Pediatric
Pediatric Oral Conscious Sedation
Tim Silegy, DDS, and Scott T. Jacks, DDS
Copyright 2003 Journal of the California Dental Association.
Author
Tim Silegy, DDS, is a diplomate of the American Board of Oral and Maxillofacial
Surgery. He maintains a private practice in Long Beach, Calif.
Scott T. Jacks, DDS, FACD, has a private pediatric dental practice in Southgate and Norwalk, Calif.
Disclosure
Dr. Silegy gives basic, advanced, and pediatric life support lectures for CME Associates in Orange, Calif., and is the director of the oral and maxillofacial surgery assistant’s course sponsored by the California Association of Oral and Maxillofacial Surgeons in Roseville, Calif.
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As the young indigent population of this state grows, access to dental care continues to be a problem. Studies show that children from poor families suffer from a higher caries rate than those from a higher socioeconomic class. The management of pain and anxiety with intravenous sedation or general anesthesia in the young, precooperative patient, can be a significant adjunct to the delivery of dentistry. However, because children in this demographic group frequently lack the financial resources necessary for these treatment modalities, they will either not receive the necessary care because they are deemed unmanageable or will have a traumatic experience causing them to become even more resistant to future dental care. This article demonstrates how oral conscious sedation can be a safe and cost-effective alternative to intravenous sedation and general anesthesia in facilitating dental care for children who could otherwise not be treated.
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Access to dental care for the children of California has become an important issue for both the California Dental Association and the California Society of Pediatric Dentists. The 2000 surgeon general’s report on Oral Health in America confirms the need for action in this area. It states that “dental caries is the single most common chronic childhood disease -- five times more common than asthma and seven times more common than hay fever.”1
The executive summary of the report also states that “the social impact of oral disease in children is substantial.” Nationally, “more than 51 million school hours are lost each year to dental-related illness. Poor children suffer 12 times more restricted-activity days than do children from higher-income families. Pain and suffering due to untreated diseases can lead to problems in eating and speaking and attending to learning.”1 Another significant finding of the report is that “25 percent of poor children have not seen a dentist before entering kindergarten.”1 Hence, the child’s first dental experience is frequently unpleasant because it involves major restorative dentistry.
Managing the dental needs of the pediatric population imparts a unique challenge to the dental practitioner. He or she must not only be skilled at diagnosing and treating the deciduous and succedaneous dentition, but also be able to assess and address the emotional and behavioral status of children. Many prekindergarten children are not capable of sitting for protracted periods. This fact makes them poor candidates for restorative dental procedures and represents a troubling issue. These children, ranging in age from 2 to 4 years, are developmentally at a precooperative age.2 The typical attention span of such a young child is four to eight minutes.3 In addition, many find restorative dentistry emotionally stressful; and research has shown that children of this age, when placed in emotionally stressful situations, tend to regress, further impeding the ability of the dentist to perform dentistry effectively.
Some of these young patients with extensive dental caries require general anesthesia to facilitate treatment. Others, with no complicating medical conditions, can be ideal candidates for intravenous sedation. IV sedation and general anesthesia are expensive, ranging in cost from hundreds to thousands of dollars, before a penny is spent restoring the mouth. In many instances, these financial issues further block access to care.
Oral conscious sedation is another, significantly less expensive, option. An appropriately trained and permitted dentist (see Silegy and Kingston in this issue) can safely perform this procedure in the office. Children, who may not be able to tolerate restorative procedures with nitrous oxide-oxygen and local anesthesia alone, are frequently ideal candidates. Oral sedation enables the dentist to perform the necessary dental treatment with minimal stress to the patient and dental team. In some instances, it may not be the treatment of choice; but when appropriate, oral sedation may make the difference between treatment and no treatment at all.
Preoperative Evaluation
Not all children are good candidates for oral sedation. Successful management of pediatric dental patients requires the dentist to have an understanding of age-dependent behavior, medical conditions that could complicate sedation, and the complexity of the anticipated dental treatment.
