Wednesday, February 26, 2014

Effect on Behavior of Dental Treatment Rendered Under Conscious Sedation and General Anesthesia in Pediatric Patients

Resident: Mackenzie Craik

Article: Effect on Behavior of Dental Treatment Rendered Under Conscious Sedation and General Anesthesia in Pediatric Patients

Author: Charles T. Fuhrer, DDS

Journal: Pediatric Dentistry, December 2009.

Purpose: The purpose of this study was to determine if there were differences in the amount of time it took to exhibit positive behavior following dental treatment under general anesthesia (GA) vs conscious sedation (CS).
Metheds: This retrospective study examined charts of a pediatric dental office between

1999 to 2003. Patients presenting before 36 months old for an initial exam who were diagnosed with early childhood caries were included in the study. Following the initial exam, the patients were treated under GA or CS. These patients were followed to determine their behavior at the 6-, 12-, and 18-month recall appointments.
Results: Thirty-nine patients who received treatment under GA were identified and 41 were treated under CS. GA patients were 3.9 times more likely to exhibit positive behavior at the 6-month recall appointment.  Although not statistically significant, a trend toward positive behavior was exhibited at the 12- and 18-month appointments.
Conclusion: Clinicians should consider future behavior, in addition to caries, when determining treatment modalities for children presenting to their office with dental caries.

Adverse sedation events in pediatrics: A critical incident analysis of contributing factors.

Resident: Derek Nobrega
Title: Adverse sedation events in pediatrics: A critical incident analysis of contributing factors.
Authors: Cote, C. J.
Journal: Pediatrics (2000) 105(4): 805-814.

Purpose: To examine the factors that contribute to adverse sedation events in children undergoing procedures using the technique of critical incident analysis.

A database consisting of descriptions of adverse sedation events derived from the Food and Drug Administration's adverse drug event reporting system, from the US Pharmacopeia, and from a survey of pediatric specialists was developed. One hundred eighteen reports were reviewed for factors that may have contributed to the adverse sedation event. The outcome, ranging in severity from death to no harm, was noted. Individual reports were first examined separately by 4 physicians trained in pediatric anesthesiology, pediatric critical care medicine, or pediatric emergency medicine. Only reports for which all 4 reviewers agreed on the contributing factors and outcome were included in the final analysis.

Key Points
- Of the 95 incidents with consensus agreement on the contributing factors, 51 resulted in death, 9 in permanent neurologic injury, 21 in prolonged hospitalization without injury, and in 14 there was no harm.
- The venue of sedation was not associated with the incidence of presenting respiratory events (eg, desaturation, apnea, laryngospasm, 80% in each venue) but more cardiac arrests occurred as the second (53.6% vs 14%) and third events (25% vs 7%) in nonhospital-based facilities.
- Inadequate resuscitation was rated as being a determinant of adverse outcome more frequently in nonhospital-based events (57.1% vs 2.3%).
- Death and permanent neurologic injury occurred more frequently in nonhospital-based facilities (92.8% vs 37.2%).
- Successful outcome (prolonged hospitalization without injury or no harm) was associated with the use of pulse oximetry compared with a lack of any documented monitoring that was associated with unsuccessful outcome (death or permanent neurologic injury).
- Pulse oximetry monitoring of patients sedated in hospitals was uniformly associated with successful outcomes whereas in the nonhospital-based venue, 4 out of 5 suffered adverse outcomes.
- Adverse outcomes despite the benefit of an early warning regarding oxygenation likely reflect lack of skill in assessment and in the use of appropriate interventions, ie, a failure to rescue the patient.

As adverse outcomes occur more frequently in non-hospital settings, we must be extremely careful when sedating patients in our offices. The most common predictor of a poor outcome is inadequate resucitation, followed by inadequate monitoring and inadequate presedation medical records. If we plan on performing sedations in-office, we must be up to date and competent in resuscitation techniques. Additionally, our monitoring must be appropriate, and we must be vigilant in our screening and case selection

Pinkham Chapter 6

Nonpharmacologic Issues in Pain Perception and Control
Resident: Margaret Maclin

Theories of Pain Perception:

Pain experience is merely a function of activating a particular set of neurons, which sends a message to the CNS of discomfort. Portions of this theory are fairly accurate, however the simplicity of the theory does not explain the multifaceted nature of the pain experience (e.g., phantom pain experienced by an amputee).

Is more complex than specificity. The recognition of painful stimuli by the individual was based primarily on the pattern of nerve activity that entered the CNS. Theory is accurate but again too simple.

