Use of Enteral Sedation in Pediatric Dentistry Considerations for the Use of Enteral Sedation in Pediatric

Treating an uncooperative, uncontrollable child can be unpleasant for all parties involved. Despite the den-
tist’s best efforts to employ traditional techniques, the behavioral management of challenging pediatric den-
tal patients often requires more than “tell, show, do.” Consequently, pre-operative pharmacological inter-
vention may be necessary. Enteral sedation may be the optimal adjunct for the dental treatment of such a
challenging patient population. However, it must be utilized with caution and is not an appropriate treat-
ment modality for all. This paper will present various considerations for the safe, appropriate and effective
use of enteral sedation in contemporary pediatric dentistry. With the strong demand for this service, prop-
erly trained practitioners can broaden their practice and provide a win-win scenario for themselves and
their patients.
Keywords: enteral sedation, oral sedation, anesthesia, pediatric dentistry

considerations for the safe, appropriate and effective use of In the pediatric dental practice, patients present the prac- enteral sedation in contemporary pediatric dentistry.
titioner with a wide variety of challenges that may pre-clude treatment, despite the dentist’s best efforts to The need for sedation in pediatric dentistry
employ traditional behavioral management techniques.
The practice of pediatric dentistry has certainly changed Interacting with an uncontrollable child who is screaming, over the past several decades. While dental materials and crying, and/or throwing a tantrum is unpleasant for all par- clinical techniques have made impressive progress, the pedi- ties involved. It is also unsafe, and often unsuccessful. At the atric dental population itself seems to have experienced a end of this type of appointment, the parents may be exasper- qualitative transformation. Supporting this statement was ated, the dentist and his/her staff may feel fatigued and dis- the survey of pediatric dentists that found children are less appointed, and the child may remain untreated and perhaps cooperative than in previous years. This conclusion was psychologically scarred with a poor association with the attributed to changes in parenting styles, primarily the fail- dental office. Not exactly a win-win-win situation. Since ure of parents to set limits on children’s behavior.1 While the optimizing the patient’s dental experience is the common high caries rate in children may be associated with patients goal, the behavioral management of challenging pediatric of a lower socioeconomic status,2 it seems that over the past dental patients may require more than “tell, show, do”. Thus, few decades the overall behavior of children in general has in certain circumstances, the need for pre-operative pharma- not improved significantly, and may have become even more cological intervention may be warranted. However, careful considerations must also be addressed prior to proceeding The source of the behaviorally challenging patient may be with such a treatment plan. This paper will present various one of extreme fear or apprehension, a young or emotionallychallenged child who cannot cooperate, or a patient withcognitive impairment who is unable to cooperate. So howdoes one proceed with such challenges? Initially, the mostconservative behavioral approach should be attempted.
* Jeffrey S. Yasny, DDS, FADSA Assistant Professor, Departments of However, some patients may have experienced multiple den- Dentistry and Anesthesiology, The Mount Sinai School of Medicine tal visits that employed conventional behavioral techniques ** Ali Asgari, Practicing Pediatric Dentistry in New York City unsuccessfully, without achieving any treatment. While not Send all correspondence to: Jeffrey S. Yasny, Assistant Professor, Mount every child is a candidate for sedation, it should be noted Sinai School of Medicine, Department of Anesthesiology, One Gustave L.
that not every child will respond to “tell, show, do” either. Levy Place, Box 1010, New York, New York 10029-6574 Without pharmacological intervention, the patient may be at risk for psychological and/or physical trauma. For the den- tist, attempting to treat an otherwise uncooperative child canresult in a difficult, stressful, and dangerous task.4 Moreover, The Journal of Clinical Pediatric Dentistry Use of Enteral Sedation in Pediatric Dentistry if the practitioner plans to use invasive rotary instrumenta- in the dental office for enteral sedation should belong to tion for a patient who may become wildly combative, it may either one of the following two classifications: A healthy inevitably place the child in harm’s way.5 Passive restraint patient without systemic disease (A.S.A. I), or a patient with may also prove to be insufficient for some of these patients.
