FACTORS INFLUENCING PATIENT RESPONSE

A number of factors interact to determine whether the pediatric patient will face a scheduled visit to the dentist or physician with eager anticipation or with fearful dread. These include the influences of the parent, of the child’s peers, of the dentist, and of the office staff. The child’s prior experience with health professionals is yet another factor.

Parental attitudes in general, and toward dentistry in particular, have a profound influence on a child’s behavior. Factors thought to be of importance include the age of the parents and their level of maturity. A positive dental attitude in parents creates an environment for the child that is conducive to the acceptance of ideal dentistry. It is frequently heard that the greatest difficulty in patient management occurs when a child is accompanied to the dental office by the grandparent. The grandparents often represent the ultimate authority in the family and will do things as they see fit to do them, not as the dentist may desire. This may be a significant factor when decisions are made regarding the site and route of administration of sedative drugs.

The parents’ prior experience with medical and dental health professionals will greatly influence their child’s attitudes. Although few, if any, parents will intentionally tell their children of prior traumatic experiences they have had, such attitudes and feelings are transferred to the child nonverbally. Children may overhear their parents discussing their experiences or may see a parent suffering either before or after a dental appointment. Children are surprisingly astute observers and pick up the many clues that parents drop relating to their attitudes toward health care.

Parents may make statements to their children that influence the children’s behavior or put the children on guard, expecting that something unpleasant might be in the offing. Simply telling a child, “If you behave yourself at the dentist I will buy you a treat later” may tell the child to anticipate the occurrence of something unpleasant.

The influence of other children, either siblings or acquaintances, must never be discounted. Such influence may be either positive or negative. In a family in which several children have undergone dental treatment without difficulty, younger children receive positive reinforcement before their visit. However, if prior appointments have been traumatic, such influence may be extremely negative. The same is true for the friends of the child. I have found that young friends tend to accentuate the more negative aspects of dentistry and medicine.

Another factor influencing the child’s behavior during treatment is his or her own prior experience with other health care professionals. Traumatic experiences (e.g., a painful vaccination injection) provoke negative behavior in the patient, whereas positive experiences lead to a better-behaved child.

Some children are fearful at their very first visit to the dental office. The collective influence of the parents, siblings, and friends has produced this unwarranted apprehension. Although the goals of the dentist and staff will be somewhat more difficult to accomplish, the attitude of the office staff can dramatically change this child’s feelings toward dentistry.

The factors that have been discussed thus far are truly out of the control of the dentist. Fortunately, the dentist is able to control several other factors. These include the attitudes of the dentist and staff and the environment (the office) in which the patient will be treated.

The dentist sets the behavior standard in the office. Kimmelman¹ has stated that firmness with kindness and a soft, clear voice is an asset in dealing with children. The dress of the dentist is important: White uniforms may provoke negative feelings in younger patients, whereas colorful uniforms (commonly worn today as pastel scrubs or scrubs with designs) evoke a more positive response. With universal precautions (gloves, glasses, and masks being standard of care), explanations and role-playing with the child to make him or her comfortable with our safety garb are suggested.

The same guidelines are important for members of the office staff. In the management of the pediatric patient, the auxiliary may have significantly greater contact with the patient than does the dentist; therefore the attitude and attire of the staff are as important, if not more so, than the dentist’s.

The time of day at which the appointment is scheduled may have bearing on a child’s behavior, especially the younger child. Interference with a child’s sleep or eating habits should, if possible, be avoided. The young child accustomed to a midday nap may be irritable if he or she is in the dental chair instead of bed at that time. Younger patients are most easily managed early in the day. This is also true for the apprehensive adult patient (see Chapter 4). The basic concepts presented in the stress-reduction protocols are of great importance in managing the pediatric patient. The length of the appointment should not exceed the child’s attention span. Younger patients are less able to tolerate longer appointments than are older, more mature children. Most children are able to tolerate 30- to 45-minute appointments with little difficulty.²

The office environment is another factor that influences the patient’s behavior. An office in which many children are treated should offer an environment that appeals to children. Although most pediatric medical and dental offices are designed with this in mind, even in the office of the busy generalist a separate area of the reception area might be set aside for younger patients. The very fact that this area requires the patient to leave the parent will be more conducive to the separation from the parent that occurs at the time of dental treatment. The color of the office, soundproofing, and odors are important factors to consider in the design of the pediatric office and reception room. Many pediatricians and pediatric dentists offer their patients a gift as they leave the office. These gifts are used as a display of friendship, not as a reward for good behavior.

