Pediatric Dental Sedation (Helpful Guide)

Category: Dr. Advocate's Insights, Kids Dentistry

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By: Dr. Advocate
Updated: November 24, 2022

Pediatric Dental Sedation Helpful Guide | My Dental Advocate

According to recent studies, 10%–20% of the US population avoid necessary dental care because of dental anxiety. What’s scary is dental anxiety develops in childhood as a result of frightening and painful dental experiences. In fact, 100,000–250,000 pediatric dental sedations are performed yearly in the USA.

Pediatric dental sedation can be scary for the child and parent. Typical questions that you should address include: Is it safe? What are the risks my child doesn’t wake up? Let’s take a closer look at pediatric dental sedation from a dentist’s perspective.

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What is pediatric dental sedation?

Pediatric dental sedation aims to reduce the child’s anxiety so they are calm and comfortable during the procedure. In addition, dental sedation (anesthesia) allows the child to relax and concentrate on the dentist’s instructions (if minimal sedation is used).

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Alternatively, deep sedation medication or general anesthesia allows for unimpeded work. To achieve adequate dental sedation, the dentist will use one or more techniques: nitrous oxide, oral sedation, IV sedation and general anesthesia. Numerous cavities, challenging behavior, and parent expectations support a need for sedation in pediatric dentistry.

Without anesthesia/sedation, the child and provider could be unsafe, leading to injury or harm.

Does my child need dental sedation?

Developing children lack the coping skills necessary to navigate the dental experience, occasionally making dentistry difficult. While tooth decay can contribute to pain, additional issues can arise because of a cavity. For example, poor sleep diminishes attention, and difficulty learning can occur secondarily. There are many reasons why your child needs pediatric dental sedation.

Pediatric Dental Sedation Helpful Guide | My Dental Advocate
Common Reasons

  • Pain – Most kids hate the dentist, especially if they need dental work. They cry, scream and even bite their parents or dentist. When they’re scared, they become very anxious and tense. This makes them uncomfortable and unable to focus on what the dentist says. Dental sedation is critical to prevent injury or more significant harm if children are moving or squirming around.
  • Fear – Kids often fear needles, loud noises, unfamiliar surroundings and being separated from their parents. All these fears contribute to dental anxiety. Fear of the unknown is normal; children don’t know how to process these new, scary feelings. Dental sedation eliminates these thoughts and alertness.
  • Difficulty concentrating – Children who have trouble focusing may find paying attention to the dentist’s instructions difficult. Simple instructions such as keeping your mouth open are paramount when a dental handpiece spins 400,000 revolutions per minute in the mouth.
  • Uncomfortable environment – Many children dislike sitting alone in the dental office for long periods. In addition, bright lights and noisy environments can be overwhelming. These factors can make children nervous and distract them. If the dentist loses the child’s attention, they are more prone to get scared and fall apart.
  • Unpredictable behavior – A lot of kids act out during dental appointments. Depending on their age, situational awareness and routine interactions are poorly developed. In addition, they may be fussy, clingy, restless or aggressive.
  • Poor self-control – Kids who lack self-control may try to touch the doctor or other team members in the office. They may also refuse to cooperate with the dentist. The pediatric dentist must connect with the child and develop a rapport for trust.
  • Special needs – Children with special needs may have difficulties following directions so dental sedation may be best for their safety. In addition, some children may have medical conditions or developmental differences, including limited jaw opening, tiny mouth or brittle teeth. These considerations are necessary for successful treatment.
  • Extensive cavities – Children with extensive cavities will require dental sedations so all treatment can be completed during one visit. Without dental sedation, the child will require multiple dental visits and is prone to anxiety during subsequent dental visits.

What are the different types of dental sedation?

Dental sedation is a continuum. Oral sedation is the most popular route of administration among pediatric dentists. However, the taste can be bitter for children, and it’s not uncommon for children to spit it out. IV sedation is an alternative method; however, placement of the intravenous cannula can be traumatic.

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One alternative is the transmucosal (intranasal, sublingual, buccal) route. The benefits of this route include direct absorption of drugs into the systemic circulation, avoiding metabolism and faster onset compared with oral sedation. Transmucosal administration also results in less discomfort than intravenous sedation and better patient acceptance. But first, let’s look at the different dental sedation methods.

