PHARMACOLOGICAL MANAGEMENT OF PEDIATRIC PATIENTS

Current understanding of pediatric dentistry includes:

➔ Absence of fear and anxiety.
➔ Maintenance of healthy oral structures and good oral health throughout life.
➔ Recognition of the expanding need for delivering painless treatment to children; the elective and
emergency use of sedative agents became an important part of pediatric dentistry practice.

Sedation in pediatric dentistry: The decision to sedate a child requires careful consideration by an experienced
team. The choice of a 1) particular technique, 2) sedative agent and 3) route of delivery should be made at a
consultation appointment to determine the suitability of a particular child (and their parents) to a specific
technique.

What are the goals of pharmacological management of the pediatric patients?

➔ Provide the best environment for high quality dentistry
➔ Control inappropriate behavior that might interfere with the treatment.
➔ Produce in the patient a positive attitude toward dentistry.
➔ Promote safety and welfare of the patient

Levels of sedation by ASA:

Minimal Sedation Moderate Sedation Deep Sedation General Anesthesia

Drug induced state during
which patient:
a) Respond normally to verbal
commands.
b) Impaired cognitive function
and coordination.
c) Maintain airway
independently and
continuously.
d) Respiratory system and
cardiovascular system
unaffected.
Drug induced depression of
consciousness enabling treatment
but during which patient:
a) Maintain airway independently
and continuously.
b) Respond appropriately to
physical stimulation and verbal
commands
(open your eyes).
c) Retain protective reflexes
(laryngeal reflex).
d) Respiratory System &
Cardiovascular System usually
maintained.
Drug induced depression of
consciousness during which
patient:
a) Respond purposefully following
repeated or painful stimulus or
verbal command.
b) May require assistance to
maintain the airway (ventilation).
c) Respiratory System and
Cardiovascular System usually
maintained.
i.e. unarousable by painful
stimulation (depression of
neuromuscular function).
Drug induced loss of
consciousness during which
patients:
a) Are not arousal even by
painful stimulation.
b) Depression of neuromuscular
function.
c) Patients often require
assistance in maintaining a
patent airway.
d) Cardiovascular System may
be impaired.

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 TYPES OF SEDATION USED IN PEDIATRIC DENTISTRY
1. Conscious sedation (moderate sedation): Is a drug induced depression of consciousness during which
patients respond purposefully to verbal commands (e.g. open your mouth) and are able to maintain a
patent airway independently.

● Prerequisites:
➢ Knowledge and experience of the practitioner with the different agents and
techniques used.
➢ Full consultation with the pediatrician of the patient.
➢ Informed consent of the parents.
➢ Office facilities that include equipment, area facilities, and location.

Indications Contraindications

Psychological Indications relating to anxieties regarding dental treatment
include:
a. Phobias:
● General: things in mouth, all dental
procedures
● Specific: drills, needles, extractions
b. Gagging: inability to tolerate objects intraorally
without stimulating the gag reflex.
c. Persistent fainting during procedures, often
associated with the site and administration of local
analgesics.
d. Idiosyncrasy to local analgesics: patients who have a
problem where local analgesics appear not to work;
the cause of the failure is sometimes psychological
rather than physical.
1. Patients must be willing and co-operative. A
failure to consent for treatment is an absolute
contraindication to the provision of care under
sedation.
2. Unaccompanied patients: A responsible adult,
who will remain with them until their recovery is
complete, must accompany patients who are
receiving sedation. The only exception to this rule is
for adult patients who are receiving inhalation
sedation with nitrous oxide and oxygen. Such
patients may be allowed to attend without an escort
provided that the dentist feels it is appropriate. A
responsible adult must accompany children receiving
inhalation.

