Policy

Managing Anxious Children by

use of Sedation in Pediatric
Document #: PP/HCO/004/03
Dentistry Review Date:18 October 2018

Issue Date: 18 October 2015 Related Forms: ☐ Yes ☒ No

1 PURPOSE:

The purpose of this document is to define Policy and, identify and set out the
guidelines for managing anxious children in the practice of pediatric dentistry by use
of sedation in Dubai Healthcare City (DHCC). The aim of the Policy is to ensure the
safe use of Sedation as an adjunct to non-pharmacological behavioral management
techniques for anxious children to facilitate effective and safe dental care.

The Policy does not include the provision of sedation and anesthesia in dentistry for
adults or for other conditions in children other than the management of anxiety.
Neither does it address specific details of drug dosages or the important aspect of
analgesia and pain control which is not within the remit of this Policy.

2 APPLICABILITY:

This Policy supersedes and replaces PP/HCO/004/02 issued on 6th December 2011.

The Policy is applicable to all Licensed Healthcare Operators and Licensed Healthcare
Professionals providing dentistry services to children within DHCC.

This Policy is to be implemented in conjunction with all other applicable policies and
standards including the CPQ Outpatient Clinic Quality Standards where applicable.

3 DEFINITIONS / ABBREVIATIONS:

3.1 Anxiety: excessive worry or fear often marked by physiological signs (i.e.,
tension, increased pulse) and limited capacity to adequately cope with
perceived threat. Behavioral examples of anxiety in the dental clinic setting
include reactive behaviors such as forceful crying, running out of room,
screaming, or aggressive behavior.
3.2 ASA: American Society of Anesthesiologists
3.3 Class ‘B’ Licensed Facility or Level 2 Licensed Facility: a facility that provides
for the delivery of minor or major surgical procedures performed in
conjunction with oral, parenteral (inhalation) or intravenous sedation or
under analgesic or dissociative drugs.
3.4 Class ‘C’ Licensed Facility or Level 3 Licensed Facility: a facility that provides
for the delivery of major surgical procedures that require general or regional
block Anesthesia and support of vital bodily functions.
3.5 CPQ: Center for Healthcare Planning and Quality

3.6 DHCA: Dubai Healthcare City Authority

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Document #: PP/HCO/004/03 Issue Date: 18 October 2015

3.7 DHCR: The Regulatory arm of Dubai Healthcare City Authority

3.8 Deep Sedation: the administration of a drug or drugs that produces sustained
depression of consciousness during which patients cannot be easily aroused
but do respond purposefully following repeated or painful stimulation and
where:
 the ability of the patient to independently maintain respiratory
function may be impaired;
 the patient may require assistance in maintaining a patent airway;
 spontaneous ventilation may be inadequate; and cardiovascular function is
usually maintained but may be depressed
3.9 General Anesthesia: a pharmacologically induced loss of consciousness during
which patients are not arousable, even by painful stimulation, and where:
 the patient’s ability to independently maintain respiratory function is
often impaired;
 the patient often requires assistance in maintaining a patent airway;
 positive pressure ventilation may be required because of depressed
spontaneous ventilation or drug-induced depression of neuromuscular
function; and cardiovascular function may be impaired.
3.10 Healthcare Operator: a hospital, clinic, laboratory, pharmacy or other entity
holding a Clinical Operating Permit duly issued by the DHCC Licensing Board in
accordance with the applicable Regulations and Rules to provide clinical
healthcare services in DHCC.
3.11 Healthcare Professional: a Healthcare Professional holding a License duly
issued by the DHCC Licensing Board in accordance with the Healthcare
Professionals Regulation and the applicable Rules to engage in professional
practice in DHCC
3.12 Minimal Sedation or Anxiolysis: a pharmacologically induced state during
which patients respond normally to verbal commands, although cognitive
function and coordination may be impaired, respiratory and cardiovascular
functions are unaffected, and protective-airway reflexes should remain intact
3.13 Moderate Sedation or Conscious Sedation: a drug-induced depression of
consciousness during which the patient responds purposefully to verbal
commands, either alone or accompanied by light tactile stimulation, and
includes dissociative anesthesia that does not constitute deep sedation or
general anesthesia and where:
 the drugs, dosages and techniques utilized for moderate sedation are
intended to provide relief of the patient’s pain and anxiety during
procedures without loss of consciousness;
 no interventions are required to maintain a patent airway;
 spontaneous ventilation is adequate; and cardiovascular function is
usually maintained