Gate Control Theory:
Various "gates" controlling the level of noxious input via small fiber neurons (pain) to the spinal cord can be modulated by other sensory, large fiber neurons (touch), higher CNS input, or both. Ex: inhibitory effect of the a parent rubbing a "bumped" area of the knee immediately following a toddler's fall. The light rubbing disproportionately activates greater large fibers that inhibit previously activated small fibers. In dentistry, shaking of the lip during an injection is the same principle to lessen the associated discomfort.

CNS on Pain Perception and Control:
Endogenous opioids are synthesized by the body and activated for pain relief. The analgesic effects of nitrous are believed to be partially mediated by the activation of endogenous opioids. Studies are looking at ways to activate this system in addressing clinical pain states.

Cognitive Elements of Pain Perception:
Involves the "knowing" and implies an awareness of internal and external environmental influences; perceiving, organizing, judging, meaning, reasoning and responding. Coping strategies may include hypnosis, relaxation techniques, modeling, distraction, and re-conceptualization. Studies have found that children who were informed of possible pain shortly before an injection, reported less anxiety and pain.

Emotional Elements of Pain Perception:
An injured child may not be overly upset until he or she notices an adult's emotional outpouring. This is an important consideration when allowing parents to observe injections, extractions, and other treatment procedure.

Children and Pain:
  •       The pain threshold tends to decline and the self management of pain becomes more effective with increasing age.
  •        It is often hard to assess pain or discomfort in children due to a lack of cognitive development.
  •       The visual analog scale (VAS) is one of the most reliable and valid measurement tools for self-report of pain. The child marks a point on a 100mm scale from "no pain" to "worst pain imaginable" (often times faces describing the pain are used for the younger children).

Behavior Management Techniques:
  •       Three most anxiety producing stimuli in the dental office to a child is local anesthesia, placement of the rubber dam and the start of the prep using a high-speed handpiece.
  •       Tell-show-do, positive reinforcement, distraction, and non-verbal techniques are indicated for any patient.
  •       Voice control: uncooperative or inattentive child.
  •       Nitrous oxide: fearful, anxious patients.
  •        Physical restraint: child who cannot cooperate due to immaturity; disability; safety of patient/provider.
  •       Conscious sedation: any ASA I/II child who cannot cooperate due to a lack of psychological/emotional maturity.
  •       General anesthesia: extremely uncooperative, fearful, anxious child; special needs; extensive/immediate tx needs.

Guideline for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures

Title: Guideline for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures

Resident: Hofelich

Sedation Risks: hypoventilation, apnea, airway obstruction. laryngospasm, and cardiopulmonary impairment
  • the ability to control behavior to cooperate depends on chronological and developmental age
    • <6yo or developmental delayed children are particularly vulnerable to sedation medication effects on respiratory drive, patency of airway, and protective reflexes, therefore they may easily slip into a deeper level of sedation than was intented
Goals of sedation:
  1. guard patient's safety and welfare
  2. minimize physical discomfort and pain
  3. control anxiety, minimize psychological trauma, and maximize potential for amnesia
  4. control behavior and movement to allow safe completion of the procedure
  5. return to state that is safe for discharge
  • best achieved by using the lowest dose of drug with the highest therapeutic index
Minimal sedation (old term: anxiolysis)
  • respond normally to verbal commands
  • ventilation and cardiovascular functions are unaffected
Moderate sedation (old term: conscious sedation)
  • drug-induced depression of consciousness during which patients respond purposefully to verbal commands and light touch
  • age appropriate behaviors (ex: crying) occur and should be expected
  • patient can maintain a patent airway
  • cardiovascular function is maintained
  • if the patient is not making spontaneous efforts to open the airway when obstructed, they are in a deeper level of sedation
Deep sedation
  • cannot be easily aroused but respond purposefully after repeated verbal or painful stimuli
  • ventilation may be impaired
  • cardiovascular function is usually maintained
  • may lose protective airway reflexes
General anesthesia
  • drug-induced loss of consciousness
  • patient is not able to maintain airway
  • cardiovascular function may be impaired
Preparation for sedation
  • acronym SOAPME
    • suction, oxygen, airway, pharmacy (includes drugs for life support in an emergency), monitors, equipment/drugs
  • personnel
    • practioner and personnel should be certified in BLS and PALS
    • support personnel is responsible for monitoring and should have specific duties in case of an emergency
  • Emergency preparation
    • it should be understood that the availability of EMS services does not replace the practioner’s responsibility to provide initial rescue in managing life-threatening complications
  • candidates: ASA I and II patient
  • NPO fasting guidelines: same as GA, may have a sip of water to take daily medication

Table 1.
Ingested Material
Minimum Fasting Period (h)
Clear liquids: water, fruit juices without pulp, carbonated beverages, clear tea, black coffee

Breast milk

Infant formula

Nonhuman milk: because nonhuman milk is similar to solids in gastric emptying time, the amount ingested must be considered when determining an appropriate fasting period

Light meal: a light meal typically consists of toast and clear liquids. Meals that include fried or fatty foods or meat may prolong gastric emptying time. Both the amount and type of foods ingested must be considered when determining an appropriate fasting period.


