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Benzodiazepines: A novel route to sedation for the anxious adolescent Kathy Wilson Senior Dental Officer Honorary

AIM OF PRESENTATION. . A presentation of current research into the field of benzodiazepine sedation for anxious adolescent dental patients. PRESENTATION. Guidelines for conscious sedationCurrent sedation techniquesBenzodiazepine sedationCurrent research .

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Benzodiazepines: A novel route to sedation for the anxious adolescent Kathy Wilson Senior Dental Officer Honorary

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    1. Benzodiazepines: A novel “route” to sedation for the anxious adolescent Kathy Wilson Senior Dental Officer & Honorary Staff Grade South Tyneside PCT & Newcastle Dental School

    2. AIM OF PRESENTATION

    3. PRESENTATION Guidelines for conscious sedation Current sedation techniques Benzodiazepine sedation Current research

    6. CONSCIOUS SEDATION

    7. Current Guidelines “A Conscious Decision” DOH 2000 “Maintaining Standards” GDC 2001 “Safe Sedation of Children undergoing Diagnostic and Therapeutic procedures” “Conscious Sedation in the Provision of Dental Care” SDAC 2003

    8. “A Conscious Decision” “A Conscious Decision” DOH 2000 Emphasises the need to provide alternatives to GA for pain and anxiety management.

    9. “Maintaining Standards” “A dentist who assumes the dual responsibility of sedating the patient as well as providing treatment must:” “be able to justify the use of the method selected with reference to current guidelines…” GDC Maintaining Standards Nov 2001

    10. “SIGN Guidelines” “Safe Sedation of Children Undergoing Diagnostic and Therapeutic Procedures – A national clinical guideline” Relates to those under age of 16 years Published in Feb 2002 www.sign.ac.uk

    11. Main Recommendations: Dental Sedation Nitrous oxide/oxygen inhalation sedation “is recommended for use in all dental settings but particularly General Dental Practice and Community Dental Service”

    12. Main Recommendations Dental Sedation Intravenous Sedation “Single agent sedation with midazolam is only recommended for IV dental sedation in patients over 16 years of age. IV sedation should be avoided in younger children in primary or community dental practice.”

    13. Main Recommendations Dental Sedation Other Routes “other routes of drug administration including the oral, rectal and intra-nasal route have no advantages over inhalation and intravenous sedation and should be restricted to a hospital setting…”

    14. “Conscious Sedation in the provision of Dental care” Aim “To lay down specific guidance for the practice of Conscious Sedation in general dental practice, community and hospital settings” SDAC 2003

    15. Main Recommendations for sedation in adolescents Must only be undertaken by teams which have adequate training and experience Nitrous oxide/oxygen should be first choice

    16. Main Recommendations for sedation in adolescents IV sedation only appropriate in a minority of cases Oral/Intranasal/Transmucosal sedation should only be administered under appropriate circumstances by a practitioner experienced in their use

    17. Current Sedation Practice Sedation is considered a safe alternative to GA for dental procedures Inhalation Sedation mainstay for those under the age of 16 Chronic exposure to nitrous oxide May not be accepted by some patients

    18. Current Sedation Practice A need to consider other forms of sedation Benzodiazepines have favourable pharmacology Limited research into the use of midazolam in dental patients under the age of 16 in UK

    19. A study of the use of Benzodiazepines in adolescent dental patients

    20. Midazolam Most favourable pharmacology of BZDs Used extensively in adults via the IV route Limited use in those under 16 years May provide an alternative where inhalation sedation contraindicated

    21. Midazolam – clinical effects Anxiolysis Sedation Muscle relaxation Amnesia

    22. Midazolam – side effects Respiratory depression Drug interactions CNS depressants Antibiotics Antacids Tolerance Dis-inhibition

    23. Advantages Can be titrated (IV route) Potent anxiolytic effect Amnesia Muscle relaxation

    24. Disadvantages May require IV cannulation Length of appointment time Side effects (minimal) Dis-inhibition

    26. A STUDY OF THE EFFECTIVENESS OF BUCCAL MIDAZOLAM SEDATION FOR ORTHODONTIC EXTRACTIONS

    27. Aim of Research Project Effectiveness and acceptability of midazolam for dental extractions in adolescent patients Different routes researched Oral (Anaesthesia 2002; 57: 860-867) Intravenous (British Journal of Anaesthesia 2003 Dec) Transmucosal

    28. Transmucosal Sedation Routes Sublingual Intranasal Buccal Rectal (not in UK) Advantages Rapid absorption Avoids 1st pass metabolism Disadvantages Taste Irritation of tissues

    29. Buccal Midazolam Concentrated formulation – 10mg/ml Produced by Special Products Formulated for use in Epileptic Patients

    30. METHOD Prospective, randomised, crossover trial 40 patients, aged 10 to 16 years, ASA I & II Referred for orthodontic extractions

