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Management of Neurological Disease |
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Patients prone to syncope should be treated with regard to avoidance of known precipitating factors as far as possible. Treatment in the supine position has obvious advantages.
¨ Epileptic patients referred for GA should not be given methohexitone or enflurane since these are epileptogenic. ¨ It is important to ensure that an epileptic patient has taken their normal medication on the day of the procedure. ¨ Intravenous sedation is useful in managing epileptic patients. ¨ The benzodiazepines have anticonvulsant properties and anxiolysis should decrease the chances of a fit. ¨ When treating epileptic patients with sedation supplemental oxygen should be provided via a nasal cannula. ¨ The use of the benzodiazepine reversal agent flumazenil should be avoided in patients with epilepsy as this drug can precipitate convulsions.
Patients who have had a CVA should have treatment only when their condition has been optimised if possible. ¨ There may be a loss of reflexes such as swallowing or the gag reflex, which has implications for the safe provision of treatment under LA, with or without sedation. ¨ Ability to protect the airway is also relevant for the provision of GA since all these modes of treatment jeopardise the airway to some extent. ¨ Stroke patients may be taking anticoagulants, or may be hypertensive.
In both multiple sclerosis and motor neurone disease, the degree of compliance achievable for treatment is likely to be impaired. ¨ It is best to use LA alone if possible. ¨ Limited mobility and/or associated psychological disorders may cause difficulties with treatment. Patients are better treated sitting so that respiration is assisted as much as possible since it may be impaired. ¨ Patients with MS may be taking corticosteroids, particularly early in the disease. ¨ Care of the airway may be made more difficult due to muscular incoordination.
Patients with Parkinson's disease suffer from excess salivation, which can cause difficulties with visibility leading to problems not only providing the treatment itself but also for the safe provision of an anaesthetic. ¨ Anti-muscarinic drugs will reduce the salivation and degree of tremor. ¨ The autonomic insufficiency often found in these patients makes them liable to postural hypotension and poor candidates for general anaesthesia.
In myasthenia gravis, local anaesthesia is the option of choice. Doses should be kept to a minimum. Muscle fatigue appears to increase during the day and therefore treatment is best carried out early. A small oral dose of a benzodiazepine is acceptable if the patient is very anxious about their treatment. For similar reasons general anaesthetics are also not advised if possible. In addition, some of the agents used with GA e.g. the muscle relaxant suxamethonium or opioids e.g. fentanyl may have their effects potentiated in these patients.
Patients with visual problems may be permanently disabled or the disorder may be transient. It is important that a 'tell-do' approach is used for these patients to minimise anxiety. It is worth bearing in mind in these patients that other senses e.g. hearing may be heightened. Other cranial nerve lesions of relevance include those affecting cranial nerves IX and X since the gag reflex may be impaired leading to potential airway compromise, particularly if sedation or GA are being used.
Patients with cerebral palsy may not be able to tolerate treatment under LA, and GA may be the only way of achieving it. ¨ In the athetoid type, potential epilepsy should be borne in mind. ¨ Anxiety will often worsen the effects of the cerebral palsy and therefore premedication e.g. with diazepam is often wise. ¨ Patients with spina bifida have increased incidence of latex allergy. ¨ Such patients may be prone to postural hypotension and are therefore best treated sitting up. ¨ Epilepsy and renal anomalies may also be associated.
REF: British Dental Journal 12 July 2003; Volume 195, No. 1
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Considerations for treatment under general and local anaesthesia and sedation. Dental considerations of the neurological patient. |