PEDO. Lec.5. / 5th/ YEAR Dr. Sami Malik Abdulhameed BEHAVIOR MANAGEMENTNon-pharmacological behavior management

Physical approach Total body control ( Restraint )For obvious reasons management techniques such as the hand-over-mouth exercise should not be used with severely handicapped children. Physical restraints are sometimes needed, however, to prevent the handicapped child who cannot control his body movements from inflicting injury to himself, the dentist, or the assistants. NOTE: Restraints should not be used as punishment for undesirable behavior.

As in all forms of treatment, restraints may be misunderstood. Therefore obtain informed consent and explain to the parents why and how you plan to manage their child's behavior. Explanations prior to treatment may prevent misunderstanding following treatment.

Restraint Generally for very young (< 3) Generally not for multiple appointment patients Trauma in the very young INFORMED CONSENT IS A MUST Discuss pros/cons with parent

psychological aspects what to expect safety issues

TYPES OF RESTRAINTS1- Human 2- Mechanical Devices

• A-Papoose board• B- Pediwraps • C- Straps • D- Other restraining devices ( Head, Extrimeties)Controle

( FOR MOUTH CONTROL ) 1- Molt`s mouth prop 2- Bite Blok

Papoose Board (Fig.- 1 –A,B). The Papoose Board secures the child against a rigid base with three pairs of canvas straps. The Papoose Board, like the Pedi-Wrap, uses the easy-to-close-and-adjust Velcro system of press together-peel apart fasteners. This device is able to restrain even the most uncooperative patient.

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Fig. 1. A, Positioning patient in papoose board. B, Patient secured in papoose board.

Fig. 2. A, Positioning patient in Pedi-Wrap. B, Patient secured in Pedi-Wrap.

Pedi-Wrap (Fig. – 2-A,B). The Pedi-Wrap is a reinforced nylon mesh sheet with Velcro closures. It is available in small, medium, and large sizes. Place the Pedi-Wrap in the prepositioned chair. The dentist and assistant stand on opposite sides of the chair. The child is placed on the wrap so that the dentist and assistant can secure the child's arms at his sides and close the Velcro fasteners over his chest.

Secure the third fastener from the head first to control excessive hand movement and then secure the remaining closures. The two over-the-shoulder straps should be removed since they are not used in dental procedures .

Sheet and leg straps. A bed sheet folded at the corners to form a triangle provides an effective method of controlling undesirable arm movements

Control of headOnce the body and extremities have been safely secured the dentist and staff must maintain absolute control of the child's head. Unexpected movement during the adminis-tration of local anesthetic or during the restorative procedures could injure the patient.The dentist should firmly cradle the child's head between his chest and arm so that his other hand remains free to hold the mirror and retract the cheek. If he can not adequately control the child's head, a second assistant should be positioned at the head of the dental

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Fig. 3. A, Cradling patient's head between chest and arm of dentist for control while examining patient. B, Second assistant holding patient's head while dental treatment is performed.

chair to assist in stabilizing the head. By having the assistant hold the child's head with one hand on each side , sit-down, four-handed dentistry can be performed.

Also Head Control on papoose Board

Control of oral cavityOnce the lateral head movements are controlled, use a mouth prop to keep the mouth open during dental treatment if needed. The ideal mouth prop should be fully adjustable and comfortable to the patient but should not interfere with the administration of local an

esthetic or rubber dam placement. The mouth prop not only protects the child from unknowingly closing on the handpiece or other sharp instruments but also protects the dentist. Few children will intentionally bite, but for the child who is subject to seizures or

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Fig. 4. , Two types mouth props commonly used: McKesson bite block and Molt mouth prop, B, Extraoral Molt mouth prop in mouth. Note that unexpected head movements can be controlled simply by holding handle portion of prop.

is unable to understand verbal commands inadvertent closure of the mouth may injure the child or the dentist.

The mouth prop, like all other instruments, should be shown and demonstrated to the child prior to its use. A substitute term for it can be used; for example, a younger child understands that "Mr. Softy" is something to rest his teeth on during the appointment. The mouth prop should be placed in the posterior to prevent injury to the anterior teeth. Two types of mouth props are commercially available.

Intraoral bite block. The intraoral bite block (McKesson) (Fig. 3-10, A) is a medium-hard rubber wedge that is inserted between the occlusal surfaces on the side of the mouth where treatment is not being performed.

