Clinical, Cosmetic and Investigational Dentistry

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Pediatric dental sedation: challenges and

opportunities

Travis M Nelson & Zheng Xu

To cite this article: Travis M Nelson & Zheng Xu (2015) Pediatric dental sedation: challenges
and opportunities, Clinical, Cosmetic and Investigational Dentistry, , 97-106, DOI: 10.2147/
CCIDE.S64250

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Pediatric dental sedation: challenges and

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Clinical, Cosmetic and Investigational Dentistry
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Travis M Nelson Abstract: High levels of dental caries, challenging child behavior, and parent expectations
Zheng Xu support a need for sedation in pediatric dentistry. This paper reviews modern developments
Department of Pediatric
in pediatric sedation with a focus on implementing techniques to enhance success and patient
Dentistry, University of Washington, safety. In recent years, sedation for dental procedures has been implicated in a disproportionate
Seattle, WA, USA number of cases that resulted in death or permanent neurologic damage. The youngest children
and those with more complicated medical backgrounds appear to be at greatest risk. To reduce
complications, practitioners and regulatory bodies have supported a renewed focus on health
care quality and safety. Implementation of high fidelity simulation training and improvements
in patient monitoring, including end-tidal carbon dioxide, are becoming recognized as a new
standard for sedated patients in dental offices and health care facilities. Safe and appropriate case
selection and appropriate dosing for overweight children is also paramount. Oral sedation has
been the mainstay of pediatric dental sedation; however, today practitioners are administering
modern drugs in new ways with high levels of success. Employing contemporary transmucosal
administration devices increases patient acceptance and sedation predictability. While recently
there have been many positive developments in sedation technology, it is now thought that
medications used in sedation and anesthesia may have adverse effects on the developing brain.
The evidence for this is not definitive, but we suggest that practitioners recognize this devel-
oping area and counsel patients accordingly. Finally, there is a clear trend of increased use of
ambulatory anesthesia services for pediatric dentistry. Today, parents and practitioners have
become accustomed to children receiving general anesthesia in the outpatient setting. As a result
of these changes, it is possible that dental providers will abandon the practice of personally
administering large amounts of sedation to patients, and focus instead on careful case selection
for lighter in-office sedation techniques.
Keywords: conscious sedation, anesthesia, general, pediatrics

Introduction
The developing child often lacks the coping skills necessary to navigate the dental
experience, making provision of quality dental care to children challenging. While
unrestored caries may contribute to pain, disordered sleep, difficulty learning, and
poor growth in children, unpleasant dental experiences can cause psychologic harm.1–3
Most dental anxiety develops in childhood as a result of frightening and painful dental
Correspondence: Travis M Nelson
experiences. If appropriate precautions are not taken, dental treatment may overwhelm
Department of Pediatric Dentistry, the child, resulting in dental fear and avoidance.4 These fears persist into adulthood,
University of Washington, 6222 NE
74th Street, Seattle, WA 98115, USA
causing 10%–20% of the US population to avoid necessary dental care.5,6 Sedation
Email [email protected] reduces such complications and instills trust in the family and child.

