BEHAVIOR MODIFICATION OF MENTAllY RETARDED DENTAL PATIENTS Robert Carrel, D.D.S., M.Ed.* William H. Binns, Jr., D.D.S., M.S.** A. J. Chialastri, D.D.S.***
Beginning with the second half of this century, there has been great progress made bringing individuals who are classified as mentally retarded into the main stream of society. Many psychological and medical treatment facilities have been instituted throughout our Country to care for this segment of our population. Dentistry has attempted to contribute its part in the care of these patients. Many sedation techniques have been utilized to cope with the problems inherent in the care of mentally retarded dental patients. The objective has been to provide volume dentistry on a level recognized as a quality service. Unfortunately, the working conditions needed to meet these standards have been very difficult to achieve by utilizing an ambulatory approach. Frequently it has been necessary to hospitalize the patient to achieve the desired results. The rising costs of a hospital stay have reached such proportions that this service is only within the grasp of a very small percentage of this needy population. In addition to other chronic and systemic diseases that this type of patient may present, the clinician is often confronted with special problems. Occasionally, these concerns center around the size or weight of the patient and the ever-present threat of open hostility towards the operator by patients who can not cope with the anxiety and stress of the dental procedures. The clinician must have a reasonably stationary subject to accomplish a service which merits using the term "successful". All types 'Associate Professor of Pedodontics, Temple University Dental School. "*Professor and Chairman of the Department of Pedodontics, Temple University Dental School. * * Assistant Professor of Pedodontics, Temple University Dental School; Director of Dental Services at St. Christopher's Hospital for Children.
MAY-JUNE, 1977
of medications have been used in an attempt to alter the mood of these patients so that dental care could be performed. At times physical "restraint" or "support" has supplemented the various sedation techniques. The end result has been successful in many cases but just as many have resulted in failure. It has long been recognized that mentally retarded youngsters can be some of the most difficult dental patients. The "spectrum of pain and anxiety control" has run the complete gamut from oral or "verbal sedation" to full endotrachael anesthesia. With every technique that has been used to meet the challenge of this type of patient, there have been shortcomings in either providing a cooperating or stationary target and maintaining a high degree of
safety. By the late 1940's, Jorgensen had worked
out the details of his intravenous sedation technique utilizing pentobarbital, meperidine, and scopolamine.1 His "base-line" dosages provided safe working conditions for long operating cases. But it became apparent with time, that selection of a very specific type of patient was necessary for successful treatment. It had the disadvantage of long preparatory periods and long recovery time. Running almost parallel to this time period, the technique of "Relative Analgesia" was being popularized by Langa.2 The use of nitrous oxide gas was introduced, in low concentrations, as an adjunct in relieving pain and anxiety of the apprehensive patient. Its use was limited in the treatment of hysterical patients and the more aggressive mentally disturbed patient. It worked well with mildly fearful patients. The technique did help to lay the ground work for many future variations of sedation on a more sophisticated level. Monheim and Berns, provided addition-
67
al intravenous sedation techniques in an attempt to provide comprehensive dental care for patients who needed some type of therapeutic support.3'4 Monheim coined the term "Chemanesia" which was a combination of Nembutal, Demerol, Phenergan, and Nitrous Oxide. It was a means of providing total dentistry in one sitting without the patient being aware of his immediate environment. Berns popularized a technique which he called "Twilight Sedation." It was an intravenous technique employing secobarbital, meperidine, and methoexital (Brevital). It offered a high degree of patient control but here again had its limitations with the highly nervous patients or those with organic mental illnesses. A new intravenous approach using very small incremental doses of an ultra short acting hypnotic, was developed by Drummond-Jackson.5 It utilized methohexital (Brevital) and provided satisfactory levels of analgesia, sedation, and amnesia for many thousands of needy patients. The main disadvantage was the accumulative effects of the Brevital when the patient was retarded and could not be controlled by the verbal commands of the clinician. A reasonably rational patient was required for this method of patient sedation. By the mid 1960's, the sophisticated Intravenous Amnesia Technique developed by Shane appeared in the literature.6 It provided the clinician with a technique which could: (a) offer a high degree of predictability; (b) a high degree of safety; (c) and permitted drugs to be titrated to optimum working conditions. The technique used a combination of Nisentil, Vistaril, atropine, and methohexital (Brevital). It was an attempt to balance the scales between the safety zone for the patient and provide adequate working conditions for the clinician. The synergistic effects of these drugs allowed many disadvantaged patients to receive dental care in a non-hospital environment. The main pitfall with this technique was the degree of predictability that could be relied upon when attempting to treat severely retarded patients. The inability to communicate with this type of patient was a continuous disadvantage. As more data was collected with the use of the Intra-Venous Amnesia Tech68
