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Sedation in the Office:  Challenges for Pediatric Dentistry


Sedation in the Office: Challenges for Pediatric Dentistry Stephen Wilson DMD, MA, PhD Professor & Chief of Dentistry University of Colorado – PowerPoint PPT presentation

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Title: Sedation in the Office:  Challenges for Pediatric Dentistry

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

Pharmacological Issues Facing Pediatric Dentistry
  • 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

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
  • 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.
Dental Needs Of Children
  • Dental caries is THE most frequent chronic
    childhood disease according to the US Surgeon
  • 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

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.
Articles on Morbidity and Mortality Related to
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
  • 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
  • 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

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
  • A majority perceived parenting styles had changed
    for the worse during their practice lifetime
  • 92 felt changes were "probably or definitely
  • 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.
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.

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.

Common Drug Combinations
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

Scheme For Selecting Agents
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

Personnel Monitoring Equipment
(No Transcript)
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

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
  • 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.

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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