Vision of the Faculty of Dentistry -

Horus University

‫رؤية كلية طب األسنان جامعة حورس‬

‫• التميز و الريادة في مجال طب األسنان محليا و دوليا و إقليميا من حيث التعليم و البحث العلمي‬
‫و خدمة المجتمع‬

• Excellence and leadership in the field of dentistry locally, regionally and

internationally in terms of education, scientific research and community
service
Mission of the Faculty of Dentistry - Horus
University
‫رسالة كلية طب األسنان جامعة حورس‬

‫• إعداد خريجين مؤهلين بالمعرفة النظرية والمهارات العملية والسلوكيات اإلنسانية التي‬
‫تمكنهم من المنافسة في سوق العمل ونقل المعرفة من خالل إجراء الدراسات والبحوث‬
‫العلمية وتقديم الخدمات المجتمعية المتميزة للمواطنين‬

Preparing qualified graduates with theoretical knowledge, practical •

skills and human behaviors that enable them to compete in the labor
market and transfer knowledge through conducting studies and
scientific research and providing distinguished community services to
citizens.
Pharmacologic management
of patient behavior
Learning Objectives
• Recognize the basic information of local anesthesia and the child management
pharmacologically
• Recognize the techniques of local anesthesia and pre-medicaments used for sedation in
the dental office.
• Use the local anesthesia and pre-medicaments used for sedation in the dental office
properly.
• Develop decisions, data base search capacity and infection control measures applications
• Develop appropriate communication skills with teamwork and community
Management of Child Behavior
• Non-Pharmacologic management of patient behavior.
• Behavioral guidance
• Pharmacologic management of patient behavior (sedation)
• Indicated for children who cannot be managed with
traditional behavioral guidance techniques and local
anesthesia.
The goals of sedation for the pediatric patient are:

1.Ensure the patient's safety and well-being.

2.Reduce physical discomfort and pain.
3.Manage anxiety, minimize psychological distress, and
promote potential amnesia.
4.Control behavior and movement to enable a safe procedure.
5.To return the patient to a physiologic state in which safe
discharge is possible
 Levels of sedation
Minimal Sedation: Moderate Sedation: Deep Sedation:

• Patients respond normally to • Patients respond purposefully • Patients cannot be easily

verbal commands. to verbal commands. aroused but respond
• Cognitive function and • No intervention is needed to purposefully after repeated
coordination may be maintain a patent airway. verbal or painful stimulation.
impaired. • Spontaneous ventilation is • Ability to independently
• Ventilatory function and adequate. maintain ventilatory function
cardiovascular function are • Cardiovascular function is may be impaired.
unaffected. usually maintained • Patients may require
assistance in maintaining a
patent airway.
• Spontaneous ventilation may
be inadequate.
• There may be partial or
complete loss of protective
airway reflexes.
Anatomic and physiologic differences
• Sedation of children is different from the sedation of adults.
• This physiological differences require special considerations
in relation to:
• Respiratory function,
• Airway obstruction risks, and
• Cardiovascular parameters.
Anatomic and physiologic differences
• Differences in size, weight, and age as a measure of maturation of
systems.
• Children have higher metabolism than adults, which affects how their
bodies react to medications and other body functions.
• Children have a higher respiratory rate and less mature alveolar system,
making them more prone to respiratory depression when sedative drugs
are administered.
• Children have
• Narrow nasal passages ang glottis,
• Hypertrophic tonsils and adenoids,
• An enlarged tongue,
• And increased secretions, which increases the risk of airway obstruction.
Anatomic and physiologic differences
• It is important to examine the airway of pediatric patients before sedation, especially if
tonsillar tissue occupies more than 50% of the pharyngeal space.
• Children have reduced tolerance to respiratory obstruction, making sudden apnea a
greater concern.
• The smaller thorax of children limits their ability for chest expansion.
• Children with sleep apnea are not suitable candidates for sedation.
• Children have a faster heart rate and lower blood pressure compared to adults.
• Children are more susceptible to bradycardia, decreased cardiac output, and hypotension
during sedation.
Classification of tonsil size for patients
before sedation
Classification of tonsil size
for patients before
sedation

• Patients classified as +3 or
greater (having more than 50%
of the pharyngeal area
occupied by tonsils) are at
increased risk for developing
airway obstruction
Patient selection and
preparation
1. Medical history & examination