Behavioral Evaluation
During the initial exam, it is important for the dentist to evaluate and classify behavior so that an estimate of the child’s cooperative ability can be determined. This determination will assist the treating dentist in deciding whether the patient is a candidate for nonpharmacologic intervention, oral conscious sedation, IV sedation, or general anesthesia. Numerous systems have been developed to accomplish this task. Two prominent classification systems have been developed by Wright and Frankl.4
Wright’s system places children into one of three categories based upon their behavior:
* Cooperative;
* Lacking in cooperative ability; or
* Potentially cooperative.
Frankl’s behavior rating scale divides behavior into four categories:
* Rating 1 -- definitely negative;
* Rating 2 -- negative;
* Rating 3 -- positive; and
* Rating 4 -- definitely positive.
Some dentists develop their own scale and use it to evaluate the behavior of young children in the dental setting. No matter what system a practitioner uses, the essential issue is that he or she documents preoperative behavior and considers it when formulating the treatment plan.
Medical Evaluation
The medical condition of the pediatric patient can have a profound effect on the dental treatment plan. To be considered for oral sedation in the dental office setting, children should be free of systemic disease (ASA Class I) or have a well-controlled medical condition such as mild asthma or diabetes (ASA Class II).
Because most cases of morbidity and mortality associated with pediatric oral conscious sedation involve airway and/or respiratory complications, it is imperative that special attention be paid to these areas.5 The most common acute medical condition affecting young children is the upper-respiratory tract infection or common cold. Preschool-aged children suffering from an upper-respiratory tract infection are more prone to complications because they frequently are obligate nose breathers.8 The hypersecretion and edema associated with an upper-respiratory tract infection can dramatically diminish their ability to keep their airway clear, especially after having received a sedative and local anesthetic. Additionally, nitrous oxide-oxygen administered via a nasal hood, will have little effect on the child with nasal congestion.7 In this instance, treatment should be deferred for two weeks from the cessation of symptoms.8
Dental Evaluation
Necessary dental procedures should be categorized based upon the anticipated time needed for their completion. The authors believe that the child whose dental work can be completed in an hour or less makes the best candidate for oral sedation. Children requiring significantly more chairtime might be better served by an IV sedation, general anesthetic, or additional appointments using oral sedation.
Standardized treatment protocols that consider the child’s behavioral, medical, and dental evaluation can aid the practitioner in determining the best course of treatment.
Agents and Techniques
Many agents and techniques have been used to sedate the pediatric patient.9,10 The administration of oral sedative medications is generally well-tolerated by children. While most agents are unpleasant to taste, when mixed with sweetened drink powders or juice, they are generally palatable to patients, particularly when thirsty from preoperative fasts.
While effective, oral sedation is much less predictable than intravenous sedation. When a sedative agent is administered intravenously, the plasma concentration rises quickly to elicit an immediate dose-dependent response. The same agent, when administered orally, may be subject to deactivation in the highly acidic environment of the stomach. Upon passing into the small intestine, there is a generally rapid uptake of the agent into the portal circulation. In the liver, a significant portion is metabolized by the cytochrome p-450 complex (phase I metabolism), conjugated with glucuronic acid (phase II metabolism), and transported to the kidneys, where it is excreted in the urine.11 Consequently, after a considerable delay, only a fraction of the administered agent enters the plasma.
A list of agents commonly used for pediatric oral conscious sedation in dentistry is given in Table 1. Of the agents listed, chloral hydrate has been and continues to be a popular sedative.12-14 Developed in 1832 by Leibig, it is currently available in capsule, syrup, and suppository form. The sedative properties of chloral hydrate are attributed to the active metabolite trichloroethanol.15 An alcohol, it follows zero-order kinetics and as such, has no definitive half-life. Consequently, the duration of the sedative effect can be highly variable and unpredictable when compared to agents that follow first-order kinetics.
The duration of the sedative effect can be significantly longer than the working time. Patients who may have moved excessively at the end of a procedure may become quite somnolent when the stimulation of treatment has ceased. This is especially true for patients having received chloral hydrate and is a significant disadvantage in the outpatient setting, where seemingly alert patients are discharged into their parent’s care.
