Control of pain and anxiety

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PHARMACOLOGY IN PEDIATRIC DENTISTS


PAIN AND ANXIETY

The vast majority of pediatric dental patients can receive their treatment in the conventional dental environment with appropriate techniques and pain behavior management.

In some cases the control of pain and anxiety needs to go beyond conventional techniques.

Drug therapy is indicated for children who can not be treated with traditional techniques of behavior management and local anesthesia.


CONSCIOUS SEDATION

Definition: Lower minimum level of consciousness that can independently maintain and further the permeability of the airway and respond appropriately to physical stimulation and verbal commands.

Conscious sedation levels:

- Light Sedation (oral)
- Sedation with nitrous oxide (inhaled)

** Deep sedation (rectal, nasal or IM)

General Anesthesia


SPECIAL CONSIDERATIONS
MONITORING IN SC
- Pulse Oximeter
- Stethoscope Precordial
- Blood pressure cuff


The sedation technique that prevents the CETP. wake up easily and intentionally respond to verbal commands at all times, is by definition:
deep sedation.


If conscious sedation techniques are applied properly and there is proper monitoring, patients present a cardiovascular and respiratory function properly.

When the patient suffers a partial or complete loss of protective reflexes and can not independently maintain airway apnea or hypoxemia may suffer, leading to danger.

Conscious Sedation Deep Sedation


OBJECTIVES OF THE CONSCIOUS SEDATION

-Reduce or eliminate the patient's anxiety and make you feel safe and comfortable so you can be a good dental treatment.

- Reduce the movements and reactions during treatment.

- Increase cooperation of the patient.

- Increase your tolerance for lengthy treatments.

- Assist in the treatment of compromised patients physically and psychically.


CONSIDERATIONS

1 .- Pre-operative assessment of behavior.

2 .- Pre-operative assessment of oral health and general.

3 .- Collaboration, parental involvement and consent signed by them.

4 .- Economic considerations.

5 .- Treatment Alternatives.

6 .- Training and experience of staff and professional work.


CONSCIOUS SEDATION INDICATIONS

- Patients with pre-existing conditions:
* Patients with psychiatric disorders or mild mental
* Patients with moderate spastic muscle disorders or
- Patients with dental phobia (apprehensive adult), children are difficult to manage (not receptive)
- After surgery
- Patients ASA I and II

** Patients with intolerance to local anesthetics (anesthetic
general)
** Patients with severe physical or mental disability (anesthesia
general)


ASA CLASSIFICATION SYSTEM

Classification system used by the American Society of Anesthesiologists (ASA) to estimate the risk posed by anesthesia for the different states of the patient.

Class I non-healthy patients undergoing elective

Class II Patient with mild systemic disease, controlled and not disabling. May or may not relate to the cause of the intervention.

Class III Patient with severe systemic disease, but not disabling.

Class IV A patient with severe systemic disease and disabling disease, which is also a constant threat to life, and not always correctable by surgery.

Class V is the terminally ill or dying, whose life expectancy is not expected to exceed 24 hours, with or without surgical treatment.

Agents oral administration (light sedation)

Narcotics: Meperidine

Anxiolytics: * Hydroxyzine
Promethazine

Benzodiazepines: Diazepam
Flunitrazepam
* Midazolam

Hypnotics: * Chloral hydrate
BENZODIAZEPINES

Activity on the CNS have anxiolytic, sedative, hypnotic, muscle relaxant, sedative, amnesic, anticonvulsant and skeletal muscle relaxant.
Adm. orally or parenterally.

Indications: Management of anxiety.
Pre-anesthetic induction.
Dental procedures.
** Use the hospital setting.

Diazepam (benzodiazepine anxiolytic with more sedative hypnotic action)
"He has a long-acting (half-life of more than 24 hrs.)
- It is widely used in dentistry (recipe-check ret.)
- Dosage: Diazepam 5mg comp Lab Chile
0.1-0.2 mg / kg


Flunitrazepam (benzodiazepine hypnotic with more action hypnotic sedative)
- It's 10 times more potent than diazepam
- Action-term (10-22 hrs.)
- Check prescription is given
- Flunitrazepam 2mg Lab Chile
Children: 0.5 - 1mg/dosis

Midazolam (benzodiazepine hypnotic)

- Action ultra short (1-2 hrs), 30-60 min delay. to take effect
- Cause Drowsiness
- Children Dose: 0.5 - 0.7 mg / kg (30 min. Before care)
Maximum total dose: 15mg
Presentation = Dormon compr. 15 mg (adults)
7.5 mg (children)
other names: Midazolam, nocturnal


Chloral hydrate (a sedative-hypnotic)

Administered orally, the depressant effects of sedation can vary from sleep, appearing at the time of administration.

