pharmacological behaviour management (quite fine) (nellore)
TRANSCRIPT
Pharmacological behaviour management
Dental anxiety is a multifaceted phenomena and a totally non pharmacologic
approach to the management of all anxious dental patients will be inadequate. The
behavioural treatment techniques provide the basis for curing dental anxieties and dental
phobias. When indicated, pharmacologic treatments may be used in conjunction with
behavioural modalities. Anxious dental patients are not all alike and each should be
managed individually. When the behavioural approach in conjunction with local
anesthesia, does not achieve satisfactory control of the pediatric patient’s behavior, the
next step is the pharmacologic approach.
When the dental disease is extensive and the child is very young, a more thorough
and immediate treatment may be necessary. In such a situation, the child can be
reappointed for an oral premedication with Meperidine and Promethazine to permit
completion of the exam and to initiate necessary treatment. Primary concern is to avoid
unpleasant dental experience so as to curb fearful behaviors as the child grows older.
Most sedation therapies in pediatric dentistry involve children in the 2 to 3 years of age
range, where inadequate language development and self-control inhibits successful use of
behavioural strategies.
A pediatric dentist is faced with one of the most difficult tasks within the
profession: maximizing comfort and cooperation while minimizing the risks and costs of
dental care. To accomplish this goal, the pediatric dentist has available few alternatives
that are universally effective.
Majority of uncooperative children can be treated using behavioural management
procedures. There are a small proportion of pediatric patients that cannot be successfully
managed totally through behavioural techniques. These patients are most frequently
preschool children who have no self motivation to be compliant or possess inadequate
coping skills to tolerate dental treatment. Behavioural techniques are most effective for
children over 5 years of age when experience, language and attention span are more
developed. For children who are behavioural management failures, some form of
anesthesia is usually recommended.
Sedation and general anesthesia have been recently classified according to
American Academy of Pediatrics into the following categories:
MINIMAL SEDATION (ANXIOLYSIS):
A drug induced state during which patient respond normally to verbal commands.
Although cognitive function and coordination may be impaired, ventilator and
cardiovascular functions are unaffected.
MODERATE SEDATION (CONSCIOUS SEDATIONOR SEDATION/ANALGESIA):
A minimally depressed level of consciousness that retains the patient’s ability to
maintain a patent airway independently and continuously and respond appropriately to
physical stimulation and/or verbal command. Viz. “Open your eyes.”
DEEP SEDATION (DEEP SEDATION/ANALGESIA):
A controlled state of depressed consciousness or unconsciousness from which the
patient is not easily aroused, which may be accompanied by a partial or complete loss of
protective reflexes, including the ability to maintain a patent airway independently and
respond purposefully to physical stimulation or verbal command.
GENERAL ANESTHESIA:
A drug-induced loss of consciousness during which patients are not arousable, even
by painful stimulation. The ability to independently maintain ventilatory function is often
impaired. Patients often require assistance in maintaining a patent airway, and positive-
pressure ventilation may be required because of depressed spontaneous ventilation or
drug-induced depression of neuromuscular function. Cardiovascular function may be
impaired.
A controlled state of unconsciousness accompanied by a loss of protective
reflexes, including the ability to maintain an airway independently and respond
purposefully to physical stimulation or verbal command.
None of these categories are universally ideal for pediatric dental treatment.
Conscious sedation of young un-cooperative patients is not effective for every child.
Clinical trials of sedative agents used in pediatrics rarely report success rates above 80 to
90 per cent. Deep sedation is also less than 100 percent successful, and carries with it the
need for additional anesthesia training and/or certification for its safe and proper use.
General anesthesia remains an effective and reliable means of treating unmanageable
pediatric patients but is expensive, inconvenient, and not without added risk.
Pharmacologic management of pediatric patients should be considered a
temporary measure. Practitioner who uses these techniques should be convinced that the
necessary dental work can only be performed humanely while the child is sedated and that
the treatment cannot be safely postponed until a time when a non pharmacologic
approach to patient management would be effective. As the child increases in maturity
and has repeated positive dental experiences, dental practitioners are usually able to
minimize drug use over time.
Goals of Sedation:
The goals of sedation in the pediatric patient for diagnostic and therapeutic procedures
are:
1. To guard the patient’s safety and welfare.
2. To minimize physical discomfort and pain.
3. To control anxiety, minimize psychological trauma, and maximize the potential for
amnesia.
4. To control behavior and/or movement so as to allow the safe completion of the
procedure.
5. To return the patient to a state, in which safe discharge from medical supervision, as
determined by recognized criteria, is possible.
Recommended Discharge Criteria
1. Cardiovascular function and airway patency are satisfactory and stable.
2. The patient is easily arousable, and protective reflexes are intact.
3. The patient can talk (if age appropriate).
4. The patient can sit up unaided (if age appropriate).
5. For a very young or handicapped child incapable of the usually expected responses, the
pre-sedation level of responsiveness or a level as close as possible to the normal level
for that child should be achieved.
6. The state of hydration is adequate.
Patient Evaluation and preparation:
Before sedating any child a thorough health and family history should be obtained
including the following
1. Allergies and previous allergic reactions.
2. Current medications including dose, time, route, and site of administration.
3. Disease, disorders, or abnormalities (Down syndrome etc.).
4. Previous hospitalization, to include the date, purpose of admission, history of
general anaesthesia and hospital course.
5. Family history of diseases or disorders (heart, kidney, and liver).
6. Review of systems with a statement as to airway patency (history of snoring and/or
mouth breathing).
7. Vital signs, including pulse and blood pressure.
8. Vital statistics: body weight in kilograms, and age in years and months should be
recorded.
The child should have had a complete physical evaluation within the past year and
preferably within the last month. This health evaluation should be used to place the
patient in one of the categories set forth by American Society of anaesthesiologists and
should be documented in the record.
(ASA) American society of Anaesthesiologists Physical Status classification:
Patients acceptable for conscious sedation should be ASA classification I or II.
Although a severe, compromising medical condition such as American Society of
Anesthesiologists (ASA) III is a general contraindication to sedation in the dental office,
some children in this classification may benefit from its use. These children should be
managed in close co-operation with the child’s physician. Treatment of children in ASA
classification III and IV might be best managed in a hospital or hospital like facility,
especially for lengthy treatment procedures.
Before the utilization of sedative drugs, the parents must be given adequate
information concerning what they are to expect and what their responsibilities will be.
• A normally healthy patient.Class I
• A patient with mild systemic diseaseClass II
• A patient with severe systemic diseaseClass III
• A patient with severe systemic disease that is a constant threat to lifeClass IV
• A moribund patient who is not expected to survive without the operation Class V
DOCUMENTATION BEFORE SEDATION:
Informed consent:
Each parent is entitled to receive complete “Informed consent” regarding the risks
and benefits of the sedation procedure and any reasonable alternatives. Written
“Informed consent” should be obtained according to National legislative requisites.
Practitioner has made it very clear initially and documented that there will be series
of treatments in which this procedure will be utilized.
Instructions and information provided to the responsible person:
The practitioner should provide verbal and/or written instructions to the
responsible person. Information should include objectives of the sedation and anticipated
changes in behavior during and after sedation.
An indication for prolonged observation would be a child with an anatomic airway
problem or a severe underlying medical condition. A 24-hour telephone number for the
practitioner or his or her associates should be provided to all patients and their families.
Instructions should include limitations of activities and appropriate dietary precautions.
DIETARY PRECAUTIONS:
Agents used for sedation have the potential to impair protective airway reflexes,
particularly during deep sedation. Although a rare occurrence, pulmonary aspiration may
occur if the child regurgitates and cannot protect his or her airway. Therefore, it is prudent
that before sedation, the practitioner evaluate preceding food and fluid intake. It is likely
that the risk of aspiration during procedural sedation differs from that during general
anesthesia involving tracheal intubation or other airway manipulation.
However, because the absolute risk of aspiration during procedural sedation is not
yet known, guidelines for fasting periods before elective sedation generally should follow
those used for elective general anesthesia. For emergency procedures in children who
have not fasted, the risks of sedation and the possibility of aspiration must be balanced
against the benefits of performing.
Appropriate intake of food and liquids before elective sedation:
Ingested Material Minimum Fasting Period (Hours)
Clear liquids: water, fruit juices without pulp, carbonated beverages, clear tea, black coffee
2
Breast milk 4 Infant formula 6
Nonhuman milk: because nonhuman milk is similar to solids in gastric emptying time, the amount ingested must be
considered when determining an appropriate fasting period 6
Light meal: a light meal typically consists of toast and clear liquids. Meals that include fried or fatty foods or meat may
prolong gastric emptying time. Both the amount and type of foods ingested must be considered when determining an
appropriate fasting period.
6
CONSCIOUS SEDATION:
Pharmacological substances serve as a valuable help when treating children and
adolescents with dental anxiety or behaviour management problems, but they can never
be effective alone. Good psychological understanding and care for child patients, effective
behaviour management techniques, and an empathic attitude and atmosphere should
form the basis for successful dental treatment for all child patients.
The most common reason for lack of cooperation is fear, often of a specific
procedure such as the injection or ‘the drill’. Sedation will be most effective with children
who are genuinely frightened but who understand the need for treatment and who wish to
be helped; sedation is meant as allaying of anxiety. It raises the patient’s pain threshold,
when the patient is sedated. Patient is conscious of all normal protective reflexes, including
the cough reflex.
Principles of conscious sedation:
1. Careful patient evaluation and selection.
2. Thorough knowledge of selected medications and maximum doses.
3. Informed consent from guardian.
4. Well equipped office – Monitors, Positive pressure O2, and High-speed suction.
5. Back up emergency service.
6. Pre, intra, post operative written documentation.
7. Maximum Recommended Dose (MRD) be calculated by weight; and never exceeded.
Goals of conscious sedation:
1. Facilitate the provision of quality care.
2. Minimize the extremes of disruptive behaviour.
3. Promote a positive psychological response to treatment.
4. Promotes patient welfare and safety.
5. Return the Patient to a physiologic state in which safe discharge is possible (as
determined by recognize criteria).
Objectives of Conscious Sedation (Bennett- 1978):
1. The patient’s mood should be altered.
2. The child should remain conscious.
3. The child should be cooperative.
4. All protective reflexes should be intact and active.
5. All vital signs must remain stable and normal.
6. The child’s pain threshold should be elevated.
7. Amnesia should occur.
Reasons for Complications:
Problems associated with these techniques range from mild to severe morbidity, or
even mortality. In most of the cases the reasons for complications usually are:
1. Dentist inadequately trained in sedative drugs or in the handling of airway emergencies.
2. Lack of necessary equipment to cope with airway emergencies.
3. An appropriate health history and physical examination not obtained.
4. The patients were not properly monitored.
5. Administration of excessive doses of both sedative drugs and local anesthetics.
Determinative factors for the use of conscious sedation:
I. Does the child already have acceptable behaviour according to Frankl’s ratings no.3 and
4? Fortunately, these ratings include about 90% of the children of all ages seen in the
dental operatory if the child does not have acceptable behaviour.
