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Pharmacological means of behavior management



Behavior management Is defined as the means by which the dental health team effectively & efficiently performs dental treatment & thereby instills a positive dental attitude. (Wright, 1975).

Managing an anxious child

Behavior management can b classified as 1) Non-pharmacological 2) Pharmacological

Pharmacological means of behavior management

Pharma ologi al Behavior management To perform the highest quality dental service for the pediatric patient one may need to utilize pharmacological means to obtain a quiescent, cooperative patient. METHODS 1) re-medication a) Sedatives & hypnotics b) Antianxiety drugs c) Antihistamines ) Conscious sedation 3) General anesthesia

Pre me i ation

Pre medication
Pre medication( Preliminary medication) are drugs with specific pharmacological actions administered pre operatively with specific goals to achieve

Relief of anxiety Sedation & analgesia Amnesia of pre operative events Antisialagogue effect Reduction of stomach acidity Prevention of nausea & vomiting Prophylaxis against allergies Facilitation of anesthetic induction.

Drug u e Sedatives & hypnotics Antianxiety Antihistaminic.

Gui eline for Pre me i ation (Stewar , 1983)  Infants (under 1 year): Atropine 0.0 mg/kg i.v. at anesthesia. i.m., 30 minutes before.  Healthy children (1-3 years of age): Atropine 0.0 mg/kg i.v. at anesthesia. i.m., 30 minutes before  Healthy children (over 3 years of age): Optimal psychological management. If indicated add 4 mg/kg diazepam suspension. Atropine 0.0 mg/kg i.v. at anesthesia. i.m., 30 minutes before.

Fa tor affe ting pre me i ation Age youngs rule:Dosage = Age* Adult dose/ Age + 1 . Weight based on childs body wt. the dosage is calculated by clarks rule:Dosage = Body Wt (kg) * Adult dose/ 150. Environment dosage required is low in non stress full environment (lying in bed) when patient is quiet as compared to an anxious patient. Route of administration i.v. drugs act rapidly are given in low doses than orally.

Time of day dosage may be reduced when child takes a nap during day. Emotional state and activity extremely anxious child will require more pre medication than a mildly apprehensive child.

Anxious child requires more pre medication

Care uring preme i ation Child should not be left unattended Childs environment to be kept as quiet as possible.

Pre me i ation failure au e Prescription of an insufficient dose of drug. Accidental/intentional reduction of dosage by parents Expectoration or vomiting of a portion of medication Failure of child to cooperate in swallowing medication.



e ation

Con iou e ation A minimally depressed level of consciousness, that retains the patients ability to maintain an airway independently and respond appropriately o physical stimulation and verbal command. O je tive (Bennett, 1978) The patients mood should be altered. Patient should be conscious, respond to verbal stimuli Patient should be cooperative. All protective reflexes should be intact. Vital signs should be stable and normal.

In i ation Patients who cant cooperate or understand for definitive treatment Patients lacking cooperation because of lack of psychological or emotional maturity Patients with dental care requirements, but are fearful and anxious. Contrain i ation  Pregnancy, COPD, myasthenia, epilepsy, obesity, bleeding disorders.  Unwilling, unaccompanied and uncooperative patients.  Dental difficulties, prolonged surgery, inadequate personnel.

Patient evaluation Detailed history is to be recorded which should include:Allergies current medication Diseases previous hospitalization family history respiratory obstruction.

Vital ign BP and pulse are to be recorded. ormal pediatric vital signs are:Age 3 years 5 years 12 years Adults Heart rate Blood pressure 86-116 100/67 25/23 80-100 94/55 14/9 53-87 109/58 16/9 72-82 122/75 30/20 Respiratory Tidal rate vol. 24 6 112 23 5 19 5 12 3 270 480 575

Pulse oxymeter



on ent

Written consent must be attained prior to procedure from the parents or legal guardians to be agreeable to the use of conscious sedation. They should be well informed about the risks, benefits and associated particulars.

I str cti s t t r ts Pr r ti NP (N t i P r t l rl ritt t r

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Pr r ti r - r t - r t - tt r

ti :tri i ir ti f iti r ti f r

l. it .

However clear fluids may be taken as follows:Child < 3 years can intake 3 hours preoperatively 3-6 years up to 6 hours > 7 years up to 8 hours.