mild systemic disease (A.S.A. II).11 In addition, the patient Sedating the patient may be the only effective means of should be evaluated for their ability and willingness to coop- treating them.6 Therefore, it may be necessary to consider an erate. For example, a mentally or physically handicapped adjunctive form of treatment (i.e. enteral sedation), upon child who is incapable of undergoing the dental procedure weighing the associated risks and benefits. without the use of sedation must be evaluated thoroughly.12The psychological and physical age of the child and whether Advantages and disadvantages of enteral sedation
or not they coincide, must also be determined in order Common routes of administration for sedation in dentistry to estimate the potential for successful acceptance of the have been defined as enteral (i.e. oral, sublingual, rectal) in which the agent is absorbed through the gastrointestinal (GI)tract or oral mucosa; or parenteral routes (i.e. intranasally, Importance of airway assessment and management
intramuscularly, intravenously, submucosally, subcuta- The patient’s airway must be meticulously assessed. For the neously), whereby the drug bypasses the GI tract.7 practitioner involved with the sedation, airway management There are several significant advantages of utilizing is vital. Patients should be able to maintain their own patent enteral sedation as an adjunct to dental treatment for a fear- airway and their normal physiological reflexes should be ful or uncooperative patient. The lack of needles can dimin- intact if enteral sedation is the desired method of sedation.
ish a patient’s fear; it is generally accepted by patients; easy An examination of the patient may reveal enlarged tonsils to administer; and the cost of medications is minimal to the which can compromise the airway during a sedation.14 Addi- practitioner. Also, there is a decreased incidence and sever- tional anatomic considerations such as macroglossia, ity of adverse and allergic reactions to medications when micrognathia, limitations of mouth opening or neck mobility administered orally. Enteral sedation may also serve as an which could potentially compromise the airway must be effective “middle ground” therapy between the traditional addressed prior to the sedation. For example, patients with non-pharmacological approach and general anesthesia.
micrognathia may have an associated syndrome such as However, sedation is not without risk. If not administered Pierre-Robin’s, Treacher-Collins, Goldenhar’s, Cornelia de carefully, by properly trained professionals, it has the poten- Lange, or mucopolysaccharidosis that likely negates this tial for serious or dire consequences including an unexpect- type of treatment.15 Furthermore, patients with obstructive edly deep sedation, respiratory depression, cardiac arrest sleep apnea (O.S.A.) are generally not good candidates for this therapy. It was found that the perioperative risk to Consequently, the disadvantages of this treatment modal- patients increases in proportion to the severity of sleep ity must also be examined. The success of enteral sedation is initially dependent on the patient’s ability or willingness to If an upper respiratory tract infection (URI) is suspected take the medication (i.e. compliance), which may not be pos- preoperatively, the practitioner is faced with an interesting sible in severely phobic or behaviorally challenging individ- dilemma. One must thoroughly assess the risk/benefit ratio uals. Compared with intravenous administration, the onset of prior to proceeding with the sedation. In the past, there was action is slow (i.e. the latent period is relatively long), usu- a blanket cancellation of surgery for the child with a URI; ally 30-60 minutes. Moreover, there is a lack of control over however, more recent literature supports the cancellation on the drug’s action. Once administered to the patient, the prac- a more selective, case-by-case basis.17 A national survey of titioner does not have the ability to titrate to effect (i.e.
anesthesiologists found that younger practitioners with less lighten or deepen the level of sedation). The results are less than 10 years of experience are less likely to cancel a proce- predictable due to a first pass effect and a variable absorp- dure due to a patient’s URI than their more experienced col- tion from the gastrointestinal tract. Furthermore, the pro- leagues.18 Emotional and economic burdens may also be longed duration of action can also affect optimal recovery placed on the parents due to a cancellation.19 In addition, it is common for children to experience six to eight URIs peryear, and young children attending day care or nursery Patient assessment as a candidate for sedation
school may demonstrate an even higher frequency annually.20 Minimizing the potential morbidity involved with sedation As a result, it may be difficult to precisely find a convenient, requires several considerations prior to the sedation appoint- symptom-free time for an elective procedure such as dental ment. Of paramount importance is appropriate patient selec- tion. Not everyone is an acceptable candidate for this treat- The patient should be evaluated for signs and symptoms ment. Prior to the sedation a complete history and physical of an URI including the following: fever, dyspnea, produc- should be performed; ideally by the patient’s pediatrician. A tive cough, sputum production, nasal congestion, wheezing review of the patient’s past medical and surgical histories, and lethargy.21 Nasal congestion, sputum production, and a current medications and any known drug allergies should history of reactive airway disease have been identified as also be documented. The physical status of patients treated predictors of adverse respiratory events.22,23 Moreover, it has The Journal of Clinical Pediatric Dentistry Use of Enteral Sedation in Pediatric Dentistry been found that airway hyperreactivity persists for several the drug type used (i.e. opiod versus benzodiazepine) may weeks following an URI.24,25 Therefore, when deciding not have been ideal for that individual.