2. Try psychological or behaviour modifications - Tell-show Do, Voice control, Hand over
mouth and Restraints.
When these steps fail, then use some form of conscious sedation-
1. Nitrous oxide analgesia
2. Oral medication
3. Oral medication plus nitrous oxide analgesia
4. Intramuscular sedation alone or with nitrous oxide.
5. The use of any of the above with some form of restraints.
6. The last resort for control of unacceptable behaviour is use of a general anesthetic
agent in a hospital.
INHALATION CONSCIOUS SEDATION: (NITROUS OXIDE – OXYGEN ANALGESIA):
The most effective and common form of conscious sedation used in dentistry is the
inhalation technique in the form of nitrous oxide and oxygen inhalation sedation which
was second to oral sedatives as the most commonly used pharmacologic technique.
Properties of nitrous oxide:
Nitrous oxide (nitrogen monoxide, N20) is a colorless, sweet-smelling gas with a
density of 1.5. The gas is marketed in steel cylinders in which it has been compressed to a
pressure of 50 atmospheres and is in a liquid state. Upon its release from the cylinder, it
reverts to gaseous state. The pressure within the cylinder is 750 psi.9
Nitrous oxide is generally used in a mix of 30% to 50% nitrous oxide and 70% to
50% oxygen, respectively. At these levels it has little effect on the cardiovascular system of
the healthy individual.
Objectives:
1. Ensuring the patient’s safety
2. Eliminating pain and anxiety
3. Reduce or eliminate anxiety in the dental patient reduce untoward movement and
reaction to dental treatment
4. Enhance communication and patient cooperation
5. Raise the pain reaction threshold increase tolerance for longer appointments
6. Aid in treatment of mentally, physically, or medically compromised patients
7. Reduce gagging
8. Potentiate the effect of sedatives.
Inhalation conscious sedation achieves this by:
So that dental procedures are no longer psychologically disturbing. Patients then become
very cooperative and allow a greater amount of treatment to be completed in less time
and in a more relaxed atmosphere also reduces the incidence of pain reactions to stimuli,
inhalation sedation does not completely eliminate pain, and local anesthesia is still
indicated.
Indications:
Success with nitrous oxide sedation is dependent on establishing close
communication with, and gaining the cooperation of the patient. Therefore, the method is
most suitable for the patient who is frightened of dentistry but who wishes to receive
treatment.
1. a fearful, anxious, or obstreperous patient;
2. certain mentally, physically, or medically compromised patients;
3. a patient whose gag reflex interferes with dental care;
4. a patient for whom profound local anesthesia cannot be obtained;
5. a cooperative child undergoing a lengthy dental procedure.
Altering the patient’s attitude
Reducing pain reactions to non painful stimuli
Actually raising the pain threshold.
Indications include the need to
1. Ease anxiety and apprehension associated with the dental environment, especially
“needle phobia” (Sorenson and Roth, 1973),
2. Create a hypnotic state,
3. Increase tolerance to long appointments,
4. Increase the pain reaction threshold
5. Suppress the gag reflex and
6. Preclude sedative premedication or enhance its effects, thereby reducing the need
for general anesthesia (Manford and Roberts, 1980).
Contraindications:
There are no absolute contraindications to administering nitrous oxide-oxygen
inhalation, only relative ones (Land, 1968; Stuebner, 1973; Bennett, 1978; Wald, 1983;
Malamed, 1985).
1. Chronic obstructive pulmonary disease (bronchitis, emphysema),
2. Upper respiratory tract infections, Otitis media, multiple sclerosis,
3. Cold, deviated septum, or enlarged adenoids and Severe emotional disturbances,
4. Any gas-filled space, such as the middle ear, will develop increased volume/ pressure as
nitrous oxide diffuses into the space results in mild auditory changes to deafness (Wald,
1983; Malamed, 1985),
5. Heart disease, epilepsy, asthma, and sickle cell anaemia (Stuebner, 1972; Barenie,
1979),
6. Drug-related dependencies
Advantages:
1. Helps to erase fears, anxieties, and apprehension.
2. Does not interfere with placement of rubber dam.
3. Helps to reduce motion.
4. Creates a semi hypnotic state.
5. Increases tolerance for longer appointments.
6. Slightly raises the pain threshold.
7. Patients recover rapidly and can be dismissed within 5 minutes of the termination
of treatment.
8. Children prefer the nosepiece to an intravenous injection.
Disadvantages:
1. Nitrous oxide does not replace behavior management techniques and in controlling
the defiant, hysterical child.
2. Nitrous oxide is less efficacious when used in highly anxious children.
3. Prolonged or multiple short exposure to nitrous oxide can result in depression of
vitamin B12 activity.
4. The dental treatment is initially more time-consuming using nitrous oxide,
especially if patients are not used to it; but this disadvantage is neutralized, if the
more relaxed patient enables the dentist to work more efficiently.
5. Lack of potency;
6. Dependant largely on psychological reassurance;
7. Interference of the nasal hood with injection to anterior maxillary region;
8. Patient must be able to breathe through the nose; Oxide for
9. Nitrous oxide pollution and potential occupational exposure health hazards.
ACTIONS, PROPERTIES AND EFFECTS of NITROUS OXIDE
Central nervous system:
The central nervous system, specifically the cerebrum, is the system primarily
affected by nitrous oxide. When administered with sufficient amounts of oxygen, nitrous
oxide is a safe, but weak, anesthetic agent. Administration of 50% to 75% nitrous oxide
with oxygen and no additional agent may place some patients into the lightest plane of
surgical anesthesia.
Respiratory system:
The respiratory system is slightly stimulated by 50% concentrations of nitrous
oxide. Observed changes include increased tidal and minute volumes of respiration, While
no definite depression of respiration occurs when nitrous oxide-oxygen are used, dentist
should be aware that the respiratory depression associated with administration of
Meperidine or thiopental is deepened by concomitant use of nitrous oxide.
Cardiovascular system:
The effects of nitrous oxide alone on the cardiovascular system are generally
considered to be insignificant. Eisele and Smith in 1972 have evaluated the effect of nitrous
oxide-oxygen on ten young adults. They reported that the heart rate decreased by as much
as 10% and cardiac output by as much as 19% when subjects inhaled 40% nitrous oxide as
opposed to 40% nitrogen.
Fetal systems:
Recently there has been growing concern about the effects of nitrous oxide on
women in the first trimester of their pregnancy. Nitrous oxide on pregnant animals and the
epidemiologic evidence indicate that Nitrous oxide may be a cause of miscarriage in
humans. Cohen and co-workers in 1971 reported that in a survey of operating room
nurses frequently exposed to anesthetic gases, 29.7% of pregnancies ended in miscarriage,
compared to only 8.5% among general duty nurses.
GI system:
The major effect of nitrous oxide on the gastrointestinal system is nausea and
vomiting.
Hazards:
Asphyxia due to equipment failure,
Diffusion hypoxia,
Malignant hyperpyrexia,
Bone marrow depression,
Pressure- volume effects,
Emotional reactions- dreams and hallucinations
Nausea/Vomiting (Ducan and Moore, 1984).
Occupational health hazards on health personnel’s:
Cohen et al in1980 had reported that chronic exposure to nitrous oxide as greater
than 8 hours/ week caused-
Liver disease, kidney disease, neurologic disease for male dentists
Spontaneous abortion for wives of dentists and chair side assistants.50
The AAPD recommends that dentists and dental auxiliaries minimize their exposure to
nitrous oxide by maintaining the lowest practical levels in the dental environment.
Adherence to the recommendations below can help minimize occupational exposure to
nitrous oxide.
Chronic nitrous oxide exposure should be kept at a minimum by
1. Use scavenging systems that remove nitrous oxide during patient’s exhalation.
2. Ensure that exhaust systems adequately vent scavenged air and gases to the outside of
the building and away from fresh air intake vents.
3. Use, where possible, 100% clean outdoor air for dental operatory ventilation.
4. Implement careful, regular inspection and maintenance of the nitrous oxide/oxygen
delivery equipment.
5. Carefully consider patient selection criteria (i.e, indications and contraindications) prior
to administering nitrous oxide.
6. Select a properly-fitted mask size for each patient.
7. During administration, visually monitor the patient and titrate the flow/percentage to
the minimal effective dose of nitrous oxide.
8. Encourage patients to minimize talking and mouth breathing during nitrous oxide
administration.
9. Use rubber dam and high volume oral aspiration when possible.
10. Flush the delivery system of nitrous oxide after completion, by administering 100%
oxygen to the patient for at least 5 minutes.
12. Provide adequate laminar flow circulation of room air.
13. Periodic evaluation and maintenance of the delivery and scavenging systems.
Equipment:
These machines should have the capacity to
1. Accurately regulate gas flow,
2. Maintain minimum level of 20% oxygen flow to prevent asphyxia,
3. Continuous flow design, and
4. Have an audible or visual warning system or system shut-down if interrupted oxygen
flow occurs.
There should be an oxygen flush level that will deliver 100% oxygen at 30 L/minute.
The gas cylinders are required to be colour coded green (oxygen) and blue (nitrous oxide)
are basically two sizes of cylinders: small and large. The large cylinders contain
approximately 12,000 to 16,000 L. The small cylinders (size E or D) contain approximately
950 to 1,596 L.
An E-size cylinder of nitrous oxide that contains 1,596 L at a continuous flow of 3.5
L/minute, could expect it to last 7.5 hours. An E-size cylinder of oxygen contains 627L
volume which at a 5 L/ minute flow rate would be exhausted in approximately 2 hours.50
Preparation of the patient:
The child should be seated in a reclining position. The child must understand that
he will not be “put to sleep”, but will be awake and aware at all times. The “Tell-Show-Do”
approach is most helpful in establishing rapport with the child during this period
It is essential that all procedures and sensations which may be experienced by the
child be described in advance. The possible sensations of warmth, tingling in the
extremities, auditory changes, and changes in perceived body weight should be described
to the child in a very positive manner.
Introductory administration:
The analgesia machine delivering a flow of 5 lts/min oxygen reservoir bag filled, the
nose piece should be placed over the child’s nose in a graceful, non threatening manner.
No sudden or rapid movements or loud noises should occur which might frighten the child.
The child should be allowed to adjust the nosepiece for comfort and should be instructed
to breathe through his nose. The nasal inhaler should fit snugly on the nose to prevent
gases from blowing into the eyes and to prevent dilution of gases with air.