Broad dosing regimens for chloral hydrate have been reported. While variability in patient response is possible, a dose of 25 to 50 mg/kg, not to exceed a total dose of 1 g provides adequate sedation. Doses of 75 to 100 mg/kg have also been suggested. These higher doses may render patients incapable of independently maintaining their airways and unable to respond appropriately to verbal command, as required by the California Dental Practice Act.16 An antihistamine may be given in conjunction with chloral hydrate to reduce the incidence of nausea and vomiting.17-19
As a group, benzodiazepines are the safest and most effective sedatives available. Their successful use in the pediatric population is well-documented in the medical and dental literature.20-25 Benzodiazepines act centrally at the gamma-amino-butyric-acid receptor in the limbic system to produce anxiolysis and profound amnesia. The two principal agents presently used to orally sedate children are diazepam and midazolam. Valium is typically crushed and mixed with juice for oral administration. It is administered in a dose of 0.5 mg/kg and has a duration of 30 to 45 minutes. A disadvantage of diazepam is an extended half-life secondary to the active metabolite oxazepam, which can render the patient sluggish for up to 48 hours.
Midazolam is twice as potent as diazepam and water-soluble, making it easy to mix with juice for oral administration. It is also available premixed with cherry syrup. Studies suggest that it is the ideal oral sedative.26-34 Normal dosing is 0.25 to 0.5 mg/kg with a duration of 30 to 45 minutes. Exceptionally anxious children may require dosing up to 1 mg/kg not to exceed a 20 mg dose. Unlike diazepam, midazolam has little if any hangover effect, allowing for a full recovery prior to discharge.
Another benzodiazepine, triazolam as been used to sedate children.23,24 To date, it has not been approved by the Food and Drug Administration for use as a sedative.
In cases of overdosage, benzodiazepines are easily reversed by flumazenil 0.2 mg IV.35,36 Some advocate injecting flumazenil sublingually in cases of emergency. A search of the literature revealed no studies to support this practice.
The sedative and analgesic properties of opioids make them desirable agents for oral sedation. When bound to specific opioid receptors in the spinal cord and central nervous system, opioids attenuate pain and produce sedation and dose-dependent respiratory depression. Meperidine hydrochloride is frequently used as an oral sedative. Administered at a dose of 1 to 2 mg/kg, it produces analgesia, sedation, and euphoria. Because of the frequently encountered side effects of nausea and vomiting and respiratory depression, meperidine is seldom administered alone. The “DPT cocktail,” a mixture of Demerol (meperidine), Phenergan (promethezine) and Thorazine (chlorpromazine), has been used extensively by emergency physicians in hospitals and, to a lesser extent, by pediatric dentists in the dental office.37,38 Chlorpromazine, a neuroleptic, increases the depth of sedation without increasing the incidence of respiratory depression. It is also a potent antiemetic. Promethezine also has sedative properties, decreases the incidence of nausea, and dries the mouth. While generally safe, the DPT cocktail has been associated with seizures and may render a child unresponsive.39
As a group, antihistamines are very safe agents to use on children.40 Blockade of serotonin receptors by antihistamines in the central nervous system produces a sedative-like effect. Although they lack anxiolytic, amnestic, and analgesic properties, antihistamines cause drowsiness and have antiemetic and antisialogogue effects. Commonly used antihistamines include promethezine and hydroxyzine administered in a dose of 0.5 to 1 mg/kg.
The patient evaluation mentioned earlier can aid the dentist in formulating a pharmacologic treatment plan. This plan might make use of one or a combination of drugs. Studies show that the failure rate (being unable to initiate or complete treatment) of oral sedation can be as high as 40 percent and that the regimen used successfully for one appointment may not be effective for the next.41 Because repeat doses of oral sedatives are contraindicated at the same appointment, it is important to have an alternate treatment plan available.
Technique
When feasible, it is advantageous to sedate children in the early morning because a more reliable NPO (nothing by mouth) status can be achieved. Table 2 lists current American Society of Anesthesiologists preoperative fasting guidelines. Pediatric patients should be scheduled to arrive at the office one hour prior to the anticipated treatment time. The treating doctor should quickly reassess the patient by evaluating the airway, listening to the heart and lungs, recording baseline vital signs, and confirming NPO status. A written consent explaining the anticipated dental treatment, the reason for utilizing sedation, the use of restraints, and the risks, complications, treatment alternatives, and expected outcomes should be signed by a parent or legal guardian prior to treatment.