BEHAVIORAL EVALUATION OF THE PEDIATRIC PATIENT

Even though there are innumerable factors that interact to influence a child’s behavior in the dental office, the dentist must still be able to evaluate the patient’s ability to cope with the planned treatment. A number of systems have been developed to aid in classification of a child’s behavior and the potential for successful dental treatment. Two of the most commonly used systems are the Frankl Behavior Rating Scale³ and the system devised by Wright.⁴

In the Frankl system the observer (dentist) places the child’s behavior into one of four categories:

Johnson has stated that the Frankl scale appears to be closely related to the attitude of the parent toward dentistry.⁵

Wright’s classification presents three major groups: (1) cooperative, (2) lacking cooperative ability, and (3) potentially uncooperative behavior, with multiple subgroups. Wright has stated that most dentists, either consciously or subconsciously, categorize the behavior of children into one of these groups. These classifications permit the dentist to more readily determine the appropriate means of overcoming the management problems presented by the patient⁴:

Successful treatment of the patient who lacks the ability to cooperate often requires the use of one of the techniques of sedation (moderate or deep). Should these fail to prove adequate, general anesthesia may be required.

The potentially uncooperative patient may or may not require sedation for successful treatment. The attitudes and technical abilities of the dentist and office staff will be the deciding factors with these patients.

DETERMINING THE NEED FOR SEDATION

The decision to use sedation should be made only following consideration of several factors:

When only minimal treatment (e.g., one filling) is necessary, the need for sedation is usually negligible. This is especially true for the parenteral techniques (intramuscular [IM], intranasal [IN], and intravenous [IV]), which involve prolonged durations of drug effects. Inhalation sedation may be the most appropriate technique for this type of procedure. If full-mouth treatment is necessary (e.g., nursing bottle syndrome), the use of IV deep sedation or general anesthesia might be considered.

Patient cooperation is obviously a factor in opting to use a sedation technique. It is the opinion of most pediatric dentists that at least one and preferably two attempts at treatment should be made before considering the use of sedation or general anesthesia. With experience, it may become quite obvious to the dentist that a patient will require sedation or general anesthesia before the initiation of any treatment. Children who are screaming as they walk, or are carried, through the parking lot to the dental office are more likely to be candidates for sedation. On the other hand, the patient who sits in the dental chair and cries throughout the treatment may be manageable without the use of adjunctive drug therapy. Crying, in the absence of overt disruptive behavior, may not be an indication for the administration of sedative drugs.

Parental attitudes must be taken into account when considering the use of sedation. Unfortunately, the use of sedation in dentistry has periodically received negative publicity, a factor that has conditioned some parents against the use of these techniques in their children. The desires of the parent should always be considered when formulating the patient’s treatment plan; however, the dentist must always be the one to make the final decision. Several pediatric deaths have occurred in part because of the dentist’s desires to accommodate the parent’s wishes that all the dental treatment be completed at one visit. Though the administration of sedatives to a child patient at home, before leaving for the dental office, is discouraged, the parent’s ability to follow prescribing instructions must be determined if the dentist is considering doing this. When any doubt exists, the child should be scheduled early, with the drug administered by the dentist in the dental office.⁶

Economic considerations are also of importance in determining the nature of the sedative procedure to be used. One reason for the increased use of outpatient sedation in dentistry and medicine has been the high cost (in both financial and emotional terms) of hospitalization. Outpatient procedures are usually a fraction of the cost of the same procedure performed in a hospital. If the economic status of the family is such that they are unable to afford even the minimal fee for sedation, it might be prudent not to charge the patient for the service. The cooperation of the patient and family is readily obtained, and treatment becomes less traumatic for the entire staff and the patient.

Alternative modes of treatment should be considered. Which technique of sedation is most likely to be effective in this patient? Many dentists develop the disturbing practice of using the same technique (and in some cases the same drugs and dosages) on all patients. Consideration in selection of the technique and drugs involves multiple factors, including the degree of cooperation of the patient and the patient’s medical history (i.e., allergies and illnesses). There is no one technique of sedation that will be effective in all patients. Indeed, in pediatric dentistry the failure rate for sedation is considerably greater than that seen in adults. Trapp has stated that a failure rate of 20% to 40% is not unusual unless the dentist is administering general anesthesia.⁷ Recent experience with pediatric sedation has demonstrated a 40% to 50% failure rate with oral sedation but a 5% failure rate with IM/IV sedation. As a general rule, the younger the patient the higher will be the failure rate of sedation techniques. The greater the number of techniques available to the dentist, the greater the likelihood of a successful outcome.

The preoperative physical evaluation of the child will aid in determining the technique of choice for the patient. Among the items to be determined are the presence of allergies, medications being taken by the patient, and any prior hospitalizations. Behavioral evaluation also aids in a determination of the requirement for sedation or general anesthesia. In addition, training and experience of the dentist and staff are important in determining the appropriate sedative technique. Only those techniques with which the dentist and the staff are well acquainted should be considered for use. The requirements for adequate training in each of the commonly used techniques are discussed earlier in this text.

GOALS AND TECHNIQUES

All techniques of sedation discussed in this book may be used in the pediatric patient. In addition, drug administration by the submucosal (SM) route is occasionally used in pediatric dentistry. All of these techniques are reviewed with an eye toward their applicability in the pediatric patient.

