Evidence-Based Perspectives on Pain and Anxiety Control in Dentistry

1
Evidence-Based Perspectives on Pain and Anxiety
Control in Dentistry

• Dr. Arthur Jeske
• Arthur.H.Jeske_at_uth.tmc.edu
• Utah Dental Association, 2/15/08

2
Todays Course Topics

• Fundamentals of anxiety management
• Current guidelines (conscious/minimal sedation)
• Enteral (oral) sedatives
• Nitrous oxide/oxygen inhalation sedation
• Basic emergency drugs
• Contemporary perspectives on local anesthetics
• Contemporary perspectives on oral analgesics

3
Disclaimers

• The opinions expressed in this course are those
  of the speaker and not necessarily those of the
  Utah Dental Association.
• The opinions expressed in this course should not
  be construed as advice for the care of specific
  patients.
• The drugs and techniques contained in this course
  must be based on the clinical judgment of the
  individual practitioner.

4
American Dental Association

• GUIDELINES FOR TEACHING PAIN CONTROL AND SEDATION
  TO DENTISTS AND DENTAL STUDENTS
• As adopted by the October 2007 ADA House of
  Delegates
• www.ada.org

5
Minimal Sedation

• A minimally depressed level of consciousness
  produced by a pharmacologic method that retains
  the patients ability to independently and
  continuously maintain an airway and respond
  normally to tactile stimulation and verbal
  command. Although congnitive function may be
  modestly impaired, ventilatory and cardiovascular
  functions are unaffected.

6
Other ADA Guideline Excerpts

• Nitrous oxide may be used with a single enteral
  drug
• Initial oral dose is no more than MRD for
  unmonitored home use
• Combination of nitrous and oral agents may
  produce minimal, moderate or deep sedation or
  general anesthesia
• Supplemental dosing is a single additional dose
  for prolonged procedures and should not exceed
  ½ the initial dose (not until the clinical
  half-life of the initial dose has passed)
• total aggregate dose must not exceed 1.5 MRD

7
Conscious Sedation Guidelines

• http//www.ncbi.nih.gov/pubmed/17187034?ordinalpos

8
Balancing Efficacy and Safety in the Use of Oral
Sedation in Dental Outpatients

• Dionne RA et al. JADA 2006137502-13
• http//jada.ada.org

9
ENTERAL ADMINISTRATION OF Benzodiazepines safe
but poorly documented in the office
settingConscious sedation, including
incremental triazolam, necessitatesmonitoring,
documentation, facilities equipment and personnel
as described in ADA and AAPD guidelines
10
Consensus (Dionne et al., 2006)

• Oral sedative wide margin of safety in ADULTS
• Most serious events respiratory depression
• State regulation required to ensure safety
• More research needed for incremental dosing
  techniques
• 0.25 mg triazolam X 2 gtgt0.5 mg single dose

11
Sedation Modifications. How Will the Proposed
Guidelines Affect Your Practice?

• Lynch, K. AGD Impact July 200748-54
• AGD White Paper at
• http//www.agd.org/members_only/advocacy/priority_
  issues/ConsciousSedation.doc

12
Heres What You Thought (AGD Impact July 2007)

• 74 use N2O
• 53 combine nitrous oxide and a BZ
• 67 have patient take sedative at home
• 43 administer sedative in the office
• 90 never had an untoward reaction
• 48 totally understand the difference between
  minimal and moderate sedtion

13
Conscious Sedation Guidance

• Coulthard, P. J. Evid. Based Dent.,
  20067(4)90-91
• www.scottishdental.org/cep/guidance/dentalsedation
  .htm
• The Scottish Dental Clinical Effectiveness
  Programme

14
Coulthard, 2006

• 48 recommendations total
• To be updated 2008
• Included general systematic reviews (Cochrane
  Library) and specific studies (Medline, Embase
  Cochrane Library)

15
Recommendations Referral

• Discuss alternative methods of anxiety management
  with patient
• Ensure that definition of conscious sedation is
  met

16
Recommendations Assessment and Record Keeping

• Discuss all aspects of sedation procedure with
  patient
• Provide written instructions
• Obtain informed consent
• Maintain and update patient records

17
Recommendations Environment and Facilities

• Ensure that environment is safe
• Correct equipment and drugs
• Emergency drugs and equipment immediately
  available

18
Recommendations Training

• All members of team are correctly trained
• Training includes monitoring techniques and
  emergency interventions
• For oral and transmucosal sedation,
  sedationist trained in other titratable
  sedation techniques and venipuncture
• Teams should provide sedation for patient groups
  they are experienced in treating

19
Recommendations Techniques

• Titrated dose of nitrous oxide
• Oral, transmucosal and i.v. require pulse
  oximetry and BP monitoring

20
Recommendations Aftercare

• Monitor patients during recovery
• Dismiss patient into care of a responsible adult
  (who also has written instructions)
• Nitrous oxide sedation might not required adult
  escort during recovery

21
Recommendations Further Research Required For

• Fasting before conscious sedation
• Pediatric conscious sedation
• Drug combinations
• Conscious sedation methods
• Cognitive behavioural effects of sedation
• Interaction of pharmacological and
  nonpharmacologic anxiety management

22
Utah Dentist and Dental Hygienist Practice Act
Rules R156-69-601

• Scope of PracticeAnesthesia and Analgesia Permit

23
Conscious Sedation for Dental Anxiety(Protocol)

• Cochrane Database of Systematic Reviews
• 2007, Issue 1

24
Primary Outcomes To Be Assessed

• Changes in anxiety scores
• Reliability and validity of anxiety measurement
  instruments/scales

25
Anxiety An internal, emotional response a
specific unpleasurable sense state of tension
which indicates the presence of some
dangerANTICIPATED
26
FearA short-lived feeling that something
terrible is going to happen accompanied by
physiologic changes (increased HR, perspiration)
and overt behavior signs (jitteriness,
shaking)Fight or FlightIMMEDIATE THREAT
27
Conscious Sedation

