Evidence-Based Perspectives on Pain and Anxiety Control in Dentistry Dr. Arthur Jeske [email_address] Utah Dental Associat...
Today’s Course Topics… <ul><li>Fundamentals of anxiety management </li></ul><ul><li>Current guidelines (conscious/minimal ...
Disclaimers The opinions expressed in this course are those of the speaker and not necessarily those of the Utah Dental As...
American Dental Association GUIDELINES FOR TEACHING PAIN CONTROL AND SEDATION TO DENTISTS AND DENTAL STUDENTS As adopted b...
Minimal Sedation A  minimally depressed  level of consciousness produced by a pharmacologic method that retains the patien...
Other ADA Guideline Excerpts <ul><li>Nitrous oxide may be used with “a  single enteral  drug” </li></ul><ul><li>Initial or...
Conscious Sedation Guidelines http://www.ncbi.nih.gov/pubmed/17187034?ordinalpos
Balancing Efficacy and Safety in the Use of Oral Sedation in Dental Outpatients Dionne RA et al.  JADA 2006;137:502-13 htt...
“ ENTERAL ADMINISTRATION OF Benzodiazepines safe but poorly documented in the office setting” Conscious sedation, includin...
Consensus (Dionne et al., 2006) <ul><li>Oral sedative = wide margin of safety in ADULTS </li></ul><ul><li>Most serious eve...
Sedation Modifications.  How Will the Proposed Guidelines Affect Your Practice? Lynch, K.  AGD Impact July 2007;48-54 AGD ...
Here’s What You Thought (AGD Impact July 2007) <ul><li>74% use N 2 O  </li></ul><ul><li>53% combine nitrous oxide and a BZ...
Conscious Sedation Guidance Coulthard, P.  J. Evid. Based Dent., 2006;7(4):90-91 www.scottishdental.org/cep/guidance/denta...
Coulthard, 2006 <ul><li>48 recommendations total </li></ul><ul><li>To be updated 2008 </li></ul><ul><li>Included general s...
Recommendations:  Referral <ul><li>Discuss alternative methods of anxiety management with patient </li></ul><ul><li>Ensure...
Recommendations:  Assessment and Record Keeping <ul><li>Discuss all aspects of sedation procedure with patient </li></ul><...
Recommendations:  Environment and Facilities <ul><li>Ensure that environment is safe </li></ul><ul><li>Correct equipment a...
Recommendations:  Training <ul><li>All members of team are correctly trained </li></ul><ul><li>Training includes monitorin...
Recommendations:  Techniques <ul><li>“ Titrated dose of nitrous oxide” </li></ul><ul><li>Oral, transmucosal and i.v. “requ...
Recommendations:  Aftercare <ul><li>Monitor patients during recovery </li></ul><ul><li>Dismiss patient into care of a resp...
Recommendations:  Further Research Required For… <ul><li>Fasting before conscious sedation </li></ul><ul><li>Pediatric con...
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 <ul><li>Changes in anxiety scores </li></ul><ul><li>Reliability and validity of anxiety me...
Anxiety   An internal, emotional response;  a specific unpleasurable sense state of tension which indicates the presence o...
Fear : A short-lived feeling that something terrible is going to happen;  accompanied by physiologic changes  (increased H...
Conscious Sedation <ul><li>Drugs and/or techniques used should carry a margin of safety wide enough to render loss of cons...
“ Bottom-Line” Requirements for Minimal/Conscious Sedation <ul><li>Comfort </li></ul><ul><li>Consciousness </li></ul><ul><...
Adult   Preferences for Sedation or General Anesthesia (Survey of 1,101 Canadian Adults) <ul><li>Routine cleaning:  7.2% <...
Clinical Considerations <ul><li>Physician consultation recommended for ASA III & IV patients </li></ul><ul><li>One member ...
Advantages of Oral Sedation <ul><li>Universal acceptability </li></ul><ul><li>Ease of administration </li></ul><ul><li>Low...
Disadvantages of Oral Sedation <ul><li>Reliance on  patient compliance </li></ul><ul><li>Prolonged, variable onset  of act...
Idiosyncrasy An unexpected, unpredictable adverse or undesirable drug action
Indications for Oral Sedation <ul><li>Mild to moderate dental anxiety </li></ul><ul><li>To assist with restful sleep on ni...
Contraindications   to Oral Sedation <ul><li>Severe  dental anxiety & fear </li></ul><ul><li>High probability of  adverse ...
What causes the sudden  death  of a  patient? <ul><li>Respiratory arrest  with or without airway obstruction </li></ul><ul...
Oral Sedation:  “Unfilled Expectations” <ul><li>Pain control , reduced need for local anesthesia </li></ul><ul><li>Control...
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 mana...
Factors Influencing Oral Drug Absorption <ul><li>Lipid solubility </li></ul><ul><li>pH of gastric tissues </li></ul><ul><l...
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-threateni...
Reasons NOT to used BZs… <ul><li>Allergy </li></ul><ul><li>Narrow angle glaucoma </li></ul><ul><li>Chronic BZ ingestion…??...
Characteristics of Benzodiazepines <ul><li>Facilitate binding of  GABA  (endogenous inhibitory transmitter) </li></ul><ul>...
Boxed Warning:  BZs “ sleep driving” (with no memory) “ severe allergic reactions” http://www.fda.gov/bbs/topics/NEWS/2007...
Pharmacokinetics and Clinical Effects of Multidose Sublingual Triazolam in Healthy Volunteers.  Jackson DL et al. J. Clin....
Advantages of Benzodiazepines <ul><li>Specificity of effect </li></ul><ul><li>Well absorbed by the oral route </li></ul><u...
Classification of Benzodiazepines <ul><li>Alprazolam:  antianxiety </li></ul><ul><li>Diazepam:  antianxiety </li></ul><ul>...
Diazepam  (VALIUM ) <ul><li>Usual dose range:  2 - 20 mg , 1 h before appointment (adults) </li></ul><ul><li>Onset:  1 hr ...
Diazepam <ul><li>Active metabolites?  Yes </li></ul><ul><li>Pregnancy category D </li></ul><ul><li>Availability:  2-, 5- &...
Lorazepam  (ATIVAN ) <ul><li>Usual dose range:  2 - 4 mg  1 hr before appointment (adults) </li></ul><ul><li>Onset:  1 hr ...
Lorazepam <ul><li>Active metabolites?  No </li></ul><ul><li>Pregnancy category D </li></ul><ul><li>Availability:  0.5-, 1 ...
Oxazepam  (SERAX) <ul><li>Usual dose range:  10 – 30 mg , 1 hr before appointment (adults) </li></ul><ul><li>Onset:  1 hr ...
Oxazepam <ul><li>Pregancy category D </li></ul><ul><li>Availability:  10-, 15- & 30-mg caps, 15-mg tabs  </li></ul>
Triazolam  (HALCION ) <ul><li>Usual dose range:  0.25 – 0.5  mg, 1 hr before appointment (adults) </li></ul><ul><li>Onset:...
Triazolam <ul><li>Active metabolites?  No </li></ul><ul><li>Pregnancy category X </li></ul><ul><li>Availability:  0.125- &...
Triazolam Doses <ul><li>Short-term management of insomnia </li></ul><ul><ul><li>0.25mg PO hs </li></ul></ul><ul><ul><li>Ma...
Triazolam <ul><li>Onset: </li></ul><ul><li>Peak effect: </li></ul><ul><li>Duration: </li></ul><ul><li>1 hr. </li></ul><ul>...
Alprazolam   (XANAX) <ul><li>Usual dose range:  0.25 – 1 mg  1 hr before appointment (adults) </li></ul><ul><li>Onset:  1 ...
Alprazolam <ul><li>Active metabolites?  No </li></ul><ul><li>Pregnancy category D </li></ul><ul><li>Availability:  0.25-, ...
Midazolam   <ul><li>ALL BRAND NAME FORMS (VERSED) DISCONTINUED BY ROCHE MAY, 2002 </li></ul><ul><li>Now available from Ran...
Midazolam <ul><li>Precautions:  may cause intense CNS/respiratory depression, use with caution with potent CYP 3A4 inhibit...
Oral BZ Biovailability &  Half-lives <ul><li>Diazepam:  100%, 43  ± 13 hrs </li></ul><ul><li>Oxazepam:  97%, 8 ± 2.4 hrs <...
Non-BZ BZ Receptor Agonists <ul><li>Eszopiclone (LUNESTA) </li></ul><ul><li>Zaleplon (SONATA) </li></ul><ul><li>Zolpidem (...
Melatonin Receptor Agonist:  Ramelteon ( ROZEREM ) <ul><li>MT 1  & MT 2  receptor agonist </li></ul><ul><li>Simulates mela...
Zolpidem (AMBIEN) <ul><li>Usual dose range:  5 – 10 mg, 1/2 hr before appointment </li></ul><ul><li>Onset:  0.5-1 hr (peak...
Zolpidem <ul><li>Pregnancy category B </li></ul><ul><li>Availability:  5- and 10-mg tabs </li></ul>
Hydroxyzine (ATARAX, VISTARIL) <ul><li>Usual dose range:  50 – 100 mg, 1 hr before appointment (adults), 1.1 – 2.2 mg/kg (...
Hydroxyzine <ul><li>Active metabolites?  No </li></ul><ul><li>Pregnancy category D </li></ul><ul><li>Availability:  10-, 2...
Promethazine  (PHENERGAN) <ul><li>Usual dose range:  25 – 50 mg , 1 hr before appointment (adults), 2.2 mg/kg (children, w...
Promethazine <ul><li>Active metabolites?  No </li></ul><ul><li>Pregnancy category C </li></ul><ul><li>Availability:  12.5-...
Agents NOT Recommended (Adults) <ul><li>Alcohol </li></ul><ul><li>Chloral hydrate </li></ul><ul><li>Opioids </li></ul><ul>...
Nitrous Oxide
Advantages of Nitrous Oxide <ul><li>Rapid onset (almost equal to that of iv) </li></ul><ul><li>Titratable ( up AND down ) ...
Advantages of Nitrous Oxide <ul><li>No injection required </li></ul><ul><li>Very few side effects </li></ul><ul><li>No adv...
Disadvantages of Nitrous Oxide <ul><li>Initial co$t of  cumbersome  equipment is high </li></ul><ul><li>Continuing co$ts o...
Indications for Inhalation Sedation <ul><li>Mild to moderate dental anxiety </li></ul><ul><li>Medically compromised patien...
Relative Contraindications to Inhalation Sedation <ul><li>Severe dental anxiety & fear </li></ul><ul><li>Compulsive person...
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 o...
