Sedation in the Office: Challenges for Pediatric Dentistry

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Sedation in the Office  Challenges for
Pediatric Dentistry

• Stephen Wilson DMD, MA, PhD
• Professor Chief of Dentistry
• University of Colorado
• School of Dentistry
• and
• The Childrens Hospital

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Pharmacological Issues Facing Pediatric Dentistry
Today

• The risks for the children involved with
  pharmacological management compared to routine
  communicative techniques,
• Past safety record of pharmacological management,
  
• Parental expectations and societal changes,
• Nature of the childs cognitive and emotional
  needs and personality, and
• Extent of dental needs of the patient,
• Monitoring,
• Practitioner training and experience including
  the ability to rescue a child when
  significantly compromised,
• Cost and third-party payors,
• Venue issues (i.e., Office vs. Out-patient care
  facility)

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Risks Pharmacological vs. Behavioral Management

• Pharmacological (sedation, general anesthesia)
• Most significant adverse outcome death
• No direct data to support an estimated ratio of
  risk/benefit prior to and following published
  guidelines on sedation.
• Fairly good estimate of number of
  deaths/morbidities in dentistry (invariably and
  indiscriminately lumping dental generalists and
  specialties together confounding interpretation),
  but no definitive data on the number of sedations
  actually attempted. Also, no summary data on how
  closely clinician followed guidelines.
• For pediatric dentistry, the number of sedations
  actually attempted in an outpatient setting may
  approximate 100,000 - 200,000 per year based on
  survey data. In extrapolating, it is estimated
  that over 1.5 million children have been sedated
  since 1985 when the first sedation guidelines
  appeared.
• Behavioral (TSD, voice control, papoose board,
  distraction, coaxing)
• Significant outcomes bone fracture/dislocation
  of limbs injury to face from bur
• No data, but there are anecdotal reports..

Houpt, M. (1989). "Report of project USAP the
use of sedative agents in pediatric dentistry."
ASDC J Dent Child 56(4) 302-9. Houpt, M. I.
(1993). "Project USAP--Part III Practice by
heavy users of sedation in pediatric dentistry."
ASDC J Dent Child 60(3) 183-5 Houpt, M.
(2002). "Project USAP 2000--use of sedative
agents by pediatric dentists a 15-year follow-up
survey." Pediatr Dent 24(4) 289-94.
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Dental Needs Of Children

• Dental caries is THE most frequent chronic
  childhood disease according to the US Surgeon
  General
• it is especially prominent in the underserved
  population (25 own 80 of caries problem)
• 4 times more prominent than asthma
• Program directors perceive that the number of
  new, recall and emergency patients and the number
  of pre-school aged children and children with
  special health care needs had increased in their
  programs over the last 5 years.
• Payment by Medicaid was the most common insurance
  for children cared for in these settings.
• The mean waiting time for scheduling treatment
  with GA for a child in pain is 28 days without
  pain 71 days. The mean waiting time for
  scheduling treatment with sedation is 36 days.

• (2000). "Oral Health in America A Report of
  the Surgeon General." U.S. Department of Health
  and Human Services, National Institute of Dental
  and Craniofacial Research, National Institutes of
  Health.

Lewis, C. W. and A. J. Nowak (2002).
"Stretching the safety net too far waiting times
for dental treatment." Pediatr Dent 24(1) 6-10.
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Articles on Morbidity and Mortality Related to
Dentistry
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Practitioner Training

• Current accreditation standard indicates that
• a minimum of 1 month of anesthesia experience is
  required (oral and maxillofacial surgery
  standards require a minimum of 4 months)
• CPR required (and many programs require PALS or
  ACLS) and
• sedation experiences (number, routes, types not
  specified).
• Overwhelmingly, sedation in training programs
  involve oral and rarely, intravenous sedation.
  Probably no other specialty has as much clinical
  experience in oral sedation than pediatric
  dentistry.
• Today, most state boards of dentistry require a
  sedation permit (facilities site visit, PALS or
  ACLS certification, sedation training).
• Currently, AAPD leadership is pursuing
  standardization of training to include
  standardized didactics and clinical sedation
  experiences amongst all accredited pediatric
  dentistry programs one of the principles
  involved would be incorporation of rescue
  training.