Medical Some conditions may be aggravated by the stress of 1. Severe or uncontrolled systemic disease.
undergoing dental treatment: 2. Severe learning or movement difficulties.
a. Asthma 3. Chronic obstructive pulmonary disease.
b. Epilepsy 4. Severe psychological/psychiatric problems.
c. Psychosomatic illness 5. Thyroid dysfunction.
d. Mild-to-moderate mental and physical handicap
e. Spasticity disorders

The use of sedation aids the management of these patients. It

is an important requirement that the patient or parents are
able to understand what is being done.

Dental Sedation may be required for difficult or unpleasant
procedures. The proper prescribing of sedation for these
indications can help to prevent many patients
having to suffer unpleasant experiences (ex. Early Childhood
Caries)
1. Those procedures considered too long or too
difficult to be earned out under local analgesia.
2. Where the presence of spreading infection in the
floor of the mouth threatens the airway, in such
cases the airway must be secured under general
anesthesia (ex. Facial cellulitis/risk of Ludwig’s
angina)

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All forms of dental treatment may be carried out under sedation. The judgment as to whether it is appropriate
to carry out any particular treatment must be made on a patient-to- patient basis.

Patient assessment: preoperative assessment is among the most important factors when choosing a particular
form of sedation:
1. Age
2. Weight
3. Medical & dental history
4. Patient medical status according to ASA classification
5. Assessment of airway: suitability for conscious sedation or GA?
6. Dental procedure being performed
➔ Patient assessment aims to discover which sedation is required and suitable.

I. Dental History:
● Current dental history
● Patient’s pattern of attendance
● Any specific fears: aid in treatment planning.
● Potential cooperation once sedated
● Patients who are phobic of anything in their mouths tend to cooperate less well than those with a
specific fear (e.g. needles/drills).

II. Medical history:

● Standard questions
● Previous history of sedation
● How the patient coped
● Current drug history
● Past drug history
● Allergies (sticking plaster and latex allergies)

Patient medical status according to American Society of Anesthesiologists (ASA) classification:

- Class I: A normally healthy patient → conscious sedation without consultation.
- Class II: A patient with mild systemic disease (eg, controlled reactive, airway disease) → conscious
sedation without consultation.
- Class III: A patient with severe systemic disease (eg, uncontrolled diabetic patient) → consider
medical consultation.
- Class IV: A patient with severe systemic disease that is a constant threat to life → mandatory
involvement of anesthesiologist (ex. Systemic lupus patient)
- Class V: A moribund patient who is not expected to survive without the operation → mandatory
involvement of anesthesiologist (ex. Late stage cancer patient)

III. Dental examination:

● Increased difficulty with anxious patients: may not permit/tolerate the use of probes (even
periodontal ones).
● The reaction to the examination helps in the assessment of the level of anxiety. It also allows
appropriate radiographs to be prescribed.

IV. Physical examination:

● Hypertensive patients (systolic pressure more than 160 mmHg or diastolic more than 100 mmHg)
should be referred for investigation.

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 ● If inhalation sedation is proposed, make sure of a patent nasal airway.
● If intravenous sedation is proposed, it’s important to establish if there are visible veins, and make
sure to ask about any previous problems with cannula insertion.

★ Antidote is given IV.

V. Establish rapport with the patient & deal with misconceptions:

● This step is important as most patients needing sedation will relate tales of a previous bad
experience at the dentist.
● The most important part of building a rapport is to persuade the patient that you’re different from
the previous dentists.
● Deal with any misconceptions, such as the difference between amnesia, as induced by sedation, and
unconsciousness.
● The patient should be given a written informed consent form at the assessment appointment to be
filled by the parent.

