Evidence-Based Perspectives on Pain
and Anxiety Control in Dentistry
Dr. Arthur Jeske
Arthur.H.Jeske@uth.tmc.edu
Utah Dental Association, 2/15/08
Today’s Course Topics…
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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
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.
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
Minimal
Sedation
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
passed”)
• “total aggregate dose must not exceed 1.5 MRD”
Conscious
Sedation
http://www.ncbi.nih.gov/pubmed/1
7187034?ordinalpos
Guidelines
Balancing Efficacy and
Safety in the Use of Oral
Sedation in Dental
Outpatients
Dionne RA et al. JADA
2006;137:502-13
http://jada.ada.org
“ENTERAL ADMINISTRATION OF
Benzodiazepines safe but poorly
documented in the office setting”
Conscious sedation, including
incremental triazolam,
necessitates…monitoring,
documentation, facilities
equipment and personnel as
described in ADA and AAPD
guidelines”
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 >>0.5 mg single
dose
Sedation Modifications.
How Will the Proposed
Guidelines Affect Your
Practice?
Lynch, K. AGD Impact July 2007;48-54
AGD White Paper at:
http://www.agd.org/members_only/advocacy/priority_issues/ConsciousSedation.doc
Here’s What You Thought (AGD
Impact July 2007)
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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.,
2006;7(4):90-91
www.scottishdental.org/cep/guidance/dentalsedation.htm
The Scottish Dental Clinical Effectiveness
Programme
Coulthard, 2006
• 48 recommendations
total
• 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…
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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
R156-69-601
Scope of Practice—Anesthesia and
Analgesia Permit
Conscious Sedation for Dental
Anxiety
(Protocol)
Cochrane Database of Systematic
Reviews
2007, Issue 1
Primary Outcomes To Be
Assessed
• Changes in anxiety scores
• Reliability and validity of anxiety
measurement instruments/scales
Anxiety
An internal, emotional response;
a specific unpleasurable sense
state of tension which indicates
the presence of some danger
ANTICIPATED
Fear:
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”
IMMEDIATE THREAT
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)
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Routine cleaning: 7.2%
Fillings/crowns: 18%
Tooth extraction: 47%
Endodontic procedure: 55%
Periodontal surgery: 68%
From Chanpong, Haas & Locker, Anesth. Prog.
2005;52(1):3-11
• http://apt.allenpress.com/perlserv
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
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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
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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 > mild
Adverse interactions of sedative drugs
Idiosyncrasy
An unexpected, unpredictable
adverse or undesirable drug
action
Indications for Oral Sedation
• Mild to moderate dental
anxiety
• To assist with restful sleep on
night before dental
appointment
Contraindications to Oral
Sedation
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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
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)
Oral Sedation: “Unfilled
Expectations”
• Pain control, reduced need for local anesthesia
• Control of defiant behavior, mentallychallenged 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
Absorption
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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 lifethreatening adverse effects
Reasons NOT to used BZs…
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Allergy
Narrow angle glaucoma
Chronic BZ ingestion…???
Tricyclic antidepressant therapy…???
Adversely interactive drugs (e.g., azole
antifungals/triazolam)
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
Boxed Warning: BZs
“sleep driving” (with no memory)
“severe allergic reactions”
http://www.fda.gov/bbs/topics/NEWS/2007/NEW01587.html
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
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Specificity of effect
Well absorbed by the oral route
High margin of safety/therapeutic index
Effective as single agents
Specific reversal agent available
(flumazenil)
Classification of Benzodiazepines
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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)
Diazepam
• 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
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
Lorazepam
• 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)
Triazolam
• 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
impairment
Triazolam
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
somnolence
Alprazolam
• Active metabolites?
No
• Pregnancy category
D
• Availability: 0.25-,
0.5, 1- & 2-mg tabs,
0.5- and 1 mg/ml
liquid
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
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 PATIENT’S HOME
• Active metabolites? No
• Pregnancy category D
• Availability: 2 mg/ml syrup
Oral BZ Biovailability & Half-lives
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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)
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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
Zolpidem
• 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
(VISTARIL)
• Non-controlled substance
Hydroxyzine
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
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
Agents NOT Recommended
(Adults)
• Alcohol
• Chloral hydrate
• Opioids
• Multi-Drug Cocktails
Nitrous Oxide
Advantages of Nitrous Oxide
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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
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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)
Disadvantages of Nitrous Oxide
• Initial co$t of cumbersome equipment is
high
• 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
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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
patients
• Produce loss of consciousness when used
correctly
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 pretreatment 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
concentrations
• 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
secretions
• Anemia/Methemoglobinemia: decreased
oxygen-carrying capacity of blood
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
Complications and
Chronic Toxicity
Excessive Perspiration
• Etiology: peripheral vasodilation
• Management: decrease nitrous oxide
concentration (5% per min)
Expectoration
• Etiology: fluid removal problems,
diminished patient coordination and
cooperation
• 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
Nausea
• Etiology: excessive length and/or depth of
sedation, over-emotional patient, overeating, frequent changes in patient
position (esp. pediatrics), frequent
changes in nitrous oxide concentration
• Management: avoid etiologic factors,
premedicate with anti-emetic drug
Vomiting
• 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
patient
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)
Chronic Exposure to
Nitrous Oxide
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
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?)