Prevention of Diffusion Hypoxia  Administer 100% oxygen for 3 to 5 minutes  at the termination of the sedation procedure
CNS Effects of Nitrous Oxide  <ul><li>All senses are slightly depressed or altered (perioral numbness, etc.)  </li></ul><u...
Nitrous Oxide Does NOT... <ul><li>Obtund sharp pain impulses </li></ul><ul><li>Substitute for good local anesthesia  </li>...
Why Nitrous Oxide is  Associated with Nausea  <ul><li>Not titrated  </li></ul><ul><li>All patients are given “fixed” conce...
Other Effects of Nitrous Oxide  <ul><li>Cardiovascular:  no clinically significant effects at recommended concentrations <...
Other Effects of Nitrous Oxide  <ul><li>Kidneys:  no effect </li></ul><ul><li>Blood:  inhibition of vitamin B-12 metabolis...
Contraindications to Nitrous Oxide <ul><li>Pregnancy (1st trimester) </li></ul><ul><li>Upper respiratory tract infection <...
Effects of Pathologic Conditions on Inhalation Sedation <ul><li>Emphysema:  decreased total surface area of alveoli </li><...
Physiologic Equivalents <ul><li>Total gas flow (LPM) = minute respiratory volume </li></ul><ul><li>Excursion of reservoir ...
Complications and Chronic Toxicity
Excessive Perspiration  <ul><li>Etiology:  peripheral vasodilation  </li></ul><ul><li>Management:  decrease nitrous oxide ...
Expectoration  <ul><li>Etiology:  fluid removal problems, diminished patient coordination and cooperation  </li></ul><ul><...
Behavioral Problems  <ul><li>Etiology:  authoritarian patient, excessive nitrous oxide concentrations </li></ul><ul><li>Ma...
Nausea <ul><li>Etiology:  excessive length and/or depth of sedation, over-emotional patient, over-eating, frequent changes...
Vomiting <ul><li>Etiology:  same as for nausea </li></ul><ul><li>Management:  remove nasal hood, turn patient’s head to as...
Pre-Operative Instructions  <ul><li>1.  Take pre-operative medications (if indicated) </li></ul><ul><li>2.  No heavy meals...
Chronic Exposure to Nitrous Oxide
Mutagenicity of Nitrous Oxide? <ul><li>Negative in  Salmonella  microsome assays </li></ul><ul><li>Negative in cultured ha...
Carcinogenicity of Nitrous Oxide? <ul><li>Negative results in mice </li></ul><ul><li>Human studies generally negative </li...
Teratogenicity of Nitrous Oxide <ul><li>Definite teratogenicity in rats </li></ul><ul><li>male rodents show chromosomal da...
Dental Office Exposure to Nitrous Oxide
Sources of Environmental N 2 O <ul><li>Normal gas flow to patients </li></ul><ul><li>Patient (talking, “washout” during re...
Office Levels of N 2 O Depend on <ul><li>Frequency of use </li></ul><ul><li>Size of operatory </li></ul><ul><li>Ventilatio...
Detection of Office N 2 O <ul><li>Visual inspection (rubber goods, connections) </li></ul><ul><li>Application of soapy wat...
Minimizing Office N 2 O
Effects of Scavenging Systems
Nitrous Oxide Levels (ppm) of Breathing Zones in Offices Without & With Scavenging Systems (from Whitcher et al., JADA, 19...
Abuse of Nitrous Oxide
Mechanism of Chronic Toxicity <ul><li>Oxidation of vitamin B-12 (cobalamin; bound co-factor for methionine synthetase and ...
Clinical Effects of Chronic Toxicity <ul><li>Bone marrow suppression, anemia,  leukopenia </li></ul><ul><li>Suppression of...
Flumazenil  (ROMAZICON) <ul><li>Competes with benzodiazepine for receptor site </li></ul><ul><li>Used to reverse CNS depre...
Sublingual Injection of Flumazenil? <ul><li>Average time to reversal with IV route = 2 minutes </li></ul><ul><li>Average t...
Flumazenil <ul><li>Only BZ antagonist available </li></ul><ul><li>Can produce agitation, confusion, dizziness & nausea </l...
Fundamentals of Emergency Preparation <ul><li>1.  Training (BLS, ACLS, PALS, TSBDE-approved courses) </li></ul><ul><li>2. ...
What Your EMS Personnel Want and NEED! <ul><li>An  accurate medical history  of the patient/victim </li></ul><ul><li>A con...
Pre-Emptive Strategies for Dental Office Emergency Preparation and Management <ul><li>Painstakingly detailed health histor...
A General Paradigm for  Assessing and Managing ASA II-IV Patients <ul><li>Monitor vital signs at every appointment </li></...
Stress-Reduction Protocol (Medically Compromised Patients) <ul><li>1. Recognize medical risk </li></ul><ul><li>2. Consult ...
Range of Dental Office Emergencies <ul><li>Syncope </li></ul><ul><li>Nausea, vomiting </li></ul><ul><li>Hyperventilation <...
Adverse events associated with outpatient anesthesia in Massachusetts D’eramo EM, Bookless SJ, Howard JB J. Oral Maxillofa...
Methods and Outcomes from D’Eramo et al. <ul><li>Morbidity data from 157 oral surgeons for year 1999 </li></ul><ul><li>Syn...
Types of Emergency Drugs and Drug Kits <ul><li>None (or expired) </li></ul><ul><li>Custom (“homemade”) </li></ul><ul><li>P...
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....
Minimum  Emergency Drugs Recommended by ADA CSA <ul><li>Epinephrine 1:1,000 </li></ul><ul><li>Injectable antihistamine </l...
“ Essential” Emergency Drugs (Haas, Dent. Clin. N. Am., 2002:46:815-830) <ul><li>Oxygen </li></ul><ul><li>Epinephrine </li...
“ Supplementary” Emergency Drugs (Haas, 2002) <ul><li>Glucagon </li></ul><ul><li>Atropine </li></ul><ul><li>Ephedrine </li...
“ Proprietary emergency drug kits are available, but none of these kits is compatible with the needs of all practitioners....
Oxygen Cylinders and Volumes <ul><li>E:  625 liters </li></ul><ul><li>H:  6,909 liters  </li></ul>
Time Available at 15 L/min Flow Rate (from 2,000 psi fill) <ul><li>E cylinder = 41 minutes </li></ul><ul><li>H cylinder = ...
Appropriate Use of Oxygen <ul><li>Any suspected cardiopulmonary emergency  </li></ul><ul><li>Complaints of shortness of br...
Precautions:  Oxygen <ul><li>Observe closely when using with patients known to be dependent on hypoxic drive (COPD; very r...
Oxygen Flow Requirments (ACLS) <ul><li>Nasal cannula:  1-6 L/min, 21-44% </li></ul><ul><li>Venturi mask:  4-12 L/min, 24-5...
Positive-Pressure Ventilation A nitrous oxide nasal hood CAN NOT provide positive-pressure ventilation
Supplementary Oxygen vs. Positive-Pressure Ventilation with 100% Oxygen
Epinephrine <ul><li>Only injectable agent which should be available in ALL dental offices </li></ul><ul><li>Use pre-loaded...
Epinephrine Precautions <ul><li>Elevations of BP and increased HR may cause ischemia, increased O2 demand and dysrhythmias...
Whenever epinephrine or another emergency drug is administered, medical assistance must be summoned
Other Bronchodilators <ul><li>Beta-2 Agonists </li></ul><ul><li>Terbutaline </li></ul>
Beta-2 Adrenergic Agonists <ul><li>Albuterol (VENTOLIN)(first choice) </li></ul><ul><li>Metaproterenol (ALUPENT) </li></ul...
Albuterol (PROVENTIL, VENTOLIN) <ul><li>Use by inhalation route for emergency airway constriction </li></ul><ul><li>May pr...
Nitroglycerin <ul><li>Available in 0.4 mg sublingual tabs </li></ul><ul><li>Decreases cardiac work load  </li></ul><ul><li...
Nitroglycerin Precautions <ul><li>Avoid in patients taking drugs for ED </li></ul><ul><li>May cause excessive decrease in ...
Aromatic Spirits of Ammonia <ul><li>Irritates respiratory mucosa, causes muscle contractions, improves venous return </li>...
Glucose/Sucrose <ul><li>Acceptable forms of sucrose include soft drinks, orange juice & candy bars </li></ul><ul><li>Gluco...
Antihistamines <ul><li>Diphenhydramine (BENADRYL) (50 mg/ml) </li></ul><ul><li>Chlorpheniramine (CHLOR-TRIMETON) (10 mg/ml...
Aspirin <ul><li>Indicated in all patients with ACS </li></ul><ul><li>Any person with symptoms of “pressure, “heavy weight”...
Aspirin Dosage <ul><li>160 – 325 mg non-enteric coated tablets ASAP </li></ul><ul><li>Chewing is preferred </li></ul><ul><...
Atropine <ul><li>Indicated for bradycardia </li></ul><ul><li>Rapid onset, short duration </li></ul><ul><li>0.5 mg i.m. q. ...
References <ul><li>Malamed,  Sedation:  A Guide to patient management, 4 th  edition, 2003 </li></ul><ul><li>Jackson & Joh...
Local Anesthetic Dosages <ul><li>ALWAYS calculated on basis of body weight (mg/kg) </li></ul><ul><li>Absolute maximum dosa...
Maximum Doses of Selected Local Anesthetics <ul><li>Lidocaine (4.4 mg/kg, 300 mg absolute) </li></ul><ul><li>Mepivacaine (...
Other Informational Resources <ul><li>Mosby’s Drug Consult,  800-545-2522 </li></ul><ul><li>Mosby’s Dental Drug Reference ...
Local Anesthetics
Approaches to Failed IABs… <ul><li>Reinject (if lower lip not numb)? </li></ul><ul><li>Increase local anesthetic concentra...
How long should you wait? Varies with anesthetic and tissue Lip = 5-7 minutes Pulps = 10-15 minutes >15 minutes (~1 in 4  ...
Malamed et al., JADA 2000, 2001 <ul><li>2% lidocaine with 1:100K epi vs. 4% articaine with 1:100K epi </li></ul><ul><li>88...
Articaine vs. Other Agents <ul><li>Absolute max dose (carts) < lidocaine (7.3 vs. 8.3) </li></ul><ul><li>Pregnancy categor...
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 <ul><li>72 cases of irreversible pulpitis </li></ul><ul><li>Compared 4% articaine 2.2 ml vs. 2% l...
Results from Nusstein et al., J. Endo. 2003
Review of Intraosseous Injection Systems:  ADA Professional Product Review, Volume 2, Issue 1, Winter 2006 <ul><li>Stabide...