Se ation- route & agent

Route of administration Inhalation: A. Nitrous Oxide

Indications & benefits

Limitations & risks

Can be used for mild to moderate levels of anxiety Rapid onset, early elimination & recovery The DOA can be easily controlled

Agent has weak potency Also can be used in claustrophobic patients, respiratory tract infections

II. Oral (several drugs are used)

Can be used for preoperative sedation Used for all levels of anxiety Better acceptability & ease of administration Incidence of ARD is less.

Delayed onset of action coupled with unpredictable absorption Depends on patient compliance Difficulty in determining drug dosage

A. promethazine (phenegran) (12.5mg/5cc)

For mild levels of Mild sedative along with antiematic & anticholinergic anxiety only action Potentiates narcotic & CNS depressants Better used in combination For all levels of anxiety Long working time Wide range of safety Not recommended in children < 6 years of age No analgesia

B. chloral hydrate (noctec) (500mg/5cc)

C. diazepam( 5 mg tablets)

Safe agent for anxiety in moderate anxiety in children with mental retardation. Good oral & perenteral absorption Rapid onset of action

Multiple dose required Not effective in severe anxiety

III. intramuscular May cause injury during administration Safety for oral use not yet established

1. Ketamine(50 mg/ml) Potent analgesic IV. intravenous A. midazolam

Requires extensive Most rapid onset of action armamentarium. Maintains a line for emergency drugs Best for invasive procedures of short duration.

N2O-O2 mixture for on


e ation

This is the mo t wi ely u e form of conscious sedation using inhalation of gases.

TRIADS OF ELEMENTS (Roberts, 1990):(for O-O induction) 1. The administration of low to moderate concentrations of nitrous oxide( O) carefully titrated to patients need. . The patient is simultaneously subjected to a steady flow of reassuring and semi-hypnotic suggestion. 3. The use of equipment, such that it is not possible to administer 100% nitrous oxide accidentally or deliberately.

Pharma ology of N2O  N2O onset and elimination occurs in few minutes as its solubility in blood is extremely low.  It is a weak GA gas but excellent analgesic. Te hnique  Slow induction technique  Rapid induction or surge technique

Sl Est

i d cti r t /

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lish t t l lit r fl

i t s f ses ith en. lts - liters/ in. hil ren ( f - ears) liters. T appr ach

Stabili e nose piece, eli er inutes

for -

Induction period increase N2O level to 30 -35% for 3-5 minutes Communicate continuously with the child to promote relaxation. In old children physical changes such as tingling sensation in finger and toe can be asked The eyelids will sag

N2O level can be increased to 50% for 3-5 minutes to provide max effect for LA administration. Conc. > 50% is contraindicated in dental practice. After treatment, continue inhalation of 100% O2 for 5 minutes to allow N2 diffusion from venous blood in alveolus that can be exhaled. Keep the child in supine position after procedure and observe carefully for 1st hour. Child can be allowed to sleep.

Rapi in u tion te hnique Administer equal parts of N2O & O2 for 10-15 mins Maintenance phase reduce N2O by half for 40 mins Withdrawal is by administering O2 only (to prevent anoxia).

Flow hart for N2O in u tion

N2O hazar o Upper respiratory tract infection o Pneumothorax o Diffusion hypoxia- can be avoided administering 100% O2.

The e on ga effe t The second gas effect usually refers to nitrous oxide combined with an inhalational agent. Because nitrous oxide is not soluble in blood, its' rapid absorption from alveoli causes an abrupt rise in the alveolar concentration of the other inhalational anesthetic agent.


General ane the ia A controlled state of unconsciousness, accompanied by partial or complete loss of protective reflexes, including to maintain an airway independently and respond purposefully to physical stimulation or verbal command.

In i ation for General Ane the ia

Patients with certain physical, mental or medically compromising condition Patients wherein local anesthesia is not effective or the patient allergic to it. Patients who have sustained extensive orofacial trauma. Fearful, uncooperative, anxious patient with no expectation that behavior will improve Patients with dental needs who would otherwise receive comprehensive dental care, e.g. rural areas

Ri k A e ment In 1963 ASA classified as: Class 1: No organic, physiologic, biochemical or psychiatric disturbance. The pathology for which operation is to be performed is localized and is not a systemic disturbance. Class 2: Mild to moderate systemic disturbance caused either by condition itself or by other pathophysiological processes. Class 3: Severe systemic disturbance, even though it may not be possible to define the degree of disability with finality. Class 4: Severe life-threatening, not always correctable by the operative procedure.