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Parental Expectations and Societal Changes

• How I was trained (almost 25 years ago)
• No parent allowed in operatory unless child is lt
  3 years of age
• Hand-Over-Mouth (HOM) w/wo airway restriction
  (99 successful and took lt 30 seconds to
  accomplish at no financial obligation and no
  documented adverse effects BUT was abused and a
  priori consent not obtained)
• 25-75 GA cases/year _at_ 100 sedations
• Todays world Board-certified pediatric
  dentists
• A majority perceived parenting styles had changed
  for the worse during their practice lifetime
• 92 felt changes were "probably or definitely
  bad
• 85 felt that these changes had resulted in
  "somewhat or much worse" child patient behavior
• More crying struggling
• Less cooperative
• Parents are primary cause because they fail to
  set limits on their childrens activities
• Practitioners report performing less assertive
  behavior management techniques than in the past
  due to these changes.

Casamassimo, P. S., Wilson S., Gross, Ll.
(2002). "Effects of changing U.S. parenting
styles on dental practice perceptions of
diplomates of the American Board of Pediatric
Dentistry presented to the College of Diplomates
of the American Board of Pediatric Dentistry 16th
Annual Session, Atlanta, Ga, Saturday, May 26,
2001." Pediatr Dent 24(1) 18-22.
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Office Accountability

• Most of dentistry is a cottage industry with
  regulation by state dental practice act. Each
  practitioner, once licensed, is responsible for
  patient safety in his/her own practice.
• Most states require practitioners who do
  sedation to have a permit to do so. Usually this
  requires a site visit from a consultant
  responsible to the state dental board. The visit
  usually involves examination of the facilities in
  terms of meeting sedation guidelines,
  practitioner training (i.e., PALS and
  educational/clinical training), emergency
  management protocol, and paperwork. Yet, there
  is considerable variability among state dental
  practice acts.
• If emergency occurs, the practitioner must be
  prepared to manage the patient until assistance
  (EMS) arrives. This issue may be most important
  challenge for our specialty for those who sedate
  in the office.

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Sedation in Pediatric Dentistry

• Most regimens involve either a benzodiazepene
  alone or a combination of agents.
• Most popular benzo is midazolam given primarily
  orally (0.5 1.0 mg/kg)
• Common agents used in various combinations
  include chloral hydrate, meperidine,
  antihistamines, and benzos.

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Common Drug Combinations
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Key Factors In Drug Selection Dose

• Child temperament personality
• Clinical assessment
• query parent(s)
• observation with parent
• observation with parent assistant
• Clinical classification
• easy
• slow to warm up
• difficult
• Type and duration of dental care
• ultra-short extraction of maxillary incisors
• short quadrant of dentistry
• long 2 or more quadrants of dentistry

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Scheme For Selecting Agents
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Current AAPD Sedation Guidelines

• 5 functional levels of sedation
• I - anxiolysis
• II - interactive
• III - non-interactive, arousable with
• mild/moderate stimuli
• IV - non-interactive, arousable with
• intense stimuli
• V - GA

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Responsiveness
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Personnel Monitoring Equipment
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Number of Publications in Pediatric Dentistry
Involving Sedation, Dentistry and Pediatric

• Topic (related) Number of Pubs
• Chloral hydrate 29
• Midazolam 21
• Meperidine 17
• Diazepam 7
• Triazolam 1
• Morphine 1
• Monitoring 20
• Blood Pressure 6
• Pulse Ox 6
• Capnography 7

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Research Needs

• Systematic, prospective studies investigating
  patient personality, drug selection/dosage,
  duration and type of care delivered.
• Relationship among peri-operative factors and
  patient safety including fasting, drug dose, and
  recovery.
• Cost analysis of sedation in terms of supplies,
  personnel, risk/benefit.
• Educational settings, training standards, and
  outcomes assessment related to patient safety and
  professional responsibility.
• Investigation and implementation of repository
  of cases categorized in terms of protocol
  variables and outcomes of sedation cases.

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Educational Needs

• Standardized training possibly involving
  regional centers of educational excellence.
• Multidisciplinary exchange of information aimed
  at educating professionals outside of ones
  discipline/specialty that will benefit patient
  care and minimize misunderstanding.

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Questions???