Procedural sedation offers an effective and humane way to deliver dental care to the young, anxious child and to those with extensive treatment needs. Delivery of sedation requires thorough understanding of its indications and contraindications, patient assessment, pharmacology, monitoring, and office protocol. Safe and successful outcomes depend on a systematic approach to care, and the ability to manage unintended cardiopulmonary events.
Key Points
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Appropriate use of procedural sedation requires thorough knowledge of its indications and contraindications, as well as alternative methods of treatment.
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Sedation and general anesthesia represent a continuum. Individual responses to medication may cause variation in sedation depth.
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Patient selection for procedural sedation includes evaluation of treatment needs, child behavior, medical history, and physical assessment.
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Vigilant monitoring is key to safe, successful care. The ability to recognize adverse events early and intervene to rescue a child is fundamental to patient safety.
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Effective office protocol enables the practitioner to provide safe and efficient care.
Introduction
Children frequently present to the dentist with treatment needs that require invasive procedures. Procedural sedation can offer an effective and humane way to facilitate delivery of dental care to the young, anxious child and those with extensive treatment needs. To safely provide dentistry using sedation, it is crucial that the provider have a thorough understanding of sedation indications ( Box 1 ), contraindications ( Box 2 ), patient assessment, pharmacology, monitoring, protocol, and the ability to rescue a patient from unintended levels of sedation.
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Fearful, anxious patients for whom basic behavior guidance has not been successful and those children with a past history of uncooperative behavior
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Patients who cannot cooperate due to a lack of psychological or emotional maturity and/or mental, physical, or medical disability
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Patients for whom the use of sedation may protect the developing psyche and/or reduce medical risk
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Young patients whom are minimally cooperative, or pre-cooperative
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Those children with extensive treatment needs for whom repeated treatment may cause psychological or emotional trauma
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Children who travel extensive distance to receive care
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Cooperative patients with minimal dental needs
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Patients with predisposing medical and/or physical conditions that would make sedation inadvisable
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Parental objection or choice of an alternative option for treatment
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Financial barriers
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Language or cultural barriers
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Inadequate training to provide safe care using sedation
Use of Sedation in Pediatric Dentistry
It is generally accepted that the majority of children can receive dental treatment through nonpharmacologic behavioral guidance; however, some children require alternative approaches. In graduate pediatric dentistry programs in the United States it is estimated that 1% to 20% of the children treated require sedation, with most program directors reporting an increase in the number of sedations performed annually. Practice surveys of pediatric dentists also indicate an overall increased use of sedation for pediatric dentistry, with an estimated 100,000 to 250,000 pediatric dental sedations performed each year. Dentists also report that children now exhibit more challenging behaviors than in the past, increasing the need for sedation. The increase in the use of procedural sedation by practitioners with varied educational and practice backgrounds has simultaneously driven public and governmental demand for regulation and education to improve patient safety.
Historical Perspective
In 1983, in response to sedation incident reports from dental settings, the American Academy of Pediatrics (AAP) first requested that the section on Anesthesiology and the Committee on Drugs work with the American Academy of Pediatric Dentistry (AAPD) to formulate guidelines for pediatric sedation. In 1992, the AAP guidelines were revised to reflect advances in technology, requiring pulse oximetry for all sedated children for the first time. Several revisions have since occurred. The guidelines established by the AAP/AAPD are now the standard of care accepted by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and others.
Introduction
Children frequently present to the dentist with treatment needs that require invasive procedures. Procedural sedation can offer an effective and humane way to facilitate delivery of dental care to the young, anxious child and those with extensive treatment needs. To safely provide dentistry using sedation, it is crucial that the provider have a thorough understanding of sedation indications ( Box 1 ), contraindications ( Box 2 ), patient assessment, pharmacology, monitoring, protocol, and the ability to rescue a patient from unintended levels of sedation.
-
Fearful, anxious patients for whom basic behavior guidance has not been successful and those children with a past history of uncooperative behavior
-
Patients who cannot cooperate due to a lack of psychological or emotional maturity and/or mental, physical, or medical disability
-
Patients for whom the use of sedation may protect the developing psyche and/or reduce medical risk
-
Young patients whom are minimally cooperative, or pre-cooperative
-
Those children with extensive treatment needs for whom repeated treatment may cause psychological or emotional trauma
-
Children who travel extensive distance to receive care
-
Cooperative patients with minimal dental needs
-
Patients with predisposing medical and/or physical conditions that would make sedation inadvisable
-
Parental objection or choice of an alternative option for treatment
-
Financial barriers
-
Language or cultural barriers
-
Inadequate training to provide safe care using sedation
Use of Sedation in Pediatric Dentistry
It is generally accepted that the majority of children can receive dental treatment through nonpharmacologic behavioral guidance; however, some children require alternative approaches. In graduate pediatric dentistry programs in the United States it is estimated that 1% to 20% of the children treated require sedation, with most program directors reporting an increase in the number of sedations performed annually. Practice surveys of pediatric dentists also indicate an overall increased use of sedation for pediatric dentistry, with an estimated 100,000 to 250,000 pediatric dental sedations performed each year. Dentists also report that children now exhibit more challenging behaviors than in the past, increasing the need for sedation. The increase in the use of procedural sedation by practitioners with varied educational and practice backgrounds has simultaneously driven public and governmental demand for regulation and education to improve patient safety.