• INCREASED RISK OF SPONTANEOUS
ABORTION IN HUMANS
• Effects require chronic exposure
Dental Office
Exposure to Nitrous
Oxide
Sources of Environmental N2O
• Normal gas flow to patients
• Patient (talking, “washout” during
recovery)
• Equipment (leaks)
• Air conditioning (recirculation)
Office Levels of N2O Depend on
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Frequency of use
Size of operatory
Ventilation of operatory
Type of operatory (open vs. closed)
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)
Minimizing Office N2O
» Test for leaks
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Vent waste gases to outside
SCAVENGE waste gases
Air sweep (oscillating fan)
Minimize patient talking
Monitor office air quality
Effects of Scavenging
Systems
Nitrous Oxide Levels (ppm) of Breathing Zones in
Offices Without & With Scavenging Systems (from
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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
Oxide
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,
leukopenia
• 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
• REVERSAL OF RESPIRATORY
DEPRESSION NOT PREDICTABLE
• Short half-life (readministration often
required)
Sublingual Injection of Flumazenil?
• Average time to reversal with IV route = 2
minutes
• Average time to reversal with SL route =
4.33 minutes
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
Fundamentals of Emergency
Preparation
• 1. Training (BLS, ACLS, PALS, TSBDEapproved 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
patient/victim
• A concise description of everything that
happened
• Doctor remains with patient/victim
Pre-Emptive Strategies for Dental Office
Emergency Preparation and Management
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Painstakingly detailed health history
Medical risk classifcation
Avoid potential drug interactions
Calculate dental drug dosages carefully
Monitor, monitor, monitor!!!
IMPLEMENT AN OFFICE EMERGENCYN
PLAN
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)
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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
Emergencies
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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
Massachusetts
D’eramo EM, Bookless SJ, Howard JB
J. Oral Maxillofac. Surg. 2003;61:793800
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
anesthesia)
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”
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
2002
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
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
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, 3560%
• Nonrebreather mask with reservoir: 6-15
L/min
• Bag-mask with nonrebreather “tail”: 15
L/min, 95-100%
Positive-Pressure Ventilation
A nitrous oxide nasal hood CAN
NOT provide positive-pressure
ventilation
Supplementary Oxygen vs.
Positive-Pressure Ventilation with
100% Oxygen
Epinephrine
• 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
summoned
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,
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
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)
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”
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)
Antihistamines
• Diphenhydramine (BENADRYL) (50
mg/ml)
• Chlorpheniramine (CHLOR-TRIMETON)
(10 mg/ml)
• DO NOT subsitute for epinephrine in
anaphylaxis
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
Aspirin Dosage
• 160 – 325 mg non-enteric coated tablets
ASAP
• Chewing is preferred
• May use rectal suppository form (if
available)
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
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.
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
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)
Other Informational Resources
• Mosby’s Drug Consult, 800-545-2522
• Mosby’s 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
Local Anesthetics
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”?
How long should you
wait?
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,
2001
• 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
epinephrine
Anesthetic Efficacy of
Articaine for IABs in
Patients with
Irreversible Pulpitis
Claffey E. et al. J. Endo.
2004;30:568-71
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
numbness
• 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
successful
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%
mepivacaine
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.”
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???)
“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
2000;131:901-907
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
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 =
1:785,000
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
extremes
• Avoid operative neural trauma (careful use of
forceps, elevators, rubber dam clamps, etc.)
New Perspectives on Pain Control
in Patients With Cardiovascular
Disease
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
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)
Beneficial Effects of NSAIDs
• Analgesic (relieve
pain)
• Antipyretic (reduce
fever)
• Anti-inflammatory
• Available OTC
The Oxford League Table of
Analgesic Efficacy
www.jr2.ox.ac.uk/bandolier/booth/
painpag/Acutrev/Analgesics/lftab.
html
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
Relative Efficacy of Oral
Analgesics After Third Molar
Extraction
Barden J, Edwards, JE, McQuay
HJ, Wiffen PJ, Moore RA
British Dental Journal
2004;197:407-411
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
CARDIOVASCULAR
DISEASE/RISK OF
THROMBOEMBOLISM
Conditions With Risk for NSAIDInduced 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
Conclusions
• VIOXX = 400 mg
ibuprofen
• VIOXX has 50%
“rescue” rate within
24 hrs
• Ibuprofen = VIOXX
G.I. problems for
30 days
• VIOXX not OTC
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
antagonist???)
• Valdecoxib (BEXTRA)
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
Use of NSAIDs. An update for
clinicians. A Scientific Statement
from the American Heart
Association
Antman, E. M. et al.
Circulation
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
concomitantly)
PRECISION…coming to a
journal near you!
Prospective Randomized
Evaluation of Celecoxib Integrated
Safety vs Ibuprofen or Naproxen
www.clinicaltrials.gov
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 9751,000 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
(COMBUNOX)**
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)
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
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