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Nelson and Xu Dovepress

Today, it is estimated that 100,000–250,000 pediatric Patient monitoring

dental sedations are performed each year in the USA, and Early efforts to provide sedation in the dental office were
practitioners anticipate a need for more pharmacologic largely unregulated, and clinicians primarily relied only
behavior management in the future.7,8 High levels of pediat- on direct physical findings such as quality of respiration
ric dental disease, increasingly difficult child behavior, and and patient color to assess the sedated patient. Over time
parent expectations support a need for sedation services.8–11 technology improved, and professional associations and
Here we review common challenges that contemporary dental regulatory bodies provided a framework for safe and effective
practitioners experience and suggest possible solutions. practice.16,23,24 Advancements included monitoring patients
with blood pressure monitors and precordial stethoscopes.
Risk factors for adverse events With the advent of pulse oximetry, electronic monitoring
Sedation is a continuum. Physiologic effects vary signifi- of blood oxygen saturation further increased safety. This
cantly depending upon a variety of factors, including medi- allowed for continuous monitoring of heart rate and blood
cation, dose, delivery route, and patient characteristics.12,13 oxygen saturation, with alarm activation when blood pressure
Minimal sedation is considered to be the mildest form of or oxygenation declined below a threshold value. In contem-
sedation. As stronger medications and higher doses are porary practice, end-tidal carbon dioxide (EtCO2) monitors
administered, the depth of sedation shifts toward moderate have become standard in operating rooms to monitor apnea
sedation, deep sedation, and possibly even general anesthesia. and hypoventilation.
At more profound levels, patients become unresponsive and In response to growing safety concerns, EtCO2 monitor-
incapable of maintaining their own breathing or cardiovascu- ing is now used increasingly in ambulatory settings17,18,20,25
lar function.14,15 In adult dental practice, titration of sedation (Figure 1). Professional association guidelines reflect this
depth through intravenous drug administration is common. In trend, and the American Society of Anesthesiologists has
pediatrics, however, due to behavioral constraints, sedation amended its standards for basic anesthetic monitoring to
by bolus oral administration is well tolerated and routine.7,13 require EtCO2 for moderate or deep sedation.25 In dentistry,
With oral administration, sedation depth can be difficult to perhaps the most widely recognized professional sedation
predict and titration is not possible.16 Consequently, over- guidelines come from the American Dental Association.
sedation and respiratory obstruction can occur. Should this For children 12 years of age and under, the American Dental
happen, it is the responsibility of the sedation provider to Association recognizes the American Academy of Pediatrics/
manage the unconscious child until she or he regains the American Academy of Pediatric Dentistry (AAP/AAPD)
ability to self-regulate. guidelines for monitoring and management of pediatric
Sedation for dental procedures has been implicated in patients during and after sedation for diagnostic and therapeu-
a disproportionate number of cases that resulted in death tic procedures. Both the American Dental Association and the
or permanent neurologic damage. 17–19 When causes of AAP/AAPD guidelines suggest that EtCO2 monitoring may
sedation-related injury and death in outpatient settings
have been reviewed, damage almost always resulted from
an inability to resuscitate once a patient lost protective
reflexes.17,18,20,21 Children under 5 years of age and those
with pre-existing medical conditions appear to be at great-
est risk.17,18,21 These findings have led to increased scrutiny
of pediatric dental sedation by the public and the medical
community.20,22 One concern is that dentists and other
non-anesthesiologist practitioners receive varying levels
of sedation training and often do not practice in settings
with immediate access to rescue resources such as a code
team. In contrast, anesthesiologists receive relatively
uniform training and practice the skills required to rescue
patients on a daily basis. They also commonly practice
in an operating room environment and have the ability to Figure 1 Nitrous oxide nasal hood modified for use with an end-tidal carbon
request backup when needed. dioxide sampling line.

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Dovepress Pediatric dental sedation