    31. METHOD Two treatment sessions 2 extractions - buccal midazolam sedation 2 extractions - nitrous oxide sedation Children randomly allocated to receive nitrous oxide or midazolam at first visit Information and consent at assessment

    32. BUCCAL MIDAZOLAM SEDATION Buccal midazolam (0.2mg/kg) 10-15 minutes pre-op Monitored by sedation trained Dental Nurse Treatment carried out (LA & Extractions) Recovery Discharged when fit

    33. NITROUS OXIDE SEDATION Nitrous oxide titrated 10% every minute (max 30%) Treatment carried out (LA & Extractions) Recovery Discharged when fit

    34. ASSESSMENT CRITERIA

    35. PHYSIOLOGICAL STATUS Baseline BP, Pulse, Weight, Respiratory Rate, Oxygen Saturation Every 2 minutes Pulse, Respiratory Rate, Oxygen Saturation

    36. LEVEL OF SEDATION “Classification of Emotional Status” (Brietkopf & Buttner) Recorded every 2 minutes Four point scale 1 – irritated & awake 2 – awake & calm 3 – tired, hardly moving 4 – drowsy, without reaction but rousable

    37. BEHAVIOUR DURING TREATMENT “Frankl Behaviour Rating Scale” Recorded every 2 minutes Four point scale: 1 – Refusal / Distress 2 – Uncooperative / Reluctant 3 – Cooperative / Reserved 4 – Interested / Enjoyed

    38. OUTCOME OF TREATEMTENT & OVERALL BEHAVIOUR “Houpt Behaviour Rating Scale” Recorded at end of visit Six point scale: 1 – Aborted 4 – Good 2 – Poor 5 – Very good 3 – Fair 6 – Excellent

    39. POST-OPERATIVELY Post-operative Questionnaire Recall of treatment Same sedation again Preference for sedation Side effects

    40. RECALL OF TREATMENT Patients were asked if they could remember: Receiving the local anaesthetic Having the extractions carried out Being in recovery

    41. PATIENT’S OPINION OF TREATMENT Patients were asked: Would you have this sedation again? Which type of sedation did you prefer?

    42. RESULTS

    43. SUBJECTS 20 to date Mean age 12.8 years (10-15 yrs) 19 ASA I, 1 ASA II

    44. PHYSIOLOGICAL STATUS Mean Dose Midazolam = 9.9mg ( 6.8-16mg) Nitrous Oxide = 30% Lowest O2 saturation Midazolam = mean 96.8% (range 95-99%) Nitrous oxide = mean 97.9% (range 95-100%)

    45. MEAN DURATION FOR SEDATION & TREATMENT Time to Maximum Level of Sedation Midazolam = mean 15.2 mins(8-20mins) Nitrous oxide = mean 6.9 mins (2-10 mins) Treatment time (La & ext) Midazolam = mean 9.9 mins (6-16 mins) Nitrous oxide = mean 7.7 mins (4-22 mins)

    46. MEAN DURATION FOR RECOVERY & TOTAL APPOINTMENT Time in recovery Midazolam = mean 41.2 mins (28-64 mins) Nitrous oxide = mean 21.5 mins (20-22 mins) Total appointment time Midazolam = mean 66.3 mins (60-90 mins) Nitrous oxide = mean 34.1 mins (28-48 mins)

    47. OVERALL BEHAVIOUR

    48. POSITIVE RECALL OF STAGES OF APPOINTMENT

    49. PATIENT QUESTIONNAIRES 2 patients failed to return their post operative questionnaires. The following results are based on 18 patients

    50. PATIENT PREFERENCE 66% would have Midazolam again 89% would have Nitrous oxide again 33% preferred Midazolam 50% preferred Nitrous oxide 17% had no preference

    51. REASONS FOR PREFERENCE Nitrous oxide/oxygen sedation Quicker Felt more relaxed Recovered more quickly Midazolam Felt more relaxed Remembered less

    52. BEST ABOUT TREATMENT Nitrous oxide/oxygen sedation Quicker Felt more relaxed Nothing Midazolam Felt more relaxed Quickness Felt no pain

    53. WORST ABOUT TREATMENT Nitrous oxide/oxygen sedation Being aware Gums being frozen Noises Midazolam Gums being frozen Taste Time for sedation to work

    54. REPORTED SIDE EFFECTS Nitrous oxide/oxygen sedation Sleepy – 3 subjects Headache – 1 subject Midazolam Sleepy – 3 subjects Headache – 2 subjects

    55. CONCLUSION Promising results to date Buccal midazolam appears to be an acceptable technique The trial is on going “Watch this space”

    56. SUMMARY Guidelines for conscious sedation Current sedation techniques employed Study of Benzodiazepines Buccal midazolam trial

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