whether to proceed or not, one may consider the followingsuggestions: any child with severe symptoms such as a pro- Different sedative agents
ductive cough, fever of >38ºC, mucopurulent secretions, Several sedative-hypnotic agents have been utilized effec- nasal congestion and lethargy should have their procedure tively for sedating children in the dental setting. This paper postponed for at least 4 weeks. Children who present with an will discuss certain drugs of various classifications includ- uncomplicated URI (i.e. clear secretions, afebrile), and are ing benzodiazepines, antihistamines, opiods, and non-barbi- otherwise healthy, should be able to undergo the procedure.26 tuates. All of these agents can be used alone, or in concertwith other sedative agents to potentiate the effects of the Preoperative guidelines for sedation
mixture and achieve a deeper level of sedation. It is essential Preoperative instructions should be made clear to the par- that any dental practitioner who opts to utilize these medica- ent(s) or legal guardian. Patients are not to have any food or tions, thoroughly understands the clinical pharmacology of drink for several hours prior to the sedation.27 Refraining these drugs, and possesses the ability to initiate appropriate from the ingestion of food and liquid for hours prior to the resuscitation during an untoward event.
sedation has been shown to minimize the risk of nausea,vomiting and aspiration of gastric contents.28 Currently, the Benzodiazepines- Pharmacology and physiology
following intake restrictions are recommended: Clear liquids Currently, benzodiazepines are the class of drugs most fre- (i.e. apple juice, tea, water) for at least 2-3 hours. Breast quently used as an oral sedative in the dental practice.
milk should not be ingested for at least 4 hours prior to the Gamma-aminobutyric acid (GABA) is the major inhibitory procedure. Liquids such as milk and any juice containing neurotransmitter in the central nervous system, and binds to pulp are considered to be “not clear” and are classified as its receptor within the protein complex of a neuronal cell solids.29 Milk and solids should be restricted from intake for membrane. Benzodiazepines attach selectively to their at least 6 hours for a child less than 3 years of age, and at receptor sites located on the alpha sub-units of GABA recep- least 8 hours for children greater than 3 years of age.30 tors within this GABA-Chloride ionophore complex, and Medications taken routinely in the morning by the patient facilitate the inhibitory actions of GABA.31 Benzodiazepines should not be ignored and taken with small sips of water.
do not open chloride channels themselves. Rather, they Insulin or oral hypoglycemics should be avoided on the enhance the chloride channel’s response to GABA. The morning of a procedure involving sedation, in accordance binding of GABA by agonist benzodiazepines causes a con- with the fasting regimen and altered glucose levels. The formational change in the receptor site that opens chloride patient should wear loose, comfortable clothing, remove any channels. Consequently, the increased influx of chloride ions jewelry or optical aids, and visit the restroom prior to the hyperpolarizes cell membranes, making them more resistant procedure. Prior to proceeding with the procedure, expecta- to excitation and less likely to transmit an action potential.32 tions of the sedation should be clarified to the patient’s par- GABA receptors are anatomically distributed almost entirely ent(s) or legal guardian. It should be clearly established that within the central nervous system (C.N.S.), resulting in this adjunct to traditional therapy may not be successful. If effects on the C.N.S. primarily. Primary therapeutic effects the dental treatment cannot be safely performed utilizing of benzodiazepines include sedation, anxiolysis, and antero- enteral sedation, it may be postponed until another day using grade amnesia – all beneficial for the treatment of the fear- another dose or sedation agent. Alternatively, another thera- ful pediatric dental patient. These drugs possess muscle peutic mode may be required (i.e. general anesthesia). Thus, relaxant and anti-convulsant properties as well. Overall, ben- the potential for an additional appointment should be dis- zodiazepines demonstrate a wide margin of safety and a cussed ahead of the sedation in order to eliminate any wide therapeutic index which represents the dosage differ- heightened or false expectations. Finally, the practitioner ence between an effective dose and a lethal dose. Its onset should document the major components of the pre-operative and duration of action are