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Sedation in Pediatric Dentistry

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 ACTA SCIENTIFIC DENTAL SCIENCES (ISSN: 2581-4893)
Volume 3 Issue 2 February 2019
Mini Review

Sedation in Pediatric Dentistry

Sahand Eslaamizaad1 and Shabnam Toopchi2*

1
Class of 2020, University of Detroit Mercy School of Dentistry, Detroit, MI, USA
2
Co-Responding Author, Assistant Professor, Pediatric Dentistry, University of Detroit Mercy School of Dentistry, Detroit, MI, USA
*Corresponding Author: Shabnam Toopchi, Co-Responding Author, Assistant Professor, Pediatric Dentistry, University of Detroit Mercy
School of Dentistry, Detroit, MI, USA.
Received: November 26, 2018; Published: January 11, 2019

Abstract
Anxiety, fear of the dentist, parent expectations, and problematic patient behaviour demonstrate the necessity for the usage of
sedation in pediatric dentistry. Pediatric patients have unique challenges for their care as a result of their differences psychologically,
emotionally, and physically from adults. The purpose of this review is to provide a comprehensive outline of sedation in pediatric
dentistry. It will provide information for practitioners who wish to administer sedative medications to their patients. The pre-opera-
tive considerations, monitoring equipment needed, the physiological considerations of the pediatric patient, pharmacodynamics and
pharmacology of commonly used sedative medications will also be outlined.

Keywords: Sedation; Ketamine; Propofol; Benzodiazepines; Anesthesia; Pediatrics; Dentistry

Introduction responsive to verbal commands although their coordination and

cognitive functions would be impaired. The patient would appear
Sedation involves the delivery of pharmacological agents for the
comfortable, calm, and would have normal cardiorespiratory func-
purpose of achieving a calm, relaxed patient able to protect their
tion [1,4].
own airway, support their own ventilation, and respond to verbal
commands. The range of physiological effects associated with seda-
Moderate Sedation
tion is variable in nature and is dependent on the depth of sedation
In contrast, a patient under moderate sedation experiences a
provided (minimal, moderate or deep)[1]. Sedation is often used
depression of consciousness. During moderate sedation, the pa-
in combination with regional or local anesthetic agents to provide
tient is able to respond purposefully to verbal commands, either
a more comforting experience for the patient. Standards for pe-
alone or accompanied by light tactile stimulation. However, it is
diatric patients with regards to the usage of sedation vary signifi-
important to note that a reflexive withdrawal is not considered a
cantly and these standards are broader relative to what is seen in
purposeful response. Moderate sedation allows for spontaneous
the adult population. Anxiety, fear of the dentist, parent beliefs, and
ventilation that is sufficient and no interventions are necessary to
problematic patient behaviour facilitate the necessity for sedation
preserve a patent airway. Cardiovascular function is also usually
in pediatric dentistry. Pediatric patients have unique difficulties
maintained during moderate sedation [4].
associated with their care as a result of their differences psycholo-
gically, emotionally, and physically from adults. Children often lack
the tolerance of adults and thus the provision of highquality dental Deep Sedation
care can be challenging [2,3]. Patients under deep sedation experience a depression in their
level of consciousness, similar to moderate sedation, but with seve-
Minimal Sedation ral key differences. These patients cannot be easily awakened but
respond purposefully following painful or repeated stimulation.
Sedation is classified upon the depth in which the patient is se-
The ability to independently maintain ventilatory function may
dated. A patient that is put under minimal sedation will be fully

Citation: Sahand Eslaamizaad and Shabnam Toopchi., et al. “Sedation in Pediatric Dentistry”. Acta Scientific Dental Sciences 3.2 (2019): 40-46.
Sedation in Pediatric Dentistry

41

also be impaired. Spontaneous ventilation may be inadequate, and chiatric conditions would be suitable candidates for sedation. Fur-
patients may require assistance in maintaining a patent airway. thermore, pediatric patients who require emergency treatment or
Cardiovascular function is often maintained [4]. complicated treatment needs would also be suitable for sedation.