It is available in the national pharmaceutical market.
Orderable preparation, (eg, FASA), using recipes retained as follows:

20 g chloral Rp.Hidrato
Distilled water 100 ml

Hypnotic dose in children: 30 - 50 mg / kg.

Effects begin 15-30 minutes. and High Activity. is reached at the time.

** Use the hospital setting.


HYDROXYZINE

- Produces sedation and anxiolytic activity and has
antihistamine
- Oral
- The effects appear within 30 minutes. and reaching peak activivdad to hr or hr 1 / 2
- Can be used in combination with CNS depressant drugs (meperidine, H. chloral) or N2O
- Properties antiemetic

Dose: 25mg 1 before the appointment.
Fasarax, compr. 20 mg syrup 10 mg/5ml


INHALATION SEDATION: nitrous oxide


Gas inerteatóxico that produces sedation, relaxation and analgesia.

Advantages:
- Fast Blood levels (low solubility in plasma).
- When stopping his adm., Blood levels decline rapidly.
- Easy to control dose (not to exceed 50% in the pediatric patient).
- No serious side effects.

Uses:
Children accept the use of mask (school age).
Children with anxiety and / or mild anxiety, but which cooperate with treatment.


Contraindications:
- Children with serious behavior problems that do not cooperate
with the use of the mask.
- Toddlers.
- Children with nasal obstruction or respiratory problems.


Disadvantages:
- Agent weak.
- Lack of acceptance by the patient.
- Inconvenience.
- Empowerment (combination with other sedatives).
- Equipment.


Administration

- Adjustment step:
It starts with the maximum concentration of oxygen and nitrous oxide minimum and is getting adjusted according to the degree of sedation achieved (gradually increasing).
- Once achieved sedation to place the local anesthetic.
- After completion of the procedure should be given 100% oxygen for 5 min.
- Must maintain verbal contact with the child to promote relaxation and enhance cooperative behavior.


** You can make combination of midazolam sedation & nitrous oxide and hydroxyzine + nitrous oxide.

SPECIAL CONSIDERATIONS

The pharmacological approach to control child behavior through conscious sedation is a very complex area and requires additional training and expertise.

The child with sedation failure may continue to be a control problem, while excessive sedation received you can quickly become a life-threatening emergency in the dental office.

Antibiotic

Penicillin G or penicillin:
- Increased activity against microorganisms G +, G-and anaerobic cocci do not produce b-lactamase. Little activity against G-bacilli.
- Parenteral administration.

Children Dose: 100,000 IU / kg / body weight per day.
Disadvantages: Acid labile, sensitive to beta-lactamase

Phenoxymethylpenicillin (penicillin V):
- Spectrum similar to penicillin G, tb lactamase sensitive.
- Oral (gastric pH stable, adm. Away from meals).
- Low relative availability (c/6hrs).

Dosage children = 25-50mg / kg / body weight per day in 4 doses.


AMOXICILLIN: Broad spectrum (including Florida G + and -).
Greater capacity. than penicillin G against G-.
Gastrointestinal absorption 80 to 90%.
May be given some food.
Infections of the skin and soft tissue infections caused by streptococci, not penicillinase-producing staphylococci, Escherichia coli and Proteus mirabilis.

Children Dosage: 50 mg / kg / day every 8 hrs (up to 20 kg)
about 20 kg. 250-500mg w / 8 hrs.

Lab Chile Bottle Amobiotic suspension 5ml/250mg
Lab Amoval Saval
Lab Abiolex Andrómaco
Lab Aminopexil Bagó

Amoxicillin + clavulanic acid

Clavulanic acid is a beta-lactamase inhibitor, prevents bacteria from destroying amoxicillin.
It is indicated mainly in skin infections and soft tissue, including cellulitis and dental abscesses with cellulitis are often spread caused by Staphylococcus aureus, Streptococcus pyogenes, and Bacteroides spp. Some strains of these bacteria produce beta-lactamase, which makes it not susceptible to amoxicillin alone.