• Drugs and/or techniques used should carry a
  margin of safety wide enough to render loss of
  consciousness UNLIKELY
• Patients who are SLEEPING and whose only reponse
  to stimuli is reflex withdrawal would NOT be
  considered to be in a state of conscious sedation

28
Bottom-Line Requirements for Minimal/Conscious
Sedation

• Comfort
• Consciousness
• Cooperation

29
Adult Preferences for Sedation or General
Anesthesia (Survey of 1,101 Canadian Adults)

• Routine cleaning 7.2
• Fillings/crowns 18
• Tooth extraction 47
• Endodontic procedure 55
• Periodontal surgery 68
• From Chanpong, Haas Locker, Anesth. Prog.
  200552(1)3-11
• http//apt.allenpress.com/perlserv

30
Clinical Considerations

• Physician consultation recommended for ASA III
  IV patients
• One member of assistant staff should be present
  (in addition to dentist)
• Direct supervision
• Monitoring required for oxygenation, ventilation
  and circulation
• Time-oriented anesthetic record

31
Advantages of Oral Sedation

• Universal acceptability
• Ease of administration
• Low cot
• Incidence of adverse reactions less than some
  other techniques
• No needles, syringes or special techniques
• Various drugs, dosage forms available
• Allergic reactions less severe than seen in
  parenteral administration

32
Disadvantages of Oral Sedation

• Reliance on patient compliance
• Prolonged, variable onset of action
• Unreliable absorption of drug from G.I. tract
• INABILITY TO TITRATE WHAT???
• Prolonged duration of action
• Ineffective in anxiety levels gt mild
• Adverse interactions of sedative drugs

33
Idiosyncrasy

• An unexpected, unpredictable adverse or
  undesirable drug action

34
Indications for Oral Sedation

• Mild to moderate dental anxiety
• To assist with restful sleep on night before
  dental appointment

35
Contraindications to Oral Sedation

• Severe dental anxiety fear
• High probability of adverse drug interaction
• Poor past experience with oral sedation
• Allergy to drug being used
• Other drug contraindications (pregnancy,
  glaucoma, etc.)
• Need for rapid onset and/or rapid recovery

36
What causes the sudden death of a patient?

• Respiratory arrest with or without airway
  obstruction
• Cellular hypoxia without respiratory depression
  (CN, CO)
• Severe hypotension (hypovolemic, etc.)
• Lethal cardiac dysrhythmias
• Post-seizure complications (pulmonary aspiration,
  hypoxia, brain damage)
• Organ damage (e.g., APAP/liver)
• Behavior aberrations (motor vehicle accidents)

37
Oral Sedation Unfilled Expectations

• Pain control, reduced need for local anesthesia
• Control of defiant behavior, mentally-challenged
  patients
• Amnesia
• Lack of adverse effects
• Consistency from appointment to appointment
• A good nights sleep the night before the
  dental procedure

38
Sedation should NOT be used to control pain and
does NOT substitute for good local anesthesia
39
Enteral Sedation

• Light to mild conscious sedation administered not
  for analgesic effect, but primarily for
  behavioral management (drug absorbed through GI
  tract or oral mucosa)

40
Factors Influencing Oral Drug Absorption

• Lipid solubility
• pH of gastric tissues
• Mucosal surface area
• Gastric emptying time
• Dosage form of drug
• Drug inactivation (first pass effect)
• Presence of food in stomach
• Bioavailability of drug
• Genetics

41
Alpha Distribution Phase

• The phase in which sedative activity is initiated
  ended, by entry into and removal from the CNS

42
Beta Elimination Phase

• The phase in which a sedative drug is inactivated
  by hepatic metabolism excretion

43
Margin of Safety

• The difference between the effective therapeutic
  dose and the dose that produces severe or
  life-threatening adverse effects

44
Reasons NOT to used BZs

• Allergy
• Narrow angle glaucoma
• Chronic BZ ingestion???
• Tricyclic antidepressant therapy???
• Adversely interactive drugs (e.g., azole
  antifungals/triazolam)

45
Characteristics of Benzodiazepines

• Facilitate binding of GABA (endogenous inhibitory
  transmitter)
• More favorable therapeutic index than older
  agents
• Can produce anterograde amnesia
• Agents differ in onset, duration metabolism
• Agents differ in regard to sedation vs. hypnosis

46
Boxed Warning BZs

• sleep driving (with no memory)
• severe allergic reactions
• http//www.fda.gov/bbs/topics/NEWS/2007/NEW01587.h
  tml

47
Pharmacokinetics and Clinical Effects of
Multidose Sublingual Triazolam in Healthy
Volunteers. Jackson DL et al. J. Clin.
Psychopharmacol. 200626(1)4-8

• 10 human volunteers
• 0.25 mg followed by 0.25 mg at 60 mins and 0.25
  mg at 90 mins
• Evaluated by observed, bispectral index and
  plasma triazolam levels
• 8 subjects met criteria for deep sedation or
  general anesthesia at later time point

48
Advantages of Benzodiazepines

• Specificity of effect
• Well absorbed by the oral route
• High margin of safety/therapeutic index
• Effective as single agents
• Specific reversal agent available (flumazenil)

49
Classification of Benzodiazepines

• Alprazolam antianxiety
• Diazepam antianxiety
• Lorazepam antianxiety/sedative-hypnotic
• Midazolam sedative/hypnotic
• Oxazepam antianxiety
• Triazolam sedative/hypnotic

50
Diazepam (VALIUM)

• Usual dose range 2 - 20 mg, 1 h before
  appointment (adults)
• Onset 1 hr (peak levels in 2 hrs)
• Duration 1 - 3 hrs
• Contraindications allergy, narrow-angle
  untreated open-angle glaucoma
• Precautions sedation intensified by several CYP
  inhibitors (3A4, 2C19)

51
Diazepam

• Active metabolites? Yes
• Pregnancy category D
• Availability 2-, 5- 10-mg tabs, 5 mg/ml
  liquid, rectal gel 5 mg/ml

