and Anxiety Control in Dentistry and Anxiety Control in Dentistry by malj

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									 Evidence-Based Perspectives on Pain
  and Anxiety Control in Dentistry

       Dr. Arthur Jeske
Utah Dental Association, 2/15/08
Today’s 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
The opinions expressed in this course
  are those of the speaker and not
 necessarily those of the Utah Dental

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
American Dental Association
        As adopted by the October 2007 ADA
                House of Delegates
        A minimally depressed level of
consciousness produced by a pharmacologic
   method that retains the patient’s 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.
      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
• “total aggregate dose must not exceed 1.5 MRD”

 Balancing Efficacy and
Safety in the Use of Oral
   Sedation in Dental
     Dionne RA et al. JADA
Benzodiazepines safe but poorly
documented in the office setting”

 Conscious sedation, including
    incremental triazolam,
   documentation, facilities
  equipment and personnel as
  described in ADA and AAPD
Consensus (Dionne et al., 2006)
• Oral sedative = wide margin of safety in
• Most serious events = respiratory
• State regulation required to ensure safety
• More research needed for “incremental
  dosing” techniques
• 0.25 mg triazolam X 2 >>0.5 mg single
           Sedation Modifications.
            How Will the Proposed
           Guidelines Affect Your

      Lynch, K. AGD Impact July 2007;48-54
               AGD White Paper at:
Here’s 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
Conscious Sedation Guidance
       Coulthard, P. J. Evid. Based Dent.,
    The Scottish Dental Clinical Effectiveness
            Coulthard, 2006
• 48 recommendations
• To be updated 2008
• Included general
  systematic reviews
  (Cochrane Library) and
  specific studies
  (Medline, Embase &
  Cochrane Library)
  Recommendations: Referral
• Discuss alternative methods of anxiety
  management with patient
• Ensure that definition of “conscious
  sedation” is met
 Recommendations: Assessment
     and Record Keeping
• Discuss all aspects of sedation procedure
  with patient
• Provide written instructions
• Obtain informed consent
• Maintain and update patient records
 Recommendations: Environment
        and Facilities
• Ensure that environment is safe
• Correct equipment and drugs
• Emergency drugs and equipment
  immediately available
  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
Recommendations: Techniques
• “Titrated dose of nitrous oxide”
• Oral, transmucosal and i.v. “require” pulse
  oximetry and BP monitoring
 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
      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
  Utah Dentist and Dental
Hygienist Practice Act Rules

Scope of Practice—Anesthesia and
        Analgesia Permit
Conscious Sedation for
    Dental Anxiety
 Cochrane Database of Systematic
          2007, Issue 1
     Primary Outcomes To Be
• Changes in anxiety scores
• Reliability and validity of anxiety
  measurement instruments/scales

An internal, emotional response;
a specific unpleasurable sense
state of tension which indicates
 the presence of some danger

A 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 Flight”

       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
“Bottom-Line” Requirements for
  Minimal/Conscious Sedation
• Comfort
• Consciousness
• Cooperation
     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.
      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
Advantages of Oral Sedation
    • Universal acceptability
    • Ease of administration
    • Low co$t
    • 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
Disadvantages of Oral Sedation
•   Reliance on patient compliance
•   Prolonged, variable onset of action
•   Unreliable absorption of drug from G.I. tract
•   Prolonged duration of action
•   Ineffective in anxiety levels > mild
•   Adverse interactions of sedative drugs

An unexpected, unpredictable
 adverse or undesirable drug
  Indications for Oral Sedation

• Mild to moderate dental
• To assist with restful sleep on
  night before dental
      Contraindications to Oral
• 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
  What causes the sudden
   death of a patient?
• Respiratory arrest with or without airway
• 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
      Oral Sedation: “Unfilled
• 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 night’s sleep” the night before the
  dental procedure
Sedation should NOT be
used to control pain and
does NOT substitute for
 good local anesthesia
   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)
    Factors Influencing Oral Drug

•   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
Alpha Distribution Phase

  The phase in which sedative
 activity is initiated & ended, by
  entry into and removal from
              the CNS
Beta Elimination Phase