Dosage children:
Lab Chile Ambila amoxic Suspension 5ml/250 mg-62.5 ac
50mg/kg/día every 8 hrs
Lab Clavinex Saval
GSK's Augmentin Lab


Ambila 57mg BID 5ml/400mg Amox .- ac
Clavinex DUO 5ml w/12 hrs.


Cloxacillin

- A company of penicillins "antistaphylococcal" since it was developed to treat infections caused by staphylococcal beta-lactamase producers. It is active against staphylococci, organisms sensitive to penicillin-resistant Streptococcus pyogenes and Streptococcus pneumoniae. However, it is less active than penicillin G against penicillin-sensitive bacteria, Enterococcus faecalis and gram-negative organisms.
- Adm. orally or parenterally.

Child dose = 50 mg / kg / body weight per day every 8 hrs.

Flucloxacillin 125mg/5ml Suspension Lab Chile - 250mg/5ml
Flucloxacillin 250mg/5ml Suspension Andrómaco Lab
Lab Vitalpen Labomed 250mg/5ml Suspension

ERYTHROMYCIN

Bacteriostatic macrolide antibiotic.
Oral or parenteral administration.
Good oral absorption (must go with ctd. Enteric).
Alternative in patients allergic to penicillin.

Children dose = 50 mg / kg / day every 8 hrs.

Erythromycin Suspension Lab Andrómaco 5ml/200-400mg
Erythromycin Lab PASTEUR
Erythromycin ES Lab Chile
Lab mercinico Mepro

CLARITHROMYCIN

Macrolide derivative of erythromycin with the following
Benefits: - better gastrointestinal absorption.
- Improved distribution.
- Long-lived (adm. w/12 hrs.).
- Pctes alternative. allergic to penicillin.

Children dose = 7.5 mg / kg every 12 hrs.

Pre-clar Lab Chile
Saval Lab Euromicina Suspension 5ml / 125-250 mg
Lab Clarimax Andrómaco


AZITHROMYCIN


Macrolide derivative of erythromycin with the following advantages:
- Better absorption than other macrolides.
- Increased volume of distribution, high [] in the tej.
- Prolonged half-life, adm. w / 24 hrs.
- Better gastrointestinal tolerance.

Dosage children =
Suspension Lab Azitrom Chile 5ml/200mg
10mg/kg Day 1
5mg/kg daily for the next 4 days
Lab Abacta Andrómaco
Trex Lab Saval

BACTERIAL ENDOCARDITIS


Infective endocarditis is an inflammation of the heart valves (endocardium).

Endocarditis is usually the result of bacteremia (bacteria in the blood), which is common during some dental procedures, among others.

Bacteria in the bloodstream can settle on damaged heart valves, and multiply to create a growth or mass of living bacteria. These masses can form clots that break off and travel to the brain, lungs, kidneys or spleen.

Most people who develop infectious endocarditis have underlying heart disease.

Streptococcus viridans, is responsible for nearly half of all bacterial endocarditis. Other common organisms are Staphylococcus aureus, S. epidermidis and E. faecalis.


Treatments that require prophylaxis:

All proce. dental manipulation involving tej. gingival or periapical region or perforation of oral mucosa

Dental procedures where prophylaxis is NOT recommended:
- Routine anesthetic injections in uninfected tissue.
- Taking Rx decay.
- Placement of prostheses or removable orthodontic appliances.
- Adjustment of orthodontic appliances.
- Placement of orthodontic Braquet.
- Loss of teeth.
- Bleeding from damage to the lips or oral mucosa.

Uses:
- Patients with a history of EBSA.
- Congenital heart disease.
- Prosthetic heart valve.
- Recipients of heart transplants with patients. Heart
valve.

Scheme for dental procedures:

Amoxicillin therapeutic scheme males = 50 mg / kg 1 hour before the attention.

In patients allergic to Penic.:
Clindamycin 20 mg / kg / weight 1 hr. before
Clarithromycin or Azithromycin 15 mg / kg 1 hr. before.

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