Sedation in Pediatric Dentistry: Levels, Indications, Contraindications and Clinical Goals

Behavior management is considered the foundation of pediatric dentistry, it consists of pharmacological and non-pharmacological approaches (Ashely et al., 2018). Majority of the pediatric patients can be managed with conventional behavioral management (Jain et al., 2020), however, very young patients who cannot overcome their fear, are extremely anxious and have special needs may require a sedative agent (AAPD, 2019). Diagnostic and minimal surgical procedures performed on pediatric patients has increased in the past several decades (AAPD 2019), along with the advancement and increased understanding of the significance of anxiolysis and analgesia, the need for sedation has raised (AAPD, 2019). Nevertheless, pharmacological management is not a substitute for effective communication and persuasive ability of the dentist (Hosey, 2002).

Definition and Goals of Sedation

Sedation is a drug-induced depression of consciousness that allow reduction of physical discomfort and pain, accompanied by behavior modification. No need for interferences to support a patent airway, and involuntary breathing is adequate (ASA, 2019). The patient is safely discharged from sedation unit after returning to the normal healthy state (ASA, 2019).

Levels of Sedation

Sedation encompasses a continuum of altered state of consciousness, varying from minimal sedation and anxiolysis to deep sedation and general anesthesia (SASA, 2020).

Minimal sedation is a state of anxiolysis where the patient can respond normally to verbal stimulus, and can maintain the airway (SASA, 2020).

Moderate sedation is a state of anxiolysis where the patient can only respond to a purposeful verbal stimulus and can maintain airway (SASA, 2020).

Deep sedation is a state of anxiolysis where the patient cannot respond normally to verbal stimulus but can respond to painful stimulus and may need assistance to maintain airway (SASA, 2020).

General anesthesia is a state of unconsciousness where the patient does not respond to any type of stimulation and have impaired ventilation which require ventilation under positive pressure (SASA, 2020).

The response of pediatric patient to different sedation medication is different than adults, due to the physiological growth, smaller masses and lower weight (SASA, 2020), therefore, the tendency to go into deeper levels of sedation is high (AAPD, 2019), that’s why a health care professional trained in sedation must be trained in basic life support in case of emergency (SASA, 2020).

Indications of Sedation

Guidelines shared by the South African Society of Anesthesiologists included:

• Dental phobia, anxiety and injection phobia (SASA, 2020).

• Special needs patient with ability to communicate (SASA, 2020).

• Patient with uncooperative behaviour (SASA, 2020).

• Increased gag-reflex (SASA, 2020).

• Patients 4 years of age and above (SASA, 2020).

• Moderate extensiveness of dental treatment (SASA, 2020).

Contraindications of Sedation

This also may serve as the indications of general anesthesia (GA) vs. sedation.

• Prolonged and extensive treatment plan that require multiple sedation appointments (SASA, 2020).

• Availability of theatre, personnel and equipments with consideration for the cost (AAPD, 2019).

• Mouth breathers that need intubation (SASA, 2020).

• ASA III or higher (SASA, 2020).

• Mallampati class 3 & 4.

• Weight under 15Kg (SASA, 2020), it was shown that children with smaller bodies and weight have a higher tendency for adverse effects of medication including loss of consciousness (SASA, 2020).

• Patient undergoing chemotherapy (Silva et al., 2015).

• Obese children (SASA, 2020).

• Patients with no communication ability such as special needs children or children of very young age (under 4 years old) (Silva et al., 2015); (SASA, 2020).

However, if the patient had a slight ability to communicate, it is preferable to allow adequate behavioural management to establish cooperation at a young age by performing sedation (AAPD, 2019). In sedation the patient can respond to verbal stimulus and is conscious, reduced anxiety. In conclusion general anesthesia should be preserved as the last resort (SASA, 2020).

A study have shown that parents may prefer sedation over GA to avoid known consequences, however, dentists and anesthesiologists preferred GA as it is easier to monitor patients' vital signs and in maintaining safe airway (Al Karaawi, 2019).

Sedation in pediatric dentistry provides an important approach for managing anxiety, fear and uncooperative behaviour while allowing dental treatment to be performed safely. Understanding the different levels of sedation, as well as their indications and contraindications, is essential when selecting the appropriate approach for each pediatric patient. Nevertheless, behavioral management and effective communication remain fundamental, with general anesthesia preserved as the last resort (SASA, 2020).

References

• Al Karaawi, Z., 2019. Dental Treatment Under Sedation Versus General Anesthesia. EC Dental Science, 18, pp.343-348.

• Hosey, M.T., 2002. UK national clinical guidelines in paediatric dentistry. Int J Paediatr Dent, 12, pp.359-372.

• Jain, S.A., Rathi, N., Thosar, N. and Baliga, S., 2020. Midazolam use in pediatric dentistry: a review. Journal of Dental Anesthesia and Pain Medicine, 20(1), pp.1-8.

• Mourão, J., Andrade, D., Silva, C.C., Lavado, C. and Areias, C., 2015. Conscious sedation vs general anesthesia in pediatric dentistry-a review. one blog