nique, there followed several modifications with the basic combination of drugs.7'8'9"101 ' A wider range of patient care was the outcome of these changes. The introduction of diazepan (Valium) to clinical practice, offered a new drug whose pharmacological properties could be used for treating specific types of dental patients. This drug could alleviate muscle spasms to some degree in cerebral palsy, for treating status epilepticus, as a psychotropic agent in Psychiatry, and as a premedication for poor risk patients undergoing general anesthesia. It appeared to have only minor effects on blood pressure and respiration.'2"13'14 Beginning in 1966, Foreman introduced the combination of diazepam and methohexital into Dentistry.'5'16 This combination of drugs produced profound amnesia for periods of time without the sustained loss of consciousness or the protective reflexes. Patients appeared to experience a high degree of emotional relaxation with a loss of fear for any operative procedures. The merits of this combination of drugs was a reduction in the amount of Brevital needed to provide the dental services for emotionally disadvantaged patients.'7 Both Spiro and Runzo have summed up the various sedation techniques available today in two separate articles. 18,19 They conclude that when nothing else is successful then general anesthesia must be utilized. One must make the assumption that the degree of predictability with present day sedation techniques is not adequate to meet the needs for special care patients. The purpose of this investigation was first, to present additional clinical evidence of the synergistic action of selective drugs; and second, to demonstrate the adaptability of this technique to the clinical care of mentally retarded patients. Methods and Materials A. Preliminary Data The type of patient selected was completely unmanageable and uncooperative. They were 7 to 19 years old. Their weights ranged from 63 lbs. to 205 lbs. All had extensive dentistry to be performed, and it was not possible to perform adequate restorative dentistry using routine methods of pain and anxiety control. These patients ANESTHESIA PROGRESS
were candidates for hospitalization. It was decided to use the technique described in this paper. The dentistry completed in this series of 52 cases consisted of resin and amalgam restorations, stainless steel crowns, pulpotomies, and extractions. The operating team was composed of one dentist and two dental assistants. All drugs were administered by the clinician and vital signs were recorded. All patients were placed in the Trendelenberg position. A four inch moist gauze was used to block the posterior oral cavity from displaced debris. A high speed drill was used for all cavity preparations without the use of a water spray. A completely dry operating field prevailed since atropine was used in every case. All patients were fasted since the midnight before appointment. B. Drug Technique Sparine (Promazine) was dispensed in an initial dosage of 50 mg. to be taken orally one hour before coming to the dental office for treatment. This dosage served as a base-line medication from which the additional drugs would be adjusted after the clinical observation of the patient. A standard intravenous dosage of 0.4 mg. atropine sulfate was injected slowly for its drying effect. The last of the atropine was completely "washed" through the needle with the patient's blood. (Atropine is absolutely essential to dry oral secretions and to dry out the tracheo-bronchial tree to avoid airway obstruction. Many of these extremely apprehensive patients have excessive salivary secretions). A separate syringe containing 10 mg. of Valium (2cc) was attached to the needle which remained in the patient's vien. (The two drugs (atropine and Valium) should not be mixed in the same syringe because of a possible precipitation taking place). Depending on the patient's response the Valium is injected slowly to a maximum dosage of 10 mg. A syringe containing 1% Brevital was connected to the indwelling needle, and an initial intravenous volume of 1 to 3cc was administered for its amnesic and analgesic effects. As soon as the' patient was "asleep", local anesthetic injections were performed. As the case progressed, small MAY-JUNE, 1977
incremental dosages of 1%o Brevital were used as the need arose. At times the patient would move because of some external stimuli such as the noise of the drill or the movement of the rubber bite block. These movements were controlled by the combination of additional fractional dosages of Brevital and the "soothing" effect from the voice of the operator. (Kindness and reassurance play a major role in helping to control a patient who may be partially detached from his surroundings. Many of these patients respond abruptly to various external stimuli and the clinician must be prepared to adjust to working conditions that change
rapidly).
