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Triazolam (Halcion) to Each Drug’S Unique Pharmacokinetic Profile

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Triazolam (Halcion) to Each Drug’S Unique Pharmacokinetic Profile 6/16/2013 Oral Sedation in Dentistry Oral Sedation for General Dentistry: “Post‐Prandial Lecture” Sedation “What Works, What’s Safe, and What’s Allowed in Florida” Florida Dental Society of Anesthesiology • State component of American Clive B. Rayner, DMD Dental Society of Anesthesiology • Membership open to all dentists •Board Certified in Oral & Maxillofacial Surgery • Annual CE meeting •Board Certified in Dental Anesthesiology • Annual SimMan ‘hands‐on’ high‐ •Board of Directors, Florida Society of Oral & Maxillofacial Surgery fidelity sedation emergency •Co‐founder & past‐President of Florida Dental Society of Anesthesiology (FDSA) simulation training •Currently Executive Director of FDSA • Newletter •Editor & author of “Vital Signs” newsletter of the FDSA • Advocacy for anesthesia in •Liaison from FSOMS and FDSA to Board of Dentistry dentistry •Consultant & Expert Witness to Board of Dentistry on Anesthesia • Website: •Member, Anesthesia Committee of Board of Dentistry – Scientific Articles •Office anesthesia site evaluator for FSOMS, Board of Dentistry – Sedation & anesthesia meeting information Conflict of Interest Disclosure FDNC lecture notes are not complete: – Go to www.fdsahome.org for complete, updated • None: no commercial or industry connections lecture notes, copies of reference articles, and • Founder, Past‐President, and currently Exec Director other course information. (unpaid) of Florida Dental Society of Anesthesiology – Contact information: • [email protected] (Dr. Clive Rayner) • [email protected] (Tricia Cross, FDSA Administrator) 1 6/16/2013 Wireless Audience Response System Question: Have you ever had to terminate a procedure because of patient anxiety? • Respond to questions with wireless keypad 80% 1. Yes 70% 67% • You will have 10 seconds 2. No 60% • Your last ‘click’ is the one recorded 50% • 40% 33% Computer will tabulate results 30% • Results are anonymous 20% 10% • Please return transmitter when you leave 0% Yes No 10 How would you manage this Question: patient? How would you manage this patient? 1. Tell him “hold still, it 35% 33% 33% 33% doesn’t hurt” 30% 25% 2. Use relaxation 20% techniques 15% 10% 3. Use sedation 5% 0% 0% 4. Take him to the 0% hospital for anesthesia 5. Send him to another dentist 10 2 6/16/2013 Question: Question: Who’s in the audience? Are you a: Did you have any sedation / anesthesiology training? 1. General dentist 80% 80% 67% 70% 67% 1. Dental school 70% 60% 60% 2. Periodontist 50% 50% 2. GPR 40% 33% 3. Endodontist 40% 33% 30% 30% 3. Specialty residency 20% 4. Prosthodontist 20% 10% 0% 0% 0% 10% 0% 0% 0% 4. Post‐grad course 0% 5. Oral surgeon or 0% Dental 5. None anesthesiologist 10 10 Question: What We’ll Discuss If you practice sedation, what kind of sedation permit do you hold? • Why, who, when, and how to use oral sedation • Non‐drug anxiety / stress reduction techniques 80% 67% 1. None 70% • Published guidelines (ADA, AAOMS, APD, etc) 60% 2. Moderate sedation 50% • Rules governing use of oral sedation in Florida 40% 33% 3. Deep sedation / 30% • Different levels of sedation 20% general anesthesia 10% 0% 0% 0% • Basic pharmacology and pharmacokinetics 0% 4. Pediatric moderate • Oral sedative classes –in general sedation • Benzodiazepines –in depth, specifically those useful to 5. Don’t know what I dentistry have 10 What We’ll Discuss Why Use Anxiolysis / Sedation? • Adult oral sedation protocols • Pain vs anxiety vs phobia • Pain is an emotional response to a noxious physical stimulus • Drug titration • PAIN is whatever the patient says hurts, • Patient evaluation and preparation not what the dentist thinks should hurt • Anxiety causes the brain to interpret all noxious stimuli (e.g. pressure) as • Informed consent pain • Recovery, disc harge, record kikeeping • Most dldental phbhobics and fflfearful patients • Monitoring were created by dentists! (So you can thank your colleagues when you get one of these patients) • Complications: emergency preparation and • “We have met the enemy and he is us” –Pogo management, airway management, drug reversal • Sedation failures, and alternatives to oral sedation • And yet, anesthesia was invented by dentistry – It is our heritage, yet we don’t use it, and we are losing it. • Resources for further training and education 3 6/16/2013 Horace Wells –dentist and father of Who should not do oral sedation? modern anesthesia (somewhat tongue in check) • You don’t want to relearn pharmacology & physiology • You don’t want to take time to review the patient’s medical history & consult with MDs • You prefer to be a technician than doctor of the mouth • You don’t want to spend time training your team • You don’t want to regularly