hardly treatable children Dr Déri Katalin Semmelweis University Department of Pedodontics and Orthodontics introduction Dentistry Fear Pain Pain subjective 152 years ID: 935120
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Slide1
Dental attendance of hardly treatable children
Dr. Déri KatalinSemmelweis UniversityDepartment of Pedodontics and Orthodontics
Slide2introductionDentistryFear
PainPain – subjective1,5-2 years old –low pain
threshold11-12 years old-
pain-pressure-discomfort
Pain
relief
Local
anaesthesia
Sedation
General
anaesthesia
Slide3etiologyCauses:Anxiety: no
definite reasonFear : concrete reasonSubjective
Objective
Slide4EtiologyDisability:Mental:
mild: IQ 50-7o medium: IQ < 50 severe : IQ < 30Phisical (
damage of central nervous
system
)
Organic
(
cardiovascular
disease
, diabetes,
renal
disease
)
Senses
(
blindness
,
deafness
)
Slide5Treatment
possibilitiesFear/Anxiety:
Not tired Not
too
long
appointments
„
get
together
/
introduction”before any treatmentTell, Show, DoFamiliar/nice enviroment- waiting room/dental officeNo long waitingPraise, rewardInvolve the child in the treatment
Slide6Treatment possibilitiesMild mental
disability:Extraordinary patience, understandingi.e.: Down sy.-kind
, good cooperationExtraordinary
speed
Simpliest
but
effective
treatment
Presence
of parentPrevention !!!
Slide7Treatment possibilitiesPhisical disability
Wheelchair, problems with movement coordinationAccess the
dental unitExtra assistance needed
suction
,
rinse
Disability
of
senses
Blindness
:
touch
Deafness
: mouth reading (mask) , slow speech
Slide8sedationConsciousness „power off
” on different levels Superficial:Maintain automatic reflexes
Conscious/awareAble
to
response
Deep:
Not
maintained
automatic
reflexes
!!!!: Consent form signed by the parents!!!
Slide9sedationOralIntramuscularIntravenous
RectalInhalation
Slide10Oral sedationBenzodiazepins:
Diazepam, midazolamAdvantage : Preparation at home (responsible
parent)Cheap Disadvantage
:
Absorption
-
uncertain
Paradox
reaction
Adequate
timing
,
adequate dosage:Diazepam: 0,2-0,5 mg/kgProlonged effect Midazolam: 0,3-0,5 mg/kg7,5/15 mg pill or venous inj. sol. swallowedEffective in 30 mins , lasts for 1-2 hoursNasal drops –
effect in 10 mins
Slide11sedationIntramuscularFaster absorption
More cooperation neededPainful If „needle”
veneflon is better
Intravenous
Directly
to
the
blood
stream
No absorption problemsLower doseMore cooperation (veneflon)RectalScandinavian countries - diazepam solution
Slide12Conscious sedationN
2O /dinitrogen-oxid/ nitrous oxideDiscovered: 1793 Joseph Priestley
(O2)Name : ”laughing
gas
” 1799
Sir
Humphrey
Davy
For
40
years
: „primary use of N2O was for recreational enjoyment and public shows”First clinical use : 1840s: Horace Wells, american dentist, tooth extraction for himselfFirst clinical use in Hungary: 1847 János Balassa
Slide13Effects of N2OAnalgesic
Anxiolytic, sedativeAnaesthetic
Slide14Characteristics of N2OGood analgetic
Mild anaestheticLow solubility in bloodElimination
without metabolismDirect
cardiodepressive
Methionin
synthetase-
,
folic
acid
metabolism-
and DNA synthesis inhibitor
Slide15Characteristics of N2OIt
can cause:Diffuse hypoxiaAgranulocytosis, bone
marrow depression , myeloneuropathy
Teratogenic
Slide16Use in dentistry2
types of methods: 1.) O2 and N2O dosage
separately 2.) O2 and N2O fix 50/
50
gas
mixture
Indication
:
Anxiolysis
or
sedationMild or medium strength pain killer
Slide171.) method :O2 n2o controllable dosages
100 % O2 inhalation for 2-3 minutesSlow raise of N2O concentration
5-25 %- mild sedation and analgesia
Mild
numbness
in
hands
and
legs
30 % - explicit analgesia- euphoria35 % < – side effects more oftenSweating, restlessness, vomiting, panic, nightmareFinishing : 100 % O2 inhalation for 5 minutesLeaving -20 minutesPresence of anaesthesiologist is required!!