Monitoring of sedated patients: All patients who are having any form of dental treatment should be
monitored by those who are providing that treatment.
➔ The importance of monitoring is greater when patients have been sedated, as they are:
◆ less aware of their surroundings and any changes that are occurring within their own bodies
◆ Respond to verbal command
◆ The patient looks relaxed and comfortable
◆ Normal skin color
◆ Electromechanical monitoring (pulse oximetry)

➢ Monitoring equipment:
1. Stopwatch
2. Automated blood pressure device
3. Pulse oximetry (blood/O2 concentration)
4. Capnograph (monitor expired Co2 levels, useful but not compulsory)
5. Emergency equipment as for all dental surgeries: defibrillator, advanced cardiac life support,
resuscitation and masks of appropriate sizes (Ambu-bag)
6. Flumazenil (benzodiazepines antagonist) & Naloxone (opioids)
7. Facility to give supplemental oxygen.
8. Special Dental Equipment
9. Mouth props
10. Dental chair with high facility

Techniques for conscious sedation: techniques that utilize drugs to induce a cooperative, yet conscious state
in an otherwise uncooperative child are most commonly referred to as techniques of conscious sedation.
1. Inhalation sedation (relative analgesia or nitrous oxide oxygen sedation).
2. Oral sedation.
3. Intravenous sedation.
4. Intramuscular sedation.
5. Rectal sedation.
6. Nasal sedation.

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 1. Inhalation sedation (nitrous oxide/oxygen):
● Also known as relative analgesia, inhalation psycho-sedation
● All the widely available techniques involve the use of mixtures of nitrous oxide and oxygen.
● Nitrous oxide induces a euphoric condition that modifies the pain threshold without loss of
consciousness. Local anesthesia is still required for painful procedures. The technique is very
useful with many patients who may be needle phobic, but are otherwise comfortable with
dental procedures, as the technique is sometimes specifically indicated to allow local
anesthesia to be administered and may be turned off following the injection.

❖ Characteristics of nitrous oxide:

1. It is odorless, colorless and not explosive.
2. Its onset is rapid. The patient is easily maintained at the desired level of
euphoria and there is rapid reversibility.
3. Fear and anxiety are diminished.
4. It produces a euphoric state and obtunds pain to a lesser degree.
5. The gas does not react chemically with body fluids and is excreted
unchanged through the lungs.
6. Side effects of the procedure are minimal.
7. There is no danger of addiction with minimal times of exposure.

Indications Contraindications

● Relieving anxiety.
● Anxious but cooperative children
● Mature children who are big enough to
be helpful during the dental procedures
1. Respiratory conditions such as common cold which prevent the patient
from breathing through his nose, also pulmonary conditions such as
bronchitis, emphysema, tuberculosis & pulmonary fibrosis.
2. Children with certain psychiatric disorders (several behavioral problems
and emotional illness).
3. Children with a history of motion sickness; who may experience vomiting
when nitrous oxide is administered.
4. Patients in the first trimester of pregnancy.
5. Respiratory tract infections.
6. Chronic obstructive airway disease.
7. Very resistant and uncooperative children and <3 years

Equivalents used for Nitrous oxide sedation

The equipment contains:
● Flow meters with valves to indicate the volume of each gas delivered to the patient in terms
of liters/min.
● An oxygen fail-safe mechanism, which will automatically shut off nitrous oxide flow if the
oxygen supply should fail.
● A double mask which has two openings, one allows inhalation of the nitrous oxide/oxygen
mixture and the other allows exhaled gases to escape.
● As a safety precaution, color coding is used for the storage of cylinders, hoses, flow meters
and outlets. (Green designates oxygen and blue designates nitrous oxide)

Administration of nitrous oxide sedation

● Before the administration of nitrous oxide to any patient, it is necessary to describe to the parents
and child what nitrous oxide sedation is and how it will affect the child’s behavior and acceptance of
dental work.

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 ● The preparation of the child includes introducing the equipment and explaining the hoses, gauges,
and nasal inhaler in terms of what the astronauts must wear when they take their space flights.
● Start administration with 100% oxygen, gradually introduce Nitrous oxide (100% oxygen for 3.5
minutes, introduce 5%-10% nitrous oxide every 3.5 minutes), final concentration 70% oxygen and 30%
Nitrous oxide.
● Describe sensations to the patient (floating, tingling of digits....).
● By the end of the session introduce 100% oxygen for two minutes (for reversal).
● After recovery the child must be discharged into the care of a responsible adult.

