Submitted by:

Department of Pedodontics Swati Markandey

Govt. College of Dentistry, indore Ashish Arya
 Introduction
 Behaviour management
 Definition
 Levels of sedation
 Objectives
 Indications
 Contraindications
 Conscious sedation in children
 Prerequisite
 Patient assessment and preparation
 Sedation techniques
 Nitrous oxide and oxygen sedation
 To perform the
highest quality dental
care in pediatric
patients, the
practitioner may
need to use
pharmacologic
means to obtain a
quiet, cooperative
patient.
 Definition:It is defined as means by which the
dental health team effectively and efficiently
performs dental treatment and thereby instils a
positive dental attitude. (Wright,1975)
 Behaviour
Management

Non-
Pharmacological
pharmacologica
approach
l approach

Communi Behaviour Behaviour Premedi Conscious General

cation shaping management cation sedation anaesthesia
A minimally depressed level of consciousness,
that retains the patient’s ability to maintain an
airway independently & respond appropriately
to physical stimulation & verbal commands.

(AMERICAN DENTAL
ASSOCIATION,1993)
 Sedation/analgesia is defined by a continuum of
“levels” ranging from minimally impaired
consciousness to unconsciousness.
 The following terminology refers to the different
levels of sedation intended by the practitioner
Moderate Dissociative Deep General
Minimum sedation
sedation sedation sedation anaesthesia

Remember: Levels of sedation are considered to be

on a continuum because a sedated child can go in
and out of an intended level quite rapidly.
A drug-induced state during which
 Patients respond normally to verbal commands.
 Cognitive function & coordination may be
impaired.
 Ventilatory and cardiovascular functions are
unaffected.
 Note: This level is rarely adequate for an infant
or young child undergoing
sedation for a procedure.
A drug-induced depression of consciousness
during which
 Patients respond purposefully to verbal
commands, either alone or accompanied by
light tactile stimulation.
 Airway is patent, & spontaneous ventilation is
adequate.
 Cardiovascular function is usually maintained.
 (Ketamine) A cataleptic state occurs with both
profound analgesia and amnesia while
maintaining protective airway reflexes,
spontaneous respirations, and cardiopulmonary
stability.
 NOTE: Due to Ketamine’s markedly different
clinical effect, it does not officially fit ASA
sedation continuum. However it is generally
recognized to produce a level of sedation
between moderate and deep sedation.
A drug induced depression of consciousness
during which
 Patients cannot be easily aroused but respond
purposefully after repeated verbal or painful
stimulation.
 The ability to independently maintain
ventilatory function, may be impaired.
 Patients may require assistance in maintaining
a patent airway.
 Cardiovascular function is usually maintained.
 A state of deep sedation may be accompanied
by partial or complete loss of protective airway
reflexes.
A drug-induced loss of consciousness during
which patients are not arousable, even by
painful stimulation.

 The ability to independently maintain

ventilatory function is often impaired.
 Patients often require assistance in
maintaining a patent airway, and positive
pressure ventilation may be required
because of depressed spontaneous
ventilation or drug-induced depression of
neuromuscular function.
 Cardiovascular function may be impaired.
Conscious sedation General anaesthesia

Patient is cooperative , but Patient is uncooperative

anxious and fearful

Generally no extensive At least basic investigations are

investigations are required must.

No premedication is required Premedication is required

Patient is conscious and contact Patient is unconscious.