Results Of the 52 cases initially suggested for general anesthesia in a hospital environment, 41 were completed as ambulatory patients in a dental office, using the sedation technique described. The cases treated presented a stationary "target" to perform quality dental care. There was no clinical evidence of significant respiratory or circulatory depression. At all times, the protective reflexes were intact. [Fig. 1] Figure 1 DM=AA 1. II.
.111
Aso 6 to 12 yrm. parine lPromanlo. (al S0 mg. orally-Walt one hour
I
Atroplne 1.4 g.l i cc I.V.l Vlim (5 to 10 m.) I to 2ce II.V. fD11uto with blood) I to 3cc Bravital 1% (i.v.) (Local anuethetic blockl
IV. QOS--l% Brovital 4.5cc to lec Incromental
doageao
MU=
Ace 12 yrm. and over 1. Oparine (Promsinea
(a) SO mg. orally-Walt on hour
I. Atropine .4 mg. Icc {I.V.) Valium 10 mg.) 2cc lI.V.X (Dilute with Blood) II.
r
to 3cc Brevital 1% l I.V.) {Local anethetlic blocks)
[V. OS.--IS Brovital (.Scc to lec Incrumntal
doWl
Vital signs did not vary from the range of acceptable clinical values throughout the sessions. [Table 1] There was an increase in pulse rate following the administration of atropine sulfate (which was expected). In several cases, there was a slight decrease in respiratory rate following the initial dosage of 1%o Brevital. This condition promptly readjusted itself to normal amplitudes and rates following stimulation by "local anesthetic injections." Patients could be aroused at any time by the use of a painful stimulus applied to an unanesthetized area. It was further 69
Table 3
Table 1 Age
Yrs.
Number of Cases
7 8 9
10 4 6 5 1 9 __ 3 6 __ 5
10 11 12 13 14 15 16 17 18 19
2 1
Wt. Lbs.
Pulse
61 69 72 78 78 84 __ 115
92 92 90 90 94 84 __ 86 84 __ 76 84 70
137 __ 156 167 205
Bld. Pres. Reep. Systolic Rate 88 84 86 92 94 92 __ 106 110
18 16 16 14 14 13 _ 13
122 136 148
12 12 12
13
The above data represents the mean values for vital signs during the Initial examination
7 8 9 10 11 12
10 4
13
14 15 16 17 18 19
6 5
1
9 __
3 6 __ 5 2
1
Brevital Mean Value
6cc. 4cc.
5cc. 4cc. 4cc. 6cc.
__ 4cc. 7cc. __
4cc. 5cc. 5cc.
Recovery Mean Time Working Cases Complete (Verbal) Time
5 4 3 5 1 7
3 2 3 2 2 3
70 Mmln.
65M1.
3 5
4 M41mn. 5 Hin.
95Min.
5 2
3 Min. 5 Min. 4 lin.
70 Ml.
50 Min.
40 Min. 40 Min. 45 Min. 65 4in.
105 Min. 60 Min.
1
Min. Min. Min. Min. 141n. Min.
Data recorded from clinical study
There were no incidences of vomiting during the operative procedures or upon leaving the office. Eleven of the cases (21%o) could not be treated by this intravenous mood-modifying technique and became progressively more agitated and apprehensive as the drugs were administered. The clinician elected to terminate treatment for these patients when additional incremental doses 70
10 4 6 5 1 9 3 6
5 4 3 5
Cases Not
Complete 5 6-
3 _
1I
7
2
3 5
-0 1 _
-
16
-
17 18
5 2
5 2
52
41
-
19
Table 2 Cases Started
7 8 9 10 11 12 13 14 15
Totals
observed that those patients amendable to treatment demonstrated purposeful responses when the addressed by the operator. Clinically, the patients appeared relaxed and less hostile towards the operator as the case progressed. Following the adjustment of the dental chair from the Trendelenberg position, the patients were completely ambulatory and were permitted to leave the office within one hour of the position adjustment. The patients required a minimum amount of assistance for ambulation. [Table 2]
Age
Cases Cases Age Started Complete
(79%
-
11 (21%)
Percentage of Cases Treated vs. not Treated.