Historical Perspective
In 1983, in response to sedation incident reports from dental settings, the American Academy of Pediatrics (AAP) first requested that the section on Anesthesiology and the Committee on Drugs work with the American Academy of Pediatric Dentistry (AAPD) to formulate guidelines for pediatric sedation. In 1992, the AAP guidelines were revised to reflect advances in technology, requiring pulse oximetry for all sedated children for the first time. Several revisions have since occurred. The guidelines established by the AAP/AAPD are now the standard of care accepted by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and others.
The role of sedation
Factors to Consider in Pharmacologic Guidance
When considering a pharmacologic approach to behavior guidance, the following factors should be considered:
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Risks involved with pharmacologic guidance compared with routine communicative techniques
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Extent of the patient’s dental needs
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Practitioner training and experience, including the ability to “rescue” a child when significantly compromised
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Monitoring
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Cost and third-party payers
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Venue issues (ie, office vs outpatient care facility, rural vs urban)
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Parental expectations
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Nature of the child’s cognitive/emotional needs and personality
Alternatives to Sedation
In sedation, as with any area of dentistry, no treatment is an option that should be presented to the parent or guardian. Deferred treatment is another strategy that may be considered. Deferring treatment may allow the child to mature and accept treatment. The child may also benefit from behavior modification or progressive desensitization. In such cases it is advisable to implement a caries management protocol. This protocol may include dietary and oral hygiene counseling, increased frequency of recall, monitoring of adequate fluoride exposure and professional fluoride application, as well as application of antimicrobial agents (eg, povidone iodine, xylitol, and chlorhexidine). Interim therapeutic restorations (ITR) may also be used to slow decay progression.
For children who are not good candidates for deferred treatment or behavior modification, general anesthesia (GA) is an effective option. However, in some situations it may not be the most desirable option despite its effectiveness. Factors to consider include the amount of treatment required, urgency, cost, parent preference, provider training, and the availability of GA services.
Goals of Sedation
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Guard the patient’s safety and welfare. This goal is foremost, and is best accomplished by minimizing complications.
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Minimize physical discomfort.
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Minimize negative psychological responses to treatment by providing analgesia and anxiolysis, and maximizing the potential for amnesia.
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Provide quality dental care in an efficient manner that respects the child and the caregiver’s time.
The continuum of sedation and anesthesia
Individual Variation in Response to Sedative Medications
In the original guidelines established by the AAP, procedural sedation was referred to as conscious sedation. Over time, this term has fallen out of favor, being considered an oxymoron. Indeed, it has been stated that there is no such thing as “just a little sedation.” In response, the 2002 AAP guideline replaced this term with the more precise label sedation/analgesia. It is now recognized that practitioners who provide this service must be prepared to manage an unconscious child, should the sedation level unintentionally deepen. Current recommendations describe sedation and GA not as separate entities but as a continuum. Environmental, genetic, and individual patient factors affect the absorption, distribution, metabolism, and excretion of a given drug. Physiologic and behavioral responses also vary. The interplay of these factors determines the profile of the drug plasma concentration over time, and its elicited physiologic effect.
Some children may be hyper- or hyporesponders to a drug administered at a level that is therapeutic for the majority of the population. The patient is best served by an alert provider, aware of the possibility that individual variation may create an unexpected drug response. If an adverse event occurs, the practitioner must be capable of rescuing the patient from a depth of sedation at least one level greater than the intended level. For instance, practitioners intending moderate sedation/analgesia must be able to manage patients who enter a state of deep sedation/analgesia ( Table 1 ).
Patient selection
Treatment Needs
The risk of untoward effects outweighs the benefit of sedation for patients with minimal treatment needs. Patients with extensive treatment needs, those who need immediate medical treatment, and those for whom local anesthesia is not effective may also not be good candidates. Examples of cases for which alternatives to procedural sedation should be considered are:
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The young child with incipient caries lesions
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Alternative: Implement caries management protocol and ITR restorations, and monitor lesions until cooperation improves
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The child who has not fasted and needs emergency dental treatment
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Alternative: Offer nitrous oxide/oxygen anxiolysis and local anesthesia. Protective stabilization may also be considered in the appropriate circumstances.
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The child for whom effective local anesthesia is not possible (severe local infection, hematological instability, history of unsuccessful local anesthesia)
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Alternative: GA after obtaining proper medical consultations
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Behavioral Assessment
Although extremely common, the oral route of sedation produces results that are inherently unpredictable. Published data show success of oral sedation ranging from 30% to 70%. By evaluating child behavior, it is possible to select cases with a high likelihood of success.
