How Can Dentists Effectively Manage Behavior, Sedation, and General Anesthesia in Pediatric Patients?
Theodore P. Croll, DDS; Joshua A. Bresler, DMD and Gerald A. Ferretti, DDS, MS, MPH
"I want my mommy!" "I want my daddy!" These are common cries often heard from anxious pediatric patients in a dental chair. In more than 47 years in dentistry, I have never heard a child shout, "I want my dentist." When Auguste Rodin, the renowned sculptor, produced the first small plaster version of "The Thinker," the figure quietly sat in repose, just thinking. Dentists who treat children don't have that luxury. Instead, they are tasked with creating "mini tooth sculptures" for vigorously moving targets, in and on teeth that have vital pulps within. In pediatric dentistry specialty programs, the term "rodeo dentistry" is well known.
The problem of treating and healing such patients is complex. Considerations encompass the safety and comfort of the child, the amount and difficulty of treatment needed, the level of the patient's anxiety and whether or not the patient is cooperative, the parent or guardian's attitude and level of trust, and whether or not the patient is physically resistant and, if so, the level of resistance. Other considerations are medicolegal implications, financial implications of treatment, insurance considerations, the dentist's and staff's training and experience, and the availability of sedation or general anesthesia.
For inexperienced dentists who are interested in treating children, perusing child behavior and development literature can be a valuable investment in time. In the 1970s and 1980s, authors such as Dr. Arnold Gesell and Dr. Benjamin Spock, who wrote Baby and Child Care, provided excellent overviews of infants, toddlers, preschoolers, and children all the way up to teenaged years. Their works, which are still relevant today, and many other more contemporary writings reveal the psychological and behavioral aspects of youngsters. Eventually, through clinical experience, handling young dental patients with nonpharmaceutical "tricks of the trade," such as show-tell-do, modeling, distraction, praise, humor, rewards, and others, becomes second nature to dentists and their staffs. However, these strategies are not always enough.
Keeping children who are cooperative but afraid safe and comfortable often can be accomplished easily by use of oxygen/nitrous-oxide nasal mask inhalation/relaxation. It is important for dentists to explain to parents the safe nature of oxygen/nitrous-oxide, noting that while room air is about 21% oxygen, the airflow to the child with this method is about 60% to 80% oxygen. Also, showing the patients and parents a photograph, perhaps in a dental textbook, of a smiling child with the mask in place can offer reassurance.
When profound sedation is required, various types of drugs and routes of administration have been used for children. These include narcotics, barbiturates, tranquilizers, and others along with combinations of such drugs. Early in my career, I was trained to use these drugs per os, intramuscularly, and subcutaneously. I did so in private practice with good success, following customary protocols, and except for an occasional vomiting from chloral hydrate, things went well. Then, as I learned through experience and gained wisdom, I realized how fortunate I was that no idiosyncratic reactions had occurred. I came to understand that the challenges of chairside clinical dentistry are more than enough to occupy the dentist's mind and concentration, such that uncooperative patients need to be attended to by someone whose sole focus is to administer the pharmaceuticals and monitor and ensure the patient's status. Thus, from that time on, I have referred children who could not be treated otherwise to dental practices that concentrate on expertly rendered controlled sedation and general anesthesia.
Taking the philosophy of "safety first," it is important for dental practitioners to spare no effort or expense to provide patients the most controlled sedation experience possible and use only medications that can be quickly reversed. Pediatric patients can fall into a deeper sedation level than intended and become apneic. This "side effect" of sedation medications can lead to catastrophic outcomes in patients who are not monitored properly. Trained professionals know how to quickly detect apnea or any respiratory distress and intervene immediately.
Five years into private practice, after performing thousands of sedations, an opportunity developed for our group practice in Philadelphia. We needed to relocate one of our existing practices, and a nearby open warehouse became available. The new facility provided us extra space to utilize after already tripling the size of the current dentistry facility. We hired an architect with experience in building ambulatory surgery centers and created an "ASC" dedicated to dental procedures only. This was an ideal plan because we had a 6-month waiting list for patients who needed general anesthesia for their oral rehabilitations. From purchasing supplies and equipment to hiring skilled medical and nursing staff, "safety first" was the principal that guided our every decision during construction of the facility.
At the surgical center, which now has been operating for 14 years, it is nice to know I am not alone any time a patient is intubated. We have a board-certified pediatric anesthesiologist with more than 25 years of experience, a certified registered nurse anesthetist, and a nurse present, all of whom are focused on providing safe and controlled anesthesia care, which allows me to focus on dentistry. Having this support is very comforting. While I used to enjoy the benefits of doing sedations in the office, it was stressful with poor reimbursements for sedation fees from insurance carriers. With a secure airway, every monitor available, and most importantly, a medical team focusing on the patient as I perform the dental work, our practice is able to provide a safe and highly controlled sedation experience for our patients.