Kopel has stated that sedation in the pediatric patient should be used to “train” or “retrain” the patient in an understanding of dental procedures and their importance.⁸ He continues by listing the following goals of pediatric premedication (sedation):

Listed are the techniques of patient management involving drug administration that are available in pediatric dentistry. These techniques are presented in the order of their desirability, from (in this authors [SFM] opinion) the most desirable to the least desirable:

The goal sought when sedating the pediatric patient is the same as with the adult: to use the most controllable and least profound technique that provides the desired goal.

Once a sedation technique is selected for the pediatric patient, the next task is to determine the appropriate dosage of the drug(s) if the technique selected does not permit titration. Physiologic functions in children may vary considerably from those same functions in the older patient. The metabolic rate is increased in the younger patient. Conversely, enzyme systems responsible for the biotransformation of specific drugs may not yet be fully functional in younger patients. This factor and others lead to the increased possibility of higher blood levels developing when pediatric drug dosages are simply calculated from the adult dosage forms commonly supplied with drugs. Instances of morbidity and mortality have been reported in which drug doses within acceptable adult limits were administered to children.

There is no simple answer to the question of proper drug dosage. Many factors act to complicate drug selection and drug action in children. In addition, the desired level of drug action varies considerably from patient to patient and from dentist to dentist. The most reliable factor in predicting adequate drug effect is a patient’s previous clinical experience with the drug in question. Once a drug has been administered to a patient, subsequent dosages can be modified according to this initial response. This is termed titration by appointment.⁵ Although previous clinical experience can provide guidelines leading to safer and more effective drug administration, it is still necessary to determine a safe and effective drug dose for a first appointment.

Drug package inserts (DPI) provide prescribing information concerning pediatric dosages. However, many drugs introduced for the management of pain and anxiety in recent years have not undergone adequate clinical trials in children to permit recommendations concerning pediatric dosage. Conversely, many of these drugs provide only adult dosage forms or indicate that “information [in children] is inadequate to establish dosage.” Wilson,⁹ in a review of the 1963 Physicians’ Desk Reference, found that 62% of listed drugs were not indicated for pediatric use, whereas an additional 16% were without recommendation for pediatric dosage. This number has steadily increased in recent years.

In those instances in which pediatric dosages of CNS-depressant drugs were indicated, the dosages were those used in normal, nonstressful environments. Administration of this dosage form, although adequate to help a child to fall asleep at home, often proves to be entirely inadequate for sedation in a stressful environment such as the dental office. Most DPI’s and pharmacology textbooks indicate the usual, nondental dosage of a drug. Pediatric dentistry texts should be consulted for appropriate dental treatment doses of these drugs.

Various factors govern the determination of drug dosages for children. These are generalizations, with exceptions to be anticipated:

Formulas, such as Young’s rule and Clark’s rule, have been suggested as aids in determining pediatric drug dosages as a fraction of the adult dose. The success of such rules is haphazard at best and cannot be recommended.

Young’s rule:

Clark’s rule:

Although age and weight are often used in determining pediatric drug dosage, they present certain problems. Because of significant variation in size among children of the same age, this factor (age) ought not be of primary consideration. Body weight is more commonly used in pediatric dose determination; however, the dose of many drugs is not always a simple linear function of body weight and to calculate dosages as milligrams per kilogram or per pound leads to inaccuracies. Surface area, rather than body weight, has been shown to be a more accurate method of determining drug dosage for a patient. Unfortunately, manufacturers of virtually all drugs marketed today still present dosage recommendations in other units (e.g., mg/kg or mg/lb of body weight).

MONITORING

Monitoring of the sedated patient is discussed in Chapter 5. As important as monitoring is for all sedated patients, in the pediatric patient monitoring is possibly of even greater significance. Because of the relative lack of communication available between the dentist and the very young, precooperative or the handicapped patient, one of the most important means of communication—verbal—is often not present. In addition, because of the inability to titrate drugs administered orally, intramuscularly, or intranasally, the possibility of a relative overdose developing is somewhat enhanced. Constant monitoring of the patient is essential.

Baseline vital signs (blood pressure, heart rate and rhythm, and respiratory rate) should be recorded before treatment if the patient allows it. In the younger, precooperative patient, this often is not possible. Until the child has been sedated, it may be physically impossible to monitor vital signs; however, while the child is screaming, yelling, and moving around, monitoring is actually being done subjectively by simply watching the child’s behavior. As soon as the child becomes quiet (sedated), more objective monitoring must be initiated. Vital signs must be recorded and a pretracheal stethoscope placed in position and respirations monitored throughout the procedure.

The pretracheal stethoscope is one of the most valuable pieces of monitoring equipment available (and the least expensive). With it the dentist is able to monitor continuously both breath sounds and, in many cases, heart sounds. The value of the pretracheal stethoscope cannot be overestimated.

Monitoring breath sounds in the pediatric patient is of great value because the overwhelming majority of complications seen in sedation of younger patients are associated with respiratory depression or airway management problems. Decreased or altered breath sounds or a slowed rate of breathing should alert the dentist to evaluate the patient’s airway and respiratory status. Most cardiac problems in pediatric patients develop secondary to respiratory distress. Recommended monitoring for pediatric sedation includes the following: