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Sedation

Sedation is sometimes necessary in pediatric patients, particularly those with disabilities. Sedation may be necessary for individuals with extreme phobia concerning dental treatment; those with involuntary movements - such as tics or other neuromotor symptoms; and patients whose cognitive disability is such that they cannot comprehend the need for dental care, nor understand the intent of the dental provider, despite attempts to explain procedures and gain compliance. Some children may be able to tolerate minor procedures fairly well; while more involved procedures may require sedation. Types of sedation range from light, or conscious, sedation, to general anesthesia. It is important for the dental practitioner to limit the use of sedation only to specific instances when there is no recourse.

Types of sedation

Inhalation: A combination of oxygen and nitrous oxide ("laughing gas") is the most commonly used agent for sedation in dentistry.

Advantages: Nitrous oxide is considered relatively safe and can be effective in relieving anxiety. Nitrous oxide is very short-acting; patients typically recover 3-5 minutes after pure oxygen inhalation.

Disadvantages: Nitrous oxide is not a potent sedative. Additionally, the patient must be able to follow instructions and cooperate with the administration requirement to wear a mask and breathe through the nose to receive optimum benefit. Nausea and vomiting may occur as a side effect in some patients.

Oral: Pediatric dentists are typically able to prescribe oral sedatives. Some oral sedatives commonly used in pediatric dentistry are midazolam, chloral hydrate, hydroxyzine, and diazepam. These agents typically induce conscious sedation.

Advantages: Oral sedatives are easy to administer. They may be used alone or in combination to enhance their effect. The use of oral agents typically allows the patient to remain awake - and thus able to assist with
positioning, answer questions, etc.

Disadvantages: Oral medications are absorbed slowly - typically requiring about 30 minutes to take effect. Medication efficacy varies among patients, depending on the rate of absorption from the stomach, rate of metabolism, and patient's level of anxiety. Also, it is not possible to quickly reverse the action of an oral agent, should it be necessary.

Intramuscular (IM): Intramuscular (IM) sedative administration may be used occasionally within the dental operatory setting. IM injections must be given into a fairly large muscle mass - typically the upper arm, buttock, or thigh. IM sedation is typically used for procedures of short duration.

Advantages: IM injections may be used with clients who refuse to swallow oral medications or are unable to do so. The IM route of administration usually offers more effective absorption, and is faster-acting than medications given orally. Intramuscular injections may be helpful when sedation is needed to facilitate intravenous access in combative or extremely noncompliant patients.

Disadvantages: IM sedation has drawbacks - such as the need for a fairly large muscle mass available for administration of the injection. Children with some types of physical disability may present with muscle atrophy which may preclude safe IM injection. Additionally, as with oral medications, the effects of IM administered medications are not quickly reversed. It is also important to remember that IM injections are painful, and most children are not fond of "needles."

Intravenous Sedation: Intravenous (IV) sedation requires the most training for the practitioner, and is thus most frequently seen in the context of oral surgery. Other dentists may use this technique if they have completed the proper training. IV sedation has the most rapid onset of action, and is the most effective route of administration.

Advantages: The advantages of IV sedation include its rapid onset of action, effectiveness, and the dentist's ability to carefully control the level of sedation by adjusting the rate or dose of medication administration continually. Should an adverse reaction occur, emergency medications may be administered through the IV access. IV sedation is especially useful for the completion of lengthy dental procedures. Sedation administered in the dental office is much more cost effective than that performed in a hospital setting.

Disadvantages: One obvious disadvantage of IV sedation involves gaining access. Typically, children are not fond of needles due to their history with immunizations, and/or their painful previous experiences with clinicians. A type of adjunct sedation, either oral or IM, may be required to relax the child before an IV site can be established. Additionally, it may be difficult to locate dental practitioners trained in the use of IV sedation. More extensive treatment needs may require sedation in a more controlled hospital setting.

General Anesthesia: General anesthesia may be used to complete needed dental care in any individual as the last alternative. General anesthesia must be performed in a hospital environment by trained personnel. It has risks and potential side effects - thus its use must not be taken lightly. All other available measures (as outlined above) to gain cooperation and compliance must first be exhausted. Before any individual undergoes general anesthesia, a thorough medical examination must be completed in order to establish medical competency. The dentist should work in concert with the child's pediatrician, not only to apprise themselves of the child's medical history, but also to determine the need for any other medical procedures which may be done while the child is anesthetized.

Advantages: General anesthesia obviously provides complete sedation. Additional medications may be administered as necessary. Also, any other currently needed medical procedures may be simultaneously accomplished while the child is anesthetized.

Disadvantages: General anesthesia, as it requires trained personnel in a hospital setting, is very expensive. General anesthesia may not be feasible for some patients due to medical incompetency. It is not unusual for such procedures to cost between $4,000 and $12,000 for the hospital fees alone. These procedures must all be pre-approved by the insurance carrier. Also, general anesthesia is not without risk. Reactions to anesthesia are rare - but do occur - and may be life-threatening.

Dougherty, N., Romer, M., and Perlman, S.P. (2004). The use of sedation., In Fenton SJ, Perlman S, Turner H, eds. Oral Health Care for People With Special Needs: Guidelines for Comprehensive Care. River Edge, NJ: Exceptional Parent, Psy-Ed Corp., 2003.