Signs & symptoms of adequate sedation with Nitrous Signs & symptoms of over sedation
Oxide

● The patient is awake. ● Persistent mouth closing

● The patient is relaxed and comfortable. ● Spontaneous mouth-breathing
● Vital signs are within normal limits ● Patient complains of unpleasant feelings
● Blink rate is reduced. ● Lack of cooperation
● Respond to verbal commands. ● Nausea and vomiting.
● Protective reflexes are normal.
● Lessened awareness of pain.
● Anesthesia, tingling, euphoria.
● Dreaming and indifference to passage of time

The treatment of a patient who is over sedated involves reducing the concentration of inspired nitrous oxide
by 5-10%, and reassuring the patient that things will improve.
Recovery from sedation:
● Once dental treatment has been completed, the patient is allowed to breathe 100% oxygen for 2
minutes.
➔ This allows the nitrous oxide to be exhaled via the scavenging system rather than into the
surgery.
➔ It can also prevent a phenomenon called diffusion hypoxia, which may arise owing to the
rapid release of nitrous oxide from blood when it is removed from the inspired air.

● After recovery, a child patient must be discharged into the care of a responsible adult. Adults may be
discharged alone and it is the dentist's responsibility to decide if the patient needs to be accompanied
or not.

Advantages of inhalation sedation Disadvantages of inhalation sedation

1. Rapid onset of sedation. The relative insolubility of nitrous 1. Bulk of equipment. The equipment required for the
oxide in blood results in the peak levels of nitrous oxide being administration of inhalation sedation is bulky and can
attained within 3-5 minutes of inhalation. cause problems in a small surgery.

2. Rapid recovery. There is effectively no metabolism of nitrous
oxide; recovery is by exhalation of the gas via the lungs. The same
factors that produce rapid induction of sedation lead to rapid
recovery.
3. Recovery is independent of treatment time. Once a stable level
of sedation is achieved, the continued administration of nitrous
oxide merely maintains the equilibrium of blood: alveolar
concentration. Consequently, patients recover as rapidly whether
2. Expense of equipment. The equipment that is to be
used must be a dedicated inhalation sedation machine.
It is not acceptable to have a general anaesthetic
machine that is used for both types of treatment. This
is because (GA) machines do not have the same safety
features as relative analgesia machines.
In addition to the equipment for drug administration, a
scavenging system to remove expired gases is required.

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 they have been treated for 10 minutes or 2 hours.
4. Absence of metabolism. Only 0.0004% of the inspired nitrous
oxide is absorbed. The almost total absence of metabolism
accounts for the safety of nitrous oxide and its ability to be used in
a wide range of patients.
5. The technique does not involve an injection. Many patients are
frightened of needles and the fact that nitrous oxide
administration does not require an invasive technique is an
advantage.
6. A degree of analgesia is produced. Although the use of
inhalation sedation will not provide sufficient analgesia to allow
dental treatment to be carried out, it will make the administration
of local anesthetic injections easier.
Finally, once in use, the costs of the gases must be
taken into account.
3. Intrusion of nosepiece into the operating field. This
can be a problem when treating upper anterior teeth.
Disruption of the seal in this area will result in both a
decrease in the effectiveness of sedation and an
increase in chronic exposure of staff.
4. Patient's perception of equipment. Patients who
have had a previous bad experience associated with
general anesthesia may find that the nosepiece
reminds them of the GA mask.

7. Inhalation sedation can be used on virtually all patients.

Inhalation sedation has very few contraindications and is the only
technique currently recommended for patients of all ages.
Adverse side effects:

Acute effects on patients Chronic effects on dentist & assistant Safety Recommendations

● Diffusion hypoxia
● Bone marrow depression,
due to prolonged use in long
term sedation of chronic
pain.
The following effects tend to be seen only when there is a. Use minimum effective
no active scavenging of waste gases: dose
● Decreased fertility in female staff b. Use scavenger equipment
● Increased rate of miscarriage in staff and partners c. Vent exhaust gases to
of staff outside
● Increased incidence of liver disease d. Check delivery system for
● Depression of hematopoiesis leakage monthly
● Neurological effects: CNS degeneration
● Malignancy, especially cervical carcinoma.