of Brevital failed to provide acceptible working conditions. [Table 3] The vital signs of these patients were not depressed nor were there any eventful after effects. These patients not receiving treatment represented the extremes on a scale of mentally disturbed patients. Discussion When one applies the term successful to a particular technique, it is important to consider the population being treated. The patients in this study would have had to be treated in a hospital environment under general anesthesia had they not been selected for this study. Of the total number of patients taking part in this investigation, 79% were treated successfully. The initial dosage of Sparine (Promazine) acted as an antiemetic and baseline tranquilizer to set the stage for a smooth transition into a working dental environment. There was no evidence of nausea or vomiting during or following treatment. The use of atropine prevented saliva from causing obstruction in the traacheo-bronchial tree and may also have compensated for any hypotension that might have been induced by the administration of Sparine and Valium. All of the cases treated in this study were completed in less than two hours. The patients were beginning to show signs of mobility at the end of that time period. It was the clinical opinion of the authors ANESTHESIA PROGRESS
that more frequent incremental dosages of Brevital would have been necessary had the cases extended over longer periods of time. For this reason, one must consider performing treatment in multiple sessions where extensive dental work might be needed. This would eliminate the possibility of a barbiturate build up leading to respiratory depression. Those patients who could not be treated (21%v) were severely retarded. Utilizing low dosages of sedative drugs, it was not possible to control the level of excitability and their primitive instincts. In addition, some of these patients were on a routine schedule of medication for many years to control their aberrant behavior and convulsive seizures. It is therefore logical to consider the possibility of a drug tolerance existing in some of these patients. Clinical observations indicated that it was extremely difficult for these patients to relate to their environment. Summary Sparine (Promazine) was administered orally as a base-line medication and then supplemented intravenously with atropine, Valium, and Brevital. These drugs were found to be a safe, effective mood changing combination for the treatment of mentally retarded patients needing dental care. Based on a study of 52 cases, this clinical technique provided smooth working conditions for up to two hours for 79 % of the patients in this study. This preliminary clinical investigation for treating ambulatory retarded patients in a non-hospital environment seems to offer the following advantages: 1. a wide margin of safety, 2. preservation of the vital protective reflexes, 3. stability of the vital signs, 4. short recovery time, 5. no nausea or vomiting,
MAY-JUNE, 1977
6. maintenance of patient airway, 7. a fast onset of action, 8. provides a stationary target to permit a quality dental service. REFERENCES 1. Jorgensen N Premedication in dentistry, J So Calif State Dent Assoc 21:1 1953. 2. Langa H Analgesia for modem dentistry, N Y J Dent 27:228 1957. 3. Monheim L General Anesthesia in Dental Practice, 3rd Ed. St Louis C V Mosby Co 1968. 4. Berns J "Twilight Sedation" J Conn State Dent Assoc 37:1 1963. 5. Drummond-Jackson S SAAD views anesthesia in Britain Anes Prog 13:313 1966. 6. Shane S Intravenous amnesia for total dentistry in one sitting J Oral Surg 24:27 1966. 7. Carrel R A supplement to an intravenous amnesia technique in pedodontic cases Anes Prog 15:39-41 1968. 8. Carrel R A clinical study of a modified intravenous amnesia technique for pedodontia patients Bull Phila County Dent Soc 38:1 14-17 1972. 9. Carrel R Intravenous anesthesia for pediatric dentistry in a hospital or institutional setting J Dent Child 42:285-289 1975. 10. Carrel R The behavior modification of a dentally disabled child J Dent Child 39-45 1976. 11. Wibby W Intravenous amnesia in general dental practice Anes Prog 19:3 61 1972. 12. Brown P Valium in dentistry Brit Dent J 125:498-501 1968. 13. Khosla V Diazepam in oral surgery Oral Surg Oral Med Oral Path 28:671-679 1969. 14. Sohn D Valium Anes Prog 22:3 74-77 1975. 15. Foreman P Intravenous sedation Anes Prog 13:218 1966. 16. Foreman P Diazepam in Dentistry Anes Prog 15:253 1968. 17. Healy T The use of intravenous diazepam during dental surgery in the mentally handicapped patient Brit Dent J 128:22-24 1970. 18. Spiro S Amnesia-analgesia for special care patients Anes Prog 17:82 1970. 19. Runzo R Dental care for the handicapped Anes Prog 19:1 9-12 1972.
