Sunday, May 8, 2011

Sedation in pediatric dentistry

Sedation may be indicated for children who have a level of anxiety that prevents good coping skills, those who are very young and do not understand how to cope in a cooperative fashion, or those requiring extensive dental treatment. Sedation can also be helpful for some patients who have special needs.

Most kids do quite well without any kind of extra medication to accomplish treatment. However, sometimes medications are needed to help kids to be comfortable and cooperate to accomplish extensive treatment. After training and a lot of experience, dentists use this valuable method of providing treatment nearly every day and am confident in the use of medications to relieve discomfort, reduce anxiety and provide a safe environment through concious sedation.

There are just a few medications used for Conscious Sedation in Pediatric Dentistry. That means the patient is awake and responsive but sedated. However, if administered improperly any of these drugs can put the patient into a deeper sedative state than is desired. In fact, due to the "Bell Curve" effect, even if done properly you can have a more profound a sedation than desired. This is not just a little valium given at home (which can help), but if we need a more profound sedation, something else may be needed. In addition, the Bell Curve (and experience) tells us that the same dosage that works well for one child may be like giving a drink of water to the next. It doesn't phase them at all. In fact, that is a more common result than you would think.

Basically, what you are trying to accomplish with sedative medications is a more cooperative patient with less movement so you can get the treatment completed, reduce any anxiety, and provide pain relief and comfort. Now it doesn't always work the way you hope, but you do try and find the best combination of medications tailored to each patient's needs.

Most of the time these are administered orally. Now,  they are more predictable IV, but if you could get an IV started in an extremely uncoperative child, then you could do the work without the drug. In addition, liability insurance rates and certain state regulations make it somewhat impractical to use these parenterally (IV or IM). So most of us are stuck with the oral route. There are some who do IV, but they usually employ an anesthesiologist to come to the office. If you do that you might as well go to the Hospital. In fact, if there is so much work that it will require several sedative appointments, then the option of general anesthesia is usually discussed. The drugs are usually liquids of course, as kids can't take pills well. It is important to dispense the medications accurately. If you use this syringe from Baxa, it works quite well. It can be difficult to administer the meds because, again the child is uncooperative almost by definition.

Baxa Syringe:
Once you get it down you have to wait a while (about an hour for most meds) to get a clinical effect, then it only lasts for a while. These drugs are often used in combination with each other so you get the complimentary benefits of each drug without getting too high a dose of any one drug. You have to be aware of the additive effect of combining drugs. Beleive me if there were a better way, it would be used in a second. Safety is of the upmost importance. Of course you have to monitor the patient and all procedures are done in accordance with sate law and AAPD guidelines. Which combination of medications to use is as much an art as a science.

 Pediatric Dentists use most often:

Chloral Hydrate. A sedative hypnotic. Makes you sleepy. Sometimes used by physicians when doing a CAT scan or MRI. (See the blue bottle cap that fits into the syring above).
Meperidine, brand name DEMEROL. A narcotic that produces sedation and releives pain;
Midazolam, brand name VERSED. This is a very useful drug which is primarily an anti-anxiety agent, produices retrograde amnesia, and is a muscle relaxant and reduces the chance of seizures. Short acting (great for short procedures);
Hydroxyzine, brand name VISTARIL or ATARAX. Hydroxyzine is a milder medication. Primarily an anti-histamine. Is often used in combination with other medications;
Other drugs include Phenergan (That's what they give the astronauts before launch to prevent space sickness), Valium, or just regular pain medicine administered before treatment. On older patients you might use Ativan. Some Pediatric Dentists have an anesthisologist come to their office and they administer general anesthesia using a variety of medications. One unique one is Ketamine, which is technically a general anesthetic with the patient all the way asleep, but they retain the ability to control their airway.


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