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 child’s cognitive and emotional needs and personality, and
Extent of dental needs of the patient,
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)
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.
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 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.**
** 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. * (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 .
Articles on Morbidity and Mortality Related to Dentistry Pts: 15 were <= 10 years Providers: 6 were pediatric dentists IV route most frequent (72%); oral (21%) Mixed (dental anesthesiologists, specialists, and general practice) 2 – 42 years 43 cases State boards of dentistry No dates given; since data was collected by each state board 1992 Krippaehne JA, Montgomery MT "Morbidity and mortality from pharmacosedation and general anesthesia in the dental office." J Oral Maxillofac Surg 50 (7): 691-8; discussion 698-9. 4 of 13 were equal to or less than 20 years.; 3 less than 10 years Oral surgeons & dental anesthesiologists 21 months – 59 years 13 cases Closed claim cases of oral surgeons 1974 – 1989 1991 Jastak JT, Peskin RM. "Major morbidity or mortality from office anesthetic procedures: a closed-claim analysis of 13 cases." Anesth Prog 38 (2): 39-44. 3/32 dental were pediatric dentists 3/95 total; Medical & Dental 1 month – 20 years (overall) 95 of which 32 were dental FDA Spontaneous Reporting System; US Pharmacopoeia; survey of medical specialists 1969 – 1996 2000 Cote CJ, et al. "Adverse sedation events in pediatrics: a critical incident analysis of contributing factors." Pediatrics 105 (4 Pt 1): 805-14. Ped Dent Providers Age Range # of Patients Source Year Article
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.
Parental Expectations and Societal Changes
How I was trained (almost 25 years ago):
No parent allowed in operatory unless child is < 3 years of age
Hand-Over-Mouth (HOM) w/wo airway restriction (99% successful and took < 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; @ 100 sedations
Today’s 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
Parents are primary cause because they fail to set limits on their children’s 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.
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
observation with parent
observation with parent & assistant
slow to warm up
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
IV - non-interactive, arousable with
V - GA
Personnel & Monitoring Equipment
Number of Publications in Pediatric Dentistry : Involving “Sedation”, “Dentistry” and “Pediatric”
Topic (related) Number of Pubs
Chloral hydrate 29
Blood Pressure 6
Pulse Ox 6
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.
Standardized training possibly involving regional centers of educational excellence.
Multidisciplinary exchange of information aimed at educating professionals outside of one’s discipline/specialty that will benefit patient care and minimize misunderstanding.