  The phase in which a sedative
  drug is inactivated by hepatic
     metabolism & excretion
    Margin of Safety
    The difference between the
effective therapeutic dose and the
dose that produces severe or life-
    threatening adverse effects
    Reasons NOT to used BZs…
•   Allergy
•   Narrow angle glaucoma
•   Chronic BZ ingestion…???
•   Tricyclic antidepressant therapy…???
•   Adversely interactive drugs (e.g., azole
           Characteristics of
• Facilitate binding of GABA (endogenous
  inhibitory transmitter)
• More favorable therapeutic index than older
• Can produce anterograde amnesia
• Agents differ in onset, duration & metabolism
• Agents differ in regard to sedation vs.
    Boxed Warning: BZs
   “sleep driving” (with no memory)
       “severe allergic reactions”
 Pharmacokinetics and Clinical Effects of
 Multidose Sublingual Triazolam in Healthy
  Volunteers. Jackson DL et al. J. Clin.
     Psychopharmacol. 2006;26(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
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
    Classification of Benzodiazepines
•   Alprazolam: antianxiety
•   Diazepam: antianxiety
•   Lorazepam: antianxiety/sedative-hypnotic
•   Midazolam: sedative/hypnotic
•   Oxazepam: antianxiety
•   Triazolam: sedative/hypnotic
       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)
• Active
  metabolites? Yes
• Pregnancy
  category D
• Availability: 2-, 5-
  & 10-mg tabs, 5
  mg/ml liquid, rectal
  gel 5 mg/ml
        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
• Contraindications: allergy, narrow-angle
• Precautions: greater likelihood of excessive
  sedation than with other agents, do not use in
  cases of depressive disorder/psychosis
• Active
  metabolites? No
• Pregnancy
  category D
• Availability: 0.5-, 1
  and 2-mg tabs
       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
• Pregancy           Oxazepam
  category D
• Availability: 10-,
  15- & 30-mg
  caps, 15-mg tabs
       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)
• Active metabolites? No
• Pregnancy category X
• Availability: 0.125- & 0.25-mg tabs
          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

Onset:                     1 hr.

Peak effect:               1.3 hrs.

Duration:                  2 – 3 hrs.
           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
• Active metabolites?
• Pregnancy category
• Availability: 0.25-,
  0.5, 1- & 2-mg tabs,
  0.5- and 1 mg/ml
• 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
• Precautions: may cause intense
  CNS/respiratory depression, use with
  caution with potent CYP 3A4 inhibitors
  (e.g., azole antifungals) NOT TO BE
• Active metabolites? No
• Pregnancy category D
• Availability: 2 mg/ml syrup
    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
 Non-BZ BZ Receptor Agonists
• Eszopiclone (LUNESTA)
• Zaleplon (SONATA)
• Zolpidem (AMBIEN)
    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
        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
• Pregnancy category B
• Availability: 5- and
  10-mg tabs
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)
• 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
• Non-controlled substance
  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
• 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
 Agents NOT Recommended
• Alcohol
• Chloral hydrate
• Opioids
• Multi-Drug Cocktails
Nitrous Oxide
    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
    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
Disadvantages of Nitrous Oxide
• Initial co$t of cumbersome equipment is
• Continuing co$ts of gases high
• Equipment takes up operatory space
• Lack of potency
• Requires constant patient cooperation
• Chronic exposure of office personnel
 Indications for Inhalation Sedation
• Mild to moderate dental anxiety
• Medically compromised patients
• Gagging (impressions, radiographs)
Relative Contraindications to
    Inhalation Sedation
  •   Severe dental anxiety & fear
  •   Compulsive personalities
  •   Poor past experience with oral sedation
  •   Claustrophobia
  •   Pregnancy
  •   URI, COPD
Concentration Effect
     The higher the concentration
       of inhaled gas, the more
     rapidly the blood level of the
             gas increases
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
  Prevention of
Diffusion Hypoxia
Administer 100% oxygen for 3
to 5 minutes at the termination
   of the sedation procedure
    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
   Nitrous Oxide Does NOT...
• Obtund sharp pain impulses
• Substitute for good local anesthesia
• Sedate agitated or extremely anxious
• Produce loss of consciousness when used
       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
   Other Effects of Nitrous Oxide
• Cardiovascular: no clinically significant
  effects at recommended concentrations
• Cutaneous vasodilation (flush, warmth)
• Respiratory: no clinically significant
  depression at recommended
• G.I. Tract: no effects liver)
   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)
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
Effects of Pathologic Conditions on
        Inhalation Sedation
• Emphysema: decreased total surface
  area of alveoli
• Pneumonia: alveolar walls thickened
• Asthma: increased thickness of bronchial
• Anemia/Methemoglobinemia: decreased
  oxygen-carrying capacity of blood
      Physiologic Equivalents