be used to evaluate respiration; however, it is not currently results of clinical trials suggest that children may be given
required for moderate sedation.16,26 In the USA, each state has intranasal midazolam with less risk of nausea, vomiting, and
unique requirements for a dentist to perform sedation. States respiratory complications.32,37 While practitioners should be
vary considerably regarding training standards, required cautious in relaxing recognized safety standards, given the
continuing education, and advanced life support credentials appropriate setting (such as a hospital emergency room), this
required to maintain a sedation permit.27 Similarly, there is technique may prove useful for uncooperative children who
no nationally recognized government standard for monitoring need emergency treatment and have eaten.
of dental patients during sedated procedures. However, some Although intranasal administration is usually simple,
states have begun to mandate the use of EtCO2 monitors for relatively painless, and requires less patient cooperation, it
dental sedation. Given this trend, it is possible that in the has been associated with mucosal irritation. This may lead to
future EtCO2 monitoring will become the standard for sedated coughing, sneezing, crying and the expulsion of part of the
patients in dental offices and health care facilities. dose. This is particularly true when a large volume of the drug
is applied.34,36 Therefore, careful administration is critical.
Modern drugs and routes When administration of intranasal midazolam by drop and
Selection of medications is a critical component of the seda- aerosolized form were compared, aerosolization was better
tion plan. When possible, consideration should be given tolerated and led to less aversive behavior29 (Figure 2).
to sedatives with available reversal agents. In the event of Nasal mucosal secretions can also affect intranasal drug
oversedation, benzodiazepine and narcotic medications may absorption. The buccal mucosa has a rich blood supply and
be preferred over drugs without known reversal agents, such is relatively permeable, yielding pharmacokinetics that are
as chloral hydrate. In recent years, both the solution and similar to intranasal administration. It therefore appears to
capsule form of chloral hydrate have been withdrawn from be an attractive alternative to the intranasal route.38 Buccal
the US market. In the future, in spite of its historic success, administration of aerosolized midazolam has been proven to
chloral hydrate will likely continue to fall out of favor for be safe, effective, and well accepted by young patients.28,39,40
pediatric dental sedation. An oral solution may also be used in place of aerosol spray;
Oral sedation is the most popular route of administra- however, the possibility of experiencing the bitter taste
tion among pediatric dentists.28,29 However, this route is increases, leading to poor patient acceptance.40 Buccal and
notoriously unpredictable, and frustration often arises when intranasal midazolam have the same maximum working time
children refuse to accept the sedative medication.28,30 Efforts while intranasal has a faster onset time. Intranasal midazolam
have been made to mask the bitter taste of the oral medica- also elicited less crying and produced a greater proportion
tions; however, it is not uncommon for children to spit or of patients with optimal sedation scores.41 Chopra et al and
regurgitate them. On the other hand, placement of an intra-
venous cannula for parenteral sedation can be traumatic to
children.30 New methods of medication delivery have been
proposed and investigated. One alternative is the transmu-
cosal (intranasal, sublingual, buccal) route. The benefits of
this route include direct absorption of drugs into the systemic
circulation, avoidance of hepatic first pass metabolism,
increased bioavailability, and faster onset compared with oral
sedation. Transmucosal administration also results in less
discomfort than intravenous sedation and better acceptance
by patients.28
Intranasal administration of midazolam has been proven
to be a safe and effective sedative for short procedures and
is widely used by pediatric dentists.29–36 In addition to quick
onset, a relatively quick recovery has also been suggested.34
Some believe that another possible advantage of intranasal
sedation is that a strict adherence to fasting requirements may
not be essential.28,32,37 This is a controversial area; however, Figure 2 Child receiving intranasal midazolam using an aerosolization device.