During the oxygenation period, symptoms the child may feel when nitrous oxide is
administered may be reviewed with him. After two to three minutes, the nitrous oxide
and oxygen should be adjusted to provide a 10% nitrous oxide and 90% oxygen mixture at
a total flow of five liters per minute. After one or two minutes further adjustment to one
liter per minute of nitrous oxide and four liters per minute of oxygen will provide a 20%
nitrous oxide concentration. Child’s reactions should be carefully monitored, he should be
questioned concerning his feelings, and a continuing description of sensations he may
become aware of should be related. The concentration of Nitrous Oxide is gradually
increased up to a maximum of 50%.
It is also necessary to remind some children to breathe through their nose, and
occasionally the use of a finger to close the lips is required. During nitrous oxide
administration both the dentist and an assistant should always be present, for both
medical and legal reasons. Once the procedure is completed, a three–to–five minute 100%
oxygenation period (five litres per minute) should be provided.
The nasal inhaler is removed before the oxygen is turned off and the child is
informed that nitrous oxide may be used at future visits. The child is allowed to return to
normal activities at this time, since any psychomotor impairment due to nitrous oxide is
rapidly and completely reversible upon oxygenation. The introductory administration
levels utilized and the results obtained should be entered in the child’s record.
Patient symptoms obtained at various nitrous oxide levels
It is recommended that local anaesthesia always be used during endodontic and surgical
procedures.
Instructions:
To reduce the slight possibility of vomiting, the parent may be advised to give the
child no more than a light meal 2 or 3 hours before the dental appointment.
Inhalational route was pioneered principally by Langa (1976) who named the
technique Relative Analgesia. This term was introduced by Guedel (1937) who, described
the stages of inhalation anaesthesia, divided the first stage (analgesia) into ‘Relative
Analgesia’ and ‘Total Analgesia’.
Nitrous oxide Concentration % Symptoms
10-20 Tingling feeling (parasthesia)
Sensation of warmth.
20-40
Numbness of the extremities
Sensation of floating
Auditory changes
(Distinct but distant humming noise)
Dissociation
(Inability to perceive Spatial orientation).
Analgesia
Euphoria
40 – 60
Dreaming, laughing or giddiness
Sweating
Nausea and vomiting
Uncoordinated movement
Loss of eyelid reflex.
The levels of nitrous oxide analgesia have been described by Roberts and
Rosenbaum (1991) as follows:
Plane 1: Moderate sedation and analgesia - 5-25% N2O
Plane 2: Dissociation sedation and analgesia - 20-55% N2O
Plane 3: Total analgesia - 50-70% N2O
Moderate analgesia is characterized by relaxation and mild analgesia; the patient
may feel ‘tingling’ sensations in the toes, fingers or other parts of the body. At the lower
levels of dissociation analgesia (about 30% nitrous oxide), analgesia is more marked; the
patient still reacts to pain but feels detached from and little concerned by it. The patient
may report mild sensations of drowsiness, of detachment from the immediate
environment, or of euphoria similar to that associated with alcoholic intoxication; higher
levels of dissociation analgesia, these sensations become more marked and unpleasant,
making such levels incompatible with relaxation.
Thus, the desired level of sedation is within the zone of moderate analgesia or in
the lower levels of dissociation analgesia, generally achieved by inhalation of between 15%
and 35% nitrous oxide. (Satisfactory results have been reported using a fixed concentration
of 25% nitrous oxide, achieved by using Entonox® (50% nitrous oxide + 50% oxygen)
diluted with an equal volume of air (Edmunds & Rosen, 1977).
Treatment Time with Nitrous Oxide Sedation:
Veerkamp et al, 1991 had done a study to investigate the influence of nitrous oxide
on treatment time, when it is used as an additional aid to behavioural management in
treating highly anxious child during sequential visits. The study shows that six-eleven years
age group is more time-consuming than the use of behavioural management as a sole
technique for allowing the child to get acquainted with dental treatment. The influence on
the rest of the treatment varies with the operator. For one operator, the use of nitrous
oxide results in a significantly longer total treatment time.
Using nitrous oxide, dental treatment does not require a greater number of sessions. The
use of nitrous oxide does not appear to be a time-saving activity. If an operator uses more
sessions for a comparable amount of dental work, this results in a longer total sedation
time.
ORAL ROUTE:
The oral route is the most commonly employed route of drug administration for pediatric
dentistry. Malamed et al in 1992, reported that oral administration was the oldest, safest,
most convenient, and most economical route for drug administration.
Advantages:
1. Almost universally acceptable
2. Ease of administration
3. Decreased incidence of allergic reactions
4. No specialized training required
5. Minimum equipment utilized
6. Low incidence of adverse reactions
7. Highly acceptable, and easily administered
Disadvantages of the oral route:
1. Prolonged duration of anxiety
2. Reliance on patient compliance and parent cooperation
3. Inability to titrate
4. Incomplete absorption of drugs from the gastrointestinal tract
5. Inability to readily lighten or deepen the level of sedation
6. Dietary restrictions
7. Patient (parental) compliance
8. Prolonged onset of action
9. Prolonged duration of action
10. Erratic absorption
Sams D. R in 1992 had done study to evaluate the two drug combinations -Chloral
Hydrate/Promethazine and Meperidine/Promethazine to establish the prevalence of
adverse reactions associated with these two oral sedation regimens in Pediatric dental
patients as well as the efficacy of these regimens.
They reported that Hypoxemia was evaluated based on pulse oximeter recordings.
Normal oxygen saturation was considered above 95%, mild hypoxemia was defined as
oxygen saturation between 91-95%, moderate hypoxemia 75-90%, and below 75% was
considered severe. They concluded that Emesis occurred in 5% of the total cases treated,
oxygen desaturation was documented in approximately 48% of the cases and there was no
statistical difference between the behavioural assessments of these two drug regimens.
Both regimens viewed good ratings.
There was no difference in the prevalence of hypoxemia with the use of a sedative-
hypnotic or a narcotic agent. Further controlled studies are needed to differentiate actual
desaturation episodes, however, to rule out recording associated with motion sensitivity.
Drugs administered orally:
1. Chloral hydrate
2. Meperidine
3. Promethazine
4. Diazepam (Houpt 1993)
Diazepam has been used frequently either in a single dose (1 hour before the dental
appointment) or in three doses (on the evening before the appointment, on rising on the
day of the appointment, and 1 hour before the appointment).
Auil et al (1983) administered a single dose of 0.5mg diazepam to 4 to 8 year old
children in the waiting room 1 hour before treatment and found it to be ineffective.
Lindsay & Yates (1985) also reported no effect with slightly older children using either a
single dose of 0.2 mg/kg given in the waiting room 1 hour before treatment, or a series of
three doses (2mg the evening before treatment and 0.2 mg/kg on rising on the day of
treatment and again 1 hour before treatment in the afternoon.
Yanase et al (1996) found a single dose of Diazepam-0.3 mg/kg given to 1 to 8 years
olds by their parents at home 1 hour before the appointment. To be effective, by parents
at home is preferable because a 1 hour wait in the dentist’s waiting room probably
increases fear and tension in a child, thus reducing the sedative effect of the drug.
Temazepam, a minor metabolite of Diazepam, given to preschool children in a dose of 0.3
mg/kg was found to be as effective as a combination of Chloral hydrate and Hydroxyzine
(Tsinidou et at, 1992). Preferable for the child is not to attend school before the dental
visit, because the drug may cause drowsiness.
RECTAL ROUTE:
The rectal route is not been used frequently in dentistry and is used in patients with
disabilities if they are unable to cooperate sufficiently for oral administration.
Drugs used:
Methohexatol and diazepam are effective rectally administered sedative agents in
pediatric patients. Methohexatol has been used very successfully to sedate children before
general anesthesia.
The lubricated tip of a cut-off French soft rubber catheter is inserted into the child’s
rectum, and the solution is injected through the catheter. After the practitioner dispenses
the medication, a bolus of air is injected into the tube to clear the contents and ensure that
all the medication enters the child’s rectum.
The administration of drugs through this route is frequently used in medical practice
but rarely in dentistry. It is employed successfully in Sweden for the dental treatment of
young, anxious patients (Lundgren et al 1978), using a preparation containing 5 mg or
10mg diazepam in 2.5ml solution.
Treatment of maxillofacial injuries (Lowey & Halfpenny 1993), its administration was
not considered by the parents or the children to be traumatic. Rectally administered
diazepam has also proved effective for sedating young children prior to restorative
treatment, using a dosage of 0.6mg diazepam/kg body weight (Flaitz et al 1985), and
rectally administered midazolam (0.25 or 0.35mg/kg body weight ) has been used
successfully in children undergoing extraction of teeth (Roelosfe et al 1990).
SUBCUTANEOUS ROUTE:
It involves the injection of a drug beneath the skin into the subcutaneous tissues
and is useful for nonvolatile, water or fat-soluble sedative drugs. Drugs that irritate tissues,
such as diazepam, should not be administered subcutaneously.
The rate of drug absorption into the cardiovascular system will vary with the blood
supply to the tissue. Because subcutaneous tissues have a relatively poor blood supply, the
absorption of drugs following subcutaneous administration is usually slow. This slow rate
of absorption following subcutaneous injection limits the effectiveness of this route in
dentistry.
SUBMUCOSAL ROUTE:
The sub-mucosal route involves the injection of a drug beneath the mucous
membranes, usually in the area of the maxillary second primary or first permanent molar.
Drugs used: Narcotics- Meperidine, Fentanyl.
The rate of absorption is only slightly slower than the intravenous route, which
makes it a very suitable technique for administering sedative drugs to children.
Very little co-operation is required, and the injection is no more painful than the
usual infiltration injection for local anesthetics. Because of possible sloughing and necrosis
of the tissues, the use of this technique must be limited to drugs that are nonirritating to
tissues. A 1-ml tuberculin syringe and a 27-gauge, ½ inch needle are generally used for this
injection.
INTRALINGUAL (SUBLINGUAL) ROUTE:
Rarely used for drug administration, except for administering drugs in emergencies
when intravenous access in not immediately available. Drugs used – Lorazepam, Atropine,
and Succinylcholine. The technique involves injection of drugs into highly vascular area at
the base of the tongue.
Nichols and Cutright reported that the uptake of emergency drugs injected in this
manner is within 35 seconds. It is been reported as a very satisfactory technique for use in
sedation children.
INTRAMUSCULAR ROUTES:
It is a parenteral technique that maintains several advantages over the enteral
techniques.
Advantages:
It is more rapid onset and its effect more predictable. It generally reaches a
maximal clinical effect in approximately 30 minutes. It is more reliable absorption of a drug
into the circulatory system
The most frequent injection sites:
Outer most superior quadrant of the buttock
The anterior aspect of the middle thigh
Needles should be 27 to 23 gauge and 1inch in length. Muscle penetration in a
child’s buttock can generally be reached at a depth of ½ to 1 inch.