• Total gas flow (LPM) = minute respiratory
• Excursion of reservoir = tidal volume
• Excursions of reservoir bag/min =
  respiratory rate = respiratory center
• Collapse of reservoir bag with maximum
  inhalation = inspiratory reserve capacity
Complications and
 Chronic Toxicity
       Excessive Perspiration
• Etiology: peripheral vasodilation
• Management: decrease nitrous oxide
  concentration (5% per min)
• Etiology: fluid removal problems,
  diminished patient coordination and
• Management: efficient vacuum operation,
  rubber dam
         Behavioral Problems
• Etiology: authoritarian patient, excessive
  nitrous oxide concentrations
• Management: decrease nitrous oxide
  concentration, allow controlled mouth
  breathing if necessary
• 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
• Etiology: same as for nausea
• Management: remove nasal hood, turn
  patient’s head to assistant, change gas
  mixture to 100% oxygen, apply 100%
  oxygen for at least 5 min and inform
     Pre-Operative Instructions
• 1. Take pre-operative medications (if
• 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)
Chronic Exposure to
   Nitrous Oxide
  Mutagenicity of Nitrous Oxide?
• Negative in Salmonella microsome assays
• Negative in cultured hamster lung
• negative in hamster ovarian cells
• negative in Drosophila melanogaster
• No human studies
 Carcinogenicity of Nitrous Oxide?
• Negative results in mice
• Human studies generally negative
  Teratogenicity of Nitrous Oxide
• Definite teratogenicity in rats
• male rodents show chromosomal damage
  (not heritable, significance?)
• Effects require chronic exposure
   Dental Office
Exposure to Nitrous
   Sources of Environmental N2O
• Normal gas flow to patients
• Patient (talking, “washout” during
• Equipment (leaks)
• Air conditioning (recirculation)
    Office Levels of N2O Depend on
•   Frequency of use
•   Size of operatory
•   Ventilation of operatory
•   Type of operatory (open vs. closed)
       Detection of Office N2O
• Visual inspection (rubber goods,
• Application of soapy water
• Air analysis (by outside service company)
  (infrared spectroscopy)
• Monitoring cartridges (Porter “Peace of
  Mind” cartridges)
          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
Effects of Scavenging
Nitrous Oxide Levels (ppm) of Breathing Zones in
Offices Without & With Scavenging Systems (from
             Whitcher et al., JADA, 1977)
•   WITHOUT                       • WITH
•   General dentist: 775          • General dentist: 21
    (+/- 63)                         (+/-2)
•   Pedodontist: 940 (+/-         • Pedodontists: 33 (+/-
    92)                              4)
•   Oral Surgeon: 1000            • Oral Surgeon: 36 (+/-
    (+/-130)                         4)
Abuse of Nitrous
   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)
 Clinical Effects of Chronic Toxicity
• Bone marrow suppression, anemia,
• Suppression of neutrophil chemotaxis
• Alterations in reproductive cells
• Peripheral neuropathy with subacute
  degeneration of spinal cord
• Layzer, R.B. Lancet 2:1227, 1978
   Flumazenil (ROMAZICON)
• Competes with benzodiazepine for
  receptor site
• Used to reverse CNS depressant effects
  of overdose and to decrease recovery time
• Short half-life (readministration often
Sublingual Injection of Flumazenil?
• Average time to reversal with IV route = 2
• Average time to reversal with SL route =
  4.33 minutes

• Only BZ antagonist available
• Can produce agitation, confusion, dizziness &
• Can precipitate withdrawal syndrome (chronic BZ
• 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
    Fundamentals of Emergency
• 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
 What Your EMS Personnel Want
          and NEED!
• An accurate medical history of the
• A concise description of everything that
• Doctor remains with patient/victim
     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!!!
          A General Paradigm for
 Assessing and Managing ASA II-IV Patients

• Monitor vital signs at every appointment
• Know patient’s 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
       Stress-Reduction Protocol
    (Medically Compromised Patients)
•   1. Recognize medical risk
•   2. Consult patient’s 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
            Range of Dental Office
•   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
Adverse events associated with
   outpatient anesthesia in
   D’eramo EM, Bookless SJ, Howard JB
   J. Oral Maxillofac. Surg. 2003;61:793-
    Methods and Outcomes from
          D’Eramo et al.
• Morbidity data from 157 oral surgeons for
  year 1999
• Syncope was most common complication
  (1 in 160 patients receving local
    Types of Emergency Drugs and
              Drug Kits
• None (or expired)
• Custom (“homemade”)
• Pre-assembled, commercial
• Complete medical emergency “crash
• Published lists
• ACLS “Core Drugs”
Office Emergencies and
     Emergency Kits

 ADA Council on Scientific Affairs
   JADA 2002;133(3):364-365
“Proprietary emergency drug kits
 are available, but none of these
kits is compatible with the needs
        of all practitioners.”