52
Lorazepam (ATIVAN)

• Usual dose range 2 - 4 mg 1 hr before
  appointment (adults)
• Onset 1 hr (peak levels in 2 hrs)
• Duration 2 - 4 hrs (use for longer procedures)
• Contraindications allergy, narrow-angle
  glaucoma
• Precautions greater likelihood of excessive
  sedation than with other agents, do not use in
  cases of depressive disorder/psychosis

53
Lorazepam

• Active metabolites? No
• Pregnancy category D
• Availability 0.5-, 1 and 2-mg tabs

54
Oxazepam (SERAX)

• Usual dose range 10 30 mg, 1 hr before
  appointment (adults)
• Onset 1 hr (peak levels in 1 4 hrs)
• Duration 2 4 hrs
• Contraindications allergy
• Precautions same as for other agents
• Active metabolites? No

55
Oxazepam

• Pregancy category D
• Availability 10-, 15- 30-mg caps, 15-mg tabs

56
Triazolam (HALCION)

• Usual dose range 0.25 0.5 mg, 1 hr before
  appointment (adults)
• Onset 1.3 hrs (peak levels in 0.5 4 hrs)
• Duration 1 hr
• Contraindications allergy, pregnancy, do not
  administer with potent CYP 3A4 inhibitors (e.g.,
  azole antifungals)
• Precautions anterograde amnesia, excessive
  sedation (especially elderly)

57
Triazolam

• Active metabolites? No
• Pregnancy category X
• Availability 0.125- 0.25-mg tabs

58
Triazolam Doses

• Short-term management of insomnia
• 0.25mg PO hs
• Max 0.5 mg PO hs
• Alternative 0.125 mg PO hs if elderly, hepatic
  impairment

59
Triazolam

• Onset
• Peak effect
• Duration

• 1 hr.
• 1.3 hrs.
• 2 3 hrs.

60
Alprazolam (XANAX)

• Usual dose range 0.25 1 mg 1 hr before
  appointment (adults)
• Onset 1 hr (peak levels in 1 2 hrs)
• Duration 1 2 hrs
• Contraindications allergy, narrow- and
  untreated open-angle glaucoma, potent CYP 3A4
  inhibitors (e.g., azole antifungals)
• Precautions sedation intensified by CYP 3A4
  inhibitors, produces little or no amnesia or
  somnolence

61
Alprazolam

• Active metabolites? No
• Pregnancy category D
• Availability 0.25-, 0.5, 1- 2-mg tabs, 0.5-
  and 1 mg/ml liquid

62
Midazolam

• ALL BRAND NAME FORMS (VERSED) DISCONTINUED BY
  ROCHE MAY, 2002
• Now available from Ranbaxy Pharmaceuticals as 2
  mg/ml cherry syrup (Princeton, NJ)
• Usual dosage range 0.25 0.5 mg/kg single dose
  up to a total maximum of 20 mg (children)
• Onset 10 20 min
• Duration 30 60 min
• Contraindications allergy, narrow-angle
  glaucoma

63
Midazolam

• Precautions may cause intense CNS/respiratory
  depression, use with caution with potent CYP 3A4
  inhibitors (e.g., azole antifungals) NOT TO BE
  ADMINISTERED AT PATIENTS HOME
• Active metabolites? No
• Pregnancy category D
• Availability 2 mg/ml syrup

64
Oral BZ Biovailability Half-lives

• Diazepam 100, 43 13 hrs
• Oxazepam 97, 8 2.4 hrs
• Lorazepam 90, 12 hrs
• Alprazolam 88, 12 2 hrs
• Triazolam 44, 2.9 1 hrs
• Midazolam 44, 1.9 0.6 hrs

65
Non-BZ BZ Receptor Agonists

• Eszopiclone (LUNESTA)
• Zaleplon (SONATA)
• Zolpidem (AMBIEN)

66
Melatonin Receptor Agonist Ramelteon (ROZEREM)

• MT1 MT2 receptor agonist
• Simulates melatonin (circadian rhythm)
• 8 mg
• Rapid onset, Tmax 45 min
• Low bioavailability, 70 protein-bound
• CYP 1A2 (fluvoxamine caution)
• Not controlled substance

67
Zolpidem (AMBIEN)

• Usual dose range 5 10 mg, 1/2 hr before
  appointment
• Onset 0.5-1 hr (peak levels in 1.6 hrs)(use
  when rapid onset needed)
• Duration 2 3 hrs
• Contraindications allergy
• Precautions reduce dosage in elderly
• Active metabolites? No

68
Zolpidem

• Pregnancy category B
• Availability 5- and 10-mg tabs

69
Hydroxyzine (ATARAX, VISTARIL)

• Usual dose range 50 100 mg, 1 hr before
  appointment (adults), 1.1 2.2 mg/kg (children)
• Onset 30 min (peak effect 2 hrs)
• Duration 3 4 hrs
• Contraindications allergy
• Precautions same as for benzodiazepines, more
  anticholinergic actions (glaucoma, respiratory
  disease)

70
Hydroxyzine

• Active metabolites? No
• Pregnancy category D
• Availability 10-, 25-, 50- 100-mg tabs
  10mg/5 ml syrup (ATARAX) 25-, 50-, 100-mg caps
  and 25mg/5 ml oral suspension (VISTARIL)
• Non-controlled substance

71
Promethazine (PHENERGAN)

• Usual dose range 25 50 mg, 1 hr before
  appointment (adults), 2.2 mg/kg (children, when
  used as SOLE sedative agent)
• Onset 1 hr (peak effect 2 hrs)
• Duration 3 4 hrs (may be up to 12 hrs)
• Contraindications allergy, conditions worsened
  by anticholinergic actions
• Precautions same as for other sedatives, also
  seizure disorders

72
Promethazine

• Active metabolites? No
• Pregnancy category C
• Availability 12.5-, 25- 50-mg tabs 6.25 mg/5
  ml syrup 25 mg/5 ml syrup fortis
• Not a controlled substance

73
Agents NOT Recommended (Adults)

• Alcohol
• Chloral hydrate
• Opioids
• Multi-Drug Cocktails

74
Nitrous Oxide
75
Advantages of Nitrous Oxide

• Rapid onset (almost equal to that of iv)
• Titratable (up AND down)
• Depth of sedation readily altered
• Flexible duration of action
• Rapid recovery from sedation
• Safe