2. Oral Sedation
The administration of oral drags is an attractive way of producing sedation. This is largely because of the
simplicity of the technique as far as the dentist is concerned and the acceptability for patients.

Indications Advantages Disadvantages

● Children of ages ● Ease of 1. Prolonged latent period: 30 minutes to 1 hour. Patients who require
2 to 8 years. administration sedation do not enjoy being in the dental environment, and waiting
● Children ASA for most children. for the sedation to act can be traumatic.
stage I or II. ● Oral sedatives are 2. Unpredictable dose: The other techniques that are recommended
● Short or simple administered for sedation involve titrating the dose of sedative drug to the
procedures. mixed in a drink. patient's response. The long latent period involved with oral
● Parents who are ● The dose is sedation means that once the dose has been administered it cannot
fit for the calculated be altered.
technique according to body
(cooperative and weight. Recommended doses range between 10 and 40 mg. This wide variation in the
understanding amount of drugs means that success is unpredictable.
parents)
3. Unpredictable absorption. There are many factors that affect the

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 absorption of drugs from the gastrointestinal tract. Elixirs and
gelatin filled capsules tend to be absorbed more rapidly than tablet
formulations. Other factors include the amount, timing and
constituents of any food in the stomach. Consequently, it cannot be
predicted exactly when the drug that has been administered will
have its effect.

4. First pass metabolism: All drugs that are administered orally and are
absorbed from the upper part of the gastrointestinal tract pass to
the liver via the portal circulation.
5. A significant proportion of the dose is metabolized as it passes
through the liver prior to reaching the systemic circulation (first-pass
metabolism). As a result, a higher dose must be used for oral drugs
to achieve the desired effect.

Drugs for oral sedation:

● Chloral Hydrate (most commonly used): 50 mg/kg body weight (maximum 1 gm)
● Benzodiazepines:
○ Midazolam: mixed in a drink, 0.5 mg/kg body weight (max. 20 mg and the adult dose is 20
mg).
○ Diazepam: sedation for 20-30 minutes.

Technique for oral sedation:

● A suitably trained member of the dental team must supervise the patient once the sedative has been
administered. The patient should be either sedated in the dental surgery or, if this is not possible,
moved to the surgery as soon as sufficiently relaxed to allow this.
● Electromechanical monitoring should ideally be commenced before administration of the sedative.
● Discharge after sedation depends on the patient being sufficiently recovered to walk unaided and
being sufficiently co-coordinated to be discharged into the care of a responsible adult.
● If the drug was inadequately administered or it did not work efficiently, stop the treatment, schedule
another appointment, and adjust the dose.

3. Intravenous Sedation
● Intravenous sedation is commonly used for anxious adult patients.
● In children it might be inappropriate as most children are frightened from needles.
● The technique requires a highly trained team including a qualified anesthetist.
● A combination of drugs (midazolam and an opioid analgesic fentanyl) is usually used.

Indications Advantages Disadvantages

● Child patients 8 1. Speed of onset of sedation. The hand-to-brain 1. The establishment of intravenous
years of age or circulation time is of the order of 20 seconds; as a result, access; many patients find the process of
older. the onset of sedation is very rapid. This prevents an having an intravenous cannula sited
increase in anxiety while waiting in the dental environment. unpleasant.
● Child is ASA stage I
or II. 2. The dose of sedative can be titrated against the 2. Rapid onset. The rapid onset of the
patient's response. The patient receives the correct dose effects of intravenous drugs means that
● Child and parents of sedative for their needs. care must be taken to ensure that patients
are both are not over sedated.
cooperative. 3. Administration is comfortable when an expert gives it.