   ADA Council on Scientific Affairs
      Minimum Emergency Drugs
      Recommended by ADA CSA
•   Epinephrine 1:1,000
•   Injectable antihistamine
•   100% oxygen with positive-pressure ventilation
•   Nitroglycerin (sublingual/aerosol)
•   Bronchodilator (inhaler)
•   “Sugar” (or glucose)
•   Others “as training and needs mandate”
    “Essential” Emergency Drugs (Haas, Dent.
         Clin. N. Am., 2002:46:815-830)
•   Oxygen
•   Epinephrine
•   Nitroglycerin
•   Antihistamine
•   Beta agonist (bronchodilator)
•   Aspirin
“Supplementary” Emergency Drugs
         (Haas, 2002)
•   Glucagon
•   Atropine
•   Ephedrine
•   Hydrocortisone
•   Morphine (or nitrous oxide)
•   Naloxone
•   Lorazepam or midazolam (seizures)
•   Flumazenil
“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 2002;133(3):364-365
Oxygen Cylinders and Volumes
• E: 625 liters
• H: 6,909 liters
  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
   Appropriate Use of Oxygen
• Any suspected cardiopulmonary
• 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
       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)
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-
• Nonrebreather mask with reservoir: 6-15
• Bag-mask with nonrebreather “tail”: 15
  L/min, 95-100%
Positive-Pressure Ventilation

   A nitrous oxide nasal hood CAN
   NOT provide positive-pressure
  Supplementary Oxygen vs.
Positive-Pressure Ventilation with
          100% Oxygen
• Only injectable agent which should be available
  in ALL dental offices
• Use pre-loaded syringes (not ampuls)
• Use 1:1,000 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
     Epinephrine Precautions
• Elevations of BP and increased HR may
  cause ischemia, increased O2 demand
  and dysrhythmias
• Avoid accidental injection of rescuer
Whenever epinephrine or another
emergency drug is administered,
  medical assistance must be
       Other Bronchodilators
• Beta-2 Agonists

• Terbutaline
     Beta-2 Adrenergic Agonists
•   Albuterol (VENTOLIN)(first choice)
•   Metaproterenol (ALUPENT)
•   Terbutaline (BRETHAIRE)
•   Peak onset = 30-60 minutes
       Albuterol (PROVENTIL,
• 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
• 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)
    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)
  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”
• 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)
• Diphenhydramine (BENADRYL) (50
• Chlorpheniramine (CHLOR-TRIMETON)
  (10 mg/ml)
• DO NOT subsitute for epinephrine in
• 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
• Relatively contraindicated in ulcer disease
  or asthmatics
           Aspirin Dosage
• 160 – 325 mg non-enteric coated tablets
• Chewing is preferred
• May use rectal suppository form (if
• 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
• 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.
       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
Maximum Doses of Selected Local
•   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)
 Other Informational Resources
• Mosby’s Drug Consult, 800-545-2522
• Mosby’s Dental Drug Reference,
• Drug Interaction Facts, Facts &
  Comparisons, 800-223-0554
Local Anesthetics
  Approaches to Failed IABs…
• Reinject (if lower lip not numb)?
• Increase local anesthetic concentration
  (prilocaine, articaine)?
• Increase the vasoconstrictor
• Wait?
• Apply the “Volume Rule”?
• Apply the “Real Estate Rule”?
    How long should you

Varies with anesthetic and tissue
        Lip = 5-7 minutes
      Pulps = 10-15 minutes
  >15 minutes (~1 in 4 patients)
 >30 minutes (~1 in 10 patients)
 Longer-acting anesthetics have
    longer onsets (Marcaine)
Malamed et al., JADA 2000,
• 2% lidocaine with 1:100K epi vs. 4% articaine with
  1:100K 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
    Articaine vs. Other Agents
• Absolute max dose (carts) < lidocaine (7.3
  vs. 8.3)
• Pregnancy category C (lidocaine B)
• Available with 1:100,000 and 1:200,000
Anesthetic Efficacy of
 Articaine for IABs in
     Patients with
 Irreversible Pulpitis

Claffey E. et al. J. Endo.
 Claffey et al./Articaine
• 72 cases of irreversible pulpitis
• Compared 4% articaine 2.2 ml vs. 2%
  lidocaine with 1:100K epi 2.2 ml
• All patients had “numb lips”
• Endo access started 15 min post
• Success rates = 24% for articaine &
  23% for lidocaine
   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
  1:100K epi)
• 18% “backflowed” (no success)
                     » 82% of remaining injections
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
 Results from Replogle et al. (1999)