There have been multiple reports of sedation being utilized

The Pediatric Patient
for dental procedures that have caused irreversible neurological
The pediatric patient differs from an adult in many ways. Be-
damage or in some cases death. In the majority of these cases, the
ginning with the airway, the tongue that is large relative to the oral
injuries sustained were due to a loss of protective reflexes in the
cavity may obscure the larynx or contribute to upper airway obs-
child during the sedation procedure [10-13]. Patients with pre-
truction under sedation. The larynx itself is positioned higher, C4
-existing medical conditions or those under the age of five appear
versus C6 in the adult, and more anteriorly [7]. Children are often
to have the greatest risk of adverse events occurring during seda-
obligate nose breathers with small nares that can be simply blocked
tive procedures.
by mucous or an edema. As a result of this, the pediatric airway
experiences obstruction more frequently than the adult airway.
Asthma is a common disease that has increased in its prevalen-
Due to their smaller functional residual capacity, which represents
ce amongst the pediatric population significantly over the past few
the volume of air in the lungs at the end of passive expiration, the
decades [14]. Patients who have a mild form of the disease or are
pediatric patient is more susceptible to hypoxemia [1]. As a result,
considered to be well-controlled are strong candidates for sedati-
careful airway examination pre-operatively is necessary in order to
ve treatment. However, patients with moderate to severe asthma
ensure the safety and success of any treatment.
with a history of several visits to the emergency room or requiring
multiple medications for control of the disease have a greater risk
Children have heart rates that are dependent upon cardiac ou-
of complications. Patients that use an inhaled β2-agonist rescue
tput. This means that with bradycardia, their stiff left ventricles are
inhaler such as albuterol three or more times per week are gene-
unable to increase stroke volume to maintain cardiac output. Clini-
rally considered poorly controlled and should be referred to their
cally, bradycardia in infants is associated with low cardiac output
primary physician for re-evaluation. Postponement of treatment
[1,8]. This is one of the main reasons that bradycardia is undesi-
is suggested for a minimum of six weeks following an asthma at-
rable in pediatric patients undergoing sedation. In addition, infan-
tack. This is because FEV1 (forced expiratory volume in 1 second)
ts also have a dominant vagus nerve [8]. Therefore, children are
remains low during this time and would impact the success of se-
susceptible to developing bradycardia in response to certain types
dation or anesthesia [5].
of noxious stimuli such as the medications used in sedation. Bra-
dycardia in the pediatric patient must always be assumed to be a
Upper respiratory infections (URI) also present with potential
result of hypoxemia and is a potential risk with sedation [1]. Brady-
problems in achieving sedation or anesthesia in the pediatric pa-
cardia is commonly prevented by pre-medication with atropine [9].
tient. Pediatric patients presenting with these infections have an
increased risk of hypoxia, laryngospasm, and coughing [15]. For a
Due to pediatric patients’ behavioural development, require-
mild URI, it is potentially feasible to treat with sedation without in-
ments for anesthetics are often higher for children compared to
creased risk. However, for a practitioner in an office setting lacking
adults. These requirements peak at six-months of age. By six mon-
the resources of a hospital, it would be best to defer treatment in
ths to twelve months of age, infants are conscious enough about
all cases. Patients presenting with mild URIs should be rescheduled
their environment to have sensations of anxiety in the pre-operati-
within 1-2 weeks, while those with severe URIs should be resche-
ve period. Infants more easily express these feelings of anxiety re-
duled 4-6 weeks later.
lative to adults. There are many different approaches to minimizing
this anxiety, which must be individualized according to the needs of
Patients with congenital heart disease also must be considered
the parents, the pediatric dentist, and the patient [1].
prior to any sedative or general anaesthetic procedures. A child
that presents with a murmur but is asymptomatic and exhibits a
Indications and Contraindications
good exercise tolerance is not likely to have any pathological con-
There are numerous indications for the use of sedation in pedia- cerns [5]. While between 50% and 85% of children may have a
tric patients of all ages. Children that have behaviour management heart murmur, most heart murmurs are non-pathological in their
problems, fear of the dentist, suffer from mental disabilities, or psy-

Citation: Sahand Eslaamizaad and Shabnam Toopchi., et al. “Sedation in Pediatric Dentistry”. Acta Scientific Dental Sciences 3.2 (2019): 40-46.
Sedation in Pediatric Dentistry

42

nature [16]. If there is uncertainty with regards to the murmur, it Patients with significant medical considerations (ASA III, IV)
is recommended that the patient be referred to their paediatrician may require consultation with their primary care physician or con-
for re-assessment. Patients that are considered to be low-risk are sulting medical specialist as indicated above.
generally those with ventricular septal defect repair, patent ductus
The patient, parent, escort, guardian or caregiver must be ad-
arteriosus repair, and uncomplicated atrial septal defects [17]. Pa-
vised regarding the procedure associated with the delivery of any
tients considered to be high-risk are those with unrepaired defects,
sedative agents, and informed consent for the proposed sedation
significant shunt dependent blood flow, or ventricular dysfunction.
must be obtained. Pre-operative dietary restrictions must be con-
A history of epilepsy and diabetes are two more conditions that sidered based on the sedative technique prescribed. Pre-operative
must be considered. It is essential to document the frequency and verbal and written instructions must be given to the patient, parent,
types of seizures experienced. If the patient presents without any escort, guardian or caregiver. Baseline vital signs must be obtained
history of seizures within the past two years, is compliant with their unless the patient’s behaviour prohibits such determination. A fo-
medications, and has not had any changes in their anticonvulsant cused physical evaluation must be performed with particular focus
medication dosing then this indicates no need for an evaluation of on the airway [19].
the patient’s medication . Anti-epileptic medication often produces
5
Prior to the procedure no clear fluids should be consumed wi-
its own sedative effect that can be additive to any sedation provi-
thin two to three hours. Breast milk or non-clear fluids should not
ded to the pediatric patient. Therefore, careful evaluation of the pa-
be consumed less than four hours prior to sedation, while formula
tient’s medication is necessary prior to any procedure. It should be
milk should not be given less than six hours prior. No solid food
recommended to the child’s parents that the anticonvulsant medi-
should be eaten less than eight hours before sedation [2].
cation be taken in the morning prior to any procedures. Regarding
diabetes, a patient under good metabolic control is a strong candi-
Personnel, Equipment, Monitoring, and Discharge
date for sedation. HbA1C targets in children presenting with type 1
Personnel and equipment necessary for successful sedation va-
diabetes is below 6.5% whereas for nondiabetic children the value
ries depending upon the level of sedation required. However, re-
should be below 7.5% [15]. Blood sugar levels should be between
gardless of the procedure, at least one individual trained in basic
150-250 mg/dL and the patient should be scheduled as one of the
life support for healthcare providers must be present alongside
first cases of the day [5].
the dentist. A positive pressure oxygen delivery systemic suitable
Pre-Operative Evaluation and Preparation for the patient being treated must be immediately available throu-
ghout the procedure. When inhalation equipment is used, it must
Patients considered for sedation must be suitably evaluated be-
have a fail-safe system that is appropriately checked and calibrated.
fore the start of any sedative procedure. There are three major rea-
The equipment must also have a functioning device with an appro-
sons to perform a pre-operative evaluation. The first is to examine
priate oxygen analyzer and audible alarm. An appropriate scaven-
and evaluate the psychological and medical status as well as the
ging system must be available if gases other than oxygen or air are
current medications of the patient in order to identify any potential
used [20,21]. Postoperative verbal and written instructions must
concerns prior to the procedure. The pediatric dentist should take
be given to the patient, parent, escort or caregiver.
steps in order to minimize the effects of any factors that have been
identified as potential risks where possible and postpone treat- With regards to minimal sedation, monitoring requirements
ment if necessary [1]. If the patient’s medical condition is unable to indicate that clinical observation is only necessary. However, an
be altered, then other actions must be taken to decrease the risk of appropriately trained individual familiar with the monitoring prac-
the procedure. This can be mainly achieved through modification tices and equipment must remain in the operatory for the duration
of the sedation or anesthetic technique, intensifying perioperative of the treatment to monitor the patient continuously until the pa-
monitoring, or cancellation of the procedure. Finally, the pre-ope- tient meets the criteria for discharge to the recovery area [20,21].
rative evaluation should serve as an opportunity to inform the pa-
In moderate sedation the equipment needed is a pulse oximeter,
rents, caregivers, and patient to establish rapport and help alleviate
precordial stethoscope, and blood pressure monitors. The patient’s
anxiety [1].

Citation: Sahand Eslaamizaad and Shabnam Toopchi., et al. “Sedation in Pediatric Dentistry”. Acta Scientific Dental Sciences 3.2 (2019): 40-46.
Sedation in Pediatric Dentistry

43

heart rate, respiratory rate, oxygen saturation and blood pressure decrease in the patient’s blood pressure via decreased vascular re-
should be consistently monitored throughout the procedure. The sistance and a reduced heart rate. Opioids and volatile anesthetics
qualified dentist who is administering moderate sedation is requi- potentiate the effects of N2O [1].
red to stay in the operatory to monitor the patient uninterruptedly
until the patient satisfies the criteria for discharge to the recovery Due to its safety and efficacy, nitrous oxide is recommended

area. The dentist must not leave the facility until the patient meets as the first choice for pediatric dental patients who are unable to

the criteria for discharge and is discharged from the facility [21]. endure local anesthesia on its own but exhibit enough understan-
ding in order to accept the procedure2. Nitrous oxide can be offered
In deep sedation all the monitoring equipment recommended in to patients with mild to moderate anxiety in order to increase the
moderate sedation is necessary in addition to electrocardiography acceptance of the proposed treatment, which may require a series
(EKG), defibrillators, and capnography. Heart rate, respiratory rate, of visits. It can also facilitate the completion of dental extractions
oxygen saturation, blood pressure, and the EKG must be monitored and more time-consuming procedures, especially for young and
throughout the procedure. A qualified dentist that is administering anxious patients [2]. However, in patients with nasal obstructions,
deep sedation must be present throughout the procedure and must chronic obstructive pulmonary disease, those who are uncoope-
regularly monitor the patient until they have recovered to a mini- rative when directed to breathe through the nose, and psychotic
mally sedated level and been discharged from the facility [19-21]. patients, nitrous oxide use is contraindicated. The dose of nitrous
oxide is 50% combined with 50% oxygen in a mixture.
Monitoring must include but may not be limited to: Conscious-
ness (responsiveness to verbal command), oxygenation via color of
Ketamine
the mucosa and skin, verification of respiration by observing chest
excursions or verbal communication with the patient [21]. If a pa- Ketamine is a phencyclidine derivative that can be used as an in-
tient enters a deeper level of sedation than the dentist is approved duction agent usually in hemodynamically compromised patients
to provide, the dental procedure must be stopped immediately un- or for sedation during painful procedures24. Ketamine produces a
til the patient returns to the intended level of sedation [19,20]. characteristic dissociative state with profound analgesia, amnesia,
and catalepsy. Due to its high degree of lipid solubility, ketamine is
Sedative Medications able to enter the central nervous system rapidly and produce its se-
Nitrous Oxide dative effects. It is thought to cause its unique clinical state by indu-
cing dissociation between the thalamo-cortical and limbic systems,
Nitrous oxide (N2O) is an inhalational anesthetic agent that is
thus preventing the higher centers from perceiving visual, audi-
characterized by its inert nature with minimal metabolism. Nitrous
tory, and painful stimuli. The result is a cataleptic state manifested
oxide is a low potency anesthetic gas with a MAC (minimum alveo-
by a vacant stare, glassy eyes, and horizontal nystagmus. Patients
lar concentration) value of 105%, indicating its lack of potency as
appear to be removed or detached from their surroundings but
an anesthetic22. It is a weak anesthetic but a powerful analgesic
may respond to commands when ketamine is administered in low
as it requires other agents to produce surgical anesthesia. Due to
dosages. Ketamine generates its effects through an antagonistic ac-
its poor solubility in the blood, lack of irritability, and high MAC,
tion on the NMDA receptors and can be administered orally to chil-
nitrous oxide allows for an immediate onset and quick recovery
dren often with midazolam [2]. It produces strong analgesic, seda-
following administration. Recent studies have suggested that both
tive, and amnestic effects. Peak plasma concentrations of ketamine
N-methyl-D-aspartate (NMDA) and gamma-aminobutyric acid type
are achieved in about one minute after intravenous administration
A (GABA-A) receptors are affected by nitrous oxide [23].
and in about five minutes following intramuscular administration.
Nitrous oxide produces effects on the major organ systems. In Termination of activity occurs through slow redistribution to the
terms of the central nervous system, nitrous oxide increases ce- peripheral compartment. Thus, the clinical effects of ketamine be-
rebral blood flow and metabolic rate as well as intracranial pres- gin to wane in about 15 minutes after intravenous administration
sure. Therefore, it is contraindicated for patients with decreased and in about 30 to 120 minutes following intramuscular injection.
intracranial compliance. Nitrous oxide also affects the cardiovas- The elimination half-life of ketamine is two to three hours in adults,
cular system by causing a mild sympathomimetic effect while also but children metabolize the drug more rapidly. Ketamine provides
producing direct myocardial depression. The net result is a modest advantages over other sedative agents with regards to its relative

Citation: Sahand Eslaamizaad and Shabnam Toopchi., et al. “Sedation in Pediatric Dentistry”. Acta Scientific Dental Sciences 3.2 (2019): 40-46.
Sedation in Pediatric Dentistry

44

cardiovascular stability and limited effects on respiratory function . 2

Propofol
Even in children with congenital heart disease, clinically it causes Propofol is an intravenous anesthetic, producing unconsciou-
only minor increases in heart rate and mean pulmonary artery sness within 40 seconds after a single induction dose of 2 to 2.5
pressure [20]. However, due to Ketamine’s sympathomimetic ef- mg/kg, followed by a rapid recovery with minimal postoperative
fects on the cardiovascular system, it is relatively contraindicated confusion. It is formulated in an oil-in-water emulsion and has a
in patients with uncontrolled hypertension, arteriosclerotic heart characteristic milky-white appearance. Propofol is an NMDA recep-
disease, and severe congestive heart failure. Ketamine can be given tor inhibitor similar to ketamine and a GABA-A receptor agonist. It
5-10 mg/kg periorally, 3-4 mg/kg intramuscularly, or 1-2 mg/kg is rapidly redistributed with a distribution half-life of 2-4 minutes,
intravenously [24]. Administering a lower than recommended dose resulting in rapid recovery following induction or maintenance do-
may be safer than the heavy doses to achieve adequate levels of se- ses. It is metabolized in the liver with an elimination half-life 3-12
dation in some children, especially those presenting with problems hours, but the clearance of propofol exceeds liver blood flow, sug-
of potentially severe respiratory depression. gesting some extra-hepatic metabolism. Other effects of propofol
include pain on injection, amnesia, and possibly some antiemetic
Random movement unrelated to surgical or painful stimuli of-
effects. The IV administration of medications such as ketamine or
ten occurs with ketamine administration along with emergence
propofol remains a problem due to the difficulty in gaining vascular
reactions. Twitching, myoclonus, and jerking movements are com-
access in an awake and frightened child [1,2].
mon. Ketamine has been demonstrated to possess anticonvulsive
effects and has been used without complication in patients with
Chloral Hydrate
seizure problems [25]. Ketamine also causes an increase in intra-
cranial pressure by producing cerebral vasodilation and increased Chloral hydrate is a chlorinated derivative of ethyl alcohol that
perfusion pressure. It is therefore relatively contraindicated in pa- can act as an anesthetic when administered in high doses [2]. It is
tients with serious head trauma, hydrocephalus, and intracranial rapidly converted into trichloro ethanol and induces sedative effec-

lesions. In addition, ataxia and dizziness may persist for up to four ts through inhibitory action on the cerebral hemisphere of central

