5/9/2019

CONSCIOUS
SEDATION IN
PEDIATRIC
DENTISTRY
Vivek Padmanabhan
BDS.,MDS.,Ph.D.,

Why Pharmacological
management in children?
• Behavior issues – Performing technically complex dental
treatment in children becomes difficult.

• Dental materials are technique sensitive-- so it becomes

difficult to treat without compromising upon the quality of
treatment provided.

• To prevent psychological trauma

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But don’t we have other

behavior guidance techniques,
then?

• Most of these techniques become unsuccessful

• Time consuming

• At the end neither you nor the patient is happy

History……
• Horace Wells – 1844

• Colton Dental Institutes – 1860’s –specialized in dental

extractions under nitrous oxide anesthesia.

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Chronological development of
Conscious sedation in dentistry

Year Developments
1940s “Relative Analgesia” (nitrous
oxide/oxygen)
1945 The Jorgensen or Loma Linda
Technique
1960s IV Methohexitone (Brietal®)
1966 IV Diazepam (Valium®)
1970s IV Diazepam (Diazemuls®)
1983 IV Midazolam (Hypnovel®)
1988 IV Flumazenil (Anexate®)
1990s IV Propofol (Diprivan®)

Uniqueness of Pediatric Patients!

• Several anatomic and physiologic differences between adults

and children

• The respiratory and cardiovascular differences are of

paramount importance

• Basal metabolic rate being higher in children leads to greater

oxygen consumption. Hence, when apnea or inadequate

ventilation occurs, hypoxia develops faster in children.

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• The enlarged tongue when displaced posteriorly, and large

tonsils can lead to respiratory obstruction.

• The lower airway of infants and children is easily obstructed

by mucus, edema and pus.

• In children, the cardiac output and oxygen demand is high

but with limited oxygen reserve. Hence, compromised oxygen

delivery can result in dysrhythmias and cardiac arrest.

Sedation Types!!!!

Sedation Continuum….

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• The sedation of a pediatric patient represents a

continuum and may result in a sequential
Respiratory depression,
Laryngospasm,
Impaired airway patency,
Apnea,
Loss of the patient’s protective airway reflexes,
and cardiovascular instability.

• Studies have shown that it is common for

children to pass from the intended level of
sedation to a deeper, unintended level of
sedation making the concept of rescue essential
to safe sedation.

• Concept of rescue would mean to reverse the

sedation ASAP with adequate cardiopulmonary
support.

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Definition of Conscious Sedation (CS)

A minimally depressed level of

consciousness, that retains
patient’s ability to maintain an
airway independently and
respond appropriately to
physical stimulation and verbal
command.(ADA 1993)

Goals of Sedation…
• To guard the patients safety and welfare
• To minimize physical discomfort and pain
• To control anxiety, minimize psychological
trauma, and maximize the potential of amnesia
• To modify behavior and or movement to allow
safe completion of procedure
• To return the patient to the pre procedural state
and function

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Sedation Continuum
• Sedation is a continuum of levels ranging from minimal
impairment of consciousness to unconsciousness.

• Different levels of sedation

Minimum Moderate Dissociative Deep GA

Levels of sedation are considered to be in a continuum as a

patient can slip into and out of a particular stage quiet rapidly

A patient who is in CS

• Must be able to open his eyes

• Must be able to protect his airway
• Responds to painful stimuli

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• Minimal Sedation (Anxiolysis): Drug induced state during

which patients can respond normally to verbal commands.

• Moderate Sedation (CS):

• Drug induced depressed consciousness.
• Purposeful response to verbal or tactile stimulation
• No interventions necessary to maintain airway
• Adequate spontaneous ventilation
• Cardiovascular function maintained

• Dissociative Sedation (Ketamine): a bizarre

cataleptic state occurs with profound analgesia &
amnesia while maintaining protective airway
reflexes, spontaneous respirations, and
cardiopulmonary stability.

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• Deep Sedation: Drug induced depression of

consciousness during which patients cannot be
easily aroused, but respond purposefully to
repeated painful stimulation.