Pediatric dentists are tasked with using a handpiece with a sharp bur that spins very fast to fix teeth in a small mouth with head movements that are often unpredictable. Although many dentists are skilled enough to perform the task successfully regardless of the patient's cooperation, there are real risks that accompany the provision of care in this manner. A parent of an uncooperative and resistant child who demands that their child be treated without sedation, even after hearing the risks of doing so, will not be forgiving when the child's head jerks and a high-speed spinning bur causes damage. At our facility, with the medical team in place, I am able to assure parents of the safety of anesthetic care.
Pediatric dentists treat most of their patients chairside safely, with traditional nonpharmacologic behavior management techniques. However, for those patients who cannot safely tolerate treatment in the traditional setting, skillfully delivered sedation and/or general anesthesia, along with a "safety first" mindset, is an essential part of the armamentarium.
The pharmacologic sedation modalities used to enable provision of dental care for children when traditional nonpharmacologic methods cannot be employed have evolved considerably. The broad scope of sedation techniques available to manage pain and anxiety during the provision of dental care extends well beyond the boundaries of this review. However, over the past 40 years one of the most fervently discussed and controversial topics has been how to sedate the young healthy child outside the operating room setting.
Historically, the practice of office sedation using single, double, and triple agent enteral and parenteral cocktails, such as the "cardiac cocktail" (Demerol, Phenergan, Thorazine) or chloral hydrate, Vistaril, with or without Demerol, resulted in a multitude of serious misadventures. These mishaps were largely due to overdose from the synergistic drug effects combined with administration of too much local anesthetic. Subsequently, new generations of sedative/analgesic drugs such as alphaprodine and benzodiazepines exhibiting reversal properties and more effective routes of administration were used widely in outpatient settings. However, the profound efficacy and false sense of safety of the resulting sedation in conjunction with minimal monitoring led to disastrous outcomes.
Ultimately, the first set of guidelines for the use of sedation of pediatric patients was adopted jointly by the American Academy of Pediatric Dentistry and the American Academy of Pediatrics (AAPD/AAP). These child-specific guidelines have been revised several times over the past 25 years. Other guidelines from professional organizations, including the American Dental Association, American Association of Oral and Maxillofacial Surgeons, American Society of Dentist Anesthesiologists, American Society of Anesthesiologists, and others, were not pediatric specific. Fortunately, the resultant call for sedation regulations by state legislatures and state boards of dentistry allowed for the AAPD/AAP pediatric sedation guidelines to be used as a template for the pediatric sedation regulations adopted through each state.
At present, safe sedation of the young healthy child in the outpatient dental setting or otherwise outside the operating room is a realistic outcome. However, this reality is based on several caveats. The most important of these is that the clinician receive extensive didactic and clinical training in accredited educational programs that incorporate accepted pediatric sedation guidelines and regulations, and that the provision of care be done in an appropriately accredited or licensed dental facility. In addition, the use of a sedation protocol consistent with the desired level of sedation by trained providers and staff current in monitoring, equipment usage, sedation technique, emergency recognition, and response is essential.
Finally, when practicing pediatric sedation on a healthy young child, the clinician should "know your patient." Know that the child is an appropriate candidate for the proposed sedation. Know that the sedation is necessary and that the child's parents/guardians are fully informed. Lastly, when preparing to sedate a child patient, the clinician should pick up one of the child's hands and look at the pinky finger as a reminder that the patient's airway is approximately the diameter of that little finger. This small opening is what keeps your patient alive.
Theodore P. Croll, DDS
Clinic Director, Cavity Busters Doylestown, Doylestown, Pennsylvania; Adjunct Professor, Pediatric Dentistry, University of Texas Health Science Center at San Antonio (Dental School); Clinical Professor, Pediatric Dentistry, Case Western Reserve (CWRU) School of Dental Medicine, Cleveland, Ohio
Joshua A. Bresler, DMD
President, Doc Bresler's Cavity Busters; Medical Director, Red Lion Surgicenter, Philadelphia, Pennsylvania; Assistant Professor of Pediatric Dentistry, Temple University School of Dentistry; Assistant Professor of Pediatric Dentistry, University of Pennsylvania School of Dental Medicine
Gerald A. Ferretti, DDS, MS, MPH
Professor, Pediatric Dentistry and Pediatrics, Chair, Program Director, Pediatric Dentistry, CWRU School of Dental Medicine; Anne Hunter Jenkins Endowed Master Clinician in Pediatric Dentistry and Orthodontics, Chief of Dentistry, Rainbow Babies and Children's Hospital