  • obtain informed consent
  • review discharge instructions with parents
    • must arrive and leave with a parent or legal guardian
    • preferrable if 2+ people attend so that someone can sit with the child in the backseat of the car (watch for airway obstruction)
    • car transportation is a risk due to drugs with a long 1/2 life (ex: chloral hydrate, IM pentobarbitol, and phenothiazine)
  • health evaluation
  • age, weight, allergies, review of systems, baseline vital signs, airway evaluation, ASA classification, and current medications
    • take into consideration any herbal medicines (ex: St. John's wort, echinacea) - may alter the pharmokinetics through inhibition of cytochrome P450 leading to a prolonged drug effect and altered blood drug concentrations
    • erythromycin and cimetidine may also alter pharmokinetics through inhibition of CP450
  • immobilization - avoid chest restriction and airway obstruction, always keep a hand or foot exposed, never leave unattended, document time in/out
  • documentation
    • name, route, site, time of administration, dosages of all drugs
  • monitors
    • O2 saturation, heart rate, BP, respiratory rate -- all on a time-based record
    • capnograph and precordial stethoscope
  • local anesthesia
    • cardiac depressants, can cause CNS excitation or depression
  • Discharge criteria
    • cardiovascular function and airway are stable and satisfactory
    • easily arousable
    • protective reflexes are intact
    • sit up unaided
    • hydration is adequate
    • for a very young or handicapped child incapable of the usually expected responses, the presedation level of responsiveness or a level as close as possible to the normal level for that child should be achieved
  • if patient was given a reversal, longer observation is required because the duration of the sedative may exceed the duration of the antagonist and resedation may occur
  • general rule: patient can be discharged if the patient remains awake for 20 minutes in a quiet environment

Review of monitors and monitoring during sedation with emphasis on clinical applications

Resident: Jeff Higbee Article: Review of monitors and monitoring during sedation with emphasis on clinical applications
Journal: American Academy of Pediatric Dentistry
Author: Stephen Wilson, DMD, MA, PhD

Review Article

Types of Monitors Reviewed

1. Pulse Oximeter:
Measurement represents the degree of hemoglobin saturation
- Sensors must be direct opposite of each other.
- Patient movement can affect reading
- Crying and sobbing can affect reading
- Pressure on vessels above probe can affect reading (ie BP cuff)
- Safe and non invasive
- Simple to use
- Info rapidly available
- Non reusable probes are expensive
- Finger probes can be easily dislodged
- Emitted light source may cause burning
- Does not directly determine airway patency

2. Automated BP cuff:
Determines BP and HR simultaneously
- Cuff size must be appropriate for arm size
- Safe and noninvasive
- Simple to use
- Determination time usually less than 30 sec
- Determination time increased with moving and uncooperative patient
3. Capnography:
Measures expired carbon dioxide
- Nasal probe must not be blocked by mucus or physical barrier ie nasal septum or alae
- Safe and slightly invasive (probe inserts 2 to 3 mm into nasal apature)
- Simple to use
- Info rapidly available for clinical decisions
- Indirectly indicates respiratory exchange
- Directly determines airway patency
- Temporary block of sample line by mucus
- May register low CO2 values when child is crying

4. Pre-Cordial Stethoscope
Measures sounds of heart and lungs/airway
- Placement of the bell on the chest wall
- Extraneous sounds (noise from handpiece)
- Fixation to chest wall
- Inexpensive
- Simple to use
- Non invasive
- Durable
- Picks up interfering vibratory sounds
- Does not determine degree of airway patency
- If improperly placed, decreases usefulness in auscultating sounds

As we transition to our conscious sedation cases it is important to have some knowledge about these measuring devices and their pros and cons.


Tuesday, February 25, 2014

Pain Control

AAPD Handbook of Pediatric Dentistry, Chapter 14
Author: Kaaren Vargas
Resident: Anna Abrahamian

Children feel pain, but they may not be able to report the severity or location. Special consideration must be given to local anesthetic dosages, especially in small children (maximum dosage should not be exceeded, which may preclude multiple quadrant dentistry).