This bite block comes in small, medium, and large sizes and has been used successfully during extensive restorative procedures for the average patient. When used with the handicapped child the bite block should be ligated with a piece of dental floss to facilitate rapid retrieval if needed.Extraoral scissor action Molt prop. The extraoral scissor action Molt prop (Hu-Friedy) is constructed of metal and covered with rubber tubing (Fig. 4). The versatility of this mouth prop far outweighs its higher initial cost. Although the scissor prop comes in different sizes, the larger one is recommended because of its heavier construction and wider occlusal rests. Since the inter-occlusal rests of the mouth prop are adjustable, the large size can be utilized in the partially closed position for smaller children .

The extraoral scissor handle provides a way of simultaneously controlling the lateral head movements and keeping the mouth open during treatment (Fig. 4). By placing the mouth prop on the opposite side of the injection site, the traditional technique for local anesthesia can be utilized. The extraoral scissor mouth prop also facilitates the use of rubber dam isolation.

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PHARMACOLOGICAL BEHAVIOR MANAGEMENT

Sedation Dentistry

No one likes the saying "no pain, no gain." This is why sedation dentistry exists; it deals with the type and amount of sedation patients need to ensure their dental visits are as painless as possible. Some sedatives relax the patient; others numb all feeling alltogether.

Dental sedation is recommended for:1· longer procedures2· young patients with behavioral difficulties3· medical conditions that cause involuntary movements, such as Parkinson's or cerebral palsy4· patients with "dental phobia"?patients who become panic-stricken and, in some cases, ill at the thought of entering a dental office

Patient Assessment Prior To Conscious Sedation The physician, dentist, or independent practitioner responsible for overall conduct

of the conscious sedation is generally required to do the following within 30 days prior to procedural sedation:

– perform a history and physical exam– assign an American Society of Anesthesiologist (ASA) health class– document a sedation plan

document NPO status and interval changes Dentists choose from different types of sedation to put the patient at ease:ASA ( American Sociaty of anesthesiologist)Classifications ASA I - A normal healthy patient. (ASA = American Society of Anesthesiologists) ASA II - A patient with mild systemic disease. ASA III - A patient with severe systemic disease. ASA IV - A patient with severe systemic disease that is a constant threat to life. ASA V - A moribund patient who is not expected to survive without the operation. ASA VI - A declared brain-dead patient whose organs are being removed for donor

purposes. Emergency operation of any variety (used to modify one of the above classifications, i.e., ASA III-E).

Focused History and Exam

History should focus on factors that may increase– patient sensitivity to sedatives/analgesics– patient risk of respiratory/cardiopulmonary complications– difficulty in managing complications

Patient Selection

Medical history and physical exam

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Parental consent Mild-moderate anxiety Strong gag reflex Capacity to be compliant and follow directions

Pre-requisites

Knowledge about the agent Documented rationale Informed consent Office facilities Mobile emergency medical facilities Patient selection and preparation Medical history and patient evaluation

Key Factors In Drug Selection & Dose

� Child temperament & personality Clinical assessment

− query parent(s)− observation with parent− observation with parent & assistant

Clinical classification− easy− slow to warm up− difficult− Type and duration of dental care

ultra-short extraction of maxillary incisors short quadrant of dentistry long 2 or more quadrants of dentistry

Common agents used for sedation

Gases Antihistamines

[Hydroxyzine ,Promethazine,Diphenhydramine]

Benzodiazepines [Diazepam , Midazolam, lorazepam] Benzodiazepines Antagonist [Flumazenil] Sedative Hypnotics [Barbiturates ,Chloral Hydrate] Narcotics [Meperidine ,Fentanyl] Narcotic Antagonist [Naloxone] Dissociative agent [Ketamine] Others [Propofol

Preprocedural Fasting Guidelines To Minimize Aspiration Risk

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Indications of C.S

Objectives

mood alteration patient should be conscious respond to verbal stimuli Intact reflexes Vital signs stable and normal Pain threshold increased amnesia

Indications uncooperative patients Cannot understand definitive treatment lack of psycho-logical or emotional maturity fearful & anxious

Contraindications COPD Epilepsy bleeding disorders prolonged surgery

DEGREE OF SEDATION Minimal Sedation Moderate = Deep = General Anesthesia

MINIMAL SEDATION(Anxiolysis) is a drug-induced state which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected

MODERATE SEDATION It is a drug-induced depression of consciousness during which patients respond purposefully** to verbal commands, either alone or accompanied by light tactile stimulation. Nor interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained

DEEP SEDATION/ANALGESIA a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully** following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.