Results from Replogle et al. (1999) <ul><li>67% of ASA I patients receiving IO injections of lidocaine 2% with 1:100K epi ...
Paresthesia “ An altered sensation of numbness, burning or pricking that may reflect an alteration in the sensation of pai...
Proposed Causes of Paresthesia <ul><li>Direct nerve trauma by needle </li></ul><ul><li>Barbed needles (“fish hook effect”)...
“ An inferior alveolar nerve block can cause occasional peripheral nerve damage.  The exact mechanism is unknown and there...
Haas, D.  J. Am. Coll. Dent. 2006 <ul><li>Focused on NON-SURGICAL cases </li></ul><ul><li>Evaluated in vitro and human cli...
Summary of Findings in IAB-Related Paresthesias <ul><li>~50% of patients experience  “ electric shock ”  sensation </li></...
Conclusions of Haas (2006) <ul><li>Data are “strongly suggestive” that paresthesia more likely with 4% agents </li></ul><u...
Avoiding Paresthesia… <ul><li>Use the lowest practical anesthetic and vasoconstrictor concentrations  </li></ul><ul><li>Us...
New Perspectives on Pain Control in Patients With Cardiovascular Disease
E-References, Antiplatelet Drugs <ul><li>Antman EM et al.  Use of Nonsteroidal Antiinflammatory Drugs.  An Update for Clin...
NSAID Classes <ul><li>Salicylic acid derivatives (diflunisal/DOLOBID) </li></ul><ul><li>P-Aminophenols (acetaminophen/TYLE...
Beneficial Effects of NSAIDs <ul><li>Analgesic (relieve pain) </li></ul><ul><li>Antipyretic (reduce fever) </li></ul><ul><...
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) <ul><li>Valdecoxib 40 ...
Relative Efficacy of Oral Analgesics After Third Molar Extraction Barden J, Edwards, JE, McQuay HJ, Wiffen PJ, Moore RA Br...
NNTs from Barden et al.  <ul><li>Valdecoxib 40 mg (BEXTRA):  1.6 </li></ul><ul><li>Diclofenac 100 mg (VOLTAREN):  1.6 </li...
Contraindications to NSAIDs <ul><li>Stomach problems </li></ul><ul><li>Aspirin Allergy </li></ul><ul><li>Bleeding  </li></...
Conditions With Risk for NSAID-Induced Nephropathy <ul><li>Volume depletion/dehydration  (diarrhea, vomiting) </li></ul><u...
COX-2-Selective Inhibitors
Selecting new drugs for pain control:  evidence-based decision or clinical impression? Jeske, AH.  JADA 2002;133:1052-6
Conclusions <ul><li>VIOXX = 400 mg ibuprofen </li></ul><ul><li>VIOXX has 50% “rescue” rate within 24 hrs </li></ul><ul><li...
Single dose oral celecoxib for postoperative pain (Barden J et al. Cochrane Review:  Issue 3, 2004)** Similar in efficacy ...
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 <ul><li>COX-2  constitutively expressed  in some tissues (brain, kidney, ovary & uterus) </li><...
COX-2 inhibitors <ul><li>Celecoxib (CELEBREX ) </li></ul><ul><li>Rofecoxicb (VIOXX) </li></ul><ul><li>Etoricoxib (ARCOXIA)...
Effects of NSAIDs on Platelet Aggregation <ul><li>Thromboxane A2 = vasoconstrictor, promotes platelet aggregation </li></u...
Use of NSAIDs.  An update for clinicians.  A Scientific Statement from the American Heart Association Antman, E. M. et al....
AHA Recommendations 2007 for Patients With Cardiovascular Disease <ul><li>Acetaminophen, aspirin and opioid analgesics (in...
PRECISION … coming to a journal near you! Prospective Randomized Evaluation of Celecoxib Integrated Safety vs Ibuprofen or...
Single Dose Oral Acetaminophen for Postoperative Pain (Barden J et al., Cochrane Review, Issue 3, 2004)** 325 mg, 500 mg, ...
Preferred Oral Opioid Analgesics <ul><li>Tylenol with codeine #2:  (2 or 3 q. 4 h.) </li></ul><ul><li>Hydrocodone 2.5 or 5...
Other Oral Opioid Analgesics <ul><li>Tramadol  (ULTRAM):  50 -  100 mg q.4 -6 h. (now available  with APAP as ULTRACET,  3...
MAGNACET ® (March, 2007) <ul><li>Oxycodone + acetaminophen 400 mg (?) </li></ul><ul><li>2.5, 5, 7.5 and 10 mg oxycodone (?...
Results from Dionne, R.  J. Oral Max. Surg. 57:673, 1999 <ul><li>Compared 400 mg ibuprofen + 2.5, 5 and 10 mg oxycodone </...
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Evidence-Based Perspectives on Pain and Anxiety Control in ...

  1. 1. Evidence-Based Perspectives on Pain and Anxiety Control in Dentistry Dr. Arthur Jeske [email_address] Utah Dental Association, 2/15/08
  2. 2. Today’s Course Topics… <ul><li>Fundamentals of anxiety management </li></ul><ul><li>Current guidelines (conscious/minimal sedation) </li></ul><ul><li>Enteral (oral) sedatives </li></ul><ul><li>Nitrous oxide/oxygen inhalation sedation </li></ul><ul><li>Basic emergency drugs </li></ul><ul><li>Contemporary perspectives on local anesthetics </li></ul><ul><li>Contemporary perspectives on oral analgesics </li></ul>
  3. 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. 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. 5. 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 .
  6. 6. Other ADA Guideline Excerpts <ul><li>Nitrous oxide may be used with “a single enteral drug” </li></ul><ul><li>Initial oral dose is “ no more than MRD for unmonitored home use” </li></ul><ul><li>Combination of nitrous and oral agents “may produce minimal, moderate or deep sedation or general anesthesia” </li></ul><ul><li>“ 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”) </li></ul><ul><li>“ total aggregate dose must not exceed 1.5 MRD” </li></ul>
  7. 7. Conscious Sedation Guidelines http://www.ncbi.nih.gov/pubmed/17187034?ordinalpos
  8. 8. 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
  9. 9. “ 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”
  10. 10. Consensus (Dionne et al., 2006) <ul><li>Oral sedative = wide margin of safety in ADULTS </li></ul><ul><li>Most serious events = respiratory depression </li></ul><ul><li>State regulation required to ensure safety </li></ul><ul><li>More research needed for “incremental dosing” techniques </li></ul><ul><li>0.25 mg triazolam X 2 >>0.5 mg single dose </li></ul>
  11. 11. 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
  12. 12. Here’s What You Thought (AGD Impact July 2007) <ul><li>74% use N 2 O </li></ul><ul><li>53% combine nitrous oxide and a BZ </li></ul><ul><li>67% have patient take sedative at home </li></ul><ul><li>43% administer sedative in the office </li></ul><ul><li>90% never had an untoward reaction </li></ul><ul><li>48% totally understand the difference between minimal and moderate sedtion </li></ul>
  13. 13. 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
  14. 14. Coulthard, 2006 <ul><li>48 recommendations total </li></ul><ul><li>To be updated 2008 </li></ul><ul><li>Included general systematic reviews (Cochrane Library) and specific studies (Medline, Embase & Cochrane Library) </li></ul>
  15. 15. Recommendations: Referral <ul><li>Discuss alternative methods of anxiety management with patient </li></ul><ul><li>Ensure that definition of “conscious sedation” is met </li></ul>
  16. 16. Recommendations: Assessment and Record Keeping <ul><li>Discuss all aspects of sedation procedure with patient </li></ul><ul><li>Provide written instructions </li></ul><ul><li>Obtain informed consent </li></ul><ul><li>Maintain and update patient records </li></ul>
  17. 17. Recommendations: Environment and Facilities <ul><li>Ensure that environment is safe </li></ul><ul><li>Correct equipment and drugs </li></ul><ul><li>Emergency drugs and equipment immediately available </li></ul>
  18. 18. Recommendations: Training <ul><li>All members of team are correctly trained </li></ul><ul><li>Training includes monitoring techniques and emergency interventions </li></ul><ul><li>“ For oral and transmucosal” sedation, “sedationist” trained in other titratable sedation techniques and venipuncture </li></ul><ul><li>Teams should provide sedation for patient groups they are experienced in treating </li></ul>
  19. 19. Recommendations: Techniques <ul><li>“ Titrated dose of nitrous oxide” </li></ul><ul><li>Oral, transmucosal and i.v. “require” pulse oximetry and BP monitoring </li></ul>
  20. 20. Recommendations: Aftercare <ul><li>Monitor patients during recovery </li></ul><ul><li>Dismiss patient into care of a responsible adult (who also has written instructions) </li></ul><ul><li>Nitrous oxide sedation “might not” required adult escort during recovery </li></ul>
  21. 21. Recommendations: Further Research Required For… <ul><li>Fasting before conscious sedation </li></ul><ul><li>Pediatric conscious sedation </li></ul><ul><li>Drug combinations </li></ul><ul><li>Conscious sedation methods </li></ul><ul><li>Cognitive & behavioural effects of sedation </li></ul><ul><li>Interaction of pharmacological and nonpharmacologic anxiety management </li></ul>
  22. 22. Utah Dentist and Dental Hygienist Practice Act Rules R156-69-601 Scope of Practice—Anesthesia and Analgesia Permit
  23. 23. Conscious Sedation for Dental Anxiety (Protocol) Cochrane Database of Systematic Reviews 2007, Issue 1
  24. 24. Primary Outcomes To Be Assessed <ul><li>Changes in anxiety scores </li></ul><ul><li>Reliability and validity of anxiety measurement instruments/scales </li></ul>
  25. 25. Anxiety An internal, emotional response; a specific unpleasurable sense state of tension which indicates the presence of some danger ANTICIPATED