relatively short when compared with other orally administered sedatives. Minimal adverse An unsuccessful enteral sedation may be due to any of the reactions are associated with these drugs, and a reversible following reasons: a patient may not be entirely compliant, ingesting only a portion of the intended dose and limiting its Although generally safe, some undesirable effects can effectiveness; severe patient anxiety can overwhelm the occur with benzodiazepines. Particularly significant clini- drug’s action; since drug absorption through the GI tract is cally is that benzodiazepines administered alone can cause erratic, the desired effect of the medication(s) may be com- respiratory depression, an effect that is amplified when promised; the timing of the drug to achieve peak blood lev- given in combination with opioids.33 Moreover, this syner- els may not coincide with the timing of the procedure; the gistic effect causing significant respiratory depression can response to medications by the patient population is a bell also occur when benzodiazepines are administered in the shaped curve whereby dosages and the desired effects do not presence of other CNS depressants such as a patient’s own apply universally to all patients, evident in some patients medications. Untoward physiological effects may include who may be classified as hypo or hyper responders. Finally, nausea, vomiting and/or unsteady movements (ataxia). This The Journal of Clinical Pediatric Dentistry Use of Enteral Sedation in Pediatric Dentistry latter condition can manifest as a loss of head control, lead- lam by 56% and increase its bioavailability by 35%, leading ing to a compromise of the patient’s airway. Other undesir- to excessive levels of sedation for the pediatric patient.44 able responses may include a paradoxical or angry response, Conversely, carbamazepine, an anti-seizure medication, whereby the patient appears irritable, agitated and/or com- induces the CYP3A pathway, decreasing the plasma concen- bative.34,35 Benzodiazepines should be avoided in patients tration of midazolam and reducing its effectiveness.45 with acute narrow angle glaucoma, and are contraindicatedfor patients with a known allergy or hypersensitivity to them Diazepam (Valium®)- Pharmacology and
Diazepam (Valium®) is the prototypical benzodiazepine,
Midazolam (Versed®)- Pharmacology and
having been widely used by adult patients for decades.
Reversibly binding to GABA receptors, its effects on a Midazolam (Versed®) is a widely used, short-acting, benzo- patient’s central nervous system are similar to that of mida- diazepine with minimal side effects. It can be administered zolam. It is 2-4 times less potent than midazolam, and is typ- orally, intranasally, intramuscularly, or intravenously. Like ically administered orally for sedation purposes in doses of most drugs, its onset of action varies greatly depending upon 0.2 – 0.3 mg/kg, with a maximal dose of 10 mg.46 Its onset its route of administration. Intravenous administration will of action (30-60 minutes) is longer than midazolam, and has result in the most rapid onset of action due to its immediate a prolonged duration and recovery. The half-life of diazepam deposit into a patient’s circulation. However, when adminis- is 20-96 hours, compared with the 2-4 hour half-life of mida- tered orally, the drug is exposed to metabolic clearance zolam. Unlike midazolam which produces no active metabo- mechanisms in the intestine and liver, and will take longer to lites, diazepam produces two principal active metabolites produce its pharmacological effects pending its eventual during its metabolism in the liver; desmethyldiazepam and deposit into the circulatory system and action at receptors.
oxazepam, which may accumulate and potentially prolong For pediatric dental patients, it is commonly administered the duration of action.47 This can result in an undesirable orally, in doses of 0.25 – 0.75 mg/kg, with an upper limit of sedation that includes a second sleep effect, whereby the up to 1.0 mg/kg.36 An effective dose is usually 0.5 mg/kg and patient appears to awaken, only to be resedated later by these should not exceed the maximally recommended dose of 20 mg. In obese children, the dose should be calculated basedon ideal body weight.37 When supplied as an oral formula- Benzodiazepine Antagonist: Flumazenil (Romazicon®)-
tion, the bitter taste often requires an accompanying flavor- Pharmacology
ing agent, (i.e. apple juice) for patient acceptance. In order One of the benefits of using benzodiazepines is the ability to to enhance analgesia, the sedative can be mixed with an reverse possible undesirable effects such as oversedation.