76
Advantages of Nitrous Oxide

• No injection required
• Very few side effects
• No adverse effects on vital organs
• May substitute for local anesthesia in selected
  circumstances (e.g., soft tissue procedures)

77
Disadvantages of Nitrous Oxide

• Initial cot of cumbersome equipment is high
• Continuing cots of gases high
• Equipment takes up operatory space
• Lack of potency
• Requires constant patient cooperation
• Chronic exposure of office personnel

78
Indications for Inhalation Sedation

• Mild to moderate dental anxiety
• Medically compromised patients
• Gagging (impressions, radiographs)

79
Relative Contraindications to Inhalation Sedation

• Severe dental anxiety fear
• Compulsive personalities
• Poor past experience with oral sedation
• Claustrophobia
• Pregnancy
• URI, COPD

80
Concentration Effect

• The higher the concentration of inhaled gas, the
  more rapidly the blood level of the gas increases

81
Diffusion Hypoxia (?)

• When the flow of nitrous oxide is stopped,
  nitrous oxide rapidly leaves the blood and
  dilutes the oxygen in the alveoli of lungs

82
Prevention of Diffusion Hypoxia

• Administer 100 oxygen for 3 to 5 minutes at the
  termination of the sedation procedure

83
CNS Effects of Nitrous Oxide

• All senses are slightly depressed or altered
  (perioral numbness, etc.)
• Amnesia does NOT occur
• Mild depression of cerebral cortex
• Produces mild sedation, analgesia
• Lacks direct respiratory depression

84
Nitrous Oxide Does NOT...

• Obtund sharp pain impulses
• Substitute for good local anesthesia
• Sedate agitated or extremely anxious patients
• Produce loss of consciousness when used correctly

85
Why Nitrous Oxide is Associated with Nausea

• Not titrated
• All patients are given fixed concentrations
  (usually 50)
• Signs and symptoms of impending nausea and
  vomiting are not recognized
• Patients are not given appropriate pre-treatment
  instructions

86
Other Effects of Nitrous Oxide

• Cardiovascular no clinically significant
  effects at recommended concentrations
• Cutaneous vasodilation (flush, warmth)
• Respiratory no clinically significant
  depression at recommended concentrations
• G.I. Tract no effects liver)

87
Other Effects of Nitrous Oxide

• Kidneys no effect
• Blood inhibition of vitamin B-12 metabolism
  (chronic administration)
• Skeletal muscle no direct effect (relaxation
  secondary to sedative effect)

88
Contraindications to Nitrous Oxide

• Pregnancy (1st trimester)
• Upper respiratory tract infection
• Nasal hood unacceptable (claustrophobia, allergy,
  etc.)
• Previous bad experience
• Drug abuse
• Chronic environmental exposure

89
Effects of Pathologic Conditions on Inhalation
Sedation

• Emphysema decreased total surface area of
  alveoli
• Pneumonia alveolar walls thickened
• Asthma increased thickness of bronchial
  secretions
• Anemia/Methemoglobinemia decreased
  oxygen-carrying capacity of blood

90
Physiologic Equivalents

• Total gas flow (LPM) minute respiratory volume
• Excursion of reservoir tidal volume
• Excursions of reservoir bag/min respiratory
  rate respiratory center firings
• Collapse of reservoir bag with maximum inhalation
  inspiratory reserve capacity

91
Complications and Chronic Toxicity
92
Excessive Perspiration

• Etiology peripheral vasodilation
• Management decrease nitrous oxide concentration
  (5 per min)

93
Expectoration

• Etiology fluid removal problems, diminished
  patient coordination and cooperation
• Management efficient vacuum operation, rubber
  dam

94
Behavioral Problems

• Etiology authoritarian patient, excessive
  nitrous oxide concentrations
• Management decrease nitrous oxide
  concentration, allow controlled mouth breathing
  if necessary

95
Nausea

• Etiology excessive length and/or depth of
  sedation, over-emotional patient, over-eating,
  frequent changes in patient position (esp.
  pediatrics), frequent changes in nitrous oxide
  concentration
• Management avoid etiologic factors, premedicate
  with anti-emetic drug

96
Vomiting

• Etiology same as for nausea
• Management remove nasal hood, turn patients
  head to assistant, change gas mixture to 100
  oxygen, apply 100 oxygen for at least 5 min and
  inform patient

97
Pre-Operative Instructions

• 1. Take pre-operative medications (if indicated)
• 2. No heavy meals (or no food intake at all) for
  4 hrs prior to sedation
• 3. Require an escort (if indicated or otherwise
  required)

98
Chronic Exposure to Nitrous Oxide
99
Mutagenicity of Nitrous Oxide?

• Negative in Salmonella microsome assays
• Negative in cultured hamster lung fibroblasts
• negative in hamster ovarian cells
• negative in Drosophila melanogaster
• No human studies

100
Carcinogenicity of Nitrous Oxide?

• Negative results in mice
• Human studies generally negative

101
Teratogenicity of Nitrous Oxide

• Definite teratogenicity in rats
• male rodents show chromosomal damage (not
  heritable, significance?)
• INCREASED RISK OF SPONTANEOUS ABORTION IN HUMANS
• Effects require chronic exposure

102
Dental Office Exposure to Nitrous Oxide
103
Sources of Environmental N2O

• Normal gas flow to patients
• Patient (talking, washout during recovery)
• Equipment (leaks)
• Air conditioning (recirculation)

104
Office Levels of N2O Depend on

• Frequency of use
• Size of operatory
• Ventilation of operatory
• Type of operatory (open vs. closed)

105
Detection of Office N2O

• Visual inspection (rubber goods, connections)
• Application of soapy water
• Air analysis (by outside service company)
  (infrared spectroscopy)
• Monitoring cartridges (Porter Peace of Mind
  cartridges)

106
Minimizing Office N2O

• Test for leaks
• Vent waste gases to outside
• SCAVENGE waste gases
• Air sweep (oscillating fan)
• Minimize patient talking
• Monitor office air quality