  26. 26. 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
  27. 27. Conscious Sedation <ul><li>Drugs and/or techniques used should carry a margin of safety wide enough to render loss of consciousness UNLIKELY </li></ul><ul><li>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 </li></ul>
  28. 28. “ Bottom-Line” Requirements for Minimal/Conscious Sedation <ul><li>Comfort </li></ul><ul><li>Consciousness </li></ul><ul><li>Cooperation </li></ul>
  29. 29. Adult Preferences for Sedation or General Anesthesia (Survey of 1,101 Canadian Adults) <ul><li>Routine cleaning: 7.2% </li></ul><ul><li>Fillings/crowns: 18% </li></ul><ul><li>Tooth extraction: 47% </li></ul><ul><li>Endodontic procedure: 55% </li></ul><ul><li>Periodontal surgery: 68% </li></ul><ul><li>From Chanpong, Haas & Locker, Anesth. Prog. 2005;52(1):3-11 </li></ul><ul><li>http://apt.allenpress.com/perlserv </li></ul>
  30. 30. Clinical Considerations <ul><li>Physician consultation recommended for ASA III & IV patients </li></ul><ul><li>One member of assistant staff should be present (in addition to dentist) </li></ul><ul><li>Direct supervision </li></ul><ul><li>Monitoring required for oxygenation, ventilation and circulation </li></ul><ul><li>Time-oriented anesthetic record </li></ul>
  31. 31. Advantages of Oral Sedation <ul><li>Universal acceptability </li></ul><ul><li>Ease of administration </li></ul><ul><li>Low co$t </li></ul><ul><li>Incidence of adverse reactions less than some other techniques </li></ul><ul><li>No needles, syringes or special techniques </li></ul><ul><li>Various drugs, dosage forms available </li></ul><ul><li>Allergic reactions less severe than seen in parenteral administration </li></ul>
  32. 32. Disadvantages of Oral Sedation <ul><li>Reliance on patient compliance </li></ul><ul><li>Prolonged, variable onset of action </li></ul><ul><li>Unreliable absorption of drug from G.I. tract </li></ul><ul><li>INABILITY TO TITRATE: WHAT??? </li></ul><ul><li>Prolonged duration of action </li></ul><ul><li>Ineffective in anxiety levels > mild </li></ul><ul><li>Adverse interactions of sedative drugs </li></ul>
  33. 33. Idiosyncrasy An unexpected, unpredictable adverse or undesirable drug action
  34. 34. Indications for Oral Sedation <ul><li>Mild to moderate dental anxiety </li></ul><ul><li>To assist with restful sleep on night before dental appointment </li></ul>
  35. 35. Contraindications to Oral Sedation <ul><li>Severe dental anxiety & fear </li></ul><ul><li>High probability of adverse drug interaction </li></ul><ul><li>Poor past experience with oral sedation </li></ul><ul><li>Allergy to drug being used </li></ul><ul><li>Other drug contraindications ( pregnancy, glaucoma, etc.) </li></ul><ul><li>Need for rapid onset and/or rapid recovery </li></ul>
  36. 36. What causes the sudden death of a patient? <ul><li>Respiratory arrest with or without airway obstruction </li></ul><ul><li>Cellular hypoxia without respiratory depression (CN, CO) </li></ul><ul><li>Severe hypotension (hypovolemic, etc.) </li></ul><ul><li>Lethal cardiac dysrhythmias </li></ul><ul><li>Post-seizure complications (pulmonary aspiration, hypoxia, brain damage) </li></ul><ul><li>Organ damage (e.g., APAP/liver) </li></ul><ul><li>Behavior aberrations (motor vehicle accidents) </li></ul>
  37. 37. Oral Sedation: “Unfilled Expectations” <ul><li>Pain control , reduced need for local anesthesia </li></ul><ul><li>Control of defiant behavior , mentally-challenged patients </li></ul><ul><li>Amnesia </li></ul><ul><li>Lack of adverse effects </li></ul><ul><li>Consistency from appointment to appointment </li></ul><ul><li>“ A good night’s sleep” the night before the dental procedure </li></ul>
  38. 38. Sedation should NOT be used to control pain and does NOT substitute for good local anesthesia
  39. 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. 40. Factors Influencing Oral Drug Absorption <ul><li>Lipid solubility </li></ul><ul><li>pH of gastric tissues </li></ul><ul><li>Mucosal surface area </li></ul><ul><li>Gastric emptying time </li></ul><ul><li>Dosage form of drug </li></ul><ul><li>Drug inactivation (“first pass effect”) </li></ul><ul><li>Presence of food in stomach </li></ul><ul><li>Bioavailability of drug </li></ul><ul><li>Genetics </li></ul>
  41. 41. Alpha Distribution Phase The phase in which sedative activity is initiated & ended, by entry into and removal from the CNS
  42. 42. Beta Elimination Phase The phase in which a sedative drug is inactivated by hepatic metabolism & excretion
  43. 43. Margin of Safety The difference between the effective therapeutic dose and the dose that produces severe or life-threatening adverse effects
  44. 44. Reasons NOT to used BZs… <ul><li>Allergy </li></ul><ul><li>Narrow angle glaucoma </li></ul><ul><li>Chronic BZ ingestion…??? </li></ul><ul><li>Tricyclic antidepressant therapy…??? </li></ul><ul><li>Adversely interactive drugs (e.g., azole antifungals/triazolam) </li></ul>
  45. 45. Characteristics of Benzodiazepines <ul><li>Facilitate binding of GABA (endogenous inhibitory transmitter) </li></ul><ul><li>More favorable therapeutic index than older agents </li></ul><ul><li>Can produce anterograde amnesia </li></ul><ul><li>Agents differ in onset, duration & metabolism </li></ul><ul><li>Agents differ in regard to sedation vs. hypnosis </li></ul>
  46. 46. Boxed Warning: BZs “ sleep driving” (with no memory) “ severe allergic reactions” http://www.fda.gov/bbs/topics/NEWS/2007/NEW01587.html
  47. 47. Pharmacokinetics and Clinical Effects of Multidose Sublingual Triazolam in Healthy Volunteers. Jackson DL et al. J. Clin. Psychopharmacol. 2006;26(1):4-8 <ul><li>10 human volunteers </li></ul><ul><li>0.25 mg followed by 0.25 mg at 60 mins and 0.25 mg at 90 mins </li></ul><ul><li>Evaluated by observed, bispectral index and plasma triazolam levels </li></ul><ul><li>8 subjects met criteria for deep sedation or general anesthesia at later time point </li></ul>
  48. 48. Advantages of Benzodiazepines <ul><li>Specificity of effect </li></ul><ul><li>Well absorbed by the oral route </li></ul><ul><li>High margin of safety/therapeutic index </li></ul><ul><li>Effective as single agents </li></ul><ul><li>Specific reversal agent available (flumazenil) </li></ul>
  49. 49. Classification of Benzodiazepines <ul><li>Alprazolam: antianxiety </li></ul><ul><li>Diazepam: antianxiety </li></ul><ul><li>Lorazepam: antianxiety/sedative-hypnotic </li></ul><ul><li>Midazolam: sedative/hypnotic </li></ul><ul><li>Oxazepam: antianxiety </li></ul><ul><li>Triazolam: sedative/hypnotic </li></ul>
  50. 50. Diazepam (VALIUM ) <ul><li>Usual dose range: 2 - 20 mg , 1 h before appointment (adults) </li></ul><ul><li>Onset: 1 hr (peak levels in 2 hrs) </li></ul><ul><li>Duration: 1 - 3 hrs </li></ul><ul><li>Contraindications: allergy, narrow-angle & untreated open-angle glaucoma </li></ul><ul><li>Precautions: sedation intensified by several CYP inhibitors (3A4, 2C19) </li></ul>
  51. 51. Diazepam <ul><li>Active metabolites? Yes </li></ul><ul><li>Pregnancy category D </li></ul><ul><li>Availability: 2-, 5- & 10-mg tabs, 5 mg/ml liquid, rectal gel 5 mg/ml </li></ul>
  52. 52. Lorazepam (ATIVAN ) <ul><li>Usual dose range: 2 - 4 mg 1 hr before appointment (adults) </li></ul><ul><li>Onset: 1 hr (peak levels in 2 hrs) </li></ul><ul><li>Duration: 2 - 4 hrs (use for longer procedures) </li></ul><ul><li>Contraindications: allergy, narrow-angle glaucoma </li></ul><ul><li>Precautions: greater likelihood of excessive sedation than with other agents, do not use in cases of depressive disorder/psychosis </li></ul>
  53. 53. Lorazepam <ul><li>Active metabolites? No </li></ul><ul><li>Pregnancy category D </li></ul><ul><li>Availability: 0.5-, 1 and 2-mg tabs </li></ul>
  54. 54. Oxazepam (SERAX) <ul><li>Usual dose range: 10 – 30 mg , 1 hr before appointment (adults) </li></ul><ul><li>Onset: 1 hr (peak levels in 1 – 4 hrs) </li></ul><ul><li>Duration: 2 – 4 hrs </li></ul><ul><li>Contraindications: allergy </li></ul><ul><li>Precautions: same as for other agents </li></ul><ul><li>Active metabolites? No </li></ul>
  55. 55. Oxazepam <ul><li>Pregancy category D </li></ul><ul><li>Availability: 10-, 15- & 30-mg caps, 15-mg tabs </li></ul>
  56. 56. Triazolam (HALCION ) <ul><li>Usual dose range: 0.25 – 0.5 mg, 1 hr before appointment (adults) </li></ul><ul><li>Onset: 1.3 hrs (peak levels in 0.5 – 4 hrs) </li></ul><ul><li>Duration: 1 hr </li></ul><ul><li>Contraindications: allergy, pregnancy, do not administer with potent CYP 3A4 inhibitors (e.g., azole antifungals) </li></ul><ul><li>Precautions: anterograde amnesia, excessive sedation (especially elderly) </li></ul>
  57. 57. Triazolam <ul><li>Active metabolites? No </li></ul><ul><li>Pregnancy category X </li></ul><ul><li>Availability: 0.125- & 0.25-mg tabs </li></ul>
  58. 58. Triazolam Doses <ul><li>Short-term management of insomnia </li></ul><ul><ul><li>0.25mg PO hs </li></ul></ul><ul><ul><li>Max: 0.5 mg PO hs; </li></ul></ul><ul><ul><li>Alternative: 0.125 mg PO hs if elderly, hepatic impairment </li></ul></ul>