acetaminophen elixir, at a dosage of 15 mg/kg.38 The oral Flumazenil (Romazicon®) is a benzodiazepine antagonist, form of midazolam has a cherry flavored vehicle that can be acting competitively at the benzodiazepine site of the GABA mixed with children’s flavored aspirin or acetaminophen to receptor, but without altering its morphology. This reversal increase the palatability.39 Qualities that increase its appeal agent is typically administered intravenously and its onset of over similar drugs in this class, are its relatively high lipid action is usually within 1 minute. The first dose adminis- solubility which produces a short onset of 10-30 minutes, tered is 0.01 mg/kg with a maximum dose of 0.2 mg. Doses and that its short half-life does not tend to produce excessive should be administered slowly over 15-30 seconds, and may sedation or recovery times. Acting on GABA receptors, it be repeated every minute at 0.01 mg/kg for up to 5 doses or depresses the C.N.S., and has a minimal effect on the car- a maximum cumulative dose of 1.0 mg.48 The duration of diovascular system. Paradoxical responses have been action of flumazenil is about 30 minutes, less than the half- life of the benzodiazepine being reversed. Therefore, the Certain medications can potentiate or diminish the effects patient should be carefully monitored after its administration of midazolam. The major cytochrome responsible for the for any signs of resedation and hypoventilation. If such biotransformation of many sedatives is Cytochrome P450 undesirable signs occur, another dose may be required or an 3A (CYP3A).41 Concomitantly present medications such as Erythromycin and Clarithrimycin can increase the levels ofsedation up to 240% by inhibiting CYP3A. Interactions with Antihistamines- Pharmacology and physiology
azole antifungals such as ketoconazole, itraconazole, flu- (Hydroxyzine)
conazole, HIV protease inhibitors such as ritonavir, indi- In addition to providing beneficial therapy for allergic reac- navir, saquinavir, nelfinavir, can also increase sedation tions, emesis, and pruritis, antihistamines are another class effects by limiting the CYP3A biotransfomation as well.42,43 of drugs that have also been effective in the treatment of the Another factor that can increase the level of sedation is the fearful pediatric dental patient. Hydroxyzine is available in consumption of grapefruit juice. Inhibition of the CYP3A two forms, Hydroxyzine hydrochloride (Atarax®) which from grapefruit juice consumption results in a delayed contains alcohol, and Hydroxyzine pamoate (Vistaril®). It absorption and reduced first pass effect of midazolam. This has been used effectively in combination with several other has been found to increase blood plasma levels of midazo- agents to reduce the incidence of nausea and vomiting The Journal of Clinical Pediatric Dentistry Use of Enteral Sedation in Pediatric Dentistry during sedation.50 The dosage form is supplied in varying metabolites produced by opiods are inactive. However, like concentrations as an oral syrup. The antihistaminic effect is morphine, meperidine produces an active metabolite, due to cetirizine, one of its metabolites and a potent H normeperidine, which has been associated with toxicity that antagonist51 Hydroxyzine competes with histamine for H may precipitate CNS excitation, twitches, tremors or receptor sites on effector cells in the GI tract, blood vessels seizures. McKee et al found a dose-dependent increase in and respiratory tract. Hydroxyzine is administered orally at adverse outcomes with this medication.58 Contraindications a dose of 0.5-1.0 mg/kg. It is rapidly absorbed from the gas- include hypersensitivity to meperidine or any component, trointestinal tract and its clinical effects are usually noted and the use of MAO inhibitors by a patient within the past within 15 to 30 minutes after oral administration.52 Hydrox- 14 days. Similar to morphine, meperidine can cause hista- yzine’s half-life can be as low as 5 hours for small children, mine release, and should also be avoided in patients with a which is beneficial because of the diminished opportunity for a prolonged sedation. Side effects of this medication mayinclude dizziness, ataxia, hypotension and xerostomia. There Fentanyl (Sublimaze®)- Pharmacology and physiology
are no specific reversal agents for this medication.
Fentanyl (Sublimaze®), like meperidine, is a synthetic com-pound classified according to chemical structure as a Promethazine (Phenergan®)
phenylpiperidine, and is in a different chemical class than Promethazine (Phenergan®) is another anitihistamine that morphine or codeine, a consideration if a true allergy to one can be administered orally. Similar to hydroxyzine, its onset of these medications exists. Fentanyl is 100 times more of action is usually within 20 minutes. A typical oral dose is potent, and 7,000 times more lipid soluble than morphine.60 0.5 mg/kg, with a maximal dose of 25 mg.53 Undesirable Consequently, it can more readily penetrate membranes such neurologic effects such as extra-pyramidal reactions, dysto- as the blood brain barrier, and become rapidly absorbed into nia, confusion and excitation may occur. Other side effects the C.N.S. where it binds with stereospecific opiod mu such as thickening of bronchial secretions, and pharyngitis receptors at many sites to produce its effects.61 Its indications have been reported with the use of this medication. A survey include sedation and analgesia. It does not release histamine published in 1987 found it to be the third most commonly but it has the potential to produce side effects such as respi- used premedication on its own, and the most commonly used ratory depression, bradycardia, hypotension, vomiting, and combination drug (with meperidine).54 However, recently its constipation. Complications may include chest wall rigidity, use for sedation in dentistry has diminished markedly.