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3.14 Physical Status: a description of a patient based on a classification system,

used in determining if a surgery or a procedure is appropriate, developed by
the American Society of Anesthesiologists, with Physical Status being
classified as follows:
 ASA I: normal, healthy patient;
 ASA II: a patient with mild systemic disease;
 ASA III: a patient with severe, systemic disease that limits activity but
is not incapacitating;
 ASA IV: a patient with incapacitating systemic disease that is a
constant threat to life.
 ASA V: a moribund Patient not expected to live 24 hours with or
without operation
3.15 Sedation: a state of calm, restfulness, or drowsiness, especially as induced by
a sedative or tranquilizing drug

4 POLICY:

4.1 The management of anxiety in children undergoing dental procedures shall

first include a ‘reasonable attempt’ to use non-pharmacological techniques as
a primary approach where possible, and not rely solely on pharmacological
techniques to modify or control behavior.
4.2 A “reasonable attempt” to use non-pharmacological techniques shall
include, at minimum, the following steps:
 Assessment of the child’s propensity for anxiety (i.e., behavioral
history with medical procedures, developmental level, tolerance for
pain, coping skills)
 Preparation of the child and parent(s) for the upcoming event:
o Offer age-appropriate sensory and procedural information to the
child and parents about the upcoming procedures (i.e.,
educational handouts, videos, exposure to setting/stressors).
Time in advance depends on age and development (for example,
a 6-7 year old can be introduced to procedures 1 week before,
whereas a young toddler would benefit from 1 day before)
o Provide opportunities to ask questions.
 Implementation of supportive coping behaviors (i.e., movies,
nonprocedural talk, toy play, other engaging activities requiring little
cognitive processing) just before, during and following medical procedure.
In general, distraction should be greatest and information provision lowest
during the procedure phase.
4.3 Licensed Healthcare Operators providing sedation and anesthesia shall be
classified in accordance with the DHCA latest Anesthesia and Sedation Facility
Standards. Healthcare Operators providing sedation at levels defined as

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minimal sedation or moderate sedation shall be licensed minimally as Class B

classification.
4.4 Deep sedation and general anesthesia are not approved for the management
of anxiety in children in the practice of pediatric dentistry in a dental clinic
environment in DHCC. Deep sedation and general anesthesia shall only be
administered in the practice of pediatric dentistry by a licensed
anesthesiologist in a suitably equipped licensed Class C facility.
4.5 The use of nitrous oxide inhalation to induce mild sedation or anxiolysis in
children shall be performed in a suitably licensed Healthcare Operator
minimally classified as Class B within DHCC.
4.6 Minimal sedation or anxiolysis by use of nitrous oxide may be administered to
pediatric patients of ASA I and ASA II classification in a licensed Class B dental
clinic by a suitably qualified licensed pediatric dentist or licensed dentist with
qualifications, training and experience in treating pediatric patients. The
dentist is required to:
 have been granted clinical privileges by the Healthcare Operator’s
clinical leaders to administer nitrous oxide to pediatric patients;
 have evidence of formal training in the management of sedation of
pediatric patients with nitrous oxide;
 have evidence of current competence in the management of sedation
of pediatric patients with nitrous oxide;
 have evidence of continuing education in the management of sedation
of pediatric patients with nitrous oxide.
4.7 A dentist may assess a patient as ASA I for the purpose of assessing risk for
minimal sedation by nitrous oxide inhalation. When a dentist initially assesses
a patient as being of a lower ASA classification (i.e. ASA II, ASA III or ASA IV), or
when ASA classification is not certain, such patients are to be further assessed
by a suitably qualified licensed physician (i.e. pediatrician or anesthesiologist)
prior to the decision to administer any sedation including minimal sedation by
nitrous oxide inhalation.
4.8 Nitrous oxide and oxygen are to be delivered using an approved gas mixing
and delivery system capable of delivering 100% oxygen and a minimum of
30% Nitrous oxide. The gas delivery equipment is to have a fail-safe system to
be checked on each day of use and preferably before each use. Safety checks,
calibrations and maintenance are to be recorded. To reduce the pollution
effects associated with nitrous oxide use, the equipment is to have an
appropriate scavenging system and is to be used in a well ventilated
treatment room. All equipment is to be approved for use by Facility Design
and Engineering Services of DHCA prior to patient use.
4.9 Mild to moderate sedation using approved sedatives either alone or in
combination may be administered to pediatric patients of ASA I and ASA II
classification in a licensed Class B dental clinic by a licensed anesthesiologist.
The anesthesiologist is required to have been granted clinical privileges by the