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 Once venous access is achieved, the patient is not troubled 3. Adverse reactions. Any adverse reactions
● Adequate venous by subcutaneous sedation. to the drugs tend to be more severe if the
access. drugs are administered by injection rather
4. Recovery: This is shorter than for drugs administered via than orally.
● Short dental the oral or intramuscular route.
procedures. 4. No easy reversal is possible. There is no
way to recover the drug once it has been
administered. The only way to reverse
sedation is by the use of antagonist drugs.

Equipment required for IV sedation:

● Surgical wipe to disinfect skin
● Gauge intravenous cannula
● Surgical tape to fix cannula
● Syringes (5 ml) to administer sedative and saline flush, gauge needle to draw up drug
● Labels to distinguish syringes
● Tourniquet
● Disposable tray

Technique of IV sedation: The primary prerequisite for the use of intravenous sedation is that all those
involved in the patient's treatment have received the appropriate training and the surgery is equipped with
the appropriate scale of equipment for administering the sedation, monitoring the patient and dealing with
any emergencies. Both dentist and dental nurse should have attended relevant postgraduate / post
certification courses.

Preparation of the drug Preparation of the patient

All drugs to be used for sedation (including normal saline) must be
drawn up by the dentist (not the nurse) administering the sedation.
As with all agents to be administered to patients (including local
anesthetics), agents must be checked to ensure that they have not
passed their expiry date and that there are no signs of damage to
the containers in which they are supplied.
Once drawn up, drugs must be clearly labeled as there are many
clear solutions, which can easily be confused.
It is important to ensure that all the formalities have been
completed before the patient is sedated. This will include
checking that the patient has signed a consent form and that
their blood pressure has been recorded.
The patient's medical and dental histories should also be
checked to ensure that nothing has happened since the
previous appointment either to change the dental treatment
plan or to modify the choice of sedation technique.
Cannulation is a prerequisite for carrying out intravenous
sedation. It is important to select a site that is accessible to
the dentist, acceptable to the patient, away from structures
that might be damaged in the process.

Signs of adequate sedation:

● A depth of sedation that will allow the patient to have treatment is often referred to as the
'endpoint', implying that it is discrete, and apparent. This is not the case.
★ There is a plane of sedation within which the patient needs to reach to allow treatment to be
undertaken.
★ Different patients will require being at different levels within this plane of sedation; indeed,
the same patient may require to be at different levels of sedation depending on the type of -
treatment proposed, and how they are feeling in general.

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 ● The judgment of the correct depth of sedation largely comes down to clinical experience. An adjunct
to assessing the adequacy of sedation is to ask the patient if they are ready to have dental treatment.
A slow, ponderous answer is usually indicative of the correct level of sedation. In general, once an
adequate level of sedation has been achieved, the duration of the dental treatment should be tailored
to the duration of the sedation, and no further increments of sedative given.

Recovery from intravenous sedation:

● Patients recover much more slowly from intravenous sedation than from inhalation sedation.
● It is impossible to set strict time limits on when patients should be discharged.
● It is more important to assess the patient's state of mind and ability to leave the surgery premises.
● A useful test is to ask the patient to walk across the room, turn and walk back. If they can negotiate
that test without undue loss of balance, they are probably fit to be discharged.
● It is also worth checking that the patient is happy to leave, and that the escort is happy to take them.
● All patients receiving intravenous sedation must be charged into the care of a responsible adult.

Complications of IV sedation: associated with IV cannulation.

All of the following responses are difficult to cope with, and patients in these categories should be
treated by those who are experienced in using sedation.
● Venospasm. This is a condition, probably anxiety related, where the veins collapse at attempted
cannulation. It is difficult to prevent even for those skilled at cannulation.
● Extra vascular injection. This results from an incorrectly sited cannula. The main thing is to prevent
the extravascular injection of any pharmacologically active agent by testing that the cannula is
correctly sited.
● Intra-arterial injection. Injection of drugs into an artery is a potentially serious event. Once again it
should be prevented by careful technique, particularly by checking that any vessel that is selected as a
potential Cannulation site does not pulsate.
● Hematoma formation. A hematoma forms as a result of blood leaking from a blood vessel into the
subcutaneous tissues. Formation may occur at cannulation, as a result of multiple vein wall punctures
or when the cannula is removed as a result of insufficient pressure being applied to the site.
● Pain on Cannulation. Venous cannulation is uncomfortable, but for most patients it can be overcome
with the use of distraction techniques.