• A comprehensive medical history & recent

physical examination to determine if a patient is
suitable for sedative procedures or any potential
risks and to evaluating the patient's overall health
condition.
• The American Society of Anesthesiologists (ASA)
has established categories to classify patients
based on their physiological status.
The American Society of Anesthesiologists (ASA)
Class I
• A normal healthy patient
Class II
• A patient with mild systemic disease (e.g.,controlled reactive airway disease)
Class III
• A patient with severe systemic disease (e.g., child who is actively wheezing)
Class IV
• A patient with severe systemic disease that is a constant threat to life (e.g., achild with status
asthmaticus)
Class V
• A moribund patient who is not expected to survive without operation (e.g., a patient with
severe cardiomyopathy requiring heart transplantation)
The American Society of Anesthesiologists
(ASA)
• patients in ASA class I are commonly considered appropriate for
sedation,
• while those in class II or III may still benefit but require consultation
with their physician.
• Patients in higher ASA classes, children with special needs, and those
with airway abnormalities or significant tonsillar hypertrophy are
typically better suited for sedation in a hospital setting.
 Parent or legal
guardian must agree to
sedation for the child.
2. Written
informed consent Risks, benefits, and
alternatives should be
explained.
3. Instructions to
parents
• Clear liquids allowed up to 2 hours before the
procedure (water, fruit juices without pulp,
carbonated beverages, clear tea, black coffee).
• Breast milk allowed up to 4 hours before the
procedure.
• Infant formula, Nonhuman milk, Light meal
allowed up to 6 hours before the procedure.
• Avoid fried or fatty foods and meat as they can
delay gastric emptying.
• Routine necessary medications can be taken
with a sip of water on the day of the
procedure.
 • Accurate documentation of the
sedation experience is important.
• Include details of the procedure,
administered drug doses, and
4. Documentation patient vital signs.
• Clear, continuous, and accurate
documentation helps in case of
adverse reactions.
5. Patient discharge

Patient should be observed in a well-equipped recovery area.

Direct observation until respiratory and cardiovascular stability are

confirmed.

Patient should not be discharged until they reach their pre-sedation

level of consciousness or a similar level appropriate for the child.
 1. The cardiovascular function is good and stable.
2. The airway is clear and functioning well.
3. The patient can be easily awakened and has normal
protective reflexes.
4. The patient is adequately hydrated.
Discharge 5. If applicable, the patient is able to speak.
6. If applicable, the patient can sit without assistance.
criteria 7. If applicable, the patient can walk short distances
with minimal help.
8. If the child is very young or disabled and cannot
respond as expected, they are at a level of
responsiveness appropriate for them.
9. There is someone responsible available.
Sedation techniques
Inhalational sedation
Nitrous oxide and oxygen sedation:

• Depends on the child's level of :

• Maturity,
• Age, and
• Understanding.
• The child needs to be cooperative and able to follow instructions during the dental
procedure for inhalation sedation to be effective.
The objectives of nitrous oxide sedation include:

1.Reducing or eliminate
• Anxiety,
• Gagging which potentiating the effect of sedatives
• Untoward movement
• Reaction to dental treatment
2. Enhancing communication and patient cooperation
3.Raising the pain threshold & tolerance for longer appointments
4. Aiding in treatment of the mentally/physically disabled or medically compromised
patient.
Advantages:

• Very safe and relatively easy technique.

• When only light sedation is required.
• Rapid induction and easily reversible with short recovery time.
• Can be titrated to required level.
• Only clinical monitoring required
Disadvantages of nitrous oxide–oxygen inhalation
may include:

• Lack of potency
• Dependence on psychological reassurance
• Interference of the nasal mask with injection to anterior maxillary region
• Need for patient to be able to breathe through the nose
• Nitrous oxide pollution and potential occupational exposure health hazards
Contraindications: blocked nose

• Children with severe psychiatric disorders.

