Pediatric Dentistry: Pharmacological Behavior Management

Pharmacological Behavior Management in Pediatric Dentistry

• Pharmacological behavior management is used to manage anxious or fearful children in pediatric dentistry.

Types of Pharmacological Behavior Management Techniques

• Minimal sedation/anxiolysis
• Moderate sedation/conscious sedation
• Deep sedation/general anesthesia

Pre-Sedation/Anesthetic Examination

• Physical examination
• Evaluation of anxiety level
• Review of medical history
• Review of medication and drug allergy
• Assign ASA classification
• Review past sedation/anesthetic history
• Obtain informed consent

Documentations

• Informed consent: The patient record shall document that appropriate informed consent was obtained
• Verbal and/or written instructions to the responsible person, including objectives of sedation and anticipated changes in behavior during and after sedation

Minimal Sedation/Anxiolysis

• Definition: A minimally depressed level of consciousness in which the patient's ability to maintain a patent airway independently and continuously and respond appropriately to physical stimulation and/or verbal command
• Objectives: Provide comfortable, efficient, and high-quality dental service, control inappropriate behavior, and produce a positive psychological attitude toward future care
• Routes of administration: Oral, rectal, intramuscular, intravenous, subcutaneous, and nasal
• Drugs used: Hydroxyzine HCL (Atarax), promethazine (Phenergan), chloral hydrate (Oral/rectal suppositories), and diazepam (Valium)

Nitrous Oxide (Inhalation Analgesia/Laughing Gas)

• Definition: A colorless, sweet-smelling gas that is neither explosive nor flammable but supports combustion as well as oxygen
• Indications: Anxious or fearful children, short attention span children, certain mentally, physically, or medically compromised patients, and patients with a gag reflex that interferes with dental care
• Contraindications: Upper respiratory tract infection, pulmonary disease, nasal obstruction, children with certain psychiatric disorders, children with a history of motion sickness, acute otitis media, and maxillofacial deformities
• Equipment: Nitrous oxide machine, reservoir bag, nasal inhalation mask, double scavenger system, oxygen and nitrous oxide tanks
• Technique: Describe the procedure to the patient, encourage the child to breathe through the nose, and deliver nitrous oxide and oxygen gradually
• Recovery from analgesia: Inhalation of 100% oxygen for 5 minutes
• Complications: Nausea, vomiting, headache, deep sleep, and disorientation

Chronic Toxicity of Nitrous Oxide

• Increased risk of hepatic disease in dentists and dental personnel exposed to high levels of nitrous oxide for periods of time greater than 3 hours/week
• Bone marrow depression
• Spontaneous abortion for female dentists
• Dental personnel sterility may occur on prolonged exposure to nitrous oxide

General Anesthesia (GA)/Deep Sedation/Analgesia

• Definition: Drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation
• Indications: Physically or seriously handicapped children, very young children and/or uncooperative, extensive treatment is required, allergy to local anesthesia, children with significant mental or psychological disorder, and severe dental disease in children with significant medical disease
• Routes of delivery: Intravenous, inhalation (nitrous oxide, sevoflurane, desflurane, isoflurane, and halothane)
• Vital signs: Blood pressure, heart rate, respiratory rate, oxygen saturation, and level of consciousness
• Monitoring: Level of consciousness, clinical observation, pulse oximetry, and blood pressure
• Undesirable aspects of GA: Represents a real risk, hospitalization can be a psychic trauma, and no patient should be exposed to that risk without sufficient cause

Comparison of Conscious Sedation and Deep Sedation

• Conscious sedation: Interactive, arousable, maintained airway, intact protective reflexes, and responds to commands
• Deep sedation: Non-interactive, non-arousable, inability to maintain airway, partial loss of reflexes, and difficult to respond to commands