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Klein et al reported better acceptance of the buccal route,28,39 Anesthesiologists score.51,52 Similarly, in-office sedation
while Sunbul et al found intranasal midazolam to be more should be limited to healthy children. Healthy children
acceptable to children.41 Interestingly, even though it was and those with mild systemic disease (American Society
poorly tolerated by subjects during administration, in one of Anesthesiologists score I and II) can generally be cared
study a greater proportion of parents preferred the intranasal for safely and effectively in the dental clinic. Complicated
route for future sedation.39 medical conditions including heart disease, obstructive sleep
Dexmedetomidine is a selective alpha2-adrenergic agonist apnea, and obesity have been shown to increase sedation risk
that provides sedative, anxiolytic, and analgesic properties and the chances of failed sedation.53 These factors must be
without causing respiratory depression.42,43 It was approved considered carefully when selecting the sedation regimen
by US Food and Drug Administration to be used for seda- and venue.
tion in adults in the intensive care setting in 1999. Due to its Appropriate dosing is another concern. In the USA,
efficacy in adults, in recent years it has been introduced into approximately one-third of children aged 2–19 years are
the pediatric population for procedural sedation outside the overweight or obese. This represents more than a three-fold
operating room. Dexmedetomidine is available in intranasal, increase in childhood obesity over the past 30 years.54 In
buccal, or oral form.43 The safe use of dexmedetomidine in an analysis of perioperative complications, overweight and
pediatric diagnostic radiology has been well documented.42 obese children had a higher incidence of difficult airway,
However, studies on its use for outpatient dental procedures upper airway obstruction, and longer postoperative recovery
are limited, especially in children. In a pilot study by Hitt period.55 Obese children are also much more likely to have
et al, intranasal delivery of sufentanil and dexmedetomidine obstructive sleep apnea.56 If total body weight (TBW) is
provided acceptable sedation without respiratory depression used for dose calculation, overweight children are at risk for
or major complications in 20 children undergoing dental overdose. Some authors suggest that dosing should be based
procedures.44 upon ideal body weight (IBW) or lean body mass (LBM),
When reviewing the small clinical trials and observa- although there is a lack of clear guidance in this area.57–59
tional studies exploring pediatric use of dexmedetomidine, Calculating IBW and LBM in children can be relatively
it is important to note that all these studies were performed complicated, and validity of the measurement is lost as the
in a medically controlled setting under the supervision of child grows. Simplified weight calculations for children are
anesthesiologists.44–46 Clearly, much work needs to be done expressed in the following equations:57,59
to define the efficacy of dexmedetomidine and its impact on
pediatric dental sedation. However, due to its unique charac- IBW = BMI50 × height2
teristics and lack of respiratory depression, this medication LBM = IBW + 0.29 (TBW – IBW)
holds great promise as an alternative option for sedation in
the pediatric dental clinic. Although this provides some guidance in dosing over-
weight children, in many circumstances calculation of
Optimizing care for patient safety appropriate dosing using this method may not be practical. It
Risk is inherent in procedural sedation. While it is impossible should also be remembered that when a child’s actual weight
to eliminate risk entirely, negative outcomes can be mini- is less than IBW or LBM, the lower figure should be used. An
mized by optimizing work systems and eliminating human alternative nomographic method has recently been described
factors for error.47–49 We also reduce the chance of future for use in children aged 5 years and older.60 A nomograph is
incidents by recognizing accidents that were avoided but constructed by placing scales for known variables (ie, age,
nearly occurred. These “near misses” should be reported so height, TBW) side by side. Known values are then plotted
that contributing factors can be analyzed and eliminated.50 on each scale. The value of an unknown variable (LBM) is
The greatest successes are achieved by focusing on determined by the drawing a straight line from the points
safety before the sedation appointment. Preparation begins plotted on each scale. The point where the lines intersect
with appropriate case selection. Using a standard form for the unknown variable scale is an approximation of its value
presedation, patient assessment helps eliminate guesswork (Figure 4). This method allows clinicians to quickly calcu-
(Figure 3). Appropriate assessment includes patient medical late LBM using a chart. One needs only to know the child’s
history, physical examination (including targeted airway age, height, and TBW. While still an ongoing area of study,
assessment), and assignment of an American Society of researchers anticipate development of nomographic charts

100 submit your manuscript | www.dovepress.com Clinical, Cosmetic and Investigational Dentistry 2015:7
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Dovepress Pediatric dental sedation

Figure 3 A presedation checklist.13

Note: The ASA classification system is a health-grading system used commonly by medical and dental providers. ASA I = healthy, ASA II = mild systemic disease.
Abbreviations: Hx, history; Tx, treatment; M, male; F, female; ASA, American Society of Anesthesiologists.

that are validated for children under age 5 years and incor- achieve a University of Michigan Sedation Scale score of 0
poration of the tool into a smartphone application. or 1 (0, awake and alert or minimally sedated; 1, tired/sleepy,
Following the sedation appointment, uniform discharge appropriate response to verbal conversation and/or sound)
criteria ensure that the child is not sent home before she or and able to stay awake for 20 minutes when undisturbed
he is ready to leave direct medical supervision. A number (the Modified Maintenance of Wakefulness Test), she or
of studies have suggested that children who are sedated for he is generally considered to be ready to return home with
dental care routinely experience prolonged sleepiness and parental supervision.63,64
difficulty waking, including sleeping in the car while riding Simulation training is increasingly being recognized as an
home after treatment.61,62 While tiredness can be expected important mechanism for improving health care quality and
following the sedation appointment, implementation of dis- safety. Basic simulation can be as simple as regularly practic-
charge criteria helps to ensure that the child is not excessively ing emergency skills with office staff. Advanced simulation
sedated when they leave the dental office. If a child is able to programs provide a means of practicing low frequency events

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Age (years)
Boys Girls Ideal body weight (kg) Lean body mass (kg)
5 5 Total body weight (kg)
115
6 6 85
7 185
7 110 180
8 80 175
9 8 105
170
75 165
9 100
10 160
95 155
Height (meters) 70
11 10 150
90 145
2.00
1.95
65 140
85
135
12
11 1.90 60 80 130
1.85 125
120
13 1.80 55
75

12 1.75 115
70 110
1.70 50 105
1.65 65
14 100
13 1.60 45
60 95
1.55 90
55 85
1.50 80
15 14 1.45 40
50 75
Instructions: Draw a line from the age through 1.40 45 70
the height to meet the Ideal Body Weight scale. The 1.35 35
65
16 15 ideal weight is read at this point. A second line is
drawn from the ideal weight to the actual weight on 1.30 40 60
the Total Body Weight scale. The Lean Body Mass 1.25 30 55
35 50
1.20
is read from its scale where this line crosses it.
16
17 In the example shown, a 11-year-old boy 1.15 45
who is 1.42 m tall and who weights 71 kg has an ideal 25 30 40
17 weight of 34 kg and a lean body mass of 45 kg. 1.10
NB: Lean body mass calculations are only valid 1.05 25 35
18 30
18
for overweight patients, ie, for those cases where ac-
1.00 20
tual weight is higher than ideal weight. 0.95 20 25

19 19 0.900.85 15 15
20
15
20 10
10
20 10

Figure 4 A novel body mass nomogram used for calculating lean body mass in children.
Note: Copyright © 2015. Dove Medical Press. Reproduced from Callaghan LC, Walker JD. An aid to drug dosing safety in obese children: development of a new nomogram
and comparison with existing methods for estimation of ideal body weight and lean body mass. Anaesthesia. 2015;70:176–182.60

using high-fidelity clinical environments and mannequins developing brain.68–70 Initial research demonstrated harm to
that accurately reproduce physiologic conditions (Figure 5). the brains of young animals.71–74 This raised concern that
When simulation is incorporated into education it increases young children might also be at risk when exposed to anes-
knowledge, clinical skills, and judgment more than lecture- thetic agents.75 Following the publication of these concerning
only teaching.65,66 Simulation is also thought to be a reliable findings, human studies were initiated.76–79 The results have
method of teaching non-emergency sedation skills, such as often revealed conflicting conclusions, with some showing
presedation assessment, and it is becoming an increasingly long-term deficits in learning and behavior while others
common adjunct to sedation education programs.67 have not.80 This is a difficult area of study, because children
who receive sedation and anesthesia commonly have patho-
Anesthesia neurotoxicity logic conditions for which they require surgery. They may
In recent years, it has been suggested that medications used therefore be fundamentally distinct from their healthy peers.
in sedation and anesthesia may have adverse effects on the Adverse neurologic outcomes are also difficult to recognize

Figure 5 High fidelity mannequin in a state-of-the-art simulation facility.

Note: Courtesy of the University of Washington Institute for Simulation and Interprofessional Studies.

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Dovepress Pediatric dental sedation