71
Beginning with the second half of this century, there has been great progress made bringing individuals who are classified as mentally retarded into the main stream of society. Many psychological and medical treatment facilities have been instituted throughout our Country to care for this segment of our population. Dentistry has attempted to contribute its part in the care of these patients. Many sedation techniques have been utilized to cope with the problems inherent in the care of mentally retarded dental patients. The objective has been to provide volume dentistry on a level recognized as a quality service. Unfortunately, the working conditions needed to meet these standards have been very difficult to achieve by utilizing an ambulatory approach. Frequently it has been necessary to hospitalize the patient to achieve the desired results. The rising costs of a hospital stay have reached such proportions that this service is only within the grasp of a very small percentage of this needy population. In addition to other chronic and systemic diseases that this type of patient may present, the clinician is often confronted with special problems. Occasionally, these concerns center around the size or weight of the patient and the ever-present threat of open hostility towards the operator by patients who can not cope with the anxiety and stress of the dental procedures. The clinician must have a reasonably stationary subject to accomplish a service which merits using the term "successful". All types 'Associate Professor of Pedodontics, Temple University Dental School. "*Professor and Chairman of the Department of Pedodontics, Temple University Dental School. * * Assistant Professor of Pedodontics, Temple University Dental School; Director of Dental Services at St. Christopher's Hospital for Children.
MAY-JUNE, 1977
of medications have been used in an attempt to alter the mood of these patients so that dental care could be performed. At times physical "restraint" or "support" has supplemented the various sedation techniques. The end result has been successful in many cases but just as many have resulted in failure. It has long been recognized that mentally retarded youngsters can be some of the most difficult dental patients. The "spectrum of pain and anxiety control" has run the complete gamut from oral or "verbal sedation" to full endotrachael anesthesia. With every technique that has been used to meet the challenge of this type of patient, there have been shortcomings in either providing a cooperating or stationary target and maintaining a high degree of
safety. By the late 1940's, Jorgensen had worked
out the details of his intravenous sedation technique utilizing pentobarbital, meperidine, and scopolamine.1 His "base-line" dosages provided safe working conditions for long operating cases. But it became apparent with time, that selection of a very specific type of patient was necessary for successful treatment. It had the disadvantage of long preparatory periods and long recovery time. Running almost parallel to this time period, the technique of "Relative Analgesia" was being popularized by Langa.2 The use of nitrous oxide gas was introduced, in low concentrations, as an adjunct in relieving pain and anxiety of the apprehensive patient. Its use was limited in the treatment of hysterical patients and the more aggressive mentally disturbed patient. It worked well with mildly fearful patients. The technique did help to lay the ground work for many future variations of sedation on a more sophisticated level. Monheim and Berns, provided addition-
67
al intravenous sedation techniques in an attempt to provide comprehensive dental care for patients who needed some type of therapeutic support.3'4 Monheim coined the term "Chemanesia" which was a combination of Nembutal, Demerol, Phenergan, and Nitrous Oxide. It was a means of providing total dentistry in one sitting without the patient being aware of his immediate environment. Berns popularized a technique which he called "Twilight Sedation." It was an intravenous technique employing secobarbital, meperidine, and methoexital (Brevital). It offered a high degree of patient control but here again had its limitations with the highly nervous patients or those with organic mental illnesses. A new intravenous approach using very small incremental doses of an ultra short acting hypnotic, was developed by Drummond-Jackson.5 It utilized methohexital (Brevital) and provided satisfactory levels of analgesia, sedation, and amnesia for many thousands of needy patients. The main disadvantage was the accumulative effects of the Brevital when the patient was retarded and could not be controlled by the verbal commands of the clinician. A reasonably rational patient was required for this method of patient sedation. By the mid 1960's, the sophisticated Intravenous Amnesia Technique developed by Shane appeared in the literature.6 It provided the clinician with a technique which could: (a) offer a high degree of predictability; (b) a high degree of safety; (c) and permitted drugs to be titrated to optimum working conditions. The technique used a combination of Nisentil, Vistaril, atropine, and methohexital (Brevital). It was an attempt to balance the scales between the safety zone for the patient and provide adequate working conditions for the clinician. The synergistic effects of these drugs allowed many disadvantaged patients to receive dental care in a non-hospital environment. The main pitfall with this technique was the degree of predictability that could be relied upon when attempting to treat severely retarded patients. The inability to communicate with this type of patient was a continuous disadvantage. As more data was collected with the use of the Intra-Venous Amnesia Tech68