seizures, and facial pruritis. Of particular significance is thatit is often used in combination with benzodiapenines, syner- Opiods- Pharmacology and physiology
gistically increasing sedative properties and concomitantly Opiods, also known as narcotics, or opiates, are named for depressing respirations. This medication is routinely admin- the class of drugs that were derivatives of opium. Currently, istered intravenously. Intranasally, fentanyl is supplied as an opiod is the preferred term since these medications specifi- injection solution of 0.05 mg/ml and may be administered in cally bind opiod receptors (mu, kappa, delta) primarily in the a dose of 1-2 mcg/kg. When administered orally, its onset of brain and spinal cord, producing generalized CNS depres- action is slightly quicker than meperidine, and produces a sion. These drugs act on many systems producing a myriad shorter duration of action. Although it has been previously of effects that can include sedation, mood alteration, respi- available for oral sedation as a lollipop, this form of admin- ratory depression, bradycardia, nausea, vomiting, constipa- istration is not currently a common practice in dentistry. It tion and pain relief. Analgesia is achieved by inhibiting should not be used in patients with a hypersensitivity or afferent transmission of pain sensation in the brain and intolerance to fentanyl or any component.
spinal cord, resulting in a patient’s increased pain thresholdand tolerance. Clinically, a patient’s respiratory pattern in the Opiod antagonists: Naloxone (Narcan®)- Pharmacology
presence of opiods may manifest as a reduced rate of breath- and physiology
ing, accompanied by a greater tidal volume. With the pres- Naloxone (Narcan®) is an opioid receptor antagonist, com- ence of other CNS depressants, opiods may act synergisti- petitively displacing opiods at receptor sites. It is indicated cally to produce a more profound sedation and significantly to reverse C.N.S. and respiratory depression secondary to depress respiration. One of the hallmarks of opiod overdose opiod overdose. For the pediatric population, doses of 0.01 is miosis, or pinpoint pupils, caused by the drug’s action at mg/kg are administered intravenously and repeated every 2 the nucleus of the oculomotor nerve (C.N. III). In the early minutes until normal patient function returns. The maximal 1980s, this was the most common class of drugs used for recommended dose is 0.2 mg. It is supplied in concentra- tions of 0.4 mg/ml, so a 1ml vial should be diluted with anadditional 9 ml of normal saline to obtain a safer concentra- Meperedine (Demerol®)- Pharmacology and physiology
tion of 0.04 mg/ml. Naloxone antagonizes mu, kappa, delta Meperidine (Demerol®) is a pure mu agonist opioid that can and sigma receptors, reversing the undesirable sedative and be administered orally at a dose of 1-2 mg/kg, with a maxi- respiratory opiod effects, but also antagonizing the analgesic mum dose of 100 mg. Its onset of action is usually within effects. It will not reverse nausea and vomiting. Since the 10-15 minutes. The duration of action is 2-3 hours.57 Most duration of action of naloxone is only 10 minutes, it is The Journal of Clinical Pediatric Dentistry Use of Enteral Sedation in Pediatric Dentistry possible that the patient may experience intense pain, lead- thetic, demonstrated an increased level of sedation compared ing to a catecholamine release after receiving an initial with patients who had received 50 mg/kg of chloral dose.62 Side effects may include nausea, vomiting, tachycar- hydrate.72 Another study measured the efficacy of midazo- dia, hypertension and pulmonary edema. 63 After its adminis- lam versus diazepam when both were used in concurrence tration, the patient should be carefully monitored.