107
Effects of Scavenging Systems
108
Nitrous Oxide Levels (ppm) of Breathing Zones in
Offices Without With Scavenging Systems (from
Whitcher et al., JADA, 1977)

• WITHOUT
• General dentist 775 (/- 63)
• Pedodontist 940 (/-92)
• Oral Surgeon 1000 (/-130)

• WITH
• General dentist 21 (/-2)
• Pedodontists 33 (/-4)
• Oral Surgeon 36 (/-4)

109
Abuse of Nitrous Oxide
110
Mechanism of Chronic Toxicity

• Oxidation of vitamin B-12 (cobalamin bound
  co-factor for methionine synthetase and
  methylmalonyl CoA mutase)
• Interferes with folate metabolism and DNA
  synthesis (decreased thymidine)

111
Clinical Effects of Chronic Toxicity

• Bone marrow suppression, anemia, leukopenia
• Suppression of neutrophil chemotaxis
• Alterations in reproductive cells
• Peripheral neuropathy with subacute degeneration
  of spinal cord
• Layzer, R.B. Lancet 21227, 1978

112
Flumazenil (ROMAZICON)

• Competes with benzodiazepine for receptor site
• Used to reverse CNS depressant effects of
  overdose and to decrease recovery time
• REVERSAL OF RESPIRATORY DEPRESSION NOT
  PREDICTABLE
• Short half-life (readministration often required)

113
Sublingual Injection of Flumazenil?

• Average time to reversal with IV route 2
  minutes
• Average time to reversal with SL route 4.33
  minutes

114
Flumazenil

• Only BZ antagonist available
• Can produce agitation, confusion, dizziness
  nausea
• Can precipitate withdrawal syndrome (chronic BZ
  use)
• Can produce seizures cardiac arrhythmias in
  patients taking tricyclic antidepressants
• Usual dose 0.2 mg iv in 15 secs, evaluate in 45
  secs. Add additional 0.2 mg if needed
• Repeat q. 5 min until recovery or total dose of 1
  mg

115
Fundamentals of Emergency Preparation

• 1. Training (BLS, ACLS, PALS, TSBDE-approved
  courses)
• 2. Development and implementation of an
  emergency plan
• 3. Purchase and maintenance of emergency
  equipment and drugs
• 4. Periodic mock emergency drills
• 5. Training new staff members

116
What Your EMS Personnel Want and NEED!

• An accurate medical history of the patient/victim
• A concise description of everything that happened
• Doctor remains with patient/victim

117
Pre-Emptive Strategies for Dental Office
Emergency Preparation and Management

• Painstakingly detailed health history
• Medical risk classifcation
• Avoid potential drug interactions
• Calculate dental drug dosages carefully
• Monitor, monitor, monitor!!!
• IMPLEMENT AN OFFICE EMERGENCYN PLAN

118
A General Paradigm for Assessing and Managing
ASA II-IV Patients

• Monitor vital signs at every appointment
• Know patients medications and why they are
  taking them
• Consult the physician to determine degree of
  disease control, compliance and ability of
  patient to tolerate dental procedure
• Utilize the stress-reduction protocol
• Plan for likely emergencies

119
Stress-Reduction Protocol (Medically Compromised
Patients)

• 1. Recognize medical risk
• 2. Consult patients physician(s)
• 3. Pharmacosedation, as indicated
• 4. Short appointments
• 5. Morning appointments
• 6. Excellent intraoperative pain control
• 7. Minimize waiting room time
• 8. Excellent post-operative pain control

120
Range of Dental Office Emergencies

• Syncope
• Nausea, vomiting
• Hyperventilation
• Acute bronchial constriction/asthma
• Seizures
• Acute elevations in BP and HR
• Acute depressions in BP and HR
• Hypoglycemia
• Acute CNS/respiratory depression
• Swallowing/aspirating foreign object

121
Adverse events associated with outpatient
anesthesia in Massachusetts

• Deramo EM, Bookless SJ, Howard JB
• J. Oral Maxillofac. Surg. 200361793-800

122
Methods and Outcomes from DEramo et al.

• Morbidity data from 157 oral surgeons for year
  1999
• Syncope was most common complication (1 in 160
  patients receving local anesthesia)

123
Types of Emergency Drugs and Drug Kits

• None (or expired)
• Custom (homemade)
• Pre-assembled, commercial
• Complete medical emergency crash carts
• Published lists
• ACLS Core Drugs

124
Office Emergencies and Emergency Kits

• ADA Council on Scientific Affairs
• JADA 2002133(3)364-365

125
Proprietary emergency drug kits are available,
but none of these kits is compatible with the
needs of all practitioners.

• ADA Council on Scientific Affairs
• 2002

126
Minimum Emergency Drugs Recommended by ADA CSA

• Epinephrine 11,000
• Injectable antihistamine
• 100 oxygen with positive-pressure ventilation
• Nitroglycerin (sublingual/aerosol)
• Bronchodilator (inhaler)
• Sugar (or glucose)
• Others as training and needs mandate

127
Essential Emergency Drugs (Haas, Dent. Clin. N.
Am., 200246815-830)

• Oxygen
• Epinephrine
• Nitroglycerin
• Antihistamine
• Beta agonist (bronchodilator)
• Aspirin

128
Supplementary Emergency Drugs(Haas, 2002)

• Glucagon
• Atropine
• Ephedrine
• Hydrocortisone
• Morphine (or nitrous oxide)
• Naloxone
• Lorazepam or midazolam (seizures)
• Flumazenil

129
Proprietary emergency drug kits are available,
but none of these kits is compatible with the
needs of all practitioners. The Council on
Scientific Affairs does not recommend any
specific proprietary drug kit.