nique, there followed several modifications with the basic combination of drugs.7'8'9"101 ' A wider range of patient care was the outcome of these changes. The introduction of diazepan (Valium) to clinical practice, offered a new drug whose pharmacological properties could be used for treating specific types of dental patients. This drug could alleviate muscle spasms to some degree in cerebral palsy, for treating status epilepticus, as a psychotropic agent in Psychiatry, and as a premedication for poor risk patients undergoing general anesthesia. It appeared to have only minor effects on blood pressure and respiration.'2"13'14 Beginning in 1966, Foreman introduced the combination of diazepam and methohexital into Dentistry.'5'16 This combination of drugs produced profound amnesia for periods of time without the sustained loss of consciousness or the protective reflexes. Patients appeared to experience a high degree of emotional relaxation with a loss of fear for any operative procedures. The merits of this combination of drugs was a reduction in the amount of Brevital needed to provide the dental services for emotionally disadvantaged patients.'7 Both Spiro and Runzo have summed up the various sedation techniques available today in two separate articles. 18,19 They conclude that when nothing else is successful then general anesthesia must be utilized. One must make the assumption that the degree of predictability with present day sedation techniques is not adequate to meet the needs for special care patients. The purpose of this investigation was first, to present additional clinical evidence of the synergistic action of selective drugs; and second, to demonstrate the adaptability of this technique to the clinical care of mentally retarded patients. Methods and Materials A. Preliminary Data The type of patient selected was completely unmanageable and uncooperative. They were 7 to 19 years old. Their weights ranged from 63 lbs. to 205 lbs. All had extensive dentistry to be performed, and it was not possible to perform adequate restorative dentistry using routine methods of pain and anxiety control. These patients ANESTHESIA PROGRESS
were candidates for hospitalization. It was decided to use the technique described in this paper. The dentistry completed in this series of 52 cases consisted of resin and amalgam restorations, stainless steel crowns, pulpotomies, and extractions. The operating team was composed of one dentist and two dental assistants. All drugs were administered by the clinician and vital signs were recorded. All patients were placed in the Trendelenberg position. A four inch moist gauze was used to block the posterior oral cavity from displaced debris. A high speed drill was used for all cavity preparations without the use of a water spray. A completely dry operating field prevailed since atropine was used in every case. All patients were fasted since the midnight before appointment. B. Drug Technique Sparine (Promazine) was dispensed in an initial dosage of 50 mg. to be taken orally one hour before coming to the dental office for treatment. This dosage served as a base-line medication from which the additional drugs would be adjusted after the clinical observation of the patient. A standard intravenous dosage of 0.4 mg. atropine sulfate was injected slowly for its drying effect. The last of the atropine was completely "washed" through the needle with the patient's blood. (Atropine is absolutely essential to dry oral secretions and to dry out the tracheo-bronchial tree to avoid airway obstruction. Many of these extremely apprehensive patients have excessive salivary secretions). A separate syringe containing 10 mg. of Valium (2cc) was attached to the needle which remained in the patient's vien. (The two drugs (atropine and Valium) should not be mixed in the same syringe because of a possible precipitation taking place). Depending on the patient's response the Valium is injected slowly to a maximum dosage of 10 mg. A syringe containing 1% Brevital was connected to the indwelling needle, and an initial intravenous volume of 1 to 3cc was administered for its amnesic and analgesic effects. As soon as the' patient was "asleep", local anesthetic injections were performed. As the case progressed, small MAY-JUNE, 1977
incremental dosages of 1%o Brevital were used as the need arose. At times the patient would move because of some external stimuli such as the noise of the drill or the movement of the rubber bite block. These movements were controlled by the combination of additional fractional dosages of Brevital and the "soothing" effect from the voice of the operator. (Kindness and reassurance play a major role in helping to control a patient who may be partially detached from his surroundings. Many of these patients respond abruptly to various external stimuli and the clinician must be prepared to adjust to working conditions that change
rapidly).