with nitrous oxide. Although both groups demonstrated aclinically acceptable level of sedation, the group receiving Chloral Hydrate (Somnote®)- Pharmacology and
the midazolam had higher levels of sedation at increased lev- physiology
els of stimulation, whereas the group that had received the Chloral Hydrate (Somnote®) is classified as a non-barbitu- diazepam was more easily aroused with less of a stimulus.73 ate, a hypnotic that has been widely used as a sedative in Chloral hydrate has been used in concert with other pediatric dentistry for decades. It may be administered orally agents utilized in pediatric dentistry with varying degrees of at a dose of 25-50 mg/kg,64 with a maximal total dose of success. It was found that children receiving a sedative cock- 1,000 mg. Its onset of action is 30-60 minutes and duration tail of chloral hydrate and hydroxyzine, compared with chil- of up to 5 hours. Its mechanism of action is unknown, yet its dren who were administered a similar mixture with an added depressant effects on the C.N.S. are primarily due to its dose of meperidine, demonstrated no significant differences active metabolite, trichloroethanol (TCE), a carcinogen in in their measured levels of compliance and sedation.74 In a mice. A major disadvantage of this medication is that of all similar study, it was demonstrated that the addition of the the orally administered sedative medications, it may have the meperidine increased the compliance and sedation levels of worst taste. Moreover, its liquid concentration is a mucosal the patients, without the added risk of increasing the respi- irritant that can cause nausea, vomiting or even laryn- ratory distress.75 In another study, a group of children that gospasm.65 Compared with other agents, other notable side received 50 mg/kg of chloral hydrate and 1 mg/kg of prome- effects include its delayed onset, prolonged recovery, possi- thazine was compared with a group that received 50 mg/kg ble cardioirregularity at higher doses, and no analgesic prop- of chloral hydrate and 1 mg/kg of meperidine. No significant erties.66 Chloral hydrate depresses genioglossus activity differences in the vital signs of the two groups were noted, causing hypotonicity of the tongue which can lead to it with all subjects being responsive throughout the proce- falling backward against oropharyngeal structures, depress- dure.76 Chloral hydrate has also been used in conjunction ing respiration and compromising the patient’s airway.67 with promethazine. In one study, two groups received differ- Moreover, it has no reversal agent.68 Although this medica- ent drug regimens. The first group received 50 mg/kg of tion was the standard of oral sedation in pediatric dentistry chloral hydrate and 1 mg/kg of promethazine. The second for many years, it has more recently fallen out of favor with group received 1 mg/kg of meperidine and 1 mg/kg of pediatric dentists and training programs.69 promethazine. The first group demonstrated better results,experiencing less crying and more sleep throughout the Review of the literature- Studies on sedation
Decades of research have confirmed the safe and effective The mixture of various sedative agents in order to obtain means of sedating an otherwise uncooperative child prior to a higher degree of sedation, achieve a longer and more effec- performing dental procedures. Numerous studies both tive treatment time, while producing less patient agitation prospective and retrospective have demonstrated the safety has been examined. In order to determine the efficacy of and efficacy of enteral sedation in dentistry. Several studies diazepam as a sedation agent, Houpt et al compared one have also shown the effectiveness of the various sedation group of children who received 0.5 mg/kg of this drug alone, agents either alone or in concert with other medications.
with another group that received the same dosage of There have also been many studies comparing and contrast- diazepam in combination with nitrous oxide at a concentra- ing various sedation agents in terms of onset of action, tion of 50:50. It was demonstrated that the nitrous oxide aug- recovery period, as well as duration and level of sedation.
mented the efficacy of the sedations by 50%.78 Although not every study will be noted, some of the more Polypharmacy or more of one drug (or drugs), does not necessarily ensure better results. In one study, 120 appre- In a study of 1,112 outpatient children given either hensive children aged 24-48 months were orally adminis- nitrous oxide or midazolam over a 10 year period, there was tered varying dosages of midazolam, mixed with varying a very low complication rate associated with the procedure dosages of meperidine. The levels of cooperation and need and induction of the sedative agent.70 Erlandsson et al found for restraint were measured for each combination. Combined the oral administration of midazolam to be a safe form of higher doses of both agents demonstrated somnolence and premedication in 160 children with a mean age of 6.7 +/- 2.6 oversedation. The higher dose of midazolam mixed with the years referred for dental treatment due to behavioral prob- lower dose of meperidine was the most effective combina- lems. The advantages of its short waiting-time and half-life, tion, allowing the successful completion of all visits with no and level of sedation obtained were specifically sited.71 need for restraint, no loss of consciousness throughout Comparisons of medications have also been made. Haas appointments, and no adverse reactions. There appeared to et al found that children who were administered 0.60 mg/kg be a synergistic effect of the two medications, increasing the of midazolam prior to the administration of a local anes- working time and facilitating the sedation.79 The Journal of Clinical Pediatric Dentistry Use of Enteral Sedation in Pediatric Dentistry Routes of Administration
agents and during the sedation at least one additional person Other research has compared different routes of administra- should be present in addition to the dentist who is trained in tions of sedatives. One study found no significant difference basic life support. During the recovery phase, patients must in efficacy or safety when the combination of meperidine have continuous supervision until oxygenation, ventilation and hydroxyzine was administered orally or submucosally.80 and circulation are stable and the patient is appropriately Moreover, a comparison of midazolam given orally (0.7 responsive for discharge from the facility. It is the dentist mg/kg) with 0.3 mg/kg administered intranasally (IN), who must determine and document that the patient is stable showed overall behavior of the pediatric dental patients to be and meets appropriate discharge criteria. Furthermore, the similar, with no significant differences in vital signs. With dentist must provide explanation and documentation of post- IN administration, mean onset time was approximately 3 operative instructions to the responsible adult escorting the times faster, but working time was 10 minutes shorter and toward the end of the session more patient movement and Despite being discharged safely from the sedation site, a less sleep was demonstrated.81 Also, sedatives are not neces- patient may still become susceptible to tragic outcomes.
