Introduction to Pharmacological Techniques: A Historical Perspective
This introduction provides a brief chronologic history of pediatric dental sedation, beginning with the 1970s. It focuses on changes that have occurred in the United States in the last forty years, as Americans have led the changes. Knowing what has transpired in the past helps to understand current regulations and practices.
In 1998, the American Academy of Pediatric Dentistry (AAPD) used the terms minimal, moderate, and deep to categorize sedations (Reference Manual 2010–2011). These are different degrees of central nervous system depression, each corresponding to a level of sedation relaxation. However, in the first edition of this book, Musselman and McClure (1975) categorized drugs differently. They opined that decisions concerning the type of drug and the suitable route of drug administration may be made, in part, on the basis of the level of a child’s cooperative behavior. They classified sedation as two types: preventive premedication and management medication. A preventive premedication is used when a child is stressed by the dental situation, but is still communicative. There are different types of behaviors—scared, timid, apprehensive—that could be considered candidates for a preventive medication. Management medication is used for children who are unable to control their behavior or for those lacking in cooperative ability. The dentist would find it difficult or impossible to obtain adequate radiographs on these children. Verbal communication may have little meaning for them.
These sedation categories are rarely used today, but it is sometimes helpful to think of the drug you are about to use in this way. Consider the following case.
Despite these observations, the dentist elected to treat Jill with Behavior Shaping, a non-pharmacologic approach. Performing dentistry quadrant by quadrant, the dentist achieved good patient cooperation at the first and second restorative appointments. At the third visit the child cried at the injection but eventually calmed down. When the time arrived for the fourth appointment, Jill’s parent had to forcibly bring her to the office. The child cried continuously and hysterically, refusing the injection.
Case 9.1, Discussion: The case illustrates an excellent example of when a preventive medication might be used. The child was obviously apprehensive at the first visit, and her behavior changed from cooperative to highly uncooperative by the fourth appointment. If the child had received a preventive medication, a more favorable outcome may have resulted. A contemporary example of a preventive medication is nitrous oxide inhalation analgesia. Thinking in terms of the child’s cooperative behavior is a useful way of guiding drug selection.
In 1975, numerous sedation agents were being used in private practices and teaching venues. To determine which sedation agents to include in the original edition of this book, a survey of members of the American Board of Pedodontics (now AAPD) was undertaken (Wright and McAulay 1973) to determine: (1) which drugs were used by the members, and (2) what the common methods of drug administration were. The survey concluded that hydroxyzine (Atarax, Vistaril) was the most popular sedating agent when used alone.
Hydroxyzine, a minimal sedation agent, can serve as an excellent preventive medication. It is best used for children three to six years of age and those who are timid, apprehensive, or highly anxious. However, the drug by itself likely will not be sufficient. Success in patient management requires both pharmacological and non-pharmacological techniques; the individual dentist’s training and experience makes the difference in choice and efficacy of techniques employed (Phero, 1993). This is especially true when using a minimal or preventive medication. Indeed, since a patient’s awareness may be somewhat dulled, greater emphasis is placed on using a very good non-pharmacologic approach. As the sole sedating agent, hydroxyzine has limited success with older children, but nowadays it is often used in combination with other agents. When used with nitrous oxide, its antiemetic effect can be advantageous.
Chloral hydrate was the next most popular drug when used alone, and it was usually employed as a management medication. In 1975, pediatric dentists were still trying to determine the proper dosage . There was little agreement. Maximum suggested dosages for a four-year-old child ranged from 750 mg to 1000 mg (Sim 1975) and sometimes as high as 1250 mg (Smith 1977). While historically there was confusion as to the correct dosage, it did not prevent its use, and deep sedations often were obtained with the limited monitoring that was available at that time. Chloral hydrate is no longer manufactured commercially in the United States, but it remains available at local pharmacies and in other countries. For this reason, it has been included in this book.
When it came to drugs used in combination, promethazine (Phenergan) and meperidine (Demerol) were the most popular. When children were “strongly apprehensive,” the combination of Phenergan and Demerol were used widely as a management medication. The 1975 survey reported that 35% of ABPD members administered medication intramuscularly. The injections were likely for meperidine.
The Wright and McAulay survey also found that only 44% of pediatric dentists were using nitrous oxide at the time. In 1996, Wilson reported that 89% of AAPD members were using nitrous oxide, doubling its usage over a span of twenty years. Similar trends are revealed by consecutive surveys undertaken by Houpt (1985, 1993, 2002) as part of the Project on Usage of Sedative Agents by Pediatric Dentists (USAP). Because nitrous oxide—oxygen inhalation analgesia—is now highly popular, an expanded chapter has been devoted to its application in pediatric dentistry.
In 1973, the survey revealed that slightly more than 10% of pediatric dentists administered drugs submucosally. The majority of pediatric dentists administered Nisentil (alphaprodine HCl) in this way. The drug was synthesized by Ziering and Lee in 1947 and was used by physicians in obstetrics for many years. Although Nisentil is not used in dental practice today, it has great historical importance, as its use led to major changes in pediatric dental sedation practices.
Pediatric dentists used Nisentil to control the behavior of difficult child patients, particularly those three to six years of age. The drug acted rapidly, with a peak effect of five to ten minutes. It was similar to Demerol, but 2.5 times more potent. Its side effects included respiratory depression, nausea, and vomiting. Like Demerol, its effects could be reversed with a narcotic antagonist. In 1980, Nisentil was suddenly withdrawn by the manufacturer Roche Laboratories, a division of Hoffman-LaRoche.
The American Academy of Pediatric Dentistry (AAPD) voiced its concern to Roche Laboratories about the sudden withdrawal of Nisentil. Many pediatric dentists were outraged, as they relied on the drug to manage their patients. To deal with the Nisentil issue, a symposium was held in Los Angeles in 1981 and its proceedings were published in a special issue of Pediatric Dentistry the following year. Chen (1982), representing Roche Laboratories, cited four cases of adverse experiences with the drug. Children twenty-eight months to four years died or suffered cerebral damage due to anoxia. Key information extracted from 7,372 cases gathered from the files of twelve dentists using Nisentil was as follows: patients ranged from two to twelve years of age, drug efficacy was rated between 2.8 and 2.9 (3 max), dosage was 5–15 mg in most cases, and severe adverse reactions occurred in 8/7,372 cases.
Aubuchon (1982) also presented an important report at the symposium. Basing his findings on 2,911 questionnaires, his main conclusions were: a narcotic sedative technique was the most popular means of sedating pediatric patients, narcotic sedations had an adverse risk reaction of 1:5,000 as compared to a risk of 1:20,000–30,000 for non-narcotic agents, and an alphaprodine sedation is as safe or safer than a meperidine sedation. Creedon (1982) and Troutman and R/>