Local Anesthesia Techniques:
Topical: Benzocaine (20%), Lidocaine ointment (5%) or spray (10%), or TAC (oral) or EMLA (peri-oral)
Maxillary anesthesia: supra-periosteal infiltration in the mucobuccal fold and intrapapillary injections for palatal anesthesia
Mandibular anesthesia: supra-periosteal infiltration (incisors, canines, minor operative for primary molars), IAN block for extensive operative or oral surgery on primary molars, PDL injection (useful only for single tooth anesthesia but not routinely for pediatric procedures)
Decrease length of anesthesia with phentolamine mesylate for children (not FDA-approved in children <5)
Maximum Recommended Dosages:
Lidocaine 4.4mg/kg, absolute maximum dose: 300mg
Articaine: 7.0 mg/kg, absolute maximum dose: 500mg
*If moderate conscious sedation is employed , then dosage of anesthetic should be well below the MRD so that potentiation of cardiorespiratory depressant effects do not occur.

Local Anesthetic Overdose:
Causes: intravascular injection, excess dosage
Effects: CNS depression, seizure, disorientation, LOC, decreased heart contractility -à CV collapse

Complications of Local Anesthesia:
Soft Tissue Injury: Epinephrine causes vasoconstriction to prolong action of local anesthetic, which also increases the potential for post-treatment soft tissue trauma/biting/scratching; warn patient/advise parent
Parasthesia: associated with some anesthetics

Analgesia for Children:
In preverbal child or child with limited verbal skills, pain assessment is via:
Physiologic responses (increased HR, BP, RR), behavioral responses (persistent crying), inability or refusal to eat or drink, or awakening from sleep.
Use Wong-Baker Faces Scale for pain assessment: 5 faces, two coding scales (0-5 and 0-10).

Analgesics Commonly Prescribed for Children:

Acetaminophen 10-15 mg/kg q4h, daily max dose: 65 mg/kg; Supplied as drops: 80mg/0.8mL, suspension: 160mg/5mL, chewable tabs: 80mg, and tablets: 325 and 500mg

Ibuprofen 2-8 mg/kg q6-8h, daily max dose is 40mg/kg; Supplied as suspension: 100mg/5mL, tablets: 200mg

Pediatric Conditions associated with Compromised Airway - Part I Congenital

Resident: Todd Bushman
Article:  Pediatric Conditions associated with Compromised Airway - Part I Congenital
Authors:  Nicolas S. Wage, DDS; Suher Baker, DMD, BDS,MS; Heddie O. Sedano, DDS, Dr. Odont

Journal:  Pediatric Dentistry V 31/No 3 May/Jun 09

Purpose: A discussion of congenital conditions which are characterized by potentially difficult airway management.

Key Points: Respiratory complications are the leading cause of pediatric anesthetic related morbidity and mortality. A thorough evaluation of the patients airway and medical conditions which may lead to airway obstruction must be evaluated prior to any decisions on medical care and treatment. Additionally, the anatomy of a pediatric airway is much different than an adult and may lead to more difficult airway maintenance. Pediatric respiratory systems require higher levels of O2 consumption, higher ventilation and limited reserve.

Congenital conditions associated with a compromised airway and a few notes... (Please read article or look up conditions for more information -I'm just noting airway and oral manifestations)

Robin sequence: cleft palate, micrognathia, glossoptsosis, downward displacement of tongue. Cyanotic attacks, respiratory difficulty, little support of tongue musculature.

Treacher Collins: Mandibular condyle and coronoid process may have sever hypoplasia, malformation, or even aplasia. Sleep apnea common, clefting in 35%. Upper airway obstruction common

Crouzon: Maxillary hypoplasia, mandibular prognathism, high arch, v-shaped palate. Cleft lip and or palate. Chronic tonsillar herniation.

Apert: Craniosynostosis, midface malformations and symmetric syndactyly. Midface retruded and hypoplastic. Cleft palate, reduction of nasopharynx, respiratory complications, cartilagenous trachea and tracheal ring abnormalities.

Goldenhar: most complex clinical manifestations of the aculoauriculovertebral spectrum. Maxillary, temporal and malar bones are reduced in size and flattened. Aplasia or hypoplasia of the mandibular ramus and condyle. After these patients undergo TMJ surgery airway management is difficult. TEF are common. Hypoplastic tongues, cleft lip and palate and VPI.

Down Syndrome: mandibular prognathism, midface hypoplasia. Open mouth, protruding tongue, enlarged tongue, tonsils and adenoids. Tracheal intubation may lead to subglottic stenosis.