Disadvantages:
The inability to titrate medications accurately in the handicapped child and in the
recalcitrant child, impossible to employ effectively is an unpleasant procedure.
Effective combination is Promethazine hydrochloride (Phenergen®) and Pethidine.
Promethazine is an antihistamine that has sedative and anti-emetic properties. Pethidine is
a potent analgesic, has little sedative effect. Anti-emetic Promethazine counteracts the
nausea that may be produced by Pethidine. Pethidine 1.5 mg/kg and Promethanize
0.75mg/kg given in the upper lateral quadrant of the buttock, the anterior aspect of the
upper thigh or the lateral aspect of the upper arm (Musselman & McClure 1975, Bennett
1978). Drug has a very rapid effect and that the dose can be given in increments until the
desired level of sedation is achieved.
INTRAVENOUS ROUTE:
Intravenous conscious sedation in dentistry was introduced in 1945 by Niels B.
Jorgensen.
Drugs used:
Niels B. Jorgensen (1945) first used a combination of Sodium Pentobarbital, Meperidine,
and Scopolamine. Jorgensen & Leffingwell (1961), used a mixure of Pentobarbitone,
Pethidine and Hyoscine. Later, diazepam became the drug choice for intravenous sedation.
Diazepam
Advantages: It produces effective sedation, muscle relaxation and amnesia
Disadvantages: It slowly eliminates from the body, injection into a vein is often
painful.
Midazolam
Midazolam has similar sedative, relaxant and amnesic properties to those of diazepam but
it is more quickly eliminated from the body and does not cause pain on injection.
Indications:
Indicated primarily with the following kinds of patients:
1. Normal , healthy children who are in need of immediate dental care but who are
quite fearful and apprehensive about treatment
2. Children who because of fear of the nasal mask, nasal obstruction, or other
respiratory problems cannot be sedated by means of inhalation conscious sedation.
3. Children with motor disturbances such as cerebral palsy
4. Most often for the management of the highly anxious but co-operative adult, older
child, or adolescent dental patient.
Advantages:
1. Rapid onset of action: The effect begins within seconds after administration. The
full effect is apparent within minutes. Effective blood levels of medications are
achieved quite rapidly.
2. Minimum recovery period: recovery is generally faster than from orally, rectally, or
intramuscularly introduced drugs.
Disadvantages:
1. Co-operation from the patient is a requirement if a successful venipuncture is to be
accomplished. Many children will not permit venipuncture to be performed;
therefore intravenous sedation is rarely attempted in disruptive child patients.
2. Need for a period of postoperative recovery.
3. Subsequent restriction of activities.
Purposes:
To allay apprehension, anxiety, and fear;
To raise the pain threshold
To control salivary secretion
To control gagging
To control motor disturbances
To reduce stress associated with oral surgery and/ or restorative pediatric dentistry.
Method of administration:
To administer a drug intravenously requires a mastery of the technique of
Venepuncture, described by Rosenbaum (1991). Midazolam is injected into a vein in the
dorsum of the hand. Dosage used is 0.1 mg/kg body weights; injected slowly, over a period
of 1-2 minutes. Sedation is deepest immediately next 10 minutes. There is complete or
partial amnesia from the time of the intravenous injection, thus, the patient may
remember the intravenous but not the intraoral injection. The depth of sedation becomes
progressively lighter and the patient usually appears normal about 1 hour after injection.
The General Dental Council (1993) has stipulated that, ‘a second appropriate person
must be present throughout the treatment session, Suitably trained dental surgery
assistant who is capable of monitoring the condition of the patient and of assisting the
dentist in case of emergency.
Trieger suggests that the most accurate and effective premedication for the
conscious patient is that achieved by gradually titrating a sedative directly into a vein. It
represents the most effective method of ensuring predictable and adequate sedation in
most patients.
Various techniques:
The Jorgensen technique:
In 1945, Jorgensen first used the combination of Meperidine, Pentobarbital, and
Scopolamine in anxious patients. The technique has proved to be effective and safe.
The Shane technique:
Uses a Narcotic (Alpaprodine), a Barbiturate (Methohexital), a minor Psychosedative
(Hydrozine) and Atropine.
Intermittent methohexital sodium sedation:
Diazepam is one of the minor tranquilizers and is presently the most prescribed drug
well suited for short (up to 45 minutes) procedures and seems to be well tolerated by both
children and adults. Drummond- Jackson recommends the following dosages for children:
4 to 6 years: 5mg of Diazepam
7 to 10 years: 7.5mg of Diazepam
11 to 14 years: up to 10mg of Diazepam
14 years and up: 10mg of Diazepam (adult dose).
The usual procedure is to inject 2.0 to 2.5 mg of diazepam slowly every 30 seconds until
ptosis is observed.
Secobarbital-meperidine-methohexital sedation-anesthesia:
This method uses the injection of 50mg of Secobarbital followed by 25 to 50 mg of
Meperidine to produce a base level of sedation.
Diazepam plus methohexital sedation:
In some patients the level of sedation achieved with recommended doses of
diazepam is not always sufficient during some dental procedures, even with the concurrent
use of regional anesthesia. To remedy this, small increments of Methohexital sodium
(about 5mg) is used when needed after the initial injection of diazepam. This method
allows the dentist to perform comfortably procedures lasting from 30 to 90 minutes.
Larger doses can lead to loss of patient consciousness, increased length of recovery period,
periodic loss of protective reflexes.
Possible problems:
Hematomas, Irritation, Venospasm, Phlebitis and Intra-arterial injection.
The dentist should always use psychological approaches to minimize dosage and
ensure a minimal level of CNS depression. Careful attention must be given to the very
young child and the special patient.
M.T. Hosey et al in2004 used Sub-anaesthetic doses of Propofol of the mean total
dose of 146.25 mg (range 10mg-356mg) in relation to body weight, the mean was 2.5 mg/
kg (range- 0.2-5.4 mg/kg) as an IV conscious sedative agent for dental treatment in 32
anxious children and they reported that Propofol facilitated the acceptance of operative
dental treatment without any adverse effects.
Drugs used for Intra venous conscious sedation in children:
The drug groups used for pediatric sedation in the dental office include,
Alcohol (e.g. chloral hydrate)
Barbiturates (e.g. Methohexitol)
Psychosedatives which include
1. Diphenylmethanes (eg.hydrozine).
2. Benzodiazepines (e.g. Diazepam and midazolam)
3. Phenothazines (e.g. Promethzine)
4. Ethanolamines (e.g. Diphenhydramin) and
5. Narcotics (e.g. Morphine, Meperidine, and Fentanyl).
SEDATIVE HYPNOTICS:
CHLORAL HYDRATE (NOCTEC):
Effects: Sedatives, soporific, hypnotic, and general anesthetic in higher doses.
Onset of action: 15 to 30 minutes PO.
Peak effect may not occur for 1 to 1½ hours or more.
Duration of Action: 5 hours or longer PO
Routes: Oral and rectal
Dose: 25 to 50 mg/kg PO.
Side effects: Gastric irritation, excitement, delirium, prolonged deep stupor,
reduced blood pressure, respiratory depression, CNS-depression, nausea and
vomiting. In small doses (25mg/kg) chloral hydrate results in very mild sedation. In
intermediate doses it acts as a soporific and produces calm, natural sleep. In higher
doses it produces general anesthesia.
The problem in pediatric dentistry is that the level of sedation produced by the
relatively equivalent dose in children is not generally satisfactory to enable the dentist to
treat the un-co-operative child. As a result, children are sometimes given relatively larger
doses so that they go beyond the “sedated” state and into the “sleep” state. It is a quiet
sleep, often accompanied by dreams.
Contra-indications:
Contraindicated in children with hepatic or renal impairment.
Larger doses may cause myocardial depression, arrhythmia, and cardiac collapse,
and the drug is therefore not recommended for use in children with heart disease.
In case of gastritis, it is generally recommended that the dose not exceed 50 mg/kg
or 1 gram (total dose), but even this dose has been known to cause morbidity and
has been associated with mortality in children. The risk of toxicity is greatly
increased when it is used with nitrous oxide and oxygen and local anesthetic
agents.
Toxicity: Deep stupor, marked vasodilation, low blood pressure, a fall in body
temperature, slows respiration, and cyanosis. Pin-point pupils may be seen. Death
results from respiration depression and cardiac failure.
BARBITURATES:
The Major action of Barbiturates is CNS depression. Any degree of depression, from
light conscious sedation, to unconsciousness, general anesthesia, and coma, can be
produced by the barbiturates. Barbiturates have few advantages and many disadvantages
as sedative drugs for pediatric dentistry.
Disadvantages:
Produces “hangover” effect on arousal.
The child may be sensitized to painful stimuli and may respond more vigorously
than if the drug had not been given. This phenomenon is called antanalgesia.
Hyper excitability in some children, particularly the hyperactive or very young.
Very potent respiratory depressants.
Therefore, the barbiturates are not widely used for the conscious sedation of
children for dental treatment. Advantage is its low storage in fat.
Methohexital has been used successfully and with increasing frequency as a pregeneral
anesthetic sedative agent and short dental procedure for pediatric patients, administered
rectally in a dose of 2.0 mg/kg.
PSYCHOSEDATIVES:
The psycho sedatives are used not only because of their tranquilizing and mild
sedative effect but also because of their antihistaminic effect. The antihistaminic effect is
highly desirable when used in combination with narcotic drugs to counteract the
histaminic effect of the narcotic.
HYDROXYZINE HCL (ATARAX® AND VISTARIL®):
Effects: Sedative, antihistaminic, antiemetic, and antispasmodic, some muscle
relaxation counteracts the vasopressor action of epinephrine
Onset of action: 10 to 15 minutes PO
Duration of Action: 4 to 6 hours or longer PO
Routes: Oral and intramuscular
Dose: 0.5 to 2.5 mg/kg PO or intramuscularly.
Side effects: Drowsiness and hyper-sedation, usually mild and transitory in nature,
potentiates the respiratory depression produced by barbiturates and narcotics.
DIAZEPAM:
Effects: Sedative, antianxiety, anticonvulsant, muscle relaxant
Onset of action: 15 to 20 minutes PO
Duration of Action: 4 to 6 hours PO
Routes: Oral, rectal or intramuscular
Dose: 0.02 to 0.5 mg/kg PO, 0.4 to 0.5 mg/kg rectally, 0.2 to 0.3 mg/kg
intramuscularly.
Side effects: Thrombophlebitis and Phlebothrombotic sequelae, burning on
injection, nausea, extended drowsiness, dizziness, potentiates phenothiazines,
barbituarates and narcotics.
May have an extended duration of action due to release from fat storage areas 5 to
6 hours after administration.