• JADA 2002133(3)364-365

130
Oxygen Cylinders and Volumes

• E 625 liters
• H 6,909 liters

131
Time Available at 15 L/min Flow Rate (from 2,000
psi fill)

• E cylinder 41 minutes
• H cylinder 460 minutes
• Reduce times by ½ at 1,000 psi

132
Appropriate Use of Oxygen

• Any suspected cardiopulmonary emergency
• Complaints of shortness of breath and suspected
  ischemic pain
• For patients with suspected stroke or unknown
  blood oxygenation
• May be administered to patients who are not
  hypoxemic

133
Precautions Oxygen

• Observe closely when using with patients known to
  be dependent on hypoxic drive (COPD very rare)
• Pulse oximetry may provide a useful method of
  assessing oxygenation (may be inaccurate in low
  cardiac output, with vasoconstriction or with CO
  poisoning)

134
Oxygen Flow Requirments (ACLS)

• Nasal cannula 1-6 L/min, 21-44
• Venturi mask 4-12 L/min, 24-50
• Partial rebreather mask 6-10 L/min, 35-60
• Nonrebreather mask with reservoir 6-15 L/min
• Bag-mask with nonrebreather tail 15 L/min,
  95-100

135
Positive-Pressure Ventilation

• A nitrous oxide nasal hood CAN NOT provide
  positive-pressure ventilation

136
Supplementary Oxygen vs. Positive-Pressure
Ventilation with 100 Oxygen
137
Epinephrine

• Only injectable agent which should be available
  in ALL dental offices
• Use pre-loaded syringes (not ampuls)
• Use 11,000 by sublingual or I.M. route only
• Adult dose 0.3 mg, q. 5-10 min monitor CV
  status before re-dosing
• Produces bronchodilation, cardiac stimulation and
  vasoconstriction

138
Epinephrine Precautions

• Elevations of BP and increased HR may cause
  ischemia, increased O2 demand and dysrhythmias
• Avoid accidental injection of rescuer

139
Whenever epinephrine or another emergency drug is
administered, medical assistance must be summoned
140
Other Bronchodilators

• Beta-2 Agonists
• Terbutaline

141
Beta-2 Adrenergic Agonists

• Albuterol (VENTOLIN)(first choice)
• Metaproterenol (ALUPENT)
• Terbutaline (BRETHAIRE)
• Peak onset 30-60 minutes

142
Albuterol (PROVENTIL, VENTOLIN)

• Use by inhalation route for emergency airway
  constriction
• May produce sympathomimetic CV effects
  (tachycardia, palpitations, elevated BP)
• May be ineffective or partially effective if
  patient taking beta blockers

143
Nitroglycerin

• Available in 0.4 mg sublingual tabs
• Decreases cardiac work load
• Administer 1 tab q. 5 min up to 3 times
• Also available in spray form (more stable)(1-2
  sprays q. 5 min up to 3 sprays)
• May produce hypotension (do not use if
  hypotension present)

144
Nitroglycerin Precautions

• Avoid in patients taking drugs for ED
• May cause excessive decrease in BP with syncope
  (patient should be in sitting or reclined
  position when taking)

145
Aromatic Spirits of Ammonia

• Irritates respiratory mucosa, causes muscle
  contractions, improves venous return
• Dose inhaled vapors of one crushed ampul
• Supplied as 0.3 ml vaporole

146
Glucose/Sucrose

• Acceptable forms of sucrose include soft drinks,
  orange juice candy bars
• Glucose also available
• Do not use oral dose forms in unconscious patient
  
• Long onset (10 min)

147
Antihistamines

• Diphenhydramine (BENADRYL) (50 mg/ml)
• Chlorpheniramine (CHLOR-TRIMETON) (10 mg/ml)
• DO NOT subsitute for epinephrine in anaphylaxis

148
Aspirin

• Indicated in all patients with ACS
• Any person with symptoms of pressure, heavy
  weight, squeezing, or crushing (suggestive
  of ischemia)
• DO NOT administer in aspirin-allergic patients
• Relatively contraindicated in ulcer disease or
  asthmatics

149
Aspirin Dosage

• 160 325 mg non-enteric coated tablets ASAP
• Chewing is preferred
• May use rectal suppository form (if available)

150
Atropine

• Indicated for bradycardia
• Rapid onset, short duration
• 0.5 mg i.m. q. 3-5 min up to total of 3 mg
• Avoid excessive reductions of heart rate and use
  in patients susceptible to adverse
  anticholinergic effects
• Also used for organophosphate poisoning

151
References

• Malamed, Sedation A Guide to patient
  management, 4th edition, 2003
• Jackson Johnson, Conscious sedation for
  dentistry risk management and patient
  selection, Dent. Clin. N. Am. Vol. 46, 2002
• American Dental Association, Guidelines for the
  use of conscious sedation, deep sedation and
  general anesthesia, 2007.

152
Local Anesthetic Dosages

• ALWAYS calculated on basis of body weight (mg/kg)
• Absolute maximum dosage reached at body weight of
  70 kg (150 lbs)
• Apply to a single appointment
• Adjusted downward to compensate for drug
  interactions, medical conditions

153
Maximum Doses of Selected Local Anesthetics

• Lidocaine (4.4 mg/kg, 300 mg absolute)
• Mepivacaine (4.4 mg/kg, 300 mg absolute)
• Prilocaine (6 mg/kg, 400 mg absolute)
• Articaine (7 mg/kg, 500 mg absolute)
• Bupivacaine (1.3 mg/kg, 90 mg absolute)

154
Other Informational Resources

• Mosbys Drug Consult, 800-545-2522
• Mosbys Dental Drug Reference, www.elsevierhealth.
  com
• Drug Interaction Facts, Facts Comparisons,
  800-223-0554
• www.rxlist.com
• www.drugfacts.com
• www.med.umich.edu/1lib/aha/umherb01

155
Local Anesthetics
156
Approaches to Failed IABs

• Reinject (if lower lip not numb)?
• Increase local anesthetic concentration
  (prilocaine, articaine)?
• Increase the vasoconstrictor concentration?
• Wait?
• Apply the Volume Rule?
• Apply the Real Estate Rule?

