4. Pharmacological management of pain and anxiety - G. J. Roberts and M. T. Hosey
Effective pain management of a child, especially an anxious one, is a challenge to every dentist. The need for good management of anxiety and pain in paediatric dentistry is paramount. A common cause of complaint from parents and their children is that a dentist 'hurt' unnecessarily. Such a complaint can jeopardize access to life-long dental care.
Children are anatomically and physiologically different from adults. The anatomy of the airway means that breathing is through a narrower, more fixed 'wind pipe'. Physiologically, a child is less capable of taking in a bigger volume of air even when urgently required. Coupled with this, both the demand for oxygen (consumption) and the incidence of periodic breathing and apnoeas are higher compared to adults. These differences mean that a child can become hypoxic more easily.
4.2 CHILDREN'S PERCEPTION OF PAIN
A child's perception of pain is purely subjective and varies widely, particularly with age. Infants up to about 2 years of age are unable to distinguish between pressure and pain. After the age of approximately 2 and up to the age of 10, children begin to have some understanding of 'hurt' and begin to distinguish it from pressure or 'a heavy push'. The problem is that it is not always possible to identify which children are amenable to explanation and who will respond by being co-operative when challenged with local anaesthesia and dental treatment in the form of drilling or extractions. Children over the age of 10 are much more likely to be able to think abstractly and participate more actively in the decision to use local anaesthesia, sedation, or general anaesthesia. Indeed, as children enter their teenage years they are rapidly becoming more and more like adults and are able to determine more directly, sometimes aggressively, whether or not a particular method of pain control will be used. The response is further determined by the child's coping ability influenced by family values, level of general anxiety (trait), and intelligence.
·ð Children are anatomically and physiologically different from adults this results in them becoming hypoxic more easily.
·ð Children's response to pain is influenced by age, memory of previous negative dental experience, and coping ability.
Before you can do anything to a patient, even a simple examination, consent must be obtained. Consent may be implied, verbal, or written. The main purpose of written consent is to demonstrate post hoc, in the event of a dispute, that informed consent was obtained. It has the considerable advantage of making clinicians and patients pause to consider the implications of what is planned and to weigh the advantages and disadvantages so that a reasoned and informed choice can be made. The responsibility for informed consent is often shared between the referring primary care dentist and the secondary care service provider, especially where sedation and general anaesthesia are involved. Many health trusts and other employing authorities are increasingly demanding that written consent is obtained for all procedures. This is especially difficult now as the lower age of consent is no longer specifically limited. The sole criterion is whether or not the patient is 'able to understand' the procedures and their implications. If so, the patient is considered 'competent' and the child may give (or refuse) consent. It is usual to arrive at a consensus view among parents, child, and dental surgeon. A sufficiently informative entry should be placed in the patient's case records. As a pragmatic rule the age of 16 years still acts as a guide. But if a procedure is proposed and a child under 16 years says 'no' then consent has been refused. Fortunately, in paediatric dentistry the prospect of a life-saving operation is rare so a refusal of consent can be managed by a change in the procedure or by establishing a temporal respite. The current advice from the protection societies is that written consent must be obtained for a course of treatment. The plan of treatment proposed must indicate the nature and extent of the treatment and the approximate number of times that local anaesthesia and/or sedation is to be used. There is no need to obtain written consent for each separate time that sedation is used. If the plan of treatment changes and along with it the frequency or nature of sedation, then it is prudent to obtain written consent for the change. The greater risks associated with general anaesthesia require specific written consent for each and every occasion that treatment is carried out under general anaesthesia. Examples of suitably worded forms are available from the Medical Defence Societies.