  59. 59. Triazolam <ul><li>Onset: </li></ul><ul><li>Peak effect: </li></ul><ul><li>Duration: </li></ul><ul><li>1 hr. </li></ul><ul><li>1.3 hrs. </li></ul><ul><li>2 – 3 hrs. </li></ul>
  60. 60. Alprazolam (XANAX) <ul><li>Usual dose range: 0.25 – 1 mg 1 hr before appointment (adults) </li></ul><ul><li>Onset: 1 hr (peak levels in 1 – 2 hrs) </li></ul><ul><li>Duration: 1 – 2 hrs </li></ul><ul><li>Contraindications: allergy, narrow- and untreated open-angle glaucoma, potent CYP 3A4 inhibitors (e.g., azole antifungals) </li></ul><ul><li>Precautions: sedation intensified by CYP 3A4 inhibitors, produces little or no amnesia or somnolence </li></ul>
  61. 61. Alprazolam <ul><li>Active metabolites? No </li></ul><ul><li>Pregnancy category D </li></ul><ul><li>Availability: 0.25-, 0.5, 1- & 2-mg tabs, 0.5- and 1 mg/ml liquid </li></ul>
  62. 62. Midazolam <ul><li>ALL BRAND NAME FORMS (VERSED) DISCONTINUED BY ROCHE MAY, 2002 </li></ul><ul><li>Now available from Ranbaxy Pharmaceuticals as 2 mg/ml cherry syrup (Princeton, NJ) </li></ul><ul><li>Usual dosage range: 0.25 – 0.5 mg/kg single dose up to a total maximum of 20 mg (children) </li></ul><ul><li>Onset: 10 – 20 min </li></ul><ul><li>Duration: 30 – 60 min </li></ul><ul><li>Contraindications: allergy, narrow-angle glaucoma </li></ul>
  63. 63. Midazolam <ul><li>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 </li></ul><ul><li>Active metabolites? No </li></ul><ul><li>Pregnancy category D </li></ul><ul><li>Availability: 2 mg/ml syrup </li></ul>
  64. 64. Oral BZ Biovailability & Half-lives <ul><li>Diazepam: 100%, 43 ± 13 hrs </li></ul><ul><li>Oxazepam: 97%, 8 ± 2.4 hrs </li></ul><ul><li>Lorazepam: 90%, 12 ± hrs </li></ul><ul><li>Alprazolam: 88%, 12 ± 2 hrs </li></ul><ul><li>Triazolam: 44%, 2.9 ± 1 hrs </li></ul><ul><li>Midazolam: 44%, 1.9 ± 0.6 hrs </li></ul>
  65. 65. Non-BZ BZ Receptor Agonists <ul><li>Eszopiclone (LUNESTA) </li></ul><ul><li>Zaleplon (SONATA) </li></ul><ul><li>Zolpidem (AMBIEN) </li></ul>
  66. 66. Melatonin Receptor Agonist: Ramelteon ( ROZEREM ) <ul><li>MT 1 & MT 2 receptor agonist </li></ul><ul><li>Simulates melatonin (“circadian rhythm) </li></ul><ul><li>8 mg </li></ul><ul><li>Rapid onset, Tmax = 45 min </li></ul><ul><li>Low bioavailability, 70% protein-bound </li></ul><ul><li>CYP 1A2 (fluvoxamine caution) </li></ul><ul><li>Not controlled substance </li></ul>
  67. 67. Zolpidem (AMBIEN) <ul><li>Usual dose range: 5 – 10 mg, 1/2 hr before appointment </li></ul><ul><li>Onset: 0.5-1 hr (peak levels in 1.6 hrs)(use when rapid onset needed) </li></ul><ul><li>Duration: 2 – 3 hrs </li></ul><ul><li>Contraindications: allergy </li></ul><ul><li>Precautions: reduce dosage in elderly </li></ul><ul><li>Active metabolites? No </li></ul>
  68. 68. Zolpidem <ul><li>Pregnancy category B </li></ul><ul><li>Availability: 5- and 10-mg tabs </li></ul>
  69. 69. Hydroxyzine (ATARAX, VISTARIL) <ul><li>Usual dose range: 50 – 100 mg, 1 hr before appointment (adults), 1.1 – 2.2 mg/kg (children) </li></ul><ul><li>Onset: 30 min (peak effect 2 hrs) </li></ul><ul><li>Duration: 3 – 4 hrs </li></ul><ul><li>Contraindications: allergy </li></ul><ul><li>Precautions: same as for benzodiazepines, more anticholinergic actions (glaucoma, respiratory disease) </li></ul>
  70. 70. Hydroxyzine <ul><li>Active metabolites? No </li></ul><ul><li>Pregnancy category D </li></ul><ul><li>Availability: 10-, 25-, 50- & 100-mg tabs; 10mg/5 ml syrup (ATARAX); 25-, 50-, & 100-mg caps and 25mg/5 ml oral suspension (VISTARIL) </li></ul><ul><li>Non-controlled substance </li></ul>
  71. 71. Promethazine (PHENERGAN) <ul><li>Usual dose range: 25 – 50 mg , 1 hr before appointment (adults), 2.2 mg/kg (children, when used as SOLE sedative agent) </li></ul><ul><li>Onset: 1 hr (peak effect 2 hrs) </li></ul><ul><li>Duration: 3 – 4 hrs (may be up to 12 hrs ) </li></ul><ul><li>Contraindications: allergy, conditions worsened by anticholinergic actions </li></ul><ul><li>Precautions: same as for other sedatives, also seizure disorders </li></ul>
  72. 72. Promethazine <ul><li>Active metabolites? No </li></ul><ul><li>Pregnancy category C </li></ul><ul><li>Availability: 12.5-, 25- & 50-mg tabs; 6.25 mg/5 ml syrup; 25 mg/5 ml syrup fortis </li></ul><ul><li>Not a controlled substance </li></ul>
  73. 73. Agents NOT Recommended (Adults) <ul><li>Alcohol </li></ul><ul><li>Chloral hydrate </li></ul><ul><li>Opioids </li></ul><ul><li>Multi-Drug Cocktails </li></ul>
  74. 74. Nitrous Oxide
  75. 75. Advantages of Nitrous Oxide <ul><li>Rapid onset (almost equal to that of iv) </li></ul><ul><li>Titratable ( up AND down ) </li></ul><ul><li>Depth of sedation readily altered </li></ul><ul><li>Flexible duration of action </li></ul><ul><li>Rapid recovery from sedation </li></ul><ul><li>Safe </li></ul>
  76. 76. Advantages of Nitrous Oxide <ul><li>No injection required </li></ul><ul><li>Very few side effects </li></ul><ul><li>No adverse effects on vital organs </li></ul><ul><li>May substitute for local anesthesia in selected circumstances (e.g., soft tissue procedures) </li></ul>
  77. 77. Disadvantages of Nitrous Oxide <ul><li>Initial co$t of cumbersome equipment is high </li></ul><ul><li>Continuing co$ts of gases high </li></ul><ul><li>Equipment takes up operatory space </li></ul><ul><li>Lack of potency </li></ul><ul><li>Requires constant patient cooperation </li></ul><ul><li>Chronic exposure of office personnel </li></ul>
  78. 78. Indications for Inhalation Sedation <ul><li>Mild to moderate dental anxiety </li></ul><ul><li>Medically compromised patients </li></ul><ul><li>Gagging (impressions, radiographs) </li></ul>
  79. 79. Relative Contraindications to Inhalation Sedation <ul><li>Severe dental anxiety & fear </li></ul><ul><li>Compulsive personalities </li></ul><ul><li>Poor past experience with oral sedation </li></ul><ul><li>Claustrophobia </li></ul><ul><li>Pregnancy </li></ul><ul><li>URI, COPD </li></ul>
  80. 80. Concentration Effect The higher the concentration of inhaled gas, the more rapidly the blood level of the gas increases
  81. 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. 82. Prevention of Diffusion Hypoxia Administer 100% oxygen for 3 to 5 minutes at the termination of the sedation procedure
  83. 83. CNS Effects of Nitrous Oxide <ul><li>All senses are slightly depressed or altered (perioral numbness, etc.) </li></ul><ul><li>Amnesia does NOT occur </li></ul><ul><li>Mild depression of cerebral cortex </li></ul><ul><li>Produces mild sedation, analgesia </li></ul><ul><li>Lacks direct respiratory depression </li></ul>
  84. 84. Nitrous Oxide Does NOT... <ul><li>Obtund sharp pain impulses </li></ul><ul><li>Substitute for good local anesthesia </li></ul><ul><li>Sedate agitated or extremely anxious patients </li></ul><ul><li>Produce loss of consciousness when used correctly </li></ul>
  85. 85. Why Nitrous Oxide is Associated with Nausea <ul><li>Not titrated </li></ul><ul><li>All patients are given “fixed” concentrations (usually 50%) </li></ul><ul><li>Signs and symptoms of impending nausea and vomiting are not recognized </li></ul><ul><li>Patients are not given appropriate pre-treatment instructions </li></ul>
  86. 86. Other Effects of Nitrous Oxide <ul><li>Cardiovascular: no clinically significant effects at recommended concentrations </li></ul><ul><li>Cutaneous vasodilation (flush, warmth) </li></ul><ul><li>Respiratory: no clinically significant depression at recommended concentrations </li></ul><ul><li>G.I. Tract: no effects liver) </li></ul>
  87. 87. Other Effects of Nitrous Oxide <ul><li>Kidneys: no effect </li></ul><ul><li>Blood: inhibition of vitamin B-12 metabolism (chronic administration) </li></ul><ul><li>Skeletal muscle: no direct effect (relaxation secondary to sedative effect) </li></ul>
  88. 88. Contraindications to Nitrous Oxide <ul><li>Pregnancy (1st trimester) </li></ul><ul><li>Upper respiratory tract infection </li></ul><ul><li>Nasal hood unacceptable (claustrophobia, allergy, etc.) </li></ul><ul><li>Previous “bad experience” </li></ul><ul><li>Drug abuse </li></ul><ul><li>Chronic environmental exposure </li></ul>
  89. 89. Effects of Pathologic Conditions on Inhalation Sedation <ul><li>Emphysema: decreased total surface area of alveoli </li></ul><ul><li>Pneumonia: alveolar walls thickened </li></ul><ul><li>Asthma: increased thickness of bronchial secretions </li></ul><ul><li>Anemia/Methemoglobinemia: decreased oxygen-carrying capacity of blood </li></ul>
  90. 90. Physiologic Equivalents <ul><li>Total gas flow (LPM) = minute respiratory volume </li></ul><ul><li>Excursion of reservoir = tidal volume </li></ul><ul><li>Excursions of reservoir bag/min = respiratory rate = respiratory center “firings” </li></ul><ul><li>Collapse of reservoir bag with maximum inhalation = inspiratory reserve capacity </li></ul>
  91. 91. Complications and Chronic Toxicity
  92. 92. Excessive Perspiration <ul><li>Etiology: peripheral vasodilation </li></ul><ul><li>Management: decrease nitrous oxide concentration (5% per min) </li></ul>
