The use of sedation in dental practices has not attained the same level of popularity as in medical practices, where it is commonly used for a wide variety of procedures, from imaging to surgery. In medicine, sedation is also used in a wide variety of disciplines, from cardiology to dermatology, in which practitioners use enteral (oral) and parenteral (intravenous) sedation. Most dentists, however, rely solely on nitrous oxide, an anxiety reducer (anxiolytic). Why the differences?
The simple answer is that medical schools teach the use of oral and parenteral sedation, whereas dental schools teach the use of nitrous oxide. Unless a dental student continues with postdoctoral education in an advanced general dentistry program or a specialty program that teaches sedation, he or she learns only about nitrous oxide. Organized dental societies and private educational firms offer courses in sedation dentistry,i but dentists typically begin their careers in practices where only nitrous oxide is used.
With medical practitioners commonly using sedation for diagnostic and minor invasive procedures, patients are seeking the same experience for their dental needs. Increasingly, dental patients are considering dentists who offer oral or intravenous sedation dentistry supplemented with nitrous oxide. This is especially true for patients who would otherwise forgo treatment due to fear.
Until recently, sedation dentistry was limited to third molar removal and other types of oral surgery. However, a growing number of general dentists and dental specialists are completing the educational and regulatory requirements for incorporating sedation into their practices. These include pediatric dentists, periodontists, endodontists, and prosthodontists.
Although some dentists are treating patients in hospitals with the use of general anesthesia, skyrocketing costs of in-hospital care, nursing staffs, and anesthesia providers have limited the practicality of this protocol. Therefore, general anesthesia is typically limited to patients who are very young, medically compromised, mentally or physically challenged, and have risk conditions that require hospital resources.
Pediatric considerations
For pediatric patients, performing multiple-appointment, invasive care can be a management disaster, even with nitrous oxide. While the first and sometimes the second visits are manageable with some stress (on behalf of the dentist and the child), subsequent visits too often become impossible. Not only are parents and children unhappy, but so are dentists and their staffs.
Orally administered sedation drugs for pediatric dentistry have been available for years, but until recently they were not popular. There were multiple reasons for this: Many of the drugs took almost an hour to sedate children, many had adverse side effects, and many took one to two days to eliminate.
However, with the introduction of modern benzodiazepines, the practice of pediatric sedation has become more widespread. Today, the most popular drug regimen is midazolam (Versed) administered as a liquid. Midazolam is called the "no memory" drug because it produces postsedation amnesia. In cases of oversedation, a reversal drug for midazolam is available. Midazolam is fast-acting and allows the dentist a good working time. It also has a short elimination time, which reduces the risk of postsedation respiratory dysfunction at home.
Adding an antihistamine (administered as a liquid) enhances midazolam's sleep effect. The antihistamine, usually hydroxyzine, is given to prevent nausea and promote drying of the mouth. Supplemented with inhaled nitrous oxide, this drug regimen has become one of the most widely used sedation protocols in pediatric dentistry.
With this protocol in place, dentists can often address the needs of a child in one visit. The protocol allows children to be comfortable, and it gives parents peace of mind. When using other oral drugs for sedation, such as narcotics, using high levels of the drug is common. This is avoided with midazolam.
Like nitrous oxide, there are guidelines and regulations for the use of pediatric sedation. Guidelines are provided by organized dental societies, including the American Dental Association and the American Academy of Pediatric Dentistry. State dental boards also issue requirements. Because oral sedation affects the central nervous system (and therefore consciousness), monitoring vital signs using instruments and trained personnel is required. The criteria for case selection are more restrictive than for nitrous oxide use. A thorough preoperative evaluation of airway competency and respiratory function is mandatory.
As an example, let's consider this situation, one that can occur in a general practice that treats children or in a pediatric practice limited to children. See if this example applies to you:
A young school-age boy, accompanied by his mother, presents to a practice. A clinical exam with radiographs is performed. Much to the surprise of the parent, the child has interproximal caries in many of the posterior quadrants. The parent remarks, "Doctor, are you sure? I don't understand how my child can have all those cavities." A restorative treatment plan is presented. Multiple appointments will be required. The parent remarks, "Doctor, can't you do all this in one appointment? Why so many visits?" The parent, who has a full-time job, requests a late appointment for the child, who attends an after-school care program.
Now, with late appointments, you know that most children are tired, hungry, and in a bad mood. They want to eat and play. The last thing they want to do is to come to a dental office and get a shot, which their friends at school have warned them about. If you're seeing children who are used to getting their own way, things are even more difficult.
Wouldn't you like to treat the child in our case study in one visit during an early morning appointment? Under the "no memory" pediatric sedation approach, 7:00 a.m. appointments are ideal, as the child must have an empty stomach. Early appointments have other benefits: parents often miss less work and save travel time, while children miss less school. When the appointment is over, the child has no memory of a shot or invasive treatment. The child leaves the office without the fear of dentists, preventing a "phobic adult" later in life. Everybody comes away happy-the parent, child, dentist, and staff.
Like everything else that was not taught in dental school (implants, adult orthodontics, complex cosmetic care, etc.), sedation requires advanced education, additional equipment, and different supplies. The benefits to the practice, however, far outweigh the costs. Because parents come away satisfied, the practice gains a great marketing advantage. You will hear parents say, "Doctor, I want my child sedated like you did for my friend's child, who needed a lot of fillings. That child said he never remembered anything."
Pediatric oral sedation has become an amazing game changer for dental practices that treat children. The benefits to all involved make it a treatment modality that is becoming more widely sought. Like our colleagues in medicine, use safe sedation in your practice to your benefit.
AUTHOR NOTE
i. Examples of organizations that teach sedation include the American Academy of Pediatric Dentistry, the American Society for Dental Anesthesia, and DOCS Education.
Roger G. Sanger, DDS, MS, is a pediatric dentist in California. He is cofounder of one of the state's largest private pediatric dental groups. Dr. Sanger serves as a director in the Institute for Pediatric Dentistry and director of pediatric sedation dentistry for DOCS Education. He recently completed a new book, The Entrepreneur's Children's Dental Practice.