Agent u e for general ane the ia 1. 2. 3. 4. Halothane Enflurane Isoflurane Sevoflurane

Team in lu e : Anesthesiologist staff & post graduates Pedodontist staff & post graduates Dental surgery assistant Anesthesia technicians.

METHODS OF ADMINISTRATION Open metho - no breathing & no reservoir is present. Semi Open- has reservoir but no breathing Semi Clo e - reservoir and partial re breathing Clo e - reservoir and complete re breathing

re ervoir

Equipment Scope (laryngoscope) Tube

laryngo ope

Airway Tape to fix tube Introducer stilet Connector mask adaptor. (masks can be scented) Suction
mask Tube stilet

STAGE 1 ANESTHESIA (INDUCTION PERIOD) - It is the period between the initial administration of the induction agents and loss of consciousness. - During this stage, the patient progresses from analgesia without amnesia to analgesia with amnesia. - Patients can carry on a conversation at this time.

ST E 2 NEST ESI EXCITEMENT ST E - It is the period following loss of consciousness and ar ed by excited and delirious acti ity. - uring this stage, respirations and heart rate ay become irregular. -In addition, there may be uncontrolled movements, vomiting, breath holding, and pupillary dilation. apidly acting drugs are used to minimi e time in this stage and reach stage as fast as possible.

STAGE 3 ANESTHESIA SURGICAL ANESTHESIA During this stage, the skeletal muscles relax, and the patient's breathing becomes regular, eye movements slow, then stop, and surgery can begin. It has been divided into 4 planes: - eyes initially rolling, then becoming fixed - loss of corneal and laryngeal reflexes - pupils dilate and loss of light reflex - intercostal paralysis, shallow abdominal respiration, dilated pupils

STAGE 4 ANESTHESIA (OVERDOSE STAGE) - Here too much medication has been given relative to the amount of surgical stimulation and the patient has severe brain stem or medullar depression. - This results in a cessation of respiration and potential cardiovascular collapse. - This stage is lethal without cardiovascular and respiratory support.

STEPS IN HOSPITAL PROCEDURES :Step 1: Initial examination and parent discussion. Step 2: Consultation Medical clearance should be obtained with childs physician.


Step 3: Patient admittance

Step 4: Preoperative procedures Verify patients personal & me i al hi tory.

Step 5: Preoperative preparations The equipments & materials should be prearranged on a trolley.


Step 6: Anesthesia induction After the anesthesiologist are ready with the monitoring devices and intravenous route, induction begins. In young children, induction may begin with a low percentage of anesthetic gases . In older children barbiturate may be used. Intravenous succinylcholine is administered to assist in the induction of the patient.

Step 7 Dental treatment procedure is rendered as per the rule of thumb:Rule of thumbAny two or more surfaces of caries should be restored with a stainless steel crown

Any incipient interproximal or developmental precarious lesion should be restored There should be no heroic pulp therapy done where prognosis is a doubt

Indirect pulp capping & direct pulp capping procedures should be avoided

Avoi pulp apping

When there is doubt as to pulpal status & the treatment choice, perform the more radical one. For e.g. in a doubt regarding the health of the radicular pulp, perform pulpectomy & not pulpotomy.

Pulpe tomy i preferre

Step 8: Postoperative procedures Reassure the patient & give postoperative instructions

Step 9: Discharge and follow-up care Patients progress is reviewed & is discharged.

Di a vantage of General Ane the ia

 GA depresses the cardiovascular and respiratory systems.  Its not recommended for routine dental work like fillings. The potential risk involved is too high. For things like fillings, a breathing tube must be inserted, because otherwise debris or saliva could enter the airway and produce airway obstruction or cause pneumonia.

 Laboratory tests, chest x-rays and ECG are often required before GA, because of the greater risks involved.  Very advanced training & an anesthesia team are required  One cant drink or eat for 6 hours before the procedure (otherwise, vomiting is possible)  Its expensive.  GA does nothing to reduce dental anxiety.

Diff /w on Con iou


e ation & GA.

e ation General ane the ia

Single sitting Patient is uncooperative Pre medication & extensive investigations required Ventilation is required NPO strict Patient cant control the situation 99% success rate reported

1. Several visits 2. Patient is cooperative 3. No Pre medication & extensive investigations required 4. Airway is maintained 5. NPO not required 6. Patient feels he is in control of the situation 7. No mortality

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