Dental Treatment for Children under Sedation (Nitrous Oxide, Oral & IV Sedation). What All Parents Should Know!
Dental treatment (dental surgery) under sedation may be completed safely and effectively at the dental office, ambulatory surgery centers, or the hospital based operating room. Here is a quick review of what to expect and some keys to doing your due diligence when is comes to having a child be treated for dental care under sedation.
In the United States each year more than a million children under age 4 have general anesthesia (GA) for surgical procedures. The overwhelming majority of these children were treated in a hospital operating room or an ambulatory surgery center (ASC). Dental surgery due to advanced severe early childhood caries is by far the most common reason children require such treatment and in fact made New York Times science section front page a few years back. This is unfortunate considering tooth decay can most often be prevented if children begin early oral assessment (by age one) and caregivers are able to maintain vigilance on proper oral hygiene and healthy diet at home. In cases where decay has advanced causing pain and or oral infection for a child that is not able to cooperate for chairside treatment, dental surgery with sedation may be advisable as a safe and effective option to help restore the child’s quality of life.
Office based sedation is utilized daily by thousands of dentists in the United States. There are usually three different levels/methods of sedation utilized in the dental office: I) nitrous oxide analgesia with no other sedative agents, II) oral sedation with or without nitrous oxide and intravenous (IV) sedation also known as General Anesthesia (GA).
The term conscious sedation (a level of drowsiness where the patient seems semi conscious but can still breath spontaneously and maintain reflexes such as coughing) is also a common term used that describes the level of sedation achieved for any patient. This state of sedation my be reached and or passed (into deeper levels) by any of the approaches above.
Nitrous oxide analgesia or sedation is the most commonly used and by far the safest of these three sedation approaches. It may be used by itself but it is often combined with local anesthesia injected into the mouth to numb the teeth. This approach is considered the safest mode of sedation for children and adults with a nearly negligible considerations for side effects. Nausea is only rarely of concern and if children have not eaten or drunk anything heavy such as milkshakes for 2-3 hours prior to the procedure this can be easily avoided. Children are usually awake with just a slight level of drowsiness during the sedation. A child does need to be able to minimally cooperate to sit on the treatment chair and accept the nasal mask for gas administration. Nitrous oxide is a very light sedative, and for some children it is not sufficiently potent to enable the needed level cooperation for completing the planned dental treatment. Your Dr. can help assess the child’s overall temperament and dental treatment needs to determine if this is the best approach for your child. Recovery from nitrous oxide analgesia is near immediate and children can go back to school or play depending the extent of the dental treatment itself. Children’s response to nitrous oxide can vary from visit to visit since since nitrous oxide is a very light sedative and children are mostly awake and are still required to cooperate at some level during the treatment. The child may need several appointments with nitrous oxide to allow for completion of all the needed dental treatment. A child may be fully cooperative for the first visit, but not wish to cooperate on the follow up visits. Also a child that was minimally sedated and calm during the treatment with nitrous oxide may become upset once the gas is off and returns to full consciousness. Such children can often be effectively helped by reassurance, positive re-enforcement and distraction with post treatment rewards!
Oral sedation involves giving the patient a cocktail of sedatives to take by mouth that will cause much greater drowsiness than is achieved by nitrous oxide alone. Children’s response to oral sedatives can be very unpredictable. Some are only minimally affected while others may become over-sedated. A passive stabilization device may be used to keep the children that are minimally sedative from any abrupt movements. It is difficult to predict how much of the needed dental treatment will be completed during the oral sedation visit per since children can respond somewhat differently to the oral sedative. Additional sedation visits may be required. Therefore it is imperative that the dentist and his or her team are super vigilant on monitoring the patients breathing heart rate constantly using a pulse oximeter. Also the parent should be aware of this and understand the follow up sedation plan in case the sedatives are not fully effective. This can be a safe approach to sedating children when all the guidelines are strictly followed. Oral sedation does not require a separate Dr. involved in monitoring the patient’s vital signs, for all monitoring is done by properly trained support staff. This approach is commonly combined with nitrous oxide analgesia as well and local anesthesia to fully numb the areas treated in the mouth. Children will need some time to recover at the office prior to being able to be allowed to go home. It would not be advised to have children go back to school after this sedative approach and they should be closely monitored for the rest of the day.
Intravenous sedation (IV) / General Anesthesia (GA) are mentioned together because it while most patients that are sedated by the IV sedation technique do not reach a depth of sedation known as general anesthesia, this can quite easily happen particularly when treating children. This approach requires giving the patient sedative agents by direct administration that involves an IV catheter into a vein. While this is more invasive than oral sedation, it is much more predictable for children since it allows for the titration of the sedative drugs and does not depend on the child’s willingness to take any medicines. Most often all of the needed dental treatment is completed during a single IV sedation visit. Children are generally induced or have the anesthesia/sedation started by breathing gas anesthetics from a mask and can be fully sedated within just a few seconds. For young children receiving IV sedation, it is required that the treating dentist works closely with an anesthesiologist who administers the anesthesia and monitors the patient during the entire procedure.
For both oral sedation and IV sedation, a medical clearance by the child’s primary care provider (PCP) may be required. Also children should not have any food or drinks (NPO) for 6-8 hours prior to the day of the oral or IV sedation appointment. For nitrous oxide analgesia, children should not eat anything 2-3 hours prior to visit and avoid any heavy meals that day.
Also if the child has come down with a upper respiratory infection (URI), be sure to inform the office to assure the child does not need be re-evaluated by the PCP or the treating dentist/anesthesiologist. Sometimes URI will require the a sedation appointment to be postponed.
Regardless of the mode of sedation used, the questions below should be addressed prior to the scheduling of a child for sedation. While these may seem like overly technical and or probing questions, any competent provider of pediatric sedation should be able to easily provide the appropriate answers to help assure the parent that they are fully prepared.
- What approach and level of sedation is being proposed (Nitrous Oxide Analgesia only, Oral sedation or IV Sedation)?
- What are the benefits, side effects, risks and alternatives for treatment with the proposed sedation technique?
- What are the most likely consequences of not getting the propose treatment under sedation?
- What drugs and dosages does the Dr. typically use who prepares and administers the drugs?
- What is the expected depth of sedation? Is the child expected to loose their gag reflex and if so how will this be managed?
- How will the child’s airway be protected during the procedure?
- Who will be doing the monitoring during the procedure and then during recovery?
- Will the treating team assure that the child will be walking and able to drink liquids before leaving/being discharged?