The oral sedative should then be administered and the patient observed by trained staff. As the patient becomes drowsy, he or she should be casually walked or carried to the treatment area. Oxygen should be administered via nasal mask or nasal canula. If nitrous oxide-oxygen is to be used, it should be titrated to effect via a scavenged nasal hood system (See Malamed in this issue). Adjuncts to pharmacologic anxiolysis such as stuffed animals, ceiling-mounted televisions, and headphones are effective and can help promote cooperative behavior.
As the child settles into his or her environment, a blood pressure cuff, precordial stethoscope, and pulse oximetry probe can be placed and vital signs recorded. Local anesthesia should then be administered slowly with a 30-gauge needle. If 2 percent lidocaine with epinephrine 1:100,000 is used, care should be taken not to exceed a total dose of 4 mg/kg of body weight.42,43 Prior to the dentist’s beginning treatment, he or she should protect the airway with a gauze throat pack or rubber dam; and auxiliary staff should be vigilant in suctioning.
At the conclusion of the procedure, the clinician must be sure that the maximum effect of the sedative has passed prior to the cessation of monitoring. If extractions were carried out, gauze hemostasis should be confirmed. Prior to discharge, postoperative vital signs should be close to baseline; and the patient must be able to maintain his or her oxygen saturation on room air. The child should be alert, oriented, and able to ambulate with minimal assistance. Finally, detailed written and verbal postoperative instructions should be given to the parents.
Safety
Anesthetic emergencies occurring in children almost always involve airway and/or respiratory compromise. Because of their disproportionately large tongues, proliferation of lymphoid tissue, and large tonsils, children breathe most readily through their noses. During dental treatment, the most common causes of airway obstruction in a child are occlusion of the posterior oropharynx with the tongue and obstruction of the nares with the nitrous hood.7 It is therefore critical to observe patients for adequate air exchange at all times.
To avoid positional asphyxiation, as much as practical, the child’s head position should be maintained in the sniffing position with the head extended. If obstruction is suspected, the tongue should be pulled forward in the mouth, the posterior oropharynx suctioned, and the nasal hood repositioned.
Apnea in the absence of airway obstruction is a complication of oral sedation rarely seen with normal dosing. When it does occur, it is easily managed with stimulation, positive pressure ventilation, and/or reversal of the sedative agent.
Summary
Thousands of children are sedated safely by dentists daily in the United States. While rare, morbidity and mortality in pediatric patients receiving oral conscious sedation does occur. Retrospective analysis has demonstrated that most mishaps can generally be attributed to four things:44,45
* Inadequate preoperative evaluation;
* Lack of knowledge concerning the pharmacology of drugs employed;
* Inadequate monitoring during the procedure; and
* Lack of training in the management of emergencies.
Competency in the administration of oral sedation is necessary for dentists who choose to treat children on a regular basis. In California, advanced training programs in pediatric dentistry are offered at Loma Linda University, the University of California at Los Angeles, the University of California at San Francisco, and the University of Southern California. Continuing education programs designed to fulfill the educational requirements mandated by the state legislature for an oral conscious sedation permit are taught by the faculties of UCLA, UCSF, Loma Linda, and CME Associates.
In the coming years, California must face and solve the growing issue of access to care for the young children of the state. With dental caries being the single most common childhood disease, the challenge will be daunting. While water fluoridation and other preventive modalities may make significant inroads into solving this problem, for the foreseeable future, the major responsibility for restoring these decayed teeth will fall on the dedicated dentists of California. If the dental needs of the pediatric population are to be addressed safely and effectively, it is vital that dentists who treat children receive appropriate training in oral conscious sedation on a regular basis.
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To request a printed copy of this article, please contact/ Tim Silegy, DDS, 6226 E. Spring St., #315, Long Beach, CA 90815.
