While general anesthesia is the gold standard in the delivery of extensive dental treatment for young children and many individuals with special health care needs, this modality is very costly, unavailable to everyone in need and objectionable to some parents. Moreover, general anesthesia is not indicated in situations when the treatment need is not extensive or the child’s behavior does not warrant such aggressive management. Administering oral medication to children is readily acceptable to most parents; the modality is user-friendly and economical.

Although dental decay is largely preventable, and its overall prevalence has declined significantly over the past 40 years, it remains the most common chronic disease, more so than asthma, of childhood. Based on the most recent data from the National Institute of Health and Nutrition Examination Survey, about 28% of children 2-5 years old and 50% of 6-11 years old have dental decay in their primary teeth, hence surgical treatment of the carious primary dentition in young children remains routine procedures. The availability of silver diamine fluoride to retard the progress of active dental decay has allowed us to defer some surgical treatment, but not all, in our patients’ population. There remain a significant number of children with considerable dental decay, abscesses or toothache requiring invasive treatment. Indeed, toothaches are still the most common reason for children missing school.

Contemporary parenting and societal norms deem the use of physical restraint, hand-over-mouth, and at times even voice modulation, to be unacceptable techniques in managing disruptive behavior in the pediatric dental setting. Yet, as pediatric dentists, we are often expected to be able to manage these pre- and uncooperative children and deliver them quality care safely while not offending the parents in any way. Judicious use of oral anxiolytics or sedatives, along with appropriate use of conventional non-pharmacologic behavior management techniques can help to fulfill that expectation.

The choice of oral sedation regimens is very limited, and because of that, pediatric dentists are often forced to select the patient to fit the regimen instead of the other way around. And some regimens have no reversal agents. In choosing any regimen, we must first consider the safety and welfare of our patients and define our treatment goals. A thorough understanding of the pharmacodynamics, pharmacokinetics and properties of these drugs, including their limitations, side effects and interaction with other drugs are crucial. Selecting the appropriate patient; clear communication of realistic expectations to the family; a thorough pre-sedation evaluation; training of the practitioner and the team; clear and concise pre-and post-sedation instructions; appropriate physiologic monitoring before, during and after the procedure; emergency preparation and readiness; and adhering to appropriate discharge criteria are all part of the systematic approach of the guidelines established by the American Academy of Pediatrics and American Academy of Pediatric Dentistry to ensure safety and maximize the successful delivery of dental treatment using oral sedation. In addition, an in-depth understanding of sedation-related adverse events and their etiologies outside the operating room should be a pre-requisite to the use of oral sedation in a dental office.

The main goal of oral sedation is to lower anxiety such that the child can be receptive to concomitant non-pharmacologic behavior management techniques and tolerate the necessary treatment safely and comfortably. In other words, oral sedation is an adjunctive behavior modifier, and it is safest when used as such. It is not meant to substitute general anesthesia or bypass the need for conventional, non-pharmacologic behavior management. Maintaining the sedation at minimal to moderate level, being realistic about the amount of treatment per visit and abiding by the maximum recommended local anesthetic dosage based on the patient’s weight and age are key to safe sedation.

Selecting the appropriate patient is the first tenet for safety and success. Select only the healthy child of ASA 1 or 2 in physical status classification, with a visible airway and tonsils no larger than Grade 3 in Brodsky’s Score. This young and anxious child must have adequate cognitive development and language skill to allow age-appropriate verbal and non-verbal communication; even limited ability to understand the concept of teamwork and that his cooperation and help is needed to succeed can go a long way. In children with other co-existing behavioral or learning problems, such as attention deficit hyperactivity disorder, sensory processing disorder, or speech delay, oral sedation can be effective, too. However, children who are very young, anxious or defiant, or unable to cooperate or communicate at an adequate level, or with personalities that are slow to adapt or become upset easily are not good candidates for oral sedation. These children most likely require general anesthesia. Certainly, there are other parenteral modalities, such as IM, IN, IV and SC, but it is well documented that practitioners mostly practice the modalities they learn in their training.

In obtaining informed consent from the parent, apart from informing them the customary risks and benefits and alternatives to no treatment, they need to have realistic expectations, which include that their child may cry, our different ways of communicating with their child and accepting their role as silent observers during treatment.

While matching the appropriate patient to one our limited regimens, nitrous oxide at 25-50% is almost always used to titrate the sedation. Our common regimens include the use of the following as single agents or in various combinations:

Vistaril (Hydroxyzine pamoate) 25mg/5ml.
Anxiolytic/sedative
Dosage: often a flat dose of 50 mg, but sometimes 2mg/kg when the weight is low
Indications: communicable 3-5-year-olds
Multiple treatment visits
Mild to moderate anxiety
Strong gag reflex
Level of sedation: minimal to moderate
Frequency: high

Halcion (Triazolam) 0.125mg tablet
Anxiolytic/sedative
Dosage: 0.125 mg and sometimes increase by 0.0625 mg increment but no more than 0.375 mg for large teenagers
Indications: similar to Vistaril but at least 6 years old. Often used in teenagers for orthodontic extraction.
Level of sedation: minimal to moderate
Frequency: high

Versed (Midazolam) 2mg/ml
Anxiolytic/sedative
Dosage: 0.3-0.7mg/kg, not to exceed 20 mg
Indications: it is usually used as a co-medication in children with moderate anxiety. It is seldom used as a single agent except for a very short emergent invasive procedure.
Level of sedation: minimal to moderate
Frequency: low as a single agent, moderate as a co-medication

Demerol (Meperidine) 50 mg/5ml
Sedative with minimal analgesia
Dosage: 2mg/kg
Indications: communicative 3-5-year-olds with moderate anxiety. Never as a single agent, often as a co-medication with Vistaril, and sometimes with Vistaril and midazolam.
Level of sedation: minimal to moderate. Rarely deep.
Frequency: low to moderate

Chloral hydrate: 100mg/ml
Sedative/hypnotic
Dosage: 25-50mg/kg, not to exceed 1g
Indication: communicative but somewhat defiant and stubborn 3-5 year olds with moderate apprehension. Used in combination with Vistaril and occasionally with Demerol too.
Level of sedation: moderate
Frequency: low

Below are some examples of how we attempt to match patients to our limited choice of regimens:

The judicious use of oral sedation according to the parameters discussed will not only ensure safety but also improve comfort and the overall care and customer service while delivering invasive treatment. So long as dental decay continues to affect children, this armamentarium in modifying their behavior for the indicated treatment will remain relevant to the practice of pediatric dentistry in the foreseeable future.

References:

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Chicka M, et al. Adverse events during pediatric dental anesthesia and sedation: A review of closed malpractice insurance claims. Pediatr Dent 2012;34:231-238

Cote C, et al. Guidelines for monitoring and management of pediatric patients before, during and after sedation for diagnostic and therapeutic procedures: updated 2016. Pediatr Dent 2016:38(4):E13-E39

Cote, C, et al. Adverse Sedation events in Pediatrics: A critical incident analysis
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Cravero JP, et al. Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the operating room: Report from the Pediatric Sedation Research Consortium. Pediatr 2006;118:1087-1096

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Ritwik P, et al. Post-sedation events in children sedated for dental care. Anesth Prog 2013;60:54-59