sarily an indication of cooperative behavior at appointments Unfortunately, with the use of sedation in dentistry, dire con- subsequent to the sedation. The sedation likely alters the sequences such as death and permanent neurologic injury uncooperative behavior only temporarily. Comparing chil- from respiratory compromise have been reported.85 Follow- dren aged 39-71 months who had previously received seda- ing an appointment involving sedation, the patient must be tion with ones that had not, McComb et al found no rela- carefully monitored during his/her transportation home. For tionship between oral conscious sedation and the future example, if a young patient is placed into the infant seat of a behavior of children in the dental setting.82 parent’s car, and is unsupervised, then during the ride homethe patient’s head can flex forward and downward, compro- Patient monitoring and safety training for sedation
mising the airway and leading to its obstruction. Respiratory procedures:
arrest can ensue (the primary cause of cardiac arrest in chil- Although numerous sedation medications have been men- dren), leading to morbidity and possibly mortality.86 There- tioned and their pharmacology and physiology discussed, the fore, postoperatively, it is imperative that a responsible adult ultimate safety and wellbeing of the patients receiving seda- continuously monitor the patient for any poor head position- tion is paramount and ultimately the responsibility of the person administering the sedation. In an effort to optimizethe safe practice of enteral sedation in the dental practice, CONCLUSION
national guidelines have been established and will most In conclusion, the current care of pediatric dental patients likely be modified in the future. In addition to possessing appears to be evolving into three main categories: behavioral proper knowledge of the pertinent pharmacology, the oper- management with “tell, show, do”; sedation with orally ating dentist should possess current completion of a Basic administered midazolam and/or nitrous oxide and oxygen Life Support (B.L.S.) course and when treating children, via inhalation; and general anesthesia.87 Yet this can also pre- Pediatric Advanced Life Support (P.A.L.S.) is vital. He/she sent complications when children with management prob- should be capable of performing bag-valve-mask ventila- lems in some areas of the United States have recently expe- tion, and maintaining advanced airway skills, should the rienced an increase in the waiting time for sedation services necessity to initiate rescue therapies become indicated. or general anesthesia88 Coincidentally there has been an Monitoring the patient clinically and with adjunctive increased demand for continuing education courses that medical equipment is extremely critical. An adequate oxy- focus on enteral sedation recently.89 Courses that involve gen supply must be determined and baseline vital signs of patient simulators provide a dynamic hands-on education the patient obtained contemporaneously with direct clinical mimicking potential real-life situations. This is similar to observation of the patient. The patient should be monitored many areas of health care which have utilized similar bene- prior to the sedation, during the procedure, as well as post- fits of combining the cognitive skills taught through didactic operatively for effective recovery from the sedation. The lectures with the psychomotor skills obtained in the use of a triad of proper monitoring includes oxygenation, ventilation, and circulation. This involves the use of equipment such as Enteral sedation in pediatric dentistry is a valuable a pulse oximeter for oxygen saturation, capnography and adjunct to dental treatment but it must be exercised with cau- pretracheal stethoscopes to obtain respiratory information, tion. Preoperatively, patients must be thoroughly examined continual evaluation of heart rate and blood pressure with an and medically optimized when necessary. Since the degree appropriately sized non-invasive cuff and finally direct of sedation and respiratory depression provided by oral seda- tive medications is difficult to predict, this treatment modal- Documentation is also imperative during sedation both ity is not recommended for all patients. However, with legally and ethically. It is critical to have this information appropriate patient selection, judicious use of medications, prior to discharge of the patient. An appropriate time-ori- careful monitoring through adequate equipment, and effec- ented anesthetic record must be maintained that includes the tive communication, this form of treatment can be safely and individuals present during the administration of the sedative effectively administered. With the strong demand for oral The Journal of Clinical Pediatric Dentistry Use of Enteral Sedation in Pediatric Dentistry sedation services evident, properly trained practitioners who 21. Tait AR, Malviya S. Anesthesia for the Child with an Upper Respira- opt to utilize this vital form of treatment can reach out to a tory Tract Infection: Still a Dilemma? Anesth Analg, 100: 59–5, 2005.
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