  93. 93. Expectoration <ul><li>Etiology: fluid removal problems, diminished patient coordination and cooperation </li></ul><ul><li>Management: efficient vacuum operation, rubber dam </li></ul>
  94. 94. Behavioral Problems <ul><li>Etiology: authoritarian patient, excessive nitrous oxide concentrations </li></ul><ul><li>Management: decrease nitrous oxide concentration, allow controlled mouth breathing if necessary </li></ul>
  95. 95. Nausea <ul><li>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 </li></ul><ul><li>Management: avoid etiologic factors, premedicate with anti-emetic drug </li></ul>
  96. 96. Vomiting <ul><li>Etiology: same as for nausea </li></ul><ul><li>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 </li></ul>
  97. 97. Pre-Operative Instructions <ul><li>1. Take pre-operative medications (if indicated) </li></ul><ul><li>2. No heavy meals (or no food intake at all) for 4 hrs prior to sedation </li></ul><ul><li>3. Require an escort (if indicated or otherwise required) </li></ul>
  98. 98. Chronic Exposure to Nitrous Oxide
  99. 99. Mutagenicity of Nitrous Oxide? <ul><li>Negative in Salmonella microsome assays </li></ul><ul><li>Negative in cultured hamster lung fibroblasts </li></ul><ul><li>negative in hamster ovarian cells </li></ul><ul><li>negative in Drosophila melanogaster </li></ul><ul><li>No human studies </li></ul>
  100. 100. Carcinogenicity of Nitrous Oxide? <ul><li>Negative results in mice </li></ul><ul><li>Human studies generally negative </li></ul>
  101. 101. Teratogenicity of Nitrous Oxide <ul><li>Definite teratogenicity in rats </li></ul><ul><li>male rodents show chromosomal damage (not heritable, significance?) </li></ul><ul><li>INCREASED RISK OF SPONTANEOUS ABORTION IN HUMANS </li></ul><ul><li>Effects require chronic exposure </li></ul>
  102. 102. Dental Office Exposure to Nitrous Oxide
  103. 103. Sources of Environmental N 2 O <ul><li>Normal gas flow to patients </li></ul><ul><li>Patient (talking, “washout” during recovery) </li></ul><ul><li>Equipment (leaks) </li></ul><ul><li>Air conditioning (recirculation) </li></ul>
  104. 104. Office Levels of N 2 O Depend on <ul><li>Frequency of use </li></ul><ul><li>Size of operatory </li></ul><ul><li>Ventilation of operatory </li></ul><ul><li>Type of operatory (open vs. closed) </li></ul>
  105. 105. Detection of Office N 2 O <ul><li>Visual inspection (rubber goods, connections) </li></ul><ul><li>Application of soapy water </li></ul><ul><li>Air analysis (by outside service company) (infrared spectroscopy) </li></ul><ul><li>Monitoring cartridges (Porter “Peace of Mind” cartridges) </li></ul>
  106. 106. Minimizing Office N 2 O
  107. 107. Effects of Scavenging Systems
  108. 108. Nitrous Oxide Levels (ppm) of Breathing Zones in Offices Without & With Scavenging Systems (from Whitcher et al., JADA, 1977) <ul><li>WITHOUT </li></ul><ul><li>General dentist: 775 (+/- 63) </li></ul><ul><li>Pedodontist: 940 (+/-92) </li></ul><ul><li>Oral Surgeon: 1000 (+/-130) </li></ul><ul><li>WITH </li></ul><ul><li>General dentist: 21 (+/-2) </li></ul><ul><li>Pedodontists: 33 (+/-4) </li></ul><ul><li>Oral Surgeon: 36 (+/-4) </li></ul>
  109. 109. Abuse of Nitrous Oxide
  110. 110. Mechanism of Chronic Toxicity <ul><li>Oxidation of vitamin B-12 (cobalamin; bound co-factor for methionine synthetase and methylmalonyl CoA mutase) </li></ul><ul><li>Interferes with folate metabolism and DNA synthesis (decreased thymidine) </li></ul>
  111. 111. Clinical Effects of Chronic Toxicity <ul><li>Bone marrow suppression, anemia, leukopenia </li></ul><ul><li>Suppression of neutrophil chemotaxis </li></ul><ul><li>Alterations in reproductive cells </li></ul><ul><li>Peripheral neuropathy with subacute degeneration of spinal cord </li></ul><ul><li>Layzer, R.B. Lancet 2:1227, 1978 </li></ul>
  112. 112. Flumazenil (ROMAZICON) <ul><li>Competes with benzodiazepine for receptor site </li></ul><ul><li>Used to reverse CNS depressant effects of overdose and to decrease recovery time </li></ul><ul><li>REVERSAL OF RESPIRATORY DEPRESSION NOT PREDICTABLE </li></ul><ul><li>Short half-life (readministration often required) </li></ul>
  113. 113. Sublingual Injection of Flumazenil? <ul><li>Average time to reversal with IV route = 2 minutes </li></ul><ul><li>Average time to reversal with SL route = 4.33 minutes </li></ul>
  114. 114. Flumazenil <ul><li>Only BZ antagonist available </li></ul><ul><li>Can produce agitation, confusion, dizziness & nausea </li></ul><ul><li>Can precipitate withdrawal syndrome (chronic BZ use) </li></ul><ul><li>Can produce seizures & cardiac arrhythmias in patients taking tricyclic antidepressants </li></ul><ul><li>Usual dose: 0.2 mg iv in 15 secs, evaluate in 45 secs. Add additional 0.2 mg if needed </li></ul><ul><li>Repeat q. 5 min until recovery or total dose of 1 mg </li></ul>
  115. 115. Fundamentals of Emergency Preparation <ul><li>1. Training (BLS, ACLS, PALS, TSBDE-approved courses) </li></ul><ul><li>2. Development and implementation of an emergency plan </li></ul><ul><li>3. Purchase and maintenance of emergency equipment and drugs </li></ul><ul><li>4. Periodic mock emergency drills </li></ul><ul><li>5. Training new staff members </li></ul>
  116. 116. What Your EMS Personnel Want and NEED! <ul><li>An accurate medical history of the patient/victim </li></ul><ul><li>A concise description of everything that happened </li></ul><ul><li>Doctor remains with patient/victim </li></ul>
  117. 117. Pre-Emptive Strategies for Dental Office Emergency Preparation and Management <ul><li>Painstakingly detailed health history </li></ul><ul><li>Medical risk classifcation </li></ul><ul><li>Avoid potential drug interactions </li></ul><ul><li>Calculate dental drug dosages carefully </li></ul><ul><li>Monitor, monitor, monitor!!! </li></ul><ul><li>IMPLEMENT AN OFFICE EMERGENCYN PLAN </li></ul>
  118. 118. A General Paradigm for Assessing and Managing ASA II-IV Patients <ul><li>Monitor vital signs at every appointment </li></ul><ul><li>Know patient’s medications and why they are taking them </li></ul><ul><li>Consult the physician to determine degree of disease control, compliance and ability of patient to tolerate dental procedure </li></ul><ul><li>Utilize the stress-reduction protocol </li></ul><ul><li>Plan for likely emergencies </li></ul>
  119. 119. Stress-Reduction Protocol (Medically Compromised Patients) <ul><li>1. Recognize medical risk </li></ul><ul><li>2. Consult patient’s physician(s) </li></ul><ul><li>3. Pharmacosedation, as indicated </li></ul><ul><li>4. Short appointments </li></ul><ul><li>5. Morning appointments </li></ul><ul><li>6. Excellent intraoperative pain control </li></ul><ul><li>7. Minimize waiting room time </li></ul><ul><li>8. Excellent post-operative pain control </li></ul>
  120. 120. Range of Dental Office Emergencies <ul><li>Syncope </li></ul><ul><li>Nausea, vomiting </li></ul><ul><li>Hyperventilation </li></ul><ul><li>Acute bronchial constriction/asthma </li></ul><ul><li>Seizures </li></ul><ul><li>Acute elevations in BP and HR </li></ul><ul><li>Acute depressions in BP and HR </li></ul><ul><li>Hypoglycemia </li></ul><ul><li>Acute CNS/respiratory depression </li></ul><ul><li>Swallowing/aspirating foreign object </li></ul>
  121. 121. Adverse events associated with outpatient anesthesia in Massachusetts D’eramo EM, Bookless SJ, Howard JB J. Oral Maxillofac. Surg. 2003;61:793-800
  122. 122. Methods and Outcomes from D’Eramo et al. <ul><li>Morbidity data from 157 oral surgeons for year 1999 </li></ul><ul><li>Syncope was most common complication (1 in 160 patients receving local anesthesia) </li></ul>
  123. 123. Types of Emergency Drugs and Drug Kits <ul><li>None (or expired) </li></ul><ul><li>Custom (“homemade”) </li></ul><ul><li>Pre-assembled, commercial </li></ul><ul><li>Complete medical emergency “crash carts” </li></ul><ul><li>Published lists </li></ul><ul><li>ACLS “Core Drugs” </li></ul>
  124. 124. Office Emergencies and Emergency Kits ADA Council on Scientific Affairs JADA 2002;133(3):364-365
  125. 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. 126. Minimum Emergency Drugs Recommended by ADA CSA <ul><li>Epinephrine 1:1,000 </li></ul><ul><li>Injectable antihistamine </li></ul><ul><li>100% oxygen with positive-pressure ventilation </li></ul><ul><li>Nitroglycerin (sublingual/aerosol) </li></ul><ul><li>Bronchodilator (inhaler) </li></ul><ul><li>“ Sugar” (or glucose) </li></ul><ul><li>Others “as training and needs mandate” </li></ul>
  127. 127. “ Essential” Emergency Drugs (Haas, Dent. Clin. N. Am., 2002:46:815-830) <ul><li>Oxygen </li></ul><ul><li>Epinephrine </li></ul><ul><li>Nitroglycerin </li></ul><ul><li>Antihistamine </li></ul><ul><li>Beta agonist (bronchodilator) </li></ul><ul><li>Aspirin </li></ul>
  128. 128. “ Supplementary” Emergency Drugs (Haas, 2002) <ul><li>Glucagon </li></ul><ul><li>Atropine </li></ul><ul><li>Ephedrine </li></ul><ul><li>Hydrocortisone </li></ul><ul><li>Morphine (or nitrous oxide) </li></ul><ul><li>Naloxone </li></ul><ul><li>Lorazepam or midazolam (seizures) </li></ul><ul><li>Flumazenil </li></ul>