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Cognitive development . The ability to assess each child’s developmental level is crucial to case selection. Sedation is a behavior guidance adjunct, typically requiring the practitioner to interact verbally with the child during treatment. A low level of verbal interaction and ability to cooperate may be anticipated from young children, whereas the school age or teenage patient may have a much greater level of understanding and interaction. Thus, for successful outcomes with younger children a more profound level of sedation may be required. The older child should interact as a “member of the team,” understanding the critical importance of his willingness to cooperate once sedated.
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Child temperament and personality . This aspect is perhaps the most critical in selecting successful cases. Factors such as the child’s adaptability to change, new environments, an unknown adult, and shyness appear to be pivotal in predicting his behavior during the sedation visit. A negative mood (ie, fear, anger) and general emotional/behavioral problems are predictive of unsuccessful sedation outcomes. Children with negative mood also have a tendency to become more easily and intensely upset, which may reduce the amnestic effect of some medications.
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In practice, patients who are anxious but generally cooperative for simple dental procedures (dental prophylaxis, intraoral radiographs, and so forth) often make very good sedation candidates. Children who accept oral medications well and those who are not “clingy” to parents also make good candidates. It has been demonstrated that parents do a reasonable job of predicting their own child’s response to new challenges, and their opinion may prove helpful during the behavioral assessment.
Medical History
Review of systems
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General: The type and severity of underlying medical problems, quantified with the American Society of Anesthesiologists (ASA) physical status classification ( Table 2 ), must be assessed. Patients in ASA classes I and II are candidates for in-office sedation.
Table 2American Society of Anesthesiologists physical status classificationExamples Suitability for Sedation I Healthy patient Unremarkable past medical history Excellent II Patient with mild systemic disease, no functional limitation Mild asthma, controlled seizure disorder, anemia Generally good III Patient with severe systemic disease, definite functional limitation Moderate to severe asthma, poorly controlled seizure disorder, pneumonia, moderate obesity Intermediate to poor: contraindicated for in-office dental sedation IV Patient with severe systemic disease that is a constant threat to life Severe bronchopulmonary dysplasia, sepsis, advanced degrees of pulmonary, cardiac, hepatic, renal, or endocrine insufficiency Poor: benefits do not outweigh risks V Moribund patient who is not expected to survive without intervention Septic shock, severe trauma Extremely poor VI A declared brain-dead patient whose organs are being removed for donation Data from Refs. - •
Age: Patients younger than 12 months (some suggest 24 months) may pose excessive risk for in-office sedation.
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Cardiovascular: Patients with known cardiovascular disease (eg, congenital cyanotic heart disease, heart failure, dysrhythmias) are not good candidates, as most drugs used for sedation and analgesia can cause vasodilation and hypotension.
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Respiratory: Pulmonary disease, especially upper respiratory infections, must be assessed by lung auscultation. Risk of respiratory complications including laryngospasm is significantly elevated in patients with active respiratory illness. Respiratory disorders (eg, asthma, bronchopulmonary dysplasia, and premature birth) are relative contraindications because these conditions may impair the patient’s ability to maintain adequate oxygenation during the procedure.
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Airway: Airway abnormalities (eg, tracheomalacia, congenital abnormalities, obese patients, children who snore, and those with craniofacial syndromes) are relative contraindications, as these conditions may predispose the patient to airway obstruction.
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Neurologic/developmental: Psychiatric diagnosis such as autism or attention-deficit/hyperactivity disorder can make sedation unpredictable. Neurologic conditions such as seizures require a consultation with the patient’s physician, because medications used for sedation may alter the patient’s neurologic status.
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Gastrointestinal: Abnormalities of the gastrointestinal system should be noted, as they may modify absorption and distribution of oral medications. Such conditions may be relative contraindications.
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Hepatic and renal: The presence of hepatic or renal abnormality may affect absorption and distribution of oral medications, and are relative contraindications.
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Obesity: Obese patients may have underlying respiratory issues, obstructive sleep apnea, limited intravenous access (needed in the event of an emergency), and altered drug metabolism and distribution.
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Pregnancy status: Because most sedation medications are contraindicated during pregnancy, pregnancy status should be verified in women of childbearing age before administration of sedation medications.
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Prior history of sedation or GA: A thorough history of the patient’s experience with sedation and/or GA will determine if any adverse events have occurred in the past.
Medications
All of the patient’s prescription and nonprescription drugs and supplements should be accounted for, as they may affect medications used in sedation or may be affected by them. Older patients should also be questioned regarding illicit drug use, as these substances may also cause potentially harmful side effects in combination with sedative agents. Allergies and any history of adverse drug reactions should also be considered.
Physical Assessment
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Airway: Airway patency is a critical aspect of the presedation physical assessment. Relative percentage of tonsillar obstruction as evaluated by Brodsky classification is a good predictor of potential airway obstruction. Patients rated as III+ or greater may not be good sedation candidates ( Fig. 1 ).