practice emergency drills with your staff • You don’t know difference between syncope and allergic reaction, nor how to treat Why Use Oral Sedation? Why Use Oral Sedation? My philosophy: Let’s not create any more Never hurt a patient, even when they say… dldental phbihobic patients…… “It’s ok doc, keep going,” …and especially if they tell you, “It hurts!!” Why Use Sedation? Why Use Sedation? • The greatest fear patients have is of PAIN • The primary goal of sedation is to permit the STRESS‐ • Local anesthetics are the most effective drugs in medicine for the INTOLERANT patient to receive dental treatment in a safe and prevention of pain efficient manner • However, the act of receiving the local anesthetic is THE most traumatic part of the dental experience for most. • 75% of medical emergencies in the dental office are related to • Deal with the FEAR first then PAIN will be a minor problem during stress and anxiety (fear and pain), usually from the injection, procedure not from the local itself. • Most “failures” of adequate local anesthesia and “reactions” to local • Therefore, another goal of sedation is to PREVENT medical anesthesia are actually anxiety reactions emergencies 4 6/16/2013 75% of dental office medical emergencies Question: are stress or pain related! How you ever had a patient that is allergic to local anesthetic? Stress‐related Non‐stress • Syncope • Allergy 1. Yes 80% 70% 67% • Angina pectoris • Postural 2. No 60% • Seizures hypotension • Bronchospasm 50% • Hypoglycemia • Hyperventilation 40% 33% • Acute pulmonary edema • Local anesthesia 30% • CVA overdose 20% • Acute adrenal insufficiency 10% • MI 0% Yes No 10 Another good use for oral sedation: When to Use Oral Sedation the gagging patient! • Oral sedation can help the majority of patients with mild to moderate levels of fear and anxiety, but may be ineffective in patients with severe anxiety or in more stressful or painful procedures. • Sedation can be useful in preventing medical emergencies in compromised patients. • Gagging is usually • However, some patients will not be successfully related to anxiety / managed with oral sedation, because empiric stress dosing is not an exact science. • That’s why hypnosis & • These patients may require deeper sedation and distraction work intravenous titration. Stress Reduction Protocol Anxiety • Recognition of anxiety • Discuss / offer sedation Evaluation • Effective pain control Questionnaire • AM appointment • Keep appointments short • New patient: start with non‐invasive, simple treatments • Get the patient out of pain before you work on them • Don’t work on a patient already in pain (they’ll associate it with you) • Good nights sleep before – Give sedative night before if needed • Reduce time in waiting room • Give patient permission to stop procedure at any time, and do it! • Guided relaxation, breathing exercises, guided visualizations Source: Stanley Malamed, DDS, “Oral Sedation for the General Dentist,” FDSA CE presentation, 2011 5 6/16/2013 Non‐drug Techniques of Anxiolysis Question: • Acknowledge patient’s fears and anxiety and discuss What is your preferred adjunctive stress • Chairside manner: calm & reassuring reduction technique? • Give patients control: give breaks, stop when asked 80% 67% • Clinical hypnosis 1. Hypnosis 70% 60% • Acupuncture 2. Distraction 50% 40% 33% • Distraction: (headphones, video) 30% – Audio, earphones 20% 10% 0% 0% 0% – Video, dark glasses 3. Breathing exercises 0% • Guided imagery / relaxation training 4. Guided imagery, • Breathing exercises guided relaxation 5. None of the above 10 Source: Stanley Malamed, DDS, “Oral Sedation for the General Dentist,” FDSA CE presentation, 2011 The Art and Science of Sedation The Art and Science of Sedation Science: Art: – Anatomy & physiology – Clinical experience in the administration of CNS depressant – Pharmacology drugs (yes, you have to learn “that pharmacology stuff”) – Clinical experience in the dental treatment of sedated – Patient evaluation patients – – Emergency preparedness Sedation is an art that is learned through experience – Techniques Guidelines for Practice Regulations for Practice • American Dental Association Board of Dentistry Rules: http://www.ada.org/sections/about/pdfs/anesthesia_guidelines.pdf Florida Administrative Code, Chapter 64B5‐14 • American Academy of Pediatric Dentisry • American Association of Oral & Maxillofacial Surgeons • https://www.flrules.org/gateway/ChapterHome.asp?Chapter=64B5‐14 • AiAmerican AdAcademy of PidPeriodonto logy • American Dental Society of Anesthesiolgoy • http://www.doh.state.fl.us/Mqa/dentistry/info_julylaws10.pdf • American Society of Dental Anesthesiologists • http://www.asahq.org/For‐Members/Standards‐Guidelines‐and‐ • American Society of Anesthesiology Statements.aspx 6 6/16/2013 Definitions of Sedation Levels But SEDATION & ANESTHESIA are really a CONTINUUM
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