• Patients require assistance in maintaining a

patent airway and spontaneous ventilation may
be inadequate.

General Anesthesia:

• Drug induced loss of consciousness during which patients are

not arousable, even by painful stimuli.
• Patients require assistance in maintaining a patent airway
and cardiovascular function and positive pressure ventilation
may be required.

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Minimal Sedation Deep Sedation

Unconsciousness
Consciousness

Moderate Sedation General Anesthesia

Indications

1. Phobias – a. Specific – Drills, Needles, Extractions

b. General – things in mouth, all dental
procedures
2. Dental extractions (Wisdom teeth or others)
3. Gagging patients
4. Persistent fainting
5. Ischemic heart disease
6. Asthma
7. Epilepsy
8. Spastic patients

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Contraindications
1. Failure to consent

2. Unaccompanied patients

3. Severe or uncontrolled systemic conditions/diseases

{Grade III Classification by American Society of

Anesthesiologists (ASA) or beyond}

4. Too long dental procedures

5. Patients with severe infections like cellulitis which may impair the

airway

6. Severe learning or moving difficulties

7. Chronic obstructive pulmonary disease

8. Psychological/ Psychiatric problems

9. Thyroid dysfunctions – Hypo/Hyperthyroidism

10. Pregnancy and lactation

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Techniques for conscious

sedation
• Basic
• Advanced

Basic
a. Inhalation sedation using nitrous oxide/oxygen
b. IV sedation using midazolam
c. Oral/ Transmucosal benzodiazepines

Advanced
a. Conscious sedation used below 12 years of age other than
nitrous oxide/oxygen inhalation sedation
b. Benzodiazepine plus any other agent- Opioid, Propofol,
Ketamine
c. Inhalation sedation with other agents like
isoflurane/sevoflurane

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Nitrous oxide
Salient features /Effects

1. Rapid equilibration between the concentration of nitrous

oxide in the alveoli and that in the blood, and therefore,
induction of and recovery from sedation is extremely rapid.

2. Main effects are “mood alteration” especially Euphoria and

analgesia.

Disadvantages of chronic exposure

1. Decreased fertility in female staff
2. Increased rate of miscarriages
3. Depression of hematopoiesis
4. CNS degeneration
5. Liver diseases
6. Malignancy, especially cervical carcinoma

BUT IF PROPER SCAVENGING SYSTEM IS AVAILABLE THEN THESE

DISADVANTAGES ARE NEGLIGIBLE

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Inhalation Sedation
Advantages of inhalation sedation
• Rapid onset of sedation
• Rapid recovery
• Recovery is independent of treatment time
• Absence of metabolism
• No needles used for inhalation sedation
• A degree of analgesia is provided but may not be enough to
substitute LA

Disadvantages
• Bulky Equipment
• Expensive
• Intrusion of nosepiece when working
• Patients may get scared of this equipment
• Chronic exposure to staff
• Potential addiction

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Technique of inhalation
sedation…
• Consent
• Pre-procedural checks
• Correct size of nose piece to be chosen
• Patient escorted and finish discussions
• 100% oxygen @ 6L/min
• Nose piece fitted on to the patient and the flow
rate titrated until the bag on the machine moves
rhythmically without collapsing

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• Nitrous oxide is introduced- initially @ 10% increments every

minute until a 20 % concentration is achieved.

• After 20% then the increments are reduced to 5%

• Constantly keep talking to the patient

• Once adequate sedation achieved, dental treatment can be

started

Signs and symptoms of adequate sedation

Signs
• Patient is awake
• Is relaxed and comfortable
• Vital signs normal

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Symptoms
• Less aware of pain
• Paresthesia or tingling
• Euphoria
• Detachment
• Dreaming

To conclude….
• You are most welcome to use this but
learn the law of the country where
you intend to use it
• Get yourself trained appropriately
• See how cost effective it is
• Then go for it ……………..
My opinion…

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Thank you ……………..

ALL THE BEST FOR THE ICA 3

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