Slide182.) method set dosage
N2O O2 fix 50-50 % gas mixtureSpecialized dentist is
enough no anaesthesiologist
required
(
in
certain
countries
)
No
chance
of diffuse hypoxiaO2 saturation does not decrease during inhalation but increasesNo need for systemic reoxygenation after inhalation
Slide19indicationsChildren older
than 3 years Adults with anxiety or
phobiaPatients with mild mental disability
Slide20contraindicationsChildren under
3 yearsPregnancyASA III.: severe systemic disease
ASA IV.: severe
systemic
disease
that
is a
constant
threat
to life Intracranial hypertensionBullosus emphysemaPneumothorax
Slide21contraindicationsAbdominal distension
After certain eye surgery Use of ophthalmological
gases (SF6, C3F8,C2F6)
Total
lack
of
patient
cooperation
Slide22dosage- 2.) methodNose-mouth
mask Natural breathing movements define
the amount of gas
inhaled
.
Suggested
flow
speed
:
Children
:
3-9
l/min
Adult : 6-12 l/min
Slide23application- 2.) methodVerbal communication
with the patient during inhalation If
no verbal feedback -> suspension
!
Effect
: 3
minutes
after
inhalation
Average
application time: 30 minutesMaximal: 60 minutesRepeated use : max 15 days
Slide24Patient monitoring -2.) M.Evaluation of clinical
conditionProperly relaxedNormal breathingPatient can
follow simple instructions
If
sedation
is
too
deep
: no
verbal
feedback/contact-> suspension!!After treatment:Remove the mask5 minutes relaxing in the dental chair
Slide25Terms of use Proper
ventillation in the operation roomN2O
cc. of air should stay
below
25
ppm
!
Proper
storage
of
gas
mixtureAbove zero celsiusFix vertical position of the product
Slide26possible side effects
NeurologicalInfrequent (1-10/1000)excitementeuphoriaheadachev
ertigoAnxiety mood
disorders
Slide27Possible side effects
Gastrointestinal Infrequent (1-10/1000)Nausea Rare (1-10/10000
) i.e.: abdominal distension
Drug interactionsPotentiates
certain CNS drugs i.e opiates, benzodiazepines
Slide29hypnosisConscious modificationUndesired
activities cannot be forcedFear controlRequires
hypnotherapist
Slide30General anaesthesiaIndication:Severe
mental/phisical disabilitySevere psychiatric disorders
Under the age
of 3
Slide31Contraindications:Severe renal/cardiovascular/respiratorical
/neurological diseasesNot controlledAnaemia/hypothyreosis/diabetes/
adrenocortical insuff.Cervical
spinal
disorders
General
anaesthesia
Slide32Premedication:Atropin (parasympatholyticum) 0,2 mg/kg Salivation decreases
Respiratory secreation decreasesEliminate vagus reflexDisadvantages
: tachycardia, dry mucose
/
not
used
/
Sedative
:
diazepam
(Seduxen) or midazolam (Dormicum) 0,3-0,5 mg /kgRelaxation Potentiates the narcoticsAmnesia prevent postnarcotic consequencesprevent convulsion/spasmSuspension: anexateGeneral anaesthesia
Slide33General anaesthesiaNarcotics:Propofol
:initial : easy sleep, fast and clear awakening
maintained : prolonged awakening
No
vomit
Breathing
depression
Easy
controlled
depth
of narcosisLower postoperative side effectsIv. 2-3 mg/kg initially, 6-10 mg/kg/hour maintainedInhalation anaesthetics:Sevoflurane (initial/maintained)Isoflurane (maintained)Desflurane (maintained)
Slide34General anaesthesiaNarcotics (earlier)
Calypsol: Intravenous/intramuscularOften : agitation, nightmares
Recently: propofolOther medication
:
Pain
killers
:
During
surgery
:
opiates
(fentanyl, nalbuphin(Nubain) )After surgery: non-steroids :algopyrin, ibuprophen, diclofenac, paracetamol
Slide35Personal terms of g.a.
