ORAL SEDATION IN CHILDREN WITH SPECIAL NEEDS

ADVANTAGES OF ORAL SEDATION

• Relative ease of administration by dentists
• Ease of acceptance by patients ?
• Painless administration
• Achieve acceptable levels of moderate sedation
• Unwanted drug effects like overdosage, idiosyncrasy, allergy and side effects are less
likely from oral route

DISADVANTAGES OF ORAL SEDATION

• EASE OF ADMINISTRATION
• UNPREDICTABLE MODE OF SEDATION DUE TO ENTERIC ABSORPTION AND FIRST PASS
METABOLISM
• DRUG UPTAKE SLOWER IN CHILDREN THAN ADULTS
• (GASTRIC PH, EMPTYING TIME, ACTIVITY OF BILE AND PANCREATIC FLUIDS)
• UNAVAILABILITY OF ORAL FORMULATIONS
• INABILITY TO TITRATE
• POST OPERATIVE CARE OR MONITORING MAY BE REQUIRED

ADMINISTRATION OF ORAL SEDATIVE

1. Medical history evaluation - ASA I/II
2. Inform parents about predictability of treatment
3. Discuss with parents about about administration of medicine
4. Fasting instructions followed
5. Medications in past 24 hours
6. Do not re-administer in case of vomiting or spitting
7. Use restroom before procedure

CLINICAL SIGNS
• Glazed look
• Delayed eye movement
• Lack of muscle coordination
• Slurred speech
• Sleepy

DRUG INTERACTIONS WITH MIDAZOLAM

erythromycin and clarithromycin,
 fluconazole and ketoconazole,

antivirals such as efavirenz, fosamprenavir, and nelfinavir

enhance the hypotensive effects of calcium channel blockers

SIDE EFFECTS OF MIDAZOLAM

• Loss of balance

• Diplopia

• Hiccups

• Respiratory depression

• Paradoxical reaction

ADVANTAGES OF NITROUS OXIDE SUPPLEMENTATION OF ORAL MIDAZOLAM

• Potentiate the anxiolytic effect of midazolam

• Additive effect under control of operator

• Make use of analgesic properties of nitrous oxide

• Increases acceptance of dental treatment

ACCEPTABLE SIGNS OF DISCHARGE

• The patient is able to respond to his or her name (MAY NOT BE ELICITED IN CHILDREN

WITH SPECIAL NEEDS )

• Eye opening and eye movement similar to baseline

• Respond to touching or shaking his/her hand

• Ability to maintain a standing posture

• Absence of dizzinessAcceptable vital signs

RAMSAY SEDATION SCALE

MALAMPATTI CLASSIFICATION - ASSESSMENT OF RISK OF AIRWAY

COMPROMISE

Patients with Mallampati scores of III/IV vs. Mallampati scores of I/II are not at an increased risk of adverse

events during pediatric sedation. However, patients with Mallampati III/IV scores showed an increased need
for repositioning, suggesting that the sedating dentist should be vigilant when performing sedation in
children with higher Mallampati scores.

AIRWAY ASSESSMENT PROCEDURES FOR SEDATION AND ANALGESIA

Positive pressure ventilation, with or without tracheal intubation, may be necessary if respiratory
compromise develops during sedation–analgesia. This may be more difficult in patients with atypical airway
anatomy. In addition, some airway abnormalities may increase the likelihood of airway obstruction during
spontaneous ventilation. Some factors that may be associated with difficulty in airway management are:

History

 Previous problems with anesthesia or sedation

 Stridor, snoring, or sleep apnea

 Advanced rheumatoid arthritis

  Chromosomal abnormality (e.g., trisomy 21)

Physical Examination

Significant obesity (especially involving the neck and facial structures)

Short neck, limited neck extension, decreased hyoid–mental distance (3 cm in an adult), neck mass, cervical
spine disease or trauma, tracheal deviation, dysmorphic facial features (e.g., Pierre-Robin syndrome)

Mouth- Small opening (3 cm in an adult); edentulous; protruding incisors; loose or capped teeth; dental
appliances; high, arched palate; macroglossia; tonsillar hypertrophy; nonvisible uvula

Jaw- Micrognathia, retrognathia, trismus, significant malocclusion

SUMMARY OF AMERICAN SOCIETY OF ANESTHESIOLOGISTS PREPROCEDURE FASTING

GUIDELINES

Ingested Material Minimum Fasting Period

Clear liquids 2 hours

Breast milk 4 hours

Infant formula 6 hours

Nonhuman milk 6 hours

Light meal 6 hours

PRACTICE GUIDELINES

* These recommendations apply to healthy patients who are undergoing elective procedures. They are
not intended for women in labor. Following the Guidelines does not guarantee a complete gastric
emptying has occurred. The fasting periods apply to all ages.Examples of clear liquids include water,
fruit juices without pulp, carbonated beverages, clear tea, and black coffee.Since nonhuman milk is
similar to solids in gastric emptying time, the amount ingested must be considered when determining
an appropriate fasting period.A light meal typically consists of toast and clear liquids. Meals that
include fried or fatty foods or meat may prolong gastric emptying time. Both the amount and type of
foods ingested must be considered when determining an appropriate fasting period.