157
How long should you wait?

• Varies with anesthetic and tissue
• Lip 5-7 minutes
• Pulps 10-15 minutes
• gt15 minutes (1 in 4 patients)
• gt30 minutes (1 in 10 patients)
• Longer-acting anesthetics have longer onsets
  (Marcaine)

158
Malamed et al., JADA 2000, 2001

• 2 lidocaine with 1100K epi vs. 4 articaine
  with 1100K epi
• 882/443 articaine/lidocaine subjects
• Used simple (single extractions, etc) and
  complex (alveolectomies, etc) for evaluations
• Articaine is an efffective agent acting in the
  standard lidocaine-mepivacaine range
• Clinical performance not sufficiently different
  to qualify it as a replacement for lidocaine

159
Articaine vs. Other Agents

• Absolute max dose (carts) lt lidocaine (7.3 vs.
  8.3)
• Pregnancy category C (lidocaine B)
• Available with 1100,000 and 1200,000 epinephrine

160
Anesthetic Efficacy of Articaine for IABs in
Patients with Irreversible Pulpitis

• Claffey E. et al. J. Endo. 200430568-71

161
Claffey et al./Articaine

• 72 cases of irreversible pulpitis
• Compared 4 articaine 2.2 ml vs. 2 lidocaine
  with 1100K epi 2.2 ml
• All patients had numb lips
• Endo access started 15 min post numbness
• Success rates 24 for articaine 23 for
  lidocaine

162
Results from Nusstein et al., J. Endo. 2003

• 33 emergency patients with irreversible pulpitis
  (mandibular posterior teeth with failed
  conventional IAB)
• X-tip injection of 1.8 ml (2 lidocaine with
  1100K epi)
• 18 backflowed (no success)
• 82 of remaining injections successful

163
Review of Intraosseous Injection Systems ADA
Professional Product Review, Volume 2, Issue 1,
Winter 2006

• Stabident
• X-Tip
• Intraflow (not evaluated)
• Clinical performance best feature
• X-Tip easiest to use
• Tachycardia most common concern

164
Results from Replogle et al. (1999)

• 67 of ASA I patients receiving IO injections of
  lidocaine 2 with 1100K epi experienced
  significantly increased HR
• Tachycardia averaged 28 bpm lasted average of
  4-5 min
• Systolic diastolic BP unchanged
• No increased HR observed with 3 mepivacaine

165
Paresthesia

• An altered sensation of numbness, burning or
  pricking that may reflect an alteration in the
  sensation of pain in the distribution of a
  specific sensory nerve.

166
Proposed Causes of Paresthesia

• Direct nerve trauma by needle
• Barbed needles (fish hook effect)
• Intraneural hematoma
• Chemical toxicity of local anesthetics/high
  concentration local anesthetic (4)
• Surgical procedures following local anesthetic
  injection
• Neural ischemia (vasoconstrictor???)

167
An inferior alveolar nerve block can cause
occasional peripheral nerve damage. The exact
mechanism is unknown and there is no known
prevention or treatment.

• Pogrel MA, Thamby S. JADA 2000131901-907

168
Haas, D. J. Am. Coll. Dent. 2006

• Focused on NON-SURGICAL cases
• Evaluated in vitro and human clinical outcomes
• All agents have potential for neurotoxicity,
  probably dose (concentration)-dependent
• Nerves with fewer fasicles may be more
  susceptible (e.g., lingual)
• RCTs not likely to discriminate differences
  between various local anesthetics

169
Summary of Findings in IAB-Related Paresthesias

• 50 of patients experience electric shock
  sensation
• 85-94 of cases recover in 8 wks or less
• Tongue (79) and lower lip most frequently
  affected
• No difference between right and left sides
• Nerve damage cannot be visualized or corrected
  surgically
• Overall incidence of permanent paresthesia
  1785,000

170
Conclusions of Haas (2006)

• Data are strongly suggestive that paresthesia
  more likely with 4 agents
• Concentration, not drug per se cause
• Cited Royal College of Dental Surgeons (Ontario,
  2005) (risks may outweigh benefits of 4
  solutions for inferior alveolar and lingual
  blocks)

171
Avoiding Paresthesia

• Use the lowest practical anesthetic and
  vasoconstrictor concentrations
• Use the atraumatic injection technique
• Check your cartridges
• Dont subject your cartridges to temperature
  extremes
• Avoid operative neural trauma (careful use of
  forceps, elevators, rubber dam clamps, etc.)

172
New Perspectives on Pain Control in Patients With
Cardiovascular Disease
173
E-References, Antiplatelet Drugs

• Antman EM et al. Use of Nonsteroidal
  Antiinflammatory Drugs. An Update for
  Clinicians. A Scientific Statement from the
  American Heart Association. Circulation,
  February 26, 2007
• http//www.circ.ahajournals.org/cgi/content/full/1
  15/6/813

174
NSAID Classes

• Salicylic acid derivatives (diflunisal/DOLOBID)
• P-Aminophenols (acetaminophen/TYLENOL)
• Indole acetic acids (etodolac/LODINE)
• Aryl acetic acids (diclofenac/VOLTAREN,
  ketorolac/TORADOL)
• Propionic acids (ibuprofen/MOTRIN,
  naproxen/ANAPROX, ketoprofen/ORUDIS,
  flurbiprofen/ANSAID)
• Fenamates (mefenamic acid/PONSTEL)
• Alkanones (nabumetone/RELAFEN)
• Diarylheterocycles (selective COX-2 inhibitors)

175
Beneficial Effects of NSAIDs

• Analgesic (relieve pain)
• Antipyretic (reduce fever)
• Anti-inflammatory
• Available OTC

176
The Oxford League Table of Analgesic Efficacy

• www.jr2.ox.ac.uk/bandolier/booth/painpag/Acutrev/A
  nalgesics/lftab.html

177
Oxford League Table of Analgesic Efficacy/NNTs
(www.jr2.ox.ac.uk/bandolier)(moderate-severe pain)

• Valdecoxib 40 mg 1.6
• Ibuprofen 800 mg 1.6
• Ketorolac 20 mg/60 mg 1.8
• Diclofenac 100 mg 1.9
• Rofecoxib 50 mg 1.9
• APAP 1,000 mg codeine 60 mg 2.2
• APAP 500 mg oxycodone 5 mg 2.2
• Naproxen 440 mg 2.3
• Ibuprofen 600 mg 2.4
• Ibuprofen 400 mg 2.4
• Morphine 10 mg i.m. 2.9