Educated anaesthesiologist and nursesEducated pediatric dentist and assistant
Capable patient: No
acute
respiratory
or
contagious
disease
In
proper cardiorespiratorical conditionBlood testCBC (Complete Blood Count)PTT (Partial Thromboplastine Time)QT / INR / prothrombine timeDetailed individual and family anamnesis about haemophiliaCurrent medication ? (syncumar, aspirin
, clopidogrel, LMWH )
Slide36Other terms of G.A.Operation
roomAnaesthetic machinePulzoximeter, capnograph
Slide37Other terms of G.a.Blood
pressure , EKGDental equipment, exhaustorInstruments and medication for
resuscitation
Slide38Instructions To the
parents:No breakfastLast drink (1-1,5 dl water/tea) at
7 a.m.Take usual morning
medication
After
narcosis
:
If
totally
conscious
and no vomit: First drink – 1 hourFirst eat – 2 hoursTerms of leaving the hospital:Full conscious, good strength, after drinking, eating, and urinate, accompanying person present, can
be delivered back to
the hospital
Slide39Consent formParents have
to read and sign it with responsibility„Status
taking”, treatment PLAN – in advance
Aim
:
eliminate
all
possible
causes
of
problems for long termTreatment plan is only estimated Changes might occur during surgeryPreliminary permission for tooth extractions needed
Slide40Dental treatmentsScaling, polishing
Primary tooth filling, grindingPrimary tooth extraction
Permanent toothFilling
Extraction
Root
canal
treatment
Minor
surgeries
i.e.:
mucocele, supernumerary tooth, wisdom tooth
Slide41Problems with treatment and planning
Examination without sedation - limitedQuite poor oral
hygiene – no hope for
improvement
Problem
solving
+
prevention
Severe
accompanying
diseases – no mastication – no use of teethProblem solving (long term without pain and inflammation versus conservative treatment)Basic disease – relative contraindication for g.a.measure cost- benefit ratio
Slide42Problems with treatment and planning
Reasonable order of treatmentsCalculus, plaque, inflamed,
bleedeng gingiva
1x
filling
2x
scaling
,
pol
. 3x
extractions
Filling
No
precise occlusal controlLow dimensions/underfilledRoot canal treatment
Unsecure success
Anterior
teeth
(
esthetics
)
In
one
session
No
x-ray
control
(
yet
)
Slide43Problems with treatment and planning
Real indication for g.a.?? Careful deliberation
i.e.: destroyed milk molars
but
no
sign
of
inflammation
under
the
age of 8 extraction would be considered „early” no mastication for years „so called” rct too
unsecure no
indication
for
g.a
.
in
case
of
inlammation
recall
trepanation
or
g.a.and
extraction
Extreme
amount
of
plaque
and
calculus
+ no
other
pb + no
hope
for
improving
oral
hygiene
no
indication
for
g.a
.(
cost
/
benefit
)
Slide44Problems with treatment and planning
Destroyed molar, caries profunda, pulp is very
close extraction
Indirect
/
direct
pulpcapping
not
suggested
Unsecure successPostoperative complaint might be impossible to follow (no clear feed back)High
speed!!!
Experianced dentist
,
assistant
Etching
+
bonding
2in1,
high
speed
polym
.
lamp
Optimal
time
of
narcosis
:
max
. 2
hours
Aim
:
everything
in
one
session!
Slide45Problems with treatment and planning
Not able to follow postop. instructions
Extraction suture (
resorbable
)
Inflammation
+
antibiotics
No local
anaesthetics
Postop
.
mucose
injuriesProsthetics Real indication? / real need? Functional need? (mastication?)
Esthetics ? Is it
a real
issue
?
Practically
possible
? (more
sessions
,
impression
,
occlusion
control
)
Slide46Follow-upIn case of complaint -
immediatelyNo complaint 6 monthsNo
absolute contraindication of
repeated
g.a
.
BUT
regarding
the
general risks of g.a. repetition is suggested as rare as possible
Aspiration
asphyxia, pneumonia
Bronchospasm
/
laryngospasm
asphyxia
Nerve
injury
(
laying
)
paralysis
Slide47Case report
11, 21
caries
penetrans
rct
apex
locator
Preparation cleaning , drying
Slide48Case report
Fluid
guttapercha
technique
(
fluid
gp
+
gp
point
)No lateral condensationFast Set in 30 minsTemporary filling for 30 mins, meanwhile other treatments:63, 65 radix extractionsuture
Slide49Case report
36, 35
composite
filling
, GIC
liner
Slide50Case report
53, 55, 46 radix extraction
11, 21
remove
temp
.
filling
, GIC
base
,
Composite
filling
Slide51Thank you for your
attention !