is maintained

Airway is maintained Ventilation is required

NPO not required NPO strict

Recuperation period is 1-2 Time consuming procedure

minutes
Benett (1978) has stated the objectives to be:
 The patient’s mood should be altered.
 Child’s pain threshold should be increased.
 Amnesia should occur.
 Patient should be cooperative.
 Patient should be conscious, respond to verbal
stimuli.
 All protective reflexes are intact.
 Vital signs stable and normal.
 Dental anxiety and phobia
 Prolonged or traumatic dental procedures
 Medical conditions potentially aggravated by
stress
 Medical conditions affecting the patient’s
ability to cooperate
 Patient lacking cooperation because of lack of
psychological or emotional maturity
 Special needs
 Chronic obstructive pulmonary disease
(COPD), epilepsy, & bleeding disorders.
 Uncooperative or unwilling patients.
 Unaccompanied patients..
 Prolonged surgery.
 Lack of equipment or inadequate personnel.
 Children receive sedation more frequently than
adults
 To meet the necessary goals sedation/analgesia
must be deeper than adults
 Child can easily slip from one sedation level to
another
 Anatomical and physiological differences exist
between children and adults
 Differences in basal metabolic rate
 Difference in respiratory rate
 Airway management
 Reduced tolerance to respiratory obstruction.
 Cardiovascular parameters are different
 Knowledge of the agents to be used
 Consent
 No lack of equipment
 Planned rationale for use of sedation
 Obtaining patient history & information.
 Age, weight, height
 Health history
 Systems review
 Airway evaluation
 ASA Physical Status Classification
 Instructions to parents preop & postop.
 Adequate documentation of the sedation
experience with monitoring of vital signs.
 The acronym “SOAPME” offers a routine
for preparing for sedation.
SUCTION FUNCTIONING SUCTION APPARATUS

OXYGEN ADEQUATE OXYGEN SUPPLY & FLOWMETERS TO

ALLOW ITS DELIVERY
AIRWAY APPROPRIATE AIRWAY (ENDOTRACHEAL TUBES, FACE
MASK)
PHARMACY ALL BASIC DRUDS NEEDED TO SUPPORT LIFE DURING
AN EMERGENCY
MONITORS FUNCTIONING PULSE OXIMETER
EQUIPMENT SPECIAL EQUIPMENT OR DRUGS FOR A PARTICULAR
CASE (E.G. DEFIBRILLATOR)

( AAP/ AAPD GUIDELINES , 2006)

 Inhalation sedation
 Oral sedation
 Intramuscular sedation
 Intravenous sedation
 Rectal sedation
 Submucosal sedation
Name of Dose Indications and benefits Limitations and risks
agent

Nitrous oxide •Used for mild to moderate levels of •Agent has weak potency
anxiety •Not used in children with severe
•Rapid onset, early elimination and behaviour problems
recovery •Cannot be used in
•Duration of action can be controlled claustrophobic patients,
respiratory tract infections
Desflurane Inhaled •Rapid induction of anaesthesia and •Irritating to airway in awake
concentration rapid emergence patients
should be 6-8% •Produces direct skeletal muscle •Result in transient tachycardia
relaxation •Concentration dependent
•No hepatotoxicity and no increase in respiratory rate and
nephrotoxicity decrease in tidal volume
Sevoflurane Inhaled •Non irritating to airway •Hypotension and decrease in
concentration •Does not produce tachycardia cardiac output
should be 2-4% •No heapatotoxicity •Concentration dependent
increase in respiratory rate and
decrease in tidal volume
•Renal injuries and renal
impairment have been reported
Name of agent Dose Indications and Limitations and
benefits risks
Hydroxyzine 1-2mg/kg •Mild sedative along with •Better used in combination with
antiemetic and anticholinergic other drugs
action •Adverse reaction in form of
•Potentiate narcotic and CNS extreme drowsiness and dry
depressant mouth , hypersensitivity

Promethazine 0.5-1.1mg/kg •With sedative and •Better used in combination with

antihistaminic properties
•Potentiate other CNS
depressant
other drugs
•For mild level of anxiety only
•To be used with caution in
children with history of asthma
and sleep apnoea
•Should be avoided in seizure
prone patients

Diazepam 0.2-0.5mg/kg To a maximum •Safe agent for mild to moderate
dose of 10mg anxiety particularly in children
with cerebral palsy, mental
retardation
•Children less than 6 years of
age
•Not effective in severe anxiety
when used alone
•Common adverse reaction in
form of ataxia and prolonged
CNS effect

Meperidine 1-2.2mg/kg Best used in combination with •Poor oral absorption

other agent •Should be used with extreme
caution in patients with hepatic/
renal diseases or history of
seizures
Name of agent Dose Indications and Limitations and
benefits risks