Klippel-Feil: Cervical vertebral fusion, short neck, limitation of head movement. Spina bifida, spnial canal stenosis, scoliosis, atlanto-occipital fusion, cleft vertebrae and hemivertebrae.

Beckwith-Wiedemann: Exopthalmos, macroglossia and gigantism. Alveolar hypoventilation at birth leading to cor pulmonale or right sided heart failure. Primary cause of airway obstruction is large protuberant tongue.

Cherubism: Expansion of the posterior mandible, fullness of face. Gingival enlargement preventing jaw closure. Airway obstruction has be a significant cause of morbidity when tongue is displaced.

Congenital hypothroidism: Obesity, lethargy, swelling of face, bradycardia and hypothermia. Fluid accumulation.

Cri du Chat: severe physical and cognitive growth retardation, feeding problems, microcephaly, micrognathia and facial asymmetry. Bifid uvula, dental malocclusion, short neck, scoliosis, hemivertebrae.

Von Recklinghausen: Neurofibromas found in organs. Neoplasms in the scalp, cheek, neck and oral cavity. Tongue lesions can cause gross tongue enlargement. VPI also noted.

Hurler: Lips enlarged and mouth open till age 3. Hyperplastic adenoids and constricted nasopharynx. Upper airway obstruction from epiglottic, tonsillar and tracheal thickening. Ramus is reduced and limited movement of the TMJ

Hunter: Airway obstruction due to macroglossia, pharyngeal deformation, short immobile neck, mucous nasal discharge, anatomical deformation and narrowing trachea.

Pompe: Most patients rely on artificial ventilation due to multisystem organ dysfunction. Swallowing is difficult with a protruded tongue. Laryngeal nerve paralysis and feeding difficulties may lead to aspiration.

Osteogenesis Imperfecta: Due to bone fractures patients should be repositioned carefully.

Moebius: Limitation of eye movement, facial expression, feeding and swallowing difficulties, choking predisposition, drooling, cleft palate and speech difficulties. Upper midfacial protrusion, hypoplastic mandible and tongue.

Saethre-Chotzen: High arch palate, malocclusion, supplemental teeth and cleft palate.

Rubenstein-Taybi - High arched palate, micrognathia, bifid uvula, palatal clefting, bifid tongue, macroglossia and natal teeth.

De Lange: Small nose with inverted nostrils depressed nasal bridge, high arch palate, short muscular neck and micrognathia.

Monday, February 24, 2014

Nitrous Oxide AAPD Guideline

Guideline on Use of Nitrous Oxide for the Pediatric Dental Patients
Resident: Avani Khera

-Nitrous oxide is a colorless and virtually odorless gas with a faint, sweet smell.
-It is an effective analgesic/anxiolytic agent causing central nervous system (CNS) depression and euphoria with little effect on the respiratory system.
-Nitrous oxide is absorbed rapidly, allowing for both rapid onset and recovery (two to three minutes)
-It exhibits a superior safety profile with no recorded fatalities or cases of serious morbidity
-Objectives of nitrous oxide inhalation include reducing anxiety, increasing cooperation, raising the pain threshold, increasing tolerance for longer appointment, and reduce gagging
-Disadvantages include lack of potency and the patient must be able to breathe through their nose
-Contraindications to nitrous oxide administration include COPD, severe emotional disturbances/drug related dependencies, first trimester of pregnancy, treatment with blemycin sulfate, methylenetetrahydrofolate reductase deficiency, and cobalamin deficiency
-A flow rate of five to six L/min generally is acceptable to most patients. The flow rate can be adjusted after observation of the reservoir bag. The bag should pulsate gently with each breath and should not be either over- or underinflated.
-Introduction of 100 percent oxygen for one to two minutes followed by titration of nitrous oxide in 10 percent intervals is recommended.
- Nitrous oxide concentration may be decreased during easier procedures (eg, restorations) and increased during more stimulating ones (eg, extraction, injection of local anesthetic).
-Side effects such as nausea and vomiting are more likely to be observed when titration is not employed.
-During nitrous oxide/ oxygen analgesia/anxiolysis, continual clinical observation of the patient’s responsiveness, color, and respiratory rate and rhythm must be performed
-Nausea and vomiting are the most common adverse effects, occurring in 0.5 percent of patients.
-The patient’s record should include indication for use of nitrous oxide/oxygen inhalation, nitrous oxide dosage (ie, percent nitrous oxide/oxygen and/or flow rate), duration of the procedure, and post treatment oxygenation procedure.