Diazepam is one of a family of sedative drugs known as the Benzodiazepines. They do not
produce CNS depression at therapeutic levels. In addition patients with hepatic dysfunction
may receive Benzodiazepines without increased risk.
MIDAZOLAM MALEATE:
Effects: Similar to diazepam, but greater amnesic effect.
Onset of action: 2 minutes intravenously 15 to 30 minutes intramuscularly.
Duration of Action: less than 1 hour intravenously
Routes: PO, rectally, intramuscularly, and intravenously.
Dose: 0.075 to 0.15 mg/kg PO or intravenously.
Side effects: Increased heart rate in doses greater than 0.15 mg/kg; It also causes
hallucinations in children.
The major difference between midazolam and diazepam is that midazolam is water
soluble rather than fat soluble. It has similar action. But it is 1 ½ times as potent as
diazepam.
The major advantages of Midazolam over Diazepam include
A shorter duration of action
Water solubility and
Better local tissue tolerance when injected intravenously.
Amnesia can be marked and extended into the recovery period but, it does benefit
from the availability of a reversal agent.
PROMETHAZINE (PHENERGAN):
Effects: Antihistaminic, antiemetic, and sedative.
Onset of action: 20 minutes PO
Duration of Action: 4 to 6 hours
Routes: PO, rectal, intramuscular. (not recommended for subcutaneous or
submucosal injection).
Dose: 0.1 mg/kg PO or intramuscularly.
Side effects: CNS depression, drowsiness, delirium, may precipitate seizures in
seizure-prone patients, postural hypotension, significantly potentiates the
respiratory depressant action of narcotics, barbiturates and other antihistamines,
soreness and tenderness at site of injection.
DIPHENHYDRAMINE HYDROCHLORIDE (BENADRYL®):
Effects: Antihistaminic with significant anticholinergic activity, pronounced
sedation, somnolence, and reverses extrapyramidal symptoms of the
phenothiazines.
Onset of action: 15 minutes PO.
Duration of action: 4 to 6 hours.
Routes: PO, intramuscular and intravenous.
Dose: 2 to 5 mg/kg PO or intramuscularly to 100mg maximum/single dose, 2mg/kg
intravenously.
Side effects: Dizziness and confusion, hypotension, sedative action in addition to
other CNS depressants, may lower the patient’s seizure threshold, excessive
drowsiness, hallucinations and excitation, respiratory depression, photosensitivity,
rash, perspiration, Urticaria, flushing, and dilation of the pupils.
o Experience with these drugs as single agents has shown clearly the
importance of patient preparation, suggestion and good patient behaviour
management techniques in achieving satisfactory psycho sedation. Because
of these requirements, these drugs cannot be recommended as single
agents for sedating children whose communication level is not satisfactory
to participate in the necessary preparation.
o When the oral route is used, these agents should be administered at least 1
½ to 2 hours before the planned treatment time and on an empty stomach.
NARCOTICS:
The narcotic drugs useful for sedation in pediatric dentistry include Meperidine
(Demerol®) and Fentanyl (Sublimaze®). The modest amount of euphoria produced by
narcotics may improve the patient’s postoperative response to dental treatment.
Most narcotics are poorly absorbed in the gastrointestinal tract and are therefore
usually administered parenterally. Meperidine (Demerol®) is the exception and is
sometimes used orally in pediatric dentistry. Most often it is used in combination with
hydroxyzine or diazepam.
MEPERIDINE HYDROCHLORIDE (DEMEROL®):
Effects: Sedation, analgesia, euphoria, mood alteration and respiratory depression.
Onset of action: 15 to 30 minutes-PO, 10 to 20 minutes-IM or sub-mucosally.
Duration of action: 2 to 4 hours PO or intramuscularly.
Routes: Oral, sub mucosal, intramuscular, and intravenous.
Dose: 2 mg/Kg PO, 1.5 to 2.0 mg/ kg intramuscularly or sub-mucosally, 0.3 mg/kg
intravenously.
Side effects: Respiratory depression, orthostatic hypotension, syncope, nausea, and
vomiting, histamine release and sweating. Meperidine has proved to be the better
psychosedative agent.
FENTANYL (SUBLIMAZE):
Effects: Same as Meperidine but not as good a psychosedative. It is 400 times as
potent as Meperidine.
Onset of action: 3 to 5 minutes intramuscularly.
Duration of action: 30 minutes.
Routes: Intramuscular and intravenous.
Dose: 0.002 to 0.003 mg/kg intramuscularly, sub-mucosally, or intravenously.
Side effects: Same as Meperidine.
NARCOTIC REVERSAL:
The respiratory-depressing effects of narcotics can be reversed with Naloxone, a narcotic
antagonist.
Route of administration:
The preferred route of administration for Naloxone, as with all emergency drugs, is
the intravenous route. In the absence of intravenous access, the sublingual route has been
shown to be effective within 35 seconds or less. Sub-mucosal injections may also be used.
DRUG COMBINATIONS
The use of sedative drug combinations to accomplish diagnostic and treatment
procedures in children dates back to early 1950s. The basis for the use of drug
combinations is the need for more than one drug’s effects and the use of one drug to
counteract the undesirable effects of another.
The most popular early combination was a combination of Meperidine (Demerol®),
Promethazine (Phenergan®), and chlorpromazine (Thorazine®) and was referred to as
‘DPT’, the “Cardiac Cocktail”. Combination of Meperidine and Promethazine has become a
more acceptable combination for use in pediatric dentistry. Such combinations of a
narcotic and a Phenothiazine derivative have been referred to as ‘Neuroleptics’ and
characterize drug combinations that reduce motor activity, diminish anxiety, and produce a
state of indifference during which an individual can still respond appropriately to a verbal
command.
A combination of Fentanyl (Sublimaze) and Droperidol known as ‘Innovar®’,
produces tranquilization and some amnesia and is commonly used for sedating adults but
is not in popular use for children.
Drug combinations that are used in pediatric dentistry include the following.
Meperidine and hydroxyzine
Meperidine and diazepam
Fentanyl and diazepam
Diazepam and hydroxyzine
Midazolam and hydroxyzine
Meperidine and midazolam
Chloral hydrate and hydroxyzine
Klingberg in 2002 reported that in Scandinavia, three main pharmacological
substances are used for sedation in pediatric dentistry: Diazepam, Midazolam and Nitrous
Oxide/Oxygen.
Diazepam may be administered orally as syrup or tables, and also rectally.
Modazolam is available for dental use as liquids for either oral or rectal administration, but
midazolam is also available as tablets in several other countries. In Sweden, in relation to
sedation for dentistry, specialists in maxillo-facial surgery only are permitted to give agents
intravenously and only then after special certification. The intra-nasal route is also very
seldom used as it is considered to be painful and uncomfortable by patients, and the intra-
muscular route is simple and used at all in relation to dentistry. Nitrous oxide/ oxygen
sedation may be used, but again, only after special certification.
The child’s weight is documented if benzodiazepines are to be used and both the
child patient and parents are always informed about the treatment. In the case of
benzodiazepines, tablets are supplied by the clinic, whereas liquids for rectal or oral
administration are administered at the dental clinic by the dentist or under his or her
supervision. After treatment, the child is kept under observation at the clinic for at least
60 min after administration of the benzodiazepine.
Rectal administration is also frequently used in patients with disabilities if they are
unable to cooperate sufficiently for oral administration. It has the advantage of fast onset
and is of achieving sedation in younger children for a single treatment of a tooth. The level
of amnesia can never be predicted and should never be assumed when treatment is
carried out. Amnesia does not occur; drowsiness and reduced attention may reduce the
risk of negative learning experiences.
Among Swedish pediatric dentists, Midazolam is frequently used substance for
younger patients. Tablets containing diazepam are mainly used in school children and
adolescents. In these patients dosage is often split, with part of the dose night before
treatment and the remainder 1-2 hours before treatment.
Nitrous oxide/oxygen sedation is frequently used in children from approximately 5
years of age of as soon as the child is able to cooperate sufficiently to breathe only through
their nose and use a nasal mask.
If the patient’s need for dental treatment is large and the patient is considered too
young to understand or to cooperate, the method of choice should be treatment under
general anesthesia.
MANAGEMENT OF ADVERSE DRUG REACTIONS IN CONSCIOUS-SEDATION:
Absolute overdose is a result of the administration of large amounts of drugs that
nearly all patients may be expected to exhibit signs and symptoms indicative of an
exaggerated pharmacologic response.
Relative overdose, other hand, is more closely related to the susceptibility of the
patient to drug effects rather than to quantifiable drug doses or blood levels. Given the
right set of circumstances, any patient may experience the effects of relative overdose
even though the amount of drug administered is within an “acceptable” range. Factors
such as biologic variability, physical condition, the presence of various genetic anomalies,
pharmacokinetic or pharmacodynamic drug interactions may alter host susceptibility to
such an extent that an adverse drug reaction follows conservative drug doses.8
This variability in host susceptibility accounts for the majority of overdose
reactions. The term idiosyncrasy was often applied to many adverse reactions taking place
in patients having been administered conventional drug doses. The term was also used to
describe events for which the practitioner could offer no explanation. It is doubtful that
true idiosyncrasy is, in fact, a clinical entity.
REACTIONS TO SPECIFIC DRUGS:
A variety of pharmacologic entities are available for the relief of fear and anxiety.
Pharmacologically, they may be categorized as psychosedatives, narcotics and sedative
hypnotics. Serious adverse reactions to nitrous oxide are extremely rare and, for the most
part may be easily reversed by discontinuing its inhalation. Adverse reactions to orally or
parentally administered agents often produce events of a more serious or long-lasting
nature requiring definitive intervention.
Psychosedative-Related Adverse Reactions:
Excessive Sedation:
Sedation is characterized by deep somnolence or slow reaction time coupled with
difficult arousability. The patient is usually incapable of rational response to verbal
command and may present a degree of reflex obtundation. A state ranging from near
unconsciousness to unresponsiveness and light general anesthesia may exist.
The condition is usually produced in one of the three following ways:
1. A cookbook-type sedation technique consisting of predetermined doses of drugs
was followed resulting in absolute overdose
2. In an attempt to “cover up” for inadequate local anesthesia or to produce a state of
amnesia, excessive doses were administered intentionally
3. The host’s susceptibility to a particular drug was such that the amounts
administered resulted in relative overdose.
These are three primary dangers of excessive sedation. Partial or complete upper
airway obstruction is likely to occur and must be corrected immediately. Vomiting with
subsequent aspiration (in-halation of the gastric contents into the lungs and upper airway)
the patient sedated to near unconscious levels is in a dangerous state. Vomiting in this
instance should be managed by placing the patient in a slightly head down position to
allow gravity to assist in removal of the gastric contents. The head and upper body should
be turned toward the right side. High-volume suction should be at hand to assist in
evacuation of foreign matter.