4. Intramuscular Sedation
Injection of sedative agent into skeletal muscle mass.
● Used to produce deep sedation in very uncooperative young patients (generally can’t be adequately
sedated by oral, IV, or inhalation).
Injection sites:
1. Upper lateral quadrant of the buttock
2. Anterior aspect of the upper thigh
3. Lateral aspect of the upper arm

Advantages Disadvantages

1. More rapid action than oral route. 1. Delayed absorption of drug.

2. Doesn’t require patient cooperation. 2. Possibility of tissue trauma at injection site.

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 5. Rectal Sedation
Most appropriate for very young children.

Advantages Disadvantages

1. Used as a substitute for oral sedation (gastritis & vomiting) 1. Psychological trauma leads to refusal.
or dislike injection. 2. Rectal infection on repeated use.
2. Most reliable.
3. Most controllable.

6. Nasal Sedation
● By using an atomizer.
● High effect: rapid absorption into the CNS (nasal mucosa the only location in the body that provides a
direct link to CNS).

Advantages:
1. No compliance (effective for uncooperative children).
2. Rapid onset.
3. High benefit in case of emergency.
4. High bioavailability.
5. Alternative in case of gastric irritation

Problems associated with sedation

● Over sedation. The most likely sign of a patient being over sedated is respiratory depression. In the
majority of patients, this can be managed by encouraging the patient to breathe and by support until
the overdose wears off. In more severe cases, supplemental oxygen may be required; should that fail,
the sedation should be reversed with the benzodiazepine antagonist.
● Hypo-response. The patient fails to sedate despite the use of large doses of sedative.
● Paradoxical reaction. The patient appears to have sedated normally but reacts in an uncontrolled
fashion- when treatment is attempted.
● Hyper-response. The patient sedates very deeply on a very small dose of sedative.

General Anesthesia
Defined as a controlled state of unconsciousness accompanied by a loss of protective reflexes.

● Indications:
1. Severe dental diseases in children with physical handicapping or involuntary movements.
2. In children where an adequate control of their behavior cannot be achieved by other
methods.
3. In cases where an allergy to local anesthesia is known
4. Children with systemic disturbances or congenital anomalies that indicate the use of general
anesthesia.
5. Maxillofacial surgeries, neurosurgery and orthopedic services
6. Patients who can’t cooperate due to lack of maturity or medical disability.
7. Extremely uncooperative, fearful, anxious or uncommunicative children.
8. Patients requiring immediate comprehensive oral or dental needs.

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● Undesirable aspect of G.A:
1. Hospitalization may be a psychic trauma.
2. No patient should be exposed to G.A without sufficient cause.
3. All dental treatments should be performed in 1 visit.

● Pre-anesthetic assessment for general anesthesia includes:

➔ A medical history and examination by the anesthetist is required prior to the procedure.
➔ Behavioral and developmental issues (e.g., autism, developmental delay, extreme anxiety
and needle phobia).
➔ Vital signs (temperature, pulse, respiration rate and blood pressure).
➔ Measurements (body weight and height).
➔ Syndromes
➔ Respiratory diseases and airway problems.
➔ Neurological disease e.g., epilepsy, previous brain injury, cerebral palsy.
➔ Endocrine and metabolic disorders e.g., diabetes.
➔ Gastrointestinal problems e.g., reflux, difficulty swallowing or feeding.
➔ Hematological disorders e.g., hemophilia.
➔ Allergies including latex allergy.
➔ Medications must be documented. Most medications should be continued until the time of
anesthesia unless there is a clear reason to withhold (e.g., anticoagulants).