hours following ketamine administration [1,2]. nervous system [6]. It is a psycho-sedative and poor analgesic with
an elimination half-life of approximately eight hours. Chloral hy-
drate is contraindicated in children with heart disease and those
Benzodiazepines
with renal or hepatic impairment. It is known to potentially cause
Benzodiazepines have a selectivity of effect and a high margin of
extended periods of drowsiness and oxygen desaturation in patien-
safety. They exert their effect at the GABA receptor complex to pro-
ts. Due to reports of paradoxical reactions and extended sedation,
duce the clinical effects of anxiolysis, sedation, amnesia, anticon-
monitoring after sedation is required. Chloral hydrate is often con-
vulsant activity, and skeletal muscle relaxation. Benzodiazepine re-
sidered to be one of the least harmful sedative agents. Despite this,
ceptors are linked to a specific GABA-receptor subtype, the GABA-A
chloral hydrate carries a risk of potentially producing upper airway
receptor, similar to nitrous oxide. Benzodiazepines also exert little
obstruction and unpredictably deep levels of sedation in some pa-
effect on cardiovascular parameters in therapeutic doses, howe-
tients [27]. Lately, studies have shown there is a risk of carcinoge-
ver excessive doses and concomitant use with other sedatives may
nesis with the use of chloral hydrate as a sedative agent, especially
result in cardiovascular system depression. They also exert little
with repeated use [27]. Recently the capsule and liquid forms of
effect on the respiratory system but can cause respiratory depres-
chloral hydrate have been removed from the US market. In spite of
sion in a dose dependent manner when administered in conjunc-
its historical success as a sedative agent, chloral hydrate will likely
tion with other central nervous system depressant drugs. Due to
continue to fall out of use for pediatric dental sedation [2].
their high lipid solubility the benzodiazepines have a rapid onset of
action. They can be administered in combination with midazolam
Opioids
as a sweetened syrup and is frequently used in pediatric dentistry.
The syrup can be given 20-30 minutes and the tablets 60 minutes For painful procedures, fentanyl is required. Fentanyl is a syn-

before the procedure. The dosage for children under 25 kg is 0.3- thetic opioid analgesic that is intermediate acting, providing an

0.5 mg/kg but should be administered in a hospital setting only [2]. adjunct to anesthesia. Its mechanism of action is stimulating the

Citation: Sahand Eslaamizaad and Shabnam Toopchi., et al. “Sedation in Pediatric Dentistry”. Acta Scientific Dental Sciences 3.2 (2019): 40-46.
Sedation in Pediatric Dentistry

45

µ-and κ opioid receptors. The µ1 receptor seems to be the major 6. Kim Jongbin., et al. “The Alternative of Oral Sedation for Pedi-
antinociception site and analgesia produced is dose dependent. It atric Dental Care”. Journal of Dental Anesthesia and Pain Medi-
is approximately 100 times more potent than morphine and has cine 15 (2015): 1.

a rapid onset and short duration. It produces excellent analgesia, 7. MacGregor Janet. “Introduction to the Anatomy and Physiol-
provides cardiovascular stability, but may produce bradycardia. It ogy of Children”. Ch. 5. Routledge, (2008).
produces profound dose-dependent respiratory depression. Fen-
tanyl also can cause chest wall or glottic rigidity with rapid admi- 8. Mcauliffe Georgina., et al. “Heart Rate and Cardiac Output af-
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Journal of Anesthesia 44 (1997) 154-159.
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-mucosal fentanyl citrate, is more accepted by children than other 9. Bansal Teena and Sarla Hooda. “Anesthetic Considerations in
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if needed. Fentanyl can also cause chest wall or glottic rigidity with es Academy 26 (2013): 127-131.

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[1]. ical Incident Analysis of Contributing Factors”. Pediatrics 105
(2000): 864-865.
Summary
11. Chicka MC., et al. “Adverse Events during Pediatric Dental An-
The use of sedation is growing within pediatric dentistry. The esthesia and Sedation: A Review of Closed Malpractice Insur-
careful administration of sedative medications, understanding the ance Claims”. Pediatric Dentistry 34 (2012): 231-238.
necessary risks and benefits of their usage, and the ability to iden-
12. Cravero JP., et al. “Incidence and Nature of Adverse Events Dur-
tify patients that would be suitable candidates for such procedures
ing Pediatric Sedation/Anesthesia for Procedures Outside the
is crucial for any pediatric dentist. Proper pre-operative evalua- Operating Room: Report from the Pediatric Sedation Research
tion, medication administration, monitoring, and discharge of each Consortium”. Pediatrics 118 (2006): 1087-1096.
patient must be followed. Sedation can make previously painful
and intolerable scenarios for pediatric patients acceptable and can 13. Lee Helen H., et al. “Trends in Death Associated with Pediatric
Dental Sedation and General Anesthesia”. Pediatric Anesthesia
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23 (2013): 741-746.

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Volume 3 Issue 2 February 2019

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Shabnam Toopchi.

Citation: Sahand Eslaamizaad and Shabnam Toopchi., et al. “Sedation in Pediatric Dentistry”. Acta Scientific Dental Sciences 3.2 (2019): 40-46.

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