178
Relative Efficacy of Oral Analgesics After Third
Molar Extraction

• Barden J, Edwards, JE, McQuay HJ, Wiffen PJ,
  Moore RA
• British Dental Journal 2004197407-411

179
NNTs from Barden et al.

• Valdecoxib 40 mg (BEXTRA) 1.6
• Diclofenac 100 mg (VOLTAREN) 1.6
• Ibuprofen 400 mg 4.7
• Ibuprofen 200 mg 4.6
• Ibuprofen 600 mg 1.9
• Celecoxib (CELEBREX) 4.8
• APAP 1,000 mg 3.8
• APAP 600 mg codeine 60 mg 2.5
• APAP 300 mg codeine 30 mg 3.3

180
Contraindications to NSAIDs

• Stomach problems
• Aspirin Allergy
• Bleeding
• Pregnancy
• Kidney disease
• CARDIOVASCULAR DISEASE/RISK OF THROMBOEMBOLISM

181
Conditions With Risk for NSAID-Induced Nephropathy

• Volume depletion/dehydration (diarrhea,
  vomiting)
• Renal insufficiency
• Heart failure
• Diabetes
• Advanced age
• Kharasch, E. Anesth. Analg. 2004981-3

182
COX-2-Selective Inhibitors
183
Selecting new drugs for pain control
evidence-based decision or clinical impression?

• Jeske, AH. JADA 20021331052-6

184
Conclusions

• VIOXX 400 mg ibuprofen
• VIOXX has 50 rescue rate within 24 hrs
• Ibuprofen VIOXX G.I. problems for 30 days
• VIOXX not OTC

185
Single dose oral celecoxib for postoperative pain
(Barden J et al. Cochrane Review Issue 3,
2004)

• Similar in efficacy to aspirin 650 mg and APAP
  1,000 mg
• Evaluated 200-mg dose (more studies needed for
  400-mg dose)
• Moderate to Severe Post-Op Pain
• 4-6 Hours

186
The Use of COX-2 Inhibitors for Acute Dental
Pain A Second Look

• Huber, MA and Terezhalmy, GT. JADA 2006137480-7

187
Unresolved Issues NSAIDs

• COX-2 constitutively expressed in some tissues
  (brain, kidney, ovary uterus)
• COX-2-synthesized PGs are pro-inflammatory early,
  may reduce inflammation promote healing later
• Is opioid-sparing effect significant?
• Cardiovascular side effects? (prostacyclin vs.
  thromboxane A-2, salt and water retention)

188
COX-2 inhibitors

• Celecoxib (CELEBREX)
• Rofecoxicb (VIOXX)
• Etoricoxib (ARCOXIA)
• Lumiracoxib (PREXIGE) (Thromboxane antagonist???)
• Valdecoxib (BEXTRA)

189
Effects of NSAIDs on Platelet Aggregation

• Thromboxane A2 vasoconstrictor, promotes
  platelet aggregation
• PG I2 Vasodilator, inhibits platelet
  aggregation
• COX-2 inhibitors prevent synthesis of PG I2 but
  have no effect on TX A2, resulting in a
  prothrombotic state

190
Use of NSAIDs. An update for clinicians. A
Scientific Statement from the American Heart
Association

• Antman, E. M. et al.
• Circulation
• February 26, 2007

191
AHA Recommendations 2007 for Patients With
Cardiovascular Disease

• Acetaminophen, aspirin and opioid analgesics
  (incl. tramadol) preferred for short-term pain
  management
• If NSAID is needed, naproxen appears to be the
  preferred choice
• Prescribe at lowest effective doses for shortest
  possible period of time
• Diclofenac not recommended as NSAID in this group
  of patients
• Ibuprofen should be given 30 mins AFTER low-dose
  aspirin or 8 hrs before (if use concomitantly)

192
PRECISIONcoming to a journal near you!

• Prospective Randomized Evaluation of Celecoxib
  Integrated Safety vs Ibuprofen or Naproxen
• www.clinicaltrials.gov
• No. NCT00346216

193
Single Dose Oral Acetaminophen for Postoperative
Pain (Barden J et al., Cochrane Review, Issue 3,
2004)

• 325 mg, 500 mg, 650 mg, 975-1,000 1,500 mg
  doses vs. placebo
• 1,000 mg 1,500 mg (NNT 3.8 vs. 3.7)
• Adverse Effects of 975-1,000 mg placebo (!)

194
Preferred Oral Opioid Analgesics

• Tylenol with codeine 2 (2 or 3 q. 4 h.)
• Hydrocodone 2.5 or 5 mg with 500 mg APAP (1 or 2
  q. 4 - 6 h.)
• Oxycodone 5 mg with 500 mg APAP (e.g., TYLOX) (1
  or 2 q. 4 - 6 h.)
• Oxycodone 5 mg with 400 mg ibuprofen (COMBUNOX)

195
Other Oral Opioid Analgesics

• Tramadol (ULTRAM) 50 -
  100 mg q.4 -6 h. (now available
  with APAP as ULTRACET, 35/325)
• VICOPROFEN 1 tab q. 4 6 h.
• Pentazocine (TALWIN COMPOUND, TALACEN)
• Propoxyphene (DARVON COMPOUND, DARVOCET)
• VOPAC (650 mg APAP 30 mg codeine)

196
MAGNACET (March, 2007)

• Oxycodone acetaminophen 400 mg (?)
• 2.5, 5, 7.5 and 10 mg oxycodone (?)
• Schedule II
• Moderate to moderately-severe pain
• Gives physicians flexibility
• Compare with PERCOCET, TYLOX COMBUNOX

197
Results from Dionne, R. J. Oral Max. Surg.
57673, 1999

• Compared 400 mg ibuprofen 2.5, 5 and 10 mg
  oxycodone
• Only 10 mg oxycodone was superior to 400 mg
  ibuprofen alone
• Opioid adverse effects were dose-related
• 65 drowsy, 20 nauseated 16 vomited at 10 mg
  oxycodone