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GENERAL ANESTHESIA(GA) a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation .The ability to independently maintain ventilatory function is often impaired. Cardiovascular function may be impaired.

TYPES OF SEDATION BY ROUTE OF ADMINSTRATION Inhalation sedation ( conscious sedation or N2O-O2 sedation) I.V. sedation Oral sedation I.M. sedation Rectal sedation Others ( nasal, sub lingual )

Onset of Action Inhalation 2-3 minutes Oral 30 min. IM 10-15 min. IV 1 min

Peak Clinical Effect Inhalation 3-5 min. Oral 60 min. IM 30 min. IV 1-10 min. TitrationAbility to administer small increments of a drug to achieve a desired clinical effect Inhalation Titration possible Oral Titration not possible IM Titration not possible IV Titration possibleRecoveryNeed for an escort to leave office Inhalation Recovery almost always complete after 5 minutes O2 100%, may be

discharged alone Oral Recovery not complete after 2-3 hrs. need escort IM Recovery not complete, after 2-3 hrs. need escort IV Recovery not complete, after 2-3 hrs. need escort

Oral sedatives. For patients with severe dental anxiety, dentists can recommend a pill that will make them severely drowsy for the duration of the treatment. The patient should take the pill about an hour before the appointment. Driving is not possible, so the patient must arrange to have a friend, relative or caregiver accompany them to the dental appointment.

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Oral SedationAdvantages– Universal acceptance– Ease of administration– Low cost– Decreased incidence & severity of adverse reactions– No needles, syringes, equipment required– No specialized training

Oral SedationDisadvantages– Reliance on patient compliance– Prolonged latent period– Erratic and incomplete absorption of drugs from the GI tract– Inability to titrate– Inability to readily lighten or deepen the level of sedation– Prolonged duration of action

Sub Lingual sedation ( SL)- Rapid onset of action (bypasses the enterohepatic circulation) - requires patient cooperation - Transdermal therapeutic system

» Fentanyl: mostly for chronic pain » rapid onset of action (depends on the rate of diffusion)

Rectal sedation• Advantages– Rapid onset of action– Decreased incidence of side effects– Ease of administration– Low cost• Disadvantages– Inconvenience to the administrator– Inability to titrate– Possible intestinal irritation– Prolonged recoveryRectal sedation• Complications– Rectal mucosal irritation– Initiation of bowel movement– Risk of over sedationIntramuscular sedation• Indications– Adult when other more controlable routes are unavailable – The disruptive pediatric patient or handicapped

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adult or child when other routes have proved ineffective– The disruptive pediatric patient or handicapped adult or child prior to IV sedation or

GA

Intramuscular sedation { IM} • Advantages – Rapid onset of action – Peak action within 30 minutes – More reliable than rectal or oral sedation – Patient cooperation is not required • Disadvantages – Inability to titrate – Inability to reverse the drug action – Prolonged duration of drug effect – Risk of injury from injection

IV Sedation

Advantages

Rapid onset of action Easily titrated Rapid onset Minimal side effects Emergency IV access available

Disadvantages

Venipuncture is necessary More monitoring necessary Prolonged recovery Most agents cannot be reversed by antagonistic agents

Inhalation Sedation

· Nitrous oxide. Also called "laughing gas." Nitrous oxide, often used in conjunction with a local anesthetic, is inhaled through a mask clamped over the nose. It relaxes the patient, leading him or her to a state of giddiness. The patient remains awake for the procedure, but is extremely calm. Nitrous oxide raises the patient's pain threshold, so the anesthesia injection is easier to bear.

General Anesthesia. Longer, more complex procedures, such as tooth implants, root canals and tooth extraction or surgeries all require general anesthesia, which knocks the patient unconscious. General anesthetics block the patient's airway and thus must be used along with tubes in to help the patient breathe during the procedure. It can only be administered by dentists or nurses with specialized training. General anesthetic drugs can

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be inhaled, injected, or both. Drugs commonly used for this procedure include benzodiazepines, barbiturates, opioid analgesics and neuromuscular blocking agents.

Four Stages of General Anesthesia Analgesia

patient is conscious reflexes are intact

Delirium Unconscious in Stages 2, 3, and 4. Surgical Anesthesia Respiratory Paralysis

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