  129. 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 2002;133(3):364-365
  130. 130. Oxygen Cylinders and Volumes <ul><li>E: 625 liters </li></ul><ul><li>H: 6,909 liters </li></ul>
  131. 131. Time Available at 15 L/min Flow Rate (from 2,000 psi fill) <ul><li>E cylinder = 41 minutes </li></ul><ul><li>H cylinder = 460 minutes </li></ul><ul><li>Reduce times by ½ at 1,000 psi </li></ul>
  132. 132. Appropriate Use of Oxygen <ul><li>Any suspected cardiopulmonary emergency </li></ul><ul><li>Complaints of shortness of breath and suspected ischemic pain </li></ul><ul><li>For patients with suspected stroke or unknown blood oxygenation </li></ul><ul><li>May be administered to patients who are not hypoxemic </li></ul>
  133. 133. Precautions: Oxygen <ul><li>Observe closely when using with patients known to be dependent on hypoxic drive (COPD; very rare) </li></ul><ul><li>Pulse oximetry may provide a useful method of assessing oxygenation (may be inaccurate in low cardiac output, with vasoconstriction or with CO poisoning) </li></ul>
  134. 134. Oxygen Flow Requirments (ACLS) <ul><li>Nasal cannula: 1-6 L/min, 21-44% </li></ul><ul><li>Venturi mask: 4-12 L/min, 24-50% </li></ul><ul><li>Partial rebreather mask: 6-10 L/min, 35-60% </li></ul><ul><li>Nonrebreather mask with reservoir: 6-15 L/min </li></ul><ul><li>Bag-mask with nonrebreather “tail”: 15 L/min, 95-100% </li></ul>
  135. 135. Positive-Pressure Ventilation A nitrous oxide nasal hood CAN NOT provide positive-pressure ventilation
  136. 136. Supplementary Oxygen vs. Positive-Pressure Ventilation with 100% Oxygen
  137. 137. Epinephrine <ul><li>Only injectable agent which should be available in ALL dental offices </li></ul><ul><li>Use pre-loaded syringes (not ampuls) </li></ul><ul><li>Use 1:1,000 by sublingual or I.M. route only </li></ul><ul><li>Adult dose = 0.3 mg, q. 5-10 min & monitor CV status before re-dosing </li></ul><ul><li>Produces bronchodilation, cardiac stimulation and vasoconstriction </li></ul>
  138. 138. Epinephrine Precautions <ul><li>Elevations of BP and increased HR may cause ischemia, increased O2 demand and dysrhythmias </li></ul><ul><li>Avoid accidental injection of rescuer </li></ul>
  139. 139. Whenever epinephrine or another emergency drug is administered, medical assistance must be summoned
  140. 140. Other Bronchodilators <ul><li>Beta-2 Agonists </li></ul><ul><li>Terbutaline </li></ul>
  141. 141. Beta-2 Adrenergic Agonists <ul><li>Albuterol (VENTOLIN)(first choice) </li></ul><ul><li>Metaproterenol (ALUPENT) </li></ul><ul><li>Terbutaline (BRETHAIRE) </li></ul><ul><li>Peak onset = 30-60 minutes </li></ul>
  142. 142. Albuterol (PROVENTIL, VENTOLIN) <ul><li>Use by inhalation route for emergency airway constriction </li></ul><ul><li>May produce sympathomimetic CV effects (tachycardia, palpitations, elevated BP) </li></ul><ul><li>May be ineffective or partially effective if patient taking beta blockers </li></ul>
  143. 143. Nitroglycerin <ul><li>Available in 0.4 mg sublingual tabs </li></ul><ul><li>Decreases cardiac work load </li></ul><ul><li>Administer 1 tab q. 5 min up to 3 times </li></ul><ul><li>Also available in spray form (more stable)(1-2 sprays q. 5 min up to 3 sprays) </li></ul><ul><li>May produce hypotension (do not use if hypotension present) </li></ul>
  144. 144. Nitroglycerin Precautions <ul><li>Avoid in patients taking drugs for ED </li></ul><ul><li>May cause excessive decrease in BP with syncope (patient should be in sitting or reclined position when taking) </li></ul>
  145. 145. Aromatic Spirits of Ammonia <ul><li>Irritates respiratory mucosa, causes muscle contractions, improves venous return </li></ul><ul><li>Dose = inhaled vapors of one crushed ampul </li></ul><ul><li>Supplied as 0.3 ml “vaporole” </li></ul>
  146. 146. Glucose/Sucrose <ul><li>Acceptable forms of sucrose include soft drinks, orange juice & candy bars </li></ul><ul><li>Glucose also available </li></ul><ul><li>Do not use oral dose forms in unconscious patient </li></ul><ul><li>Long onset (10 min) </li></ul>
  147. 147. Antihistamines <ul><li>Diphenhydramine (BENADRYL) (50 mg/ml) </li></ul><ul><li>Chlorpheniramine (CHLOR-TRIMETON) (10 mg/ml) </li></ul><ul><li>DO NOT subsitute for epinephrine in anaphylaxis </li></ul>
  148. 148. Aspirin <ul><li>Indicated in all patients with ACS </li></ul><ul><li>Any person with symptoms of “pressure, “heavy weight”, “squeezing”, or “crushing” (suggestive of ischemia) </li></ul><ul><li>DO NOT administer in aspirin-allergic patients </li></ul><ul><li>Relatively contraindicated in ulcer disease or asthmatics </li></ul>
  149. 149. Aspirin Dosage <ul><li>160 – 325 mg non-enteric coated tablets ASAP </li></ul><ul><li>Chewing is preferred </li></ul><ul><li>May use rectal suppository form (if available) </li></ul>
  150. 150. Atropine <ul><li>Indicated for bradycardia </li></ul><ul><li>Rapid onset, short duration </li></ul><ul><li>0.5 mg i.m. q. 3-5 min up to total of 3 mg </li></ul><ul><li>Avoid excessive reductions of heart rate and use in patients susceptible to adverse anticholinergic effects </li></ul><ul><li>Also used for organophosphate poisoning </li></ul>
  151. 151. References <ul><li>Malamed, Sedation: A Guide to patient management, 4 th edition, 2003 </li></ul><ul><li>Jackson & Johnson, Conscious sedation for dentistry: risk management and patient selection, Dent. Clin. N. Am. Vol. 46, 2002 </li></ul><ul><li>American Dental Association, Guidelines for the use of conscious sedation, deep sedation and general anesthesia, 2007. </li></ul>
  152. 152. Local Anesthetic Dosages <ul><li>ALWAYS calculated on basis of body weight (mg/kg) </li></ul><ul><li>Absolute maximum dosage reached at body weight of 70 kg (150 lbs) </li></ul><ul><li>Apply to a single appointment </li></ul><ul><li>Adjusted downward to compensate for drug interactions, medical conditions </li></ul>
  153. 153. Maximum Doses of Selected Local Anesthetics <ul><li>Lidocaine (4.4 mg/kg, 300 mg absolute) </li></ul><ul><li>Mepivacaine (4.4 mg/kg, 300 mg absolute) </li></ul><ul><li>Prilocaine (6 mg/kg, 400 mg absolute) </li></ul><ul><li>Articaine (7 mg/kg, 500 mg absolute) </li></ul><ul><li>Bupivacaine (1.3 mg/kg, 90 mg absolute) </li></ul>
  154. 154. Other Informational Resources <ul><li>Mosby’s Drug Consult, 800-545-2522 </li></ul><ul><li>Mosby’s Dental Drug Reference , www.elsevierhealth.com </li></ul><ul><li>Drug Interaction Facts , Facts & Comparisons, 800-223-0554 </li></ul><ul><li>www.rxlist.com </li></ul><ul><li>www.drugfacts.com </li></ul><ul><li>www.med.umich.edu/1lib/aha/umherb01 </li></ul>
  155. 155. Local Anesthetics
  156. 156. Approaches to Failed IABs… <ul><li>Reinject (if lower lip not numb)? </li></ul><ul><li>Increase local anesthetic concentration (prilocaine, articaine)? </li></ul><ul><li>Increase the vasoconstrictor concentration? </li></ul><ul><li>Wait? </li></ul><ul><li>Apply the “Volume Rule”? </li></ul><ul><li>Apply the “Real Estate Rule”? </li></ul>
  157. 157. 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)
  158. 158. Malamed et al., JADA 2000, 2001 <ul><li>2% lidocaine with 1:100K epi vs. 4% articaine with 1:100K epi </li></ul><ul><li>882/443 articaine/lidocaine subjects </li></ul><ul><li>Used “simple” (single extractions, etc) and “complex” (alveolectomies, etc) for evaluations </li></ul><ul><li>Articaine “is an efffective agent acting in the standard lidocaine-mepivacaine range” </li></ul><ul><li>Clinical performance not sufficiently different to qualify it as a replacement for lidocaine </li></ul>
  159. 159. Articaine vs. Other Agents <ul><li>Absolute max dose (carts) < lidocaine (7.3 vs. 8.3) </li></ul><ul><li>Pregnancy category C (lidocaine B) </li></ul><ul><li>Available with 1:100,000 and 1:200,000 epinephrine </li></ul>
  160. 160. Anesthetic Efficacy of Articaine for IABs in Patients with Irreversible Pulpitis Claffey E. et al. J. Endo. 2004;30:568-71
  161. 161. Claffey et al./Articaine <ul><li>72 cases of irreversible pulpitis </li></ul><ul><li>Compared 4% articaine 2.2 ml vs. 2% lidocaine with 1:100K epi 2.2 ml </li></ul><ul><li>All patients had “numb lips” </li></ul><ul><li>Endo access started 15 min post numbness </li></ul><ul><li>Success rates = 24% for articaine & 23% for lidocaine </li></ul>
  162. 162. Results from Nusstein et al., J. Endo. 2003
  163. 163. Review of Intraosseous Injection Systems: ADA Professional Product Review, Volume 2, Issue 1, Winter 2006 <ul><li>Stabident </li></ul><ul><li>X-Tip </li></ul><ul><li>Intraflow (not evaluated) </li></ul><ul><li>“ Clinical performance” best feature </li></ul><ul><li>X-Tip easiest to use </li></ul><ul><li>Tachycardia most common concern </li></ul>
  164. 164. Results from Replogle et al. (1999) <ul><li>67% of ASA I patients receiving IO injections of lidocaine 2% with 1:100K epi experienced significantly increased HR </li></ul><ul><li>Tachycardia averaged 28 bpm & lasted average of 4-5 min </li></ul><ul><li>Systolic & diastolic BP unchanged </li></ul><ul><li>No increased HR observed with 3% mepivacaine </li></ul>
