As a parent, I would love it if my children’s doctor visits went smoothly; there would be no screaming or crying, and the visit would end with the kids skipping out of the office with a smile on their face and a sticker on their shirt. Realistically, I know very well that this is not the typical situation and I don’t expect it, but I’m thrilled when it happens. As a pediatric dentist, I try to give my patients and their parents the most positive experience possible. The realities of my profession, however, are that we have to treat children for dental decay, a process that has many opportunities to upset a small child. With patience and appropriate behavioral techniques, most children can be treated for fillings, extractions, and pulpotomies (partial root canals) without getting upset. Some children are especially fearful, are too young to understand the situation, or have developmental or physical disabilities that preclude cooperation. In these cases, a parent has four options: delay treatment until the patient is a little older and can better cooperate; attempt treatment in the dental office with a papoose wrap and nitrous oxide; enteral sedation in the office; or general anesthesia in a hospital with an anesthesiologist.

Delaying treatment is possible in cases where the decay is not very deep, but if a child requires an extraction of an infected tooth or root canals then delaying treatment is not an option. If it is an option, application of a fluoride treatment, such as silver diamine fluoride, to the affected teeth will arrest the progress of the decay, but the decayed area will turn black in color. Multiple applications of fluoride varnish can also help arrest decay.

If treatment cannot be delayed, as a practitioner I believe it is very important to attempt treatment in the dental chair. Often, when presented correctly, nitrous oxide alone can be enough to calm an uncooperative child. In some cases a child is too agitated to lay still and breathe through the nose—in such a situation a papoose wrap can be very helpful. Many parents shy away from the thought of a papoose because they are uncomfortable with the idea of restraining their child in this way. As a parent I understand this feeling, but when used appropriately the papoose board does not have to upset a child at all, and can allow the necessary treatment to be completed without having to sedate the child or use general anesthesia, both of which carry risks. When I need to use a papoose board to complete treatment on a child who will not or cannot cooperate, my first course of action is to have the parent lay the child on the papoose, which I typically call a “rainbow surfboard,” and before we close the wrap I place the nitrous oxide nose on the child and wait for the child to calm down. Distractions such as music or television, or simply talking, can effectively calm the child enough to breathe the nitrous oxide and relax, and after about 5-10 minutes, we gently close the wrap while explaining to the child that we are “wrapping him up snug so you don’t get cold,” or “wrapping you up like a burrito so that you don’t fall off the surfboard.”

In some cases a child will not calm down enough to effectively inhale the nitrous oxide and treatment can either be attempted in the papoose, or the child can be sedated with general anesthesia or conscious sedation. These procedures should be carefully considered and researched before use, and should only be considered as a last resort, as there are potential risks to life in both. The gold standard of sedation is general anesthesia. It is much safer than conscious sedation when applied to healthy children, in a controlled setting, and provided by an experienced anesthesiologist.

Conscious sedation in pediatric dentistry is achieved by either oral or intranasal administration of a sedative drug—usually a narcotic or a benzodiazepine. Some pediatric dentists use a “cocktail” of sedative drugs, which involves combining two or more agents for a better sedative effect. The most common oral agents used in pediatric conscious sedation are Valium (Diazepam), Versed (Midazolam), Atarax (Hydroxizine), Demerol (Meperidine) and Chloral Hydrate. The effectiveness of a sedative drug on a child is not reliably predictable. Some children may become very sleepy and calm, but others may be crying and relatively alert. There are conditions that can alter the effectiveness of a sedative drug, such as behavioral or psychiatric disorders, and renal or hepatic disorders. If the child has any significant medical history or is on medications, the dentist will likely require a medical clearance from the primary care physician. In addition, if the child has a sore throat or an upper airway infection (both of which can obstruct a patient’s airway) on the morning of the appointment, the sedation should be postponed.

In New Jersey, a dentist who performs sedations must have a sedation permit. This permit is given to a dentist who completes 60 hours of didactic education in sedation and 50 patient cases of sedation. It is renewed every two years with the requirement of 20 didactic hours of sedation. In addition, New Jersey law states that the office must be properly equipped to monitor a patient’s vital signs and manage emergency situations that can occur during sedations. The doctor and the assistants must be CPR certified, and the office should have an emergency preparedness procedure. The drugs must be administered in the office and the patient has to be continuously observed and monitored by qualified personnel. A pulse oximeter and blood pressure cuff are used to check vital signs, and once the procedure begins a pretracheal stethoscope or a capnograph are also affixed to the patient. The patient’s vital signs should be recorded every 5-15 minutes, depending on the depth of sedation. During the procedure, there should ideally be a designated assistant charged with monitoring vital signs.

Depending on the age of the patient and the amount of treatment needed, multiple sedation appointments may be necessary. As stated before, sedation should only be done as a last resort. When considering sedation, a parent should ask their dentist the following: Can the procedure wait until the child is older? What medication(s) will be used? How will the child be monitored? Once these questions have been answered, parents together with the pediatric dentist can make an informed decision as to what is the best modality for treating the child.

By Dr. Talya Gluck