and measure. Investigation into these findings continues, and vary in the literature, research has elucidated the type of child
poses a significant challenge to resources and study design. temperament associated with positive sedation outcomes.
While it will likely be many years before we are able to Characteristics such as emotionality, impulsivity, inflex-
determine the neurologic effects of sedation and anesthesia ibility, shyness, and difficulty dealing with new situations
drugs with confidence, this is an area that providers must appear to be associated with sedation failure.89–91 Conversely,
be familiar with. We do not definitively know the long-term adaptability, persistence, and the ability to self-regulate
effects of these drugs, so we must exercise judgment in may be associated with increased likelihood of success.92,93
recommending these services to pediatric patients. Parents Therefore, when considering a child for sedation, pay close
should be informed of procedural risks and benefits, and attention to the behavior of the child during the consultation
sedation must only be employed when a significant benefit visit. Children who are shy, cling to parents, have difficulty
to the patient can be expected. tolerating simple tasks (such as dental prophylaxis or radio-
graphs), and are unwilling to interact with the clinician may
Increasing sedation success be better suited for alternative methods of behavior guidance,
A number of sedation rating scales have been used to evaluate including general anesthesia or delayed treatment.
sedation quality and child behavior. According to a recent Children who receive mild to moderate sedation are
review of the pediatric dental sedation literature, the Houpt expected to be awake and responsive to direction from the
Behavior Rating Scale (HBRS) has been used most frequently treating dentist. Therefore, it is imperative that clinicians
in research.81 The advantage of the HBRS is that it allows employ their best non-pharmacologic behavior management
for evaluation of sedation depth, the child’s behavior, and an skills with sedated patients.13 While these skills are generally
overall rating of the visit (Table 1). One disadvantage of this regarded as a core competency of pediatric dentistry, they
rating system is that the measure of success focuses primarily are increasingly being recognized as important in the medi-
on the clinician’s ability to complete treatment. While clearly cal literature as well.94–98 Interventions such as distraction
central to the HBRS, this characteristic is found in many other have been shown to decrease anxiety and pain perception in
common sedation scales, including the Frankl, Ramsay, and non-sedated patients.99 When effectively incorporated into
Ohio State University Behavior Rating Scale.82–85 A number the sedation scheme, a combined pharmacologic and non-
of authors have suggested that outcome assessment should pharmacologic technique was also more effective at reduc-
be more patient-focused. This recognizes that the intent of ing child distress than pharmacologic techniques alone.100
sedation is not only to complete a procedure with minimal Non-pharmacologic methods may be particularly effective
movement and crying, but also that the child leaves with a for sedated young children with active imaginations. Also,
positive impression of dental care.81,86 because adequate sedation requires both anxiety reduction
When considering lighter sedation techniques, case selec- and pain control, excellent local anesthesia is critical. A child
tion becomes increasingly important.87 Child temperament with profound analgesia is much more likely to be in a state
or “behavioral style” is one factor associated with success of mind that facilitates good sedation.
in procedural sedation. Temperament has been defined as
“[…] constitutional differences in reactivity and regula- Increasing role of dental anesthesia
tion […] influenced over time by heredity, maturation, and Today’s sedation practitioner faces significant challenges to
experience”.88 Since the 1950s, a number of instruments have achieve the described levels of child-centered care. Reports
been used to evaluate child temperament. While measures indicate that while child behavior in the dental office is

Table 1 Houpt Behavior Rating Scale

Alertness Crying Movement Overall
Asleep No crying No movement Excellent: no crying or movement
Drowsy, disoriented Intermittent or mild crying Controllable, not interfering with Very good: some limited crying or movement
treatment
Fully awake, alert Continuous or strong crying Continuous, making treatment difficult Good: difficult, but all treatment was performed
Hysterical crying Violent, interrupting movement Fair: treatment interrupted, but eventually
completed
Poor: treatment interrupted, only partial
treatment was completed
Aborted: no treatment rendered

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becoming more difficult, parents are becoming increasingly 5. Milgrom P, Newton JT, Boyle C, Heaton LJ, Donaldson N. The effects
of dental anxiety and irregular attendance on referral for dental treat-
particular about their child’s experience.8,101,102 At the same ment under sedation within the National Health Service in London.
time, concerns about child safety during sedation procedures Community Dent Oral Epidemiol. 2010;38:453–459.
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Conclusion google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&
ved=0CB8QFjAA&url=https%3A%2F%2F2.zoppoz.workers.dev%3A443%2Fhttp%2Fwww.jointcommission.
Providing quality dental care to young children can be a org%2Fassets%2F1%2F18%2F2011_ahc_hdbk.pdf&ei=MyWgV
Y3nPNb6oQSX85CQCw&usg=AFQjCNFLGu_ST4go7xbcMEW
challenge. Pediatric dental sedation allows the clinician to
5IFXnwP3U_w&sig2=JBHPPDxeRDJ0AomJjRNvRQ&bvm=bv.
provide treatment in a way that is minimally traumatic and 97653015,d.cGU.
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events during pediatric sedation/anesthesia for procedures outside

Disclosure the operating room: report from the Pediatric Sedation Research
Consortium. Pediatrics. 2006;118:1087–1096.
The authors report no conflicts of interest in this work. 21. Lee HH, Milgrom P, Starks H, Burke W. Trends in death associated
with pediatric dental sedation and general anesthesia. Paediatr Anaesth.
2013;23:741–746.
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