Prevention:
Obviously the best method of prevention for this reaction is to avoid the use of
those techniques that rely on pre calculated doses based on age, weight, square meters of
body surface area, and so forth ideally, the intravenous titration method of drug
administration is preferred. However, that method cannot always be used. In those
instances in which oral or other parenteral routes must be employed, conservative doses
of drugs should prevail.
Under no circumstances should the sedative technique be “pushed” to the point of
over sedation in an attempt to render the patient free of operative dental pain, to gain
patient cooperation or to produce amnesia.
Management:
Pharmacologic reversal of psychosedatives has been postulated by the intravenous
administration of 1 mg doses of physostigmine. It may also induce bronchospasm; for this
reason, caution is urged when psychosedative-induced oversedation is treated by the
administration of physostigmine. Similarly, aminophylline in doses of 1 mg per kg has been
shown to reverse the excessive effects of diazepam. The exact mechanism of action of
these drugs has not been fully elucidated nor is the alerting effect completely predictable.
Pharmacologic management must therefore be coupled with the previously described
mechanical measures.
Postural Hypotension:
All major psychosedatives produce ganglionic as well as α-adrenergic blockade,
postural hypotension or a feeling of dizziness, lightheadedness and a tendency to
experience syncope may be exhibited upon assuming an upright position. The ability of all
psychosedatives to produce this adverse reaction is accentuated when combined with
narcotics which directly depress the vasomotor center in the medulla which by itself may
lead to the production of postural hypotension.
Prevention:
The adverse effects can be prevented by avoiding the use of major psychosedatives
and preventing the patient from sitting upright or standing suddenly. Patients should also
be cautioned against sudden positional changes for 24 hours following dismissal. As an
additional caution following intravenous sedation cases, the intravenous infusion should
be allowed to remain in place at least until the patient has assumed an upright sitting
position.
Management:
Dilation of the microcirculation caused by pharmacologic actions results in the production
of “Relative Hypovolemia” Although no blood loss has take place, the dilated vasculature is
deficient in circulating volume
This can be best managed by placing the patient in a semi recumbent position with
both the lower extremities and upper body slightly elevated. Venous return to the heart
from the head and neck, as well as the lower extremities is augmented by the force of
gravity. The result is greater cardiac output and organ perfusion which corrects the
problem.
If deemed necessary, additional fluid in the form of 5 percent dextrose in water or
dextrose in lactated Ringer’s solution may be rapidly infused to correct the relative
hypovolemia. The use of vasopressors is rarely, if ever indicated.
Central Anticholinergic Syndrome:
All major psychosedatives have the ability to block the effects of acetycholine at
both perpheral and central sites. On occasion, this action leads to the production of a
syndrome manifested by excitation, delirium, amnesia, belligerent behaviour, or stupor
and coma. The effects are more pronounced and more likely to occur with major
psychosedatives and particularly when combined with other anticholinergic agents such as
atropine or scopolamine.
Prevention:
It is prevented by confining the choice of drugs to psychosedatives of the minor
category; the psychosedative and scopolamine combination is therefore best avoided.
Management:
With conservative drug doses employed for outpatient sedation, only mild
symptoms of the syndrome are usually manifested. The first tendency is usually to confuse
the reaction with improper behaviour and to instruct the patient to control himself. The
patient may become increasingly argumentative or belligerent and require restraint.
Pharmacologic intervention will usually dramatically terminate the episode.
The cholinesterase inhibitor, physostigmine, administered intravenously in 1mg
doses, allows the accumulation of acetylcholine at CNS sites. This overturns the adverse
reaction. Caution must be exercised when administering physostigmine because it may
induce bradycardia or, rarely bronchoconstriction and a mild asthma-like condition in
susceptible individuals.
Extrapyramidal Reaction:
The reaction is manifested by uncontrolled movement of voluntary muscle groups
producing symptoms resembling Parkinson’s disease. Involuntary yawning and protrusion
of the tongue coupled with twisting and turning movements of the head, neck and
extremities are most frequently noted.
All psychosedatives are dopaminergic blocking agents; that is, they have the ability
to block the effects of dopamine within the CNS. In cases of dopamine deficiency or
blockade by psychosedatives, the inhibitory effect is lost allowing a facilitory system to act
in an unopposed manner. The facilitatory system has acetylcholine as its neurohumoral
transmitting agent.
Prevention:
Because the primary offending pharmacologic agents for the production of
extrapyramidal reactions are the major psychosedatives avoiding the use of these drugs is
the best method or preventing the reaction. When their use is specifically indicated, as for
antiemesis, the dose should be kept to a minimum as the adverse reaction occurs with
greater frequency as the dosage increases.
Management:
Best agent is benzopine (Cogentin®). This synthetic anticholinergic (atropine-like)
agent acts almost exclusively within the CNS to block the unopposed facilitory system. The
drug may be administered orally or intravenously in 1-mg doses. Intravenous
administration will rapidly terminate the reaction whereas symptoms will gradually subside
within 20 to 30 minutes following oral administration.
Other anticholinergics, such as atropine or scopolamine, may be similarly effective
in 0.2 to 0.4 mg doses. Their peripheral effects may also produce bothersome dryness of
the mouth, slight elevation of heart rate or blurred vision.
Narcotic-Related Adverse Reactions:
1. Postural Hypotension:
These drugs directly depress the vasomotor center in the medulla. Rapid
assumption of the upright position leads to the signs and symptoms of postural
hypotension.
Prevention: When narcotics are combined with psychosedatives. Best preventive
measure to be taken is to caution against rapid positional changes for the patient.
Management: Is managed as described earlier.
2. Nausea and Vomiting:
This response occurs in ambulatory patients. All narcotics have been shown to
stimulate the chemoreceptor trigger zone (CTZ) of the medulla which in turn stimulates the
vomiting center, thereby initiating the nausea and vomiting
Prevention:
When narcotics have been employed, all patients should be instructed to curtail
activities for 12 hours following administration. As major psychosedatives have the ability
to block the CTZ and thereby prevent narcotic-induced nausea and vomiting, the narcotic–
psychosedative combination is a valid one and may be used to reduce the incidence of this
problem.
Management:
Once induced, nausea and vomiting may best be managed by
Reducing bodily movement and ambulation:
Administering a narcotic antagonist, for example, Naloxone (Narcan®), in
doses of 0.2 to 0.4 mg intramuscularly or intravenously or
Administering a major psychosedative of the Phenothiazine or
Butyrophenone category. Prochlorperazine (Compazine®) in 5.0 mg dosage
or 2.5 mg of Droperidol (Inapsine®) administered intramuscularly or
intravenously.
3. Dysphoria:
Rarely produce a state of dysphoria or unplesantness characterized by restlessness
and agitation. Rather than producing a calm and euphoric state, the narcotic provokes
signs of hyperactivity, annoyance, and a feeling of uneasiness.
Prevention:
Avoiding the use of narcotics as dysphoric.
Management:
Administer a narcotic antagonist such as naloxone to terminate the episode. This
agent is given in doses of 0.2 to 0.4mg intramuscularly or intravenously. The addition of a
psychosedative such as diazepam (Valium®) in 2.5 to 10mg oral intramuscular or
intravenous doses will usually be effective.
4. Respiratory Depression:
Narcotic – induced respiratory depression results in the production of both hypoxia
and retention of carbon dioxide, the combination of which is termed asphyxia. Death by
asphyxia has taken place in dental offices following the injudicious administration of
narcotics.
The majority of circumstances involved the subcutaneous (mucobuccal fold)
injection of Alphaprodine (Nisentil®) to children. Alphaprodine is not a particularly
dangerous drug. In several instances the condition was aggravated by physically
restraining a child with a “Papoose board”, a procedure that itself may produce respiratory
embarrassment because of its confining nature.
Prevention:
This may be accomplished carefully selecting the drug, dose, and route of
administration based on the requirements of each and every patient.
When possible, intravenous route of administration selected for patient
management and relief of intraoperative anxiety. A small increment of prediluted narcotic
is titrated to the desired effect. Patient is carefully observed for signs of “relative overdose,
inappropriate or no response to verbal command, snoring, should show respiration with or
without a decrease in respiratory rate paradoxical respiratory movement, apnea, and
inability of the operator to hear or feel air movement.
Cyanosis, or a blue colour to the mucosa, nail beds and skin, is a late manifestation
of respiratory distress due to narcotic effects and should play no part in the recognition or
prevention of this adverse reaction.
Management:
In cases involving partial or complete obstruction of the upper airway (with or
without ventilatory inadequacy) mechanical measures must be the first and immediate
steps taken to safeguard the life and welfare of the patient. Pharmacologic assistance in
the form of narcotic reversal should only come after respiration is being adequately
supported by mechanical measures (maximal back ward tilt of the head and artificial
ventilation of the lungs).
Patient suffering from severe respiratory depression must have his or her lungs
artificially inflated by forcing air or oxygen into the pulmonary system. Placing an oxygen
mask over the face of an apnoeic patient or one exhibiting paradoxical respiratory
movement is totally worthless. After mechanical means, naloxone (Narcan) is administered
in doses of 0.2 to 0.4 mgs intramuscularly or intravenously. Mechanical support must
continue until pharmacologic reversal is accomplished.
Chest Wall Rigidity:
It is a condition in which the chest wall assumes “lead pipe” rigidity. It is most
frequently seen following high doses of Fentanyl (Sublimaze®). In these instances the
patient was unable to communicate the problem because the rigid chest wall not only
prevented respiration but vocalization as well.
Prevention:
Completed avoidance of the administration on parenteral narcotics is the only
method of completely preventing this misadventure.
Management:
Chest wall rigidity may occur in the alert as well as the unresponsive patient.
Patency of the airway must be assured as the first step. The alert patient may not be able
to breathe when instructed to do so and the operator will be unable to inflate the lungs
with the application of positive pressure ventilation. The immediate administration of 0.2
to 0.4 mg of Naloxone via the intravenous route quickly reverses the reaction.
SEDATIVE HYPNOTICS:
All drugs in this category are generalized depressants capable of depressing all
tissues functions of the body. If given in progressively larger doses, these drugs produce
sedation and relief, of situational anxiety, excitement or disinhibition, hypnosis, general
anesthesia, medullary depression, and death.
Most psycho sedatives are incapable of producing general anaesthesia (except in
extremely large doses). Patients administered psycho sedatives can usually be aroused
even following large doses.
There are two categories, barbiturates and non-barbiturate hypnotics. Barbiturates
administered through the oral, rectal, intramuscular or intravenous whereas non-
barbiturate hypnotics are confine to application.
Sedative-Hypnotic-Related Adverse Reactions:
At present, no pharmacologic antagonists for sedative-hypnotics are clinically
available. Practitioners should choose agents having short durations.