● Instructions to the parents

○ Fasting: Normally, the stomach is empty of clear fluids two hours after ingestion. Accepted
practice for fasting before general anesthesia is 6 hours from solids and milk.
○ Any change in the child's health the few days before the operation must be reported.
Sometimes it’s better to delay elective anesthesia for 2-3 weeks (e.g., cases of upper
respiratory tract infection).
○ The child must be accompanied by a responsible adult on arrival and departure.

● Operating theater environment:

○ Minimize the waiting time prior to the procedure.
○ Leave children in their own clothes in case of routine restorative procedures.
○ Allow parents to be present during induction of anesthesia and in the recovery area.
○ Reassure parents at all stages.
○ Premedication and induction: some children may require oral premedication prior to
anesthesia (paracetamol 15mg/kg and midazolam 0.2-0.5 mg/kg)
○ Induction may be intravenous or gaseous.
★ Induction:
Induction is the process by which the patient is brought from a state of consciousness into surgical
stages of anesthesia. This is usually accomplished through the use of inhalation agents. The induction
procedure can be a stressful psychological experience for the unprepared patient, and every effort
should be made to minimize this stress.

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● Sharing the airway:
➔ Nasotracheal intubation: a hollow tube is inserted into the trachea through the nose.
Nasotracheal intubation provides good access for both the dentist and the anesthetist and is
preferable for oral procedures.

➔ Oro-tracheal intubation: The tube is inserted into the trachea through the mouth; it provides
a satisfactory airway for the anesthetist but may not give the dentists the access they
require.

➔ Face masks may be used for simple extractions.

● Securing the Endotracheal tube

● The endotracheal tube (nasal or oral) and all of the monitoring equipment must be
appropriately secured to prevent displacement and possible injury to the patient.

● Restorative dentistry in the operating room:

○ Before the dental procedures:
➔ Eye protection using special eye guards to cover the eyes or using surgical sheet and triangular
draping of the oral cavity area.
➔ Perioral cleaning using three sterile gauze pads:
◆ the first pad is saturated with a bacteriostatic agent
◆ the second with sterile water
◆ the third with alcohol.
➔ Draping the child’s body.
➔ Mouth opening with the aid of a mouth prop.
➔ Placement of pharyngeal throat packs (moistened 2-3-inch gauze that’s placed in the patient’s
pharynx to make a tight seal around the endotracheal tube and to prevent any foreign debris from
entering the pharynx).
➔ A thorough intraoral examination and radiographic assessment if needed.
➔ Local anesthetics may be used to minimize pain and bleeding.
➔ The use of quadrant isolation with a rubber dam is preferred if possible.
➔ All carious lesions should be restored.
➔ Topical fluoride treatment should be applied before removal of rubber dam.
➔ Surgical procedures (e.g. extractions) should be delayed till the end of the procedures.
➔ Before waking the patient all foreign material such as rolls, gauze throat packs must be removed
and accounted for.

● Postoperative care: postoperative instructions and consultation notes should be completed by the
dentist and recorded in the medical chart.
○ Effective communication with parents or guardians to assure cooperation in performing oral
health care procedures.
○ Follow-up visits.

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● Special considerations for sedation in pediatric dentistry: the use of any form of sedation in children
presents an added challenge to the clinician.
a. Children’s responses are more unpredictable than adults.
b. Children may be easily over-sedated as their smaller bodies are less tolerant to sedative
agents.
c. Anatomical differences between the adult and pediatric airways (children have a relatively
larger tongue and epiglottis, possible presence of large tonsillar/adenoid mass besides
having smaller lung capacity).
d. The use of monitoring devices such as pulse oximetry is mandatory for moderate and deep
sedation.
e. Any dentist who sedates children must be capable of resuscitating the patient or rescuing a
patient from a deeper level of sedation than the one intended.

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