Pediatric Dental Sedation: How to Select Patients and Assess Airway Risk

Patient Selection and Preparation

All patients scheduled for sedation should be assessed preoperatively and reviewed for risk factors prior to the start of procedure (SASA, 2016).

Physical Assessment

This include medical history questionnaire and recording of vital signs, which serve as a baseline measurement to the day of procedure (SASA, 2020).

Medical questionnaire is filled by the patient/guardian and then revised in depth; it consists of:

Weight, current medications and allergies, previous sedations, general anesthesia, hospitalization, family history (SASA, 2020) and diseases or syndromes especially, central nervous system, cardiovascular system and respiratory system, these systems tend to be affected the most by the action of sedative agents (Jackson & Johnson, 2002).

A useful method of assessing the level of risk involved in treating a child is to assign a physical status classification to the child (Jackson & Johnson, 2002), such as the American Society of Anesthesiologists (ASA) Physical Status Classification (Figure 1).

ASA I & II are considered appropriate for sedation, including mild, moderate or even deep at the dental office (AAPD, 2019), however ASA II patients may become ASA III by the morning of the procedure, that is why children should be evaluated again immediately prior to the procedure (SASA, 2020). ASA III & IV are not recommended for sedation particularly moderate and deep, although, if sedation is still indicated special considerations must be made and should be done in a hospital setting in presence of an anesthesiologist (SASA, 2020).

Airway Assessment

Regarded as the most vital aspects to assess the possibility of adverse events in sedation (AAPD, 2019).

The frontal and lateral view of the face is observed for abnormalities or asymmetries in the mouth, nose and neck (SASA, 2020). Mouth opening is also examined for loose teeth and enlarged tongue also known as macroglossia (SASA, 2020). Examination of the pharynx for enlarged tonsils close to the medial side of the mouth is crucial along with Mallampati classification (SASA, 2020).

Mallampati Classification

Provides different classifications from I to IV (Figure 2) used to assess the patency of the airway and consist of a visual inspection space from the base of the tongue to the roof of the mouth (Malamed, 2010), it’s also used to provide a prediction for the ease of endotracheal intubation (Malamed, 2010).

This technique is done when the patient is in sitting posture with maximal protrusion of the tongue with phonation (Mallampati et al., 1985).

A high Mallampati score (class III or IV) indicates a higher chance of compromised airway and Sleep Apnea under sedation or GA (Malamed, 2010). Sleep apnea is interrupted breathing caused by obstruction of the airway by the tongue and soft palate (Young et al., 2004). It was shown that patients with rigorous obstructive sleep Apnea (OSA) and multiple incidence of desaturation will suffer from malformed Mu-Receptors (Brown et al., 2004), opioid analgesics primarily work on Mu-Receptors (Brown et al., 2004), so childrens with OSA become analgesic at opioid levels of half to one third that of a normal healthy patient (Moss et al., 2006), therefore, lower dosages of opioids must be utilized in these patients (AAPD, 2019).

Facilities and Equipments

Part of providing safe and systemic approach for sedation procedure is following an easy to remember acroynm which stands for the equipment in need, such as SOAPME;

• Suction: Appropriate suction catheters.(AAPD, 2019);(SASA, 2016).

• Oxygen : O2 supply, working flow meters and delivery devices.(AAPD, 2019);(SASA, 2016).

• Airway : Endotracheal tubes, oral & nasal airways, laryngoscope blades.(AAPD, 2019);(SASA, 2016).

• Pharmacy : Basic life saving drugs & antagonists as indicated.(AAPD, 2019);(SASA, 2016).

• Monitors : Pulse oximeter, BP monitors.(AAPD, 2019);(SASA, 2016).

• Equipment : Special equipment for the particular patient.(AAPD, 2019);(SASA, 2016).

  
  

Personnel

This include a sedation-ist who usually is a medical practitioner or an anaesthesiologist that only preforms the sedation procedure(Piercy & Roelofse, 2010), operator-sedation-ist who performs the procedure and sedation(Piercy & Roelofse, 2010) and lastly, dental sedation nurse or sedation assistant that monitors the equipment and record vital signs, sometimes also called an observer.(Piercy & Roelofse, 2010).

Healthcare professionals involved must be competent and trained with the technique used.(SASA, 2020). Personnel trained must be trained with Basic life support (BLS) in case of emergency and Paediatric Advanced life support (PALS) training is also recommended.(AAPD, 2019).

References

• Brown, K.A., Laferrière, A. and Moss, I.R., 2004. Recurrent hypoxemia in young children with obstructive sleep apnea is associated with reduced opioid requirement for analgesia. Anesthesiology: The Journal of the American Society of Anesthesiologists, 100(4), pp.806-810.

• Jackson, D.L. and Johnson, B.S., 2002. Conscious sedation for dentistry: risk management and patient selection. Dental clinics of North America, 46(4), p.767.

• Mallampati, S.R., Gatt, S.P., Gugino, L.D., Desai, S.P., Waraksa, B., Freiberger, D. and Liu, P.L., 1985. A clinical sign to predict difficult tracheal intubation; a prospective study. Canadian Anaesthetists’ Society Journal, 32(4), pp.429-434.

• Moss, I.R., Brown, K.A. and Laferrière, A., 2006. Recurrent hypoxia in rats during development increases subsequent respiratory sensitivity to fentanyl. Anesthesiology: The Journal of the American Society of Anesthesiologists, 105(4), pp.715-718.