Results Of the 52 cases initially suggested for general anesthesia in a hospital environment, 41 were completed as ambulatory patients in a dental office, using the sedation technique described. The cases treated presented a stationary "target" to perform quality dental care. There was no clinical evidence of significant respiratory or circulatory depression. At all times, the protective reflexes were intact. [Fig. 1] Figure 1 DM=AA 1. II.
.111
Aso 6 to 12 yrm. parine lPromanlo. (al S0 mg. orally-Walt one hour
I
Atroplne 1.4 g.l i cc I.V.l Vlim (5 to 10 m.) I to 2ce II.V. fD11uto with blood) I to 3cc Bravital 1% (i.v.) (Local anuethetic blockl
IV. QOS--l% Brovital 4.5cc to lec Incromental
doageao
MU=
Ace 12 yrm. and over 1. Oparine (Promsinea
(a) SO mg. orally-Walt on hour
I. Atropine .4 mg. Icc {I.V.) Valium 10 mg.) 2cc lI.V.X (Dilute with Blood) II.
r
to 3cc Brevital 1% l I.V.) {Local anethetlic blocks)
[V. OS.--IS Brovital (.Scc to lec Incrumntal
doWl
Vital signs did not vary from the range of acceptable clinical values throughout the sessions. [Table 1] There was an increase in pulse rate following the administration of atropine sulfate (which was expected). In several cases, there was a slight decrease in respiratory rate following the initial dosage of 1%o Brevital. This condition promptly readjusted itself to normal amplitudes and rates following stimulation by "local anesthetic injections." Patients could be aroused at any time by the use of a painful stimulus applied to an unanesthetized area. It was further 69
Table 3
Table 1 Age
Yrs.
Number of Cases
7 8 9
10 4 6 5 1 9 __ 3 6 __ 5
10 11 12 13 14 15 16 17 18 19
2 1
Wt. Lbs.
Pulse
61 69 72 78 78 84 __ 115
92 92 90 90 94 84 __ 86 84 __ 76 84 70
137 __ 156 167 205
Bld. Pres. Reep. Systolic Rate 88 84 86 92 94 92 __ 106 110
18 16 16 14 14 13 _ 13
122 136 148
12 12 12
13
The above data represents the mean values for vital signs during the Initial examination
7 8 9 10 11 12
10 4
13
14 15 16 17 18 19
6 5
1
9 __
3 6 __ 5 2
1
Brevital Mean Value
6cc. 4cc.
5cc. 4cc. 4cc. 6cc.
__ 4cc. 7cc. __
4cc. 5cc. 5cc.
Recovery Mean Time Working Cases Complete (Verbal) Time
5 4 3 5 1 7
3 2 3 2 2 3
70 Mmln.
65M1.
3 5
4 M41mn. 5 Hin.
95Min.
5 2
3 Min. 5 Min. 4 lin.
70 Ml.
50 Min.
40 Min. 40 Min. 45 Min. 65 4in.
105 Min. 60 Min.
1
Min. Min. Min. Min. 141n. Min.
Data recorded from clinical study
There were no incidences of vomiting during the operative procedures or upon leaving the office. Eleven of the cases (21%o) could not be treated by this intravenous mood-modifying technique and became progressively more agitated and apprehensive as the drugs were administered. The clinician elected to terminate treatment for these patients when additional incremental doses 70
10 4 6 5 1 9 3 6
5 4 3 5
Cases Not
Complete 5 6-
3 _
1I
7
2
3 5
-0 1 _
-
16
-
17 18
5 2
5 2
52
41
-
19
Table 2 Cases Started
7 8 9 10 11 12 13 14 15
Totals
observed that those patients amendable to treatment demonstrated purposeful responses when the addressed by the operator. Clinically, the patients appeared relaxed and less hostile towards the operator as the case progressed. Following the adjustment of the dental chair from the Trendelenberg position, the patients were completely ambulatory and were permitted to leave the office within one hour of the position adjustment. The patients required a minimum amount of assistance for ambulation. [Table 2]
Age
Cases Cases Age Started Complete
(79%
-
11 (21%)
Percentage of Cases Treated vs. not Treated.
