or respiratory depression
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Moderate Sedation
! Depressed level of consciousness
" Respond purposefully to verbal commands, either
alone or with light tactile stimulation! Nointerventions are needed to maintain a
patent airway
" Spontaneous ventilation is adequate
"
Airway reflex impairment possible! Cardiovascular function is usually maintained
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Deep Sedation
! Depressed level of consciousness" Cannot be aroused easily
"
Dorespond purposefully to repeated or painfulstimulation
! Ability to maintain patent airway may becompromised" May require airway support
"
Airway reflexes impaired" Spontaneous ventilation may be inadequate
! Cardiovascular function is usually maintained
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General Anesthesia
! Unconscious
" Not arousable, not even to painful stimulation
!
Respiratory function is often impaired" Airway support/patency may be required
" Hypopnea/apnea
" Positive pressure ventilation
"
Airway reflexes impaired! Cardiovascular function may be impaired
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! Best viewed as a continuum
! No defined step to reach a setlevel
!
Ability and speed to move alongthe continuum varies greatly
!"#$%&"'$
)#%"#$%&"'$
*+,-
How high is this plane?
How far away is it?
Is it high enough to fly over orunder the sun?
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Stage I: Induction! Analgesia
! Conscious sedation
Stage II: Excitement!
UnconsciousStage III: SurgicalAnesthesia
! Planes 1-4
Stage IV: MedullaryParalysis
!
Respiratory arrest
! Cardiovascularcollapse
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Dionne, R Drug Interactions and Adverse Effects In: Anesthesia and Sedation in the Dental
OfficeDionne R and Laskin D (eds). Elsevier 1986 p. 63
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! Levels of sedation! What is the main goal
of the sedation?! What physiologic signs
are we looking for?
! Minimal sedation! Conscious sedation! Anxiolysis
! Moderate sedation!
Deep sedation!
General anesthesia
???
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!
History of dental anxiety, fear or phobia! Phobic patient
!
Patient management issues! Mentally disability" Alzheimers dementia
! Physically disability
"
Cerebral palsy" Parkinsons disease
! Precooperative children
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! Invasive or extensive procedures! Full mouth extraction
! Mandibular resection and reconstruction
! Physically compromised patients! Ischemic heart disease
! Stress-induced asthma
Need to match the level of sedation with thepatient and the surgical procedure!!!
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Class Description
I Normal, healthy patient
II Mild systemic disease
III Severe systemic disease that limits activity but is notincapacitating
IV Incapacitating systemic disease that is a constant threat
to lifeV Moribund patient not expected to survive 24 hours with
or without operation
VI Clinically dead patient kept alive for organ donation
E Emergency operation*
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Enteral Parenteral!
Drug is absorbed throughthe GI tract or oral mucosa
! Subject to first passmetabolism
! Oral
!
Rectal
! Sublingual*
!
Drug bypasses the GI tract!
NOT subject to first pass
metabolism
! Intravenous
! Intramuscular
!
Intranasal
! Submucosal
! Subcutaneous
! Inhalational
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! Route DOES NOT determine the depth of sedation
! Any route has the potential to induce any degree of sedation or anesthesia*
! Route of administration MUST comply with the needs of the surgery and thepatient
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Providers MUST:
1. Be able to identify thedepth of sedation
2. Be able to rescue patientswho become sedateddeeper than the intendedlevel- Reversal of sedation
3. Be able to manage
sequela that arise due tothe unintended depth ofsedation- Airway support
- Cardiovascular support
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! 3 As! Anxiolysis! Amnesia! Analgesia
!
Cardiovascular and respiratory stability! Quickly alter depth
! Rapid, comfortable induction! Rapid, clean emergence
!
Postoperative analgesia! No PONV! Inexpensive
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!
There is no magic bullet
!
Use of balanced anesthetic
! Combination of techniques
!
Benefit/risk of each drug
! Example: Benzo + opioid + LA
! The right combination is the one that
works
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! No additional licensing for the following:
! Inhalation Minimal Sedation" Nitrous oxide + Oxygen
! Enteral and/or Combination Inhalation-EnteralMinimal Sedation
! Moderate Enteral Sedation
! However, this is likely to change in the nearfuture
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! Great for anxiolysis
! Includes supplemental
oxygen
!
Easily reversible! If pt is breathing!!!
! Can be titrated, even
with oral sedation
! Very safe
!
Caution"
Significant additive sedationand muscle relaxation
" AIRWAY, AIRWAY, AIRWAY!!!!!
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Light Parenteral Conscious Sedation Deep sedation
! Minimally depressed level ofconsciousness
! Maintain own airway
! Respond to stimulation
! THIS IS OUR GOAL!!! Awake!
Breathing! Calm! Responsive! Relaxed
! Depressed consciousness
! Partial loss of protective
reflexes
! Inability to continually
maintain airway
!
Unresponsive to
stimulation
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!
Applicant must meet one of the followingcriteria:
!
(1) Graduation from an approved dentalschool which included training in conscious
sedation techniques at the predoctoral level
!
(2) Completion of an intensive postdoctoraltraining program in the use of light parenteral
conscious sedation
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! Satisfactory evidence of completion ofeducational and training requirements means thefollowing:
!
(1) Certificate of completion of the educational ortraining program
! (2) Official transcript from a board approved dentalschool which clearly designates completion of theeducation or training.
! (3) Certificate of completion of a continuingeducation program
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Requirements:
!
Valid Indiana dental license
!
Valid LPCS permit
!
Provide training certificate
! Equipment affidavit
! ACLS certified
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Requirements:
!
Valid Indiana dental license
!
Valid GA/DS permit
!
Provide training program certificate
" Dental Anesthesiology
" Oral and Maxillofacial Surgery
!
Equipment affidavit! ACLS certified