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 Managing Anxious Children by
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Healthcare Operator’s clinical leaders to administer sedatives and manage the

sedated patient.
4.10 At least one member of the sedation team shall hold current certification in
Pediatric Advanced Life Support (PALS) and shall be present during any
procedure for pediatric patients performed under sedation and remain
available in the facility until the patient is discharged.
4.11 Mild or moderate sedation may lead to a deeper state of sedation than
intended. Patients who are inadvertently sedated to a level of deep sedation
are to be stabilized and provided appropriate care until they are safely
transferred to a hospital for management and observation. Such cases are to
be classified as an ‘adverse incident’ and recorded and acted upon in
accordance with the Healthcare Organization’s risk management / incident
reporting policy and process.
4.12 Documentation in the patient’s medical record shall be in accordance with
DHCC and DHCA Rules, Regulations and Standards and shall include:
 mental, behavioral and emotional assessment;
 assessment of physical status as per ASA classification;
 non-pharmacological behavioral guidance used (see 4.1 & 4.2);
 the reason for selection of sedation on each occasion that it is
planned;
 consent for sedation (see 4.13);
 dose, route and time/s of administration of sedation agents;
 record of physiologic monitoring of patient during sedation
(recommend as a minimum pulse oximetry recordings every 5
minutes);
 details of adverse reactions or complications associated with sedation;
 post sedation assessment and time of discharge.
4.13 The informed consent process shall be conducted with the patient’s parent or
legal guardian, and the child where appropriate, prior to performing any
procedure under sedation and recorded in the patient’s medical record.
4.14 The use of restraining devices or immobilization devices is not permitted. In
cases where the patient becomes combative or aggressive during a procedure
and it is not possible to terminate the procedure, it is recommended that
when required to ensure the safety of the patient, reasonable physical
restraint may be used with the consent and preferably with the involvement
of the patient’s parent or guardian.
4.15 The Healthcare Operator shall define discharge criteria for patients having
undergone sedation. The Healthcare Professional administering sedation to
pediatric dental patients (dentist or anesthesiologist) is responsible for
discharging patients in accordance with the defined discharge criteria.

5 RESPONSIBILITY:

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 Managing Anxious Children by
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5.1 It is the responsibility of the Healthcare Operator to ensure the

implementation of policies, procedures, guidelines, equipment, and trained
and experienced staff for the safe provision of sedation in pediatric dentistry
in accordance with this Policy.
5.2 Each Licensed Healthcare Professional is responsible for the safe provision of
sedation to pediatric patients under their care in accordance with this Policy.

6 REFERENCES:

6.1 American Academy of Pediatric Dentistry. Guideline on Behavior for the Pediatric
Dental Patient. Pediatric Dentistry, 2011;33(special issue): 161-173.
http://www.aapd.org/media/Policies_Guidelines/G_BehavGuide.pdf
6.2 Hosey, M.T. UK National Clinical Guidelines in Pediatric Dentistry. Managing anxious
children: the use of conscious sedation in pediatric dentistry. International Journal of
Pediatric Dentistry, 2002:12 (5). 359 -372. ISSN 0960-7439.
http://www.rcseng.ac.uk/fds/publications-clinical-
guidelines/clinical_guidelines/documents/paed_sedation.pdf
6.3 American Academy of Pediatric Dentistry. Guideline on use of nitrous oxide for
pediatric dental patients. Pediatric Dental Patient. Pediatric Dentistry,
2011:33(special issue): 181-184
http://www.aapd.org/media/Policies_Guidelines/G_Nitrous.pdf
6.4 Standing Dental Advisory Committee, Department of Health. Conscious sedation in
the provision of dental care. Report of an expert group on sedation for dentistry.
2003.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyA
ndGuidance/DH_4069257
6.5 Holroyd, I. Conscious sedation in pediatric dentistry. A short review of the current UK
guidelines and the technique of inhalational sedation with nitrous oxide. Pediatric
Anesthesia, 2008:18. 13-17
6.6 Scottish Dental Clinical Effectiveness Programme. Conscious sedation in dentistry.
Dental clinical guidance. 2006. http://www.sdcep.org.uk/index.aspx?o=2331

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