Paradoxical Excitement:
Under certain predictable circumstances, sedative–hypnotics will produce
excitation and agitation rather than sedation. This is because most drugs in this category
have been shown to possession depress the cortical control over lower centres.
Prevention:
Sedative-hypnotics should not be administered or prescribed to patients
experiencing or about to experience pain.
Sedative-hypnotics should never be used to alleviate pain in the conscious patient.
Whenever Sedative-hypnotics are used, intra-operative pain should be controlled
using adequate Local Anesthesia.
Asthma:
Barbiturates and many non-barbiturate hypnotics are para-sympathomimetic
agents. They block the actions of the sympathetic nervous system, thereby allowing the
parasympathetic division of the autonomic nervous system to predominate. As a result,
these drugs may provoke asthma-like symptoms in patients known to have asthma
manifested by prolonged expiratory wheezing and difficult exhalation.
Prevention:
Avoiding the use of barbiturates in susceptible individuals (those with a history of
asthma) is the best means of prevention. Preoperative or intra-operative administration of
mild sedatives to anxious patients having a history of asthma helps prevent attacks.
Management:
Asthmatic patients often carry various bronchodilators packaged in aerosol
inhalers and should be allowed to treat themselves. If an unexpected asthmatic attack
occurs, aerosols that contain isoproterenol or epinephrine cause instantaneous relaxation
of bronchiole smooth muscle. Attacks that are resistant to the inhalants may be managed
by intravenous or intramuscular administration of 0.3 to 0.5 ml of 1:1000 Epinephrine,
alternative 250 to 500 mg of aminophylline.
Acute Intermittent Porphyria:
Porphyria is an autosomal dominant disorder of porphyrin metabolism
characterized by intermittent abdominal and neurologic manifestations. Symptoms usually
appear at puberty or include nausea, vomiting, and colic abdominal pain. Variable
neurologic findings such as paresthesias, neuritic pain, and psychoses may also be noted.
Prevention:
Avoiding the administration of Barbiturates to patients with a positive history of
the condition helps prevent an acute episode.
Management:
Symptomatic treatment is important in the management of abdominal and neurologic
manifestations. Mild abdominal symptoms can be controlled with antiemetics such as
Promethazine (Phynergan®) in 25 to 50-mg doses. Mild analgesics such as aspirin or
propoxyphene may be used to control mild extremity pain. Meperidine (Demerol®) in 50-
mg doses is effective for severe pain. The acute attack must be terminated as quickly as
possible to prevent lasting neuronal damage. For this reasons, definitive care and
hospitalization are recommended.
ANTICHOLINERGICS:
The primary use of the anticholinergic agents in dentistry is as antisialagogues.
These agents may produce tachycardia, dry mouth, and blurred vision. Adverse reactions
to these drugs may occur but are extremely infrequent and rarely of a serious nature.
Atopine, scoplamine, and glycopyrrolate (Robinul®) are the only anticholinergics currently
used in dentistry.
Anticholinergic-Related Adverse Reactions:
Atropine Flush:
Because of its ability to produce vasodilation of the microcirculation of the “blush” aread-
the head, neck and upper chest- atropine frequently produces a red, rash-like appearance
in this area. It is not accompanied by itching or a palpable change in skin texture.
Prevention: Avoiding the use of atropine.
Management: No treatment is required for atropine flush.
Central Anticholinergic Syndrome:
It is classically produced by scopolamine, occasionally following atropine. It is
unreported following glycopyrrolate as this compound does not cross the blood brain
barreir. The appearance of this syndrome is enhance when either atropine or scopolamine
are administered in conjunction agents that are also likely to produce such as
psychosedatives or tricyclic antidepressants.
Prevention:
It is best prevented by avoiding the use of scopolamine or at least by restricting its dose to
a minimum. When an anticholinergic is employed for its ability to dry the oral cavity,
atropine or glycopyrrolate are the agents of choice.
Management: Management of this adverse reaction is the same as described for the
psychosedatives.
DRUG DOSAGE:
The following points should be considered when determining the dosage of a sedative drug
for a child patient.
1. Age of the child: The younger the child, the less medication is required. The younger
child may also exhibit a more atypical response to drug therapy. It should be kept in
mind that allergencity is greatest during child hood.
2. Weight of the child: The heavier child will require greater medication.
3. Mental attitude of the child: A nervous, excitable or defiant child will usually require
greater medication.
4. Physical activity of the child: A child who appears to be hyperactive and hypersensitive
must be considered a candidate for increased drug dosage. because children have a
higher basal metabolic rate, their dosage in proportion to body weight must be greater
than in adults.
5. Contents of the stomach: The presence of food in the stomach can greatly alter drug
adsorption from the gastrointestinal tract following oral administration. To reduce
nausea, the child should not take anything by mouth for 3 to 4 hours before the
appointment when the use of sedation anticipated.
6. Time of day: In general, a large dosage will be necessary at times other than normal
rest periods. A young child patient, for instance, requires a greater amount during
morning hours.
7. Dosage formulas: A therapeutic dose can cause unforeseeable problems in all age
groups, especially in the very young or very old. The metric system is convenient in
calculating drug dosages. Some investigators mentioned the following rules in
calculating children’s dosages.
Young’s rule: Age of the child (years) x adult dose = child dose Age of child+12
Cowling’s rule: Age of child next birth day x adult dose = child dose 24
Clark’s rule: Weight of child (Kgs) x adult dose = child dose 150
Freeman and Carson in 2003 had done a study to examine attitudes and intentions
of general practioners’ who work with in the remit of the National Health Service to
provide relative analgesia for pediatric extractions. They suggest that Government Dental
Practitioners concerns of clinical competence and costs have an inhibiting effect upon their
intention to provide regional analgesia for pediatric extractions. These concerns must be
addressed by planners and policy makers if there is to be a shift from hospital based dental
general anesthesia to surgery based pediatric extractions.
GENERAL ANAESTHESIA: Office-based deep sedation/ dental sedation / Pediatric
sedation
It is a controlled state of unconsciousness accompanied by a loss of protective
reflexes, including the ability to maintain an airway independently and respond
purposefully to physical stimulation or verbal command.
Hospitalization and the use of general anaesthesia are sometimes required to deal
effectively with the extreme management problem. It should be emphasized that it is
required only infrequently and should not be used as a substitute for good office
management techniques. Before a decision is made to hospitalize a child and perform
treatment under general anaesthesia, an attempt is made to provide the required dental
care in the office environment.
Restraint of child and premedication is more desirable, providing an acceptable
standard of care.
Indications:
Children with mental retardation to the degree that the dentist cannot
communicate effectively.
Children in whom adequate co-operation cannot be achieved by the usual
behavioural guidance procedures, analgesia, premedication and physical
restraints.
Children with systemic disturbances and congenital anomalies
Children who have sustained extensive orofacial and dental trauma
Children in whom local anesthesia is ineffective because of acute infection,
anatomic variation or allergy.
Children in need of extensive dental care with a high failure rate for dental
appointment.
Arch L. M, Humphris G. M, and Lee G. T. R compared the Dental anxiety levels
experienced by children having dental extractions using general anaesthesia and inhalation
sedation in children aged 9-15 yrs and demonstrated lower post operative dental anxiety in
children who had chosen IHS in comparison to those who had chosen G.A. Dental anxiety
remained unchanged in children who had chosen G.A for their extractions.
ANAESTHESIA PERSONNEL IN THE ADMINISTRATION OF DEEP SEDATION:
Office-based deep sedation/general anesthesia techniques require at least 3
individuals. The anesthesia care provider’s responsibilities are to administer drugs or direct
their administration and to observe constantly the patient’s vital signs, airway patency, and
adequacy of ventilation. In addition to the anesthesia care provider and operating dentist,
staff should be present to assist the operator and support resuscitative measures, if
required. It is the obligation of treating practitioners, when employing anesthesia
personnel to administer deep sedation/general anesthesia, to verify their credentials and
experience.
1. The anesthesia care provider must be a licensed dental and/or medical practitioner with
appropriate state certification for deep sedation/general anesthesia.
2. The anesthesia care provider must have completed a 1- or 2-year dental anesthesia
residency or its equivalent, as approved by the American Dental Association (ADA),
and/or medical anesthesia residency, as approved by the American Medical Association
(AMA).
3. The anesthesia care provider must be licensed by and in compliance with the laws of the
state in which he/she practices. Laws vary from state to state and must be respected.
4. If state law permits a certified registered nurse anesthetist or anesthesia assistant to
function under the supervision of a dentist, the dentist is required to have completed
training in deep sedation/general anesthesia and be licensed or permitted, as
appropriate to state law.
The dentist and anesthesia care provider must be compliant with the AAP/AAPD’s
Guideline on Monitoring and Management of Pediatric Patients During and After Sedation
for Diagnostic and Therapeutic Procedures or other appropriate guidelines of the ADA,
AMA, and their recognized specialties. The recommendations in this document may be
exceeded at any time if the change involves improved safety and is supported by currently-
accepted practice and/or is evidence-based.
USE OF IMMOBILIZATION DEVICES:
Immobilization devices, such as papoose boards, must be applied in such a way as
to avoid airway obstruction or chest restriction. The child’s head position and respiratory
excursions should be checked frequently to ensure airway patency. If an immobilization
device is used, a hand or foot should be kept exposed, and the child should never be left
unattended. If sedating medications are administered in conjunction with an
immobilization device, monitoring must be used at a level consistent with the level of
sedation achieved.
GUIDELINES FOR OUTPATIENT GENERAL ANESTHESIA TO PROVIDE COMPREHENSIVE
DENTAL TREATMENT (GERALD. A. FERRETTI, 1984):
Following points are considered during outpatient general anesthesia
1. Patient Selection.
2. Preoperative Workup and Assessment.
3. Anaesthesia Management.
4. Operating Room Dental Facilities.
5. Surgical Management.
6. Postoperative Management
7. Discharge and Follow up Care.
A major objective of same day surgery is to provide safe ambulatory surgery experience
and satisfaction of patients and parents. For this reason care must be taken to ensure that
each procedure is performed efficiently and effectively.
1. PATIENT SELECTION:
The patient with a major medical problem such as congenital heart disease a blood
dyscrasia, or a seizure disorder is a good candidate for General Anesthesia.
The patient with sensory, physical, or mental handicapping conditions.
Patients with extensive dental needs on whom local anaesthetic is ineffective because of
acute infection, anatomic variations or allergy.
Extremely uncooperative, fearful, or anxious child or adolescent who has extensive dental
needs but has resisted all other management procedures.
Patient who has sustained significant orofacial and dental trauma.
Patient with extensive dental needs who lives in a remote area where dental care is not
available and transportation is a problem.