  1. Nitrous oxide sedation – Laughing gas is considered minimal sedation and uses nitrous oxide gas to induce sleep. It is commonly used for minor procedures such as fillings, cleanings, and sealants. Nitrous oxide generates a “heaviness-like” feeling. It has no known side effects but may cause nausea, vomiting and dizziness. In addition, the child can respond to simple cues and instructions while remaining calm and collected.
  2. Oral sedation – This type of moderate sedation is administered orally and is also known as conscious sedation. The pediatric dentist or oral surgeon provides it after completing all necessary pre-procedure instructions. Oral sedatives are administered orally based on the child’s weight. The medication enters the bloodstream after digestion in the stomach. It takes effect rapidly and lasts approximately 30-60 minutes. Commonly used oral sedative agents include benzodiazepines such as diazepam (Valium), midazolam (Versed) and lorazepam (Ativan). Intranasal midazolam can also be administered. Conscious sedation is more challenging to control than IV and general anesthesia.
  3. IV sedation – This deep sedation is administered intravenously and enters the bloodstream quickly. It is often used on children with complex medical issues or extensive dental work. IV sedatives last longer than oral sedatives and are more accessible to manage. Commonly used IV sedative agents include propofol (Diprivan) and ketamine. In addition, reversal agents will be used upon treatment completion. The clinician will closely monitor the child’s vitals during and after the procedure until they are cleared to go home.
  4. General anesthesia – General anesthesia is used in hospitals for more extensive procedures or children with high-risk medical issues. General anesthesia is administered with drugs that put you “asleep” or become unconscious. The child will have no memories of the procedure and, more importantly, be still for the dentist to work without distractions. The child may experience altered sensations after the reversal agent is used and the treatment is over. Commonly used general anesthetic agents include chloral hydrate, thiopentone and etomidate. The clinician will closely monitor the child’s vitals during and after the procedure until they are cleared to go home.

Intranasal sedation administration

According to research, intranasal administration of midazolam has been proven to be a safe and effective sedative for quick procedures. Along with rapid onset, a relatively speedy recovery has also been observed. Another advantage is that strict adherence to fasting requirements is not essential. In addition, according to clinical trials, children sedated with intranasal midazolam had less risk of nausea, vomiting, and breathing complications.

Although intranasal administration is usually straightforward, relatively painless, and requires less patient cooperation, it has been associated with mucosal irritation.

Pediatric Dental Sedation Helpful Guide | My Dental Advocate

Is dental sedation safe for children?

Dental sedation is considered safe if a complete medical history is taken, clinician competency is recognized, and standard of care is observed. Unfortunately, in recent years, dental sedation has been responsible for a disproportionate number of cases that resulted in death or permanent brain damage. Young children with more complex medical conditions appear at the most significant risk.

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However, implementing simulation training and improvements in patient monitoring, including carbon dioxide measurements, are becoming a new standard of care. In addition, appropriate case selection and medication dosing (especially for overweight children) are also paramount.

Does sedation have adverse effects on the brain?

Although there have been many positive developments in dental sedation medications and technology, it is believed that drugs used in sedation and anesthesia may have adverse effects on the developing brain. In fact, initial research conducted on the brains of young animals demonstrated harm to the brains of young animals. Following the publication of these findings, researchers initiated human studies. However, the results have revealed conflicting conclusions, with some showing long-term deficits in learning and behavior while others have not.

Results are difficult to assess as adverse neurologic outcomes are tricky to recognize and measure. Further investigation into these findings continues. While it will likely be many years before we have a greater understanding of sedation and anesthesia drugs, providers must be familiar with them.

Parents should be informed and weigh the pros and cons of dental sedation. In addition, dental sedation should only be indicated when a significant benefit to the child can be expected.