Ketamine 10 and 50mg/ml Dissociative

anaesthesia

Midazolam 1 and 5 mg/ml •Possesses •Little data for

hypnotic, effective dose in
anticonvulsant, paediatric
muscle relaxant context
properties as •Used mainly for
well as being short procedure
antegrade
amnesic and
anxiolytic
Name of agent Dose Indications and Limitations and
benefits risks

Propofol 2mg/kg bolus iv •Suited for •Respiratory

for induction outpatient depression
9mg/kg for surgeries as
maintenance incidence of
postoperative
nausea and
vomiting is low
DESIRABLE CHARACTERSTICS OF
N2O/O2 SEDATION:
 Analgesic Properties (Pain Control)
 Amnestic properties
 Anxiolytic properties (sedative effects)
 Onset of Action
 Recovery
 Elimination
 Acceptance
 It quickly agent crosses the pulmonary
membrane & enters the blood stream.
 It is an insoluble drug & remains unchanged in
blood & does not combine with any blood
elements.
 Since N2O does not break down, so peak
clinical effects may be seen within 3-5 minutes.
 There is no biotransformation & 99% of gas is
rapidly eliminated by the lungs.
 Itproduces nonspecific CNS depression.
 At concentrations 30-50%, N2O will produce a
relaxed & dissociated patient who is easily
susceptible to suggestion.
 Moderate sedation is achieved when N2O
concentration is 50% .
 At concentrations greater than 60%, patients
may experience discoordination, ataxia,
giddiness, and increased sleepiness.
 Concentrations greater than 50% are not to be
used in dental practice.
 The gas is non-irritating to the respiratory tract
 Nitrous oxide is a good analgesic, even 20%
produces analgesia equivalent to that produced
by conventional doses of morphine.
 A mixture of 70% N2O+25-30% O2+0.2-2%
another potent anesthetic is employed for most
surgical procedure.
 The Central Storage System
 The nitrous oxide tanks are always marked
blue for identification, and the oxygen tanks
are green.
 Nitrous Oxide-Oxygen Machine
 Breathing Apparatus
 Nasal hood
 Safety Features
Schematic diagram to show
components of a N2O/O2
delivery & scavenging system
A-Poorly fitting mask with leakage under nares.
B-Well -fitting mask.
•Bag is filled with 100% oxygen and delivered to the
patient for 2/3 minutes at an appropriate flow rate of 5-6
L /minute.
•Once the proper flow rate is achieved, the N2O can be
introduced by slowly increasing the concentration at
increments of 10% to 20% to achieve the desired level.

•SENSATIONS- Felt are floating, giddy feeling with

tingling of digits. The eyes will take on a distant gaze
with sagging eyelids.
 When this state is reached, the local anaesthetic may
be given. Once this is completed, the concentration
can be reduced to 30% nitrous oxide and 70% oxygen
or lower. The patient can now be maintained and
monitored & procedure carried out.
 Recovery can be achieved quickly by reverse
titration. Once the sedation is reversed, the patient
should be allowed to breathe 100% oxygen for 3-5
minutes.
 The patient should be allowed to sit. Even though
psychomotor effects return to normal within 5 to 15
minutes, it is not advisable to allow teenage patients
to drive themselves.
 Plane 1:Moderate sedation and Analgesia
 Achieved with concentration of 5-25%N2O
 Plane 2: Dissociation sedation and analgesia
 Concentration of 25-45% N2O
 Plane 3: Total anaesthesia
 Achieved with 45-65% concentration
 Lightest plane
 Somnolent state
 Deepest plane
 Plane4
 Nausea and vomiting
 Middle ear pressure can increase pain in
patients with acute otitis media.
 Neurotoxicity, renal/liver toxicity.
 The greatest concern regarding toxicity centres
on exposure of dental personnel to high
ambient air levels of the gas during its use for
patient sedation (i.e. longer than 3 hours per
week
 Diffusion hypoxia
 DENTISTRY FOR THE CHILD &
ADOLESCENT; 9th edition; R E McDonald,
D R Avery, J A Dean.
 TEXTBOOK OF PEDODONTICS; 2nd
edition; Shobha Tandon