Transcript 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 Children’s Hospital
Pharmacological Issues Facing
Pediatric Dentistry Today
 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,
 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 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.

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 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.**
* (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.
** 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 Dentistry
Article
Year
Source
# of Patients
Age Range
Providers
Ped Dent
Cote CJ, et al.
"Adverse sedation
events in pediatrics:
a critical incident
analysis of
contributing
factors." Pediatrics
105(4 Pt 1): 805-14.
2000
FDA Spontaneous
Reporting System;
95 of which 32 were
dental
1 month – 20 years (overall)
Medical & Dental
3/32 dental were
pediatric dentists
3/95 total;
US Pharmacopoeia;
survey of medical
specialists
1969 – 1996
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.
1991
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.
1992
Closed claim cases
of oral surgeons
13 cases
21 months – 59 years
1974 – 1989
State boards of
dentistry
No dates given;
since data was
collected by each
state board
43 cases
2 – 42 years
Oral surgeons &
dental
anesthesiologists
4 of 13 were equal to or
less than 20 years.;
Mixed (dental
anesthesiologists,
specialists, and
general practice)
Pts: 15 were <= 10 years
3 less than 10 years
Providers: 6 were
pediatric dentists
IV route most frequent
(72%); oral (21%)
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 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
Less cooperative

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.
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
Combo
Dosages
(Oral Only)
Onset
(Min)
Trait
Cautions
CH + Vis
CH (20-50)
Vis (1-2)
(40-50)
hyper; cry; sleep
airway
CH + Vis +
Dem ****
CH (20-35)
Vis (1-2)
Dem (1-2)
(30-45)
hyper; euphoric; dysphoric; airway; resp dep;
sleep
(Narcan 0.1 mg/kg)
Dem + Vis
Dem (1-2)
Vis (1-2)
(40-45)
same as above
Same as above
Mid
(0.5-1.0)
(5-15)
floppy doll; slow to react;
cry
"Angry child Syn";
Flumazenil (0.01 mg/kg)
Mid + Vis
Mid (0.3-0.7)
Vis (1-2)
(10-20)
same as above
Same as above
Mid + Dem
Mid (0.3-0.5)
Dem (1)
(10-30)
same as above
(Narcan 0.1 mg/kg)
Flumazenil (0.01 mg/kg)
Diazepam
2-5 yrs (5 mg);
6-10 yrs (5-10mg)
11-20 yrs (10-15 mg)
(30-60)
cry; mellow
Flumazenil (0.01 mg/kg)
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
Dental Needs
Temperament
Drugs (All oral drugs supplemented with
N2O/O2)
Ultra short
(Extract incisors)
Easy
Nitrous alone (40-50%); midazolam (0.5 mg/kg)
Difficult
Midazolam (1.0 mg/kg) + nitrous oxide (50% plus)
Easy
Midazolam (0.5 mg/kg) + Demerol (1 mg/kg)
Difficult
Chloral hydrate (20-25 mg/kg)
Demerol (2 mg/kg)
Vistaril (2 mg/kg)
Short
(1 quadrant)
Long
Easy
(2 or more quadrants)
Difficult
Chloral hydrate (20 mg/kg)
Demerol (2 mg/kg)
Vistaril (2 mg/kg)
Chloral hydrate (30-35 mg/kg)
Demerol (2 mg/kg)
Vistaril (2 mg/kg)
CONSIDER GENERAL ANESTHESIA!!!
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
Responsiveness
Level 1
Level 2
Interactive; Minimally
depressed;
totally
“awake”
Level 3
Level 4
Level 5
Mimics physiologic
sleep;
Sleep state;
Sleep state;
eyes open or
eyes mostly closed;
briefly closed; may or may not
respond to verbal
prompts;
does not respond to unresponsive to
verbal prompt;
surgical stimuli;
responds to
commands
reflex withdrawal
only to intense
painful stimuli;
responds to mild or
moderate painful
stimuli (e.g.,
injection or repeated
trapezius pinch);
withdrawal AND
appropriate
verbalization;
airway only
occasionally
requires adjustment
airway requires
constant monitoring
and frequent
management
partial or complete
loss of reflexes
Personnel & Monitoring
Equipment
Level 1
Level 2
Level 3
Level 4
Level 5
2
2
2
3
3
PO & Capnograph,
ECG, precordial, BP,
defibrillator
desirable
PO, Capnograph,
ECG, BP,
temperature &
defibrillator
required
Clinical
PO; precordial PO, precordial, BP,
observation recommended capnograph
*
**
desirable
*Clinical observation should accompany any level of sedation & general anesthesia.
** “Recommended” & “Desirable” should be interpreted as not a necessity, but an
adjunct in assessing patient status.
Number of Publications in Pediatric Dentistry:
Involving “Sedation”, “Dentistry” and “Pediatric”
Topic (related)
Number of Pubs
Chloral hydrate
Midazolam
Meperidine
Diazepam
Triazolam
Morphine
29
21
17
7
1
1
Monitoring
Blood Pressure
Pulse Ox
Capnography
20
6
6
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 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.
Educational Needs
 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.
Questions???