Benefits

According to a recent survey, over the past 30 years, parents have become much more accepting of general anesthesia for dental treatment. With general anesthesia, minimal, moderate and deep sedation effectively facilitates a successful treatment case. In addition, there are many benefits of pediatric dental sedation. Some of these include:

Pediatric Dental Sedation Helpful Guide | My Dental Advocate

  • Reduced pain – Dental sedation eliminates the pain response during dental treatment. Children who experience pain during dental treatment are more prone to move around and be less compliant during the procedure. Most sedatives induce amnesia, which prevents the child from remembering the dental treatment.
  • Improved cooperation – When kids are anxious about their upcoming appointment, they are more to misbehave or not cooperate with the dentist. However, if they are sedated and comfortable, treatment success is increased. The clinician desires to perform the best work in the least amount of time.
  • Increased safety – With proper monitoring, you can rest assured your child is safe while under sedation. In addition, with the increased anesthesia training, general anesthesia in the dental clinic has become a safe and cost-effective mechanism for delivering dental care to healthy children. Patient vitals, including blood oxygen levels, blood pressure, pulse and carbon dioxide levels, are routinely monitored during the procedure.
  • Decreased stress – Anxiety and fear cause stress, which can increase heart rate and breathing. During dental procedures, this stress response can make the child tense up, cry, and even run away. With proper sedation, the child remains calm and relaxed throughout the visit.

Risks

Currently, there is limited data on the mortality and morbidity induced by anesthesia and sedation in pediatric dental procedures. According to previous studies, the highest mortality rate is observed in 2- to 5-year-old children in office-based dentistry operations with untrained team members. Children younger than six are more susceptible to life-threatening complications, including apnea, airway obstruction, bronchospasm, and laryngospasm.

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However, deep sedation with propofol is a suitable technique with a high success rate for dental procedures in children. Researchers also concluded that a skilled anesthetist’s presence and a close monitoring process are required in pediatric dental procedures. Lastly, the presence of a dentist anesthesiologist for providing office-based sedation is an emerging trend in the United States of America and should prevent complications.

Frequently asked questions (FAQ)

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Kids need sedation during dental treatment for various reasons. The most common reasons are the inability to tolerate treatment, children with special needs, extensive tooth decay and medically compromised children.

Encourage your child that the dentist is there to help and make them feel better. Be sure the child does not eat or drink 8 hours before the procedure (unless nitrous oxide will be used). In addition, keep the mood light with your child as they may be nervous.

Children have died during dental sedation; however, it is extremely rare. Technology has continued to evolve, providing critical safety measures to prevent damage or harm to the child. Talk to your dentist if you have any other questions or concerns.

Final thoughts

Children’s level of anxiety can be induced by many factors, including past experiences or fear of the unknown. Pediatric dentistry has dramatically advanced over the years, and now many sedation options are available to manage the most medically complex child. Sedation guidelines and best practices are available; however, talk to your pediatric dentist if you have any questions or concerns.

The more you know, the more healthy habits you can develop, saving you and your family from avoidable and potentially expensive dental procedures. Talk to your dental professional for more suggestions on improving oral health, and check back for more blog posts and relevant information. Please share this site and let us know what else you’d like to know!


Sources

  1. Nelson TM, Xu Z. Pediatric dental sedation: challenges and opportunities. Clin Cosmet Investig Dent. 2015 Aug 26;7:97-106. doi: 10.2147/CCIDE.S64250. PMID: 26345425; PMCID: PMC4555969.
  2. Committee on Quality Management and Departmental Administration. Continuum of Depth of Sedation. American Society of Anesthesiologists. 2019.
  3. Jevtovic-Todorovic V, Hartman RE, Izumi Y, et al. Early exposure to common anesthetic agents causes widespread neurodegeneration in the developing rat brain and persistent learning deficits. J Neurosci. 2003;23:876–882.
  4. Razavi SS, Malekianzadeh B. The Efficacy and Complications of Deep Sedation in Pediatric Dental Patients: A Retrospective Cohort Study. Anesthesiol Res Pract. 2022 Jun 22;2022:5259283. doi: 10.1155/2022/5259283. PMID: 35783546; PMCID: PMC9242812.

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About the Author

Dr. Advocate is an actual board-certified dentist with clinical practice experience and a mission to provide accurate dental patient education. He believes everyone should access easy-to-read dental resources presented in layman’s terms with relevant, up-to-date dental research and insight to improve their oral health.