of Brevital failed to provide acceptible working conditions. [Table 3] The vital signs of these patients were not depressed nor were there any eventful after effects. These patients not receiving treatment represented the extremes on a scale of mentally disturbed patients. Discussion When one applies the term successful to a particular technique, it is important to consider the population being treated. The patients in this study would have had to be treated in a hospital environment under general anesthesia had they not been selected for this study. Of the total number of patients taking part in this investigation, 79% were treated successfully. The initial dosage of Sparine (Promazine) acted as an antiemetic and baseline tranquilizer to set the stage for a smooth transition into a working dental environment. There was no evidence of nausea or vomiting during or following treatment. The use of atropine prevented saliva from causing obstruction in the traacheo-bronchial tree and may also have compensated for any hypotension that might have been induced by the administration of Sparine and Valium. All of the cases treated in this study were completed in less than two hours. The patients were beginning to show signs of mobility at the end of that time period. It was the clinical opinion of the authors ANESTHESIA PROGRESS
that more frequent incremental dosages of Brevital would have been necessary had the cases extended over longer periods of time. For this reason, one must consider performing treatment in multiple sessions where extensive dental work might be needed. This would eliminate the possibility of a barbiturate build up leading to respiratory depression. Those patients who could not be treated (21%v) were severely retarded. Utilizing low dosages of sedative drugs, it was not possible to control the level of excitability and their primitive instincts. In addition, some of these patients were on a routine schedule of medication for many years to control their aberrant behavior and convulsive seizures. It is therefore logical to consider the possibility of a drug tolerance existing in some of these patients. Clinical observations indicated that it was extremely difficult for these patients to relate to their environment. Summary Sparine (Promazine) was administered orally as a base-line medication and then supplemented intravenously with atropine, Valium, and Brevital. These drugs were found to be a safe, effective mood changing combination for the treatment of mentally retarded patients needing dental care. Based on a study of 52 cases, this clinical technique provided smooth working conditions for up to two hours for 79 % of the patients in this study. This preliminary clinical investigation for treating ambulatory retarded patients in a non-hospital environment seems to offer the following advantages: 1. a wide margin of safety, 2. preservation of the vital protective reflexes, 3. stability of the vital signs, 4. short recovery time, 5. no nausea or vomiting,
MAY-JUNE, 1977
6. maintenance of patient airway, 7. a fast onset of action, 8. provides a stationary target to permit a quality dental service. REFERENCES 1. Jorgensen N Premedication in dentistry, J So Calif State Dent Assoc 21:1 1953. 2. Langa H Analgesia for modem dentistry, N Y J Dent 27:228 1957. 3. Monheim L General Anesthesia in Dental Practice, 3rd Ed. St Louis C V Mosby Co 1968. 4. Berns J "Twilight Sedation" J Conn State Dent Assoc 37:1 1963. 5. Drummond-Jackson S SAAD views anesthesia in Britain Anes Prog 13:313 1966. 6. Shane S Intravenous amnesia for total dentistry in one sitting J Oral Surg 24:27 1966. 7. Carrel R A supplement to an intravenous amnesia technique in pedodontic cases Anes Prog 15:39-41 1968. 8. Carrel R A clinical study of a modified intravenous amnesia technique for pedodontia patients Bull Phila County Dent Soc 38:1 14-17 1972. 9. Carrel R Intravenous anesthesia for pediatric dentistry in a hospital or institutional setting J Dent Child 42:285-289 1975. 10. Carrel R The behavior modification of a dentally disabled child J Dent Child 39-45 1976. 11. Wibby W Intravenous amnesia in general dental practice Anes Prog 19:3 61 1972. 12. Brown P Valium in dentistry Brit Dent J 125:498-501 1968. 13. Khosla V Diazepam in oral surgery Oral Surg Oral Med Oral Path 28:671-679 1969. 14. Sohn D Valium Anes Prog 22:3 74-77 1975. 15. Foreman P Intravenous sedation Anes Prog 13:218 1966. 16. Foreman P Diazepam in Dentistry Anes Prog 15:253 1968. 17. Healy T The use of intravenous diazepam during dental surgery in the mentally handicapped patient Brit Dent J 128:22-24 1970. 18. Spiro S Amnesia-analgesia for special care patients Anes Prog 17:82 1970. 19. Runzo R Dental care for the handicapped Anes Prog 19:1 9-12 1972.
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