  165. 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. 166. Proposed Causes of Paresthesia <ul><li>Direct nerve trauma by needle </li></ul><ul><li>Barbed needles (“fish hook effect”) </li></ul><ul><li>Intraneural hematoma </li></ul><ul><li>Chemical toxicity of local anesthetics/high concentration local anesthetic (4%) </li></ul><ul><li>Surgical procedures following local anesthetic injection </li></ul><ul><li>Neural ischemia (vasoconstrictor???) </li></ul>
  167. 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 2000;131:901-907
  168. 168. Haas, D. J. Am. Coll. Dent. 2006 <ul><li>Focused on NON-SURGICAL cases </li></ul><ul><li>Evaluated in vitro and human clinical outcomes </li></ul><ul><li>All agents have potential for neurotoxicity, probably dose (concentration)-dependent </li></ul><ul><li>Nerves with fewer fasicles may be more susceptible (e.g., lingual) </li></ul><ul><li>RCTs not likely to discriminate differences between various local anesthetics </li></ul>
  169. 169. Summary of Findings in IAB-Related Paresthesias <ul><li>~50% of patients experience “ electric shock ” sensation </li></ul><ul><li>85-94% of cases recover in 8 wks or less </li></ul><ul><li>Tongue (79%) and lower lip most frequently affected </li></ul><ul><li>No difference between right and left sides </li></ul><ul><li>Nerve damage cannot be visualized or corrected surgically </li></ul><ul><li>Overall incidence of permanent paresthesia = 1:785,000 </li></ul>
  170. 170. Conclusions of Haas (2006) <ul><li>Data are “strongly suggestive” that paresthesia more likely with 4% agents </li></ul><ul><li>“ Concentration, not drug per se” cause </li></ul><ul><li>Cited Royal College of Dental Surgeons (Ontario, 2005) (risks may outweigh benefits of 4% solutions for inferior alveolar and lingual blocks) </li></ul>
  171. 171. Avoiding Paresthesia… <ul><li>Use the lowest practical anesthetic and vasoconstrictor concentrations </li></ul><ul><li>Use the atraumatic injection technique </li></ul><ul><li>Check your cartridges </li></ul><ul><li>Don’t subject your cartridges to temperature extremes </li></ul><ul><li>Avoid operative neural trauma (careful use of forceps, elevators, rubber dam clamps, etc.) </li></ul>
  172. 172. New Perspectives on Pain Control in Patients With Cardiovascular Disease
  173. 173. E-References, Antiplatelet Drugs <ul><li>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 </li></ul><ul><li>http://www.circ.ahajournals.org/cgi/content/full/115/6/813 </li></ul>
  174. 174. NSAID Classes <ul><li>Salicylic acid derivatives (diflunisal/DOLOBID) </li></ul><ul><li>P-Aminophenols (acetaminophen/TYLENOL) </li></ul><ul><li>Indole acetic acids (etodolac/LODINE) </li></ul><ul><li>Aryl acetic acids (diclofenac/VOLTAREN, ketorolac/TORADOL) </li></ul><ul><li>Propionic acids (ibuprofen/MOTRIN, naproxen/ANAPROX, ketoprofen/ORUDIS, flurbiprofen/ANSAID) </li></ul><ul><li>Fenamates (mefenamic acid/PONSTEL) </li></ul><ul><li>Alkanones (nabumetone/RELAFEN) </li></ul><ul><li>Diarylheterocycles (selective COX-2 inhibitors) </li></ul>
  175. 175. Beneficial Effects of NSAIDs <ul><li>Analgesic (relieve pain) </li></ul><ul><li>Antipyretic (reduce fever) </li></ul><ul><li>Anti-inflammatory </li></ul><ul><li>Available OTC </li></ul>
  176. 176. The Oxford League Table of Analgesic Efficacy www.jr2.ox.ac.uk/bandolier/booth/painpag/Acutrev/Analgesics/lftab.html
  177. 177. Oxford League Table of Analgesic Efficacy/NNTs ( www.jr2.ox.ac.uk/bandolier)(moderate-severe pain) <ul><li>Valdecoxib 40 mg: 1.6 </li></ul><ul><li>Ibuprofen 800 mg: 1.6 </li></ul><ul><li>Ketorolac 20 mg/60 mg: 1.8 </li></ul><ul><li>Diclofenac 100 mg: 1.9 </li></ul><ul><li>Rofecoxib 50 mg: 1.9 </li></ul><ul><li>APAP 1,000 mg + codeine 60 mg: 2.2 </li></ul><ul><li>APAP 500 mg + oxycodone 5 mg: 2.2 </li></ul><ul><li>Naproxen 440 mg: 2.3 </li></ul><ul><li>Ibuprofen 600 mg: 2.4 </li></ul><ul><li>Ibuprofen 400 mg: 2.4 </li></ul><ul><li>Morphine 10 mg i.m.: 2.9 </li></ul>
  178. 178. 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
  179. 179. NNTs from Barden et al. <ul><li>Valdecoxib 40 mg (BEXTRA): 1.6 </li></ul><ul><li>Diclofenac 100 mg (VOLTAREN): 1.6 </li></ul><ul><li>Ibuprofen 400 mg: 4.7 </li></ul><ul><li>Ibuprofen 200 mg: 4.6 </li></ul><ul><li>Ibuprofen 600 mg: 1.9 </li></ul><ul><li>Celecoxib (CELEBREX): 4.8 </li></ul><ul><li>APAP 1,000 mg: 3.8 </li></ul><ul><li>APAP 600 mg + codeine 60 mg: 2.5 </li></ul><ul><li>APAP 300 mg + codeine 30 mg: 3.3 </li></ul>
  180. 180. Contraindications to NSAIDs <ul><li>Stomach problems </li></ul><ul><li>Aspirin Allergy </li></ul><ul><li>Bleeding </li></ul><ul><li>Pregnancy </li></ul><ul><li>Kidney disease </li></ul><ul><li>CARDIOVASCULAR DISEASE/RISK OF THROMBOEMBOLISM </li></ul>
  181. 181. Conditions With Risk for NSAID-Induced Nephropathy <ul><li>Volume depletion/dehydration (diarrhea, vomiting) </li></ul><ul><li>Renal insufficiency </li></ul><ul><li>Heart failure </li></ul><ul><li>Diabetes </li></ul><ul><li>Advanced age </li></ul><ul><li>Kharasch, E. Anesth. Analg. 2004;98:1-3 </li></ul>
  182. 182. COX-2-Selective Inhibitors
  183. 183. Selecting new drugs for pain control: evidence-based decision or clinical impression? Jeske, AH. JADA 2002;133:1052-6
  184. 184. Conclusions <ul><li>VIOXX = 400 mg ibuprofen </li></ul><ul><li>VIOXX has 50% “rescue” rate within 24 hrs </li></ul><ul><li>Ibuprofen = VIOXX G.I. problems for 30 days </li></ul><ul><li>VIOXX not OTC </li></ul>
  185. 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. 186. The Use of COX-2 Inhibitors for Acute Dental Pain: A Second Look Huber, MA and Terezhalmy, GT. JADA 2006;137:480-7
  187. 187. Unresolved Issues: NSAIDs <ul><li>COX-2 constitutively expressed in some tissues (brain, kidney, ovary & uterus) </li></ul><ul><li>COX-2-synthesized PGs are pro-inflammatory early, may reduce inflammation & promote healing later </li></ul><ul><li>Is opioid-sparing effect significant? </li></ul><ul><li>Cardiovascular side effects ? (prostacyclin vs. thromboxane A-2, salt and water retention) </li></ul>
  188. 188. COX-2 inhibitors <ul><li>Celecoxib (CELEBREX ) </li></ul><ul><li>Rofecoxicb (VIOXX) </li></ul><ul><li>Etoricoxib (ARCOXIA) </li></ul><ul><li>Lumiracoxib (PREXIGE) (Thromboxane antagonist???) </li></ul><ul><li>Valdecoxib (BEXTRA) </li></ul>
  189. 189. Effects of NSAIDs on Platelet Aggregation <ul><li>Thromboxane A2 = vasoconstrictor, promotes platelet aggregation </li></ul><ul><li>PG I2 = Vasodilator, inhibits platelet aggregation </li></ul><ul><li>COX-2 inhibitors prevent synthesis of PG I2 but have no effect on TX A2 , resulting in a prothrombotic state </li></ul>
  190. 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. 191. AHA Recommendations 2007 for Patients With Cardiovascular Disease <ul><li>Acetaminophen, aspirin and opioid analgesics (incl. tramadol) preferred for short-term pain management </li></ul><ul><li>If NSAID is needed, naproxen “appears to be the preferred choice” </li></ul><ul><li>Prescribe at lowest effective doses for shortest possible period of time </li></ul><ul><li>Diclofenac not recommended as NSAID in this group of patients </li></ul><ul><li>Ibuprofen should be given 30 mins AFTER low-dose aspirin or 8 hrs before (if use concomitantly) </li></ul>
  192. 192. PRECISION … coming to a journal near you! Prospective Randomized Evaluation of Celecoxib Integrated Safety vs Ibuprofen or Naproxen www.clinicaltrials.gov No. NCT00346216
  193. 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. 194. Preferred Oral Opioid Analgesics <ul><li>Tylenol with codeine #2: (2 or 3 q. 4 h.) </li></ul><ul><li>Hydrocodone 2.5 or 5 mg with 500 mg APAP (1 or 2 q. 4 - 6 h.) </li></ul><ul><li>Oxycodone 5 mg with 500 mg APAP (e.g., TYLOX) (1 or 2 q. 4 - 6 h.) </li></ul><ul><li>Oxycodone 5 mg with 400 mg ibuprofen (COMBUNOX)** </li></ul>
  195. 195. Other Oral Opioid Analgesics <ul><li>Tramadol (ULTRAM): 50 - 100 mg q.4 -6 h. (now available with APAP as ULTRACET, 35/325) </li></ul><ul><li>VICOPROFEN : 1 tab q. 4 – 6 h. </li></ul><ul><li>Pentazocine (TALWIN COMPOUND, TALACEN) </li></ul><ul><li>Propoxyphene (DARVON COMPOUND, DARVOCET) </li></ul><ul><li>VOPAC (650 mg APAP + 30 mg codeine) </li></ul>
  196. 196. MAGNACET ® (March, 2007) <ul><li>Oxycodone + acetaminophen 400 mg (?) </li></ul><ul><li>2.5, 5, 7.5 and 10 mg oxycodone (?) </li></ul><ul><li>Schedule II </li></ul><ul><li>“ Moderate to moderately-severe pain” </li></ul><ul><li>“ Gives physicians flexibility” </li></ul><ul><li>Compare with PERCOCET, TYLOX & COMBUNOX </li></ul>
  197. 197. Results from Dionne, R. J. Oral Max. Surg. 57:673, 1999 <ul><li>Compared 400 mg ibuprofen + 2.5, 5 and 10 mg oxycodone </li></ul><ul><li>Only 10 mg oxycodone was superior to 400 mg ibuprofen alone </li></ul><ul><li>Opioid adverse effects were dose-related </li></ul><ul><li>65% drowsy, 20% nauseated & 16% vomited at 10 mg oxycodone </li></ul>

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