• Obstructive pulmonary disease.
• Chronic obstructive airway disease.
• Communication problems.
• Unwilling patients.
• Pregnancy.
• Acute respiratory tract infections
 Technique:
1. Inspect the equipment thoroughly before use.
2. Introduce the mask to the patient and explain its purpose at a level they can understand.
3. Carefully place the mask over the patient's nose.
4. Fill the bag with 100% oxygen and deliver it to the patient for 1 or 2 minutes at an appropriate flow rate.
5. Slowly increase the concentration of nitrous oxide in increments of 10% to 20% until the desired sedation
level is achieved.
6. Once the desired level is reached, the concentration can be reduced to 30% nitrous oxide and 70%
oxygen or lower.
7. Monitor the patient while maintaining the desired sedation level.
8. To achieve a quick recovery, the sedation can be reversed by gradually reducing the nitrous oxide
concentration.
9. After reversing the sedation, allow the patient to breathe 100% oxygen for 3 to 5 minutes.
 Oral Route
Onset Time:
• The longest time of onset of any route used for sedation.
• The delay ranges from 15 to 90 minutes
Advantages:
• Convenience, economy
• Lack of toxicity: extremely safe If therapeutic doses are calculated and single drugs are used in
single doses.
Disadvantages:
• Variability of Effect: individuals of the same weight may respond quite differently to the same
dose of drug, depending on many variables.
• Absorption of the drug from the gastrointestinal tract can be altered by several factors.
Intranasal Route

• Sometime used , especially for young children who may have difficulty drinking.
• In this situation the medication is sprayed or dripped into the nostrils.
Advantages:
• Requires little to no child cooperation.
• The full calculated dose is given.
• Drugs pass to the blood-brain barrier through the cribriform plate, allowing onset of the medication faster
than the oral route
Disadvantages:
• The drug may cause a burning sensation
• The drug effect cannot be titrated with intranasal delivery
• Cost
Intramuscular Route

Advantages:
• Absorption from an injection deep into a large muscle is much faster and more
dependable than absorption from the oral route
• Might be considered the easiest of all routes
Disadvantages:
• Onset depends on some variables (e.g whether injection is in muscle or fat layer).
• Drug effect cannot be titrated safely
• A hematoma may occur at any injection site.
Intravenous route

• the optimal and ideal route for administration of sedative agents.

• Advantages .
• Titration: Intravenous sedation allows precise titration of the drug to achieve the desired
effect.
• The drug is directly injected into the bloodstream, ensuring consistent absorption and a
predictable time to peak effect.
• This allows for incremental dosing until the desired level of sedation is reached, minimizing
the risk of underdosing or overdosing.
• In case of a medical emergency: Intravenous administering drugs is most effective route.
Disadvantages of intravenous sedation:

• Difficulty with intravenous access:

• Placing and maintaining an intravenous catheter in children can be challenging.
• Increased potential for complications:
• Such as drug extravasation into tissues, hematoma, and accidental intra-arterial
injections.
• Higher level of monitoring required:
• Need more intensive monitoring to ensure their safety.
• Cost:
• May be more expensive compared to other routes of sedation.
Common agents

• I-Antihistamines:

• II-Benzodiazepines:

• III-Sedative hypnotics:

• IV-Narcotics:
 Antihistamines:
-Hydroxyzine:
• Mild sedative and antiemetic properties
• Has no cardiovascular or respiratory depressant effects.
• Rapidly absorbed from the GIT with clinical effect seen in 15 to 30 minutes,
• Peak levels occur at 2 hours,
• Administration is preferably by the oral route.
• Intramuscular injections must be deep in a large muscle mass.
• Should not be injected subcutaneously or intravenously because of potential tissue necrosis and
hemolysis
• .Adverse reactions:
• Extreme drowsiness
• Dry mouth
• Hypersensitivity.
• Dosage:
• Oral—1 to 2 mg/kg;
• Intramuscular—1.1 mg/kg.
Antihistamines
2. Promethazine (Phenergan)
• Well absorbed after oral ingestion. • Interactions:
• Onset is within 15 to 60 minutes, with a peak • Potentiates other CNS depressants
a 1 to 2 hours • Adverse reactions:
• Duration of 4 to 6 hours. • Dry mouth
• Should be used with caution in children with • blurred vision
a history of asthma, sleep apnea, or family
history of sudden infant death syndrome. • thickening of bronchial secretions
• Lower the seizure threshold and should be • mild hypotension.
avoided in seizure-prone patients. • Dosage:
• Oral/intramuscular—0.5 to 1.1 mg/kg
I-Antihistamines
3. Diphenhydramine (Benadryl)
• It is rapidly absorbed through GIT, with maximum effect in 1 hour
• Duration :4 to 6 hours.
• It is metabolized by the liver and completely excreted in 24 hours.
• Has additive effects with other CNS depressants.
• Adverse reactions:
• Disturbed coordination,
• Epigastric distress,
• Thickening of bronchial secretions
• Dosage: Oral, intramuscular, or intravenous—1.0 to 1.5 mg/kg.
II-Benzodiazepines 1. Diazepam (Valium)
• It is rapidly absorbed from GIT
• Reaching peak levels at 2 hours
• Has strong anticonvulsant activity and provides some prophylaxis against this adverse reaction
of other drugs during the operative procedure.
• Diazepam can be administered orally, rectally, or parenterally. If the intravenous route is
selected, use of a large vein and slow administration is recommended because of the drug’s
propensity to cause irritation of the vein, with resultant thrombophlebitis. Dosage: Oral or
rectal—0.2 to 0.5 mg/kg to a maximum single dose of 10 mg; intravenous— 0.25 mg/kg
2. Midazolam
• A significant advantage of midazolam over diazepam is its high-water solubility.
• administration,
• IV sedation occurs in 3 to 5 minutes.
• IM
• Orally Onset 20 and 30 minutes
• Recovery occurs in 2 hours and may require up to 6 hours .
• midazolam produces better anxiolysis and amnesia
• Midazolam is three to four times more potent than diazepam.
• Dosage: Oral—0.25 to 1.0 mg/kg to a maximum single dose of 20 mg;
• intramuscular—0.1 to 0.15 mg/kg to a maximum dose of 10 mg
III-Sedative hypnotics Chloral hydrate:
• Onset of action: Chloral hydrate takes about 30 to 60 minutes to start working
when taken orally.
• Duration of action: The effects of chloral hydrate last between 4 and 8 hours.
• Gastric irritation: Chloral hydrate can irritate the lining of the stomach.
• Sedation and respiratory effects: The drug causes prolonged drowsiness or
sleep and can depress the respiratory system.
• General anesthesia: In large doses, chloral hydrate can induce general
anesthesia.
III-Sedative hypnotics
Chloral hydrate:
• Cardiac effects: Large doses of chloral hydrate can depress the heart muscle so It should be
avoided in patients with cardiac disease.
• Drug interactions: Combining chloral hydrate with nitrous oxide, narcotics, or local anesthetic
agents can increase the risks associated with its use.
• Airway problems: At higher doses and in combination with other agents, chloral hydrate can
cause a loss of a patent airway, making it difficult for the patient to breath.
• Dosing: The typical oral dose of chloral hydrate is 25 to 50 mg/kg.
• Variable toxicity: Chloral hydrate has a wide range of reported toxicity, and higher doses are
often used to achieve the desired sedation, which increases the risks associated with its use.
IV-Narcotics
1. Meperidine:
• Meperidine may be administered orally or by subcutaneous, intramuscular, or intravenous
injection.
• It is least effective by mouth.
• Dosage: Oral, subcutaneous, or intramuscular—1.0 to 2.2 mg/kg, not to exceed 100 mg when
given alone or 50 mg when in combination with other CNS depressants
IV-Narcotics
2. Fentanyl:
• Fentanyl has a rapid action, and after a submucosal or intramuscular injection the onset
occurs in 7 to 15 minutes;
• duration of effects is 1 to 2 hours.
• Fentanyl can be administered by the intramuscular, intravenous, or submucosal route.
• When it is used with other CNS depressants, the dose should be reduced.
• It is not recommended for use in children younger than 2 years of age.
• Dosage: 0.002 to 0.004 mg/kg
Combinations of methods and agents

• Balanced conscious sedation is a technique that combines different methods

and medications to achieve a balanced state of sedation, pain relief, and
memory loss.
• Combining medications can enhance their effects, allowing for lower doses of
stronger drugs and reducing the risk of severe respiratory depression.
• Using local anesthesia in combination with sedation improves effectiveness, as
sedation alone may not be sufficient for pain control during surgery.
• Nitrous oxide and oxygen can be used alongside other sedation methods,
increasing sedation and providing better oxygen availability.
• To minimize the risk of excessive sedation or adverse effects, it is
recommended to lower the doses of each drug by 20% to 50% when using
combination therapy.
Thank you