The young patient with a craniofacial anomaly, such as a cleft palate.
The child or adolescent in need of extensive dental care with a high failure rate for dental
appointments because of psychosocial problems or medical neglect and whose health and
welfare is new being managed by a social service agency.27
2. PRE-OPERATIVE WORK UP AND ASSESSMENT:
Thorough medical, social and familial history is obtained and a review of systems is
made. As assessment of the patient’s oral condition is made in order to plan for the
amount of operating room time, equipment, and materials needed to do comprehensive
dental treatment.
Arrangements are made for the patient to be cleared by his physician for general
anesthesia within 72 hours of the day of surgery. Explanatory letter containing professional
requests is sent to the physician, a letter with preoperative instructions is sent to the
parent. (72 hours before treatment), the young child or adolescent should have the
following laboratory and diagnostic work up.
1. Complete blood count (CBC) with differential.
2. Electrolyte screening sodium, chloride, glucose, potassium, carbon dioxide, blood
urea nitrogen (BUN).
3. A blood disorder screening (if necessary).
4. Prothombin time (PT)
5. Partial thromboplastin time (PTT)
6. Platelect count.
7. P.A. and lateral chest films (within one month before surgery.
8. Routine urinalysis (UR).
3. PRE-ANESTHESIA EVALUATION AND CONSENT:
On the day of surgery the patient and responsible party are requested to arrive in
ample time to have a pre-operative evaluation by an anaesthesiologist and operating
surgeon. A final evaluation by the dental team and an explanation of the surgery are made
and the consent forms are completed and signed. Final chart write-up includes the
following basic components.
The final patient evaluation is conducted with special attention paid to the following:
1. The history and a review of systems completed and signed.
2. Laboratory and other diagnostic work completed, Interpreted, and found
not to contraindicate surgery.
3. A physical examination (within 72 hours) by a physician with clearance for
general anaesthesia.
4. An anaesthetic evaluation and clearance.
5. Nothing by mouth for the required time period.
6. A consent form reviewed and signed after explanation of possible
complications such as bleeding, infection, pain, swelling of the tongue, lips
and face and anaesthetic risks.
7. A day of surgery update of the patient’s physical status and written
clearance for surgery by the responsible member of the dental team.27
4. ANESTHESIA MANAGEMENT:
The choice of premedication and general anesthetic technique to be used is
determined by the anesthesiologist. Most of our outpatient surgery patients do not
receive premedication. Allowed to stay in the waiting room with their parents because
being with the parents helps to reduce the child’s stress and in a sense eliminates the need
for pre-operative sedation.
At the time of surgery a parent is allowed to escort the child into the minor
corridor. This assures the child that someone will be there when the treatment is finished.
Consult with the anesthesiologist about the placement of a nasotracheal tube. This type of
tube does not interfere with working space in the month and requires less airway
manipulation and reduces the chance of laryngeal oedema. Also treatment is completed
sooner.
Pre-operative administration of an anti-sialagogue, such as atropine, that helps
reduces salivary flow and prevents aspiration of oral secretions. Administered
intramuscularly I hour before or intravenously just before anesthetic induction. It is
important to let the anesthesiologist know what equipment you will use and the
procedures you will do so that the risk of fire or explosion of flammable agents can be
eliminated.
The anesthesiologist uses a general anesthetic or combinations of general
anesthetics that provide rapid postoperative recovery. After mask induction in intravenous
line is started and maintained throughout the operative and post-operative fasting and
prolonged general anesthesia. It also provides an open channel in which more anesthetic
or emergency drugs can be administered quickly should a crisis occur.
A common course of outpatient anesthetic management with apparently very few
postoperative side effects is the following:
Because most patients are not premedicated with narcotic, it is not a good idea to
give them an anesthetic from which they rapidly awake because they are going to be in
pain during the post-operative period and will have greater anxiety during the first part of
the recovery period. There are chances of nausea and vomiting as well. For this reason
Sublimaze acts as a good post-operative analgesic and is thought to provide a smooth
emergence from anesthesia into the recovery period without greatly increasing the
recovery time.
5. DENTAL EQUIPMENT AND FACILITIES:
The circulating operating room staff and the operating room dental assistant should
be well trained in setting up the needed dental equipment, instruments and supplies. They
are informed about the treatment to be performed as accurately as possible.
The major dental equipment and a cabinet containing the basic instrument
cassettes and materials are stored in the operating room area. All instruments are colour
coded and sterilized in individual cassettes and labelled by procedure. Before the patient
is brought to the operating room the appropriate equipment and instruments are made
ready for use.
6. SURGICAL MANAGEMENT:
After induction, intubation and stabilization of the endotracheal tube the dentist is
ready to begin treatment. Perform a surgical hand scrub, and wear surgical gloves, mask,
and cap.
Depending on the desire of the operator, the size of the operating room and the
equipment available, sit-down or stand-up dentistry can be performed. It is most efficient
if there is a dentist, first assistant and second assistant available.
Diagnostic radiographs, when needed, are secured before the patient is drapped.
Take a full mouth series with a bisecting angle technique. A folded 4” x 4” gauze pad is
used to position the film adjacent to the teeth. While the films are being developed, the
patient is drapped and a 2-inch moist continuous gauze throat pack is inserted after the
mouth and oropharynx have been carefully examined and suctioned out. The radiographs
are ready for treatment planning before the dental prophylaxis and examination are
finished.
After treatment planning is completed all operative, endodontic, periodontic, and
surgical procedures are performed. Operative and endodontic procedures are done first
under rubber dam to minimize foreign body scatter in the oral cavity. Topical fluoride is
applied after the restorative procedures are complete. Regional anesthetics for
gingivectomics and multiple extractions to minimize bleeding, enhance general anesthesia,
and aid in postoperative pain control. When necessary, use resorbable sutures and local
hemostatic agents such as topical thrombin or oxidized cellulose packing to achieve better
post-operative control of bleeding.
It is advisable to inform the anesthesiologist before a surgical procedure especially
if a local anesthetic is not used. With outpatient anesthesia for restorative dental
treatment, the patient may be so lightly anesthetized that the surgical stimulus may cause
a change in the patient’s vital signs or actually arouse the patient. To avoid this
anesthesiologist may want to increase the general anesthetic levels of the patient for a
short time until the surgical manipulations are finished.
About 10 minutes before completing treatment, the anesthesiologist should be so
informed. The oral cavity is thoroughly cleansed, suctioned out, and examined to ensure
that it is free of debris. After the throat pack is carefully removed, inspect the oropharynx
and pay special attention to see that no pharyngeal bleeding occurred becaused of a
traumatic intubation. The patient is awakened, extubated, and transported to the
recovery area.
7. POST – OPERATIVE MANAGEMENT:
It is important to write comments in the postoperative orders about the vital signs,
diet, analgesic needs of the patient, and any other specific considerations. For example:
1. Check vital signs every 15 minutes until stable then every hour until the patient is
discharged.
2. Continue or discontinue intravenous fluid (name of fluid, amount and rate of
administration is noted).
3. Maintain haemostasis if necessary.
4. Medications for infection, pain, temperature and nausea.
5. Suction at bedside (extraction cases)
6. Encourage clear fluids
7. Other orders as needed
8. Discharge the patient in care of the responsible person
9. Follow up appointment in one week in the dental office.
10. Fact sheet reviewed with the responsible party by the recovery room nurse
11. Special management orders.
The patient is observed frequently until fully recovered. Orders can be added,
discontinued or amended. The most common problems have been short episodes of
nausea, vomiting, and mild discomfort. Unlikely complications are croup, haemorrhage,
unstable vital signs, laryngeal oedema, traumatic injury, aspiration, and persistent
temperature elevation.
A short operative note is placed in the patient’s chart to give a general description
of the procedures done, the anesthetic used, the names of the dentists and the condition
of the patient. During recovery the progress notes can be written in S.O.A.P. format, that
is S-subjective findings, O-objective findings, A- appraisal of the patient’s status, and P-plan
for discharge and follow-up.
A complete and comprehensive operative report is dictated. This is a precise
description of the procedures performed on the patients from the time they entered the
operating room to the time they left it. Complete this report immediately after surgery
and at the latest within 24 hours.
Talk to the parents and discuss the case with them. They are usually anxiously
awaiting information about their child. Words of reassurance are greatly appreciated.
8. DISCHARGE AND FOLLOW-UP:
Discharge depends on a rather rigid set of criteria established by the dentist and
the anesthesiologist. These criteria include being free of airway problems, stable vital
signs, no hemorrhage or pain, taking and retaining fluids, voiding, awake, alert ability to
manage the patient by the responsible adult, and home instructions reviewed.
Provided there are no complications and the discharge and follow-up orders are
properly written, the patient is discharged after clearance by the anesthesiologist. Chart is
reviewed to make sure it is in order, prescriptions are written, and a follow up
appointment is made. Patient follow-up normally includes a phone call. At the time of
discharge a fact sheet is provided for the parents and it is reviewed by the recovery room
nurse.
DISCUSSION OF OUTPATIENT SURGERY:
Although certain similarities exist in the management of the hospitalized patient
and those treated by outpatient surgery under general anesthesia, modifications of the
treatment technique by the dentist, physician, anesthesiologist, and recovery room
personnel are necessary in order to perform this newer treatment mode.
It is essential that prior arrangements are made for each patient with the family
physician or a hospital medical staff member familiar with your approach to have them
available. Provisions are also made in the unlikely event that post-operative
hospitalization is necessary.
Patient selection for ambulatory surgery is most important. Providing dental care
in this manner seems to be very well tolerated and accepted with minimal side effects by
most patients. This technique is particularly beneficial for the mentally or physically
disabled patient who can be properly cared for by a responsible party. Hospitalization of
these patients is often difficult because of the need for closer supervision, trained
personnel and special equipment.
The pre-operative exposure is designed to reduce anxiety, allow for completion of
the medical record, the anaesthesia evaluation, the surgery area preparation, and to
provide the patient and responsible adult with the opportunity to ask questions.
Some of the advantages of treating dental patients under outpatient general
anaesthesia are the tremendous economic savings to the patient the streamlining of
admitting and discharging procedural red tape, the time saved from making evening and
morning inpatient rounds, elimination of the psychological disadvantages of a three day
separation of the patient from the home environment and elimination of parental
occupational lost time that results in a financial loss.
David Martinez and Stephen Wilson had done a study to investigate post sedation
events during the first 24 hours after discharge from the treatment facility in children for
dental treatment, and concluded that opportunities for the occurrence of an adverse event
may account on the way or at home following a sedation appointment and discharge
criteria of the AAPD guidelines on elective use of minimal, moderate or deep sedation and
G.A for paediatric dental patients should be met or exceeded as a precautionary measure
to prevent adverse events once a child who has received sedative agents leaves a health
care facility.
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