• 67% of ASA I patients receiving IO
  injections of lidocaine 2% with 1:100K 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%

     “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
    Proposed Causes of
• 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???)
“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
   Haas, D. J. Am. Coll. Dent.
• 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
Summary of Findings in IAB-Related
  • ~50% of patients experience “electric
    shock” sensation
  • 85-94% of cases recover in 8 wks or less
  • Tongue (79%) and lower lip most frequently
  • No difference between right and left sides
  • Nerve damage cannot be visualized or corrected
  • Overall incidence of permanent paresthesia =
   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)
       Avoiding Paresthesia…
• Use the lowest practical anesthetic and
  vasoconstrictor concentrations
• Use the atraumatic injection technique
• Check your cartridges
• Don’t subject your cartridges to temperature
• Avoid operative neural trauma (careful use of
  forceps, elevators, rubber dam clamps, etc.)
New Perspectives on Pain Control
 in Patients With Cardiovascular
     E-References, Antiplatelet
• 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
          NSAID Classes
•   Salicylic acid derivatives (diflunisal/DOLOBID)
•   P-Aminophenols (acetaminophen/TYLENOL)
•   Indole acetic acids (etodolac/LODINE)
•   Aryl acetic acids (diclofenac/VOLTAREN,
•   Propionic acids (ibuprofen/MOTRIN,
    naproxen/ANAPROX, ketoprofen/ORUDIS,
•   Fenamates (mefenamic acid/PONSTEL)
•   Alkanones (nabumetone/RELAFEN)
•   Diarylheterocycles (selective COX-2 inhibitors)
Beneficial Effects of NSAIDs
   • Analgesic (relieve
   • Antipyretic (reduce
   • Anti-inflammatory
   • Available OTC
The Oxford League Table of
    Analgesic Efficacy
     Oxford League Table of Analgesic
       •   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
 Relative Efficacy of Oral
Analgesics After Third Molar

  Barden J, Edwards, JE, McQuay
     HJ, Wiffen PJ, Moore RA
       British Dental Journal
       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
      Contraindications to NSAIDs
•   Stomach problems
•   Aspirin Allergy
•   Bleeding
•   Pregnancy
•   Kidney disease
Conditions With Risk for NSAID-
    Induced Nephropathy
• Volume depletion/dehydration
  (diarrhea, vomiting)
• Renal insufficiency
• Heart failure
• Diabetes
• Advanced age
• Kharasch, E. Anesth. Analg. 2004;98:1-3
COX-2-Selective Inhibitors
 Selecting new drugs for pain
   control: evidence-based
decision or clinical impression?
         Jeske, AH. JADA 2002;133:1052-6
• VIOXX = 400 mg
• VIOXX has 50%
  “rescue” rate within
  24 hrs
• Ibuprofen = VIOXX
  G.I. problems for
  30 days
  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
The Use of COX-2 Inhibitors
 for Acute Dental Pain: A
       Second Look
    Huber, MA and Terezhalmy, GT.
        JADA 2006;137:480-7
   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)
     COX-2 inhibitors
• Celecoxib (CELEBREX)
• Rofecoxicb (VIOXX)
• Etoricoxib (ARCOXIA)
• Lumiracoxib (PREXIGE) (Thromboxane
• Valdecoxib (BEXTRA)
  Effects of NSAIDs on Platelet
• Thromboxane A2 = vasoconstrictor,
  promotes platelet aggregation
• PG I2 = Vasodilator, inhibits platelet
• COX-2 inhibitors prevent synthesis of
  PG I2 but have no effect on TX A2,
  resulting in a prothrombotic state
 Use of NSAIDs. An update for
clinicians. A Scientific Statement
     from the American Heart
      Antman, E. M. et al.
      February 26, 2007
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
 PRECISION…coming to a
    journal near you!
    Prospective Randomized
Evaluation of Celecoxib Integrated
 Safety vs Ibuprofen or Naproxen
        No. NCT00346216
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 (!)
   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
Other Oral Opioid Analgesics

• Tramadol (ULTRAM): 50 -
  100 mg q.4 -6 h. (now available
  with APAP as ULTRACET,
• VICOPROFEN: 1 tab q. 4 – 6 h.
• Pentazocine (TALWIN
• Propoxyphene (DARVON
• VOPAC (650 mg APAP + 30 mg
    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 &
 Results from Dionne, R. J. Oral Max.
          Surg. 57:673, 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

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